Obesity and Incontinence

Introduction

Obesity is on the increase in developed countries, including Australia. In 2017-18, the Australian Bureau of Statistics' National Health Survey showed that 67.0% of Australian adults¹ and 30.9% of New Zealand adults were overweight or obese.²

Talking with a client about their weight can be very difficult, as most are embarrassed, if you then add that the excess weight could be causing leakage it becomes very difficult.

Obesity is complex and requires a non-judgemental approach to gain trust from clients to discuss issues and then for them to be ready to make changes. You may be the first person to address their weight and the link to incontinence with them. The information below aims to help you as a health care professional, understand the link and how to assist your clients with this issue.

How to identify if your client is obese?

1. BMI (Body Mass Index) calculation. Body fat is calculated on an individual's weight in relation to his/her height and age. A person with a BMI of 25 - 29.9 is considered overweight and a BMI > 30 is considered obese⁴.

2. Waist circumference is also an indicator of obesity, with a measurement over 88 cm for women and over 102 cm for men, indicative of obesity³.

3. A weight over 100 kg is what is termed “Bariatric” in hospitals and community settings by medical, nursing and allied health staff. This weight alerts staff that they may need to order special “bariatric” equipment for a patient with this weight (bed, armchair, wheelchair, shower chair etc.)

Obesity tape measure

Obesity and Urinary Incontinence - Prevalence

1. In a study of over 3,000 women, the prevalence of Urinary Incontinence (UI) was 17%, stress UI 15%, urge UI 9%, and mixed UI 7%. Irrespective of other risk indicators, BMI was positively associated with UI prevalence, particularly stress incontinence.⁷

2. Another study reviewed 368 incontinent women and found 63% had stress UI, 27% had detrusor instability. Obesity was significantly more common in women with genuine stress incontinence and detrusor instability than in the normal population⁸

Why does incontinence occur due to Obesity?

Stress Incontinence
Obesity increases intra-abdominal pressures which adversely stresses the pelvic floor and can contribute to urinary stress incontinence.⁹

Mixed incontinence or neurogenic bladder
Obesity may also affect the neuromuscular function of the genitourinary tract, thereby contributing to incontinence⁹ such as urge incontinence or bladder emptying difficulties.

Functional incontinence
An inability to reach the toilet in time resulting in incontinence due to reduced mobility or environmental barriers. See link for more information here: types of incontinence.

Also see functional incontinence.

Obesity can also be linked to many co-morbidities such as:

Heart disease
stroke
high blood pressure
type 2 diabetes
some types of cancer
kidney disease
back & knee pain
breathing problems
anxiety and depression
sleep apnea
gall bladder & fatty liver disease⁵.

Many of these co-morbidities will also exacerbate incontinence, and given these life threatening conditions incontinence is often pushed to the bottom of the list. Incontinence may not be life threatening but can be quality of life threatening.

Obesity comorbidity

How to raise the topic of Incontinence?

Talking about incontinence can be difficult on its own. But coupled with the issue of obesity it is even harder to raise the topic. Below are some insights into obesity, common causes of obesity and tips to raise the topic of incontinence.

Insights into Obesity

To give health care professionals some insights into how those that are obese feel, market research was conducted by Essity in 2018 (TENA manufacturer). Findings were:

Feelings of isolation (even if have people around them)
Guilt as feel it is their own fault
Hate for themselves for having inflicted this situation on their family and loved ones
Hard to lead a normal life as this is defined by what they can’t do
Depression and hopelessness
Self-deprecation and self-disgust – therefor often struggle with health, hygiene and skin issues
Aware of the implications of their obesity
Stigma and shame makes them feel like outcasts and a burden
Many have been “fat shamed” by friends and strangers
Their size can force can them into a “disabled” condition⁶

Common Causes of Excess Weight and tips to address

Medication side effects
Hormonal imbalances
Emotional eating
Poor food choices
Reduced mobility or exercise
Psychological issues⁵
Changes in lifestyle/circumstances

1. Medications - Review them to ascertain if they could be a cause for weight gain and refer client to their GP to establish if weight gain could be reduced by other medication choices. Common illnesses that could have medications that contribute to weight gain are:

Mental illness
Diabetes
Epilepsy
Inflamation¹⁰

2. Hormonal imbalances - Menopause, endometriosis, or possibly elevated cortisol due to an acute or chronic stress, can cause weight gain.

3. Emotional eating - Identify if binge eating is occurring by discussion if possible (although many may not disclose this). Refer client to their GP for a referral to a dietician or psychologist if client is agreeable.

4. Poor food choices - High fat & sugar diet, poor intake of fibre, fruits vegetables are identified during discussion, refer client to their GP for a referral to a dietician.

5. Reduced mobility or exercise - refer client to their GP for a referral to an exercise physiologist, physiotherapist, or a local rehabilitation program or starting with a walking program.

6. Psychological issues - There are many types of psychological factors that could impact a client’s thinking and behaviour. Ascertain if your client would be open to a discussion with their GP about a referral to a psychologist or a psychiatrist.

7. Life circumstances and stages in life - These can dramatically affect one’s weight. For example, irregular hours, night duty shifts, cost or time pressures. Many may be working full time and parenting or caring for elderly parents, affecting time and energy to eat well, exercise or find motivation.

Offering support, empathy, and non- judgement advice, may go a long way to helping someone start on a weight loss journey to improve their incontinence. Read more on how to discuss incontinence.

Obesity and Skin Issues

1. Dry Skin – skin can become incredibly dry due to poor circulation, poor hygiene, or lack of moisturizing.

2. Excessive Moisture – this can be an issue due to sweating.

3. Weight and Pressure – due to their weight they may develop pressure ulcers between skinfolds or on extremities, or pressure from tight spaces on skin (e.g. if the chair is too tight) a lack of movement, or from acid from urine and faeces due to incontinence.

4. Cellulitis – a bacterial skin infection can occur due to poor hygiene.

5. Other related Health Issues can cause skin problems: