Introduction

High body weight is a challenge for society as a whole, affecting more older people (65+) in times of demographic change. A look to Germany is revealing of such developments: the prevalence of obesity has significantly increased across all age-groups between 2009 and 2018, with the highest prevalence reported for the age group 65–74 years and the greatest increase observed for those over the age of 80 (Steffen et al. 2021). Despite the growing number of older persons with obesity in the country, there is limited knowledge regarding the situation and needs of this group. Especially in European countries, the nexus of obesity and old(er) age constitutes a research gap in both empirical data and normative reflection. One reason for this gap has been described by Gallagher and Tadd (2016, p. 132): “many people fear ageing and its consequences, and as is frequently the case when something is feared, it is stereotyped and ridiculed in a number of ways.” This view of older people in health and nursing care poses a serious ethical challenge, as individuals are reduced to their age, which neglects social categories of importance to health and well-being (Weßel 2022). As a result, older persons fail to be seen as complex, whole persons which can lead to diagnostic disadvantages such that diseases are detected and treated only late (Weßel and Schweda 2023).

The reductionist and stigmatizing view applies to obesity as well (Westbury et al. 2023). Persons with obesity often face stigma and discrimination, not least of all by health personnel (v. d. Knesebeck et al. 2019; Ryan et al. 2019). For older persons with obesity, the risk of multiple stigma and discrimination is particularly salient (Makowski et al. 2019). The lack of medical evidence for analyzing and treating high body weight in older persons is often based on the exclusion of people aged 65+ in obesity studies. This contributes to a lack of visibility and introduces a new dimension of intersectional discrimination.

Whether living with or without obesity, older persons face a variety of unmet care needs, particularly in the area of long-term care (LTC)Footnote 1 where services in many countries are yet underdeveloped or nonexistent (Fischer et al. 2021). LTC refers to a range of nursingFootnote 2 and social care services designed for individuals who can no longer perform everyday activities on their own and which can be carried out in different care settings including the home, community, and in nursing facilities (National Institute on Aging 2023). While individuals belonging to other age groups may also require LTC, older persons make up the largest share of recipients owing to the rising prevalence of dependency associated with aging (Fischer et al. 2021).

It is important to recognize, however, that older persons represent a heterogeneous and diverse group, whose needs in health and LTC may vary widely from person to person (Kalánková et al. 2021). Accordingly, older persons with obesity may have different needs than those living with lower body weight, and these needs may be very diverse. Managing such care diversity can give rise to ethical issues such as inequities in resource allocation, but also inappropriate communication between care providers and recipients.

Against this backdrop, the present study explores ethical challenges associated with the LTC of older persons living with obesity and puts forth a new agenda to guide future empirical–ethical research. To address this topic, the paper first provides background information and a normative perspective of a needs-based approach. We then proceed to delineate our mixed methods approach involving a scoping review of relevant literature on the topic and the thematic analysis of three case studies. A more detailed overview of the methodology is provided below. We argue that mixed methods approaches are necessary to understand both the systematic factors in health and LTC and the individual, relational and context-specific consequences of such systematic factors. Subsequently, the results from both methods are presented, contributing to a novel research agenda to analyze and reflect ethical challenges in the terrain of nursing, obesity, and old age. The paper concludes with a summary and an outlook on future research.

Background

Obesity, aging, and long-term care

Obesity is increasingly prevalent worldwide, particularly in Europe and North America, and across all age groups (NCHS 2023; WHO 2022a). It is expected to continue to rise in all countries (NCD-RisC 2019; OECD 2019), with a projected peak between years 2030 and 2052 (Janssen et al. 2020).

Obesity is typically assessed using the body mass index (BMI), which describes the ratio of body weight to body surface area in square meters. A BMI of ≥ 30 to < 35 is classified as obesity class I; class II ranges from a BMI ≥ 35 to < 40 and class III is categorized with a BMI ≥ 40 (CDC 2022). The risks of somatic and psychological comorbidities of chronic conditions increase with higher BMI (Schwenke et al. 2020). Obesity in old age leads to significant morbidity and increased mortality, and comorbidities such as frailty, sarcopenia, immobility, and functional impairment limit quality of life (Hajek et al. 2015). In the context of geriatric care, BMI is considered an inadequate means of assessing body weight in older people, as it normalizes weight and height in the calculation and does not consider changes in aging bodies (e.g., loss of muscle mass) or fat distribution (Crow et al. 2019; Batsis and Zagaria 2018). Hence, for a comprehensive assessment of the situation of care-dependent individuals regarding obesity in Germany or elsewhere, suitable measurement instruments are currently lacking.

While obesity is a widespread phenomenon, significant differences in prevalence can be found. In Germany, the prevalence of obesity among the adult population is approximately 20% (Schienkiewitz et al. 2022, p. 27). The prevalence is significantly higher in the United States, where more than 40% of adults are currently considered obese (Stiermann et al. 2021, p. 6). Childhood trauma, especially sexual abuse, represents a major risk factor for obesity (Bentley and Widom 2009; Mason et al. 2013; Gooding et al. 2015; Schulze et al. 2019). In the context of LTC, in which very sensitive bodily care is often involved, such traumatic experiences pose special challenges, especially if people with obesity are ashamed of their body weight (Mensinger et al. 2018). Being obese also involves a statistically higher likelihood for being socially vulnerable or having low socioeconomic status (Hoebel et al. 2019), which, in turn, leads to fewer personal resources for purchasing health and LTC services.

Data for Germany point to 41.6% of women and 31.3% of men in the age group of 70 to 79 that were obese over years 2008 to 2011 (Mensink et al. 2013). However, this data is based on a self-reported survey. Steffen et al. (2021) estimate that the diagnosed prevalence is significantly lower. There is evidence that individuals with obesity are at a higher risk of entering nursing homes (Yang and Zhang 2014). Recent representative data from Germany indicates that in the age group of 80+, individuals requiring care exhibit a significantly higher obesity prevalence of 19.5% compared to those without care needs (Albrecht et al. 2022). In a meta-analysis of international studies among the population aged 80+, Hajek et al. (2022) report a pooled prevalence of nearly 20%. These initial studies on obesity in older age lament the insufficient state of scholarship and highlight the relevance of new research due to demographic change (Hajek et al. 2020).

