Professional Barriers to Obesity CareThursday, January 14, 2021
Put simply, one of the biggest barriers to setting up an obesity program is that most clinicians have little or no formal training in obesity assessment and management. Indeed, in most jurisdictions, there is currently no established or recognised pathway to becoming an obesity doctor (with rare exceptions for e.g. the ABOM certification), let alone any incentive to specialise in this area. Furthermore, as established centres are rare and far between, most clinicians will never have worked at such a centre or even seen one in action and will have to figure out most aspects of their programs for themselves.
Thus, although one may see the need for, have the interest in, and be enthusiastic and dedicated to creating a program for patients living with obesity, the lack of formal training and expertise in obesity medicine may be the first barrier to overcome (we’ll come back to pursuing training in this field in later posts).
Given that there is currently no universally accepted standard of expertise or criteria for an obesity clinic, pretty much anyone with an interest in this area can set up shop and claim to be running an obesity program. Indeed, we often see physicians or other health professionals from diverse backgrounds and with various motivations setting up “weight-loss” clinics based on a wide range of ideas and personal philosophies. While some may well take an evidence-based approach built on the understanding that obesity is a complex and heterogeneous chronic disease requiring multi-modal approaches to management that must include behavioural, medical and even surgical treatments, this is, by far, not the most common approach.
Rather, we often see obesity programs built around a single or dominant treatment that is offered to most (if not all) patients at that clinic. Although the programs may describe themselves as being comprehensive and holistic, they are often limited in the treatments they offer. Thus, for example, surgical obesity programs are built around surgery, formula-diet programs are built around the use of formula-diets, low-carb or keto-program are built around low-carbs and ketogenic diets, “lifestyle” programs are built around addressing “lifestyle”, psychological programs are built around psychological interventions, etc. This segmented approach to obesity care is obviously confusing to patients, who have no way of knowing whether the recommended treatment at a given centre is really the one likely to serve them best, or rather, just happens to be the one available at that centre.
This selective (and sometimes dogmatic) approach to obesity management can also be a barrier to recognition and respect from professional colleagues, as it appears arbitrary and simplistic. No doubt, this state of affairs is partly responsible for the criticism and apprehension from colleagues, who often do not look at running a “weight-loss clinic” as practicing “real” medicine. Indeed, even bariatric surgeons, despite the considerable evidence supporting the positive impact of surgery on morbidity and mortality, have had to (and continue to) fight for legitimacy and respect from many of their non-bariatric surgical colleagues.
Finally, as in any field, there are folks with strong opinions and beliefs about what obesity treatment should or should not look like. Thus, there are champions of keto diets or exercise programs, who not only don’t “believe” in the need for medication or surgery, but actively advocate against their use. Even within the conservative field, we find colleagues arguing about which dietary approach is most effective, not dissimilar from surgeons passionately arguing about which operation or endoscopic procedure is best. As an interesting quirk, we have in the field of obesity medicine, those who focus on weight loss as the primary outcome and those who sternly discourage their patients from even weighing themselves and rather embrace “non-scale victories”. While such controversy should be embraced and respected as it helps drive the field forward, it can also be perceived by policy makers, funders, patients, and colleagues as a state of chaos and uncertainty, thereby discrediting the entire field.
Thus, anyone considering setting up an obesity program must be aware of their own limitations in knowledge and experience as well as the challenges and barriers arising from within their own professions.