Training physicians to tackle obesity and motivate patients has been attracting greater attention from academic medicine—and with good reason.
In the United States, 30.6 percent of adults were obese, according to data collected in 2015 from the U.S. Centers for Disease Control and Prevention (CDC). In 1997, the CDC reported that rate was 19.4 percent.
Recognizing that no one can solve the obesity crisis alone, health professionals are teaming up—from medical educators and researchers to psychologists and bariatric surgeons—to address the national problem through multipronged strategies.
Although stress, nutrition, physical activity, metabolic rate, and changes in circadian rhythm have an effect on obesity, “there’s usually more to the story,” said W. Scott Butsch, MD, MSc, an instructor at Harvard Medical School and an obesity medicine specialist in the Weight Center at teaching affiliate Massachusetts General Hospital. “It’s a complex picture.”
The challenges in treating obesity may be compounded by physician bias or simply limited understanding about causes and treatments. “It’s more than just somebody not eating the right foods,” Butsch said. “Often times, that’s the perception, especially if we see somebody who is overweight and eating a bag of chips. But if we saw somebody thin eating a bag of chips, we wouldn’t think the same thing.”
The University of Mississippi Medical Center (UMMC) and School of Medicine have made a major commitment to obesity research and treatment. Mississippi has the third-highest incidence of adult obesity in the nation (35.5 percent), only slightly lower than Arkansas and West Virginia, according to 2014 data from the CDC.
To address this population health problem, UMMC launched the Mississippi Center for Obesity Research in 2013. Jussara M. do Carmo, PhD, an assistant professor in the Department of Physiology and Biophysics at the University of Mississippi School of Medicine, has been studying the role of leptin—a hormone released by fat cells.
“We are trying to understand how this hormone works in the central nervous system to differentially regulate appetite, body weight, glucose uptake, and blood pressure,” she said.
Many medications approved to treat obesity had adverse side effects and were withdrawn from the market. Others have not proven to be effective. The patient may initially experience an appetite-reducing response that results in weight loss, but that effect dissipates with continued use, and over time, the brain tries to adjust back to the body weight before treatment, do Carmo explained.
Obesity education and training
Eric Westman, MD, MHS, teaches an elective four-week rotation on obesity management to fourth-year students at Duke University School of Medicine, where he’s an associate professor and director of the Duke Lifestyle Medicine Clinic.
On a patient’s first visit, Westman supervises his trainees as they take a detailed medical history and conduct a physical exam. The patient is also asked about factors fueling the interest in implementing a lifestyle change. Is it the desire to become healthier? To see children or grandchildren grow up? To live a long life?
“The treatment of someone affected by obesity is so complicated and individualized that you really do need to take a comprehensive approach for each person,” said Westman, former president of the Obesity Medicine Association.
“Patients will come and say, ‘You’re actually the first doctor who asked me to tell my story about obesity,’” he said. For some, general life stress could be the culprit. For others, having children left little time to exercise. And for another subset of patients, addictions to certain foods or ingredients, such as sugar, led to unhealthy weight gain.
Yolanda Lewis-Ragland, MD, an obesity clinician and researcher at the Children’s National Health System in Washington, D.C., would like to see more medical education about the toxic effects of processed foods and overconsumption of carbohydrates and sugar, as well as about the negative effect of sleep deprivation on the immune and digestive systems. Yet, current curricula place more emphasis on hypertension, high cholesterol, diabetes, and fatty liver disease, she said.
Nutrition education is in dire need of a boost, according to Martin Kohlmeier, MD, PhD, who has been following nutrition curriculum at U.S. medical schools since 2000. On average, U.S. medical schools offer 19.6 hours of nutrition-related education across the entire four-year curriculum. Kohlmeier, a research professor in nutrition at the University of North Carolina (UNC) Schools of Medicine and Public Health, noted that this is “significantly less” than the recommended minimum of 25 hours of nutrition instruction. “Many highly motivated residents and students are clamoring to learn about nutrition because they know they need the skills.”
Kohlmeier developed a program that uses a virtual patient, allowing students and physicians to practice nutrition counseling. “The more they use it, the better they get,” he said. “The patient even talks back if the learner ignores the patient’s needs.”
Treatment concerns
Serving on the Obesity Medicine Association curriculum committee, Lewis-Ragland is helping develop coursework to identify and manage obesity. A pilot study is under way at four medical schools. The curriculum committee devised an algorithm to identify which protocol—depending on the patient’s age, body mass index, and any comorbidities—a clinician should follow in treating obesity. The goal is to set a “gold standard” of education and treatment of obesity by medical providers.
Keeping an open mind and remaining nonjudgmental are also important considerations in treating patients who struggle with weight loss, noted Butsch, who has observed “weight bias” among health care professionals. The prevailing attitude is that excess weight and obesity stem mainly from behavioral issues, but that’s not necessarily the case, he said.
For instance, one of Butsch’s patients developed uncontrollable hunger and gained 200 pounds after resection of a benign tumor from an area of the brain that controls food intake and energy expenditure. Other patients gained weight after starting medications for other conditions or working the night shift.
“Patients will come and say, ‘You’re actually the first doctor who asked me to tell my story about obesity.’”
Eric Westman, MD, MHS
Through doctor-patient role-playing, Butsch’s students learn how to counsel patients, which can include fielding questions about fad diets or managing a patient’s expectations. Students also study the physiological mechanisms affecting weight and the potential differing responses to lifestyle changes, medications, or surgery.
A paradigm shift is needed to focus on prevention of obesity, particularly in young people, Lewis-Ragland said. “If we could actually train pediatricians and family medicine docs to understand the science behind early intervention for children facing obesity and convey their concerns to parents with compassion and understanding, then we would really make the progress we need to make.”
On a national level, Butsch is a member of the Obesity Medicine Education Collaboration (a small group of educators from the Obesity Society and the Obesity Medicine Association) formed in March 2016, and an education working group within the National Academy of Medicine. Together, they plan to develop core competencies and professional activities for undergraduate medical education, physician residencies, and other health professions.
Malika Fair, MD, MPH, senior director for health equity partnerships and programs at the AAMC, noted that some nonprofit medical centers are exploring strategies to reduce obesity in response to federal requirements of the Patient Protection and Affordable Care Act to conduct health needs assessments every three years. “This is a perfect opportunity for medical educators to work with health system officials on education efforts that align with hospital plans to reduce local obesity rates,” she said.