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verweight and obesity are quickly becoming a national epidemic. Many studies indicate the substantial rise in obesity is found among all age, ethnic, racial, and socioeconomic groups.1 Unfortunately, these trends are also erasing the gains we have made against heart disease, cancer, and many other chronic conditions. This diagnosis has additionally been shown to decrease life expectancy by up to 20 years.2 What is the cause of this epidemic and what effect is this having on our healthcare system and its dwindling resources?
       First, let's define bariatrics. The term bari is Greek for weight, and the treatment of obesity as a medical disease has only been defined as such since 1985. Since then, the "art and science of medical weight management" for obesity and related conditions have created the specialty of bariatric medicine.3
       How are overweight and obesity defined? According to the National Institutes of Health, overweight refers to having excess body weight compared to a set standard. This standard, for example, was the life insurance height-weight tables or the most up-to-date chart, Dietary Guidelines for Americans published by the US Departments of Agriculture and Health and Human Services, which can be accessed at http://www.niddk.nih.gov/health/nutrit/pubs/images/healthyweight.gif.
       Obesity, on the other hand, refers to having a high proportion of body fat to lean muscle tissue. Most Americans are concerned with the "tale of the scale," but what is more important is body composition. Body fat analysis can range from simple estimates using tricep skin-fold measurements to more involved studies, such as bioelectrical impedance analysis or underwater weighing. Most obesity studies, however, refer to a patient's body mass index (BMI) score. The BMI is used to measure both overweight and obesity. This measure is not gender specific and is found by dividing the patient's weight in kilograms by his or her height in meters squared. A nomogram provides a quick, at-a-glance BMI score (see Figure 1).

Figure 1. Body mass index nomogram

* Overweight is >27.5
* Obese is >33
* Morbidly obese is >40.
       What is most staggering about this epidemic is that approximately 280,000 people die per year as a direct result of obesity.4 With approximately 39 million Americans classified as obese (BMI >30), their corresponding increase in comorbidities has created an estimated direct healthcare cost of $51 billion dollars per year.4 Obesity has many contributing factors. Genetics, psychological, dietary, medical, cultural, environmental, and sedentary lifestyles may all play a role. Considering that obesity is a known risk factor for diabetes, heart disease, stroke, hypertension, osteoarthritis, various forms of cancer, and sleep apnea among other things, it is no wonder that healthcare costs have skyrocketed.
       A typical bariatric resident's medical history may include the following findings: diabetes mellitus, hypertension, atherosclerosis, exercise or activity intolerance, depression, and malnutrition. With these conditions in mind, treatment strategies are tailored to meet the resident's current care needs while focusing on reducing his or her life-threatening body weight. A multidisciplinary team approach is most effective in treating the bariatric resident. The team includes the patient, the attending physician or possibly a bariatric medicine physician, a registered dietitian, nurses, physical and occupational therapists, respiratory therapists, pharmacists, psychologists or psychiatrists, and durable medical equipment suppliers. These specialists all work together to meet the unique needs of the patient and synergistically improve his or her clinical outcomes. The sooner the team treats the resident, the better. Preventing a problem is much easier and less costly than treating one!

Simple Complexities
       The bariatric client encounters many functional challenges on a daily basis. Things that the nonobese resident finds simple become insurmountable tasks to the bariatric individual. Performing activities of daily living (ADLs) will be mildly to profoundly impaired as compared to the nonobese resident. Simple supine-to-sit bed mobility tasks can be exhaustive if not completely impossible for the morbidly obese individual. Without assistance or assistive aids, bed mobility, bed-to-chair transfers, toileting, bathing, and maintenance of personal hygiene become obstacles to independent living. Many of these patients rely on family for the most routine, personal hygiene tasks due to their size and obvious anatomical reach limitations. This is compounded by the extra time and energy required for functional ambulation or wheeled mobility and the vicious cycle of activity intolerance, exercise-induced asthma, dyspnea on exertion, sleep apnea, and decreased muscle strength. All of these limitations are just the beginning for patients who are ill or in the hospital for medical reasons.

