Fatima Stanford, an obesity medicine clinician researcher at Harvard Medical School, has never been swayed by group consensus — not even when she was five years old.
Stanford’s father took her to meet Alvin and the Chipmunks face to face. Her sister and the rest of the children were jumping up and down, running on stage as the characters beckoned the kids to catch monopoly money as they threw it in the air. To her father’s chagrin, Stanford was not impressed. “Dad, those are just short people in costumes,” she told him. “And that money is worthless.”
Likewise, Stanford was not jumping for joy with the state of obesity medicine when she started working as a physician. She was unimpressed with the “Biggest Loser style approach” where people with obesity are told to simply eat less and exercise. The rate of obesity tripled between 1975 and 2015, a resounding signal that the current medical approach was ineffective. She felt strongly that obesity was a disease that deserved specialized treatment like any other. Today, she is one of only about 50 physicians who completed a fellowship in obesity medicine.
But being an obesity medicine physician wasn’t enough to move the dial forward. She still meets doctors who don’t understand why an obesity medicine specialization is needed. When she applied for jobs, some doctors saw the “ob” in obesity and assumed that she was an obstetrician. Now, Stanford travels the world spreading the message about obesity medicine and the arsenal of treatment strategies available to help this patient population. Stanford gave fifteen lectures on obesity in January, emphasizing her commitment to spreading the word about its etiology and therapeutic treatments.
Her meteoric rise from a pithy child to a sought-after clinician researcher and diversity advocate mirrors that of her chosen field of obesity medicine. Although there are still few graduates of obesity medicine fellowships in the United States, about 4,000 clinicians are board certified, the number of anti-obesity drugs on the market has doubled, and many more are in development.
“It's nice to be a trailblazer, and to be at the forefront of encouraging people to care for this patient population that's often neglected — almost always neglected, I would say,” said Stanford.
Blazing a trail
Stanford’s lengthy resume — including a Gold Congressional Award — has one common theme: caring for those overlooked by the healthcare system. For example, she conducted behavioral research as an undergraduate student at the American Cancer Society examining disparities in cancer care for Black patients. And she worked for the office of women’s health as a communications intern at the CDC when they began releasing information specific to women’s health. Her passion for helping these patients led her to obesity medicine.
Although the WHO formally recognized obesity as an epidemic in 1997, it wasn’t until 2013 that the American Medical Association declared it a disease. Obesity is defined using the body mass index (BMI), which uses an individual’s height and weight to calculate body fat. People with a BMI of 25-29.9 are overweight, and people with obesity have a BMI over 30. According to the WHO, nearly 2 billion adults were classified with overweight in 2016, and 650 million of those individuals had obesity; 340 million kids had overweight or obesity.
“Nobody was interested in obesity. People thought ‘obesity is people eat too much. They can’t control themselves.’ But for some reason, I was interested,” said Lee Kaplan, a gastroenterologist, and the founder of the first obesity medicine fellowship program at Massachusetts General Hospital.
Even pharmaceutical and biotech companies interested in developing drugs for obesity — including the pharmaceutical leader Abbot Laboratories — struggled to develop effective medications. Many of the early anti-obesity drugs were riddled with severe cardiovascular side effects such as tachycardia and heart attacks, and some increased the risk for suicide. Methamphetamine, in addition to its cardiovascular side effects, carried a high risk for addiction. Six of the twelve drugs that were approved for obesity treatment in Europe or the United States before 2000 were ultimately pulled from the shelves (1).
Stanford was undeterred. She discovered Kaplan’s program in the middle of a 30-hour shift while Googling on her phone. She was 18 hours into her shift and had finally sat down after intubating three very sick kids in the pediatric intensive care unit when a wave of uncertainty overcame her. She had her sights set on orthopedic surgery during medical school and completed a one-year fellowship. But then she switched paths and started residencies in internal medicine and pediatrics.
“In some ways, I was floundering because I had no idea what this meant for my career. I’d be a doctor for adults and kids, but did I just want to do general medicine? That didn’t really fit me,” she said. “I was like, ‘What do I really like? What am I passionate about?’”
She Googled obesity medicine, and Kaplan’s fellowship program appeared in her results. Prior to that moment, she had no idea that this new specialty existed, but it seemed like a good fit. She reached out to Kaplan and the other fellows in the program to learn more, and eventually joined the program.
Stanford’s entry into the obesity medicine field meshed well with her passion for helping those confronted with bias within the healthcare system. “What she brought to the table was her passion for policy, which was not my area of focus, and her ability and eagerness to make connections at other parts of the institution,” said Kaplan. “She was the first fellow to go outside of the center and interact with others to create a project that was more to her interest, which is more policy-oriented research.”
