SCOPE International Fellowship Interview: Dr Abd Tahrani | World Obesity Federation

SCOPE International Fellowship Interview: Dr Abd Tahrani

NewsSCOPE International Fellowship Interview: Dr Abd Tahrani

International Fellowship Interviews

SCOPE recognises the importance and expertise of healthcare professionals in obesity management by awarding SCOPE Fellowship at a National or International Level.

Our International SCOPE Fellows are world-class experts in the field of obesity management and possess a wealth of clinical experience in treating patients with obesity and overweight.In addition to clinical experience, our Fellows are also authors of important peer-reviewed publications on obesity or obesity-related conditions. They also play an important leadership role in many internationally renowned congresses and teaching courses for healthcare professionals.

To share insights and experiences from our Fellows we have developed an International Fellowship interview series. Read our latest interview below.

Dr Abd Tahrani is an international obesity expert. At the time of the interview, he was a senior lecturer in metabolic endocrinology and obesity medicine at the University of Birmingham and a Consultant in Endocrinology, Diabetes and Weight Management at the University Hospitals Birmingham NHS Foundation Trust (UHB).

Since then, he was appointed as the International Medical Vice President for Obesity Research at Novo Nordisk. Dr. Tahrani is the author of over 160 peer-reviewed journal articles and is a key opinion leader in the fields of obesity, diabetes and sleep medicine. As an obesity specialist at UHB, Dr. Tahrani led a team of multidisciplinary healthcare professionals to develop weight management services and patient pathways.

Please Note: The opinions expressed in the interview are solely those of Dr. Tahrani and do not represent the opinions of his current employer – Novo Nordisk.

Why did you decide to specialise in diabetes and obesity?

It was a two-step decision making process. The first step was to go into endocrinology and diabetes. In 2003, I had to decide which speciality to pursue, on my list were cardiology, gastroenterology, respiratory medicine and endocrinology and diabetes. I decided to pursue endocrinology and diabetes. I selected it because of the nature of the speciality. So, you have got endocrinology on one side, which is a lot of biochemistry and a lot of puzzles you need to solve. But then you can treat the patient and make their lives better, fairly easily. If you make a diagnosis, you can provide the right treatment.

Then on the other end of the spectrum you have diabetes, which is a chronic disease, where the diagnosis is obvious, there is not a puzzle to work out in terms of figuring out the diagnosis, but treatment is more complicated. It is very reliant on developing a very strong doctor- patient relationship, to help the patient with this very long journey. A journey that requires a lot of skills and behavioural change. I also realised very quickly that what I enjoyed in other specialities was all related to diabetes. So, for example, what I really enjoyed in cardiology was cardiovascular disease prevention, which is obviously an essential part of diabetes work. What I enjoyed in gastroenterology was non-alcoholic fatty liver disease, which is also obviously obesity related, and so on. So that was why I picked that combination as my speciality.

And then the next decision was why should I go for obesity, and that came years later, probably around 2008. As I started developing my insight into diabetes, I realised the negative impact that obesity has on peoples’ lives, and how addressing and treating obesity can improve health and quality of life in many ways. I saw a lot of women in the endocrine clinic who required fertility assistance and obesity was the main barrier that prevented them either receiving fertility treatment or getting pregnant naturally.

Secondly it was also realising that people with obesity are not supported. For instance, even in the reproductive clinics, women with obesity would just be told, "You need to have this treatment to get pregnant, but we can't give it to you because you have obesity, you must lose weight to get the treatment". Often, they were being told to lose significant amounts of weight, sometimes 15-20 percent, without any advice or support. So, seeing those issues made me very interested in the field, because I came to see that something huge was missing. When we are trying to help someone with obesity to get pregnant, we are treating the result of obesity, or when we try to treat diabetes, we are really treating the consequences rather than the cause – obesity.  So that is where my interest in obesity came from, and it has developed a lot since then.

What do you find the most interesting about working in obesity - prevention or treatment?

So not only in obesity, probably, in general, we doctors are very poorly trained in prevention. We do not do prevention very well and we do not understand it very well, either. I do understand it now because I had to do a lot of self-learning. Earlier in my career, my interest was solely in treatment. My interest in prevention developed later, as I understood the challenges more and more. I started to understand that prevention is something we need to work on simultaneously while trying to treat the disease. And then you discover that there are really two camps in the system, you have got some public health specialists who only care about prevention and they think treatment is a waste of money. Then on the other side you have some of the treating clinicians who only think about treatment, and they think prevention is a waste of money. The reality is, we need both of them. Because currently, we are in a position where the bathtub is full of water and to stop the flooding, we need to switch off the tap. But we also need to open the exit. I leave prevention to the public health specialists, and experts in other fields. But I understand how important it is.

My practice is obviously treating people, which I find very rewarding. Many of my patients have had terrible journeys either due to their personal circumstances or in the healthcare system.  Some of them have been bullied, abused and discriminated against. So, it is very important to develop a relationship with them. I enjoy getting to know my patients and helping them through each step. Treatment involves a range of things including using motivational interviewing techniques, behavioural interventions, bariatric surgery, and more recently, pharmacotherapy. We are getting some very good drugs coming into the system. It is a very long journey we have with the patient, quite often not only with the patient but with their family as well. I do not make any judgements about my patients - what they eat or how physically active they are. I focus on developing a strong professional relationship to help aid them to change their lives.

