Michael Gorman refused to see a physician, even as his weight surged past 500 pounds. He could no longer go to movie theaters that had chairs with armrests or take long flights because he could not fit in airplane bathrooms. He’d been heavy since childhood, and in his experience, physicians did little but shame him.

“I started realizing that going to the doctor meant I was going to get a lecture on my weight, so I stopped going except in dire emergencies,” he says.

It wasn’t until the 46-year-old marketer from Providence, Rhode Island, realized that his obesity might cut his life short that he decided to lose weight. He wanted to live long enough to take care of his parents, so he knew he had to make a dramatic change. Instead of turning to his physician, he did his own research and decided to adopt a ketogenic diet in the winter of 2017.

It wasn’t easy. He went to bed early to avoid hunger pangs and sometimes cried himself to sleep.

Now, nearly 3 years later, he has lost more than 260 pounds. He typically doesn’t eat between noon and 9 AM the next day, and he works out 5 to 6 days a week. He sees his physician twice a year for checkups, but says he actually gives weight loss advice to him. His physician has joined him on a keto diet, Gorman says.

A Lack of Knowledge

Obesity is among the most common chronic diseases in the United States yet one of the most undertreated. And it’s only going to get worse, with almost half of US adults predicted to have obesity by 2030, up from 40% now.

One of the reasons primary care physicians struggle to successfully treat patients with obesity — particularly extreme obesity — is that many don’t know how, says Scott Kahan, MD, MPH, director of the National Center for Weight and Wellness in Washington, DC.

Medical schools traditionally haven’t taught students how to treat obesity, says Kahan, and the American Medical Association did not even recognize obesity as a chronic disease until 2013.

“I can’t think of another disease where, if treated, it helps patients with so many other diseases,” says Fatima Cody Stanford, MD, MPH, an obesity specialist at Massachusetts General Hospital and faculty member at Harvard University Medical School, Boston. Yet there is a worldwide scarcity of obesity education programs for medical students, residents, and fellow physicians even though they often improve outcomes when administered.

To address that, the Obesity Medicine Education Collaborative (OMEC), a joint initiative of several medical societies, has created 32 competencies to introduce obesity medicine education earlier and improve training. Additional resources are available from the Centers for Disease Control and Prevention and National Institutes of Health. However, practicing physicians are largely on their own in training themselves.

‘It Shook Me to My Core’

Until being diagnosed with gout, Steven Ray saw his physician only for colds, flu, and routine matters. Even though he weighed as much as 368 pounds, the 31-year-old from Tuscaloosa, Alabama, said he had no obesity-related health problems.

He had lost weight many times by dieting, but always regained the pounds and more. The property manager was eventually unable to climb a ladder and couldn’t ride comfortably in most vehicles. However, he had accepted his obesity until receiving the gout diagnosis. He researched the complications of gout and obesity, and knew he was looking at a future of kidney disease, diabetes, joint pain, and more.  

“It really shook me to my core and made me decide to wake up and lose weight,” says Ray.

His physician put him on a strict diet of 1400 calories per day. Now Ray typically skips breakfast and has a grilled chicken thigh or salmon for lunch. He has an afternoon snack of mixed nuts and finishes the day with a dinner of a baked potato or bowl of oatmeal. He also walks for an hour or more daily and lifts weights. “I literally went from a couch potato to an exercise warrior overnight,” he says.

At the time of writing, he had lost nearly 100 pounds in a year. He sees his physician regularly for checkups and encouragement.

“My doctor is one of those old school doctors who is very stern and one you really don’t want to cross. Him monitoring my weight loss has helped me tremendously because it’s kept me grounded and knowing that I have to stay on it. His plan is also the only plan that has worked for me long term,” says Ray.

No Simple Solutions

The diet that has worked for Ray won’t necessarily be effective for everyone else, says Kahan, who added that physicians should remember three things when advising patients on diets:

1. There are no studies showing that any diet is better than another.

2. Diets work differently for people and depend on a number of individual factors.

3. There are no tests to determine beforehand which diet will work best for a patient.

It’s important to take a thorough patient history and to understand the patient’s lifestyle and relationship with food and weight before deciding on any course of treatment, says Stanford. Physicians should never prescribe a diet or lifestyle change that a patient will not be able or willing to follow for the rest of their life, she says, because going on and off diets leads to weight cycling and, ultimately, greater weight gain. Many patients don’t understand that permanent weight loss requires a lifelong commitment.

Of course, diet and exercise are not the only options. The US Food and Drug Administration has approved five prescription medications to treat obesity by curbing appetite or making patients feel full with less food.

Stanford says she first tries lifestyle modifications such as improved diet and exercise, but will prescribe medication for patients who have a body mass index (BMI) of 27 kg/m² or higher with obesity-related conditions such as high blood pressure, type 2 diabetes, or obstructive sleep apnea. Those who have a good response to the drugs can lose 5%-10% of their body weight, she says.    

