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A New Outlook on Obesity

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Pharmacy schools can help address the nation’s obesity crisis by incorporating competencies into the curriculum.

By Emily Jacobs

Despite public health efforts at all levels of government, obesity continues to be a serious issue in the United States. Defined as having a body-mass index (BMI) of 30.0 or higher, obesity has been linked to numerous chronic health conditions, including diabetes, cardiovascular disease and hypertension, according to the Centers for Disease Control and Prevention. Obesity affected 42.4 percent of U.S. adults in 2017–18.

Various providers may find opportunities to address obesity among patients because it can have such wide-ranging effects on health. However, many health professionals have not been trained to talk about obesity effectively, partly due to a lack of standardized obesity education. Improved education and training could help medical students and healthcare professionals better communicate with their patients about obesity.

This has created a need for health professions educational institutions to include obesity training in their curricula. The Provider Competencies for the Prevention and Management of Obesity aim to address this need. These competencies are the interdisciplinary creation of the Provider Training and Education Workgroup of the Integrated Clinical and Social Systems for the Prevention and Management of Obesity Innovation Collaborative, an ad hoc activity associated with the Roundtable on Obesity Solutions at the National Academies of Sciences, Engineering, and Medicine that culminated in a Robert Wood Johnson Foundation funded project via the Miliken School of Public Health at George Washington University.

“It was an incredibly collaborative, positive group, recognizing that we all had our different areas of primary competence,” said Dr. Jan Kavookjian, associate professor of health outcomes research & policy at Auburn University Harrison School of Pharmacy (HSOP), and member of the interprofessional panel selected to develop the competencies. “We were trying to generate broad competencies in specific categories that would make them relevant across health professions.”

The workgroup created a list of 10 competencies that emphasize the need to approach obesity as a disease. The competencies also note that collaboration among health professionals can help achieve better results for patients and practitioners alike. Practices should have safety accommodations specific to individuals carrying extra weight. The competencies also emphasize the use of evidence-based care for individuals with obesity, obesity risk or obesity comorbidities. Providers are also encouraged to minimize biases or discrimination against individuals with obesity and use person-centered communication.

These competencies are not meant as a stand-alone set or curriculum; they can be integrated into current curricula or used to create new curricula. Obesity competencies are intended as general concepts for obesity knowledge, obesity care or prevention and weight-related patient interactions. Competencies are meant to provide a common language for clinical experiences involving obesity. Several health professions education institutions across the nation are incorporating these competencies into their curricula.

An Opportunity for Pharmacy Schools

The gap in knowledge regarding obesity management presents an opportunity for pharmacy schools. By implementing obesity competencies into the curricula, colleges of pharmacy can help train future pharmacists to address the obesity crisis within their communities. At Auburn University, HSOP leaders have developed an integrated Pharm.D. professional curriculum, with an aim to create a “Practice Ready Graduate.” This curriculum prepares student pharmacists to deliver both pharmacological and nonpharmacological obesity management services in community-based settings. This includes an introduction to obesity as a disease and the impact of lifestyle changes and pharmacological approaches.

HSOP’s curriculum also gives students training in providing direct patient care, thus expanding the role of the pharmacist beyond dispensing medications. For example, in their fourth year, student pharmacists rotate through HSOP’s two on-campus pharmaceutical care clinics. This provides experience in patient care activities, including caring for persons with obesity. Students deliver counseling under the Healthy Habits Weight Management Program and conduct biometric screenings for university employees as part of the award-winning Healthy Tigers Wellness Program.

While HSOP first developed its “Practice Ready Graduate” vision in 2014, it began transitioning to a new, competency-based curriculum in the 2017 fall semester. This incorporates many of the obesity competencies developed by the Collaborative. Other pharmacy schools have expressed interest in applying this approach to varying degrees to their curricula.

Dr. Margarita DiVall, associate dean for faculty affairs, diversity, equity and inclusion, Northeastern’s Bouvé College of Health Sciences, supports incorporating obesity competencies into the curriculum, especially given that obesity is a major risk factor for many chronic diseases. “It’s critical for us to educate our pharmacy students about obesity, particularly because it disproportionately affects people of color and those with lower socioeconomic status,” DiVall said. “While treatment can include pharmacological agents, it is also important to instruct students on nutrition and lifestyle factors that impact obesity and to teach them about the role they play on an interdisciplinary team. They need to know everybody’s role, including the role of the pharmacist, and how to work with the team on identifying the right time for implementation of pharmacological agents. In our curriculum, we talk about obesity as a risk factor for many chronic diseases and have specific time dedicated to the topics of obesity epidemiology, racial and ethnic disparities, prevention and management.”