Paving the way to better policies
Stanford continues to push policy in the obesity medicine field forward alongside treating patients. She is a strong proponent for person-first language for obesity. The Office of Disability Rights passed the People First Modernization Act in 2006, which suggested referring to a person first rather than their disability to reinforce that a person is not defined by their disability. For example, rather than “obese person,” one would say “person with obesity.”
She also played a major role in a policy adopted by the American Medical Association in 2017 that encouraged clinicians to use person-first language when discussing obesity with their patients and resolved to educate the medical community about using more considerate language when speaking about patients with the disease.
“The idea of morbid obesity is disturbing. We don’t call it morbid cancer, morbid diabetes, morbid heart disease, or morbid COVID,” said Stanford.
In 2021, Stanford worked with an undergraduate student, Simar Singh Bajaj, at her home institution of Harvard University, to pen an article in response to a study published in Obesity Surgery that reported that bariatric surgeries — including gastric bypass and other weight loss surgeries — significantly reduced the rate of diseases such as coronary heart disease in type 2 diabetes (T2DM) in patients (2, 3). However, the article failed to use person-first language, instead referring to patients as “severely obese T2DM patients.”
Stanford helps more than just people with obesity when she pens perspective articles in professional journals. She gives aspiring clinicians and students the opportunity to write these perspectives with her, which is just one example of her dedication to recruiting future clinicians who share her passion.
Stanford took Bajaj under her wing during his freshman year when he asked to discuss her work on health and policy. During their first virtual meeting, the two had an in-depth conversation about vaccine mistrust during the COVID-19 pandemic. Stanford thought he had a unique perspective and asked him to write up an opinion piece about it. To her surprise, he sent her a draft only 12 hours later, which was eventually published in The New England Journal of Medicine (4).
“She opened my eyes to see that you can write perspective type articles for medical journals. That was something I hadn’t considered. I always thought if I was going to publish in a medical journal it would have to be some drawn out original research, which as a freshman in college, I felt not too equipped to do myself,” Bajaj said. “She was very encouraging. She cares a lot about mentoring, but I don’t think she expected much from me…I messaged her shortly after [our first meeting] with an idea for a piece that eventually became the NEJM piece. After working together on that, we were off to the races. We’re at 16 publications together now.”
Stanford admitted to originally meeting Bajaj out of courtesy, but she is glad she did. When he sent her the first draft of The New England Journal of Medicine piece, she was blown away. According to Kaplan, that’s a high compliment coming from Stanford.
“She’s very passionate, she works very hard, and she is demanding of herself and the people around her. But she’s very effective at what she does. And she’s a natural networker. She brings people together. She’s very effective in that way,” said Kaplan.
Stanford has recruited more than Bajaj to her cause. She met with legislators to introduce the Treat and Reduce Obesity Act, which expanded Medicaid coverage of treatments for obesity, which was introduced for a second time in 2019. Limited coverage of treatments for obesity by health insurance limits access to effective treatments including bariatric surgery, medication, and cognitive behavioral therapy. And there are more effective therapies available for patients than ever before. In addition to the six drugs made and approved in Europe and the United States that are still used today, six more were approved, and countless drugs are in development by companies such as Eli Lilly and Pfizer (1).
Even with these emerging drugs, a study from 2019 published in Obesity reported that only 3% of the eligible 2.2 million patients across eight healthcare organizations take medication (5).
Stanford and Kaplan agree that this problem goes beyond a lack of insurance coverage, extending to a lack of education amongst clinicians about obesity as a disease.
“People with obesity can’t bring this upon themselves. They can’t control it themselves. They can’t reverse it themselves. It’s not for lack of motivation or lack of other abilities, it’s the fact that obesity is a disease. When you have Parkinson’s disease, you can’t wake up in the morning and say, ‘I have Parkinson’s disease. I’m going to fix this myself.’ Nobody expects that. And those of us who are blessed to have genetics that prevent obesity have to recognize that we didn’t do anything good and patients didn’t do anything bad. What we have is somebody with a disease that should be addressed fairly in an unbiased way,” said Kaplan.
Stanford recognized this when she looked for positions as a full-time clinical researcher after she completed her fellowship in 2015. There were limited job opportunities, particularly for someone who wanted to do research in addition to clinical work because few institutions recognized obesity medicine as a field. This has improved since then, and interest is growing. “I think the reason I get the volume of speaking engagements [I get] is that people are receptive and want to learn,” she said.
Leading them down the path
Stanford focuses much of her presentations on how she approaches treating patients with obesity in the hope of guiding others to recommend treatments for their own patients. “I utilize the entire armamentarium of tools that are available, which include lifestyle and behavioral modifications, medication, surgery, and I always tell my patients that I want to use the right tool for the size of the problem,” said Stanford.
