UACOM-P alum Dr. Erica Wadas is an Internal Medicine physician and private practice owner. In this interview, she reflects on practicing weight-inclusive medicine in a world that often stigmatizes it. Dr. Wadas covers everything from eating disorders and poor nutrition counseling to whether we should be doing regular weight checks at annual check-ups.
1. What drew you to internal medicine, and then later to obesity medicine?
It took me a long time to decide on internal medicine as I liked everything. In retrospect, that should have been my clue that I am a generalist. I did think about Family Medicine and Med/Peds but ultimately realized that I didn’t like OB. Also, sick kids broke my heart to the point I couldn’t function well as a physician. Internal medicine it was!
I also knew early that I wasn’t interested in procedures or surgery. I think that should be most medical students’ starting point: Do I want to do surgery? Do I want to do procedures, etc.? You can absolutely do procedural things from internal medicine (i.e. interventional cardiology, gastroenterology), but you don’t have to, and I liked that.
I decided to pursue further education by obtaining a board certification in obesity medicine after I was still undecided on sub-specializing during my third year of residency. I thought this would be a way to help people, whether I did primary care or not.
I obtained the certification through continuing education and was struck during one conference where the lecturer said, “We can help people lose weight, but we can’t help people maintain weight loss.” I should have stopped pursuing the certification then, but I continued … more on that evolution below.
2. Why did you start your own practice?
I started my own direct primary care practice after I tried both Fee-For-Service (FFS) and a capitated system at the VA (and much existential crisis about not taking insurance). What I realized was that I was not helping people in the way I wanted. I was drowning in administrative work that was unpaid and existed outside clinical hours. Four hours of administrative time is not enough when you have hundreds to thousands of patients.
It was unsustainable to me. I was either going to leave clinical medicine or choose to have full autonomy of where I practiced, how I practiced, and how many patients were in my practice. So, I gave Direct Primary Care a try and never looked back. I absolutely love it. It allows me to practice medicine in a way that is sustainable for me and allows me to give the patient good care.
Is 20 minutes enough for anyone ever? In my experience, I truly just needed more time with each patient to care for them wholly, address most of their medical needs, and talk about prevention.
3. What is one fact you wish all physicians knew about promoting weight-inclusive medicine?
More of a question to them: Why do we continue to recommend an intervention that fails people and the typical response is that they end up at a higher weight? This is the exact opposite of the physician’s intention with recommending weight loss.
The data is pretty clear that the majority of people at 5 years have gained back all their weight from a calorie restriction diet program.1 The majority of these people actually end up at a higher weight than when they started (and probably lost muscle mass along the way).1-5
Why are we recommending an intervention that leads to the opposite of our intention?
4. Do you treat eating disorders in your practice?
I do treat eating disorders in my practice. And what I didn’t know is that by percentage anorexia has a death rate close to opiate use disorder. Eating disorders are life thieves that can be fatal. I don’t think that was stressed enough in any of my training (medical school or residency).
5. What does it mean to you to provide medical care aligned with the ‘Health At Every Size’6 program?
To me it means focusing more on health behaviors than weight. And the health behaviors are the goal (if that is also what the patient wants and can do). I focus on quality sleep, stress reduction and management, well-rounded nutrition, movement and strength training, and social connection.
If a patient’s goal is to be as healthy as they can be, then we are going to talk about these health behaviors, intervene on them, and then let their weight fall where it may after making these changes. There is some nuance when patients are on medications that can promote or suppress appetite and/or cause metabolic changes.
In general, my recommendations remain the same—let’s focus on sleep, nutrition, movement, stress management, and connection.
6. What are your thoughts on the value of regular weight measurements at yearly primary care visits?
Probably unnecessary for adults. I’m not pediatric trained so won’t speak to anything peds related. Most adults will tell you if their weight or size has changed dramatically. That’s what I need to know and how or why they think it’s changed. But I don’t need a scale to tell me that. I can just ask the patient.
For chemotherapy, anesthesia, and a few other exceptions (congestive heart failure for example), weight measurement may be necessary at that time.
7. What is a physician’s ethical imperative when discussing nutrition, regardless of specialty?
My experience of training was that I received very few hours on nutrition. I have hours upon hours of training in many other things that I give advice on, but definitely not on nutrition.
