A Q&A With Dr. Fatima Cody Stanford on Treating the Disease Obesity

Fatima Cody Stanford, MD, MPH, MPA, MBA, is Director of Equity for the Endocrine Division at Massachusetts General Hospital and has completed a three-year fellowship in obesity medicine. There are only approximately 55 obesity fellowship-trained physicians in the U.S., and about 4,000 who are board-certified by the American Board of Obesity Medicine (ABOM). With her multiple roles, Stanford puts in 80 to 100 hours of work a week as she gives lectures and TED talks (about 150 a year) in which she educates physicians and others on the treatment of obesity, why it’s a disease, how it relates to racism, why it played such a role in COVID morbidity and mortality statistics, how we might treat it more effectively and how the American lifestyle isn’t conducive to preventing it. She speaks quickly, has an abundance of infectious energy and wears not one fitness/health tracker, but two.

In late October Generations Today spoke with Dr. Stanford about the disease of obesity. This Q&A has been edited for length.

Generations Today (GT): You refer to yourself as an obesity medicine physician/scientist. Can you please explain that title?

Fatima Cody Stanford (FCS): Obesity medicine is dedicated to the care of patients with obesity. This is a disease process that can have significant impacts on health and health outcomes, but it’s classified by weight status of an individual. In addition to me seeing patients who range in age from 2 to 90, I am a physician scientist who publishes research in medical journals about obesity in different populations regarding different treatment modalities with a focus on issues regarding disparity.

GT: How did you decide to concentrate on obesity?

FCS: My path in obesity began a little over 20 to 25 years ago, when I was completing my master’s in public health at Emory University. A lot of the projects I was focused on then were looking at overweight and obesity within the black community in Atlanta, which is where I was born and raised. Several of the projects evaluated obesity in faith-based communities, within Black churches in the Atlanta area. One evaluated overweight and obesity among adolescent girls, whereas another evaluated obesity in persons from in the WIC program.

I kept noticing that you could get behavior to change, you could do all of these things and in many cases, people still dealt with excess weight. And the only tools we were providing them were tools surrounding behavior change and if they didn’t lose weight, then it was presumed that it was their fault. That they should just work harder, eat less, exercise more. Without doing a deeper dive.

So what brought me to the field of obesity medicine was that recognition of seeing my patients struggle, seeing that it wasn’t a one-size fits all approach, and then really listening to their concerns and recognizing that in medicine we have tools that could affect the individual and that could have a major impact on weight status.

GT: What are the other tools?

FCS: In addition to behavior change, we have many medications we can utilize for the chronic treatment of obesity. Most of my patients are on pharmacotherapy for the treatment of obesity.

Then, the next tool beyond medication, would be metabolic and bariatric surgery—quite a few of my patients undergo surgical interventions. We don’t particularly have age cutoffs in either direction. Most of our adolescent patients start around 12 or 13, and I’ve sent patients up to surgery in their 70s.

The two most common surgeries are sleeve gastrectomy, where you cut away a portion of stomach, but this also disrupts the making of an appetite-regulating hormone and causes changes in stomach-to-brain communication. And gastric bypass, which causes more weight loss on average, it bypasses a portion of stomach, and the beginning portion of the small intestine, so when you go to eat you just have a small gastric pouch, and then things process directly into the intestine.

‘Obesity is a multifactorial disorder with genetics, environment, development and behavior all playing a role.’

With surgery, we see a resolution of: migraines, 57 percent; depression, 47 percent; sleep apnea, 74–98 percent; high cholesterol, 63 percent; asthma, 69 percent; high blood pressure, 69 percent; fatty liver disease, 90 percent; metabolic syndrome, 80 percent; diabetes 82–98 percent. Within three to four days, we often see the diabetes resolved, not even that much weight has been lost but we’re seeing that resolution. Quality of life is improved in 95 percent of patients, and mortality is reduced by 89 percent in five years.

The key thing I hear in the aftermath of surgery is [older patients] wish they had done it sooner. They have the ability to move, and to navigate the earth in ways they didn’t when they were in their 30s, 40s and even 50s. They’re wishful for having had the opportunity to live their life to the fullest.

