Robert Dorfman, a fourth-year student at Northwestern University Feinberg School of Medicine, has seen his fair share of weight-loss fads: there’s the pizza diet, which requires people who partake to live on pizza alone, and the bulletproof diet, which instructs participants to put butter in their coffee.
But it was during his primary care rotation in 2017 that he realized just how misinformed patients were about achieving a healthy weight.
“There are a lot of crash diets out there. We’d see this all the time,” says Dorfman. “It’s such a complex topic, and I think that’s why there’s so much confusion around it.”
Confusion over effective weight-loss practices is one of the many factors fueling the obesity epidemic. So are unhealthy eating habits. Indeed, a study in The Lancet released in April 2019 found that 1 in 4 deaths globally can be traced to a poor diet. This includes high consumption of salt, sugar, saturated fats, processed meats, and sugar-sweetened beverages.
And the obesity epidemic continues to grow. In the United States, 18.5% of children and nearly 40% of adults were obese in 2015-16, according to the most recent National Health and Nutrition Examination Survey (NHANES). Those are the highest rates ever documented by NHANES, up from 13.9% of children and 30.5% of adults in 1999-2000.
“Medical schools respond to crises like the opioid epidemic. Obesity clearly doesn’t have that sense of a crisis or urgency, but [it’s] an important chronic disease.”
Robert Kushner, MD
Feinberg School of Medicine
Given this reality, medical schools need to do much more to train future physicians about obesity, says Robert Kushner, MD, professor of medicine at the Feinberg School of Medicine.
“Medical schools respond to crises like the opioid epidemic,” adds Kushner. “Obesity clearly doesn’t have that sense of a crisis or urgency, but [it’s] an important chronic disease.”
In response to the obesity crisis, some medical schools are weaving obesity education throughout all four years of curricula. Because the disease affects the entire body, students learn about it from multiple angles: biology and epidemiology, environmental factors, the role of nutrition and exercise, and more. And because obesity can be so difficult to discuss, students also learn how to talk effectively about it with patients.
“Obesity is the biggest nutrition problem we face,” says Craig Jensen, MD, associate professor of pediatrics at Baylor College of Medicine, who incorporates obesity into his classes. “Every person in medical school is going to be impacted by obesity.”
Obesity as a disease
After extensive research and debate, the American Medical Association designated obesity a disease in 2013. Advocates of the move hoped it would help reduce the stigma around obesity and draw attention to the condition’s many dangers.
Obesity is among the leading causes of cardiovascular disease, and it is estimated to cause 20% of cancer cases. In addition, weight gain and high body mass are the primary drivers of the rising incidence of diabetes. And the disease is quite complex, with subtypes that include congenital, stress-induced, and menopause-related obesity.
In 2018, to help academic medicine better prepare future physicians to understand and address obesity, the Obesity Medicine Education Collaborative released 32 comprehensive competencies. These competencies include the ability to take an obesity-related history and a full knowledge of treatment options, explains Kushner, who is a member of the collaborative’s steering committee. They also include effectively educating patients about obesity and knowing how to use appropriate, nonjudgmental language when discussing it.
“One of the toughest things is just getting the subject out there as something to be acknowledged by the doctor and patient.”
St. Louis School of Medicine
Patient communication also is one of 10 competencies that the Stop Obesity Alliance, a group that represents 20 leading health organizations including the AAMC, created in 2017 to help providers in numerous specialties better treat patients with obesity. “Such competencies provide a means to identify gaps in curricula and to design assessment strategies that can guide learners’ development,” says Lisa Howley, PhD, senior director of strategic initiatives and partnerships at the AAMC.
Talking sensitively with patients who may have long borne the burden of excess weight is essential, says Kimberly Zoberi, MD, clerkship director at the Saint Louis University School of Medicine.
“We encourage students to use proper, nonjudgmental terminology,” she says. “One of the toughest things is just getting the subject out there as something to be acknowledged by the doctor and patient.”
Learning the basics of obesity
At Baylor College of Medicine, students learn about obesity at times throughout all four years, starting with a basic understanding of the disease and its etiology. The topic is also woven into related courses, such as those that cover cardiovascular and endocrine functions. The issue isn’t addressed by just a single department, notes Jensen. “We recognize that it has to be a team approach to treating obesity,” he says.
