Obesity, diabetes take toll on community: Addressing the challenges

Obesity, diabetes take toll on community

What’s available in terms of nutrition? What are the competing factors? What are the challenges?

By Klaus Krøyer Madsen, MPH with Cities Changing Diabetes – Philadelphia

Editor’s note: The physical and mental cost to a community during the American crisis of diabetes and related comorbidities can be high. Part 1 in the fall 2021 issue of Philadelphia Medicine examined several community efforts to battle obesity and diabetes. Part 2 looks at specific ways to battle these comorbidities.

Since 2019, Philadelphia County Medical Society has been an active member of Cities Changing Diabetes – Philadelphia, a global program sponsored by Novo Nordisk that creates local private/public partnerships with communities to understand their unique obesity and diabetes challenges, identify areas and populations at greatest risk and design and implement targeted solutions. The program brings together medical and public health institutions, communities of faith, employers, insurers and nonprofit organizations. Philadelphia Medicine asked two of our members involved in Cities Changing Diabetes to share their perspectives about the challenges of obesity prevention: Ajay D. Rao, MD, MMSc, associate professor of medicine, Lewis Katz School of Medicine at Temple University Center for Metabolic Disease Research. Annette Gadegbeku, MD, associate professor, Department of Family, Community & Preventative Medicine, assistant dean of community health, Drexel University College of Medicine; associate program director, DUCOM/ Tower Health Family Medicine Residency Program chief, division of community health.

What the specific things that physicians can do in their practice to reduce obesity?

Dr. Gadegbeku: First, just be available and develop a relationship. I sometimes talk to a few people who struggle with the conversation around weight and obesity. I know that people also feel challenged by the way we define obesity with the BMI. But I think the most important thing as a physician, that I see that I can do, is have a relationship with my patients where I can have that conversation, where they feel comfortable to talk to me about the challenges that they’re having with their weight. And most of them do, most of them disclose it on their own and start the conversation. But there are other times where I’m able to start that conversation in a comfortable way because I have established that relationship with that patient, and they know that I care and that I want to help.

So, asking questions that not only are related to their lifestyle, diet, exercise, their other chronic conditions, medications, all of that, but also asking those questions that delve into the determinants of health. We know that medical care only accounts for 10% to 20% of the modifiable contributors to healthy outcomes. The other 80% is related to these other determinants of health, be it their physical environment, their economic status, their education and what’s available to them in terms of opportunities.

What’s available in terms of nutrition? What are the competing factors? What are the challenges? Why are there challenges for them to make any kind of lifestyle changes? Do they know that lifestyle changes are not the end-all, be-all? They are definitely the first line to addressing this issue, but also as a physician I feel that I’m obligated to explore all the options, including medication and surgical management, which we know are also effective and, maybe in some patients, even more effective, in addition of course to the changes in their lifestyle.

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Who are the patients that have insurances that are covering surgical management, bariatric surgery or medications? We know that a lot of the approved medications for weight loss are not well covered by insurance. But just trying to help with patients, and making sure patients have access to all the options that can support them in their challenges, their health and then their journey, are important.

Dr. Rao: First and foremost, one of our challenges is that we as physicians do not yet fully recognize obesity as a disease. Electronic health records are a critical tool in this effort, because they drive treatments in health systems and clinics. It is important to document obesity and properly code it in the medical record: That is essential for providing adequate care of a patient living with obesity.

It is very clear that some of us are still sheepish about doing that because we worry that may be labeling the patient as obese. They walk out of our exam room with this paper now labeling them with being obese. But unless we do that, they don’t understand how serious this disease is.

Proper coding may finally allow us to tap into appropriate treatment options. In addition, it prevents us from routinely forgetting about the condition. Patients who now have access to their medical records can finally understand the seriousness of obesity. The electronic medical record (EMR) systems can help us with various triggers that force us to think about how we can provide better care for each patient.

Patients today have a gamut of treatment options for obesity. I think everybody can benefit from medical nutrition therapy with a registered dietitian, someone who really knows what contributes to overweight and obesity, and how to make behavior changes.

There are many programs in the community as well that you can get involved with when it comes to keeping yourself active and learning how to cook healthier. These programs are really helpful for changing the way our patients behave.

Finally, there is clear and emerging evidence that weight loss surgery is very effective in reducing the burden of this disease. And then of course, there are newer medications in this space that patients can finally get and can at least help them kick-start the process of achieving weight loss and establishing healthier lifestyles at the same time.

Dr. Rao, how do you approach weight management overall for the overweight and obese patients you see as an endocrinologist?

Dr. Rao: First and foremost, we get our nutritionists and dieticians involved. Small changes can go a long way.

Weight loss in any fashion is the key. Weight loss surgery remains a valuable option for many patients. There have been some newer injectable agents that can be taken weekly that can really help with weight loss, also.

