Obesity Medicine, Stigma, and Health Disparities: A Conversation with Physician-Scientist Dr. Fatima Cody Stanford

Interview by James Jolin

HHPR Senior Editor James Jolin interviewed Dr. Fatima Cody Stanford, MD, MPH, MPA, MBA, FAAP, FACP, FAHA, FAMWA, FTOS, an obesity medicine physician-scientist, educator, and policymaker at Massachusetts General Hospital and an Associate Professor of Medicine and Pediatrics at Harvard Medical School. Dr. Stanford’s clinical interests include health and fitness, health services, weight gain and obesity, healthcare policy, and healthcare for vulnerable populations. Dr. Stanford received her BS and MPH from Emory University as an MLK Scholar, her MD from the Medical College of Georgia School of Medicine as a Stoney Scholar, her MPA from the Harvard Kennedy School of Government as a Zuckerman Fellow in the Harvard Center for Public Leadership, and her MBA at the Quantic School of Business and Technology as a merit-based scholar. She completed her Obesity Medicine & Nutrition Fellowship at MGH/HMS after completing her internal medicine and pediatrics residency in South Carolina. This interview has been edited for brevity and clarity.

James Jolin (JJ): Thank you for speaking with me, Dr. Stanford. My first question concerns your academic background. Can you walk our readers through the trajectory of your career? How did you arrive at your current academic interests, which lie at the intersection of obesity, health policy, and health disparities?

Fatima Cody Stanford (FCS): That’s a great question, James. I was born and raised in Atlanta, Georgia, and that’s important, because that was the birthplace of the Civil Rights Movement here in the United States. I’ll come back to that point, and that will illuminate my interest in health disparities — being born and raised in black Atlanta, for lack of a better way of saying it.

My undergraduate degree was in Anthropology and Human Biology, and I was a Dance minor — so a variety of interests. Looking at that biological anthropologic piece was, I would say, an introduction also to the world of public health. So immediately after finishing my undergraduate degree I did my Master’s in Public Health and Health Policy Management at Emory University also, which is where I did my undergraduate degree. I worked in the American Cancer Society; I worked in the CDC developing the first content for women here in the US. I then worked at the De Kalb County, Georgia, rape crisis center, and I was their head of prevention and one of the consultants to the National Center for Victims of Crime for Rape and Sexual Assault in the US.

After that, I went to medical school. I did one year of orthopedic surgery sports medicine in New York City before completing residencies, and internal medicine and pediatrics at the University of South Carolina in Columbia, South Carolina. I came to Boston to do my three-year obesity medicine and nutrition fellowship at Massachusetts General Hospital and at Harvard. In my final year, I did my mid-career degree at the Harvard Kennedy School of Government as one of the Zuckerman Fellows. At that time, I really felt public health had its own domain, and public health people talk to public health people, and medical people talk to medical people. But what I found that was most intriguing specifically about my training at the Kennedy School, which supersedes all my other degrees, is the fact that you brought people from really different areas of interest together to talk about policy.

In my class, we had the Leader of the Opposition party in South Africa, an individual that was running for president of South Sudan at the time, Navy SEALs, architects, doctors — just the most varied interests that you could potentially have. And I think that is the real world. I didn’t just talk to public health people. I didn’t just talk to physicians. The world is a microcosm of what we were seeing at the Harvard Kennedy School. In my most recent past, I completed my Master’s in Business Administration. As you can see, I had a variety of interests. And over the span of 25 to 26 years, I was able to bring that together.

Now, why obesity? That is a question that people often asked. Obesity is by far the most prevalent chronic disease of humankind, yet it is the most under-treated and least understood, and a lot of it has to do with just our lack of education at the medical school, residency or fellowship level. Some of it has to do with our bias. Some of it has to do with some of the disparities that you might see with patients with excess weight. So there is a variety of things.

I started my research more on the prevention side when I was in public health back in the late-90s, early 2000s. 20-plus years later I work now in a broader context of looking at those public health implications but looking at treatments and policies and things that shape access or lack thereof for particularly racial ethnic minorities, who tend to have higher rates of overweight and obesity and other subsequent chronic diseases. This is how it ties altogether.

JJ: Thank you for your response. My next question delves a bit more into the content of your work. Recently, the medical community has focused its attention on health disparities — be they racial, socioeconomic or gender-based. Health disparities also stand at the center of much of your work. I am interested in understanding which health disparities you find are the most concerning or the ones that need the most attention from the medical community.

