Nonsurgical inpatient care of people living with class II or III obesity

Background

Globally the population of people living with obesity is increasing. Obesity is classified into three classes; Class I is defined as having a body mass index of 30 kilograms divided by height in metres squared; Class II obesity is defined as having a body mass index of 35 kilograms divided by height in metres squared while Class III obesity is defined as a body mass index of 40 kilograms divided by height in metres squared at the most basic screening level. There are negative health outcomes for the people living with obesity which increase in the later stages of life with additional obesity-related health comorbidities. This results in people living with obesity having a poorer quality of life, increased healthcare needs and increased costs for the healthcare system.

Surgical intervention is considered the best practice for the management of this group, however, many people living with obesity are ineligible, unable to access or do not want surgical intervention. There are international variations in care with countries in the northern hemisphere, identifying this level of obesity as a chronic disease and offering treatments within publicly funded accessible primary, secondary and tertiary models of care. The non-surgical inpatient care of people living with obesity within Australia is unclear. However, with new effective pharmacological treatments there is the opportunity for improvements in care for this patient group (Rubino et al., 2025). There is a lack of high-quality evidence in the literature identifying the holistic inpatient healthcare received or required by this inpatient group. All stakeholders’ (including inpatients’) experiences and perspectives and current practice gives a holistic overview and avoids bias giving a greater understanding of the overall view of current care. Therefore, this study sought to identify current non-surgical inpatient care of people living with Class II or III obesity by gaining the healthcare professionals’ and inpatients’ experiences and perspectives and completing a prospective clinical audit.

Literature Review

Scoping Review: Non-surgical inpatient care of the older person with Class II or III obesity.

The focus of this review was to identify the current non-surgical inpatient care, (including any models of care), of people living with Class II or III obesity. For published studies we searched the electronic databases of MEDLINE® and Epub Ahead of Print, In-Process and Other Non-Indexed Citations and Daily (Ovid); CINAHL (EBASCO); EMBASE (Ovid); PsychInfo (Ovid); Cochrane Library; and Scopus. For unpublished studies we searched Mednar; Clinical Trial Registry (clinical-trials.gov); Theses from the Australian Digital Theses Program and Dissertation and Abstracts and ProQuest; Australian National Health and Medical Research Council (NHMRC) Guidelines; American Guidelines; New Zealand Guidelines; PROSPERO; Australian Policy online and Open Grey. Reference lists of all included studies were then searched for relevant studies. Inclusion criteria included studies written in English and published between 1990-2019 with adult inpatient participants living with Class II or III obesity. The literature searching continued during this work to ensure recent advances and the emerging international literature was reviewed.

The scoping review identified a paucity of studies with only 12 articles from 10 studies eligible for inclusion. Variations in the non-surgical care for people living with obesity were observed depending on whether Class II or III obesity was treated as a chronic disease with funding and services supporting treatment or not. The studies reported intensive lifestyle interventions, comparison of oxygen administration and a total parental nutrition regimen, and pre-surgical rapid weight loss. The most successful lifestyle intervention programs included inpatient/outpatient programs with long term follow-up. However, this scoping review highlighted that research, clinical practice, health service funding, and support are mainly focused on the surgical and primary healthcare interventions suggesting evaluation of person centred inpatient models of care are required for this patient group.

Methods

The experiences, perspectives, and health status of people living with Class II or III obesity admitted to hospital for nonsurgical care.

The aims and objectives of this mixed-methods study were to explore the lived experience of inpatients with Class II or III obesity including their non-surgical care, and health-related quality of life. People (n=20) with Class II or III obesity receiving non-surgical care were recruited within an Australian tertiary referral hospital. Semi-structured interviews were inductively analysed, and the themes of Barriers and Facilitators to care and Patient Suggestions for improved care were deductively mapped to the Theoretical Domains Framework. The RAND-36 health related quality of life tool assessed participants as inpatients and at 28-day post discharge if they had not been readmitted.

Healthcare professionals’ perspectives of nonsurgical care of older inpatients with Class II or III obesity and comorbidities.

This qualitative study explored the experiences and perspectives of 24 healthcare professionals (from seven disciplines) delivering non-surgical inpatient care to older people with Class II or III obesity in an Australian tertiary referral hospital using semi-structured interviews. The healthcare professionals identified the barriers and enablers to the delivery of best practice care and made recommendations to improve practice. The inductive themes from their interviews were deductively mapped to the domains of the Theoretical Domains Framework.

Obesity-related health in the non-surgical care of inpatients living with Class II or III obesity in Australia: a clinical audit.

