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Conversations With the Editors: Combating Caregiver and Patient-Perceived Obesity Stigmatization

2021; Elsevier BV; Volume: 43; Issue: 7 Linguagem: Inglês

10.1016/j.clinthera.2021.05.001

1879-114X

Fatima Cody Stanford, Jill L. Maron,

Obesity, Physical Activity, Diet

View Large Image Figure ViewerDownload Hi-res image Download (PPT) Featured Guest Biography: Dr. Fatima Cody Stanford practices and teaches at Massachusetts General Hospital/Harvard Medical School (HMS) as one of the first fellowship-trained obesity medicine physicians in the world. Dr. Stanford received her BS and MPH from Emory University as an MLK Scholar, her MD from the Medical College of Georgia School of Medicine as a Stoney Scholar, her MPA from the Harvard Kennedy School of Government as a Zuckerman Fellow in the Harvard Center for Public Leadership, and her executive MBA as a scholarship recipient from the Quantic School of Business and Technology. She completed her Obesity Medicine & Nutrition Fellowship at Massachusetts General Hospital/HMS after completing her internal medicine and pediatrics residency at the University of South Carolina. She has served as a health communications fellow at the Centers for Disease Control and Prevention and as a behavioral sciences intern at the American Cancer Society. Upon completion of her MPH, she received the Gold Congressional Award, the highest honor that Congress bestows upon America's youth. Dr. Stanford has completed a medicine and media internship at the Discovery Channel. An American Medical Association (AMA) Foundation Leadership Award recipient in 2005 and an AMA Paul Ambrose Award for national leadership among resident physicians in 2009, she was selected for the AMA Inspirational Physician Award in 2015. The American College of Physicians selected her as the 2013 recipient of the Joseph E. Johnson Leadership Award, and the Massachusetts American College of Physicians selected her for the Young Leadership Award in 2015. She is the 2017 recipient of the HMS Amos Diversity Award and Massachusetts Medical Society (MMS) Award for Women's Health. In 2019, she was selected as the Suffolk District Community Clinician of the Year and for the Reducing Health Disparities Award for MMS. She was selected for The Obesity Society Clinician of the Year in 2020. In 2021, she was awarded the MMS Grant Rodkey Award for her dedication to medical students and the AMA Dr. Edmond and Rima Cabbabe Dedication to the Profession Award, which recognizes a physician who demonstrates active and productive improvement to the profession of medicine through community service, advocacy, leadership, teaching, or philanthropy. Featured Guest Biography: Dr. Fatima Cody Stanford practices and teaches at Massachusetts General Hospital/Harvard Medical School (HMS) as one of the first fellowship-trained obesity medicine physicians in the world. Dr. Stanford received her BS and MPH from Emory University as an MLK Scholar, her MD from the Medical College of Georgia School of Medicine as a Stoney Scholar, her MPA from the Harvard Kennedy School of Government as a Zuckerman Fellow in the Harvard Center for Public Leadership, and her executive MBA as a scholarship recipient from the Quantic School of Business and Technology. She completed her Obesity Medicine & Nutrition Fellowship at Massachusetts General Hospital/HMS after completing her internal medicine and pediatrics residency at the University of South Carolina. She has served as a health communications fellow at the Centers for Disease Control and Prevention and as a behavioral sciences intern at the American Cancer Society. Upon completion of her MPH, she received the Gold Congressional Award, the highest honor that Congress bestows upon America's youth. Dr. Stanford has completed a medicine and media internship at the Discovery Channel. An American Medical Association (AMA) Foundation Leadership Award recipient in 2005 and an AMA Paul Ambrose Award for national leadership among resident physicians in 2009, she was selected for the AMA Inspirational Physician Award in 2015. The American College of Physicians selected her as the 2013 recipient of the Joseph E. Johnson Leadership Award, and the Massachusetts American College of Physicians selected her for the Young Leadership Award in 2015. She is the 2017 recipient of the HMS Amos Diversity Award and Massachusetts Medical Society (MMS) Award for Women's Health. In 2019, she was selected as the Suffolk District Community Clinician of the Year and for the Reducing Health Disparities Award for MMS. She was selected for The Obesity Society Clinician of the Year in 2020. In 2021, she was awarded the MMS Grant Rodkey Award for her dedication to medical students and the AMA Dr. Edmond and Rima Cabbabe Dedication to the Profession Award, which recognizes a physician who demonstrates active and productive improvement to the profession of medicine through community service, advocacy, leadership, teaching, or philanthropy. Jill Maron, MD, MPH: Dr. Stanford, thank you so much for being here with us today. I want to start by recognizing that you have been such a champion and leader in changing the paradigm of how we address obesity in our