Episode #38: Opening a Weight Loss Clinic with Guest: Dr. Carolynn Francavilla

Dr. Sarah Stombaugh:
This is Dr. Sarah Stombaugh, and you are listening to the Conquer Your Weight Podcast, episode number 38.

Announcer:
Welcome to the Conquer Your Weight podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here’s your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh.

Hey everyone, thanks for joining me today. I am so excited to share with you today’s episode. I interviewed a guest, Dr. Carolynn Francavilla. She like me is also a family medicine physician and an obesity medicine specialist. And in addition to practicing family medicine and obesity medicine, she works with physicians to help teach them how to launch their own practices. All of her information will be on the show notes page. So do scroll down and check that out because she is a wealth of knowledge and I would love to share that with all of you. And with that, here is my interview with her.
Welcome Today, I am so excited. We have a guest with us, Dr. Carolynn Francavilla. Thank you so much for joining me today.

Dr. Carolynn Francavilla:
Hi. Thanks for having me. I’ve been loving your podcast.

Yes, you as well. We are two physicians in the obesity medicine world, and I’m glad we’re connecting here on my podcast this evening. And I would love to hear a bit about you both personally and professionally and how you are showing up in the weight loss world.

Yeah, so I’m a family physician by training in my residency program. I knew I wanted to do something with lifestyle and helping people prevent medical problems, and I discovered what was then called bariatric medicine, now obesity medicine, and knew that was just what I wanted to do. So I was very lucky that I discovered this early in my career and did additional training during residency, came out, took the board exam for obesity medicine right away after my family medicine boards and really hit the ground running practicing obesity medicine gosh, eight, nine years ago, straight outta residency. So and because I had done that pretty early in my career and started a practice taking insurance, as the field has grown, I started to have more and more clinicians reach out to me. Like, how do we start an obesity medicine practice?

To the point where I just couldn’t answer that question anymore on a daily basis. So about a year and a half ago, I created a course for physicians and other clinicians to really implement obesity medicine in their practice. It walks them through everything from how to do an intake with a patient, to how to use medications, how to do nutrition coaching, how to do exercise coaching, how to look for and treat eating disorders. So really just wanted to brain dump everything that I had learned in the previous several years into a toolbox that clinicians could just jump in and really start helping people.

Yeah. Well I love that it’s the field of obesity medicine is growing, as you said over the last 10, 15 years. I, you know, I feel like when I was in medical school even, it wasn’t something, I don’t think we had a single lecture specifically targeted towards weight. And then similarly in my residency, I started to realize, wow, in family medicine, we’re trying to do preventative medicine. Let’s look at some of these root causes. And so I love that you’re helping docs to be able to further their education in that.

Yeah, I mean, my understanding is that even now, you know, the education in med school and residency is not that strong in this area. It’s really kind of taking education a while to catch up. So many of us, you know, have to use other tools to learn these skills.

Mm-hmm. Well, and it’s so applicable. There are certainly people like you or and I who are in the obesity medicine world and seeing patients sometimes just for that. But there’s a lot of people who are practicing in general primary care and you know, whether it’s family medicine in internal medicine, even pediatrics, a lot of OB/GYN with physicians. Yeah. Especially. Yeah. And so being able to incorporate those things into their practice is really important.

Yeah, absolutely. We all need in medicine to have some skills here to at least talk about things with appropriate language with our patients and have appropriate options that can help people that are evidence-based. And so I think pretty much every clinician needs to have some knowledge base here. And of course then some of us, you know, really love it and, and have a hard time doing anything else once we start doing this. But you know, really it’s something that everyone in medicine should have exposure to.

Tell me in your program are, is there a certain type of person or certain type of physician that’s attracted to you or is it, is it people who are doing primary care? Is it people who are doing obesity medicine?

It’s both. So we, I definitely see that there are a lot of primary care physicians who, who take the course for sure. but I have interacted in the last couple years with like radiologists who have an interest in this field. Wow. there are definitely, you know, lots of people coming from OB/GYN ER docs, definitely ER docs who you know, I think got kind of overworked in the last couple years with the pandemic. Sure. So a variety of specialties. Absolutely. And one group that seems particularly interested in this have been the DPC doctors. It seems like that group, because they do form closer relationships often with their patients and have the ability to focus more on prevention. The direct primary care group really seems to have a lot of interest in obesity medicine.

Yeah. And for those, for a lot of my listeners, they may not know what direct primary care is, and it is primary care physicians and in a lot of different areas. So internal medicine, pediatrics, family medicine, sometimes other people, there’s people coming in and what they call the direct specialty care arena. But that this idea that physicians are providing care directly to the patient. So a lot of times it’s outside of insurance, although it doesn’t have to be, and the physician may have a membership model and patients are coming just directly. It’s oftentimes one doc or a couple docs, you know, a couple of staff. There’s not these huge practices owned by another healthcare system. It’s just a doc hanging their own shingle and running a practice in the way that they really would like to. Yeah.

