The relationship between obesity and nursing care problems in intensive care patients in Austria

Abstract Objectives To describe the characteristics and nursing care problems of intensive care patients in Austria stratified by obesity. Background Obese people in intensive care units (ICUs) present nurses with special challenges. Therefore, nurses need to receive education and training regarding how to treat obese patients to provide them with the best care. Most studies on obesity in ICU patients have not specifically addressed the problems and challenges from the nurses' perspective. This may be because nursing science programmes in Europe rarely introduce the topic of obesity. Design This was a secondary data analysis of a longitudinal study. Methodology The “Nursing Quality Measurement 2.0” is the Austrian version of the “International Prevalence Measurement of Care problems”. It is an annual cross‐sectional study, which has been carried out since 2009. Data from all ICU patients for 2009 to 2018 were extracted and combined into one file (n = 460). The main outcome measures were obesity and various nursing care problems, including care dependency. Results Of the ICU patients. 25% were obese. Obese ICU patients suffered significantly more often from diabetes mellitus and endocrine, nutritional, or metabolic diseases than non‐obese patients. About 30% of the ICU patients were totally care dependent, and 85.6% of the ICU patients were at risk of developing pressure ulcers, whereas the risk was higher for non‐obese than obese patients. ICU patients with a risk of pressure ulcer (measured with the Braden Scale) had a reduced risk of being obese (OR = 0.544). Conclusion Overall, the prevalence of nursing care problems found in this study was high. No significant differences in the prevalence of nursing care problems between obese and non‐obese patients were found. However, because of the increase in the number of obese patients in all nursing settings, a stronger focus on obesity research in the area of nursing science is recommended.


| INTRODUCTION
Obesity is defined as an abnormal or excessive fat accumulation that poses a health risk to those affected. Obesity presents an extremely complex and heterogeneous clinical picture with many different subtypes. It is not caused simply by an imbalance between food intake and energy consumption but also involves environmental factors and genetic aspects. 1,2 Adults with a body mass index (BMI) of 30 kg/m 2 and above are classified as obese, whereby the following three classes are distinguished: class 1 (BMI 30.0-34.9), class 2 (BMI 35.0-39.9), and class 3 (BMI > 40.0). 1 According to the World Health Organization, 1 the prevalence of obesity has tripled globally over the last four decades. In Austria, the prevalence has constantly increased and represents a great public health challenge. In 2014, the age-standardized prevalence of obesity was 14.6% amongst Austrian adults. 3 Obese people present health professionals with special challenges.
Therefore, health professionals need to receive education and training regarding how to treat obese patients to provide them with the best care. This can prevent treatment problems and delays. A special situation arises when obese patients are admitted to the intensive care unit (ICU). The care of intensive care patients is already complex, cost-intensive, and poses huge challenges for health workers. However, providing obese patients in an ICU with optimal care is even more demanding because of their obesity-related pathophysiology, 4 the disease itself, the severity of the obesity, and obesity-associated comorbidities. Many secondary diseases can co-occur with obesity (eg, type 2 diabetes mellitus, heart failure, pancreatitis), and thus, increasing care difficulties arise in ICUs. Obese ICU patients have a higher risk of acute cardiovascular, pulmonary, and renal complications than normal-weight patients. 2 They experience longer stays and longer ventilation times in ICUs, as well as a higher number of readmissions to ICUs than non-obese patients. Overall, obese patients in ICUs require more resources. 5,6 The care of obese ICU patients requires a higher level of teamwork and an increased use of human resources. Obese ICU patients often receive lower-quality care because the prerequisites for high-quality care cannot always be met, diagnostic tests cannot be carried out, and corresponding aids are not available. 4,7 A phenomenon that has been the subject of extensive research, especially in ICUs, is that a mild or moderate form of obesity has a positive effect on the survival of those affected, while morbid obesity (class 3) seems to be negatively associated with mortality. 8 This phenomenon ("obesitysurvivalparadox") has been confirmed in several studies. 9 The nursing profession is the only one whose members are present at the patients' bedsides 24/7. Most studies on obesity in ICU patients have not specifically addressed the problems and challenges from the nurses' perspectives. This may be because nursing science programmes in Europe rarely introduce the topic of obesity.