Affairs of the Skin
       Skin and wound care issues are another common concern for most morbidly obese patients. Adipose tissue creates a barrier to adequate blood flow and can also produce internal pressure. These include pressure ulcer risk (sometimes in unique locations), skin tears, poor temperature regulation leading to excess moisture, and shear and friction problems with transfers and bed mobility.
       A skin and wound care professional can offer options for addressing skin issues, such as moisture and skin fold erosion. Superficial opportunistic cutaneous manifestations, such as Candida albicans (fungus), can bring about a rash-like appearance, which may be ineffectively treated with a barrier ointment or antibiotic cream. Having important items, such as broad-spectrum antifungal powders, on your formulary is imperative for this patient population. Generally, powders are preferred to ointments, since they additionally help to absorb moisture.
       Cleanliness is another issue facing the bariatric resident. Something as simple as personal hygiene after using the bathroom can present a dilemma to these individuals. Involving the occupational therapist and the skin care professional is a first step. Your protocol should consider easy-to-use pH-balanced cleansers, skin wipes, devices to help the client "reach," and other products that assist the resident and staff to maintain a clean and dry environment is paramount.
       Skin folds impact this population and can cause skin issues and skin-to-skin pressure ulcers. Special dressings, such as transparents, hydrocolloids, foams, and absorptives as well as skin prep can protect vulnerable tissue and help heal pressure, shear, friction, and moisture induced damage. Therefore, an involved patient with skin integrity issues will require due diligence with skin care as well as a room environment that provides an optimal environment for healing damaged and fragile skin.

Addressing Unique Needs
       The bariatric patient's needs can be met by taking a global assessment to include more than just larger gowns and blood pressure cuffs. For this patient, a bariatric suite may be necessary. He or she may require longer needles and tourniquets, wider door frames, armless chairs, and reinforced and often bolted-down furniture and bathroom facilities. It will also include a heavy-duty, oversized bed frame with a built-in scale, removable or foldable leaves for expanding width, and a therapeutic true low air-loss support surface or a no-weight-limit or high-weight-limit capacity mattress in a width up to 60 inches. Enough room for the resident and allowance for turning and repositioning is imperative (see Figure 2). Some surfaces offer the ability to augment the existing support surface with modular pieces to address the bariatric customer, an often low-cost alternative.

Figure 2. Bariatric bed frame with low air-loss mattress replacement

       Considerations for a low air-loss support surface versus a nonpowered support surface may include profuse diaphoresis, heavily exudating or draining wounds, impaired temperature regulation, or an adverse patient-bed boundary microclimate. These support surfaces aid in decreasing the humidity between the patient and the mattress thereby evaporating potentially damaging excess moisture. Low air-loss support surfaces do this by slowly losing air through pinholes in the top of the mattress baffles and having this cooler air contained in a vapor-permeable, fluid-impermeable cover. As the patient builds up excess moisture, the change in humidity in the interface between the patient-bed boundary promotes evaporation and decreases the chance for skin maceration and fungal and bacterial colonization.
       Other unique issues, such as those involving the respiratory system and sleep apnea, may require continuous positive airway pressure (CPAP). Make sure that you have all the systems covered.

Low Air Loss--An Important Bariatric Essential
       Low air-loss support surfaces can work in one of three ways.5 Be sure the ones that your facility chooses offer "true" low air loss. The first form of low air loss doesn't employ pin holes in the mattress but rather loses air through an exhalation port or hose, which has absolutely no impact on the resident's skin microclimate. This type of surface, regardless of being called "low air loss," is really nothing more than powered air. The second form of low air loss offers air flow to the resident's skin that is direct, and one can feel this air flow across the patient-bed boundary. This could potentially dry out the skin and cause cooling to the point of vasoconstriction. Think of a fan blowing directly on a marathon runner after the race. The runner is quickly cooled but could become cold and dry if they continue to stand in front of the fan. The third and preferred method of low air loss employs the use of baffles with pin holes and a moisture vapor-permeable cover, which allow the air flow to wick away moisture without direct air flow. Imagine that same marathon runner walking into the lobby of an air conditioned hotel. Although there is no direct air flow, her moisture and heat issues are addressed as the environment and humidity has changed around her. The same goes for the final type of low air loss or "true" low air loss. Make sure that you are getting what you paid for.
       Shear and friction reduction is also enhanced with specially designed covers, sheets, and materials. These specially coated fabrics allow the support surface to reduce parallel shearing forces and decrease surface friction coefficients. However, correct usage of powered bed frames and support surfaces is paramount. Most bariatric clients will not tolerate being completely supine; therefore, limiting the elevation of the head of the bed to 30 degrees will help reduce the shear forces at the sacrum and ischial tuberosities while also reducing hypoxia. It is imperative to check for bottoming out with any support surface, especially when the bed is placed into Trendelenburg position or the head of the bed is greater than 30 degrees in elevation. Assuming these positions decreases the surface area in which the patient's weight is concentrated and consequently increases peak pressures.

