Joseph Kim, MD, MPH, MBA:
A few years ago, we worked on an obesity quality improvement initiative, and part of that involved the development of your intervention to better support patients in their obesity care journey. Can you tell us more about your practice and what you developed to support patients and provide them with resources?

Sejal Desai, MD, DABOM:
I was in family medicine for approximately 20 years and got additional board certification in obesity medicine approximately 10 years ago. Then I created my practice: Tula Medical Weight Loss and Wellness in Houston, Texas.

My practice is aimed at helping patients achieve sustainable weight loss and improved metabolic health. I take a personalized, comprehensive, and evidence-based approach to care that emphasizes lifestyle factors and pharmacotherapy to treat chronic medical conditions. My goal is to provide a judgment-free and supportive environment where patients feel empowered and informed while on their weight-loss journey.

As an obesity medicine physician who has been doing this for such a long time, I think all patients with obesity are on a lifelong journey because this is a chronic disease. Patients need ongoing support outside their medical visits, so I started thinking about how I can better support my patients on a daily or weekly basis over time.

I tried several different initiatives and ended up developing chat rooms for virtual support groups, as well as additional patient resources. The support groups allow patients to discuss anything in their lives that relates to their obesity care. Further, in creating these support groups, we identified 5 key topics to focused on, including nutrition, physical activities, sleep, stress, and nonscale wins. The intention is to help patients talk about how they feel in a nonjudgmental environment and receive accountability and emotional support outside the clinic. Creating this intervention was an incredibly eye-opening process.

Joseph Kim, MD, MPH, MBA:
Let us talk through the structure, format, and logistics. Are these support groups scheduled or asynchronous? Can you tell us a little bit more about how they function?

Sejal Desai, MD, DABOM:
These virtual support groups operate asynchronously. As mentioned before, we have several topic-specific groups that are each based on a lifestyle factor. There is a group dedicated to discussions on nutrition, and others that each focus on physical activity, sleep, stress reduction, and nonscale victories. In addition, these groups are only available to patients in my practice. They can choose to join any or all of them, and they basically function as any other chat group. Patients can post in a virtual support group at any time.

Further, I have a moderator helping me ensure patients are posting appropriate content, such as their struggles, wins, and questions. Whereas patients can post at any time of the day, the other patients who opt-in to these groups can give their information and respond back. We get to learn from each other, which is so incredibly important because I learn from my patients all the time.

These chats are also a great way for me to provide information. I can share resources like apps that I hear about and that I think patients may like to try. I can also discuss something that happened with another patient that may be interesting and might help other patients. Of course, this must follow confidential protocol. I cannot give away a specific patient’s identifying information, but I can provide examples of things that other patients are struggling with. Another critical element is that patients can ask questions and get responses and other useful information.

Of note, the fifth support group dedicated to nonscale victories is more for me to encourage patients to post their wins. This is important because a goal of mine is to help them not focus solely on the scale, but include other factors that are improving their health and well-being. For example, in thinking about their health or how they are feeling, patients can share about how they slept well last night. That is a great nonscale victory. Although this might seem small, it is necessary to help them stay motivated, learn that this is a long-term journey, and understand that we are all in this together. With these posts, others can chime in and say, “Yay, great job! I know you have been struggling with that.” Therefore, it truly helps with providing accountability and support.

Joseph Kim, MD, MPH, MBA:
In addition to the virtual support groups, are there other things that you do to host that real-time, asynchronous type of interaction with patients outside the clinic?

Sejal Desai, MD, DABOM:
When I first started my practice, it was fully virtual. Now, I have a hybrid practice where I see patients in person and virtually. But when I was fully virtual, I hosted monthly meetings with patients that allowed them to ask questions. I would present a topic related to health and wellness and then we would have a question and answer session. I did that about once a month at different times during the week.

One of the challenges I had with this was getting patients to show up to the meetings. It is difficult; we are all busy and have so much going on in our lives. Two to 3 patients would show up, and it was difficult to have meaningful conversations and a support group with so few people. Part of the issue also had to do with me being the only one and I could only do 1 session.

In addition, when I tried to host a meeting once every 2 weeks, I still did not receive the level of engagement I wanted from participants in person. Many people just wanted the recorded version afterward because they were having a hard time showing up in person. This continues to be one of my struggles and challenges, and I would love to go back to that structure.

Now that I am in the office, I also invite patients to participate in in-person support groups where we are together physically. I love virtual telemedicine and its platforms that we now have (it a silver lining of the COVID-19 pandemic), but I miss the in-person connection with my patients. I think that a lot of people are missing that actual social connection, which is such a big part of our overall health. For that reason, I want to create in-person groups, with the potential of opening that up to the community at-large. That is something that is in development. I have been going through some different iterations on these types of things, so it is in the works.

