Cherise Dyal, MD/Orthopedic Surgeon
Why did you pursue obesity medicine certification?
As an orthopedic surgeon I treat patients with musculoskeletal problems. A significant number of those patients are overweight or obese. Studies have shown that overweight and obesity increases the risk of musculoskeletal pain, chronic pain, osteoarthritis, injury, overuse syndromes, and tendinosis as well as co-morbidities such as diabetes. In addition, obesity is associated with post-operative complications and poorer surgical outcomes. It was not uncommon for me to treat a patient for their presenting complaints only to have them return at a later date with some other manifestation of a musculoskeletal problem related to excess weight. I began to realize that to truly have an impact on the cycle of pain and symptoms I was going to have to help patients address one of the root causes of their problem, their excess weight. This led me to pursue my Master of Science Degree at Columbia University in Nutrition. Through this program I formally studied obesity and its impact and became aware of the opportunity to pursue obesity medication certification. I felt it was important for me to be Board Certified in Obesity Medicine if I was going to seriously begin to treat my patient’s obesity as part of their orthopedic treatment.
Many doctors have told us about the “aha” moment that stimulated their interest in obesity medicine. Do you have an obesity medicine “aha” moment that sticks out in your mind?
Several years ago I began recording my patients’ BMIs as part of their medical record. It is my opinion that if you are going to record a vital piece of data that you must discuss and counsel your patient on it. I wrote a one page handout summarizing the meaning of BMI, the health ramifications and how to begin to address an unhealthy BMI thorough diet and exercise. The first week that I instituted this practice only 2 out of 100 patients seen had a normal BMI. That was the moment it struck me what a prevalent and fundamental issue this was for orthopedic patients. Based on this experience I decided to expand my knowledge to include treatment of the etiology of the problem.
How do you currently incorporate your obesity medicine training into your practice?
Through my discussions with my patients it became clear that while the majority of patients are aware that they have excess weight and may have been told by previous physicians that they need to lose weight, many have no idea how to realistically do this to make long term changes. Most know they should exercise but don’t know how to begin or are afraid to start for fear of getting hurt. Many have no knowledge of nutrition and extremely poor dietary habits. I currently take a multiple step approach in incorporating my obesity medicine training. First I treat the presenting orthopedic complaint. Once the acute episode has been treated and my patient is more comfortable I discuss the effect that excess weight has on the condition and the role it plays in possible future episodes. I also discuss that very often the treatment suggestions of the American Academy of Orthopedic Surgeons for the management of their orthopedic issue is weight management and appropriate exercise. Then we discuss ways they can begin to lose weight incorporating dietary and physical activity strategies that we agree on and set a very modest goal of weight loss or maintenance that we follow up on the next visit. Their progress is monitored and feedback given on subsequent encounters. If they are struggling I offer them more formal counseling as the “obesity medicine specialist” and we establish a separate appointment dedicated to weight management.
What is the biggest challenge you face in your practice?
Time, patient commitment and financial issues are the biggest challenges I face. As we all know, appropriately counseling patients on and treating obesity takes a significant amount of time. As an orthopedic surgeon this is extremely challenging for me and I find I must often take this out of the setting of the orthopedic visit and schedule an appointment focused solely on weight management. Patients who have been unsuccessful in past efforts or who have had the experience of weight cycling are at times reluctant to attempt weight loss again. It can be difficult to get them to commit to another weight management program. In addition, financial issues can be a barrier to treatment. Many patients do not have the insurance coverage for intensive weight management programs needed to help them make lasting changes. Few if any cover the physical activity programs needed to attain and sustain their weight loss. Coverage for medications used as an adjunct to their weight management plans can also be difficult to obtain.
What has been your greatest achievement so far?
My greatest achievement has been the establishment of a medical fitness and weight management facility to support my patients in their weight loss and wellness efforts. Individualized programs of dietary, physical activity and lifestyle intervention are developed in conjunction with my patients. Patient preference based dietary meal plans are utilized. We provide customized supervised exercise programs to accommodate medical and orthopedic conditions that ensure safety and minimize risk of injury. Intensive behavior and lifestyle modification counseling is offered as part of their weight loss program to give them the tools and skills they need to make life long changes. Support is provided for all aspects of their weight management plan including maintenance once their weight loss goals are achieved. Individualized and group settings are provided based on patient preference so everyone can have the environment they are most comfortable with. Patients have been very successful in this setting and have been able to improve their health and fitness and attain many of their personal goals.
What do you wish other orthopedic surgeons knew about obesity?
I wish other orthopedic surgeons knew that obesity is a chronic disease like hypertension or diabetes. Treatment is available and requires a multidisciplinary approach. Many patients do not know where to begin or are overwhelmed by the changes they need to make to be successful in weight loss. They need our guidance and support to effect ongoing change. We can be influential in our patients lives on this issue. If we are unable to spend the time required we can give our patients general guidelines and information about dietary and physical activity intervention and refer them for further treatment to specialists in the field. It is imperative that we not only tell our patients that they need to lose weight and develop more healthful lifestyle habits, but also provide them with the resources they need to accomplish it.
Is there anything else you would like to share about your experience with obesity medicine?
Obesity medicine a dynamic and challenging field. As an orthopedist I am regularly confronted with the effects obesity has on my patients and the recurring and progressive musculoskeletal problems that occur if it is not treated. I feel that as an orthopedic surgeon I am in a unique position to help my patients break this chain of events if I address their excess weight early in their treatment. Understanding the causes, challenges, ramifications and treatment of obesity is invaluable to our patients and I encourage all physicians, regardless of their specialties, to learn more about this extremely prevalent disease and what they can do to help their patients overcome it.
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