GT: Why should obesity be thought of as a disease?

FCS: People don’t think of it as a disease is because they don’t know about it as a disease. Unfortunately most of us as physicians don’t learn anything about it. I published a paper in The International Journal of Obesity in 2020. Nobody’s being taught anything about anything related to obesity besides the fact that it’s the largest chronic disease in the United States and around the world. It affects 42.4 percent of U.S. adults (based on 2018 data). Yet somehow, we don’t learn anything about obesity, but we treat patients who have obesity all day, every day.

We learn energy balance: We learn about calories in, our food and beverage intake, and our calories out, our bodily secretions and our physical activity. And if we can just get this right, eat the right amount, exercise the right amount, then we should be the weight we want to be, right? This is wrong.

It’s so much more complex. There are things that are influencing or inhibiting your energy intake, things like leptin and other dipeptides and appetite-inhibiting hormones, and then there are things that increase our demand to eat, like ghrelin, an appetite-stimulating hormone. All of these interact with our GI tract, our exercise and our energy balance, and regulate how much we weigh.

Obesity is a multifactorial disorder with genetics, environment, development and behavior all playing a role, but a lot of people underemphasize genetics. We know that weight is more inheritable than height. If you have parents who have obesity the likelihood that the child will have obesity is really high, on the order of 50 to 85 percent likelihood, even with doing optimal behaviors, eating well, exercising.

GT: How does racism play into obesity incidence?

FCS: Racism is characterized by chronic stress. The study that did this best, really capturing the impact of racism on weight status is called the Black Women’s Health Study. Yvette Cozier at Boston University is one of the pioneers of the study and I give kudos to her.

This is an observational cohort study where they follow black women, mostly middle-income, highly educated black women. They assessed both daily versus lifetime racism and what that impact was on women’s weight status. They found that both daily encounters but also lifetime prevalence of racism led to major changes in weight status in the cohort.

That makes sense because what we know about obesity is that it’s a chronic inflammatory disease. The stress that comes with racism, which is unfortunately what so many of us have to deal with on a daily basis, can lead to greater storage of adipose or fat. It’s a defense mechanism for the body. Because back when we were hunter/gatherers, stress usually meant there was an acute stressor, some type of predator, but it was acute and then it resolved.

Nobody’s being taught anything about anything related to obesity besides the fact that it’s the largest chronic disease in the United States and around the world.

When we had acute stressors, meaning a famine was coming, our body stored more adipose to prepare for that famine. Now our stressors are due to other things in our life, racism for us as black Americans being one of them, and one that we can’t choose to stop, because we’re not the ones that cause it. How we navigate that can differ from person to person.

I might do kickboxing, which is part of my coping mechanism, someone else may choose something else, or some may not know how to navigate it, and even if you think you do, you can’t change how your body reacts, what it senses, and how it decides to store fat. My recent TED talk this year was on the collision of three pandemics: obesity, racism and COVID-19 and the interplay between them. We really should be paying attention to what we’re experiencing and what we’re seeing and how it’s disproportionately impacting certain communities.

GT: Why is it difficult to prevent obesity in the United States?

FCS: If almost half of adults have obesity, that means their offspring are going to unfortunately also have a certain card that they are dealt. And then we have to navigate it. Since 50 percent of all pregnancies in the U.S. are unplanned, people probably didn’t prepare. The weight status and the health of the parents has huge implications for the offspring, but that’s not something people are thinking about when they’re having children, they’re thinking about the health of the child, but not that their health needs to be optimized to be able to not only have healthy offspring but to be healthy so they can influence the offspring.

Our environment is obesigenic [tending to promote or contribute to obesity]. If we look at factors that play a role, sleep quality is not optimal, many of us are on devices, watching TV, Netflix, Hulu, etc., before we go to sleep. We’re on our phones, it’s the last thing we do before bed. That’s unhealthy.

We are applauded, even lauded for being able to communicate with our colleagues in Australia in the middle of the night. We’re given kudos, we’re promoted, because we’re being really harmful to our bodies. And medications. There are a lot of weight-promoting medicines. Our doctors are not being taught that they are complicit when prescribing medicines. All of these factors are causing this major shift.

