The Value-Based Healthcare Podcast: Fatima Cody Stanford

In episode 11 of The Value-Based Healthcare Podcast series, Dr. Fatima Cody Stanford joins Jay Ackerman and talks about obesity medicine and how obesity disproportionally impacts minority communities. Dr. Stanford is a physician, policy maker, researcher, speaker, media professional and educator. She is an Assistant Professor of Medicine and Pediatrics at Harvard Medical School and an Obesity Medicine Physician at Massachusetts General Hospital.

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Podcast transcription: 

Jay Ackerman:
Hello and good day. I'm Jay Ackerman, CEO of Reveleer, a software and services company committed to providing health plans with innovative technologies to maximize their return from quality, risk adjustment, and compliance initiatives. It's a must in the value-based care world we operate in.

I'm back again with yet another installment of The Value Based Healthcare Podcast. This is truly one of my job highlights, as I have a regular opportunity to engage with thought-leaders, visionaries working across the healthcare ecosystem. And through our podcast we aim to widen the visibility and voice of people working to change how healthcare is provided and the impact it has on all those who participate in the care delivery chain.

I'm excited to be here for our podcast with Dr. Fatima Cody Stanford. Dr. Stanford, welcome.

Dr. Stanford:
Thank you for having me, Jay. It's a delight to be here.

Jay Ackerman:
We're delighted to have you. And so, for our listeners, let me give a little background on Dr. Stanford. She's an obesity medicine physician/scientist at Mass General Hospital and Harvard Medical School. 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, and her MPA from the Harvard Kennedy School of Government as a Zuckerman Fellow in the Harvard Center for Public Leadership.

She completed her obesity medicine and nutrition fellowship at MGH, HMS, after completing her internal medicine and pediatrics residency at the University of Southern Carolina. She served as a health communications fellow at the Centers for Disease Control and Prevention, and as a behavioral sciences intern at the American Cancer Society. Upon completion of her MPA she received a Gold Congressional Award, the highest honor that Congress bestows upon America's youth. Dr. Stanford has completed medicine and media internship at the Discovery Channel.

Jay Ackerman:
Well clearly, you've been pretty busy in your career, Dr. Stanford.

Dr. Stanford:
Just a little bit, I slack around a little bit (laughs).

Jay Ackerman:
Yeah, it has me questioning what I've been up to over the last 20 years. With that mouthful, let's begin. And obviously there are some questions about your career journey that I need to ask, so how about you give us a little context on yourself and your journey, and what brought you to be in medicine.

Dr. Stanford:
I've known since about the age of three that I wanted to pursue a career in medicine. I would say that I definitely have a different career than what I envisioned as just a community doctor, being in academics and spending a lot of time in public health. So, medicine has been entrenched in who I wanted to be. People then of course will often ask, “Was it influenced by my family?” Were my parents or grandparents physicians? And no, they weren't. But for some reason I saw that, medicine is where I saw myself, as a strong advocate for patients, and I saw that I could be a resource to patients from a very early age. And so, that's where I guess it started.

What I initially did in undergrad was, I thought I was going to go immediately to medical school, but I took a medical anthropology course in my third year of undergrad, and really became introduced to the field of public health, and decided that I would first do my Master's in Public Health and Health Policy and Management at Emory, really in what I consider to be the mecca of public health. Right next door to Emory is the CDC, and I spent quite a bit of time at the CDC, working in the Office of Women's Health, specifically making sure that we communicated messages about women's health to the public here in the United States.

From there I actually worked at a rape crisis center, then went to medical school, and I actually went into more of a surgical field, actually orthopedic surgery, before making a shift to internal medicine and pediatrics, which is where I completed residencies, and then finally to obesity medicine, which is where I spend my time as an expert within that field.

So I would say that I've taken some twists and turns. Obviously, medicine was a common theme, with public health overlaid, and then public administration. And I see public health and public administration really helping to propel a larger message. So, I can only do so much work if I see patients all day every day, seven days a week, and those patients can benefit from my care. But if I deliver the message via communication means, whether it be through doing interviews such as this one, or lectures, or the books that I've written, then I'm able to impact a much larger segment of the population, and then have an impact truly on the public's health. So, I hope that answers the question in terms of why I started here, why I stay within this space, and why I continue to do the work that I do every day.