Particularly lacking are qualitative studies on the situation of LTC recipients with obesity, especially concerning the unique challenges associated with their care. In terms of the limited information that is available on the subject, studies have primarily identified an increased demand for personnel resources (Harris et al. 2018) and the need for adjustments in infrastructure (Apelt et al. 2012). Additionally, there have been reports of negative attitudes among caregivers towards care recipients with obesity (Apelt et al. 2014). Other studies indicate that nurses express negative attitudes toward individuals with obesity less frequently compared to physicians and therapists (Sikorski et al. 2013). These challenges give rise to ethical issues, which have not yet been discussed. In the following, we propose that they should be systematically categorized and analyzed from a needs-based perspective.

“Need for care” vs. “Needs of care recipients”

Nurses are frequently involved in caring for residents in nursing homes or other assisted living facilities. Nursing institutions face complex situations that involve patient care, interpersonal relationships, and professional responsibilities (Chadwick and Gallagher 2016). Through the example of nursing, we can gain a nuanced understanding of ethical considerations associated with the care of older people with obesity, which contributes valuable insights to both the nursing profession and the broader healthcare community.

Nursing also illustrates two sides of a healthcare system. On the one hand, nursing and LTC are characterized by a lack of resources which has important consequences for access and quality of care. This scarcity encompasses a range of issues, including staffing levels, equipment availability, financial constraints, or educational resources, often resulting in a lack of time (Schmucker 2019, p. 53). In what follows, we will write about the means to address this lack of resources as a matter of need—that is, something that can be measured and quantified as in the “need for” bariatric beds, lifts, more time, etc.

On the other hand, nursing is known for adopting a holistic approach to patient care, considering physical, psychological, and social aspects of health. Training nurses according to ethical standards is essential to ensure that older adults receive compassionate, respectful, and dignified care. Nursing ethics guide nurses in making ethically sound decisions to improve the quality of care for vulnerable populations (Wöhlke and Riedel 2023). Ideally, empathetic listening, professionalism, compassion and good communication skills are nursing values (International Council of Nurses 2021). Nurses are trained in these skills and competencies for delivering quality care. They often play a crucial role as advocates for older patients who may be unable to communicate effectively. In the following, we consider the preferences and demands of such patients as needs, as in the “needs of” older persons living with obesity.

In contrast to need, needs usually cannot be quantified or measured. Rather, they are analyzed with qualitative or hermeneutic approaches. However, they are of great importance, as nurses respond to patients’ preferences and demands in concrete situations: They must navigate decisions about withholding or withdrawing treatment, discussing palliative care options, and respecting the patient’s wishes regarding resuscitation and life-sustaining interventions (the needs of). In doing so, they are also constrained by systematic factors, such as the lack of resources (the need for). Moreover, nurses often face moral distress when ethical principles conflict with institutional policies or personal values (Wöhlke 2018). The high workload, personnel shortages, and resulting stress can lead to situations in which ethical dilemmas arise and remain unresolved in care provision. The debate about how to evaluate need is without doubt of high importance in healthcare systems (Primc 2020).

In Germany, there are currently more than five million people in need of care as defined by the LTC insurance (Federal Statistical Office of Germany 2023). By 2050, this number is projected to increase to approximately eight million (Federal Statistical Office of Germany 2023; Rothgang and Müller 2021). Approximately 800,000 individuals in need of care are provided for in nursing homes. In 2021, there were 1.25 million care professionals working in both outpatient and inpatient care facilities (Federal Statistical Office of Germany 2023). The staffing levels in LTC facilities have been deemed inadequate for over two decades (Wingenfeld and Schnabel 2002; Federal Ministry of Health 2023) and are expected to worsen in the coming years due to demographic trends (Flake et al. 2018). As a result, challenges have arisen in ensuring adequate care provision and maintaining an appropriate quality of care. Not only does this have consequences for care recipients, the situation places a burden on the working conditions of care professionals (Schmucker 2019) and are associated with poorer physical and mental health, negatively impacting self-assessed work ability and job satisfaction (Auffenberg et al. 2022; Rennert et al. 2022, p. 92).

We will systematically map this care need and its challenges for the field of old age and obesity in our scoping review (see below). However, we will mainly focus on individual needs, as this is from our perspective a particular research gap in ethical reflection of healthcare. Consequently, we will later illustrate such needs through our thematic case analysis (see also below).

Conceptualizing an ethical perspective on needs

Needing something means that “something is necessary for something else to be accomplished” (Culyer 1995, p. 727). Here, we can differentiate between the needs (of a person) and the objects needed (by a person). In daily life, people might say they need many things. A person might need to listen to their favorite music to work productively. Another person might argue they need their SUV (sports utility vehicle) for a smooth commute to work. These persons need certain objects, but these objects are only required to perform a task well or to reach a certain goal. However, such needs are not a good basis for moral claims. Instead, morally salient needs are “necessary, indispensable, or inescapable” (Brock 2011, p. 56) in social settings. From an ethical point of view, it is important to separate mere “instrumental” from “constitutive” needs (Miller 2006, p. 142).Footnote 3 Constitutive needs are those needs which serve as a foundation for moral demands. They require a moral response from individuals or institutions because they imply that a person would experience serious harm arising from factors beyond their control if they do not receive adequate response to their needs (Thomson 2005; Wiggins 1987, p. 16; Hope et al. 2010). Examples are recognition as a person, emotional well-being and autonomy.

Against this backdrop, needs reveal a gap, a lack of something, and a space for moral action (Reader and Brock 2004). This, in turn, makes a person in need dependent on others who can provide the objects needed. Such ‘objects needed’ can be resources or certain actions (Hope et al. 2010, p. 473). Consequently, “the central focus of the ethics of care is on the compelling moral salience of attending to and meeting the needs of the particular others for whom we take responsibility” (Held 2006, p. 10). Whereas needs-based approaches are quite nuanced in their terminology and scope, they all have in common that needs of others should steer our moral thinking and action.

In line with Miller (1999, p. 203–229), a person is harmed when they are unable to live a minimally decent life in the society to which they belong.Footnote 4 This view illustrates that harm can also include a certain cultural and societal variance, which defines the details of such decency. Similarly, Doyal and Gough (1991, p. 14) state that, “[t]o be seriously harmed is thus to be fundamentally disabled in the pursuit of one’s vision of the good.” In the context of LTC, to pursue one’s vision of the good means that a person is able to take as much individual and autonomous action as possible despite living with dependency. Following Miller (1999), standards of a decent end-of-life, which includes adequate and dignified care, can be claimed. Based on these normative assumptions, in the present study we consider the needs of older adults living with obesity as a claim for their well-being; and we argue that LTC that can also be deemed as constitutive needs.

