For Healthcare Professionals

As a nurse or physician, physical or occupational therapist, dietitian or nutritionist, psychotherapist, or other health professional, you may sometimes wonder about how to help your "bariatric" patient, especially those who are very large. Amplestuff has some products and information that may help for patients of all sizes of large. We have customers from 150 to 900 lbs or more.

Click here if you would like to go to "Further Information for the Healthcare Professional".

Click here if you would like to go to the essay "Bariatric Ergonomics".

Click here if you would like to see a list of the websites of those organizations referred to in the text in this section.

At Amplestuff, our focus is primarily on retail sales of items directly to larger customers. Although we also sell to businesses and institutions (hospitals, clinics, doctors' offices), our main concern is in rehabilitation and home care. We provide merchandise that is designed to help larger people live happier, healthier, more effective lives, whether or not they are in a weight loss program.

Many healthcare providers despair of helping their larger patients, because there are so many obstacles imbedded into our institutions that make it difficult. Indeed, many such patients have such low self-esteem that it can be hard to help them improve their health and their lifestyles. Obesity is stigmatized in our society, leaving many fat people blaming themselves for their condition.

People come in all shapes and sizes, and body size appears to have a complex series of causes, including genetics, diet and level of physical activity, previous history of yo-yo dieting, aggressive promotions by the food and diet industries (which may encourage unhealthy eating habits and yo-yo dieting), and so forth. It is a controversial field, with medical experts frequently disagreeing on the causes of obesity, what constitutes a successful treatment, and so forth. However, most can agree that there are a lot more fat people these days than two decades ago, despite a national obsession with weight loss; and that it is not fair to deprive these folks of a place to sit down in a chair that will hold them, or a job if they are able to perform the work competently, or medical care if they are trying as hard as they know how to improve their health. Nor should anyone make fun of the appearance of a larger person. Beauty is in the eye of the beholder--in another era, the plus size figure was revered.

Is obesity a disease? On July 15, 2004, the U.S. Department of Health and Human Services announced that they have dropped wording that had routinely denied Medicare and Medicaid reimbursement for weight loss therapies, leaving the door open for possible payment in the future. Some people interpreted this as an announcement that obesity is officially a disease. Regardless of whether or not having a higher-than-average BMI or percentage of body fat is a disease rather than a normal variation on the bell-shaped curve, we know that such variations exist, always have, and probably always will. Amplestuff takes no position on the various weight-loss therapies, except to note that in the past, so many such therapies have ill-served the people they were supposed to help. Also, it is well-known that the majority of people seeking reimbursable weight loss therapies do so not for their health, but rather for the sake of their appearance, due to the stigma they encounter every day in western societies.

In any case, healthcare institutions can expect to see many more large Americans seeking their help in the future, as the population ages. One way of dealing with the problems of these folks is to become aware of new products and procedures that are designed to help them. As a healthcare professional, you can be better able to help your larger patients improve their health and their lives.

We have concluded this web page with an essay on Bariatric Ergonomics, which can be very helpful in the clinical setting; we'd like to praise the work of Michael Dionne, PT, of Choice Physical Therapy, Inc, which is described in the essay. You might consider visiting his website. If you are interested in the work of advocacy groups for larger people, you could check out the sites listed below, for starters. All sites have links to many other sites, some of which might interest your patients.

For more information on the science of treating larger patients, especially including the Health At Every Size® approach, it may be helpful to look at information provided by the Association for Size Diversity and Health (ASDAH). The association includes membership from diverse medical and healthcare disciplines. For more information on advocacy and size acceptance, another organization, the Council on Size & Weight Discrimination, can provide information on discrimination, including that in healthcare settings.

Bill Fabrey
Proprietor, Amplestuff

Atlanta, August 8, 2002 -- The Awards Luncheon speaker at the 2002 NAAFA Convention in Atlanta, GA, was Michael Dionne, PT, founder of Choice Physical Therapy, Inc. Mr. Dionne is a practicing physical therapist and national consultant in the area of working with very large patients. He has 15 years of clinical practice and specializes in the field of bariatric ergonomics, i.e. how to deal with extremely large patients when they need to be moved or require medical treatment. NAAFA (National Association to Advance Fat Acceptance) is a human rights advocacy organization for larger people founded in 1969.