| Study aim
No studies have been conducted on nursing care problems and obesity in ICUs. Therefore, this study was carried out to illustrate the challenges faced by ICU nurses regarding obese patients.
These study findings have the potential to help improve obesityassociated nursing outcomes and streamline organizational processes. The aim of conducting this research was to describe the characteristics and nursing care problems of obese intensive care patients in Austria.

| DESIGN AND METHODS
The study design is a secondary data analysis of a cross-sectional study. The "Nursing Quality Measurement 2.0" is the Austrian version of the "International Prevalence Measurement of Care problems" (LPZ). 10 It is an annual cross-sectional study, which has been carried out since 2009. The study is performed annually on one specific day in different health care organizations in several European countries to collect data on different nursing care problems. For this analysis, only data from ICUs from 2009 to 2018 were used. All patients on an ICU on the day of measurement were asked to participate in the study.
All Austrian health care institutions with more than 50 beds were invited annually to participate in the measurement. A training session was held at the participating institutions to train the nurses about the questionnaires used and the online data entry program. In addition, all training documents were accessible to the participants via a password-protected area of the website.

What is Known About the Topic
• Care of obese patients in an ICU is even more demanding.
• Most studies dealing with obesity in ICU patients have not specifically addressed problems and challenges from the nurses' perspectives, which is necessary to improve obesity-associated nursing outcomes and organizational processes.
• The nursing science programmes in Europe rarely introduce the topic of obesity.

What this Paper Adds
• A quarter of the ICU patients investigated was obese.
• The prevalence of nursing care problems among ICU patients was high, but no significant differences between obese and non-obese subjects were found • Pressure ulcer risk was identified with lower risk for obesity; this agrees with literature reports that the BMI does not influence pressure ulcers and that being underweight or malnourished is a risk factor for pressure ulcers.

| Data collection
Two trained nurses from different wards (ie, one from the patient's ward and one from another ward) collected the data together by mainly physically examining the patient. In addition, the patient files could have been used as a source of information. In cases of disagreement, the external nurse's decision was accepted. The original questionnaire was developed based on guidelines and by experts in the Netherlands and tested for different psychometric properties. This questionnaire was translated into German and back-translated into Dutch by professional translators. 10 It was used to collect general characteristics and information on different nursing care problems. A secondary data analysis of the general patient characteristics and data on pressure ulcers, falls, and physical restraints was conducted because these data could be compared with data collected from 2009 to 2018.

| Variables
The general patient characteristics collected included their age, gender, BMI, medical diagnosis according to ICD-10, 11 and level of care dependency. 12,13 The BMI was measured directly whenever possible or was conveyed by the patient or relatives. The WHO definition of obesity was used 1 as BMI ≥30 kg/m 2 . Care dependency was measured using the Care Dependency Scale (CDS). This was rated as a valid and reliable tool for ICU patients. 14 The 15 items of the CDS are assessed on a 5-point Likert scale. The measurement of pressure ulcers included an assessment of the risk of developing pressure ulcers using the Braden Scale. 15 Scores between 6 and 23 can be obtained; a score ≤ 20 was considered a pressure ulcer risk. Pressure ulcers were classified according to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. 16 A fall was defined as an event where the patients fell to the ground or lower level unintentionally. 17 All falls that occurred in the 30 days prior to the survey were measured. Physical restraints were defined as measures that restrict human rights and freedom of movement, including all restrictions of personal mobility, such as observation, isolation, manual restraints, and the use of psychological measures. 18 Physical restraints that had been used in the institution in the 30 days prior to the survey were measured. Data on falls and physical restraints were collected through systematic medical record review.

| Prevalence of nursing care problems
A risk of developing pressure ulcers was detected for 85.6% of the ICU patients studied, whereas the risk was higher for non-obese than obese patients ( Table 2). The prevalence of restraints did not differ between non-obese and obese patients. All found differences between obese and non-obese ICU patients were not significant (P > .05).

| Bivariate and multivariate logistic regression analysis
The bivariate logistic regression analysis yielded two variables with a P-value lower than .200 (Table 3). These variables were included in the multivariate analysis. ICU patients at a risk of pressure ulcer (measured with the Braden Scale) had a 0.544 reduced risk of being obese.