Building the Perfect Environment
       These specially designed suites can be built into your existing facility and can contain numerous other products designed specifically for the bariatric client's size and weight. Accommodation is the name of the game. Hiring a skilled architect to determine which particular rooms would be appropriate for modification is a crucial first step. Designing the room in conjunction with the bariatric resident's needs as well as the staff members' needs is next. Having the rooms spread out can help minimize the extra effort required by the staff. There's more to addressing the environment than making the door frame wider and offering a larger bed frame!
       Over-the-bed lift systems, heavy-duty walkers, bedside commodes, shower/tub benches, stand-assist devices, and wheelchairs and recliners aid the patient in resuming normal ADLs and gaining independence. Providing continuity of care for pressure management in all positions is also paramount for the bariatric patient. The seated position in recliners, wheelchairs, and commodes will require therapeutic devices that redistribute peak pressures and reduce friction and shear thus maximizing the blood perfusion in the skin and underlying tissues.
       Be certain to ask this key question when renting or purchasing any so-called bariatric equipment: "What is the weight limit?" Just because the company touts the product as appropriate for the bariatric client does not necessarily mean that it will meet all your larger residents' needs.

Educating the Team
       Training healthcare providers and all staff within your facility is another stage in providing adequate care for the bariatric resident. Since obesity is associated with psychosocial diseases, such as depression, and conditions, such as social isolation, embarrassment, and decreased self-esteem,6 and prejudice among the general public, including healthcare providers, is high, sensitivity classes help bridge the gap offering empathy and compassion training and word choice education. Involve social services to get this type of program off the ground.
       Education of staff should also include safe resident transfer, lift, and maneuvering techniques and use of all special equipment. Properly performed and documented education is extremely important for patient and caregiver safety. Understanding the correct usage of equipment and assistive devices will enhance patient confidence, reestablish independence with ADLs, minimize secondary complications due to immobility, and promote safety. It is also prudent to have emergency procedures in place in the event a facility evacuation is necessary. Doorways, elevators, transfer devices, and mobilization teams must be prepared with agressive protocols in place. Training caregivers as well as the resident on equipment and emergency procedures is extremely important. Although many of these devices are easy to use, the entire care team should be well versed on their indications and contraindications.
       Training seminars should be offered on all shifts and be repeated to address new staff as well as to review with existing staff. Adding a bit of fun and offering certification to those who pass all aspects of bariatric care training is a plus. One long-term care facility that we know actually offers a pay differential for staff members who are "bariatric certified." What a wonderful plus to offer to referring bariatric physicians and the public!

The Challenge on the Horizon
       Health and Human Services' Secretary, Tommy Thompson, has identified obesity and diabetes as one of the largest public health problems facing the US. Obesity and related conditions are directly responsible for over a quarter of a million deaths annually and cost our society nearly 100 billion dollars a year. The ever-expanding waistline of the American populace is creating new medical challenges that require special consideration for safe and efficacious care for the bariatric patient. Redistributing pressure and maintaining skin integrity are important factors that can prevent expensive and debilitating pressure ulcers and further compromise the bariatric resident. Meeting these challenges requires successful medical management and a concerted team effort with the resident being the most important member.
       Your medical equipment manufacturer and distributor can offer simple, cost-effective solutions to protect your residents and staff. Choose them carefully. Do they have all the special equipment that the bariatric resident requires? How long have they provided solutions for the obese patient? Can they offer the suite essentials that your facility needs? Addressing the long-term care bariatric suite will definitely impact your facility. It's only a matter of time. Will you be ready? Proactively assessing needs and addressing this growing epidemic will ultimately make your facility more attractive to bariatric clients, their families, and their needs.