Wider Care Needs of People Living with Obesity

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Okay, I think we might slowly get started anyway. I'm just here to welcome everyone, my name is Lisa, I just want to welcome you to today's EASO Comms Network webinar, the title of which is Wider Care Needs of People Living with Obesity. We've got an amazing session lined up for you today and the session is going to be chaired by Professor Luca Bassetto, who is the Vice President of the EASO Southern Region and ex officio co-chair of the EASO Obesity Management Task Force.

So I'll just take a second just to tell you about the house rules of the webinar and then I'll hand over to our panel of experts. So you'll already have received a notification but today's webinar is being recorded and you'll have access to the link after the session if you would like to watch it back. The session is going to run with around 45 minutes of presentation and talks and then we're going to have a Q&A after, so there'll be about 10 to 15 minutes to have a discussion moderated by Luca with the experts.

So if you do have questions about anything that's presented today or any relevant other subjects that you're interested in that the speakers will be able to speak about, please do ask your questions in the and Luca will make sure your questions are answered. So your feedback is really really valued as well, so when you leave the session today a survey will pop up, please do complete this for us because your comments really do help develop the future webinars. A final note, these EASO webinars are free to join, so if you do have colleagues that you think would be interested in things that are being discussed, please do send them all the information and encourage them to come along.

So that's it from me for now, please follow EASO's social media and I'll drop the links into the chat and any more relevant information that you might be interested in, but I'm going to hand you over to our session chair Luca, so thank you very much. Thank you Lisa, hello to everybody, I am Luca Busetto, I am talking to you from my room in the University Hospital in Padova, Italy. I am the Vice President of the EASO for the southern region and an additional important thing, I am the one of the chairmen of the next European Congress of Obesity that we will have in Venice in May, so if you are interested you can look at the website of the Congress, we believe that we will have a very nice Congress.

Today I am here for chairing the EASOcomes webinar entitled Wider Care Needs of People Living with Obesity. The webinar aims will be to explore the social, physical and emotional care needs of people living with obesity beyond weight management, so we hope to extend our vision to not to only weight or weight loss and ultimately we hope to help health professionals and you to understand the changes needed with general health care to include people living with obesity. We will have three very good expert speakers, including a representative of the European Association for People Living with Obesity, ECPO, and registered nurses with research expertise including bariatric care.

At the end we will have some questions and answers. So I think that we are ready to start and I will start with the first talk. The title of the first talk will be lived experiences of poor care from wider services and this talk will be given by our friend Andrew Helling, the Director of Communication of the European Coalition for People Living with Obesity and today Andrew will share his personal experiences in this particular point.

So Andrew if you want to start the floor is yours. Thank you Luca. So my name as you you've heard there is Andrew Helling.

I am the Director of Communications for ECPO which is European Coalition of People Living with Obesity. I'm also a patient advocate and somebody who has lived with obesity for just about my whole life. I wanted to kind of start off by setting the scene a little bit and going back to my original care that I had with my own general practitioner.

The care that I received from this area, it was always very very positive. There was no issues that were kind of focusing on the weight that I was carrying. If anything she was there to kind of see over and past that.

There was times where I would attend the general practitioner and we would have conversations about the issues at hand and she would very politely ask if there was anything else that I wanted to speak about and that naturally went into issues with my obesity that I was living with. I was lucky enough through the NHS here in Scotland to receive surgery, bariatric surgery and I had a gastric band fitted in 2014. Following the fitting of the band I was able to successfully lose a significant amount of weight.

I lost 14 stone in total and so I was classed as being the success from the weight management services that were offered. Unfortunately because I was so successful the aftercare only lasted for a short period of time so it was two years following surgery that I was then able to remain in the aftercare. In which case because I was classed as a success I was discharged with no further follow-up.

I was just left to kind of go on my own at that stage. That's where I personally started to see issues with regain of weight. My weight slowly started to regain and come back on.

I reached out to kind of seek some help in that aspect but the weight management services that were offered in my location they focused mainly on people who were going through the journey for the first time. There was no aftercare, there was no care that I could be put in for as somebody that's already had surgery and already been classed as a success. So I had to restart just a normal weight management from the beginning where there was no specialist care that was given for somebody who was living with surgery and who had already lost a significant amount of weight.

That was in the run-up to Covid and as we all know the pandemic closed down all services that were there so I was effectively discharged from the service with no follow-up at all and I have just been left to kind of go on my own just now. There's been no further aftercare. That kind of brings me to the kind of discussion point that I wanted to have today and that's when I experienced my first really significant issues with poor care within a kind of medical environment.

Unfortunately during the kind of Covid pandemic I was unlucky enough to catch Covid, that's absolutely fine. I was able to handle it without any issues at all and it wasn't until the summer of 2022 where kind of long-term issues started to kind of show. I had been at work as normal for the day.