Jay Ackerman:
It sure did. Let's go to the current area focus on obesity medicine, and from the dialogue that we had earlier, it's clear that you kind of sit at the top of the mountain in the specialty that you have. What brought you to be so focused on obesity in both adults and in children?

Dr. Stanford:
I'm going to take you back to the late 1990s when I was doing my work in undergrad, and actually starting my Master's in Public Health. And all the projects that I was focused on at that time within the public health space were looking at overweight and obesity, particularly within the African American community in Atlanta, Georgia, which is my hometown. I was working with a lead investigator by the name of Dr. Kenneth Resnicow, who's now at the University of Michigan, on two primary projects. One was called Healthy Body, Healthy Spirit, which specifically looked at obesity within African American church communities, and another project called Go Girls, which was specifically targeting overweight and obesity within African American adolescent girls.

So at that point I was very interested in looking at the disparity of obesity within the African American community. And just to delineate that disparity, 40% of the US adult population has the disease of obesity. When we look at that and we can concentrate, for example, on African American or black women, whichever term is more preferable for you, we find that 60% of African American women have obesity here in the United States. And so, I was particularly struck as a black woman here in the United States by the disparity that exists. Yes, obesity is prevalent, it is by far the most common disease, but it disproportionately impacts minority communities. So that was what really drew me to this space.

When I was in, even medical school, there wasn't really a specialty in obesity medicine, so I didn't know that that was a path I could pursue, and it was really something that I stumbled upon. When I was completing my residencies in internal medicine and pediatrics, I literally was on call one night in the pediatric ICU, it was about 2:30 in the morning, and I went to our friendly tool that all of us use, Google, and typed in ‘obesity in medicine.’ And the fellowship here at Massachusetts General Hospital, Harvard Medical School, appeared before my eyes. I had no idea what it meant. I called my husband immediately, literally at 2:30 in the morning, and he told me that I needed to do some more research to figure out what that meant.

I began contacting the program director, Dr. Lou Kaplan, who's the President Elect of the Obesity Society, and working with the group here to find out what this meant, and I rotated here as a fourth-year internal medicine and pediatric president, and learned that wow, I can actually make a difference in the lives of these patients that struggle with this chronic disease of obesity, in a way that I had never seen done prior to my time here.

And so I applied, was thrilled to be selected, and then have really just become very much entrenched in the care and delivery of care to patients that struggle with the disease. And there's a lot of stigma, a lot of miseducation, or just lack of education, not only here in the US, but throughout the world. And so hopefully I will continue to serve as a leader, but not just a leader to make myself feel good, but really to move and shift the dynamic of how we care for this patient population here in the US and abroad.

Jay Ackerman:
That's fantastic. Thanks for that background. Let's talk a bit about health and wellbeing and healthcare in the US. What do you see as the greatest barriers and challenges that affect patient improvement in today's environment?

Dr. Stanford:
I think one of the issues that, if I think about it from a policy lens, is that if you look at CBO, or congressional budget office estimates, when we're looking at care delivery, it's done on a very short timeframe. And when we're looking at short return on investment, we're not looking at the treatment of chronic disease, which is by far more pervasive than infectious diseases here in the US. As such I think that we don't divert our attention and resources to the prime diseases that actually are the ones that are killing us here in the US, and I think that the CBO estimates need to be adjusted to account for the longevity of chronic disease so that we are able to best serve that patient population that deals with chronic diseases as the primary source of both mortality and morbidity.

Jay Ackerman:
Any thoughts on how we shift that focus onto the chronic diseases?