What I enjoy most of all is seeing the outcome. We have seen so many women become pregnant and come back to see us with their baby. Or other patients who succeed in getting the surgery they need, or those that simply become a lot happier and enjoy a better quality of life. So that is really what drives the whole process, knowing the positive impact our treatment can have.

How does the relationship with patients impact on treatment outcomes?

It is crucial. When my team say, we have tried everything, and the patient is still gaining weight or not losing weight. I always say, well, it means that we have not developed a strong relationship with the patient. It means we have not managed to find out what is driving their obesity. We need to know what the driver is to develop the correct treatment plan. If the team say to me, we have tried multiple things and nothing is working, it means that we as healthcare professionals have failed to understand the patient well enough, their circumstances, the underlying drivers of obesity, or perhaps we have missed another condition or even medication that may be having adverse impact on their ability to follow treatment plans. Sometimes finding out the real cause can take multiple visits. The patient may not feel able to discuss their issues openly at the outset. Treatment starts only when we identify the cause of obesity. So, within my clinics I do not have what some describe as ‘non responders’ or ‘non-compliant’ patients who are not losing weight, rather we have some patients who we are continuing to work with to identify drivers before effective treatment plans can be developed. Fortunately, most of our patients lose weight because we have successfully built those bridges and identified the reasons why they have developed excess weight.

Why do you think obesity training and education are important?

There is a big gap in the system, in medical school we get very little nutrition training and after that we get almost no obesity training. I have taught in multiple medical schools in the UK, where the questions in the finals about obesity still focus on how to calculate a body mass index. Nothing about the pathogenesis of the disease, nothing about how to treat it, nothing about the stigma and the false assumptions that people with obesity face.

The assumption that basically anyone with obesity eats too much and does not exercise is false, anyone who practices in an obesity clinic knows this. Many people with obesity are physically active and have a calorie intake which is not much higher than the average person. What is different is that for their body, it is too much, and they develop obesity. At medical school you are not taught about the role of the genes, adipocytes, maternal programming or how the environment interacts with the genes to cause obesity. Doctors are not being equipped with everything they need to know to effectively help patients living with obesity.

The reality is any specialist will meet people with obesity, whether you are an orthopaedic surgeon, a gynaecologist, a physician, a cancer specialist, you pick up any specialty, obesity is related to it. But this lack of training means that doctors across a range of specialisms do not have all the necessary knowledge and skills to help patients with obesity.  Often specialists will struggle to talk to patients with obesity and are unable to even sign post relevant services. So, it is essential that we really embed obesity education in our medical training systems. I appreciate there are time constraints, however if you consider that a significant portion of the UK population has obesity, the health and economic impact of obesity education should be seen as a priority.  For instance, we teach medical students a lot about rare disorders, and we do so because they are fascinating. But they are rare, they affect a small number of people. We do not need every doctor in the country to know how to deal with them. We need the small number of doctors in the country to really be expert in these, but we need everyone to know about obesity because it is everywhere.

 It is absolutely crucial that we embed this in the medical education system, particularly focusing on understanding the pathogenesis of obesity, and how it is a disease and has nothing to do with willpower. It is also very important that all doctors fully understand the impact of weight stigma and how detrimental it is to people with obesity.  By embedding these topics within medical training, we will have a workforce better equipped to offer patients support and the expertise will also help to combat stigma. Obesity education should not be confined to medical schools, many healthcare professionals are exposed to people with obesity, including nurses, nutritionists and pharmacists. In many instances a patient will interact more with their pharmacist than their GP, so pharmacists have a huge opportunity to at least sign post where patients can go for dedicated support.

What would you say to those medics from other specialisms who think the obesity education and training via SCOPE is unnecessary for them?

My question to these people is – within their specialism are there not diseases that can be improved with weight loss?  For instance, if you are a cardiovascular disease doctor, we know that weight loss by bariatric surgery and lifestyle interventions can reduce CVD risk significantly, based on just 10% weight loss over 12 months. If you are a respiratory physician, we know that weight loss can have a huge impact on obstructive sleep apnoea, whether it is lifestyle intervention, or pharmacotherapy or bariatric surgery. If you are a liver doctor, we know that 10% weight loss can put non-alcoholic fatty liver disease into remission and reduce the development of cirrhosis. I often get referrals from neurologists, because they have patients with idiopathic intracranial hypertension and weight loss has a huge impact. I also get referrals for patients with neurodegenerative disorders who are immobile due to muscle weakness and consequently gain a lot of weight. The extra weight can really make their lives miserable.

Even if you are an infectious disease doctor, we have seen with COVID-19, the negative impact of obesity on immunoregulation, and the responses to infection. I really cannot think of any single speciality, which does not have at least one disease, if not more, that will be improved or cured or put into remission by weight loss.