I was getting ready to pack up, to leave, to go home and I started having what I can only describe as palpitations and flutters in my chest. So I kind of put it to the side. I managed to get home.

I drove myself home and I thought I would lie down and see if these issues would kind of go away and fix themselves. Unfortunately that wasn't meant to be and I eventually had to present at accident emergency to get this seen to. It was starting to really concern me.

It wasn't something that was fixing itself. The care that I received within the A&E department of my hospital was second to none. There was no pointing at my weight as being an issue that was here.

They were purely focused on making me feel better and getting me back to a kind of normal for me. So they treated me and I was discharged but they also referred me to the cardiology unit at my local hospital. So a couple of months had gone by and I eventually received my initial appointment through from the cardiology unit.

It was for an evening appointment so it was the last appointment of the evening at 7pm and I can only presume that it would have been the last appointment of the evening. I showed up at the hospital. I got there.

There was nobody else waiting. It was just me that was there. To set the scene a little bit, my local hospital is built on quite a steep hill so you have to park at the bottom of the hill.

You walk up the hill to go into the hospital. As soon as I sat down in the waiting room I was called in to get the kind of pre-assessment checks done. The first issue that I experienced was the scales that they tried to weigh me on did not go up to my weight.

I wasn't able to be weighed at that point which gave me quite severe anxiety that they weren't able to get away from what was there. My blood pressure was also taken at that point and it was passed on to the consultant that I later went to see. Again as soon as I'd finished within the kind of pre-assessment I was taken straight into the consultant and I sat down in front of him and described the issues that I had experienced previously.

Immediately there was no other words spoken. It was put down to my weight. Everything was attributed to the weight that I was carrying.

There was no discussion around what possible underlying issues could be there. It was focused on my weight. The treatment options that were given, again he described what the treatment options would be.

However he said I wouldn't be suitable for that because it would be too much high risk given my weight and I would need to lose a significant amount of weight before I was even considered to have this remedial surgery to kind of make things as better as possible with the heart condition that I had. He also mentioned that he wanted to arrange another appointment for me to come in to have an ultrasound of my heart but what really got me at this point was that he followed that up by saying he probably wouldn't be able to see anything because of all the fat that would be around my heart. That took me aback.

Now obviously as a patient advocate I advocate for somebody that is carrying extra weight and what to do but when it was directed at me for the very first time in my whole adult life I didn't know how to process that in any way whatsoever so it really took me aback. I didn't know really what to say. The only thing that kind of sprung to mind was the that when I was in hospital for the first time they had to do an ultrasound of my heart before they could prescribe me the medication that they sent me away with.

They were able to see my heart fine so why would it now be an issue a couple of months down the line? Why would they not be able to see my heart? When I questioned that with him his response was well I'll need to go deeper than what they would have had to go that they would have had to went within the accident emergency. Again I didn't really know how to process that or how to challenge that back. It really took me aback and it really left me on the back foot.

I had a list of questions that I wanted to ask before I went in but those questions disappeared. They were gone. I didn't know how to ask the questions that I had.

He also questioned my blood pressure at that point in time. Now as somebody who is living in a larger body I have been very very fortunate that I have never had an issue with my blood pressure. It's always been classed as a normal range so my GP has never had to question it or put me on medication for it or anything like that at all.

However he chose to question my blood pressure at that point. He didn't do it in a sensitive way either. His exact words to me at the time were what's your doctor doing about your high blood pressure? At that point my back is getting up a little bit now.

I'm starting to get annoyed with this man that's in front of me. So I snap back to say I don't have high blood pressure so she's not doing anything about it. And he said well you do have today.

So I'm getting angrier and angrier at the he's questioning me. So I told him that I wanted him to look back in my records on the computer that was in front of him where he would see that I did not have high blood pressure. He looked back, he acknowledged the fact that I didn't have high blood pressure but he still went along with the fact that I did on this particular day.

At that point I'd kind of really lost my whole functioning of why I was there in the first place and I just snapped back at him well maybe that was to do with the hill that I've just had to climb before coming into your room and I left. I received another appointment in to go back to cardiology but that wasn't until September of this year. Bearing in mind that's 18 months prior to my last appointment.

I've not questioned that. Normally I would phone up and see if that was right, if I could get another appointment but right now I don't want to go back and see this particular individual. So I will leave that appointment as it is and I will manage the condition that I have got over medication and I will go back at that point but I will go back with my heckles up.

I know that I'm going to go back there and I'm going to be in such a mood where I will be questioning his every move. Essentially he's a professional but I will be questioning everything and I will be challenging him and the language that he used the last time that I spoke to him. From this kind of story I just want to kind of put across that the point that words that you use when speaking to patients matter.