Taking out a lot of the middlemen, you know, taking out, ensuring and bringing it directly to the patient. Right. Not letting as much stuff get in the way between that doctor patient relationship, I think is, is the heart of DPC.

Absolutely. So tell me, when you’re working with doctors, are there, are there certain weight loss strategies that you are helping to teach them or things that you’re really emphasizing and encouraging more than others?

So I was thinking about this a little bit today because, you know, it’s March of 2023 and like GLP medications, like Wegovy are like every, you know, you can’t go 10 feet without hearing about them from someone it seems like, and I am as excited as anyone about these medications, but I’ve also practiced in this field for many years before we had those tools. And so when I was thinking about, you know, what percentage of my course covers that with, with actually the update version that’s coming out, it’s like, I don’t know, maybe 5% of the course is really about that particular thing, right? Because I really individualize the treatment of weight for my patients. I always start with underlying causes. Why does this person struggle more than someone else? We know that there’s this energy balance issue for everyone, right?

You burn less calories as you lose weight and your hunger goes up and your lack of feeling full goes, goes up. And so that’s kinda universal, but is there insulin resistance? Is there PCOS, is there hypothyroid? Is there sleep apnea? Is there depression? Is there an eating disorder? Is there alcohol abuse? What else is going on that’s making it hard for this person to lose weight? If we can identify that. And I think there’s lots of unknowns. So I emphasize that emphasize all of the medications. We’ve had a toolbox of medications for a while, they are immensely useful. And not everyone is gonna respond or have access to our newer medications. So we need to be able to use that whole toolbox of medications. I really am a big fan of individualized nutrition counseling. I really do much more like coaching in the way of nutrition.
I don’t think there’s one right diet for people. So I always like to get a really thorough nutrition history for my patients and figure out, you know, what can we do to improve nutrition for them and their weight goals and their overall health goals, right? So if someone has a sensitivity to gluten, we need to keep that in mind. If someone doesn’t feel good when they eat dairy, we need to keep that in mind. If someone wants to be plant-based, we need to keep that in mind. If someone’s super, super busy and doesn’t have time to cook, we need to keep that in mind. So I really do a lot of nutrition and coaching to figure out what’s gonna make sense for that person. Same thing with exercise. We know more movement is better for all of us, right? So for some people that may be doing a dedicated workout class five days a week, fantastic for some people that may be going on a 15 minute walk at lunch and doing some stretching later in the day.
And so we have to figure out what those individual health goals are for the person in front of us. and then looking into behavior change, which I think you do so much of on your podcast, right? Like the million different things that, that we can do to improve our habits and improve consistency. So I really teach in all of those domains so that you have this really broad skillset that you can do for every patient. There’s no like system, right? There’s no like, well just give people this, this diet and use this med and you’re done. It really is a practice of medicine, right? Just like we wouldn’t use one treatment strategy for depression. We don’t use one treatment strategy for weight loss.

Yeah. And I think especially with the GLP one medications, because they’ve been around for a while, so some of the earliest ones have been around actually almost 20 years now, but it’s just in the last two or three years that they have exploded as, especially Wegovy have gotten approved specifically for weight loss. And then we’ve seen other like Mounjaro come in the market as well. And with those medications, it’s, they’re excellent tools, but I feel like it, there is this aspect of, oh, it’s the magic weight loss, I’ll say pill, but is an injection, right? So this magic weight loss and injection and we can’t lose sight of all of the other lifestyle aspects. So working through the nutrition, I mean

They are a little bit magic, you know, I will say, that I’ve worked with for years and they’ve tried all the other tools and now you know, they’re finally on Wegovy and it really is like a switch in their head. They’re really able to finally achieve their goals, but they have been working for years on consistent exercise and consistent nutrition and consistent sleep and all these other things. And so that tool finally lets them be successful with all the things they have been doing for a long time.

Right. Well, and that’s exactly it is how can we have this comprehensive approach to make sure that, okay, let’s, we’ve got this medicine that is working on the underlying physiology and the pathophysiology of obesity. So the problems that we’re having as a result of our long-term weight, but then what are all the other tools that we can do? And like you said, we, you know, if we’re prescribing the same type of diet for everyone, and if you tell someone to eat a very, you know, you have to cook these foods and they don’t even like those foods or they don’t have access to them or time to prepare them or whatever it is, that’s not going to be a successful plan for you. So I love that you’re encouraging docs to do that.