The moral relevance of constitutive needs can be illustrated from both a care giver and care recipient perspective in the context of nursing and LTC. For caregivers, constitutive needs are necessary for functioning in their professional context, which includes equipment and skills to work safely. An institution that provides caregivers only with equipment that they cannot use properly because of their physical constitution or training amounts to an insufficient response to a constitutive need and is thereby acting immorally. It exposes the caregivers to an increased risk of injury.

Care recipients (and their relatives) have constitutive needs concerning the receipt of dignified care in a professional context (Tadd and Calnan 2009). A focus on patients’ needs reveals morally relevant health-related goals that are rooted in specified standards and practices in healthcare (Nielsen 2022; Gustavsson 2014). Such needs are special, because they require expert diagnosis and personnel with special training and skills. These needs can only be met by professional caregivers, which is of particular relevance in nursing older people with obesity, whether within the acute or LTC setting (Hodgson 2008). Following a biopsychosocial model of health, unmet needs can be physical, psychological, and social (Hodgson 2008). Accordingly, harm can include physical, psychological, and social wrongdoing.

Depending on the level of care dependency, care recipients are entitled to different services. In the context of residential LTC, the staffing levels are contingent among other things upon the degree of care dependency among the residents. The provision of individual nursing services and, consequently, the satisfaction of needs are negotiated between care givers and care recipients, which illustrates the potential of needs as an analytical category to understand and reflect care practices. Understood as such, nursing can be viewed as a genuinely needs-meeting practice, one which requires attention to needs also on a theoretical and methodological level. In what follows, we will lay out a mixed methods approach to analyze both need and needs at the intersection of obesity and LTC.

Methods

In the present study, we applied mixed methods to identify ethical challenges related to the (long-term) care of older persons living with obesity. In a first step, we conducted a scoping review on the state-of-the-art using international databases that covered peer-reviewed publications and monographs to identify care need. In doing so, we identified resource-related problems that impact the access and quality of care provided to older persons with obesity and the challenges of their professional caregivers. However, while such a review can provide abstract (and often quantifiable) results on care need, it often fails to offer deeper insights into the individual needs of older persons, particularly as concerns the relationships between care givers and care recipients. As a result, in a second step, we complemented our scoping review with the thematic analysis of three case studies on patients in specific care settings to identify how the needs of individuals are defined and met within the context of healthcare nursing and LTC. The case studies also provided an important basis for exploring how the ethical challenges surrounding care need, as identified in the scoping review, (inter)relate to the individual care needs expressed through narration of lived experience by both care givers and care recipients.

More specifically, case studies point to an inherently narrative structure in the form of implicit evaluations, condensed knowledge, or individual experiences (Chambers 1999, p. 21). Understanding the specific context of a situation, including the motivations and emotions involved, is crucial for making ethical judgments (Charon 2008). Consequently, narratives encourage a more nuanced and contextually sensitive approach to ethical analysis. If a moral conflict is localized in concrete social relations and contexts, new causes and solutions can arise. By examining a variety of narratives, a multiplicity of perspectives and values (Greenhalgh 2016) is acknowledged, which is essential for addressing the complexity of ethical issues in diverse societies (Garden 2015).

Scoping review

In order to identify the state-of-the-art on ethical challenges associated with the care need of older persons with obesity, we conducted a scoping review (between 20 March 2023 to 31 June 2023). An initial search for literature using seven databases (PubMed; Web of Science; Scopus, Science Direct, Cochrane, PhilPapers, and Belit) that dealt only with persons aged 65+ in LTC settings led to very limited findings (0 to 2 hits across the databases). As a result, we lifted the age restriction of our search and broadened the care setting to include healthcare and nursing (i.e., not specific to the hospital or LTC settings) to arrive at a greater number of articles for analysis. We selected only studies that had direct or indirect relevance for ethical challenges in LTC, excluding studies that solely focused on clinical trials or medical treatments (e.g., bariatric surgery) without reference to ethical concerns or to nursing.

Our methods followed the criteria and checklist of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (Tricco et al. 2018; Table 1). We relied on two databases—PubMed and Web of Science—as an initial search. We added databases (i.e., Scopus, Science Direct, Cochrane, PhilPapers, Belit), which led to duplicate, irrelevant, or otherwise zero hits. The final search terms used for the two databases were “care,” “obesity” and “ethic” or “equity” and included variations using obes* (Table 1). It is important to note that these search terms were also used to scan English language abstracts for German articles.Footnote 5 However, these efforts did not yield relevant results.

Table 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) scoping review methods’ checklist (in line with Tricco et al. 2018)
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Databases were searched with no period of observation or geographic restrictions. It is important to note that although initially included, the term “nursing” was omitted from the final search procedure, as it led to articles that focused either exclusively on medicalized care or on acute care conditions (e.g., postoperative care) without relevance for LTC. The search process resulted in 391 (PubMed) and 298 (Web of Science) hits.

In total, 689 articles (titles and abstracts) were screened for relevance. Although PubMed and Web of Science cover books in their collections, none emerged as hits during our search. Studies were deemed relevant if they addressed one or more ethical challenges (such as unequal care, treatment bias, stigmatization) related to the care of persons with obesity. Studies that focused on healthcare and/or were not specific to older persons were also included if they had importance for the study’s main objective. The first reviewer carried out an initial round of screening, which led to the preliminary selection of 11 out of 689 articles. The second reviewer conducted a final round of screening which led to the further exclusion of one of the 11 articles based on lack of relevance. This resulted in a total of 10 articles for final inclusion.

Once articles were screened and selected, the reviewers went through the articles for key data points that were extracted into templates. The templates served to guide the systematic identification of the most important information to answer the scoping review’s main research question, “What are the key ethical challenges associated with the care need of older persons with obesity?” It is important to note that because most literature does not frame challenges in ethical terms, the latter had to be identified in one of two ways: first, in cases in which authors did make explicit reference to ethics, these were flagged accordingly; second, when challenges (e.g., structural barriers, limited resources, but also normative biases by providers) were reported without reference to ethics but that had an impact on patients’ access, utilization, or quality of care, these too were flagged as ethical challenges that demanded a need for action to improve the lives of older persons with obesity and their caregivers.