health care. You've done this on 2 levels, both at the American Medical Association level talking about how we describe individuals with obesity using person-first language, as well as getting the medical community to define obesity as a disease. Can you discuss the importance of these recognitions for the field? Fatima Cody Stanford, MD, MPH, MPA, MBA: Absolutely. First, thank you so much for having me here today. It's a delight to be able to bring my knowledge and passion for the subject of obesity as it relates to patient care. So first, when we look at obesity as a disease and its importance, I want to take us back to the historic roots of just 2013 when the American Medical Association decided to acknowledge obesity for the disease it is. And the reason why that shift, which happened not so long ago, was important is that if we don't recognize it for disease that it is, then we will continue to place blame and shame on patients. We will continue to actually not treat the disease that is obesity. What we do know about obesity as a disease is that it actually has pathophysiology. The most important organ to regulate our weight is our brain, particularly the hypothalamus, because it receives inputs about whether or not to store food or whether or not it will burn food. That is really governed by 2 primary pathways in the brain—the proopiomelanocortin pathway in the paraventricular nucleus of the hypothalamus, which is anorexigenic, and the agouti-related peptide pathway in the hypothalamus, which is orexigenic, or causes us to store more. When we recognize the complex pathophysiology of obesity, we can begin to offer the care for our patients across the age spectrum, whether they are pediatric or adult. Recognizing that we will always look at lifestyle modifications as the big kind of base of the pyramid in terms of our approach to care for patients across the age spectrum, and recognizing that there are evidence-based modalities of therapy that go beyond that, we will explore modalities such as pharmacotherapy for the treatment of obesity and endoscopic therapies and/or metabolic and bariatric surgery. These approaches ensure that patients have the proper tools to help them navigate this disease, which is the precursor for >200 other diseases that we know of. Dr. Maron: That's great. As we talk about obesity as a disease, I wanted to get your input on how society has had a long history of stigmatizing individuals with obesity and how this disproportionately affects minority and lower income individuals and families. I know you've done work in this area as well, and I wanted to give you an opportunity to also discuss that. Dr. Stanford: Absolutely, well thanks, this is a really important question, and this gives me a chance to talk about bias. I'm going to talk about the 2 most common forms of bias that we have here in the United States. The most common form is race bias. A very, very close second place is weight bias. So, when you brought up a very important question of how do we deal with this idea of weight bias and stigma in the general population and then, how this disproportionately impacts communities of color, you can imagine if we had a Venn diagram, we have this overlap of race and weight bias. For those who are from communities of color who have obesity, they are disproportionately impacted on their ability to navigate their daily lives, in terms of things such as being hired for roles that they are qualified for but may not fit the aesthetic appeal either by their racial status and/or by weight status for such roles. And let's go back and look at weight bias. We know that is indeed acceptable, it's germane in our media, for us to be able to make fun of those who have excess weight. Often people in the media who have excess weight are portrayed as eating poor-quality foods, being inactive, being slothful, and being lazy. So, the presumption is if someone happens to have excess weight that that must be their behavior types. This is so germane to the thinking that when I see a patient for their initial visit, much of what I'm having to do during that visit is undo that negative thinking so that we can just have a dialogue about what's led to their obesity, and I can begin to find the proper treatment modalities to address it. They have a defense mechanism. Their engagement with the health care community has also set them up for this need to prove that they are who they say they are, and they've been doing the things that they've been saying they're doing as their brain defends a higher set point for weight. So that bias that is pervasive in the larger community, is perhaps even more harmful in the health care community when patients are coming in for trusted advice, for care, and finding that because of their weight status, they're getting lesser care or being judged based upon whatever biases, both implicit and explicit, that we have about those that have obesity. That race piece—let's bring that into the piece of the puzzle here. What we do know is that racial and ethnic minority populations by far have higher rates of obesity. This starts in early life. If we were looking at young children, we know Hispanic boys here in the United States have the highest