Gitanjali Srivastava, MD, professor of medicine, pediatrics & surgery, and the medical director of obesity medicine at Vanderbilt University School of Medicine in Nashville, Tennessee, was nearly 10 years into practicing pediatric medicine when she graduated from the obesity medicine fellowship at Massachusetts General Hospital in Boston in 2013. "We were the very first sort of fellows to speak of then; there were no standards or curriculum," she said.
Obesity was already epidemic, but stigma and bias were still pervasive in the medical community and within the public. After graduating, Srivastava spent months vying for a position with hospital CEOs. She traveled across the country explaining the specialty and its value, going into detail about the budget, business model, space requirement, and revenue potential of obesity medicine.
Today marks a very different era.
Obesity medicine is exploding. Patients are spilling into doctors' offices looking for obesity treatment. Healthcare systems are seeking out obesity specialists and building metabolic health centers. Since 2020, the number of doctors board-certified by the American Board of Obesity Medicine has nearly doubled, and the number of obesity medicine fellowships across the country has more than doubled. Next month, another 2115 doctors from primary care, surgery, orthopedics, pediatrics, fertility, endocrinology, and beyond will sit for the 2024 exam. The once niche specialty is quickly becoming intertwined with most of modern medicine.
The Need to Treat
It's no mystery that the rapid expansion of obesity medicine coincides with the US Food and Drug Administration's approval of GLP-1 injections. The drugs' radical weight loss properties have captured headlines and driven up patient demand. Meanwhile, doctors are finally able to offer effective treatment for a disease that affects 40% of US adults.
"We are finally treating it as a chronic disease, not as a lifestyle," said Marcio Griebeler, MD, director of the obesity medicine fellowship at the Cleveland Clinic. And "I think it's fulfilling for physicians," he said.
For so long, the advice for obesity was about lifestyle. Move more, eat less, and harness willpower, "which really is a fallacy," said Kimberly Gudzune, MD, MPH, an obesity medicine specialist and chief medical officer for the American Board of Obesity Medicine (ABOM) Foundation. For people with obesity, "your brain is operating differently," she said. "Your body really is set up to work against you."
Brianna Johnson-Rabbett, MD, medical director of the ABOM, told Medscape Medical News that with the advent of GLP-1s, "there's a clearer recognition that obesity is a disease that needs to be treated like other diseases." Some of that is, thanks to clinical trial data showing that just as with other diseases like high blood pressure or diabetes, obesity can be treated with medication and it resurges when the medication is stopped, she said.
Doctors don't have to go looking for patients with obesity, Griebeler adds. Now that treatment options exist, they're showing up in droves at the doctor's office — all the doctors' offices. In primary care, endocrinology, surgery, pediatrics — a wide variety of doctors are being asked about obesity drugs, Griebeler noted.
And while doctors are often just as excited as patients about the potential for treatment, many find themselves under-equipped when it comes to obesity. "More physicians are…recognizing the value in treating this, and some are realizing, "Oh gosh, I never learned how to do this," said Gudzune.
Information Patients Waiting For
Medical training has traditionally devoted minimal, if any, curriculum to obesity and metabolism. "To be honest, we didn't really cover this at all in my training," said Nina Paddu, MD, obesity medicine specialist at Maimonides Medical Center in New York City who finished her training only 2 years ago. "The guidance even in residency was 'let's send them to nutrition' and 'recommend exercising.'"
In addition to the medical education gap, until recently there was a "paucity of robust evidence," Srivastava said. Leaders in the field wanted to establish standards and guidelines, but there wasn't enough strong evidence on obesity and its treatments to build them, she said.
Only in the last 5 years or so has the evidence-based understanding of obesity's pathophysiology truly accelerated: The brain's driving roles, its interplay with hormones, and its interactions with other diseases. "We are just at the cusp of understanding all the different factors," Gudzune said.
But already endocrinologists, surgeons, fertility specialists, gynecologists, and oncologists, to name a few, see the critical overlap with their own field. "Conditions were once suspected of being intertwined [with obesity], and now we have data to connect them," Srivastava said. For example, there's now data connecting semaglutide to a 20% reduction in cardiovascular events for people with obesity. That's a game changer for multiple specialties, she told Medscape Medical News.
Getting Trained in Obesity Management
The recent uptick in obesity insights and increased patient need has doctors from every career stage seeking additional training.
The ABOM offers two board certification pathways: 60 hours of CME credits or a 12-month fellowship. Both paths require doctors to pass the board's exam.
Many doctors incorporate the training into their existing practice. The CME credit pathway, especially, is designed to help get doctors up to speed without requiring them to upend their lives for a fellowship.
Srivastava said that the fellowship is more consuming and immersive. While it's often younger doctors just out of training who apply to fellowship, every year, "I'm astonished at the number of talented physicians with clinical and research experience who want to immerse themselves in a fellowship experience."
Some doctors return to their previous specialties after fellowship. But many will go on to take obesity medicine–specific roles or set aside clinic hours for obesity medicine. Their credentials are "really attractive to institutions, especially those looking to open up obesity medicine or weight management programs," said Srivastava.
Paddu, who finished her obesity medicine fellowship this year, said there are a variety of obesity medicine jobs to choose from — far different from Srivastava's job search 15 years ago. Paddu's new role combines 2 days of primary care with 2 days devoted to obesity medicine and 1 day each week set aside for administrative work so she can build up the hospital's new metabolic health clinic.
Still Not Enough Obesity Specialists
As with all things, rapid growth requires careful oversight. "Part of the responsibility of the board is to think critically of how the field is growing" and conduct ongoing monitoring, Gudzune said.
This is also why the board's credentials are time-limited and must be recertified, Johnson-Rabbett added.
But even with the rise in certified doctors and obesity medicine positions, the 8263 doctors certified by ABOM are only a tiny fraction of US physicians. As a result, there's genuine likelihood that many patients seeking GLP-1s or other obesity treatment don't yet have access to the holistic care they need. Plus, doctors may still not have obesity expertise within their networks.
"The field has grown rapidly, but it's still such a small field relative to the patient need," said Gudzune.