Case study analysis

To find the cases, an extensive literature search was conducted from February to March 2023. PubMed, National Library of Medicine, Proquest, Google Scholar, Cochrane Library, local library catalogues and Research Gate were searched for case studies on obesity in geriatric care. Additionally, German- and English-language journals (e.g., Pflege, BMC Nursing, Bariatric Nursing and Surgical Patient Care, Nursing Management, American Journal of Public Health, European Journal of Public Health, The American Journal of Nursing) were searched using relevant search terms (e.g., geriatric care, older people, case, obesity). Ethics was not included as a search term, in order to avoid overlaps with the scoping review and also to facilitate an inductive ethical analysis of the cases. In total, the case study search included 15 databases, 11 German- and 24 English-language journals. Five publications on nursing home care of obese people, two on primary care in hospitals and four reports from the perspective of nursing staff could be found. Among the 11 publications, we picked two publications with three different cases (see below). Cases were identified as relevant and the content was analyzed using the expert judgement of our author team. All cases depicted situations of older people with obesity.

In an initial step, we analyzed and compared the cases based on the assessment modules of the German social security law code book (SGB XI) on LTC as a matrix to evaluate the cases from a nursing point of view (see Table 3).Footnote 6 Thus, we could systematically identify and compare the care needs of the patients in the two cases. This categorization encompasses all individuals unable to independently compensate for physical, cognitive, psychological, or health-related challenges. This condition must persist for a foreseeable period of at least 6 months. The severity of care dependency is determined using an assessment tool that considers a total of 65 aspects across six life domains, which are consolidated into the following modules: Module 1: Mobility, Module 2: Cognitive and communicative abilities, Module 3: Behaviors and psychological issues, module 4: Self-care, Module 5: Coping with and independently managing disease- or therapy-related demands and stresses, Module 6: Structuring daily life and social contacts. To determine care dependency, the various aspects are assessed, and depending on the modules, the assessment is based on independence, ability, or the frequency of assistance from others. Points are assigned according to a fixed scheme, which is subsequently weighted. Using the weighted point values, it is determined whether a care level (Pflegegrad) is applicable, and one of the five care levels is determined (MDS 2022, p. 3 f.). In a second step, we analyzed the cases for those ethically relevant issues, which did not come up in the scoping review. Thus, the key ethical challenges identified in the scoping review were brought into comparative perspective with those of the case studies.

Results

Key findings—scoping review

Basic characteristics of reviewed studies

Of the 10 articles selected for inclusion in the scoping review, all but two relied chiefly on qualitative methods (except Flint et al. 2021 and McAloon et al. 2022) involving small numbers of participants or cases (see e.g., Flint et al. 2021; Hales et al. 2018; Kanagasingam et al. 2023; Schneider and Li 2016). Six consisted of reviews or summary articles that did not involve original research (see e.g., Craig et al. 2018; Giese 2016; Perumalswami et al. 2019 and Washington et al. 2023). Two studies offered no geographic focus (Giese 2016 and Kanagasingam et al. 2023), whereas the rest referred to developments in either the United States or Europe, with one exception (i.e., New Zealand in Hales et al. 2018). As concerns the period of observation, this information was largely absent or not pertinent to the research design of the articles reviewed, with the exception of Flint et al. (2021) that conducted a case study over years 2018 to 2020, and Hales et al. (2018) that carried out interviews over years 2015 and 2016.

In regards to the stakeholder perspectives, nine studies included providers (exception: Flint et al. 2021 only dealing with patients) or took multistakeholder perspectives involving providers and patient experiences. Four studies also addressed policy makers and healthcare systems as additional actors of concern (Craig et al. 2018; Kanagasingam et al. 2023; Schneider and Li 2016; and Washington et al. 2023). It is important to note that seven papers focused on primary and/or hospital-based care. Exceptionally, Felix et al. (2011) and Schneider and Li (2016) dealt with nursing homes; and Perumalswami et al. (2019) addressed palliative/hospice care. Meanwhile, whereas all studies dealt with obese populations, only one focused on older persons with obesity (Felix et al. 2011). All others concerned either patients with obesity (BMI greater than/equal to 30 or 40) with comorbidities (Craig et al. 2018; Giese 2016; Schneider and Li 2016) or did not refer to the specific morbidity status or grade of obesity of patients. Only one study focused on persons with obesity in the United States that also represented ethnic minorities of low socioeconomic status (Washington et al. 2023).

Taken together, the basic characteristics of the reviewed studies point to an undercomplex treatment of the category of obesity, with little or no attention to levels or types of needs thereby associated. Scholarship is also characterized by a lack of representativity in geographic terms and in coverage of societal groups. Research that targets older persons with obesity specific to the LTC setting is especially lacking, as is scholarship that examines intersectional vulnerabilities in old(er) age, whether related to socioeconomic status, gender, sexual orientation, or ethnicity. Studies tend to overrepresent provider perspectives, with no studies available that exclusively target care recipients. Finally, extant research favors qualitative methods to the exclusion of larger, systematic comparisons involving quantitative research design and methods that would better afford replicability and validity testing.

Ethical challenges in reviewed studies

Extracted data from the 10 articles gave way to four analytical categories that were inductively generated based on the ethical challenges presented in the literature (Table 2). The first set of challenges relates to the high demands placed on “inadequate and insufficient resources”, both material and personnel and/or nonmaterial, that have direct consequences for the capacity of providers to ensure good access and quality care for patients with obesity (Table 2, column 1). In terms of material resources, these included the lack of properly sized beds and insufficient bariatric equipment (see e.g., Craig et al. 2018; Felix et al. 2011; Giese 2016; Perumalswami et al. 2019 and Schneider and Li 2016), as well as the role of unwelcoming environmental cues (e.g., blood pressure cuffs, scales and chairs that are too small for obese patients) (Giese 2016) and low or disparate services across geographic areas in a country (Washington et al. 2023). Concerning personnel and nonmaterial resources, studies mainly referred to insufficient time and staffing (Felix et al. 2011; Perumalswami et al. 2019). One study also cited the lack of interprofessional collaboration needed to address the health needs of patients with obesity (Kanagasingam et al. 2023). Crucially, these challenges give rise to ethical concerns relating to the availability and nature of care provided to persons with obesity. In line with Hope et al. (2010), where resources are insufficient or inadequate, individual needs go unmet. This results in inequities that require moral action in the form of greater investment in material and personnel resources to dismantle barriers in access and quality of care for older persons with obesity.