rates of obesity, followed by black girls. If we look at the adult population, we know that black women have the highest rates of obesity. Now it's a complex relationship as to why we see this disproportionate impact of obesity in these communities. We can talk about measurement, BMI, for example, or body mass index. It's based upon Metropolitan Life Insurance tables from the 1930s, which did not consider people that look like me. This was an actuarial table that was used to determine life expectancy based on what they were seeing from data from white individuals in the 1930s. But even with the recent data that I published where I've redrawn the BMI chart, it does show some differences, for example, for black women.1Stanford FC Lee M Hur C. Race, ethnicity, sex, and obesity: is it time to personalize the scale?.Mayo Clin Proc. 2019 Feb; 94 (PMID: 30711132; PMCID: PMC6818706): 362-363Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar We see a slight shift up from a body mass index of 30 which is what we typically define as obesity, to somewhere between 31 and 33 depending on what other obesity-related diseases they may have. We still know that there's a big disproportionate impact. I've recently written on obesity and systemic racism. Coming out of the Black Woman's Health Study in 2014, Dr. Yvette Cozier showed that both every day and lifetime racism lead to higher obesity rates,2Cozier YC Yu J Coogan PF Bethea TN Rosenberg L Palmer JR. Racism, segregation, and risk of obesity in the Black Women's Health Study.Am J Epidemiol. 2014 Apr 1; 179: 875-883Crossref PubMed Scopus (85) Google Scholar which I really think is characterized by higher levels of inflammation associated with stress. Higher levels of interleukin-1, interleukin-6, tumor necrosis factor-α, monocyte chemoattractant protein-1, and C-reactive protein, for example, which causes storage of adipose tissue or fat tissue, which then leads to higher obesity rates. So, the chronic stress of racism is a contributor but not the only contributor. It's a very complex interplay. There's so much to discover in this space. It's why my work in this space is so exhilarating. It's because every single time you think you're about to get an answer, you have 10 other questions, and so you have this constant proliferation of knowledge that needs to be acquired to do the best service for patients on the ground. Dr. Maron: You brought up so many really important points. I'm going to focus on the bias first. Since it is so tangible to all of us right now, let's talk about access to coronavirus disease 2019 (COVID-19) vaccines and how obesity was considered a morbidity that allowed you to have the vaccine. Society really viewed that in some ways even more stigmatizing to the population. I know you were heavily involved in reducing that stigmatization. Can you discuss how this most recent event brought so much of what you just discussed to the forefront? Dr. Stanford: Absolutely. First, it's a great question that you posed here. As I work to undo the stigma associated with obesity, it is important for patients to realize obesity is a disease, rising to the top one or two conditions prioritized for the COVID-19 vaccine. So in my interviews, I ask people about feeling kind of guilty for being able to access the vaccine earlier because of their obesity if they would feel the same way if they were able to access the vaccine because they had cancer, or diabetes, or heart disease or any other any other disease process that is chronic in nature. The resounding answer that I would get is "no." It is because they recognize those as diseases, and they recognize their obesity as just something that they have that they caused themselves, based upon their lack of willpower. That's what they've been taught. When you begin to change the narrative and explain to them how this is a disease, then they recognize—Oh, my goodness I've even had those biases against myself because I presumed that it was my failure as a human. That's how patients with obesity often view themselves. Their failures as a human led them to this disease that now leads them to being able to access this vaccine, for the first time in their lives actually getting a "benefit" for their disease of obesity. Once people recognize obesity as a disease, they don't feel that same pressure or guilt because it's not something that they caused themselves. Not to say they weren't a contributor, because I want to be clear on that. Some people think, well you're taking all the blame, you're putting it all on pathology and, yes, maybe there are certain things they may have done wrong. But similarly, we could say that maybe there were certain things that may have led to someone having diabetes, or similarly with heart disease. But we don't place that same blame on them. We need to change that mantra and that thinking. Once we can change that thinking we can shift the stigma associated with obesity, particularly with COVID-19. We do know with COVID-19, what I call a "disaster" associated with poor outcomes, sickness, and death with obesity, is that obesity is a chronic inflammatory condition. People don't see it that way, but it is. And we have this acute inflammatory condition of COVID-19. When