For somebody like myself who is normally confident who will have the discussion using words that are negative, that are derogatory, that are stigmatizing, they do have an impact on people and I would really ask for everybody to kind of bear that in mind when you are dealing with patients who are living with obesity. At the end of the day we are a person first. We are not obesity.

We are somebody who is living with obesity. Thank you for listening to me today. Thank you.

Thank you so much, Andrew. It is always very important to listen to the personal stories of our friends and I think that your story is very individual. Of course it's your story but I have many patients even here in Italy they are telling pretty the same stories.

This means that we have a problem, a general problem. It's not an individual problem. It's not the problem that your cardiologist has.

It's a general problem in my opinion. So I think that we can move to the second talk and we will have the discussion at the end. The second talk will be entitled Unmet Care Needs of People Living with Obesity and the speaker will be Dr. Kate Williamson.

Kate is a registered nurse and bariatric care specialist working as manual handling advisor and district nurse in National Health System Lothian in Edinburgh and she is also an honorary research fellow at the School of Health and Wellbeing based in the University of Glasgow, both in Scotland. Please, Kate, start with your talk and we are here for listening. Thank you, Luca.

That's a lovely introduction and I'm hoping that you can see my screen. Yes, we are. Lovely.

Hello, everyone. Thank you for joining us and thank you Andrew for being prepared to share his experience and to Yaso for hosting this webinar. I'm a community nurse by background.

I finished my PhD last year. I'm an honorary research fellow at the University of Glasgow, manual handling advisor and I also do some training on bariatric care needs. So as a community nurse, I would generally care for people at home, mainly older people or people with disabilities.

But since the mid 2000s, I saw increasing numbers of people living with severe obesity, often cared for quite poorly, if I'm honest, with very little evidence to guide practice. So this got me into doing my PhD and I would attend obesity research conferences as part of that. And here the focus was largely on weight management with minimal mention of wider care needs.

So in this session, we hope to show that many of these wider care needs, like Andrew has described, are currently unmet and that alongside weight management and weight stigma, we need to do better. So what are wider care needs and why are they important? Well, we have increasing recognition of obesity as a chronic relapsing disease, spanning the life course that individuals live with over the long term. Even if people get weight management treatment, it's likely that they will still be living with some degree of excess weight and if they stop treatment, they will experience weight regain.

Current studies show that 90% of people living with severe obesity, that's a BMI of 40 or over, are not in weight management treatment. That's a significant number. But they could be receiving wider care.

So that is any service outside of weight management. So their local doctor's surgery, hospital or care home. These are the wraparound services that care for people before, during and after weight management, much as Andrew mentioned.

So it's really important that they are appropriate for people living with excess weight. Lived experience reports from both patients and staff such as Andrew's, tell us that services are struggling to care for people with poor quality care. This quote on the right hand side comes from someone with multiple sclerosis, living with higher weight.

They needed an annual MRI scan to see their progress of the MS that they experienced. But they found going for the scan a hugely distressing experience due to the worries over whether they would fit in the scanner as its weight limit was 20 stone. And much like Andrew described, evidence shows that where care is poor, people are less likely to use it and want to go back.

And that applies to wider care services, but also to whether people will even consider going to weight management treatments if the experience with perhaps their referring health professional or other services is not good. So the result overall is unsafe and unequal care. In Scotland, where I'm talking to you from, 67% of adults live with excess weight.

So this concerns the majority of the adult population. We cannot ignore it. So what wider care needs do we see day to day in community in my practice? What I'm going to do is use Charlie, who is the main character from the recent film, The Whale, and a film which I found actually fairly true to my clinical experience.

He was socially isolated, stigmatized, struggling to manage everyday tasks such as washing and walking. And I'm going to combine that with examples from my own clinical practice to create a fictionalized but true to life case study to help you understand some of the issues. So in the first picture, we can see that Charlie's legs are quite large and heavy, partly due to lymphedema, meaning that he cannot lift his legs into bed himself.

So he ends up sleeping in an armchair. His occupational therapist is assessing him for specialist seating, much like the chair in the middle of the top row there. But the OT needs a current weight to ensure that it will support him safely.

The standard scales, pictured top right, are too small for Charlie due to his wide legs. But the OT is struggling to access wider bariatric scales in the community. So Charlie's much needed chair is on hold.

Charlie can't get to his bathroom. So two carers help Charlie with his personal care needs. Due to his body shape, with a large abdominal panus, as in the figure and the drawing bottom left, the carers can really struggle to fully reach into his skin folds to clean and dry them, especially with Charlie seated in the chair.

So they and Charlie do the best they can. But despite four visits daily, Charlie's skin is never properly clean with constant skin infections. Over time, Charlie's skin breaks down on his bottom, abdomen and legs, causing pain and risk of infection.