Dr. Stanford:
I think we just need to extend it. So, CBO estimates are three years, so I can potentially have an impact on the life of a person that has obesity within three years if I do something like a bariatric surgery, for example. But for many people it will take a much longer time for me to have an impact on their life, so we need to extend those CBO estimates to the life of these chronic diseases. Even if we extend them to like 10 years, so you can see some meaningful change with regards to chronic diseases such as diabetes, heart disease, etc. Then I think that we'll be able to have a better handle on how we need to allocate resources to care for a patient population which is largely struggling from chronic disease, and not those acute illnesses like Ebola or something like that.

Jay Ackerman:
Any thoughts you can share on how you use your voice, your platform, to drive that focus on shifting from three-year estimates to something longer term?

Dr. Stanford:
Yeah, so I'm very active in organized medicine. I'm currently an officer for the American Medical Association, American College of Physicians, American Academy of Pediatrics, the Obesity Society, the Obesity Medical Association, and the Massachusetts Medical Society, which are the ones I can think of right now. I hope I don't miss anyone and someone gets upset. But with those roles I spend quite a bit of time on Capitol Hill advocating for the treatment of chronic disease issues, which I think are paramount of the focus of a lot of the organized medical associations, including the AMA, which of course is the largest here in the United States.

I spend time speaking with my Senators, who are Ed Markey and Senator Elizabeth Warren, of course a household name now. And then of course our Congressmen and women here in Massachusetts, who appear to be aligned with what my thinking is in terms of us needing to better cover chronic disease processes. That is not a pervasive thought throughout the country, however, and so often I feel that I'm preaching to the choir here in Massachusetts. I would say that California probably aligns with some of those principles, although I would say I spend more time with my particular legislators. So, I think that places that have a higher likelihood of suffering from more disparities in terms of these chronic diseases, the voice of the clinicians, the voice of the people in those states, is not supportive of what I'm saying, needs to be our focus when we're looking at illness and disease in the treatment of these patients, and prevention of disease for vulnerable populations.

Jay Ackerman:
Is there anything you can share about a patient, perhaps, that's touched your heart, and maybe how that patient or somebody like that has changed the way you approach this dialogue?

Dr. Stanford:
I'm going to take you back to my residency, and I'm going to reveal how I realized that I had biases towards patients that have chronic diseases such as obesity. I had a woman who was about 45 years of age, who had been in my care for about a four-year duration of my residency. She struggled with severe obesity and had some other chronic illnesses that plagued her. Every time I would see her, I would spend a lot of time focusing on behavioral modifications that she could make as it relates to diet and exercise and things of this sort, and the needle never budged with regards to her weight. Her body maintained her set point, and of course I wondered, was she really heeding to any of these recommendations?

One day, in my fourth year of taking care of her, I happened to run into her in the grocery store as she was about to check out at the checkout line for all of the food that she had purchased. In our short and brief interaction, I had a chance to glance at her cart to get a sense of, what is she buying? Is she really abiding by the things that we've talked about over the last four years? And what I noticed when I did glance at her cart, which she of course noticed me doing, was that she had purchased really every single item that I've ever mentioned over the last four years. She had no idea of course that she was going to see me as she was about to check out at the grocery store. And so she says to me, as she notices me glancing at her cart, she says, "Dr. Stanford, see I've been doing everything that you told me to do."

So, that was a place for me to check myself about my own biases in terms of recognizing the effort that she had been putting forth, year after year, with no significant shift. I realized that we needed to do better for her. I needed to find better therapies to treat her severe obesity, and I was not doing her a service, and making assumptions about her engagement of her own health. That was one of the biggest lessons I've learned. I've taken that and used that to the inform how I now treat my patients, and how I encourage others to treat their patients, both here in the US and around the world. So, listen to your patients. Your patients are giving the answers, and often we're not listening. And if don’t listen, we're never going to be able to best serve them.

Jay Ackerman:
That's a powerful story on a number of levels, both how it caused you to kind of rethink your therapies, but also as a good reminder, just how we need to check our biases throughout life. Let's keep it moving. What about recommendations you would have for the public regarding their empowerment and the ownership of their own health and wellbeing?