However, there is evidence that physicians are underprescribing these medications. A recent study found that only 1.3% of eligible patients received a prescription for a weight-loss medication, and that less than one quarter of prescribing providers accounted for approximately 90% of all prescriptions. The authors said there could be a number of causes, including providers’ lack of experience with the medications, lack of insurance coverage, and bias that obesity is primarily a behavioral problem that should be treated with behavioral measures.

The Surgery Option

Jeanine Sherman had been trying for years to lose weight through diet and exercise without medical help when she finally asked her physician to prescribe anti-obesity medication. He surprised her by recommending bariatric surgery instead.

She researched it and found what she describes as a stigma against the procedure. It took her 3 years and an additional 30 pounds before deciding to have the operation in 2017. She now weighs 143 pounds, well below her peak of 262 pounds, and is a high-profile advocate of bariatric surgery.

The 47-year-old homemaker from St Charles, Michigan, adopted the Twitter handle “iamabariatricpatient” (@JeanineMSherman) and began spreading the word about the procedure she says is underused. In 2018, she began attending patient conferences and has received financial support from a supplement company.

“The more people we can band together, the more our voices will be heard and we’ll make a difference,” she says.

Bariatric surgery has been shown to be effective in achieving large weight loss and improving many weight-related health problems. It’s generally considered for those with severe obesity (BMI ≥ 40 kg/m²) who have not been able to achieve a healthy weight with lifestyle modification or anti-obesity medication, or for those with moderate obesity (BMI ≥ 27 kg/m²) with obesity-related conditions.

Surgery should be prescribed in more cases, including for children, says Stanford. Indeed, the American Academy of Pediatrics in 2019 recommended bariatric surgery as a safe and effective treatment.

The Importance of Support

People have been more successful losing weight and keeping it off when they had others to encourage them, either through a weight loss support group or by enlisting others in their weight loss journey. Meetings can be in person or online.

Ray experienced the ugly side of social media first.

Before he lost weight, he posted YouTube videos about college football and detractors mocked him for his weight. Depressed, he quit social media for 6 months, but later used those attacks to fuel his determination.

“Nobody thought I would ever lose weight,” he says. Now, under the Twitter handle @StevenRay30 and on his Facebook page, he still opines about college football, but also updates his weight loss progress to a largely supportive audience, including some of those who had trolled him earlier.

“I have learned a lot about myself,” says Ray. “I have incredible determination and the willpower to do what I want to do. My confidence has come a long way.”

Before losing weight, keto-disciple Gorman was on Instagram “reveling in my life as a fat guy,” posing with his shirt off and with heaping portions of food. He says he realized he was seeking validation for his obesity.

Now, under the Instagram handle @gormy_goes_keto, he posts before-and-after photos. He even started a podcast, Fat Guy Forum, on which he shares others’ weight loss stories and encourages people to lose weight.

“For me, social media has been a way to hear about other people who were in my situation and a way to reach out and help people,” Gorman says.

Talking to Patients Is the First Hurdle

Treatment begins with talking, but even broaching the subject of obesity with patients can be tricky. Kahan says too many physicians take a heavy-handed approach, lecturing patients and using scare tactics or shaming them.

“It ruins the doctor–patient relationship. Patients don’t want to see the doctor because they haven’t lost weight or they don’t want to be told to lose weight,” he says.

Instead, a physician should ask for a patient’s permission to discuss obesity and respect their authority if they refuse, says Kahan, regardless of their degree of obesity. If a patient agrees, the physician should proceed gently, discussing the complications of obesity and why he or she might want to lose weight, he adds.

Stanford recommends a more aggressive approach, even if the patient does not want to have the conversation.

“I think we’re being a bit timid,” she says. “I don’t ask for permission to discuss diabetes, high blood pressure, or heart disease. We should treat obesity like we do any other chronic disease.”

And when a patient does ask for help losing weight?

Physicians should be empathetic and supportive, making it clear that they intend to help, says Kahan, adding that physicians who are not confident in their ability to treat obesity can educate themselves. Physicians who think that a patient requires treatment by a specialist can find one on the American Board of Obesity Medicine website, which lists more than 3000 specialists by location.

Extreme weight loss is difficult and seldom accomplished on the first try. Failures and setbacks are common.

It’s a mistake to treat weight loss simply as a matter of willpower or desire, says Stanford, adding that obesity is caused by many factors, such as the environment, mental health, and individual biology. “It’s much more out of our control than we think,” she says.

For that reason, physicians must be patient and understand that they’re in it for the long haul, she says. “Obesity doesn’t happen overnight, and it’s not going to get solved overnight.”

James F. Sweeney is a freelance writer in Cleveland, Ohio.

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