you bring this acute inflammatory condition into a chronic inflammatory milieu, the interaction between those 2 disease processes is less than ideal, which is how we began to see obesity continue to rise in level of importance. If we looked at the early beginnings of the pandemic in the United States, the Centers for Disease Control and Prevention placed only those with severe obesity—body mass index of ≥40—at the list of consideration for poor disease associated with COVID-19. But very quickly, within about a 2-month period, they changed it to include obesity across the spectrum, because they recognize it wasn't just those who had severe obesity. It was those who had obesity, regardless of severity. That's the rationale behind why obesity is a strong consideration for access to the COVID-19 vaccine. I say to people, don't feel guilty, it is a disease, it warrants consideration. There's true pathophysiology, and as doctors we can help you live your healthiest life with this disease obesity. Dr. Maron: You mentioned so much about the importance of self, and, I imagine from your own experience, that is critical to success. Dr. Stanford: Absolutely. Dr. Maron: I don't know if you want to elaborate any more on that. When we talk about your own strategies, are there certain approaches you take with your patients to really get that critical piece across to them? Dr. Stanford: Absolutely. First of all, every single patient, if they can hear me right now, would be shaking their heads. Before they see me for their initial visit, I have them watch a video of a talk I delivered for the Radcliffe Institute, Obesity: It's More Complex Than You Think. The link is https://www.youtube.com/watch?v=Aoh7tYBjeGc. The reason why I have them watch that is because if they don't have that knowledge before we start our initial visit, I am spending that entire hour, yes, 1 hour, just trying to undo all of the negative things that they've learned about themselves or their negative thinking about themselves because of something they've done wrong. Which won't allow me to get to the work that I need to do to offer them the best treatment plan or strategy. So, when I have them watch that, when I begin my conversation or approach to the discussion surrounding obesity, they have a framework that is different from what they've often gotten from anyone before they see me. So that's number one. Number two—one of the early questions that I ask in my initial visit is, do you believe you have a healthy diet? I often get all of these tangents of considerations. I just asked them a very simple question, do you think you have a healthy diet? I see it as a yes or no response. But because they've had such a lifetime of trying to prove to their doctor, they're doing whatever, I usually have to stop and say, look I'm not judging. I just want to know what you believe. Yes or no? And so I have to reel them back in. I also must change their language about themselves often during the visit, especially the initial visit and those earlier follow-up visits. Often, they're calling themselves derogatory names or terms such as "fat" or "morbidly obese" or any of these types of things. And I tell them, stop, I will not finish the visit. Let's change the language. You can say I'm someone who has had severe obesity. And they'll say well, you're going make me say that? Yes, I am, or I will not continue the visit. So it's about changing how they think about themselves because that can really hinder our ability to make progress. I tell them, look I'm the coach. You are the star player. I can sit on the sidelines and coach you, but if you don't show up for the game, the game isn't played. So, I need their head in the right space to be able to play this game, which is how we're going to address their obesity, with them at the center. Dr. Maron: So let's go off that theme of therapy and tie in both your treatment strategies as well as the biases and the disparities you have written about. I want to actually quote something you authored in a recently published article regarding "a higher prevalence and reduced treatment response to lifestyle behavior, pharmacotherapy, and surgery in racial and ethnic minorities."2Cozier YC Yu J Coogan PF Bethea TN Rosenberg L Palmer JR. Racism, segregation, and risk of obesity in the Black Women's Health Study.Am J Epidemiol. 2014 Apr 1; 179: 875-883Crossref PubMed Scopus (85) Google Scholar What factors do you think contribute to these outcome discrepancies? Dr. Stanford: So, I think there are so many different contributors to why we see differences in response. Number one, I think genetics plays a role. We've had some recent GWAS or genome-wide association studies that show certain variance, such as the SEMA4D variant, an African variant, which was only present in individuals who were of African descent here in the United States and from 3 countries in Africa, particularly Ghana, Nigeria, and Kenya. They looked at large segments of the population, here in the United States and in Africa. They looked at White populations, they looked at Asian populations, and they could not find anyone who had this variant that accounted for a 5 BMI point increase compared with those who did not have this