So clearly, all of these people need to have an idea how to deal with patients with obesity. Yes, we accept that they are not going to be obesity specialists, as I am not a kidney doctor. But I know enough about kidneys to be able to help my patient, and they need to know enough about obesity, to be able to help their patients, especially with conditions where weight loss is clearly the only solution.

The only treatment for fatty liver disease is weight loss. But often patients end up going to clinics, which do not offer any weight loss. Or people suffering with sleep apnoea, they are given the CPAP machine, (the mask to help them breath while sleeping) but many patients do not use it because they do not like to sleep with masks. However, we know that if they lose weight their sleep apnoea will also get better. It does not make sense to keep treating the end result of the disease and ignoring the real cause. That means that professionals in all specialties such as neurology, cardiology and respiratory need to have more knowledge so they can address the underlying root cause, and signpost patients to the right treatment approaches.

Now, I found SCOPE extremely useful, because SCOPE really gives you the skills that you do not have. You will find modules that cover psychological therapy, dietary interventions, stigma, modules that explain how to investigate and explore the underlying drivers and causes of obesity and how to start discussing obesity with the patient. Honestly, they are magic, these are the topics that you do not learn about at medical school.  Some topics such as how to treat type two diabetes or hypertension you may already know, so those are not the modules you should do, instead focus on modules outside your comfort zone and outside your speciality area. On the other hand, if you are a psychologist, then obviously you know a lot about psychology and behavioural change, but you may find value in completing the modules on how to treat type two diabetes or hypertension because they will expand your medical knowledge. To best serve a patient with obesity, it is important that specialists develop skills outside of their speciality so that the patient benefits from a more holistic approach. Because clearly not every patient is going to end up seeing a psychologist, dietician or even an obesity specialist.

Over the last ten years what significant changes have you seen in obesity treatment and prevention?

There has been a general change of attitude, especially within primary care. People in primary care in the UK and more globally are keen to treat obesity. Many healthcare professionals reach out to me and ask for advice to help their patients. That is an amazing change as ten to fifteen years ago, nobody was interested. Patients would simply be told to lose weight, now a lot more people have managed to grasp the concept of obesity as a disease.

The second thing that has significantly developed is our understanding of how bariatric surgery works and the fantastic outcomes that can be achieved. New pharmacotherapy treatments have also brought a lot of hope. Previously weight loss agents only caused modest weight loss and were largely poorly tolerated. But now we are looking at drugs that can potentially allow patients to lose 15% of their weight and there are other drugs in development that will help patients lose up to 20 -25% of their weight.  In comparison to surgery, these medications will allow us to treat a much larger number of people and have a big impact.

Now, that does not mean that that behavioural intervention will no longer be pursued. Lifestyle, behavioural interventions remain the first and most important treatment step for people with obesity. But for those patients who cannot achieve the appropriate weight loss needed with behavioural interventions, there will now be another option. Bariatric surgery is also another route. Improving the availability of different treatment options is going to change the landscape in obesity treatment.

In terms of prevention, I think a lot of governments are now taking obesity more seriously and considering how to apply system wide approaches to prevent obesity. Have we seen a change in the last 10 years? I think, yes, more policy decisions are being made. I think we have seen small, gradual changes over the last 10 years and eventually it will reach a critical stage where those changes will really make a difference. But I think we are a little bit away from that level yet.

We still need to address the clinical inertia, by that I mean the delay in stepping up the treatment. Treatment escalation should be applied when needed, rather than two years later. But overall obesity treatment and prevention is in the best place it has ever been.

What are the specific challenges to treating obesity in the UK?

So, when talking to specialists globally you realise that stigma is everywhere, but the stigma in the UK is at a different level.  There have been studies that show that weight stigma in the UK is severe and is within the healthcare system.

I can only speculate, but I think that the stigma is probably driven by the messaging that has been given over the years. In the UK, the NHS is very dear to people and quite rightly so, it is really the jewel in the UK system. For a long time there has been news about obesity bringing the NHS to its knees, either via direct costs or because it is causing diabetes or other health complications.

Now, a lot of this might have been generated with good intention, to force the policymakers to take action to address obesity. But a side effect to this message was that people started thinking - ‘well, the reason I'm getting poor service from the NHS is because there are too many fat people draining resources’. Or people thinking - ‘I have a condition that is not my fault, while people with obesity are causing their own ill health’. I think that type of thinking has driven a lot of stigma. I have seen a lot of weight stigma in the last twenty two years working in the UK.

Even when we look at policy making, obesity is rarely prioritised. For people that claim obesity is self-inflicted, which clearly it is not, that logic is not applied in other areas.  As a society we are very willing to treat people who consume excess alcohol or drugs, and of course people who smoke, but for some reason obesity is treated differently. Currently hospital trusts are facing a surgical backlog due to the pandemic, bariatric surgery is at the very end of the list. Bariatric surgery is seen as the least important surgery to restart. Why? Cancer surgery can be time sensitive so that prioritisation is understood but there are lots of other surgeries that should not automatically be considered more important than bariatric surgery. 

Even if you look at the commissioning level, when there are budget restrictions, as there are now, the first thing commissioners will stop funding is obesity treatment. They say – ‘we need to reduce weight management funding because we don't have enough money’. My question is why do they pick on obesity and not other diseases?