GT: How are we evolving the way we measure obesity? Do you have an opinion on the BMI as a measurement?

FCS: BMI is an indirect measure of adiposity, or fat, and it’s also not based upon medicine. The BMI scales we currently use are not based on medical data, but on actuarial data from the Metropolitan Life Insurance Agency from the 1930s. They determined what was one’s weight status and likelihood of dying. These people in that category died sooner than these people over here and that’s how the cutoffs were developed as we use them today.

The problem with BMI is there’s no scientific basis (well I guess dying is a measure, but still), and racial and ethnic minorities weren’t included, as we weren’t insured by MetLife back in the ’30s.

Also say someone has congestive heart failure, often these people go into the hospital with fluid overload, and our goal is to get all of this fluid off of them. We give them medicine, pull off 25 pounds of fluid, they leave the hospital 25 pounds lighter. Did their weight status change that much? According to BMI it did. But did I fix their health? I fixed their heart failure at least temporarily, with medications. But you can see the problem, it’s an indirect measure, it doesn’t really capture adipose, it doesn’t capture fat in the areas where it’s most important, which is around the organs. Despite this, BMI is a decent population-wide measure.

GT: Can you explain why social disparities of health are critical to use as a vantage point from which to do research or treat patients?

FCS: When I treat patients for obesity, when I open a patient’s chart I do an assessment, first to the left of the screen, where they tell me what their insurance status is, and then I have to make a decision based upon what their insurance tells me. Not on what I think is best, based upon science, based upon data, based upon research. But what the confines of their insurance tell me.

‘They’ve been experiencing stigma and bias from individuals in healthcare since they saw their pediatrician 65 years ago, and they remember it.’

If we’re talking about older adults, Medicare has put me in a box, where they say you can use generics and nothing else because Medicare Part D has an exclusion where they do not cover anti-obesity medicine. And they don’t cover behavioral therapy. If you want to see a dietitian, no. But Medicare will cover bariatric surgery everywhere in the U.S. We’ll cover surgery, we won’t cover the medicines, and we won’t cover the dietitian that might be able to help you make healthier choices.

If you have Medicare and you have diabetes, your visit with a dietitian is covered. You have to get diabetes to get that covered. We have been trying to push a bill through Congress since 2019 called TROA (Treat and Reduce Obesity Act) to get coverage under Medicare for behavioral therapy and medications for the treatment of obesity. Now if they have diabetes you get “excited” because with diabetes the better classes of medications are covered. But with obesity they’re not. That is a poor way to think.

GT: How does living with obesity tend to affect a person as they age?

FCS: It affects them in a lot of different ways—we see the prevalence of other chronic diseases go up dramatically, but even without chronic diseases there are issues with mobility, the ability to navigate the space, patients say it just hurts to walk, it hurts to do things—it’s not universal, but this is not an uncommon phenomenon.

It affects their heart, it affects their likelihood of developing metabolic disease. All of those diseases mentioned above. It affects their mental health, because when patients have obesity they are often judged based upon their weight status. And that’s problematic because should the value of their work be determined by their weight status?

When I’m meeting with older adults for their first visit, all of whatever trauma they’ve experienced grounded in their weight and weight stigma and bias, they bring all of that to that appointment, and a lot of it unfortunately came from doctors, it came from nurses, it came from other people in the healthcare setting. A place that’s supposed to be a safe space no longer is a safe space because they’ve been experiencing stigma and bias from individuals in healthcare since they saw their pediatrician 65 years ago, and they remember it.

This is the first time they’ve had the opportunity to share what their experience has been in healthcare or with their family or with their colleagues or whomever, and it really affected their entire life. The older the patient gets, the more I have to breakdown, the more I have to reframe their thinking. If you’re coming in for your first visit at 85 I have to breakdown 82 years of being told who you are, and whether you are valued or not. That’s hard. That’s a lot of years I have to break down.

Alison Biggar is ASA’s Editorial Director.

Photo: Dr. Fatima Cody Stanford.

Photo credit: Jeff Schear; @jeffschear on Instagram