Table 2 Key ethical challenges identified in the scoping review related to care need
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The second set of challenges identified in the literature pertains to the “harmful norms and attitudes of carers” which impact on the way in which doctors and nurses interact (e.g., discrimination, avoidance) with patients and consequently affect the take-up and quality of care (Table 2, column 2). Here, studies pointed to the general lack of compassion and curiosity guiding clinicians’ work (Kanagasingam et al. 2023), compounded by a paucity of self-reflection (Giese 2016). One article cited the need for providers to create “culturally safe care” for patients with obesity (Giese 2016, p. e9). A prevalent theme that emerged across most studies is the role played by negative biases and expectations, which led to patient distress and stigmatization (Craig et al. 2018; Felix et al. 2011; Flint et al. 2021; Hales et al. 2018; Perumalswami et al. 2019 and Washington et al. 2023), linked to verbal abuse and neglect by staff (Schneider and Li 2016). In one study, these were linked to frustration and demotivation on the part of providers due to the (assumed) lack of adherence by patients to dietary and other therapeutic measures (Schneider and Li 2016). Schneider and Li (2016) reported on inner conflicts experienced by clinicians due to their perceived lack of authority to effectively help patients, as well the dilemma faced by choosing between soft and hard paternalism. As in the case of insufficient material and personnel resources, negative provider norms and attitudes directed at patients with obesity can generate adverse conditions for care, disincentivizing the utilization of services on the part of patients and undermining the quality of care once received. Following from Miller (1999) and Tadd and Calnan (2009), this detracts from the ability of the patient to live a minimally decent life in line with their constitutive needs.

The third category of challenges relates to “unequal quality of care and treatment biases” issues that generally result from the lack of standards and safety measures in place which undermine the quality of care received by patients and the safety of both patients and providers in the delivery of care (Table 2, column 3). They also arise in connection with treatment biases that affect care experiences. Concerning the former, Felix et al. (2011) reported higher risks of pressure on patients with obesity due to improperly sized beds, discomfort and scrapes owing to ill-fitting diapers/briefs, as well as longer wait periods for diaper changes. Schneider and Li (2016) emphasized the inability of staff to lift and move patients safely, due to a lack of equipment and personnel. Meanwhile, Kanagasingam et al. (2023) referred to the need for greater person-centered care to improve the treatment of persons with obesity, whereas Craig et al. (2018) pointed to the need for greater adoption and enforcement of internationally recognized medical and ethical standards in bariatric care. In the context of the latter, Flint et al. (2021) underscored the lack of dignity in existing care. Three studies pointed to poorer quality care owing directly to prejudicial attitudes by providers (Felix et al. 2011; Hales et al. 2018), which even translated to delayed prescription practices on assumption of nonadherence to therapy by patients (Washington et al. 2023).

Treatment biases were associated with poorer take-up of care by persons with obesity, who avoided or postponed doctors’ visits due to negative past experiences and lower self-esteem (Craig et al. 2018; Flint et al. 2021). Finally, patients with obesity also endured higher deferral and/or transfer rates by hospital units that were either unable or unwilling to take on their care (Schneider and Li 2016), as well as greater end-of-life care costs due to higher rates of institutionalization than nonobese counterparts (Perumalswami et al. 2019). As in the case of challenges related to provider norms and attitudes, quality issues owing to the lack of standards and safety measures, as well as treatment biases pose serious concerns for care ethics and the health and well-being of persons with obesity. Quality issues also stand to impact the safety of caregivers, as they risk their own health due to injuries incurred by inadequate means of lifting and moving patients. In line with the ethical approaches of Thomson (2005) and Wiggins (1987), such risks require a moral response from individuals and institutions to protect people from experiencing serious harm for factors beyond their control and to ensure that their needs are met.

The fourth and final set of challenges emerging in the literature includes issues of “vulnerability and justice” (Table 2, column 4). Unlike the aforementioned studies, ethical concerns falling under this category were made explicit by the authors. By way of example, McAloon et al. (2022) referred to moral tensions or conflicts experienced by providers who struggled to balance patients’ rights, needs, and responsibilities on the one hand, and the use of societal resources and public welfare for other’s needs on the other. A number of studies also drew attention to ethical concerns over issues of justice and equity of care for the vulnerable (Craig et al. 2018; Giese 2016; Perumalswami et al. 2019; Washington et al. 2023). Despite the common ethical threads running through these articles, however, the moral responses implied by authors tended to vary, ranging from the need for greater guidance to better direct clinical decision-making (McAloon et al. 2022) to political advocacy and the increased availability and fairer distribution of resources to meet needs.

Key findings—case studies

Basic characteristics of selected cases

The cases selected for the present study provide valuable insights that allow for a deeper understanding of obesity in LTC. The cases also reveal the complex, intertwined physiological, psychological and social subjective needs of older people with obesity. For instance, we learn about the role of language and communication in this field; and we open up a contextualized research perspective through which emotions become visible.

The first case (Rotkoff 1999) represented the oldest one found in the literature. Age and BMI of the female patient remain unclear in the publication but since she is referred to as “geriatric patient” (Rotkoff 1999, p. 310), we assume that she is a resident in a LTC facility.Footnote 7 Although the data are somehow incomplete, we picked this case because the patient’s social, emotional, and physical needs are fully described in the context of her care. The two other cases selected were published in Sabol et al. (2020). Here, patient data are available: “Resident A was a 71-year-old African American woman with a calculated BMI of 39 (Class 2)” (Sabol et al. 2020, p. 20); and “Resident B was a 76-year-old white woman with a calculated BMI of 51 (Class 3)” (p. 21). In Table 3, general, medical, and nursing information from the three cases is summarized. All three patients exhibit varying degrees of mobility limitations, ranging from mild restrictions that can be partially compensated for with appropriate aids to bedridden states. It is evident that they possess the ability to communicate, but they are described as varying in terms of their conversational and social skills.