It ends up with two nurses visiting for one hour daily, applying over 130 pounds worth of dressings to the broken areas. Given the large areas to cover, the dressings don't stick well, filling up with fluid quickly, becoming heavy and falling off within two hours of being applied. Charlie can't put the dressings back on and the nurses can't come back.

So an incontinence pad on the floor is the best that they and Charlie can do to manage the fluids coming out of Charlie's skin. It's not safe and it's not dignified. But research shows a stark lack of evidence, particularly around intervention studies to guide skin care.

Because Charlie can't get to the toilet, he has a urinary catheter, but it comes out or blocks repeatedly, requiring the nurses to replace it often, up to nine times in two weeks, with two staff each time, in a procedure that's not nice for Charlie or pleasant for the nurses. It puts Charlie at high risk of urinary tract infection. The nurses contact Urology looking for some advice, hoping to do better.

But they're told there's little research to guide care, just to manage the best they can. None of the staff in this scenario have received any training in care of people with high body weight. There are no care pathways to follow and there's minimal evidence base to guide care.

As with this picture of an iceberg, the evidence regarding basic care needs is the bit under the water, largely unknown. Shut-ins, that's people who are housebound to Americans, are shut out of the evidence base. Thinking about people who are not housebound, when you or I go to the doctor, clinic or hospital, a basic expectation would be a chair to sit on, a safe chair.

But for people living with excess weight, that can't be assumed. The top row of pictures here shows seats from clinics all around my local area. They're quite narrow, some with arms, which may cause discomfort for people with excess weight.

But most importantly, their safe working load, which is the maximum weight they're designed to take, is 120 kilograms or under. That's 19 stone, which is not that high. Which means that if you're over that weight, there's an increased risk of these chairs breaking underneath you, potentially resulting in both physical and psychological distress and injury, shame and embarrassment.

On the lower line are chairs that can take higher weights, up to 254 kilograms. But there's tiny numbers of these available, usually quite randomly distributed, could be in a waiting room, but not in the consulting room. So it's very difficult for people to know if services are prepared for people with larger bodies and if there will be a safe seat for them to sit on.

But it's not just lack of access, it can be a lack of equity and people receiving undertreatment, where people with higher weight don't receive appropriate care and can be undertreated with significant consequences. Examples are where standard drug dosing regimes which don't take body weight into account are used. So this could be for chemotherapy for cancer, meaning treatment regimes are less effective.

Or as a nurse, we would often use anticipatory care medication for people at the end of life, potentially meaning someone experiences less effective pain relief if they're of a higher weight. And there's very little guidance for staff around this. Another area is rehabilitation.

If you're living with severe obesity and lose your mobility in the community, but have no acute illness requiring hospitalisation, in my area we are very limited for being able to get you back on your feet again at home, partly because of the increased risk of falling and availability of appropriate equipment. Hospitals do not want to admit people because of concerns around length of stay and specialist equipment needs, which makes it more likely that you will receive limited input, then become confined to bed or admitted to long-term care. And we know from evidence coming out from America that people with severe obesity are more likely to be in care homes of poorer quality, because providers are concerned about the extra resources needed to meet their needs.

So hopefully I've given you an insight into unmet wider care needs in the community. But moving forward, what should we do? I hope that we are aiming for evidence-based, person-centred care for all, regardless of people's weight. We need to plan for increasing need by developing wider care pathways, focused on health outcomes.

Moving away from just thinking about weight, so people are helped to live meaningful lives, of which weight management will be a part, but so is being able to use a right-sized wheelchair or get an MRI scan to check on their MS. If you're a practitioner or a clinician listening to this, then a bit of advice for you would be thinking about preparing your area to care. Look at the equipment that you've got, such as the seating and the blood pressure cuffs. The other thing is enabling people with higher weight to get the help that they need.

For some people, we know that they can have difficulty with intimate personal care needs, especially around toileting and cleaning, with feelings of anxiety and shame around not managing, especially when society implies that you've done this to yourself, so why should we help you? Meaning that people often find it hard to ask for help, so we as professionals can help them by saying, how are you managing? Would you like some help? We know that this can be an area that people struggle in, rather than assuming that people will ask. The Canadian and Irish obesity guidance is a great place to start, with chapters on activities of daily living, and I commend it to you. But the guidance is limited, because essentially the research we have is lagging behind practice.

Often clinicians will say to me, what are the answers, Kath? And I don't have them, because there isn't the evidence base to inform the care that we're giving. What we need is more research done by wider professionals. At the moment, it tends to be we have a lot of research done by medics on cardio metabolic issues, which is important, and dietitians on weight management, which is also great, but we need to broaden out the research by wider professionals, with OTs, nurses, physios, social care staff, podiatrists, looking into the care needs in their wider area.