Registered dietitians have a master’s degree in nutrition. What I have done in the past and what I have observed other physicians do is speak from their personal experience about nutrition instead of evidence-based interventions or hours of training. I think this is problematic.
I think most physicians should be referring out to registered dietitians as we have not completed supervised practice in nutrition therapy.
If the physician feels like they have to talk about nutrition:
1. They should get trained on nutrition from an RD.
2. They should ask the patient before giving advice, i.e. “Is it okay if we talk about nutrition?” (If the answer is yes, then start by asking about their relationship with food.)
This conversation—as you would imagine—takes time. If you don’t have the time or the training, then refrain from giving blanket nutrition advice or any advice at all.
Most of the time my patients say they hear things like, “just eat less” or “just eat more fruits and vegetables.” For many of my patients with eating disorders who live in larger bodies, this has been said to them before the physician asks a single thing about the patient’s relationship with food or even what they ate that day.
These words fall flat (and can be fatal) when they land on a patient who hasn’t had anything to eat that day. Another way to approach this lack of expertise but still have the physician feel like they are helping is to say, “(This disease we are treating) might be improved by dietary changes –would you like to be referred to a Registered Dietitian to discuss further?”
8. Do you perceive a high demand for physicians who openly practice weight-inclusive care?
Yes. I know of very few physicians who practice in this way. Patients are looking to join my practice (which is on a waitlist) or get referrals from me to another physician who practices this way.
9. Is there anything I didn’t cover that you think should be included?
I think it’s important to acknowledge what lives in our body in a weight-centered society. Medical students, physicians, and others are going to have a visceral response when someone says, “Health at Every Size.” I want to acknowledge that feeling. It’s real. It’s years of saying things are one way and a person challenging that.
The most impactful thing for me was wondering: Is what we are currently doing working?
It’s not and we can change it.
References:
1. Hall KD, Kahan S. Maintenance of Lost Weight and Long-Term Management of Obesity. Med Clin North Am. 2018 Jan;102(1):183-197. doi: 10.1016/j.mcna.2017.08.012. PMID: 29156185; PMCID: PMC5764193.
2. Wing RR, Phelan S. Long-term weight loss maintenance. Am J Clin Nutr. 2005 Jul;82(1 Suppl):222S-225S. doi: 10.1093/ajcn/82.1.222S. PMID: 16002825.ss
3. Jacquet P, Schutz Y, Montani JP, Dulloo A. How dieting might make some fatter: modeling weight cycling toward obesity from a perspective of body composition autoregulation. Int J Obes (Lond). 2020 Jun;44(6):1243-1253. doi: 10.1038/s41366-020-0547-1. Epub 2020 Feb 25. PMID: 32099104; PMCID: PMC7260129.
4. Melby CL, Paris HL, Foright RM, Peth J. Attenuating the Biologic Drive for Weight Regain Following Weight Loss: Must What Goes Down Always Go Back Up? Nutrients. 2017 May 6;9(5):468. doi: 10.3390/nu9050468. PMID: 28481261; PMCID: PMC5452198.
5. Sumithran P, Prendergast LA, Delbridge E, Purcell K, Shulkes A, Kriketos A, Proietto J. Long-term persistence of hormonal adaptations to weight loss. N Engl J Med. 2011 Oct 27;365(17):1597-604. doi: 10.1056/NEJMoa1105816. PMID: 22029981.
6. Bacon L, Aphramor L. Weight science: evaluating the evidence for a paradigm shift. Nutr J. 2011 Jan 24;10:9. doi: 10.1186/1475-2891-10-9. Erratum in: Nutr J. 2011;10:69. PMID: 21261939; PMCID: PMC3041737.
Images: Creative Commons/Public Domain
Sarah Brady is a member of The University of Arizona College of Medicine – Phoenix, Class of 2026. She was born in Georgia, raised in Florida, and currently lives in Arizona. She graduated from Arizona State University with consecutive degrees in English Literature and Biomedical Engineering. She loves to garden and particularly enjoys attempting to grow plants that are entirely unsuited to the Arizona climate.
Image © Ashley Lorraine Baker