Dr. Stanford:
I would say to individuals throughout the world to take ownership by learning, and using reputable sources to learn about health. Right now, if you look at our current focus in terms of where we get our healthcare, unfortunately we're getting it from Instagram or Snapchat or whatever it might be, and I can tell you definitively that those are not reliable sources of information about chronic disease. And so, we need to use reliable evidence-based sources, and by that, I mean using hospital information that you can get from Massachusetts General Hospital or the Mayo Clinic, or all of these which are widely available and free online. Those would be reputable sources that are governed by the medical evidence that we have from research that we conduct about how we either prevent and-or treat chronic disease.

Often what I find with patients is, they go on Instagram, somebody tells them they did X, Y, and Z, they bring in something they brought from GNC or some other store, and I have no idea what any of the ingredients are, and you can't find anything, any research, that's ever been conducted ever on any of these substances, and then they have an adverse event, and I have no idea what was really the etiology. Which thing was it that they were taking that I didn't know anything about? And so, I would just be wary of people that are posting pictures that encourage you to consider one thing without any strong background on what's being done. And so, I would say, that's probably my strongest advice for the general public in terms of, make sure you're taking ownership, but with reputable information.

Jay Ackerman:
How about advice for healthcare executives in navigating our industry during these rapidly changing times. We've got value-based care accelerating, demand for greater transparency, public empowerment. Any thoughts you can share?

Dr. Stanford:
What we've seen over time, and I would say that this has definitely happened within the last 20 years, is we've seen a significant shift in healthcare where many of the execs aren't necessarily people that have a strong medical background. And with that comes lack of insight with regards to what actually happens on the ground with patients when we're looking at new models of care, and how we can implement this on a population level. And so what I would recommend to healthcare executives is really making sure that you have experts on your team that are versed in the medical side, but also have a good finger on the pulse, I guess, of some of the health policy changes that are occurring rapidly throughout our country, to ensure that we're able to provide the best health for our patient population.

I would say that's the best advice I can give, because I can tell you that if I think back even to when I was a medical student, when they did a complete overhaul in the emergency department for one of the hospitals that I was rotating in, something as simple as not having the X-ray bay stretch long enough to accommodate patients being in this particular room show poor design. So, all this money that had been spent, it was this really gorgeous looking trauma bay, but it wasn't really functional, so obviously they didn't speak to people that do that here every day to say, "Hey, when we design this we need to ensure that we're able to actually stretch the X-ray over to an area where a patient would be." So something as simple as that, while it seems like it should make a huge difference, it has a huge impact on the care that's being delivered at the point of care, and money is wasted, because now they have to go and fix it, and that could've just been addressed at the outset if you had someone that had a medical background to offer their expertise in how to navigate those unique challenges in different spaces.

Jay Ackerman:
So we've talked a little bit about the member, the healthcare executive; how about taking a look at regulatory bodies? So, what about regulatory changes that you'd like to see come from CMS over the next couple of years? Any thoughts that you can share there?

Dr. Stanford:
Obviously in the current political environment, I think we've seen not as much progress as we might like regarding healthcare as a whole. I would say that it is not completely clear what the focus is in terms of what we're doing specifically to enhance the care of our US population. I think that we need to turn our attention back. I think during the last administration there was focus, obviously with the passing of the ACA. And during the Obama administration I think that there was at least a focus on trying to ensure that all persons were guaranteed at least some level of healthcare.

Right now of course there a lot of desires to undo the ACA with no significant replacement available for us for our patients, and I really think that if we're going to make changes, we need to have an alternative that, we can potentially demonstrate superior care to what is currently available under the current ACA. We need to pay attention to states that have chosen not to expand Medicaid. We can see that poor health outcomes exist within those states, especially related to all chronic disease processes.

And there needs to be some type of continuity in terms of what level of care is being provided here in the US. And there are significant differences from state to state, and I think that just is not what we should allow for our citizens here in this country. Some people live like they're in third-world countries in terms of the care that they're being provided, and then some get a quite high level of care, and there should not be such a drastic difference between one area versus another. So, I think CMS needs to somehow work on ensuring that there is more equitable care throughout the country, and I'm not sure exactly how they would do that, but I think that should be a purpose at this time.