Yeah, absolutely. It has to make sense for the, the person in front of us. And even there’s probably some risk to these medications, especially the newer, more powerful ones, the GLP without appropriate nutrition and exercise counseling because people can have rapid weight loss and we don’t want them losing too much muscle mass, right? So we need to make sure that they have some counseling and guidelines around protein goals. We need to make sure that they’re, you know, continuing to build muscle and do a little bit of strength training if possible. And we all know that exercise is good for all of us, right? We all live longer and better, but most of the data, it’s like, it’s that extra sauce when we’re trying to lose weight, right? That it really it adds an extra 20 something percent when you’re losing weight. So yeah, nutrition is huge. The meds are huge, but the exercise really is how you maintain weight and it gives you that extra little bit of weight loss too.

Yeah. Well, and when you look at that energy in versus energy out, we all know that the equation is so much more complex than that, but there is still some fundamental of there is a, the energy and energy out balance is not there. And so what are the things that we can do to alter that equation?

Absolutely. Yeah. We, I think the data’s really good that more exercise is great for weight maintenance. If you look at the national weight control registry is, you know, some of my favorite stuff to site. The people who lose large amounts of weight and keep it off, they exercise consistently, usually an hour a day, usually by walking, which you had just a fantastic podcast episode recently that emphasized some of the walking. And so we do know that it’s, it’s really important we have to use all the tools together.

Yeah, absolutely. Well, and who caress if you lose weight, right? Like there, the point is not to lose weight, the point is to lose weight and then to maintain your weight loss.

Yes. Yes. I just said earlier today on a little Instagram post, like, there’s a million ways to lose weight, but like, what are you gonna do to maintain it? ’cause that really is the key.

Well, and I think that’s where so much of this comes in because you can do the juice fast or the crazy, you know, whatever diet, whatever plan that you come across. But when it doesn’t fit at all and you do that for a limited period of time, it’s not going to be a long-term solution.

Absolutely.

So tell me, when you are working with, with doctors, are there things that they, that are new to them or that they hear from you that they are just so excited to bring back to their patients?

You know, I think that the nutrition side is actually the hardest part for a lot of docs to wrap their head around because we always get told, and I always say when I teach, like if, if you have a test question, okay, you have a board exam question, the right answer is Mediterranean diet <laugh>, I don’t even care what is the answer? Is the Mediterranean diet, if that’s one of the options, right? Absolutely. So absolutely we get pigeonhole into being told like certain things are the best thing. Like the Mediterranean diet’s really good, the Mediterranean diet’s really good, but in my clinical experience, like the Mediterranean diet is not necessarily like the easiest to teach or adapt in real life. It’s not always like a realistic real world strategy. And even though it is a very healthy diet and it has I think good data on health, it’s not always a weight loss diet.

And if our patients are coming to us to lose weight, then we need a plan that helps them lose weight. So my nutrition counseling has gotten simpler and simpler over the years because it really goes back to what’s the patient doing right now and how can we, you know, tidy that up, how can we make it work better for them? And then utilizing a medication so they can actually stick to that plan. Because most of my patients have tried many of those diets and they work for a period of time, but then they don’t work. And that’s where the medication allows them to be successful long-term with a nutrition plan that works for them. So I think that’s often the most surprising thing when I’m teaching is people are like, well what’s the best diet? like I’ve got some secret, right? You know, what do you tell your patients to eat? And there’s, there’s really no best diet. It really has to be individualized. And I think our nutrition vice can actually be fairly simple when we are using our other tools.

Yeah, I agree. Because the best diet is the one you’ll stick to.

Exactly. Exactly and we like, we have data that says that, right. Best diet. Exactly.

Yeah.

Both health and the best diet for weight loss is the one you can stick with and not stick with for 30 days or 12 weeks, but stick with for years.

Exactly. Well, and learning how to, how do you incorporate all of the things you love into a way that’s going to serve your needs. And so if you absolutely love that piece of chocolate cake to find a way that you can eat that and really enjoy it on your birthday or you know, on the infrequent occasions to be able to fit it into your plan as opposed to just, nope, you can never have a dessert ever again for the rest of your entire life is pretty daunting,

Which just isn’t realistic. Right? I remember when I first started doing this in residency saying, I never wanna be the person who doesn’t eat cake at a wedding. Right? Like, I wanna be able to have those treats and those celebrations in their appropriate setting, right? And I want my patients to be able to do that as well. I would never wanna take that away from someone. And I don’t think it’s realistic for someone to feel like they can never eat cake again.

Yeah. And so those strategies of how do I work around that and be able to apply this in a way that I can do it but not overdo it and feel totally in control.

Yeah.

Tell me with your, as doctors, how do you feel like we can best support patients through their weight loss journeys?

The most important thing I think I have learned is when I first meet with a patient to number one, get their whole story listen to their whole story and give them support that they’re not alone in their experience and that they haven’t done anything wrong. So that’s sort of the first thing that I think is really powerful in establishing care with the patient for their weight. And then I think the next thing is letting them know early on, usually at that first visit that I’m here no matter what. So the beginning is often really fun because you’re gonna be coming to each appointment and you’re gonna be losing weight and you’re gonna be excited and you’re gonna be telling me about all your wins. And then at some point there’s likely to be a setback. So maybe that’s that you stop losing weight and I’m gonna say, you’re doing great, but you’re gonna feel frustrated.

