Upward mobility – the stigma surrounding obesity

In the UK, column inches continue to carry news of an obesity 'crisis' or 'epidemic'. Only recently, the National Obesity Forum predicted that more than half the population will be obese by 2050, further fuelling debate over the country's 'big problem'. Herein, there lies a curious contradiction: many are getting larger, but the social stigma around bariatric care seemingly remains as rampant as ever.

For instance, few will forget the furore surrounding a Ricky Gervais podcast from 2008, in which the comic actor claimed obese people should be mocked on the street so as to be shamed into losing weight.

It's not unlikely that Gervais was simply looking for a rise from his audience, but his comments also highlighted the problem of self-consciousness that obesity sufferers face when out and about.

For Anita Rush, clinical nurse -specialist equipment/bariatrics at NHS Berkshire West, such stigma is stymieing independence among the obese, leading more and more to stay at home and overeat.

"People say they don't stigmatise, but they do. I see it all the time," she says. "Even this morning, there was a programme on the radio, and people were saying, 'Oh, it's their own fault - let them deal with it themselves.' But, for a big percentage, it's not their own fault. So, yes, stigmatisation is a problem."

Plus-sized problems

While the link between obesity and disability is obvious, keeping the community mobile has proven to be difficult. Unlike the elderly or sufferers of neuromuscular diseases - or indeed any conditions that have a clear, clinical progression or diagnosis - the plus-sized can find it tricky to avail themselves of mobility equipment.

"Independence is so important - we need to keep patients mobile," says Rush. "When you are talking about bariatric patients, most of them have limited mobility; they can only walk a couple of paces before they become breathless, so I would say that mobility remains their biggest problem. But they are being increasingly disenabled, because we can't provide the equipment for them."

In less serious cases, walkers, rollators and heavy-duty crutches can ease the burden for travelling short distances. Mobility scooters and wheelchairs (manual and motorised), however, can throw up a number of complex challenges for patients and care providers.

A common misconception with wheelchairs is that plus-sized people are hard to push and propel due to their sheer weight. This is incorrect. In fact, the isssue is more to do with uneven weight distribution: as a rule of thumb, the centre of gravity for a bariatric person tends to be more anterior, with excess weight applied on the front castors, which hinders motion.

Wheelchairs need to be designed to accommodate this. Solutions posited in recent years include everything from the attachment of weights on the back of the chair - to even out the weight distribution - to seats with openings in the back.

In the UK, obesity for adults is currently defined as anyone who has a body mass index (BMI) of between 30 and 40 - anything over 40 constitutes morbid obesity. It's a wide spectrum of measurement, which means caregivers need to adopt a wide degree of adaptability in their approach before a scooter or wheelchair is allocated to a patient.

"There are a number of factors that need to be taken into consideration," says Rush. "For example, you've got to think of the push-pull factor. If you've got caregivers taking that person out, obviously the wheelchair has got to have a battery motor in it, otherwise it is going to take two carers to move that person.

"Equally, when a person sits down, their body mass spreads. When that person is standing up, it's more compact, but, when they sit down, the width of the wheelchair is going to have to accommodate the large legs. It is also not uncommon for patients to have one leg with a bigger diameter than the other. And, if the patient has a particularly big stomach, which is common, then you've got to accommodate that as well."

Measured for measures

The prevailing image - of obesity sufferers confined to their homes, or even just their bed - is a worrying one. Recent solutions to have become available on the market include the likes of heavy-duty stairlifts and powered stair-climbers, able to accommodate users who weigh up to 30st.

There are also heavy duty through-floor vertical lifts that can facilitate greater independence for a wheelchair user or an ambulant individual who is too obese to manage stairs. They tend to have a weight limit of 39st and can be installed in just a few days with minimal disruption.

However, according to Rush, working on a such an ad hoc basis is no mean feat - particularly when it comes to the modification of homes to accommodate such equipment.

"No one size fits all, we know that," she explains. "While we have to work within the resources we've got, you've also got to look at the home and housing environment of the particular patient.

"So, if we are going to supply a plus-sized person with a mobility aid, the first thing you've got to think about is, will it go though the doorway? Also, what is its circulation around the house? I mean, the houses we are building today are smaller. Yet, it is a well-known fact that we are getting bigger."

There is clearly no such thing as a typical bariatric patient. Some of today's wheelchairs are also fine-tuned and customised so as to not only enable mobility but also play a part in the overall rehabilitation process.

This can include simple measures, such as articulating leg rests in order to reduce pressure on the lower legs. As those with obesity are also vulnerable to maceration and skin-integrity problems due to prolonged periods of immobility, wheelchairs can now be modified to include arm-rest systems that allow excess tissue to flow through the back and sides. The deployment of tilt systems can also be effective in relieving pressure and redistributing weight.

While Rush is obviously an advocate of the benefits of mobility equipment, she also believes that rehabilitation is still predominantly contingent on physiotherapy work.

"Rehabilitation is still up to the physio. Physios have to give the patient exercises or some sort of exercise regime. Bariatric patients aren't going to visit the gym or go swimming, as they are going to be embarrassed about their body shape. So, it's about trying to take the treatment home and encouraging them to do exercises within that environment."

Bariatric equipment also doesn't come cheap, which - returning to the idea of social stigma - is the main issue for many. With some mobility scooters costing more than £10,000, there is still a paucity of funding for most patients.

The reason for this, almost unequivocally, is down to a lack of empathy among the taxpaying public. If you were to take a straw poll on the street, it is likely that many would take issue over the taxonomic upgrading of obesity to a disease, as opposed to a matter of dietary choice/culpability. This means patients are often required to undergo rigorous assessment to ascertain whether they qualify for such solutions. This question of cost will, predictably, remain a cornerstone in the obesity debate for many years to come.

Counter to the ongoing argument over entitlement to mobility aids, it is worth considering the number of other conditions associated with being overweight, which include diabetes, skin infections, ulcers and gallstones.

Suitably adapted wheelchairs and scooters can play a huge role in lessening the chances of developing such conditions; hospitalisation, on the other hand, costs far more than the purchase of said equipment.

Care providers can only hope that such rationale will one day overtake present-day prejudices. For obesity sufferers, their lives may depend on it.