Some schools make sure to examine obesity through the lens of health equity and social determinants of health. Rates of obesity are high among some racial and ethnic groups, report the Centers for Disease Control and Prevention, with a prevalence of roughly 47% among Hispanics and non-Hispanic blacks. In contrast, prevalence among non-Hispanic whites is 37.9%.
At Duke University School of Medicine, for example, students learn about how food deserts and neighborhoods saturated with fast-food options contribute to obesity, says Don Bradley, MD, consulting professor in family medicine and community health at Duke.
“We look at obesity rates among ethnic groups, and we try to get the students to think about what can be done about the prevalence in certain communities,” he notes.
Nutrition and exercise
Before students can teach patients about healthy eating, they need to learn how to make their own changes in the kitchen, says Laura Moore, RD, director of the Nourish program at the University of Texas Health Science Center at Houston School of Public Health.
To that end, the school built a holistic garden in the medical center, along with a research and demonstration kitchen. Students can take an eight-week extracurricular course where instructors teach them to focus on food rather than the issue of obesity.
“We take them through the process of learning how to cook and teaching patients [about] how to cook,” Moore says. “They all prepare two or three recipes and go to discussion rooms to talk about how flavor impacts people’s diet choices.”
“They learn basic skills,” Moore says. “They learn how to cook. That’s the first step.”
At The George Washington University (GWU) School of Medicine and Health Sciences, students learn such essentials as the basic recommendations for physical activity: 150 minutes each week of mild to moderate exercise.
“We take them through the process of learning how to cook and teaching patients [about] how to cook.”
Laura Moore, RD
University of Texas Health Science Center at Houston School of Public Health
Less than 50% of physicians know the recommended dose of exercise, according to William Dietz, MD, PhD, director of the Sumner M. Redstone Global Center for Prevention and Wellness at GWU’s Milken Institute School of Public Health.
“Many people with obesity have tried unsuccessfully to lose weight,” Dietz notes. “The standard practice is just to say, ‘You need to exercise and eat better,’ but there needs to be more guidance.”
Surgery and other solutions
Because exercise and nutrition aren’t always enough to treat obesity, students also learn other approaches.
At the John A. Burns School of Medicine at the University of Hawaii at Manoa, students get a comprehensive education on treatment options for obesity, including pharmacology and surgery.
To put treatments into context, Cedric Lorenzo, MD, medical director of the bariatric program at the University of Hawaii Department of Surgery, provides one-hour guest lectures to classes in which he discusses local and national obesity trends.
Residents participate in the school’s Queen’s Comprehensive Weight Management Program, which uses weight-loss physicians, surgeons, dietitians, behavioral health specialists, and bariatric nurses to treat patients with obesity. Residents and medical students doing third-year clerkships or fourth-year subinternships get firsthand experience in the clinic and operating room working with patients affected by obesity-related issues like heart disease and diabetes.
“Patient contacts and the health issues they present become springboards for discussion and learning opportunities with our students and residents about the epidemiology, pathophysiology, and impact obesity has on the individual and society,” says Lorenzo.
At Saint Louis University School of Medicine, students learn about bariatric intervention during their surgery rotation. They also learn about pharmacology, including how certain medications like antidepressants can contribute to weight gain.
In the past, Zoberi explains, such information was covered in a formal class dedicated to obesity. The school opted to change the approach, though, to make the topic more relevant to students and to connect it to related health areas, threading it holistically throughout the curriculum.
Such a holistic approach makes a lot of sense, notes the AAMC’s Howley. “Obesity care and other complex public health topics require creative integrated and longitudinal approaches to curriculum design,” she says.
Learning to communicate
At medical schools across the country, students learn that the power of words is also a key component of treating obesity.
Dorfman says he felt prepared to talk to patients because he was taught some specific techniques.
“One super important thing I’ve learned is the concept of motivational interviewing,” he notes. “The biggest factor that drives change is their own motivation. If I can figure out what they think they can be doing differently, they’re much more likely to do that than if they’re sitting and being lectured.”
At Baylor College of Medicine, students also learn how to talk to patients, including recognizing where the patient lies in the continuum of readiness to change. Is the patient in the precontemplation stage, meaning they are not really ready to think about making modifications? Are they in the contemplation stage, when they’re starting to think about lifestyle changes?
Students also learn to resist the urge to dictate what a patient ought to do and instead ask open-ended questions in an attempt to understand where the person’s motivation lies.
“We practice with role-playing,” Jensen notes. “We recognize and discuss that many patients often become discouraged. There is usually a series of small but important victories.”