Over the past few years, attitudes toward obesity care have evolved towards treating the condition more like a chronic disease. However, a gap in the transition between pediatric and adult obesity care persists. Cleveland Clinic’s Endocrinology & Metabolism Institute has taken several steps to help reduce this gap, including creating an obesity fellowship. The program recently completed its first year in which the current fellow, a pediatric endocrinologist, spent time with other endocrinologists, bariatric surgeons and pediatricians.
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“What is unique about this program, is the combination of the bariatric perspective and then the non-surgical perspective of obesity management with endocrinology,” explains Marcio Griebeler, MD, a staff endocrinologist in the Institute and one of the fellowship programs creators. “I think the endocrinology field is helping advance the reality that obesity is a chronic disease. There is a strong relationship between obesity and other medical problems — non-alcoholic steatohepatitis, diabetes, sleep apnea, hypertension, etc. As endocrinologists, we have a responsibility to take ownership of how obesity is treated and work closely with other specialties simply because obesity affects so many aspects of our patient’s health.”
Overview of the program
The year-long fellowship program spends about 40% of the focus on endocrine, 40% on bariatric and 20% are electives. The program also includes rotations with pediatrics, sleep medicine, lifestyle and nutrition. Lina Alkhaled, MD, the current fellow in the program, also spent time with exercise physiologists, psychologists, lifestyle medicine and dieticians.
“My perspective is a little bit different because I’m a pediatrician who is trained in pediatric endocrinology, and now I’m doing this combined fellowship,” says Dr. Alkhaled. “I practice obesity medicine in both worlds, and one of my biggest areas of interest is this gap in what we call transition. The model of care in pediatrics is much different compared to the model of care in adulthood. In pediatrics, we’re more supportive and it’s almost like you hold your patient’s hand throughout their entire time with you. In adult care, it’s much different because we give adult patients more independence and autonomy.”
Preparing patients for the transition
Dr. Alkhaled explains that the transition from pediatrics to primary care in late adolescence results can be startling since many patients have not been prepared for the shift in how care is delivered. Further complicating this issue is the fact that there are so many parties involved in the healthcare system. For example, steps like finding a primary care doctor, figuring out how their insurance changes and establishing a pharmacy can be overwhelming for an 18-year-old patient. So if these patients are not well equipped to make the transition ahead of time, then, unfortunately, this gap will continue to persist, and the likelihood that a patient will be lost to follow-up will remain high.
“It’s important to remember that this gap is not just limited to obesity,” says Dr. Alkhaled. “It’s a transition as a whole in any specialty, in any disease, in any condition actually. Obesity happens to be interconnected with so many other conditions, so the gap here is much more obvious. But this is actually one of my interests — the transition clinic. So even during my residency, I was involved in a transition project for kids with diabetes from pediatrics to adulthood.”
Closing the gap
Dr. Alkhaled is a major proponent of shared family visits and is working on trying to find a model where she can see multiple family members who suffer from obesity. By helping parents recognize that obesity is a chronic disease, addressing the root causes with the adults and developing healthy habits, these lessons can spill to their children. This would help tackle the problem more effectively because now obesity is being managed in different age groups.
“In pediatric care, we’re trying to have our patients start a discussion of transition at around 12 years as per the American Academy of Pediatrics recommendation,” says Dr. Alkhaled. “We want to gradually introduce the concept of transition and make sure that the patients do not have any gaps in their knowledge. So I’m hoping that we can apply the same model to diabetes and in obesity. Ideally, this it’s something actually I think needs to be done in terms of transition for all conditions.”
Cleveland Clinic’s Endocrinology & Metabolism Institute has already begun a program to help facilitate this type of transition care for children and parents with Type 1 diabetes, and Dr. Alkhaled is hopeful that the lessons learned from that program can be applied to their patients with obesity.