Treatment usually starts with the patient working with a nutritionist to create a diet and exercise regimen to help them lose weight. However, these interventions are often not enough. Depending on the severity of an individual’s obesity, the patient can either undergo bariatric surgery or take medication that ramps up their metabolism or minimizes cravings.
Stanford dives into the details of the medications she recommends for her patients during her lectures. Many physicians comment that these medications are new and that their efficacy is still in question due to the murky history of anti-obesity drugs, but this isn’t true for all medications. Phentermine, a norepinephrine reuptake inhibitor prescribed for weight loss, was approved by the FDA in 1959. And options keep getting better.
According to Stanford, WeGovy, a new FDA-approved drug for weight loss by Novo Nordisk, is a blockbuster drug. Results from phase three clinical trials of the drug published in 2021 show that it helps patients maintain a 15% reduction in weight for up to a year after the first treatment (5). The small molecule drug is a new type of glucagon-like peptide-1 receptor agonist (GLP1-RA).
Liraglutide was the first GLP1-RA approved in 2015. It is nearly structurally identical to the natural GLP1 hormone; its amino acid sequence is 97% similar. GLP1 in the body interacts with the GLP1 receptor in the beta cells of the pancreas where it regulates insulin release, making it an effective treatment for diabetes as well. GLP1 does more than regulate insulin release, however. It also slows gastric emptying and reduces hunger, helping patients more easily lose weight and keep the weight off. The newest addition to the GLP1-RA arsenal is another GLP-1 analog called semaglutide, which is 98% similar to the natural hormone. WeGovy requires a weekly injection, while liraglutide requires a daily injection, and has proven more effective in clinical trials in adults (6, 7).
Novo Nordisk isn’t the only pharmaceutical company trying their hand at GLP1-RAs. Eli Lilly and Pfizer have GLP1 analogs in development too. Eli Lilly has a promising small molecule drug called tirzepeptide that acts on both the GLP1 pathway and gastric inhibitor polypeptide (GIP), another hormone that regulates insulin release. In 2001, scientists from Eli Lilly published results of a phase 3 study in patients with type II diabetes showing that it not only relieved symptoms of diabetes better than insulin, but resulted in greater weight loss (8). The company hopes that the anti-diabetic drug can moonlight as an anti-obesity drug.
Unlike other obesity medications, anti-obesity drugs that modulate GLP1 can be used long-term. Jason Brett, executive director of medical affairs in diabetes and obesity at Novo Nordisk, is sometimes asked how long a patient is required to stay on WeGovy. He echoed Stanford’s frustrations about the recognition of obesity as a chronic disease.
“Just like we would treat hypertension, high cholesterol, or diabetes chronically with chronic medications, whether it’s antihypertensives, or antidiabetics, or statins, or hyperlipidemic drugs, most experts in this space really believe that obesity is indeed a chronic disease, and it needs chronic treatment,” Brett said. “The bottom line is that patients are going to need medication and treatment chronically for this problem.”
In the end, this is Stanford’s overall goal: To treat patients with obesity with the same care and respect as anyone else with a chronic disease. “I see my patients as my family. I treat them as if they’re my family. I ask, how would I want my family to be treated?” she said.
- Muller, T.D., et al. Anti-obesity drug discovery: advances and challenges. N Revs Drug Discov 21, 201-223 (2022).
- Bajaj, S.S. and Stanford, F.C. Dignity and Respect: People-First Language with Regard to Obesity. Obes Surg 31, 2791-2792 (2021).
- Hussain, S. et al. Impact of bariatric surgery in reducing macrovascular complications in severely obese T2DM patients. Obes Surg 7 (2021).
- Bajaj, S.S. and Stanford, F.C. Beyond Tuskaegee — Vaccine Distrust and Everyday Ra cism. N Engl J Med 384, e12 (2021).
- Saxon, D.R et al. Anti-Obesity Medication Use in 2.2 Million Adults Across 8 Large Healthcare Organizations: 2009-2015. Obesity 27, 1975-1981 (2019).
- Wilding, J.P.H, et al. Once-Weekly Semaglutide in Adults with Overweight or Obesity. N Engl J Med 383, 989-1002 (2021).
- Pi-Sunyer, X., et al. A Randomized, Controlled Trial of 3.0 mg of Liraglutide in Weight Management. N Engl J Med 373, 11-22 (2015).
- Del Prato, S. et al. Tirzepatide versus insulin glargine in type 2 diabetes and increased cardiovascular risk (SURPASS-4): a randomised, open-label, parallel-group, multicentre, phase 3 trial. The Lancet 398, P1811-P1824 (2021).