Table 3 General, medical, and nursing information about all cases
Full size table

Ethical challenges in selected cases

In contrast to the scoped literature, the cases focus explicitly on older people with obesity. Therefore, their analysis is a helpful addition to the findings of the literature review. Regarding “inadequate and insufficient resources,” the case of patient C adds important information, starting with the remark that “[w]eighing her was deferred because the scale could not accommodate her; she appeared to weigh at least 325 pounds” (Rotkoff 1999, p. 310). Since the case is relatively old, we might expect that compared to the mid-1990s, institutions today are better equipped to weigh patients with obesity. However, as this is not yet an official requirement by law,Footnote 8 it is not clear whether facilities are better prepared today for patients with high BMI. This case further reveals that due to a lack of adequate equipment, patient C could not be transferred to a LTC facility: “A morbidly obese patient may remain hospitalized until an LTC facility in the same area is prepared to accept the application” (Rotkoff 1999, p. 309 f.). The healthcare system could not respond to the staff and the patient’s needs of giving and receiving appropriate care within the right institutions. Instead of being transferred to a LTC setting, patient C had to stay in hospital. We can assume from this case that patients with obesity are rejected by nursing homes due to a lack of adequate equipment. However, this kind of rejection—including its ethical implications and consequences—did not arise in the scoped literature.

The case of patient B deepens the scoping review’s results by illustrating the consequences of increased care burden for people with obesity: “Inconsistency of resources not only delays timely opportunities […] but it also creates work-related dissatisfaction” (Sabol et al. 2020, p. 22). From a perspective of providers’ needs, work-related dissatisfaction is very important. Besides its obvious potential effects (negative impact on teamwork, reduced employee engagement, or even quitting), this case also stimulates the hypothesis that work-related dissatisfaction can have negative effects on staff’s physical and mental health. Stress, burnout, and other health issues may arise, leading to decreased well-being. This, in turn, might contribute to reduced empathy, delayed response to patients’ needs, or lower quality of care. Comparing this hypothesis to the scoping review, we can detect a certain pattern of how a lack of resources and negative or prejudicial attitudes towards patients with obesity might be connected.

Sabol et al. (2020) emphasize that patient B is willing to be active both physically and socially, but she was hindered to move around due to unequipped facilities. Due to frequent falls in the past, this patient preferred to use the wheelchair but she could not enter many of the facility’s rooms. Repositioning events can trigger fear and pain, they potentially compromise the safety of both resident and caregiver. As patient B was also diagnosed with anxiety and depression, we can hypothesize that her needs are not only physical but also social and psychological—thus, a response to her fear and anxiety might have a positive effect on her mobility. Here, we can clearly see how individuals are harmed by a context that is incapable of responding to their needs. Accordingly, this case points to the worsening of a health condition through inadequate resources.

The present case studies also speak to the ethical challenges emerging under the category of “harmful norms and attitudes of carers” in the scoping review. In the case of patient C, a care plan was designed “to treat her with the same high regard as others in their care” (Rotkoff 1999, p. 310). In contrast to the results of the scoping review, in this case the staff reports their best efforts to nurse patient C according to her physical, psychological, and social needs, being aware of the effect of weight stigmatization:

Obese patients typically are very aware of their size, and conscious patients may be embarrassed by the number of staff and the type of equipment and services needed to care for them. The professional caregiver must refrain from admonitions, judgmental advice on dieting or lifestyle, or outright complaining about the extra work created in caring for such a patient. (Rotkoff 1999, p. 310)

We can conclude that a patient’s embarrassment and the staff’s judgmental advice might lead to conflicts. From this case, we do not know how other staff members evaluate the team’s attitudes towards patient C. If they were indeed as empathetic and professional as the text narrates, we can conclude from this case that patients are subject to a certain level of chance or luck, when it comes to care providers’ attitudes regarding their weight.

Sabol et al. (2020, p. 25) confirm the results of the scoping review by pointing out that “residents may be able to perform behaviours (either partially or independently) at some but not other times of the day depending on a variety of factors.” Among these factors are verbal responses by staff regarding sedentary behavior, fatigue, withdrawn mood or sadness, social isolation, uncooperativeness, or disengagement. Thus, we can hypothesize that certain behaviors of patients (due to their health condition) trigger verbal offense by healthcare professionals which rather creates conflicts instead of adequately responding to the care recipient’s needs.

Patient A was isolated and at risk for social isolation, loneliness, cognitive decline, depression; patient B was diagnosed with anxiety and depression (Sabol et al. 2020). Self-care abilities vary in their degree of impairment, with some limitations being partially mitigated through the use of assistive devices. Both patients share a common reluctance or refusal to participate in therapies such as physiotherapy and adherence to diets. The abilities to structure daily life and social contacts of the patients differ significantly. Patient A exhibits minimal self-initiated interaction, whereas patient B is highly social and seeks companionship. Although the cases do not go into details of the influence of social relationships on the health condition, we can see differences in the patients’ behaviour and social relationships. We can take this as a hint to the heterogeneous group of older people with obesity, including a diversity and spectrum of their needs.

Regarding “unequal quality of care and treatment bias,” the cases illustrate that caring for older people with obesity requires special training in order to adequately respond to their needs, e.g., to operate specialized, heavy-duty lift equipment devices. Rotkoff (1999, p. 310) proposes the idea of a nursing care plan, which sets goals for medical, psychological, and social needs. Such a plan parallels plans for nonobese patients in terms of “self-care and maximal independence” (Rotkoff 1999, p. 312 f.), whereas goals regarding diets and meals and exercise are special. As a matter of care quality, Rotkoff (1999) describes skin care of patient C in detail, illustrating crucial emotional, material and physical challenges for the staff. Rotkoff (1999) also raises the new point that the facility’s therapists trained nursing assistants and professional staff. For instance, lifting techniques are demonstrated in order to avoid harm to both staff and patients. In contrast to the scoping review, this case emphasizes the influence of teamwork that is oriented toward the patient’s needs and well-being as a positive example.

Sabol et al. (2020) acknowledge that fear by both residents and staff can expose both groups to safety risks. They state that also the staff’s health is very important and needs to be included in organizational policies. However, in their view, “[a]ppropriate nursing responses to obesity-related behaviours include acceptance of refusal to reposition, increased administration to control symptoms such as pain, soliciting more staff to help reposition, or use lift equipment” (Sabol et al. 2020, p. 24 f.). Thus, it becomes evident that nurses are not only challenged physically, but that they need to develop a professional attitude towards the patients’ needs. Again, having in mind the results of the scoping review, such professional attitudes might be difficult to develop in a care setting which lacks adequate resources.

