As Obesity Grows, New Strategies to Combat It
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- Created on Tuesday, 06 October 2020 09:15
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Obesity researchers are learning a lot about what works best in helping people lose weight. Perhaps most important: doctor training.
In the Covid-19 pandemic, people with obesity are at higher risk for severe illness and death—adding new urgency to efforts to rethink the way doctors treat what has long been a public-health problem. Instead of focusing only on diet and exercise, medical experts say, health-care providers need to shift to a multipronged strategy that includes new prescription weight-loss medications, behavioral therapy and possibly surgery. And to ensure the best results, they argue, this new approach should be overseen by clinicians specially trained in treating obesity.
To be sure, doctors have long known that combating obesity could involve a combination of approaches. But recent research has deepened the understanding of each strategy and how they work together, so doctors can offer more-effective guidance to patients.
The current crisis is heightening the need for better treatment of obesity, but the problem has been growing more serious for years. New federal data show that the obesity rate in the U.S. has hit 42.4%, up from 30.5% in 1999-2000. And many of those affected are in minority groups and underserved populations with little access to care.
A growing number of medical groups classify obesity—defined as a body-mass index of 30 or greater— as a chronic disease and are pushing for wider coverage of treatment costs.
Scientists now know that excess fat tissue can become enlarged and turn into “sick fat,” leading to abnormalities that result in high blood pressure, heart disease and cancer. Abdominal fat releases hormones that cause dangerous inflammation.
Covid-19 puts the body’s response into overdrive, and the inflammation already present due to obesity may be one reason such patients do worse. Compared to people of normal weight, obese patients also are more likely to have other chronic conditions and pulmonary problems such as asthma and lung disease, that increase the risk for serious illness.
“It has taken a devastating and potentially fatal illness like Covid-19 to shine a light on obesity, which has always been thought of as a background factor, chronic and hard to treat, so why bother?” says Robert Kushner, a professor of medicine at Northwestern University and director of the Northwestern Medicine Center for Lifestyle Medicine.
Here are some developments in obesity care that hold promise.
Turning to specialists
One longstanding obstacle to a more-comprehensive treatment of obesity is that many doctors haven’t gotten specialized training. That’s one reason physicians have tended to frame treatment as a matter of eating less and moving more—and when that doesn’t work, they often see it as a failure on the part of patients, rather than a condition that can be out of their control. For instance, the more patients cut calories or exercise, the more the body’s metabolism wants to compensate, slowing down to maintain weight and releasing hormones that increase appetite. Genes have also been associated with difficulty losing weight.
But the fast-emerging specialty of obesity medicine aims to close the education gap.
“Nobody is denying that there is behavioral component to obesity, but it is shortsighted and dangerous to fully blame an individual’s behavior when there is so much evidence that the human body does not function normally in the condition of obesity,” says Dr. Rekha Kumar, an endocrinologist who treats patients at the Weill Cornell Medicine Comprehensive Weight Control Center in New York. “Many physicians recognize the important role they can play in treating patients with obesity, and now there is an entire field of medicine dedicated to providing these patients with high-quality, evidence-based treatment.”
Obesity-medicine specialists learn about the complex interplay of biological, genetic, psychological and environmental factors that contribute to obesity and how to personalize the most-effective strategies for diet, exercise and behavioral change to lose weight and keep it off. They also are trained to recognize which patients need extra help from drugs or weight-loss surgeries after lifestyle-change strategies have failed.
Caroline Andrew completed an obesity fellowship at the Weill Cornell center in 2018 and now has her own practice at the Hospital for Special Surgery in New York, where surgeons often refer patients to her to help them lose weight before a joint replacement. She works with patients for at least three to six months to lose 5% to 10% of their body weight, which can produce immediate benefits in reducing pain and improving blood pressure and heart rate, among other things. Among her services, Dr. Andrew may provide behavioral counseling or prescribe a weight-loss drug or refer patients to a therapist or dietitian for additional help.