variant. So we have, for example in that situation, genetic thoughts in terms of why there may be some contributors. Number two, I would say that there are some issues as it relates to interaction with health care providers. When people feel like they have a sense of trust with their provider, they remain engaged in care, which leads to better long-term outcomes for their obesity. Because it's a chronic disease, you don't just come in and be treated and then it's gone. It's not a magical treatment that we have. That ability to engage in a consistent fashion with trusted health care providers plays a role. There are some issues with regard to cultural influences, and certain racial and ethnic minorities. It may be more advantageous for you to have more of a larger body type. Maybe that's seen as more attractive. So that cultural influence may play a role in terms of weight status. Physical activity may play a role. We know that physical activity really does a great job of causing weight stability or weight maintenance. Certain groups like to be more active than others. A lot of that influences again what is considered to be culturally acceptable. I think that accounts for some differences. As I mentioned before, exposure to racism, we know is a contributor to storage of adipose tissue. This was demonstrated in the largest prospective trial of black women in the Black Women's Health Study I mentioned before.1Stanford FC Lee M Hur C. Race, ethnicity, sex, and obesity: is it time to personalize the scale?.Mayo Clin Proc. 2019 Feb; 94 (PMID: 30711132; PMCID: PMC6818706): 362-363Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar There are a variety of factors that I think play a role in why we see differences in outcomes. Particularly in some of these larger studies that have evaluated race and ethnicity with regard to lifestyle, all the way through surgical interventions. Dr. Maron: And I imagine so much of your own success in treatment has to be personalized based on all of these factors together. Dr. Stanford: You have hit the nail on the head. I tell my patients, whomever the patient is, look, I care about you in this moment, not the patient that came before you or the patient that came after you. The focus is you. Often patients ask, "How do people do"? And I say, well I don't really care about how people do. I can give you a generalization, but what I now care about is how you do and how do we get you to your healthiest self, not how we got the other person or this person to their healthiest self. Because what we're likely going to need to do for you will different drastically, even from your siblings. I take care of some whole families where every sibling really needs something very different. It's about personalization. It's about trying to do what I can to fit what works for that patient and then continue that and sustain that over the long haul. Dr. Maron: I wanted to take the last few moments that we have together and really focus on something that's near and dear to my heart, which are infants and pregnant mothers, and I'm going to quote back to you again. You've reported that "rapid weight gain during infancy has been observed to influence African American children more than white children and predicts increased future health problems in this group."3Byrd AS Toth AT Stanford FC. Racial disparities in obesity treatment.Curr Obes Rep. 2018 Jun; 7 (PMID: 29616469; PMCID: PMC6066592): 130-138Crossref PubMed Scopus (47) Google Scholar How do you approach taking care of a child who may be suffering from overweight or obesity, to be both effective and destigmatizing? Dr. Stanford: Such an amazing question. This is why I love the care that I provide for families. I'm going to go back to it being about families. We have seen that when we're working with overweight and obesity in children, that child-focused therapy is not as successful as family-focused therapy. We often put our sights on the 2-year-old or the 4-year-old, but that 2-year-old or 4-year-old exists within the context of their family. And so, thankfully, as someone who's an internist and a pediatrician, I'm able to take care of generations. There are several families that I'm treating where I'm taking care of 3 generations within that family. And although the treatment modalities may differ across those individuals within the family, the messaging is the same. I'm teaching them about obesity as a disease. I'm teaching them how to reduce biases and use language that is uplifting as opposed to degrading. When I'm able to tie these things in together within the family structure across generations, it changes the entire milieu. It changes the entire dynamic of that family as they navigate this child who has obesity because often the parents and the grandparents have obesity themselves. And so, when you begin to change that dynamic, you can see how much harmony that brings about. I want to bring out this one family because they really stand out in my mind and bring warmth to my heart. It was a Latin grandmother who came in, and I began to care for her. She obviously made some significant strides, and then she told me she really wanted me to see her granddaughter who she had custody of with her husband. I began to