Public Health

For patients with obesity, brain’s pathways tell the tale

Marc Zarefsky , Contributing News Writer

It's always nice to be appreciated for your work, but obesity medicine physician Fatima Cody Stanford, MD, MPH, MPA, revels in the fact that she treated a child patient’s condition for two years without the girl ever realizing that Dr. Stanford was “the weight doctor.”

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Such a light touch in patient care is key when treating a condition as stigmatized as obesity, said Dr. Stanford, who practices at Massachusetts General Hospital and is an associate professor at Harvard Medical School.

The patient is now 12 years old. One day the child's parents asked the girl how the visits with her weight doctor was going.

"Who are you talking about?" the girl asked.

Dr. Stanford, the parents clarified.

"Oh, that's what she does?" the child asked.

The story still brings a smile to Dr. Stanford's face.  

"I take significant pride in knowing that she had no idea what I do for a living and didn't feel like this was a combative visit—a visit that she has to be embarrassed of when she looks back at her 12-year-old self in 20, 30 or 40 years," Dr. Stanford said during a recent episode of “AMA Update.”

The story is no fluke. It’s a result of Dr. Stanford's approach to treating obesity—as a brain disease.

More than 40% of adults in the U.S. have obesity, according to the Centers for Disease Control and Prevention. Earlier in her medical career, Dr. Stanford routinely told her patients with obesity to focus on their diet and exercise.

"I wasn't recognizing what their struggle was," she said. "I wasn't empathizing. I wasn't living in their shoes."

What she later discovered is the strong connection between a person's brain and the number on the scale. Dr. Stanford explained that people have two pathways in their brain: the proopiomelanocortin (POMC) pathway tells people to eat less and store less food, while the Agouti-related protein (AgRP) pathway tells people to eat and store more food in the body.

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People with obesity have an active AgRP pathway. Beyond boosting physical activity and being aware of food intake, another way to treat the disease is with Food and Drug Administration-approved anti-obesity medications that predominantly target the brain.

Such medications "upregulate that POMC pathway that tells us to eat less and store less, and it downregulates that pathway of the brain that tells us to eat more and store more," said Dr. Stanford, an AMA member who is immediate past chair/at-large representative of the AMA Minority Affairs Section’s governing council.

"When people take these medications, they'll [say]: ‘This doesn't feel like I'm having to work,’” she noted. “That's because we've changed how the brain sees weight."

The reason that 12-year-old girl didn't realize she was seeing an obesity medicine specialist is because Dr. Stanford doesn't put the sole emphasis on weight and its regulation.

"I do that at the very beginning of the visit," Dr. Stanford said, "and then I just talk about her. What can we do to make her life better? … It's not by hyper-focusing on the number on the scale or the number on the growth chart."

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Putting that attitude into practice can be challenging. The key, she said, is to put yourself in your patient's shoes—something that she struggled to do reliably at the outset of her career.

"The key tenet is to treat people how we want to be treated," she said. "If you aren't doing that as a physician, then I want you to reconsider what you're doing. … What would make you feel whole, valued and somewhat feel like this is not the end of the road? That's really what I think about when I'm working with my patients."

AMA Update” covers health care topics affecting the lives of physicians and patients. Hear from physicians and experts on public health, advocacy issues, scope of practice and more—because who’s doing the talking matters. You can catch every episode by subscribing to the AMA’s YouTube channel or the audio-only podcast version, which also features educational presentations and in-depth discussions.