One patient, John Kelly, 56, was referred by his surgeon before a hip replacement. He had struggled with his weight for years, he says, due to a “haphazard life,” working in pubs, and as a chef, caterer and hotel food and beverage manager. At one point, he weighed 372 pounds and was never able to stick to a diet program on his own. In addition to a low-carbohydrate diet with protein shakes as meal replacements and snacks, Dr. Andrew started him on metformin, a diabetes drug that has shown benefit for weight loss. He cut down on his admitted weaknesses—potatoes, bagels and Guinness ale.
Dr. Andrew “gave me the strength to stick to a commitment” to drop at least 2 pounds every appointment, he says. Over eight months, he lost 77 pounds and had a successful hip replacement in December 2018. He is now able to add in more exercise and continues to see Dr. Andrew for weight-loss maintenance.
Educating general practitioners
While there are not enough full-time obesity specialists to treat the majority of patients, the American Board of Obesity Medicine certifies doctors who have taken at least 60 hours of education on obesity causes and treatments. There are now 4,152 physicians with the certification in the U.S. and Canada.
“We want the average doctor to be able to deal with obesity and overweight patients, starting with being able to bring it up in a conversation,” says Louis J. Aronne, director of Weill Cornell’s weight- control center in New York and a director of the obesity medicine board.
The training covers a number of areas. One of the most important: treating patients with sensitivity.
Doctors learn to create a patient-friendly environment, including training office staff to be careful with language, such as “a patient who has obesity” instead of “obese patient” to avoid labeling patients by their disease. Then, rather than dictate a specific diet, doctors are encouraged to listen to patients about their food preferences and what diets or exercise programs have been effective or ineffective in the past. From there, doctors prescribe a regimen based on patients’ preferences and health status and determine whether weight-loss drugs or surgical procedures are appropriate.
Sadaf Mustafa, an internal-medicine doctor at MedStar Health in Baltimore and assistant professor at Georgetown University School of Medicine, decided to become certified in obesity medicine two years ago. The training helped her communicate with patients and better understand how some medications used to treat common conditions like diabetes and depression can cause weight gain. She prescribes alternative medications that are equally effective without the weight-gain side effect or that may help with weight loss.
“The impact of changing from one medication group to another can give them a huge benefit, and that was a big eye-opener for me,” Dr. Mustafa says.
Acceptance of drugs and surgery
There are also signs that a big obstacle to obesity treatment is starting to crumble: resistance to weight- loss drugs and surgery.
These can be highly effective treatments, but they often aren’t covered by insurance, and doctors are often reluctant to prescribe them. In part, that is because doctors tend to focus on diet, and in part because drugs and surgery have carried risks in the past.
But that is changing. Recent research has shown some surgeries to be effective on a broader range of patients than previously thought. And newer generations of drugs are much safer and more effective than earlier ones, studies show.
So, more private insurers and employers are covering weight-loss medications, and some states are considering legislation that would expand coverage of surgery and weight-loss drugs by public health plans.
Gayle Novak, a 57-year-old Chicago advertising executive, says her weight rose to almost 285 pounds on her 5-foot-9-inch frame over several years and she began to have health issues, including high blood pressure.
Dr. Kushner at Northwestern’s Center for Lifestyle Medicine helped her design a diet plan that focuses on healthy choices and intermittent fasting but allows her to keep some of her favorite indulgences, Ms. Novak says. “He really took the time to know me, know my history, know my medical issues and understand what does and doesn’t work for me.”
He also prescribed the drug Qsymia, which helps curb her cravings and control portions. She noticed right away that she did not have the cravings that would lead her in the past to gorge on food.
But the treatment hasn’t focused only on physical issues. Ms. Novak had been coping with the deaths of her sister and her best friend within a few years of each other. Part of her treatment has been therapy to cope with her grief and emotional and stress eating patterns.
After a year she lost about 75 pounds, and is now down 106 pounds from her peak weight.
During the Covid-19 pandemic, she has been working from home and having phone and video sessions with Dr. Kushner and her therapist. She tries to get outside to walk every day and do strength training at home. “I have not allowed the stress and strangeness of this time to fall back to old habits,” Ms. Novak says.
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By Laura Landro
Ms. Landro, a former Wall Street Journal assistant managing editor, is the author of “Survivor: Taking Control of Your Fight Against Cancer.”
https://www.wsj.com/articles/as-obesity-grows-new-strategies-to-combat-it-11591652380?mod=ig_healthreport
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