A prospective clinical audit of 30 healthcare records with convenience sampling was reviewed to identify current non-surgical inpatient care delivered to inpatients living with Class II or III obesity. Readmission data at 28-days post discharge were compared between 2020/21 and 2013/14 for the study hospital and local health district. Parametric data are represented as means (SD) and non-parametric data as medians and interquartile ranges one and three (Q1,Q3).

Findings

The experiences, perspectives, and health status of people living with Class II or III obesity admitted to hospital for nonsurgical care.

In this mixed-methods study inductive analysis of the 20 qualitative interviews resulted in the four major themes of Barriers, Facilitators, Patient Goals and Patient Suggestions with three subthemes of Patient Related Factors, Provider Related Factors, and Health System Factors. These themes were mapped to 10 domains of the Theoretical Domains Framework. The most frequent domains were 1. Beliefs about capabilities, 2. Beliefs about consequences and 3. Environmental context and resources. Participants discussed their ability (or not) to self-care and manage their health issues and identified significant past life events resulting in fear, grief and loss, trauma, and gaps in their health literacy as contributing factors to their weight gain. Lack of theirs and their healthcare professionals’ education and knowledge around obesity-related health, communication breakdowns and lack of services and resources negatively impacted their care, continuing post discharge with lack of services hindering their continuum of care. Conversely, good communication, empathy, compassion and involving patients in their care plans and decision making were identified by the participants as facilitators. The inpatients health related quality of life was poor, (with the RAND-36 means below 50), remaining poor post-discharge with some improvements in three categories. Participant suggestions to improve care included specialised wards with specialist staff and accessible community services on discharge. This aligns with the findings in the healthcare professional study below.

Healthcare professionals’ perspectives of nonsurgical care of older inpatients with Class II or III obesity and comorbidities.

In this study the four major themes of Barriers, Facilitators, Current Practice, and Recommendations and 11 subthemes were mapped to nine domains of the Theoretical Domains Framework. Aligning with the inpatient participants, the healthcare professional participants identified barriers and facilitators to the care received by the inpatient participants. Subthemes common to both were Provider Factors and Health System Factors. Gaps were inpatient participant and healthcare professionals’ knowledge, education, communication, services, resources and partnering with patients. These gaps impacting on inpatient care were also identified within the clinical audit.

Recommendations and suggestions from healthcare professional and inpatient participants

Both the healthcare and inpatient participants identified the need for education, specialist staff training, and a culturally appropriate patient centered chronic disease model of care (similar to diabetes and respiratory disease) with a focus on obesity-related health with comorbidities rather than a siloed comorbidity focus with an ad hoc approach to obesity assessment and management in hospitals.

Obesity-related health in the non-surgical care of inpatients living with Class II or III obesity in Australia: a clinical audit.

Aligning with the themes of the inpatient and healthcare participants experiences, the prospective clinical audit of 30 medical records to identify inpatient care received also highlighted missed opportunities and gaps in the delivery of holistic healthcare inclusive of obesity-related healthcare. There was poor implementation of those guidelines and processes available to assist the frontline healthcare professionals who deliver care to this group.

Conclusion

An absence of best practice guiding documents and services and resources within Australia hinders inpatient care for this group. Obesity-related health was not treated within hospital unless it delayed the inpatients’ discharge or recovery. In Australia obesity is not treated within a chronic disease model of care (like diabetes or respiratory disease). The majority of the population has limited access to services and resources for the assessment and management of Class II or III obesity. Most services are limited to the major metropolitan areas and/or within the private health sector resulting in physical and financial access barriers. Internationally there are guiding documents and models of care for best practice obesity-related health assessment and management across primary, secondary, and tertiary setting of the healthcare systems with demonstrated successful outcomes. There are significant gaps in relation to equity of access and implementation of best practice for the unique non-surgical care of inpatients with Class II or III obesity in Australia.

My thesis presents an understanding of the nonsurgical care (and gaps in care) of the inpatient living with Class II or III obesity identifying the barriers and facilitators to care from the inpatients’ and healthcare professionals’ perspectives and experiences and healthcare professionals’ clinical practice with a clinical audit. The major barriers to best practice care were provider issues and health system issues including gaps in inpatient/healthcare professional education and knowledge, and resources and services including supportive documents to guide clinical practice. Implementation to the frontline of systems currently available could improve inpatient care. By mapping inductive findings from our qualitative studies to the Theoretical Domains Framework targeted strategies can be developed and (when used within an appropriately resourced co-design or the Capability, Opportunity, Motivation – Changing Behaviour Framework (COM-B framework) improve inpatient care to overcome the inequity of access and lack of implementation of best practice for obesity-related health within Australia.