Public Health

Ending the obesity shame game

Sara Berg, MS , News Editor
Fatima Cody Stanford

People with obesity are often their own worst critics. Using derogatory names and poking fun at themselves allows them to cope with their disease, but it can also sabotage their lifestyle-change efforts. But what happens when the criticism comes from someone else?

Think about this: Do you know the impact of what you said when you were a kindergartner? For Fatima Cody Stanford, MD, MPH, MPA—who has devoted her professional life to combating anti-obesity bias in medicine and popular culture—it became evident when a physician colleague she grew up with approached her at a conference.

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After 35 years of knowing each other, the other physician said, “I don’t know if you’ve noticed, Fatima, but over the course of our lifetime I’ve been very standoffish towards you.”

Dr. Stanford had assumed that was just a reflection of her colleague’s aloof personality. But there was a reason for it.

“Back when we were about 5 or 6 years old,” her physician colleague explained, “you came up to me in dance class and you told me that I was fat.”

As an obesity medicine specialist and assistant professor at Harvard Medical School, Dr. Stanford was jarred to learn what she had said as a child. However, her colleague added, “When I saw you doing this work, I figured if you were capable of change in this way that anybody is capable of change.”

This resonated with Dr. Stanford because she didn’t know she had caused such harm to her colleague that she had harbored the ill will for so long.

“There were opportunities to say this to me, but I guess I wasn’t personally doing this work and she didn’t feel compelled to do so until I got into this work,” says Dr. Stanford, who pushes to remove blame and reverse self-hate among people with obesity.

Her goal is to educate and spread the word about obesity as a disease—no matter what it takes—because it affects everyone.

Dr. Stanford’s patients at the Massachusetts General Hospital Weight Center in Boston often come in with a lot of negative talk about themselves. Her first goal is to get them to stop hating themselves.

“Look, I hear what you’re saying, and I know you’re talking about yourself, but I cannot allow you to talk about yourself in such a negative way,” she often explains. “We need to reframe this because I don’t think I’m going to be able to do the work that we need to do together unless we can reframe this conversation.’”

This is where the work starts—by changing the accusatory language patients use to talk about themselves.

“It’s often worse than what you ever hear anyone else say,” notes Dr. Stanford. 

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Every patient who walks into Dr. Stanford’s practice has a unique story to tell and she works to uncover every angle. By establishing a trusting relationship with her patients, she has found that she can further shape their goals and outlooks on treatment.

“I always start every patient visit with a bit of education,” she explains. “I pull up a slide set that I have specifically for my patients, and I teach them about the complexity of obesity to reduce blame and remove a lot of stigma that they may have.”

“Then I help them understand how I’m thinking about their diagnosis and their treatment. I think that does help break the ice because we’re approaching a subject that causes patients a lot of pain,” adds Dr. Stanford.

“They’re living in these bodies every day with judgments that come along with that. I quickly let them know that this is a safe space.”

And Dr. Stanford also has some tricks up her sleeves to help her patients. She typically can be found in 5- to 6-inch heels every day, but that doesn’t stop her from displaying different exercises for her patients.

“I do pushups in my office in my heels to show or demonstrate proper form. I tell them that the thing that’s not proper performance is my heels,” says Dr. Stanford. “I will do wall slides to show them how to really build up quadricep strength.”

Even when faced with hesitancy or excuses, Dr. Stanford finds a way to counter patients’ reasons for not exercising.

“I tell them my goal for them in terms of activity is not for them to do what I do. I’m doing the things I enjoy doing,” she explains. “There are certain things I hate doing. I hate skiing, so I’m not going to go skiing as my activity because I hate that. I want them to find their soulmate workout, whatever that is for them.”

“A lot of people want a quick fix and they want to just jump to this and then be done, but that’s not how it works,” adds Dr. Stanford.

Dr. Stanford’s dedication to helping people began when she was only 3 years old. At that tender age, she knew she wanted to be a doctor.

Photo of Fatima Cody Stanford, MD, MPH, with her arms crossed.

With her mind set on being a physician as a girl, she shifted her medical specialty choice the way other children switch career dreams from firefighter to librarian to astronaut.

“I happened to have some great role models! Many of my role models in medicine were black physicians in the Atlanta area who were colleagues and friends of my parents,” she says. “Each time I became close to one, I would take an interest in their respective field of medicine.”

Beginning at age 6, she wanted to be an anesthesiologist, followed by a passion for cardiothoracic surgery, then emergency medicine. Later, she wanted to pursue geriatrics, and then leaned toward orthopedics as she entered medical school.