The title of his presentation was "Transfer and Mobility of the Obese Patient," a fascinating topic that provided a great degree of information and insight in an area that is the nightmare of many fat people: What will happen to me if I have an accident and they have to move me to a hospital? How will they treat me there? Will they be able to accommodate me? The problem, Dr. Dionne pointed out, is that many hospitals and healthcare facilities simply don't have equipment necessary for very large people, and they have no expertise or experience in trauma treatment of large people. As a result, Dionne is often called in on behalf of very large patients who simply cannot be moved with conventional methods.

He explained that in many cases and whenever possible, movement needs to be planned ahead of time. This is because many people who haven't moved in a long time need to be prepared, physically and mentally. In addition, most medical personnel don't know what sort of lifts, wheel chairs, and other equipment are available. Dionne explained some of the problems that occur when housebound and practically immobile people need to be moved, and also why any degree of movement is always a good thing. One such problem is muscle atrophy, the permanent loss of muscle tissue that can occur when certain muscles simply are not used. Once those muscles are gone, they are gone forever. Preventative movement therapy can go a long way to keep that from happening.

Mr. Dionne presented a number of case histories. One example was an 800 pound man he helped in the early 1990s. The patient was married to a thin woman, they had a great marriage, he was a business owner, and a very intelligent and motivated man. Dionne said this positive experience helped him as much as it helped his patient who engaged in a very productive dialog about his physical problems and the problems of people of size in general. Some of this dialog became the foundation of Dionne's work and expertise, and the basis of his educational programs that he is presenting throughout the United States.

Mr. Dionne then talked about different bariatric body types, which affect how a large patient can be treated and moved. In fact, recognition of body type and fat distribution is crucial in determining the proper equipment, for use in medical care. At this point, the lecturer brought up another key point when it comes to moving a very large patient. It's anasarca, "the congested state," which is an acute care phenomena. It is a generalized swelling (edema) of the body, especially in the legs and abdomen. It results from the accumulation of fluid in body tissues. In very fat patients, the lack of mobility and movement results in water in the lungs and other places. As a result of this, sudden movement can be very dangerous or deadly. Constant monitoring of the heart rate and oxygen may be required. Dionne pointed out that anasarca is not a condition unique to obese patients. It can also happen to anorexics. The presence of anasarca requires special attention to cardiac telemetry, edema, skin damage, deformities, bowel/bladder issues, and anxiety. Unless all those are addressed, a patient can die or get badly hurt before they receive care at a facility.

Once moved out of a house and to the hospital, standard beds are just not going to work. Dionne pointed out that there IS equipment out there but that many hospitals simply don't know where to find it and buy or rent it. The presence of wider beds, beds with extensions for the legs, special air mattresses, air mattress overlays, etc., can be a literal life saver. If all of the above has been successfully dealt with, the danger of heart failure phase has been addressed, and the phase of critical care is over, movement often becomes much easier. It then becomes an issue of recognizing the proper bariatric body type for proper treatment.

Dionne identified five different basic types. The apple ascites, apple pannus, pear with LE abduction, pear with LE adduction, and pear with bulbous gluteal region [since renamed "gluteous shelf"]. Each body type needs different treatment, because no two people are alike. Issues that may come into play for every different body type are the tolerance or intolerance to the movement of certain body parts, the ability to breathe in different positions, and mobile or immobile belly button/umbilicus. People of the same height and weight may be very different in the way they can be moved.

Michael Dionne then showed slides of a number of different cases and discussed how the patients' body types affected treatment, and the methods he used to move them. An often overlooked, yet vitally important piece of information, is that very large people who lose a lot of weight may continue to have problems because vital parts of their bodies have not changed. As a result of drastic changes in body weight, muscles may become too long or improperly located, resulting in dangerous and at times deadly conditions. Somebody with an apple shape and hard round belly requires very different treatment than someone with a soft tummy. Apple-shaped people often cannot lie on their stomachs while people with much larger but softer bellies can do so. This can also affect the way people can or cannot use wheelchairs or walkers. Some very large people have great endurance and can push a wheelchair for miles. Some people with tummies hanging very low have great problems with back muscles, both in standing upright and also when turning. They may be taught to lean back when turning and also to improve their balance.

Also very important is to listen to the patients affected. They know their bodies and they know what comes easiest for them. Sometimes complementing such natural movements and abilities works very well. "Pear shaped abducted" people have a body type that forces the legs are out to the side. They can't move their knees together. "Pear shape adducted" can put their knees together, but such patients are rare. Both types have their own problems. Urinary tract infections and skin irritations are common in those types.

