Meet W. Scott Butsch, MD, Bariatric and Metabolic Institute’s New Director of Obesity Medicine

Obesity is a big issue in this country, affecting 36.5 percent of the U.S. adults and 17 percent of children and adolescents. Consult QD talked with W. Scott Butsch, MD, to learn about the obesity medicine program he will implement at the Bariatric and Metabolic Institute.

Q: What are your priorities as the new director of obesity medicine?

A: My first priority is to establish obesity medicine as a subspeciality field in medicine at Cleveland Clinic’s Bariatric and Metabolic Institute. Secondly, I would like to standardize a multidisciplinary, comprehensive treatment model to assess people with obesity across the Cleveland Clinic enterprise. There are many programs that try to help patients lose weight, but there’s no standard of care. My goal is to establish a treatment protocol. When patients are identified with obesity, there will be an individualized treatment pathway available that’s unique to them.

Q: How is our understanding of obesity changing?

A: Obesity is often thought to be just a lifestyle choice, that it’s the patient’s responsibility to lose weight. But we know too much about the regulation of energy and body weight and the heritability of obesity to know that it’s not that simple.

Obesity is like other chronic diseases, such as cancer. There are different forms that require different treatment protocols. Since the discovery of leptin in 1994, for example, we’ve learned a lot about the pathophysiology of obesity and genetic forms of obesity. Leptin is a hormone from adipocytes that talks to the brain, getting feedback on how much energy we have on board, or how much fat we have in our body. Patients who lack this hormone or lack the receptor in the brain that recognizes this hormone, develop a severe form of obesity at an early age. This genetic form of obesity causes their body to be in a chronic state of energy conservation. Yet, on the surface, one might perceive these individuals as having an eating disorder that requires behavioral modification. Obesity is more complex than people realize.

Q: What is your background? How did you become interested in the field of obesity medicine?

A: When I was a resident working in a community health clinic, I had a patient who weighed 300+ pounds. The scale only went up to 300. She was a working single mother with no medical problems. She wanted to lose weight. Quickly, I thought about sending her to the dietitian at the county hospital, but the dietitian was away on maternity leave. So, I took the patient’s diet history and learned that there were no grocery stores in the area, that she shopped at the Mobil Mart, and that with food stamps, there were only certain things available for her to buy.

At the time, I remember being surprised a woman of her size didn’t have any medical problems. She didn’t fit the stereotype. That patient sparked my interest in learning more about obesity. Yet, there were no training programs in obesity at the time, so I trained at the University of Alabama-Birmingham on a nutrition fellowship. While I was there, I met a gastroenterologist from Massachusetts General Hospital who was equally passionate about obesity. He convinced me to do a subspecialty training in obesity medicine as he was creating a fellowship. It was the first in the country and there were two of us inaugural fellows in 2007. I completed that fellowship in 2008. For the past 10 years, I was on staff at Massachusetts General Hospital and taught at Harvard Medical School. I was the co-director of a second-year course in nutrition and obesity and, over the last 5 years, a co-director of the continuing medical education course at Harvard Medical School called the Blackburn Course in Obesity Medicine.

Q: What do you think are the greatest challenges in obesity medicine today and how do you plan to address them in your new position?

A: To treat obesity, we use dietitians, psychologists and exercise trainers well for lifestyle modification. But what do we do beyond lifestyle modification? Many patients with obesity are not offered more aggressive treatments like anti-obesity medications and bariatric surgery. Some of the barriers to providing a more appropriate treatment for obesity are provider weight bias and a lack of education in obesity medicine. There’s a need to teach health professionals about implicit bias, physiological regulation of body weight and the genetic nature of obesity. Competencies in obesity in professional schools including undergraduate medical education are currently being developed and address these areas. This is just the beginning of several initiatives to educate healthcare professionals and hopefully reduce weight stigma while providing appropriate care to patients with obesity.

We need to think differently about treating obesity. For example, thinking about the cancer model, if somebody doesn’t respond to chemotherapy, we say the chemo didn’t work. We don’t blame the patient; it’s not the patient’s fault. We should apply the same method of practice in obesity medicine. We need to embrace the heterogeneity of the disease. We can show it by pursuing different treatments options in those who don’t respond to the therapy. We need to be open to the possibility that lifestyle modification may not be the only treatment option for an individual with obesity. Overall, obesity medicine is a fascinating science. I look forward to supporting the array of treatment programs Cleveland Clinic provides to improve patient outcomes, both with weight and those that go beyond the scale.