| DISCUSSION
Our study results show the characteristics and nursing care problems of the studied ICU patients in Austria, stratified by obese and nonobese patients. In our study, the prevalence of obesity is 25%. We found that ICU patients were generally largely dependent on care. A large proportion of ICU patients in this study (85.6%) were at risk of developing pressure ulcers. No significant differences in the prevalence of nursing care problems between obese and non-obese patients was found. ICU patients with a risk of pressure ulcer had a reduced risk of obesity.
The prevalence of obesity found among ICU patients in our study (25%) is very high compared with the estimated rates in the Austrian adult population (15%). In Australia, the prevalence of obesity in ICU patients is also higher than in the general population. Approximately 75% of the Australian ICU cohort were overweight or obese. 20 4,7 In addition, functional ability has been shown to be a predictor for 1-year mortality. 23 Functional ability and, therefore, care dependency may even worsen after discharge from the ICU. 21 The literature suggests that incontinence is a particularly relevant problem among ICU patients, 21 but the number of incontinence studies that include obesity as a potential risk factor is limited.
We found that the pressure ulcer risk in the investigated ICU patients is quite high (85.6%). Results on the prevalence of pressure ulcers in ICUs varied from 33.7% 24 to 98.7%, 25 but this variance may also be because of the different risk assessment tools used. In our study, non-obese patients had a higher risk of developing pressure ulcers and a higher prevalence of pressure ulcers than obese patients.
These results agree with those from the logistic regression analysis.
Some studies have indicated that BMI does not influence pressure ulcers 26 and that being underweight or malnourished is a higher risk factor for pressure ulcers. 27 Nevertheless, pressure ulcers increase the risk of complications, 26 and therefore, ICU patients should be offered adequate pressure ulcer prevention measures and treatment.
More nursing staff are also required to be able to carry out important prophylactic measures for obese patients, such as changing their position. People with a BMI over 40 kg/m 2 require at least four carers to carry out appropriate repositioning. 28  where the prevalence of obesity class III is high. 34 The use of a convenience sampling technique resulted in a non-representative sample.
Less than half of the eligible participants could be included in this study. Furthermore, the mechanism of recruitment (those sedated were excluded as being unable to consent to the study) risks the sample being far less likely to be representative of the ICU population in Austria. Nevertheless, a response rate of 61.3% is regarded as satisfactory for an ICU population. The use of the Braden Scale to assess the risk of pressure ulcer also represents minor additional limitations.
Results of a recent meta-analysis show that the Braden Scale had only moderate predictive validity and should be modified for use in ICUs. 35 Data on falls and physical restraints in the 30 days prior to the survey were collected by reviewing the medical records. In every Austrian health institution, it is obligatory to report physical restraints and falls in the nursing records. 36 However, especially when the patient is transferred from a prior health institution to an ICU, it could be that these data were not transmitted to the ICU. It is also possible that no medical records will be available when the patient is admitted to an

| CONCLUSIONS
In this study, we found that the prevalence of the investigated nursing care problems was quite high but saw no significant difference between obese and non-obese ICU patients. We recommend that future researchers investigate this question with large representative samples in ICUs in order to confirm our results. In terms of future research, it would also be interesting to examine other nursing care problems that are potentially related to obesity, such as pain, incontinence, or intertrigo. Findings from these studies could provide important insights that support improvements in nursing care. As the proportion of obese patients increases in all nursing settings, more obesity research in the area of nursing science is needed as well.

IMPLICATIONS FOR PRACTICE
• Critical care nurses need to be prepared to provide care for obese patients as the number of obese patients is predicted to increase.
• Obesity should be assessed (BMI ≥30) in all patients by the nurses, so they can offer high-quality care for obese subjects.
• Nurses play a fundamental role in initially identifying and providing advice and care for obese patients early in the treatment process and in helping prevent long-term negative consequences of obesity.

AUTHOR CONTRIBUTIONS
All authors have read and approved the paper. FG: Conceptualization, data curation, investigation, development of methodology, project administration, writing this paper. SB: Data curation, formal analysis, writing this paper.

DATA AVAILABILITY STATEMENT
Data can be made available if required.

ETHICS STATEMENT
All participants or their legal representatives had to sign a written informed consent form. Approval for the study was obtained from an ethical committee (EK number: 20-192 ex 08/09).

PATIENT CONSENT STATEMENT
All participants or their legal representatives had to sign a written informed consent form.