Mr. Dionne also teaches sensitivity training. He thinks it is very important to not just concentrate on a person's large size, disability, or large features. He suggests that we also look at smiles, charm, hair, or anything else that makes a person special. He showed a slide of a very large woman and said all the medical personnel only looked at her size when, in fact, she had one of the sweetest smiles he had ever seen. A problem above and beyond the movement of very large patients is that some health care providers do not understand that some people simply cannot and will not lose weight no matter what program they are put on, be it for genetic or medical reasons. The obvious answer is that it doesn't matter what gave people their body types; what matters is to help those people.

Another interesting thing, the lecturer pointed out, is that he's seeing many more very large older patients. This, he feels, indicates significant advances in medicine. Before, many of those people may not have survived to an old age either due to insufficient treatment or the lack of proper medication. Now they can be saved and they can be given quality of life and the proper tools and equipment.

One area Dionne is dealing with is safety, both as in keeping fat people safe, and in teaching medical personnel how to handle fat patients so that accidents do not occur. He talked about some basic issues that most people are not aware of. For example, fat people fall very differently from average-sized people. And not only do they fall differently, the resulting injuries are different and often entirely unexpected. Joints and limbs move in different directions, thus potentially tearing muscles and tissue in ways different from that observed in thin patients. One of the most common times problems occur is the first time people go to the bathroom after an operation. In such cases, Dionne suggests an egress test: Three repetitions of sit to stand. Three steps of marching in place. Advance step and return twice each foot. Successfully negotiating those exercises can greatly reduce falling. Before leaving the hospital it is important to try things out and see what will be needed at home.

Dionne showed a number of video clips that demonstrated different techniques of getting up from a chair or bed, and sitting down into a chair or a bed. Depending on the shape, size, and physical condition of a patient, there are many different ways, and many ways to assist and make it easier. All of this needs to be observed and analyzed, with the goal of making it as easy as possible for the patient to have movement. The proper equipment may include rails, or strategically placed handles at different heights. Dionne often provides expert opinions and analysis in cases where accidents involving fat patients occur. When he does deposition reviews he looks at what was actually done and what warning signs were missed. Examples of such warning signs are if someone cannot lift their trunk, if they cannot move arms or legs, if they cannot sit, or if they cannot move up or down in bed.

All of the above are signs that a safe and appropriate transport is needed and that such people cannot simply be asked to get up. Ignoring those warning signs can be very dangerous for all involved. Medical personnel need guidelines when to stop and ask for help, use a lift, or other means. Education is also needed in describing such conditions scientifically and accurately. Other red flags are less obvious: a patient's frequent calls for help, fear, anxiety, a lack of history on the patient, elevated pain level, or insufficient staffing. In addition, there is a need for a general inventory and assessment of a medical facility. This includes many areas. Pathways must be identified and measured to see if they are wide enough for extra-wide beds. Equipment motors must be strong enough to handle fat patients. Vendors of special equipment must provide appropriate education. Project Managers must be assigned to oversee the entire process.

Overall, Michael Dionne gave a passionate, knowledgeable, common sense presentation about a field that almost no one knows anything about. Throughout the speech, we learned of a large number of special, entirely new terms that the medical establishment needs to become familiar with. Dionne pointed out that until two or three years ago his services were not much in demand, but now he is frequently getting calls for programs and advice. Obviously, the field of medicine is beginning to realize that providing proper care to large patients is a winning proposition for both sides.

Conrad H. Blickenstorfer

Past Chairman of the Board, NAAFA

Copyright 2002 NAAFA, Inc. - No reproduction in any form without permission from the author or NAAFA, Inc.

Note: Michael Dionne's unique and informative book is titled AMONG GIANTS: Courageous Stories of Those Who Are Obese and Those Who Care for Them. It can be ordered from his website.

Clicking these links will open a new page. Simply close that page to return to this one.

CPT (Michael Dionne, PT — Choice Physical Therapy, Inc. — Gainesville, GA): www.bariatricrehab.com

CSWD (Council on Size & Weight Discrimination): www.cswd.org

NAAFA (National Association to Advance Fat Acceptance): www.naafa.org

ASDAH (Association for Size Diversity and Health): www.sizediversityandhealth.org

Please note: Health At Every Size® is a registered trademark of the Association for Size Diversity and Health and used with permission.