There is a lot of information out there about the effects of body shaming on mental health and behavior. I think this is a perfect opportunity for interprofessional education in this space. Mental health experts and others can work with student pharmacists to train them on best approaches in communicating with patients who are dealing with obesity.

Dr. Margarita DiVall

Communication Style Matters

One of the key obesity competencies is the use of “person-centered communication.” This means that a healthcare professional uses person- and family-centered communication, which engages the patient and other individuals through active listening and empathy, encourages a patient’s autonomy and uses shared decision making. With person-centered communication, obesity is discussed in a non-judgmental manner that takes into account the different environmental, social, emotional and cultural factors that may be involved.

HSOP’s curriculum broadly integrates person-centered communication, including motivational interviewing skills training. This helps future pharmacists develop communication skills that create a positive, therapeutic relationship with their patients. “When you think about person-centered communication, it’s about seeing them as an individual, not identifying them by their disease,” said Kavookjian. “This is an individual person with a whole life and identity beyond his or her diseases or conditions. When we say that someone is ‘morbidly obese,’ it is just simply derogatory, it implies something is hopeless, there’s a judgment to it. [Person-centered communication brings] a focus on removing stigmatizing language like, ‘She’s obese’ and instead conveying something like, ‘This is a person with obesity’ or ‘She is a person carrying extra weight.’”

DiVall added, “There is a lot of information out there about the effects of body shaming on mental health and behavior. I think this is a perfect opportunity for interprofessional education in this space. Mental health experts and others can work with student pharmacists to train them on best approaches in communicating with patients who are dealing with obesity.”

HSOP’s obesity teaching unit, as well as other first-semester teaching units, strongly emphasize person-centered communication. The second semester also includes person-centered communication within a comprehensive disease management unit focus that connects comorbid conditions, including obesity, with related self-management behaviors that pharmacists can discuss with patients. Communication skills training for motivational interviewing and shared decision-making are further emphasized in the second year with focus on the self-management behaviors needed for neurological and psychiatric conditions, and again focusing on comprehensive disease management in the third year in preparing student pharmacists for their fourth-year clinical rotations.

“This aspect of the curriculum is key to raising awareness among students about implicit or explicit biases they may have against individuals with obesity,” Kavookjian pointed out. “It helps them speak to and about patients in a way that highlights their strengths and reduces stigma. This includes talking about healthy eating, physical activity, sleep hygiene and other positive behavioral changes that can empower individuals. A lot of what we see in mainstream healthcare uses really judgmental, provider-centered language that does more harm than good. When individuals feel stigmatized, they are not only less likely to seek treatment, they are less likely to return [to their provider].”

Pharmacists Can Lead the Conversation

Pharmacists in particular play a critical role in addressing obesity in the U.S. population. They are widely considered one of the most accessible and trusted health professionals, thanks to frequent face-to-face interactions with patients. Pharmacists can help provide medication monitoring and disease management services, offering suggestions for lifestyle changes and informing patients about specific risk factors. They are also well positioned to work with other healthcare professionals to address the needs of patients with obesity.

“This is a great opportunity for interprofessional collaboration because we often focus on teaching pharmacy students about pharmacotherapy,” DiVall noted. With the treatment and prevention of obesity reaching across the spectrum of health professions, “many professionals, including physical therapists, physicians, nutritionists, dieticians and mental health specialists can work with pharmacists to address risk factors, prevention and treatment with patients.”

Additionally, pharmacists can help lead changes in language and communication with patients. This may include the use of person-first terms, such as “individuals carrying extra weight” or “a person with obesity,” rather than disease-focused terms like “obese patient.” With pharmacy school training, professional pharmacists can become more aware of biases they may have toward individuals with obesity. This can help create a more collaborative, strengths-based and non-judgmental environment for patients that can better encourage healthy behaviors.

“As the profession of pharmacy advances, these future pharmacists really are going to enter a practice that has so much opportunity to advance [this approach],” Kavookjian said. “Future pharmacists are really going to have an opportunity to make an impact…Regardless of what setting a student pharmacist goes into, there will always be opportunities to talk to persons carrying extra weight.”

Emily Jacobs is a freelance writer based in Toledo, Ohio.

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