Is Obesity Best Managed by Generalists?

Obesity is complex and few medical professionals have any formal background or training in obesity management. Furthermore, the range of problems that patients can present with (potentially affecting every organ system and mental health as well as socio-ecomonic aspects), is rather broad, thus requiring expertise across a wide range of disciplines. 

These circumstances have of course fostered the notion that obesity is best managed by specialists – ideally working in a multidisciplinary team that includes dietitians, exercise specialists and clinical psychologists.

While there is little doubt that health care providers, who have undergone specific training in obesity medicine, will likely do a much better job of managing patients with obesity that a doctor with no such experience or training, it is quite unrealistic to expect that we will ever have enough obesity specialists to address the needs of the millions of patients living with this chronic disease. 

Indeed, the vast number of people living with obesity means that it would be entirely unrealistic to expect that any speciality, be it endocrinology or cardiology, will ever have the capacity to handle this vast demand. 

Thus, as with other common chronic diseases (such as hypertension or diabetes), the vast majority of patients with obesity will have to be managed by their family doctor in primary care. 

As it turns out, this may not be a bad thing. In fact, given the broad nature of medical and psychosocial challenges presented by these patients, the fact that it can occur throughout the lifespan, and the need for life-long management, one may well argue that family medicine is indeed the discipline best suited to managing the vast majority of patients living with obesity.  

In contrast to specialists, who by nature tend to focus their care on their respective specialty, family doctors tend to be generalists who are just as comfortable managing hypertension or diabetes as they are managing depression, anxiety, chronic pain, or any of the other multitude of issues that can make obesity management challenging. 

Thus, while a cardiologist may primarily focus on controlling hypertension, a diabetologist may focus on optimising glycemic control, a pulmonologist may focus on sleep apnea, a hepatologist may focus on NAFLD, and a psychiatrist may focus on depression or ADHD, a family doctor would probably step back and look at the “big picture” thereby prioritising and integrating the various aspects of care across disciplines, while also taking into consideration the socio-ecomonic and personal situation of each patient (and their families). 

Indeed, one could easily argue that most specialists simply do not have the knowledge or bandwidth to assess and consider all of the relevant problems and issues that these patients present – especially over the life-course. 

The issue thus, is not how to train more obesity specialists, but really how to train more generalists (such as family doctors or general internists) to feel more comfortable and enthusiastic about providing evidence-based obesity care. 

This does not mean that we do not need more obesity specialists. Obviously, like in patients with hypertension or diabetes, there will always be those who require referral to specialists or specialist centres due to the particularly complex nature of their individual case – but this should be the minority of people living with obesity. No matter how many specialists we train, they will always be a finite resource and should best be reserved and dedicated to those with the most severe and complicated or advanced disease. 

I would certainly hope to see the day where all generalists have at least a basic understanding of obesity and are as comfortable managing patients living with this disease as they are managing patients with other common diseases such as hypertension or diabetes. 

@DrSharma
Berlin, D