So if that's you and you'd like to be involved with that, we're going to offer you an opportunity at the end of the session to note your interest. These are my references, and if you're interested in getting in touch, then I'd love to hear from you. But otherwise, I'm going to pass on to Kaz.

Thank you for listening. Thank you. Thank you, Kath.

Very, very nice presentation. I think that you highlight very aspects in the clinical care of people living with obesity, and the problem that we face in having adequate equipment. Of course, this equipment usually is ready in services prepared in weight centre or obesity management clinics, but the problem is how to have this equipment in the general practices, in particular in the GP.

And I think that this is a problem that is not only a problem that GP alone can solve, because this equipment is also costly, and maybe we should also ask for the system to help clinicians to be prepared, because otherwise we stay only on personal initiatives, and this could be not enough. I will move to the third speaker. The speaker is Dr. Kath Hales.

Despite the clear sky that we can see behind Kath, we are aware that New Zealand is around midnight in the night, so thank you, Kath, for coming with us, despite your difference in timing. Kath is a registered nurse and senior lecturer working in the School of Nursing, Midwifery and Health Practice, which is part of the Wellington Faculty of Health at the Victoria University of Wellington in New Zealand. And the title of the presentation will be Evidencing the Evidence Gap Around Wider Obesity Care.

Please, Kath, the floor is yours. Excellent. Thank you very much.

And thank you, Andrew. Thank you, Kath, for setting the scene. So welcome, and thank you for the opportunity to talk today about wider obesity care.

It's an area that I'm passionate about bringing to the attention of all health professionals. My name is Kath Hales. I'm a registered nurse and academic working in New Zealand.

I specialise in research that focuses on advancing safe healthcare practices and equitable services for people living with obesity. So my work explores patient and staff factors that impact on quality of care, patient experiences and patient and staff safety. I've been an intensive care nurse for about 18 years, and part of that time I've worked as an intensive care flight retrieval nurse and as part of the medical emergency team.

And my experiences of the aeromedical transportation and care of people living with severe obesity has really informed a lot of my research. So I'm going to present today about the evidence gap around wider obesity care and what research there is to support service delivery. So a challenge I frequently encounter as a registered nurse and an academic is locating the robust evidence that specifically guides the care practices of the wider care and service delivery needs of people living with severe obesity, who are not accessing the health services for weight management.

So why is this evidence so critically important? And I think both Andrew and Kath have alluded to this already, but many people living with severe obesity are admitted acutely to hospital from their home via the ED department or accident emergency, or transferred to one of our regional hospitals via our intensive care ambulance service. And the evidence that my team needs to support care is not directly about weight management, but evidence to answer questions like, how do we safely turn a patient into the prone position? Can we? Should we? And is there any clinical benefit in doing this? What is the best equipment to use to provide high quality care, to maintain skin integrity, maximise physiological functioning and mobility and enable rehabilitation whilst minimising patient and staff harm? How do we prevent avoidable patient harm, prevent falls, prevent injury during patient moving and handling? How do we prevent avoidable staff injury, particularly when patients are sedated and immobile? How do we safely transfer patients from one clinical area to another? So as you are all acutely aware, many people living with severe obesity who are in weight management programmes are still living in a bigger body and will have other health concerns and health events during their life. So these issues are important for all health professionals to engage with.

So there's so much written about obesity and weight management, but when searching for evidence to support wider obesity care practices, I'm often challenged by my academic and clinical colleagues that I haven't looked hard enough to find the evidence. And I immediately refute this and say, well, you're wrong. There isn't any evidence.

So this led me to this project funded by the Health Research Council of New Zealand to establish what evidence is out there. So the aim of this evidence and gap map was to identify and assess the available evidence of healthcare interventions to improve healthcare outcomes for hospitalised patients living with severe obesity. The target population was hospitalised adults with severe or extreme obesity.

And this was defined as a BMI of 40 or over, weighing 150 kgs or more, which is about 23 and a half stone, or having a large physical dimension, which affected mobility and made moving and handling difficult. Now, this is a definition commonly used across Australasia. And now this evidence gap map does specifically focus on hospital services, so not the community literature.

So anyone attending this webinar today will receive a link to this interactive map, and you can also access the interactive map after the presentation via the webpage link. So the intervention outcome framework was developed by an expert advisory team using internationally recognised health system performance indicators that are used around the world to measure the performance of hospitals to deliver patient care. So the interventions were specifically related to care considerations important to addressing the needs of people living with severe obesity.

So as you can see from the table, these were things like assessment tools, moving and handling, and equipment. So here's a screenshot of what the evidence and gap map actually looked like. So we reviewed around 65,000 studies that were related to obesity care interventions.

However, only 247 studies were included in the evidence gap map following full text review. Most of the excluded studies specifically related to bariatric weight loss surgical procedures or interventional techniques, which could not be generalised to wider obesity care or service provision. Despite this, though, over half the studies included involved patients who were involved in bariatric surgery as part of the study's design.