Jay Ackerman:
Thanks for sharing that. There clearly is a wide degree of variability and care that one can obtain in the US.

So earlier you talked about platforms that you use to get your message out and to try to impact a larger audience. So why don't you talk to our audience a little bit about your most recent book, Facing Overweight and Obesity: A Complete Guide for Children and Adults. I've had the pleasure of reading it. It's quite valuable, it's informative, it's eye-opening, and there's a lot to be gained from it, and so maybe you can share what you were trying to accomplish with it, and thoughts that you would have for people in making that a priority to read.

Dr. Stanford:
Yeah. As I mentioned before, we have 40% of the US adult population that has obesity, and about 19% of the pediatric population, which means that this is the disease that we need to be discussing. And it's not just to make me feel good as someone that has decided to focus in this space, but it just is the reality that the numbers are high here in the US and many places throughout the world. And as such, I feel as though there needs to be a reliable source of information where you can learn about some of the complexities of obesity, and learn about some of the things that have really influenced this significant shift.

And so when I decided to write this book with my coauthors and coeditors, it was really because I didn't have a reliable source for my patients to turn to, where they could get some of the nitty-gritty on obesity and the associated disease processes, and how they might go about working with themselves if they struggle, with their family or their friends, to address this disease. And so that was part of why I felt like it was essential that I work on ensuring that there was some source of information that I could turn my patients to that was a reliable source, based on evidence, based on information that we know can actually help treat patients with obesity.

That book, it's 358 pages, so it's dense, it's a lot to take in, and I don't expect people to take it in all at one time. And part of why we've segmented the chapters in the way that we did, which is covering things like the medical conditions associated with obesity, or like the bad diets over the years, or weight bias, was so that you could get a taste for how broad this disease is, and how broad the impact is. So, I felt like that was what we were able to achieve by this work.

We had a wide variety of experts that were involved in writing the chapters that ranged from physicians that were in internal medicine or pediatrics or psychiatry, to psychologists to dietitians, really a multidisciplinary view on how to address the disease of obesity. I think that broad-based approach is really what's significantly important for helping us realize that we can approach it, we just need to be more understanding of its complexity, and here's a book that allows us to get a little bit of a handle on that.

Jay Ackerman:
One of the things that struck me in reading your book is... certainly you can't walk down the street and not realize that there's an obesity problem. You talked about the top five states in the US measured by obesity, and if you compare that to where we were in 2000, the rate of obesity is up over 50% in those five states. I'm blown away by those numbers. In less than 20 years it's increased by over 50%.

Dr. Stanford:
I consider this to be the perfect storm, Jay. And what I mean by that is, we live in an obesogenic environment. Our bodies are supposed to exist as they have for millions of years without the significant shifts that we've had in our environment, and by our environment we're going to focus on a few key things. We're going to focus on diet quality, we're going to focus on physical activity, we're going to focus on the fact that circadian rhythm is completely disrupted.

What is the first thing that most of us do when we wake up and when we go to sleep, is we look at our phone. But our brain doesn't want to look at any type of screen. It disrupts how the brain regulates weight, but it's something that we do, it's something that's inherent in who we are, in this environment.

We are applauded and even congratulated if we're talking with our colleagues over in Europe in the middle of the night. They think we're great, they think we're a go-getter, and wow, if we're a business man or woman, we are able to accomplish things, because we're able to stay up during the middle of the night. That's not what our body wants, it's what has become commonplace because we have this lovely thing called the internet that allows us to be accessible to anyone in the world at any given time.

And so these significant shifts have led to this rapid degree of weight gain, and not only in the United States but around the world. It's not just us. I just did a talk in Italy and even here in Boston on obesity as a threat to global health. We have 10% of the world's population that has obesity, and there's several countries that exceed that of the United States that we don't ever think about or we don't talk about: Micronesia, Polynesia, for example, are a few examples. The Middle East struggles quite a bit.