FCS: I think it all goes back to obesity, and it will be hard to give you a single answer because obesity affects so many other disease processes — it’s really, unfortunately, the elephant in the room that often just goes ignored. Obesity leads to many mental health disorders; it leads to 15 types of cancers; it leads to high blood pressure and obstructive sleep apnea and diabetes and arthritis. There is no organ untouched by obesity, and so it is hard for me to hone in and say it is this one thing.

I would say the gross under-treatment of the disease, particularly in communities that have higher prevalence, is problematic — but there’s gross under-treatment, even in the majority population. So, if you look at access to evidence-based therapies beyond lifestyle — which I am a huge proponent of — the problem is that we’re dealing with close to half of the country that has this disease of obesity, and so are we preventing something that people already have? Or are we not treating the stuff that people already have? We very readily will treat other chronic diseases. So, I would say the biggest disparity is just our lack of recognition, the understanding of the disease, that is at the core of all the work that I do, if you really kind of tie it together.

It hurts me to know that many people can have health and have healthier lives and have no idea that that’s a possibility, and that lack of knowledge starts at the medical school level, I really think. If doctors don’t understand it, how do we expect everyone else to understand it? And unfortunately, we, as doctors, along with other health care providers, often hold a lot of both implicit and explicit bias toward those that have obesity, and it gets in the way of them getting the level of care that they deserve. You can imagine that when you have that overlay of race and weight bias, that it only intensifies the issues that I’m saying are applicable to patients with obesity. When you, say, happen to be a black woman who has obesity, we have lots of intersectionality — we have race; we have gender; we have weight status. The intersectionality of those three can make the lived experience, even without addressing necessarily weight and the downstream health impacts just their lived experience of navigating life, as it relates to employment, as it relates to promotion — all types of things.

All these things can play a major role and are a bit intangible in some ways. No one really knows that they didn’t get a promotion because of their weight status. We don’t know. You could presume that potentially, but it is kind of hard to capture right in a research format.

JJ: Thank you for those insights. Your response brings me to my next question, which concerns stigma. Obesity is a medical condition that incurs significant stigma among the general population — specifically within the media. In what ways do you see stigma against people with the disease of obesity present in the medical community? And despite any progress that has been made among physicians, how do you see social stigma against obesity impacting patients’ ability to manage obesity?

FCS: Well, data shows that at least 79% of doctors have significant weight bias towards patients. We have this bias that permeates medicine and our larger culture, our assumptions about how a patient looks because of their size, whether they are lazy or slothful or unmotivated or passive — or all these types of adjectives that we might use. These are founded in our belief that their weight status, their obesity, is a product of their inability to do something or their inactivity or whatever it might be.

It’s genuinely hurtful to patients, not just in terms of their motions, but leads to poor health outcomes such that if patients experienced this in the healthcare setting, do you think they want to come back and see us? It only continues to compound it, and it makes that lived experience and even the health care outcomes worse if the patient recognizes that their voice, their value, is not there.

We in healthcare are some of the unfortunate culprits of this bias and stigma, but it permeates all of society. Weight bias is kind of like the last “acceptable” form of bias. And what I mean by “acceptable” is that people get paid to make fun of themselves on television. Comedy often will do this. People are paid to make fun of themselves because that’s acceptable.

JJ: Very interesting — thank you for your insights. Given what you’ve just said, in your work, how do you sort of try to destigmatize obesity when treating your patients? Do you think that there’s sometimes a tension between treating the disease of obesity and trying to destigmatize it?

FCS: I think that, in general, potentially, there is a tension — it depends on how you approach it. So I’ll tell you how I approach it.

I never give my patients a target weight. It drives them crazy because they want a target. But I don’t know what that number is. And when we look at something like BMI, which I am not a fan of — body mass index just considers height and weight; it is an indirect measure of fat. While that’s a guiding principle, and all the guidelines that have been published here in the US and around the world, with regard to addressing weight, I never give my patients a target BMI. I don’t hyper-focus on that; I focus on their entire health. So, beauty is more than skin deep, right? Well as a common phrase that is, health is more than skin deep.

So let’s say someone looks thin, but let’s also say the reason that they are very thin is because, unfortunately, they’ve had a history of drug use. So, while they may be aesthetically pleasing to Western culture, there is not a lot of health behind that — whereas a person with obesity has great health parameters; their lipid or cholesterol profile is good; they have no evidence of fatty liver, no high blood pressure, no arthritis. The assumption would be that that person with obesity is an unhealthy person, and the lean person is the healthy person. I try to get people out of that mindset, because it’s so ingrained and how they think because that’s what we’ve taught them. And we need to do better.