“I did do a yearlong orthopedic surgery-sports medicine fellowship right out of medical school in New York City,” says Dr. Stanford. But then she ended up going into internal medicine and pediatrics because she yearned to delve deeper into treating the major issue that can have a full-body impact. That’s what led her to obesity medicine. 

“We put a lot of Band-Aids on things. We can replace your knee, but if you carry 200 pounds of excess weight, I don’t know how long that knee is going to last you,” she says.

“And so, how do I improve your overall quality of life in such a way that I’m impacting many organ systems simultaneously?” asks Dr. Stanford.

It took a lot of soul searching to come to this decision, but the choice felt true to her girlhood aspirations. Dr. Stanford had always wanted to help change the patient’s overall quality of life, taking on the challenge of the physician as healer.

Two areas about which Dr. Stanford speaks passionately are among the most commonly tied to widespread bias in the U.S.—weight and race. 

“Why not pick up the biggest flags and wave them around and really make some noise with regards to these issues?” she says, adding that more than 40% of the American adults and 20% of kids have obesity. That’s about 14 million children and more than 95 million adults.

“If they struggle with this disease in such sheer volume of numbers, the idea that we would exhibit—especially in health care—bias toward these populations that are obviously quite large is of significant concern,” says Dr. Stanford. “If we are not treating this patient population, then I think we are failing at our jobs.”

This is particularly evident in medical education, residencies and fellowships throughout the world. Physicians are not learning how to adequately treat patients with obesity. When completing a systemic review of obesity education in medical education and residency programs, Dr. Stanford found that pretty much everyone around the world is failing on this front.

That is “despite the fact that this disease of obesity is not just an issue here in the United States—10% of the world’s population has obesity,” she says. “We’re dealing with the sizable issue throughout the world.”

 “This should be integrated fully in every curriculum in medicine,” says Dr. Stanford. “We learn a ton of information, starting with day one about very esoteric disease processes.”

No matter what their specialty or subspecialty is, if a physician is asked “about obesity, they have limited knowledge,” she says, adding that it is “tragic because it is by far our most prevalent chronic disease.”

“It’s sad because if we treat that one disease, then we can get rid of about 10 to 15 others depending upon what the patient has,” adds Dr. Stanford.

Working with the American College of Physicians and the American Academy of Pediatrics, along with many other organizations, Dr. Stanford continues to look at how to better educate everyone.

In 2017 she played a pivotal role in garnering support for a resolution on person-first language for obesity that was adopted as policy by the AMA House of Delegates. She also served as an adviser from the American College of Physicians to review the obesity medicine education competencies from an internal medicine perspective. This was to see if these competencies aligned with what internal medicine is doing or not doing in the area of obesity.

Dr. Stanford has met with legislators in Washington to pass the Treat and Reduce Obesity Act, which has gone before the House and the Senate for several years now. She has also worked in collaboration with the Obesity Society, Obesity Medicine Association, Obesity Action Coalition and the American Academy of Nutrition and Dietetics on this bill.

While the legislation—which would expand Medicare coverage of intensive behavioral therapy for obesity and cover anti-obesity medication—has bipartisan support, it has not made it across the finish line.

“Passing that bill will have huge implications for how we’re able to treat both the pediatric and adult population that has obesity,” she says.

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Some of the standard advice offered to people with obesity is well-known: move more and avoid sugar-sweetened beverages. But the bigger, more complex picture of obesity often gets lost.

“Many of my patients who have obesity aren’t drinking sugar-sweetened beverages. Many of them are active in sports and maybe multiple sports,” says Dr. Stanford, adding that “hyper-focusing on a single area with regards to how do we delve into the issue is what’s led us into this significant pandemic nature of obesity.”

Instead, the focus is on calories in, calories out, which is an incorrect mantra, she explains. This is because it does not consider the complexity of weight and weight regulation.

“With the calories in, calories out mantra, it does not take into account that some people’s bodies will retain more calories than others, which may be in part determined by their brain’s regulation of weight,” says Dr. Stanford.

Instead, there are many reasons why someone may have excess weight, such as genetic predisposition, environmental factors or psychological factors.

“I really saw that there were some deficits on what patients are learning. A lot of it is because if the physicians don’t know. How do we expect the patients to know?”

To raise awareness of obesity as a disease, she wrote a book that helps the general population and physicians. She also participates in up to 200 news media interviews a year to expand the conversation.

“If I can get my message out ... that obesity is a disease that we can treat and there is evidence to support what we’re doing in this field, I will take those interviews,” she says, adding that while she does get coverage from big media outlets such as ABC News or The New York Times, she wants to make sure she reaches all groups of people and “have as many tentacles as it can.”

Dr. Stanford also shares information through an average of 150 lectures worldwide each year, for the general population and medical community.

“Every group needs to hear it.”