Maybe it’s that you’re gonna regain weight, maybe you’re gonna have an injury or a surgery that sets you back. And my patient’s instinct is not to come back until they’ve gotten to their previous weight, right? They don’t wanna come in and feel like a failure and feel like they’ve regained weight and that they’re gonna disappoint me. And so I realized that pretty quickly that people were doing that. And so now I get that out of the, in the open at the beginning and say, it’s gonna be great, but there may be a hard time, I don’t know when it’s gonna be, it might be in three months, it might be in six months, it might be in four years, but that’s when you really need me. You need me when you’re gaining weight, you need me when it feels like it doesn’t working. You need me when life gets really tough and you don’t know if you can stick with your nutrition plan anymore and you need something else. So I think putting that out there that like, I am here no matter what. It’s fun and exciting when you’re losing weight, but when you really need me is when it gets hard.

Yeah. Well I love that you’re saying that right from the beginning because setting that expectation like this isn’t a homework assignment. Like this isn’t, you’re not getting graded the times when you’re not doing well. I am here to support you the most. And so you better, like, you show up then and I’m here to help you.

Yeah.

Yeah. I absolutely love that. So let me ask you, for a lot of my listeners, they may be looking for an obesity medicine physician and you are working with lots of them. What do you think is the best way to get connected with someone who can help my patients or my listeners to lose weight?

Yeah, so hope in someday that I’ll have more docs on my team. I’m in Denver and you’ve got solutions in a couple states, right? Yeah. But you know, the databases where you can look for a obesity physician is the American Board of Obesity Medicine. So those are doctors who, you know, have done additional training and passed a board exam in this field. So that is a great resource. And then the Obesity Medicine Association also has a resource where you can look up clinicians who are members of that organization. So that’s someone who also has shown that they have an interest in this field and are actively engaging in education around weight. So I think those are two tools to find someone who’s gonna be evidence-based and hopefully up to date with the newer things. there’s a lot available right now, you know, even two years ago, maybe even eight months ago there was not as many resources to get help with weight and it definitely is growing. So you know, I think looking for someone who’s done additional training, not someone who’s just jumping on some of the new newer trending meds, if you’re really looking for support is probably helpful.

Yeah, I agree completely. Thank you for sharing that. And as we wrap up today, are there any things that you would want to make sure to share with my listeners? Share with docs who may be listening that they make sure to take away?

Oh gosh, that’s tough because I could talk about.

All things, we’ll talk for one more hour about that. Yeah.

But I think, you know, one of the, the biggest challenges that patients have and that clinicians can have is if they don’t truly understand that weight regulation is sort of a medical problem, that there’s a lot of judgment and bias and blame. And I think the best thing that anyone can do for themself if they are struggling with their weight is to like, let go of that blame and realize that you’re probably not doing anything wrong. And if it feels like it’s a lot easier for your friend or your sister or your husband, it probably is because they have different biology than you. And same thing for, you know, clinicians. Like, you really have to start wrapping your head around the idea that there are biologic reasons why people struggle with their weight, and we have tools to counteract that and we need to think of it that way and we need to get rid of any blame or judgment about this problem.

Yeah. Well, and I think it keeps people from seeking treatment. It’s, you know, there’s really no difference between having an elevated weight as opposed to having an elevated blood pressure. But the difference is it’s a condition that we wear on the outside of our body so other people see it. We have a lot of thoughts and judgements about it, and there’s a big bias that can come with that.

Absolutely. And so there’s that bias internally, right? We judge ourselves and then that bias towards other people. And so practicing recognizing when you are having that bias again for yourself or for others, because it is still a really prevalent bias in our culture. And I think for any of us to move forward we have to just truly let go of that.

Yeah, absolutely. And so to be able to best support our patients, that is one of the most important things we can do.

Yeah, absolutely. And that’s applicable for everyone, right? Like we have to let go of that, that bias, whether we’re seeing someone in the ER or we’re seeing someone who needs surgery or seeing someone who’s asking for help with their weight.

Yeah, absolutely. Well, if my, if my listeners want to learn more about you, where can they do that?

Yeah, so my podcast is focused on health and weight and it’s the Dr. Francavilla show. So that is a great place to continue some of these discussions. And my practice Colorado is Green Mountain Partners for Health. And we have a great team that is accepting new patients.

That’s excellent. Well, thank you so much for joining me today. I really appreciate your time.

Thank you.

SARAH STOMBAUGH, MD

Episode #38: Opening a Weight Loss Clinic with Guest: Dr. Carolynn Francavilla

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