"48 year old female, keeps fainting, patient is obese, weighs 35 stone"
A few months ago I wrote a blog called ‘Fat people, stairs and backs’. This particular post received a lot of praise but also angered a few. It was suggested I criticised without foundation or research and offered no reasoning to may argument. I did a follow up post which was a knee-jerk reaction to a rather abusive e-mail but decided I should in fact back up what I was saying with a much more researched piece. So I did! I wanted to look at the social reasons behind obesity and what impact obesity has when not prevented in childhood. I also wanted to highlight the benefits of using prevention rather than cure in tackling such a huge social problem.
Obesity is a significant societal trend with effects being felt throughout the health care system, economy and society as a whole. A person is deemed overweight if their body mass index (BMI) is between 25 and 30; a BMI over 30 is classed as obese and a markedly increased health risk. I attended a middle-aged female who had been experiencing DIB for several days as a result of chronic heart failure and episodes of fainting. The patient was of low socioeconomic status, weighed 35 stone and was in her upstairs bedroom. We began treating her breathing while carrying out a risk assessment of her extrication. Her condition was deteriorating but due to her size we were unable to safely carry her down the stairs. The decision was made to mobilise the fire brigade to assist us and the bariatric ambulance was called to convey. The patient was taken out of the house through the window by a crane. This caused considerable delay in her receiving definitive care and despite aggressive management at hospital she died shortly after arrival. What led the patient to be in this position? Why was nothing done to avoid this situation? Why was she allowed to stay like this? How long had she been like this?
The NHS has been forced to focus on treatment of illness rather than prevention due to increasing demands and costs. This leads one to question, however, where the responsibility for obesity prevention should lie. Obesity costs the economy not only in health care but also in sick days, workplace injuries and disability pay. Not only is the prevalence of obesity increasing in the Western community, those who are overweight are also heavier. This paints a bleak picture of a problem which has increased rapidly since the 1970’s; despite being on nearly every major government’s agenda. The literature is focused towards prevention because ‘cure’ is a nearly impossible ideal and to achieve this we must look at children.
Nearly a quarter (23.1%) of children are overweight or obese by the time they start primary school, this increases to over a third (33.4%) by the time they finish. Health promotion is fraught with difficulties in school aged children as poor management of obesity can result in life-long unhealthy eating habits and avoidance of medical help. Our patient may have had a negative experience with a health care professional and avoidance behaviour is common in obese patients who do not want to be lectured or humiliated. Conversely to the conception that patients will use an illness to seek attention from their doctor, obese patients often avoid this interaction. There is risk of promoting the ‘sick role’ with obese children and all children could benefit from nutritional and physical activity advice. This should not be taught as ‘treatment’ for overweight children who may feel they have an illness as a result.
Obesity is not a disease, however it does appear to spread through social ties. There is literature to support that neighbourhood does increase childhood obesity especially when coupled with a lower socio-economic status. I firmly believe it is time for people to assume personal responsibility for the improvement of society. Although our patient’s obesity is juxtaposed to this ideal her individual community may have made her weight more acceptable. In the school environment however, a lower SES and being overweight are both major factors in teenagers suffering social marginalisation. This leads to emotional distress, low self esteem and lower expectations of their educational future . It is pertinent to note that class position is responsible for health, health does not determine class.
Careful education is imperative for these young people but education needs to be extended to the home. Our patient may have been obese for a number of reasons, however, it is likely she developed obesity from a young age. Poor family functioning, authoritarian parenting styles and single parent families have been cited as factors increasing the risk of childhood obesity . Other factors increasing the risk within the home are stressors; stressors in adults have been linked to obesity, this could be attributed to poor eating habits among stressed individuals and with a huge increase in incidence of stress these days it is of little surprise there is a similar increase in obesity. This phenomena has been extended to children with specific factors being recognised for younger and older children. A positive association with obesity has been found in younger children who have a lack of cognitive stimulation and emotional support, whereas older children who live in a household with financial strain or members experiencing mental or physical problems (which could be a result of obesity) are at increased risk.
There is a strong correlation between obese parents and obese children and while there is an argument for a genetic predisposition, environmental factors are thought to be the most important. The increase in obesity has occurred among all socioeconomic groups therefore cannot be explained by genetics alone. Genetics can increase ones risk of developing the wide ranging complications of obesity, such as diabetes, high blood pressure and heart disease, some of which were observed in my patient. Obesity is associated with many chronic conditions the cost of which have a huge impact on the economy. The parliamentary committee omit some of the most expensive areas of the cost of obesity from their calculations this made it impossible to glean accurate figures for the true cost of obesity. It is estimated obesity costs the economy £4 billion a year and this is expected to rise to £6.3 billion a year by 2015. This kind of required financial support is not sustainable so a way to prevent the need for this financial burden is urgently needed.
Schools are the most appropriate setting for prevention, and therefor there is little we can physically do in the ambulance service other than refer. The health promotion these kids need should only be undertaken by specialist educators as the message can be distorted. Poor management can lead to starvation, laxative and slimming pill abuse amongst other drastic measures at a time when nutrition is vital for their developing bodies. If childhood obesity is allowed to progress to adulthood without specialist intervention the individual increases their risk of physical, emotional and social problems in later life. I do not know the cause of our patient’s obesity or why it was allowed to continue to the situation I met her in. Unfortunately, my patient did not get the help she desperately needed but hopefully if the right people set up the the right referral process maybe we as a nation can get to a point where prevention is a realistic option.