While the cases support and add to the results of the scoping review for the three categories above, it is striking that aspects of “vulnerability and justice” are almost absent. The cases are not taking up a more systematic perspective on costs or burdens; none is raising the conflict of balancing the needs of patients with obesity against other residents’ needs. This, in turn, illustrates that single person cases alone can rarely provide a complete picture, which speaks to the need for mixed methods studies going forward.

Although the cases do not provide a broader, more systematic view to ethical challenges facing older persons with obesity, in one instance, a glimpse into the importance of the social determinants of health is afforded. The biography of patient C reveals how socioeconomic factors may have played a role in her health status. Particularly owing to the context and time in the US, one can assume that the patient had little or no health insurance. At the point of her admission into the facility, her brothers took care of her, thereby lacking the professional skills and also the strength for adequate care. Although the case description does not overtly say so, we can interpret from the author’s sensitive description that the team was quite aware of social determinants of health influencing health status and also the quality of care for home residents. The case of patient C also illustrates that those caring situations are always highly relational. The staff tries to include the patient’s brothers in decision-making but this leads to a conflict since her relatives continue to bring food in addition to the meals at the clinic:

During Ms. B’s tenure at the LTC facility, she was complacent and emotionally detached. If she had chosen to participate in her care, treatment modes […] that could enhance her quality of life would have been given serious attention. Poor eating habits pervaded Ms. B’s life and those who cared about her, even in the facility. Ms. B’s siblings daily augmented the “house” 1800-calorie diet designed for her needs with high calorie snacks. The patient and her relatives resisted suggestions that they not do this and were polite but nonadherent with the staff. Neither Ms. B nor her family would consent to a psychiatric evaluation, so the staff had to perform palliative rather than curative care. (Rotkoff 1999, p. 312)

Although not explicitly stated, the case implies that patient C is an emotional eater (Samuel and Cohen 2018), maybe even with an addictive symptomatic.Footnote 9 This leaves the reader curious to know more about patient C’s story, her biography and eating habits, in order to understand the psychologically complicated for all actors involved (patient, relatives, and staff). A personal value of cooking and eating is also visible in patient B, who wants to cook and bake for herself, which was not allowed in the facility due to safety reasons (Sabol et al. 2020). Again, another case leaves us curious about the person’s story and her values—an aspect that was missed in the scoped literature.

Comparing the three cases, their analysis brings to the forefront that care needs do not necessarily increase with BMI: patient B has a higher BMI than patient A. However, patient B is more mobile and interactive (Sabol et al. 2020). The level of mobility in older people with obesity is as different as the level of mobility in persons without obesity. Less mobility is not necessarily linked to high body weight but can be based on a variety of reasons. Sabol et al. (2020) recommend restorative care recommendations: an ongoing nurse assessment with an evaluation of underlying causes of immobility. Although socially withdrawn, patient A was never diagnosed with depression or anxiety—as opposed to patient B, who was more active but also more vulnerable in term of psychological diagnostic. Again, this illustrates a variety and heterogeneity of the care takers which was not visible in the scoping review.

Identifying paths and crossroads in the ethical terrain

While our analysis presents a rather consistent picture of ethical challenges affecting older persons with obesity, the picture remains relatively small. That is, the number of published articles and cases on the topic is undoubtedly slight, making strong conclusions on the validity and generalizability of the findings difficult at best. Studies originating in Europe or Germany were rare or nonexistence, which illustrates the extent of the research gap. It also bears noting that ethical arguments were rarely teased out fully in the literature or served as the main subject of study. We will now discuss the results of our analysis in light of further interdisciplinary research on this topic.

Exploring needs of older persons with obesity and their carers

Our results shine a light on gaps that can direct future research regarding the care needs of older persons with obesity. In the context of Germany, where recent data points to approximately 20% of care-dependent individuals living with obesity (Albrecht et al. 2022), resources for LTC should be analyzed and projected (e.g., through health insurance data, scenarios and modelling) to adapt to changes in the population. However, while such quantitative studies are important to understand the need for care, they are also limited in their scope when it comes down to the needs of both institutions, care givers, and care recipients. As Miller (2020, p. 284) notes, we have to understand how “needy” people are in absolute terms and how needy they are relative to others. Are residents rejected due to their high body weight? How does the staff in concrete situations cope with multiple challenges? Would training ameliorate the situation? These are just some questions for further qualitative research in this field. Hypothesis generation from the cases can be a helpful source for identifying future research directions.

The case analysis clearly shows that residents’ health status as well as their adherence and motivation highly vary. Here, qualitative research could help to better understand patients’ needs within their social context. Eating habits and body weight are deeply linked to personal identity and biography, to traditions within family, friends, workplace or the wider community. Food, eating behavior, and emotions “occur in an interdependent web of relationship s” (Mulvaney-Day and Womack 2009, p. 252). Cooking and eating are social interactions. With whom, when, how and where people consume food, arises in a socioculturally shaped living environment. “Food experiences” (Barnhill et al. 2014, p. 188) are of particular value for many people. Food can be pleasure and comfort, and it can (de)stabilize “social bonds” (Barnhill et al. 2014, p. 190). People make food choices in certain sociocultural contexts where food experiences become valuable for them. Some studies report family histories in which food played a special role—for instance, as a reward or punishment (Brewis 2014). Some people “depend psychologically on food as a means of manipulating [their] immediate environment” (Gilman 2010, p. 114). The meaning of such food biographies for LTC is widely unexplored. For older people in particular, it might be challenging to change eating habits that developed over decades. Some people might experience externally determined changes of food habits as patronizing or assaulting.

From the case studies, we can assume that patients find their own—sometimes unhealthy—coping strategies if their food habits are ignored. Staff or family members are influenced to bring in external food, or the patient refuses cooperation as a reaction to their neglected needs. All three cases give illustrative examples in portraying three women for whom cooking and eating are highly private, intimate actions—they prefer to cook by themselves and eat with their families or alone in their rooms. As the selected case studies do not elaborate further on the biographical reasons for this, they once again elucidate the necessity for more qualitative research in this field.