see the granddaughter, who at the time, I think, was around 12 years old. Her confidence, her ability to even focus on me as a physician was challenging. It was several years before she would even really make eye contact with me as we began to approach her weight. From a family perspective soon thereafter, I began taking care of the grandfather. It's wonderful now, today, I can say that all of them have made significant strides. None of them has the disease of obesity because of whatever treatment modalities. They support each other. When I'm doing their telemedicine visits, I can just book them all back-to-back and they just shift the camera to the other person. Or when they come into the office, they all come in as one family, and they all sit in the office with me. They're comfortable with sharing their individual nuances of how they've had to navigate their current issues surrounding their obesity. I can't think of any other treatment strategy that's that effective. Where they're each supporting each other, each lifting each other up, recognizing that their struggles in this disease may be different but complimentary. Being each other's support structure across generations is just amazing to watch. It's even more amazing to see the positive outcomes that can be yielded from approaching it from a family-based structure. Dr. Maron: Absolutely, I think this disease lends itself to that concept of breaking the cycle, doing it together to be your best healthy self. I have one final question for you, Dr Stanford. It is to help our readers become better clinicians. I'd like to ask you if you've had personal life events that have helped you to define your approach to the care and treatment of obesity that other caregivers can draw off of in their own practice. Dr. Stanford: Yeah, I have to talk about my recognition—actually I didn't recognize that I had any bias toward patients with obesity until a physician colleague of mine came up to me at a meeting about 5 years ago and told me that when we were about 5 or 6 years old, that I came up to her in dance class and told her that she was "fat" and then I walked off. This was shocking to me. I'm the person that is supposed to undo bias, and here I am. Then she goes to say to me, "Fatima, I decided that if you were capable of change that anyone is capable of change." So in this situation, I am the bottom of the barrel. She waited for almost 35 years to tell me this. I've known we were always distant, but I'd known her obviously most of my life, and had no idea that I caused significant harm to her very early. And here I am doing the work that obviously she sees as the antithesis of who she saw as like an arch-enemy, an arch-rival. So even people, the worst of the barrel, which I guess, I was considered, can become champions for our patients who have this disease. We know that 42.4% of US adults have the disease of obesity, 18.5% of US children. And that's based on 2018 data. We don't have the COVID-19 pandemic data. We know that the American Psychological Association stated that the average amount of weight gain during COVID-19 was about 29 pounds for adults. So, I believe these numbers are going to be significantly more. But with all of these things being said, there is a way to be better. Educate yourself about this disease of obesity. There are numerous places that you can get solid evidence-based information. The Obesity Society, the Harvard Blackburn Obesity Course, and Colombia and Cornell's courses in obesity are wonderful courses that offer CME credits that you can learn about this disease. For those of you who are physicians, consider certifying in this area if you see this is a big part of the work you want to do. We now have >5000 physicians board certified in obesity medicine in the country. There are only a few of us, about 50 of us, who have done fellowships, and about 5000 who are now certified. You can imagine, with >100 million adults with obesity, 5000 physicians barely touch the surface of what we need. So, there will not be an issue with competition. There will be enough patients to go around. What I'm hoping in my lifetime, which probably won't happen, is that we're able to not have a need for me, at least not in the space of obesity. That we could come up with something that allows a tangible, durable solution. That would be the dream. That's the dream to put ourselves out of business in our work in medicine. So there's ways to learn and understand your own bias. I would take the weight IAT, which is the implicit association test that is free of charge here at Harvard, to get a sense of how much bias you actually have, and you'll be often surprised by the bias you have as a clinician. And once you recognize that bias, work to undo that bias and just treat these patients with the dignity and respect that they deserve like we would with any other disease process. Dr. Maron: I think that's so true, and I think what we've learned, certainly in this last, is that we all need to evolve and recognize our biases. Dr. Stanford: Yes. Dr. Maron: Well with that, I really want to thank you for your time, Dr. Stanford. It has been a wonderful conversation. Dr. Stanford: Thank you so much; it's been a delight, thank you.