So let's take a closer look at the actual map. So each cell compiles the research at the intersection of particular interventions and outcome categories. So the outcomes are listed across the top in the columns and the interventions along the left hand side margin in the rows.

The number of studies in each cell is denoted by the size of the data bubble. So as you can see in the image here, the large light blue bubble represents 158 studies and the small green bubble just see it there only represents two studies. The quality of the research in the cell is denoted by the colour of the data points.

So green represents high quality research. Light blue is moderate quality research. Dark blue, low quality and purple are protocols of studies that are in progress.

Now, the interactive map allows you to filter the evidence by different preset data points. So here's a quick look at what the evidence of what evidence has been conducted across Europe. So as you can see, there have been 63 studies.

That's just under 26% of the evidence that's been led and undertaken by European countries. And you can also see which interventions have been the focus of that work. So what were the main findings? So our results found little evidence of holistic patient or centered approach to care for people living with severe obesity when considering their wider obesity care and service provision needs.

So instead, the research contained within the evidence gap map is very targeted and very focused at specific points on a patient's healthcare journey and is focused around peri-optive care, surgical recovery pathways, so things like enhanced recovery after surgery pathways, airway management and medical devices. And these mainly fit under the interventions of special care pathways. So the areas of least research are the areas that have been identified of most clinical need, the areas that Cath has talked about.

So for assessment tools, the research here focused on pre-surgical assessment and intubation scoring systems. And again, there was no general focus on the assessment of holistic care needs of the patient and their rehabilitation needs. There was minimal research on equipment.

Only 13 studies focused on equipment that supported patient rehabilitation, functional mobility and activities of daily living. Unfortunately, those 13 studies focused on all used clinical audit, single patient case reports and expert opinion methodologies. So these were low quality evidence.

Moving and handling intervention studies was also minimum. And given that preventable patients and staff injury and harm are frequently reported in literature, it was really disappointing to see that there were only 11 studies that specifically focused on interventions to support safe staff assisted moving and handling. So what happens when we don't have good evidence? Well, let's take moving handling as an example, same as I'm on a bit of a theme on that.

As we know, it's not uncommon for people living with severe obesity to have some limitations in mobility, which is further restricted during hospitalizations requiring additional support from staff. So in these situations, there is an increased risk of patient and staff injury when there is limited evidence to support care practices. And I'm going to add here that this extends to further risk of patient and staff harm when education of staff around these practices is limited as well.

So the consequences of preventable moving and handling injury to staff are personal in that they have an inability to continue working. There are organizational consequences as hospitals incur staff shortages to provide care. And there are societal consequences in the form of continued weight bias and prejudice.

And these combined issues may reinforce biases that affect the overall workplace culture. And I think Andrew highlighted this at the very beginning of our seminar, is that when patients experience the weight bias from health professionals, this negatively influences a person's engagement with health care services. It can create barriers to accessing health care.

There's an expectation of differential health care treatment. There are feelings of low trust in health professionals and in the system and poor communication and a tendency to avoid and delay seeking care, health care services. So all this can lead to health inequalities and poorer health care outcomes.

So what evidence is currently informing our obesity care practices? Well, quite honestly, as highlighted in this evidence and gap map, very little is informing our care practices. We currently rely on guidelines of best practice and two important guidelines are the Irish and Canadian guidelines. Both of these are really good starts to informing our care practices.

However, both do highlight in their documents that there is a lack of evidence informing this important part of our care and practice. So what can you do to help us? Firstly, we need you to advocate for wider care services. We need you to work with us to eliminate the barriers that prevent people living with severe obesity from accessing appropriate health care.

Second, we do need you to use the guide, the guidance that currently does exist as limited as that is. But most importantly, now that we know that the evidence gaps exist, we need you to join us to engage in research and build that evidence base. This is a critical area of research and a critical area of clinical need.

Our goal is to have an inclusive health and care service where people living with severe obesity have access to equitable service provision. So if you're interested in forming an obesity care network, then please scan the QR code that you can see on the screen and complete the contact details or email myself or Cath directly. We're interested in forming clinical research collaborations and there is huge scope and potential for international work.

We're really excited and really passionate about tackling these wider care issues together and are looking forward to the ESO conference in Venice and meeting many of you there. So thank you. Please come and join us.

I'm going to hand over now to Luca and I do have some references of that presentation. Thank you. Thank you.

Very nice presentation too. Now we will have 10 to 15 minutes for questions and answers. My first point here is that, of course, this is a question for both, I think.