When working with your internal medicine colleagues, how do you feel they are helping patients manage their weight before they even see an endocrinologist, Dr. Rao?

Dr. Rao: They are trying their hardest, but there is so much they are managing. A lot of times a referral does not happen until diabetes is present.

There is a push for more obesity specialists, and this can be either endocrinologists or internists with special interest in obesity medicine. There are certification programs for this.

Having more providers who can focus on this problem is crucial.

Dr. Gadegbeku, how would you like to see general practitioners and endocrinologists work better to address obesity?

Dr. Gadegbeku: Oh, that’s a great question. I think utilizing each other. I don’t know how many primary care physicians reach out to endocrinologists to assist in managing their patients with obesity. Then I’m not sure how the reciprocal feedback or support is with endocrinologists reaching back to primary care physicians to support the management. So, I think even just partnering better, knowing each specialty and how they can support each other and what strength they both have in supporting and managing their patients together. Each specialist, myself as a primary care physician and another like Dr. Rao as an endocrinologist, can reinforce each other’s recommendations for management and goals for the patient. I think that would be most helpful, just recognizing our skills in each other and our strengths in each other, and working together to manage the patient together.

‘I think the most important thing as a physician, that I see that I can do, is have a relationship with my patients where I can have that conversation, where they feel comfortable to talk to me about the challenges that they’re having with their weight.’ — Dr. Annette Gadegbeku

You mentioned the stigma of having obesity as a major barrier to treating the disease. How do you address that when providing care to your patients, Dr. Gadegbeku?

Dr. Gadegbeku: I think it’s hard to even address that without having a really good relationship with your patients or having really developed a relationship and trust in you, to even engage in a conversation about that. Again, not only focusing on the negative, and the stigmatized language that we use, and conversation that we use around weight. But also focusing on the positivity and the esteem of that patient, uplifting them, supporting them, encouraging them and letting them know that they’re valued and that they’re loved, that they are beautiful, they’re skilled, they’re educated, all of the things that you can know about a patient to encourage them and support them and to build self-esteem, and to let them know that they can be successful.

I think they feel so beat down. There’s even a lot of self-deprecating language that they use toward themselves. And so just even calling that out and helping to reverse some of that mindset. And it’s not an easy thing. It’s definitely easier said than done. But it’s important to let the patient know that they’re valued; encouraging them to achieve attainable, achievable goals; celebrating their successes, no matter how minute it might seem to them; and really encouraging that this was a great accomplishment, whatever they did, whether they changed their way of eating, regardless of whether they saw results.

I mean, they are working toward being healthier inside as well, whether their numbers improved on their labs or they lost pounds or inches, whatever it is. And encouraging them to accomplish their other life goals, whether it’s a job or education. And I think those are the areas where people do feel discriminated against, and they lose opportunities because they are not chosen for certain jobs or certain opportunities, even based on their weight. And so, having those conversations is really important, I think.

Health is so personal for all of us. Do you mind sharing how you and your families stay healthy?

Dr. Rao: I think first and foremost, this has been a very difficult time for all of us. In general, this is very hard to do, and then, especially in the last 20 months, I think it’s been even more difficult. Recently in our family, we’ve been just focusing on what we call small victories. Just getting up out of your chair, walking around the block for a little bit and taking walks in the evening when it’s a little bit cooler out there. If you’re worried about going outside, even within your house, moving around can make a big difference. Somehow, we all have to stay away from being just stationary and having that bag of chips near you.

My wife and I have a young child and we’ve been trying to keep him active, and it’s unusual for him the way things have been recently. And it’s unusual for a lot of us.

Sometimes we think that, oh, I need to get on the treadmill, I need to go to the gym, and I need to do a big workout session. But it can be just small victories, short walks and just short periods of more robust activity that can really make a big dent on this problem.

Dr. Gadegbeku: I try to stay healthy myself. I try to practice what I preach. Again, it’s making lifestyle changes, not fads, not quick fixes in terms of how we eat, avoiding diet fads or overcome exercise challenges and all of that. But really trying to incorporate, when I can, healthier meals, healthier choices and trying to put the physical activity in some routine in my day.

I may not exercise every single day, but at least trying to establish goals to get more physical activity in. And most importantly is taking care of also my mental health. Again, I can see personally where mental health can really impact my eating choices or activity and sleep, so trying to get adequate sleep is essential. But trying to do things that I enjoy, get an outlet and those will all eventually feed back into hopefully that healthier lifestyle for myself as well. •

For more information about Cities Changing Diabetes – Philadelphia, visit https://www.citieschangingdiabetes.com/ network/philadelphia.html.

Klaus Krøyer Madsen, MPH with Cities Changing Diabetes – Philadelphia.