And so, we need to do something, but the problem is that this is the environment we live in. Our bodies don't know how to exist within this environment without this continuous gain in weight, and-or fat or adipose tissue, that we've seen over the last 20, 25 years. Like if you look at those lovely CDC maps which have captured our epidemic here in this country.

Jay Ackerman:
Yeah, as you put it, it's perfect storm. With all those changes unfolding, and not enough being done to change the way we diet, or change the way we move and get active. The way I was active as a teenager is totally different than the way my two boys are active now.

Dr. Stanford:
We were different Jay. We had different things that we were going for.

Jay Ackerman:
We definitely were. Dr. Stanford, you've been an amazing guest for us today, with a wealth of information to be shared, and hopefully this platform here, our podcast, is one that's helpful in getting your message out a little broader, at least to some people that might not have heard you through some of your other channels, so thanks for joining us.

Dr. Stanford:
Absolutely. Well thanks for having me, and it was a delight to be here. I liked your questions, and the diversity and the complexity of the questions, so thanks for challenging me.

Jay Ackerman:
I'm going to challenge you one final time with rapid fire, so we're going to move really quick and kind of top of mind.

Dr. Stanford:
Okay.

Jay Ackerman:
What is something that you're curious about right now?

Dr. Stanford:
One of the questions I was asked actually earlier today was how I could deliver the type of care that I deliver here in Massachusetts to people throughout the country. And I don't really have a good answer for that, so that's at the top of my mind, how can I do that? How can I make sure that my expertise is available to those that want it, and I'm willing to provide it? That's at the top of my mind.

Jay Ackerman:
Great. You have accomplished a lot, and I'm sure as you've gone through the many steps in your life you've thought about kind of what are some other paths you could've taken. So, could you indulge us with, if there was one decision in your life that you could change, what would it be and why?

Dr. Stanford:
That's a hard one. I would say that one of the things I've always thought about, and one of the things I would still enjoy doing, is doing media as a large portion of my life. Spending about 90% of my time engaging in broadcast journalism in the field of medicine of course. So, if I think back to my college days in the late 90s, one of the things I would've done is spend a lot more time with some of the broadcast journalism work that was going on at Emory. I constantly thought about it, and I feel pretty comfortable with that work, but maybe that would've propelled me more within that domain, still in the context of healthcare.

Jay Ackerman:
Well it seems with all the time that you're spending on it, that that door may more fully open to you at some point down the road.

Dr. Stanford:
Maybe. You tell your people, Jay.

Jay Ackerman:
How do you invest in yourself?

Dr. Stanford:
I think the key thing that I do to invest in myself is, I am what I consider to be a fitness enthusiast. So, in order for me to be grounded, in order for me to alleviate the intense stress that I have in my daily life, I have to commit to fitness and exercise to be in tune with myself. When I'm working out, when I'm in class, I'm not responding to emails, I'm not responding to anyone. I'm focusing on being the healthiest, best person I can be. Because if I can't be the healthiest, best person I can be, how am I supposed to be that for my patients, and for the patients of others around the world that I'm giving talks, or speeches, or interviews to. How can I be that person if I'm not doing that for myself?

Jay Ackerman:
Yeah, amen. And lastly, what's your favorite quote?

Dr. Stanford:
Ooh, my favorite quote. "It must be borne in mind that the tragedy of life does not lie in not reaching your goal, the tragedy of life lies in having no goal to reach." It's a long quote, and it finishes with "Not failure, but low aim, is sin." It's by Dr. Benjamin Elijah Mays, who was Dr. Martin Luther King's teacher, and head of Morehouse College, and also the namesake of my high school in Atlanta, Georgia.

Jay Ackerman:
Fantastic. And based on all that you've accomplished thus far in your career, it seems like one that you've taken to heart.

Dr. Stanford:
Definitely.

Jay Ackerman:
Well Dr. Stanford, I'm going to bring this podcast to a close. I'll let you get on with the rest of your day. You've been an awesome guest. This will bring our Value-Based Healthcare Podcast to a close.

Dr. Stanford:
Okay, thanks so much Jay. Thanks for having me.

Jay Ackerman:
Thank you. Over and out.