So I, and also for Andrew, I think that we have the experiences in the bariatric centres, in the obesity management centres and in those centres, of course, the level of preparation is relatively good or, of course, it can be improved, but the equipment is good, the personnel is prepared, we have attention to the stigma. So these centres can be used as a reference and the hope that we have is to spread the reference to the general hospital emergency department. So I think that this would be more easier to do in centres where something is already there, so in a centre in which you have a bariatric centre or you perform bariatric operation.

And this, because the implementation can be done locally, so spreading the knowledge from one particular service in the hospital to the other services. Because I am reading the chat during your presentation, there is a lot of claiming or personal negative experience in the chat, but we need to search a solution or a possible solution to the problem. So what do you suggest, what do you think about my idea to start from the services more prepared and try to modulate the rest of the hospital on those services? It could be more practical in your opinion.

I don't know if, Kath, you can? Yeah, I can start off, that's fine. I think that's a good idea, particularly for things like looking for the environment. So for outpatient departments in hospitals, they certainly could go to where they've got weight management or bariatric clinics and learn from them, absolutely.

And definitely in terms of thinking about weight stigma and how they may be dealing with that, so language. And I think that's good and that's definitely positive. But I think where we're looking at community, often our hospitals don't really realise some of the challenges that our community staff are dealing with.

And so I think what we need there is an evidence base to try and support that and wider awareness of it. And probably people working together in a multidisciplinary, interdisciplinary way. What sometimes we find in my local area is that they will discharge people from hospital because they don't want to be a problem in hospital and into the community and then it's their problem.

And so, yeah, I think that we need to join together as a research community to say that this is happening worldwide. And actually, a lot of the answers we could find with research would help guide people across the countries. So that would be my hope that by doing a seminar like this today, we get to have the power of our voice come together to help people.

But yeah, I think it's definitely a start for people to go to have a look at the weight management centres and bariatric care areas. You agree, Kath? Yeah, I do. Definitely, definitely.

I think working together to put systems in place is really important. I think that sharing of the ideas of what works and and taking those ideas and you know, putting them throughout the whole hospital is really, really important. But I think having the support of all the teams to help make that happen is really important.

Often the funding for, and I'm speaking now for New Zealand, what happens in our healthcare system is that funding for the additional care needs doesn't sit under a department or a service. So therefore, there is no who pays. And that's what one of the challenges is.

So who pays for the equipment? Who pays for the support? And that's where the challenge comes in. Who pays for the service that supports the individual's care needs? Because it doesn't fit with the reason that they've come into hospital, which is their heart problem, or their lung problem. And so that's where the challenge comes in with in terms of setting up the service.

But I know, Mary, that you've done a lot of work with setting up hospitals and how you might have encountered or overcome those challenges. Please. Me, Mary? I didn't know.

Sorry, Mary. Yes. Yes.

I'm looking at you on the camera. Thanks so much. This has been fantastic.

My heart is filling with the fact that this conversation, I started this conversation. It's interesting because we didn't have even internet when I started working in this area. So to be able to bring a community together this way.

So I'm Mary Forehand. I'm an Occupational Therapist and a professor at the University of Toronto in Canada. And I'm the past Scientific Director of Obesity Canada.

So I'm here as a researcher, as a professor, but also someone who's really passionate about bariatric care. And I met Cath and Kaz in our journeys. And little did we know, we were doing this parallel work for decades, really, in our clinical careers, but never had the opportunity to share and collaborate.

So look out, because we're going to be working together internationally. And I'm very excited. I think in terms of what we've seen in Canada, which isn't that different, actually, to New Zealand, I think in Australia, in terms of the experiences, and even talking with people across Europe, is there's a very strong focus and a lot of funding for the medical intervention.

So we're talking about pharmacotherapy and surgical interventions to some degree, through industry partnerships. And I'm not saying that's a bad thing. But when we talk about things like nursing care, and rehabilitation, and allied health services, like occupational therapy, physical therapy, psychology, kinesiology, all those other important social work, the funding packages aren't there.

We don't have the industry partners that have deep pockets to support some of this work as well. And it becomes much more challenging. Yet, this is such an important part of the care journey, that supports all the great interventions that might be pharmaceutical, that might be surgical.

And we talk, Andrew, your talk about the care of the cardiology program, similar stories that we're hearing in Canada. So where we found some traction, though, was, and this is a gap in the evidence, too, is the the economics of it. And I put a little comment in the chat, that to justify the cost of the equipment, to justify maybe renovations to spaces where care is taking place, is minimal compared to what we know, and what all of us who work in healthcare know, the injury of a nurse is hundreds and hundreds of thousands of dollars of lost productivity for that individual, but also the care to the hospital and the insurance that comes with that.