Balancing needs and allocating resources

Based on the assumption that demographic change will increase costs in the healthcare system, age as a distributive criterion has been extensively discussed in the context of social justice and health equity for older persons (Schweda et al. 2018; Schweda 2013). Our analysis illustrates that nursing older people with obesity requires systematic normative reflection, including on the allocation of material and nonmaterial resources (the need). Reflections on fair debates about these allocation processes are striking against the backdrop of staff shortage in care. Daniels (2001) develops criteria for allocating healthcare services to meet competing healthcare needs fairly under reasonable resource constraints. He defines needs in terms of functional capacities or capabilities that are essential for individuals to pursue a fully realized life. Daniels argues that health needs are not solely based on the preferences or the desires of individuals, but are linked to the basic requirements for functioning as a normal human being in a given society. Healthcare, he argues, is tasked with maintaining or restoring individuals’ “normal functioning” (Daniels 2001, p. 2.) to compensate for poorer opportunities. In the case of older people, however, physical limitations are part of the aging process and do not necessarily indicate a disease. Social resources, well-being, and the ability to cope with life crises are also factors in limiting life chances, but they remain largely ignored in the discussion of distributive justice and age rationing. For a full picture of the situation, we argue that the needs should be included into this normative analysis, because abstract quantified need and concrete, subjective needs do not necessarily overlap. Moreover, when balancing needs in the future, we should consider both the residents and the staff’s needs. As both the findings of the scoping review and case studies illustrate, the health and well-being of care personnel stands to be jeopardized by work-related injuries due to the lack of equipment available for caring for patients with obesity.

A needs-based perspective potentially turns abstract ethical debates into bottom-up ways of decision-making on resource allocation, which respects complex care needs of the older persons detached from the pervasive stigma that underlies obesity. So far, little attention has been paid to need-based claims, as theories of justice are rather considered as a matter of rights and obligations (Miller 2020). A needs-based perspective also includes psychological and emotional needs. However, within standard debates on resource allocation, “needs are defined by medical doctors, by health service planners and occasionally by politicians rather than by the community” (Mooney 1998, p. 1173). While it is important to discuss resource allocation on a political level, there is a risk of exclusion and bias when the affected and their needs are not adequately included (Schicktanz et al. 2012). It is therefore crucial that any policy making discussions and processes involve multiple stakeholders (e.g., self-help groups, nurses, health insurers, policy makers, gerontologists) and include longstanding specialists on obesity, especially regarding its psychological, psychiatric and social implications.

Alongside considerations of balancing needs, it is also necessary to ask whether care needs should have certain limits. As the case of patient C illustrates, a constant desire to consume food might be mistaken as a need. However, such desire might also be classified as self-harm, and there might be good reasons not to respond to it. From the results of the scoping review, we see conflict between patient autonomy and beneficence in cases where patients are resistant to nutritional recommendations and efforts to improve their health, while the staff knows this will worsen their situation.

Further conflicts arise if residents are rejected by nursing homes due to their body weight. Although this seems very unfair at first sight, our analysis shows that if a facility is not properly prepared, then taking in a resident with obesity is harmful to both the affected person and the staff. Moreover, if the institution is underequipped and understaffed, taking care for this resident blocks capacities for the care of others. Our analysis suggests that this is rather dealt with on a case-by-case basis at the moment. However, keeping in mind the developing prevalence, we see a necessity to reflect systematically on these issues in the future.

Developing needs-based practical solutions

There are two ideas from the case studies, which we consider bearing in mind when thinking about the future of LTC for older persons with obesity. First, Rotkoff (1999) proposes the vision of changing the infrastructure into special care facilities for patients with obesity. Such special care facilities could provide all the resources needed (lift, environmental facilities, etc.) as standard. They could integrate specialized technical equipment and could also educate the staff on the various aspects of obesity. Such special care facilities already exist for other populations, such as for individuals with dementia. Facilities are designed to provide a supportive and safe environment tailored to the unique needs of those with dementia-related conditions (Alves et al. 2024). Second, Sabol et al. (2020) brought forward the idea of digital tools in assisting the nursing process. In their intervention study, digital tools could assist in monitoring movement and mobility of residents with obesity, serving as objective and data source and countering biased or stigmatizing views of health personnel. Wearable technology documents residents’ movements on a larger scale, which is more reliable than BMI alone. This technology also serves as a warning system within the facility, reminding nurses to (re)evaluate their patients.

Another promising idea can be found in Schneider and Li (2016) who analyze a case of clinical ethics counseling which centers normative questions from a clinical case view. To our knowledge, such cases have not been reported from Germany, and ethics counseling in LTC is only beginning to be implemented (Riedel 2015). Discussing such a case within the institution but also within the medical and ethical community (including students of medicine, public health, and nursing) could be a first step to developing practical, needs-based solutions.

Conclusion

Rotkoff (1999) stated already 25 years ago that the cost of caring for older persons will increase, as facilities will inevitably need to take in more residents with obesity due to rising prevalence in the population. Not only has this proven to be true, it is a fact that has given rise to a series of ethical concerns that we have aimed to shed light on in this paper and thereby raise awareness on the complex interplay of nursing, obesity, and old age.

As the analysis shows, the needs of persons with obesity appear to place special moral duties on providers. Moreover, a number of alarming deficits in access to and quality of complex care provided to this population can be observed in the scoping review. In addition, studies show evidence for strong provider biases against patients and report a lack of standards in bariatric care. These, in turn, may be contributing to the negative care experiences and inequities in access to care. However, through the case analysis, we see institutions with professional teams well aware of stigmatization processes. Such teams follow ethical codices of nursing. The cases add two issues rarely mentioned in the review: the necessity of teams to communicate about the cases, to find standardized ways of training and to minimize harm for both staff and patients. All cases illustrate that patients’ progress and health status depend, at least in part, on staff attitudes, viz. whether a caregiver motivates them or rather reinforces their anxieties.

The three cases highlight that standards of care vary greatly within the respective social and institutional context of care. Emotions and relationships are important factors that influence both the patients’ and the staff’s decisions and actions. Understanding the relevance of biographies and other social factors, combined with ethical reasoning and practical decision-making, will hopefully respond to constitutive needs of care takers and patients.

Our paper is limited to depicting what is a rather scant, state-of-the art at this point, leaving normative guidance on balancing needs in concrete situations for future empirical–ethical work. The sources of the scoping review were not derived from Germany, but mainly from other European countries and the US. Consequently, the generalizability of the results is limited, given the differences in healthcare systems between countries. Additionally, substantive distinctions exist in the design of LTC services. This constrains the applicability of the scoping review results and simultaneously underscores the research gap within the German-speaking region.