So, I just tell my patients we’re not going to target anything; we’re going to try to get to you to the happiest, healthiest weight for you. If that happens to be in this BMI category that’s still severe by BMI criteria, that’s where you must be. It’s not about me trying to have you achieve a certain milestone that is reflective of someone that doesn’t look anything like you. So that’s how I try to balance the two.

JJ: One other point that I think has been a recurring theme in your work is the idea of language. How do you think we can use language better to try to destigmatize obesity?

FCS: Absolutely, so I am a huge advocate of something called people-first language, so deleting the word obese, saying a patient with obesity, like you see a patient with depression or a patient with diabetes. They have the disease but aren’t characterized by it. When you say “obese” patient, for example, it implies that that’s defining of who they are. That’s not who they are; it’s something they have, so I try to be very, very clear on my language to reduce weight bias and stigma.

Also, the use of the term “morbid” — I hate the use of the term morbid as it relates to obesity. We don’t call it morbid COVID-19; we don’t call it morbid cancer; we don’t call it morbid heart disease. Why do we call it morbid obesity? So even in the language that we use to define the disease, we use stigmatizing terms, and my goal is to help eliminate that. So I’ve worked at the level of the Mass Medical Society, and the American Medical Association to rephrase these types of things and pass resolutions to support the better use of language and communication with our patients.

JJ: Thank you for that. My last question looks at the policy and system-wide level. As we have seen throughout the COVID-19 pandemic and beyond, disease doesn’t operate within a vacuum. It’s influenced by myriad social and structural factors. With this in mind, what policy decisions has your research shown can be effective to treat obesity on a system-wide level? Alternatively, what are some ineffective ways to craft obesity policy?

FCS: Right now, there is no obesity policy in the United States. That is a problem. And so let’s talk about how we conflate nutrition and obesity policy. We’ve been trying to pass a bill called the Treat and Reduce Obesity Act, which is called TROA, through the House and Senate, which has “strong,” and I put in strong in air quotes on purpose because it has strong bipartisan support, meaning like if you were to look at who are the sponsors of the bill, the number of people that have signed on, you would be surprised. But we’ve been trying to get this through the House and Senate since 2013. And we’re in 2022.

It’s a very basic bill that we’re trying to get through. It covers two things. Number one: it covers work with a dietician. Right now, if you are a Medicare beneficiary, and you have obesity and like to spend time with a dietician, your visit with that dietician is not covered. You must get diabetes to then begin working with the dietician, so the message I hear is we only care if you have diabetes — wait until you get that. It seems to be backwards. Shouldn’t we be thinking about preventing diabetes? That’s what I think.

The second tenet of the TROA is to cover anti-obesity medications. Currently, under Medicare Part D, coverage of medications to treat obesity is a complete exclusion. If Medicare sets the standard for all insurers, we then find out why there is no treatment of obesity from a pharmacotherapy perspective, because it’s not being covered — even very, very effective forms of therapy with strong evidence in the peer-reviewed literature to support it.

So, I would say number one, let’s get a policy — a policy. Can we pass the one that we’ve been introducing for nine years? I think that’s a start. I think it’s a strong bill. It is not asking to do a lot — coverage and medication, simple. We could add a lot more, but then it becomes more complicated. If we can’t get those two things through in terms of considerations, I think that it says a lot about us as a country.

Your other question was about what is ineffective: our hyper-focus on nutrition policy — i.e., menu labeling, which is never shown to improve weight status, i.e., calorie fixation, all of these things that we’ve seen never to improve the outcome of those individuals exposed to those measures. And so I’m not opposed to people having some aggression and concerns about big food, right, in terms of their ability to sway legislators, etc., and getting tax subsidies for ultra-processed foods — but that is one area. What about everything else? What about all the other factors? What about the fact that stress is a major cause of obesity? Stress causes storage of fat; stress comes from your lived environment. There are also a lot of things I think we could do that will give people a better awareness of potential behavioral things that can have an impact beyond the hyperfocus on sugar-sweetened beverages, which I think is where our time and attention have been. Also, for kids, the built environment in terms of playgrounds. We’ve done that research. Yes, I love activity — playgrounds are fun. I used to love being on the playground back in the 80s, but that’s not solving obesity.

So, I think we have to be cognizant of the fact that those simple fixes will not fix this disease. We need aggressive, comprehensive, multimodal, multidisciplinary policy to really make any significant change.

JJ: Thank you so much for those and all your insights, Dr. Stanford! I know our readers will benefit from hearing your perspective.