Injuries to patients through lawsuits, this is a big thing in the US for sure, is we need the data from all of that to leverage, you know, funding the type of work that we want. So there's comprehensive care, I know we need to do education with healthcare practitioners, we need to include the decision makers, the people who hold the purse strings of the hospitals, to be seeing the value of this work. And we also need to be able, you've mentioned it lots of times around weight bias and stigma, and also working with our industry partners in mobility equipment, scales, lifting mechanisms, so that they can partner with us so that once we can build some momentum in there, that's where we've started to see change, hospital by hospital in Canada, we have a long way to go.

But look out, we're going to really do some great things together. And this is a wonderful start. Thanks for letting me know about this too, Kath and Kaz, so I could join this morning.

So nice to see familiar faces. I need to get back to Europe, I need to come to a conference now that COVID is over. And I don't have the huge responsibilities with obesity Canada, I've got more time to do it.

So I look forward to seeing all of you. Nice, nice. Thank you.

Nice to have experience also from other parts of the world. Lisa, do you do we have some some time for additional questions? I have two questions in the chat. So we can proceed.

If people are happy to stay. Yes, we can run over just a few minutes just because it's so lively. So there is a question from from Kathy Brand, specifically to Kath.

So you described that the evidence base is so poor in so many areas. What areas do you think we should prioritise for generating a better evidence care? So what are the best? Or the most important? Where do you will put the money? That's a really, really good question. I mean, um, I suppose it depends where you're working.

And what is really important to you and the people you're caring for and working with. And I am always work from the basis of the, the impact I can make with the community I'm working with. And so that's the basis to which I work with my research.

So that's a really difficult one to answer, whereas other people will think about what's the biggest reach in terms of their research to have more global impact. So it depends where you sit in terms of how you want to be in the research space. All research is desperately needed right now.

And it depends where you what your specialty is. So if you're an occupational therapist, then do work in in your specialty, because there is no research in that space. So go do it.

Go do your specialty work in this in this area. That would be my that would be what I would advise. Go be experts in your area in supporting this really important area of research and clinical practice.

Thank you. But just get out there and do it. Thank you.

Thank you. And one question for for Cath. We talk about the GPs.

Of course, this is a very huge problem, in my opinion, because they are so many people very usually not very well equipped, at least in Italy. And so you highlighted the lack of training for wider health care professionals. And what kind of training do you think needs to be developed? So where in which area you concentrate the training and the attention in general for healthcare professional and in my opinion, for GPs in particular? So I would probably focus on the psychosocial needs to begin with.

I think as a manual handling advisor, that seems to be one area where people will approach us about bariatric care. But usually when we start doing training in that, then they'll say to me, I don't know how to talk to people of higher weight. I don't want to stigmatize them, but I don't know what to say.

And so I think some of the education around actually the contributors to obesity these days, because a lot of health professionals don't get any of that in their education, whether it's undergraduate or not. So understanding all the different factors that we understand so much better now in the mate management world. But I don't think wider health care professionals are getting that.

And that's not their fault. There's an awful lot going on. But that's probably where I would start is the psychosocial for them.

And just saying, this is what it's like living with excess weight. And this is where I think we can really combine together with the people of lived experience coming alongside and really advocating together. Yeah, this is a part of the general need that we have in expanding or extending and sharing the notion of obesity as a chronic disease in general.

So I think that it is the most important point. Andrew, do you have some final words for us or what's your personal opinion on this discussion? So my personal opinion would have to be starting with the kind of education of wider health care professions and starting from when they're still students, when they're still going through the course to become that health care professional, start with the education around obesity, with stigma, how to approach the subject with an individual who is living with obesity and kind of focus on that area. And that can then expand to every health care provider.

Just knowing how to sensitively bring up the topic of somebody's weight is important. It kind of sets the scene, it gets you on the front foot, you get the buy-in from the person who is suffering from obesity. So that would be my kind of takeaway is to focus on the education and start from there and build it up.

Yeah, education, education, education, education. It's a mantra. And I think that we are here for doing education in some way.

So I think that we can close the webinar here. I thank the speaker in particular, the attendees. A big thanks to Lisa for organizing so well as usual.

This webinar, Lisa, is fantastic, in my opinion. It's perfect. Manage the webinars in a perfect way.

Thank you. And again, Lisa, please close the meeting because I think that you have some technical notes or something similar. Thanks, Luca.

I'll just echo that and say thank you very much to our expert panelists and thank you to all of the attendees for coming along, learning about this topic and also just contributing so much to the Q&A discussion. I think we had some really good talks. I will just close it with the technical side.

As I mentioned, you will see the survey pop up when you leave the meeting. Please do provide some comments. There's also a space to add ideas for other topics that you might be interested in.

And please look out on the EASO website and social medias for future webinars hosted by the EASO POMS Network. So as Kaz said, I've got a couple of links to share with you and I'll send you them by email using the email address you signed up to this webinar with. I'll be in touch.

But thanks again, everyone, for coming and goodbye. Have a nice day.