Commenting in a “Good Questions” commentary exploring the ethics of anti-obesity advocacy for Duke University’s Kenan Institute For Ethics, Professor Gary Bennett addresses the conundrum of how to provide solutions for patients battling obesity that don’t ask them to reject who they are fundamentally. The Good Questions series is an ongoing publication project of the Kenan Institute for Ethics that allows faculty and students to frame their work through the lens of ethics.
Dr. Bennett, whose central research focus is on exploring ways of reducing risk of obesity-related chronic diseases, is the Bishop-MacDermott Family Professor of Psychology & Neuroscience, Director of Undergraduate Studies at the Duke Global Health Institute, and Director of the Duke Global Digital Health Science Center.
Dr. Bennett observes that obesity is recognized as one of the largest preventable risk factors for many other diseases and health problems, and has been declared a national epidemic. He notes that more than 65% of the US population is overweight and a third are obese, and although the epidemic seems to be slowing down for the general population, it is not for high risk populations, leaving tens of millions of Americans with high obesity risk in need of evidence-based treatment strategies.
Gary Bennett as an undergraduate was attracted to Duke’s long tradition of behavioral medicine, a field substantially pioneered by Duke researchers. Toward the end of his studies, he found that patients he saw were looking to receive organ transplants, but having difficulty meeting weight requirements. This was particularly true of patients who were from poor, from rural areas, and had to travel substantial distances for treatment. A longtime computer geek and technology aficionado, Dr. Bennett began to wonder what solutions might be engineered to leverage technology so that patients would not be obliged to come all the way to him, at least not as often.
“Behavioral solutions are needed to provide patients with the skills and support necessary to make healthful behavior change,” says Dr. Bennett. Those changes would include consideration of psychological and social factors like income status, education levels, culture, and race factors outside of the patient’s control. He notes that obesity rates are much higher in medically vulnerable populations.
However, while clinical protocols for treating obesity have traditionally required individuals receiving treatment to keep meticulous records of everything they eat and drink, as well as their exercise participation over 6-12 months, for persons struggling to make ends meet, raise children as single parents, and who may have limited transportation options, practical solutions that fit their circumstances need to be found, and Dr. Bennett maintains that technology can help.
The Duke Obesity Prevention Program has invested heavily in leveraging advanced technologies to treat obesity interventions in high risk populations, developing approaches for the web, interactive voice response, text messaging, and mobile apps. The researchers do most of their development in house, and tout these systems’ promise for extending obesity treatment to large high risk populations at low cost, making them ideal for use in primary care.
Dr. Bennett says his lab’s research program has three major themes: 1) use of new media technologies to deliver obesity interventions; 2) examining social and psychosocial determinants of obesity and physical inactivity, and; 3) exploring the dissemination of evidence-based interventions.
“Many of our ongoing research studies are based in the primary care setting, where efficacious obesity intervention approaches are particularly necessary,” he says. “A major focus of our work is health disparities and we’re heavily invested in understanding why rates of obesity vary by a range of demographic characteristics. Underlying all of our research is the goal of developing empirically supported solutions that can be used to reduce obesity in the US population.”
Dr. Bennett believes that by enabling technological solutions for obesity patients, personalized treatment can be delivered as well as helping persons receiving therapy for obesity to visualize their progress and keep their entire health team informed. He observes that while many people think digital health solutions aren’t viable for the poor, the mobile revolution is quickly closing the digital divide. And the technology itself doesn’t have to be complicated, and even a basic cell phone can be leveraged to improve outcomes significantly.
In his commentary, Dr. Bennett cites a study developed in Boston for obese patients with hypertension. “Nearly everyone was impoverished, he says [and] it would be hard to overstate the complexity of their daily lives. Dealing with obesity just want a priority. We knew that it would be very difficult for them to carry around a notebook all day to track and record the data.”
Because collecting clinical information can be a major intrusion into people’s lives, and literacy challenges add more complexity to the dynamic, Dr. Bennett relates how the investigators developed a system to “smarten” patients’ regular telephones, establishing an automated system that called them regularly to ask how things were going, analyze their responses, and provide personalized feedback. “We recorded hundreds of hours of audio that we pieced together seamlessly on the call,” he explains, so that they’d feel like they were talking to a real person, not a computer.”
Dr. Bennett says that a Boston study found people much more receptive to providing information using technology than with traditional paper studies, and that in the grand scheme of things, researchers are trying to devise solutions that can benefit study participants as well as the greater public.
He says that current standard practice is that patients are asked to adjust their lives for the researchers benefit, and that needs to be turned around with researchers able to meet patients where they are, recognizing practical, economic, and logistical challenges patients are routinely confronted with, and then figure out how to make treatment as positive an experience for them as possible.
Dr. Bennett concludes that typically when we hear about personalized or precision medicine, what comes to mind is costly treatments for mostly advantaged patients in top-tier medical centers. “But we can use technology to deliver personalized treatments at low costs for patients in the most resource-constrained care settings,” he contends, “patients for whom few real solutions exist.”
Kenan Institute for Ethics Good Questions
The Duke Obesity Prevention Program
Duke Global Health Institute
Duke Global Health Institute