Joseph Kim, MD, MPH, MBA:
This intervention sounds like it is a great way to keep the momentum going as you mentioned. I also imagine, given the diversity of patients who might join such a group, that there is the risk that someone might post medical misinformation or bad advice. Do you encounter situations like that and how did you navigate those?

Sejal Desai, MD, DABOM:
That does happen occasionally. Patients get excited about telling each other how they are handling their weight loss, which is why you need a moderator to review what they are sharing. A rule of mine is that patients agree to not post anything that could be considered medical advice. Sometimes patients do not realize that what they are posting is medical advice. But the moderator picks up on this, lets me know about it, and I then address the patients individually to let them know that their post is giving medical advice. Then I can delete that comment on my end. But most of the time, I just rephrase the post in a way that is not so much medical advice but providing information.

Regarding my rules, the second is that patients must not judge or shame others in the support group. We want to help each other, and I have seen all patients abide by this rule. Thus far, everybody has been kind and the process has been wonderful.

Third, I do not allow any promotion of unverified treatments or products. Nobody has tried to do that either. So we have a respectful community, and I encourage that respect.

Of course, confidentiality is key. Everything that is said in a chat stays in the chat. It does not go beyond that. This is necessary to keep the space positive and inclusive that can be truly beneficial for everyone.

Joseph Kim, MD, MPH, MBA:
In this type of virtual environment, do you find that there are patients who are willing to be vulnerable and share sensitive topics or stories? Or do you find that most focus on the encouragement and positivity aspect of addressing obesity?

Sejal Desai, MD, DABOM:
Both scenarios occur because everybody is so different. There are some patients who are incredibly positive and focus on the encouragement aspect, while others are being vulnerable with sharing their experience. It is wonderful to have that aspect, and I encourage it because we all have our vulnerabilities.

One of the things that I have an issue with is that social media often is only a place for the “good.” Few people post about their bad days, their hair being a mess or not having any makeup on, or that they are lounging around because they cannot get out of bed. I think patients can get depressed thinking and seeing how everybody else is doing so great except for them on social media.

In the support groups, I encourage those who are struggling to let us know that they are struggling. This is because others are having the same struggles, too. So there are some patients who post about their vulnerabilities, and as more patients do so then others feel encouraged to follow suit.

In contrast, there are many patients who do not post at all. They just want to see what others are saying. My own perspective on this has changed since the start of these virtual support groups. At first I wanted to create a place and have everyone post and be involved. I would tell patients that this will not work unless they post and get involved. But over time, I changed my mind. I always want these support groups to be a safe space. Therefore, if patients do not feel comfortable with posting, then that is absolutely OK. They can still see the chat, read about others’ experiences, and receive information. Maybe in the future they might become more comfortable with posting.

Joseph Kim, MD, MPH, MBA:
Are there any specific platforms or resources that you have found to be helpful, whether on the technology, administrative, or logistical side?

Sejal Desai, MD, DABOM:
Yes, many and there are a handful that have really benefited my practice. One is my newsletter platform. There are several options out there like Mailchimp. I use Constant Contact, which has helped me stay connected with my patients as well as others who find my website. It is a great tool to share all the information you want to share with your audience. I send newsletters periodically, as I do not want to overburden anyone.

For the administrative things, I am a big fan of Google Forms and Typeform. Then there is Google Sheets to keep everything organized, and the larger Google Workspace that is Health Insurance Portability and Accountability Act (HIPAA) compliant. I also have virtual assistants who can help, and these platforms can be shared virtually.

I am in love with Canva. It helps me create much of my content. I have this big artistic side that I never get to use in practicing medicine. I love to create my own content, such as flyers, emails, brochures, and other avenues to share information. For example, I create handouts for patients using Canva. It makes creating content so easy and simple.

I also use Zoom as a platform for certain webinars and virtual meetings that I host free of charge for patients. Then my electronic health record uses Elation Health, which streamlines my televisits and other group visits.

Then I use a platform called BodySite, which is where the virtual support groups are. It is a HIPAA-compliant platform that offers different plans and tools. The plans can be customized and there are templates along with the group chat features.

Joseph Kim, MD, MPH, MBA:
Have you received any feedback from your patients? Have they shared if the virtual support groups have had a meaningful impact on them?

Sejal Desai, MD, DABOM:
We see these wins all the time. For example, I have a patient who is in her early 50s, and she was one of the quiet ones in the group. Every time we met in our monthly meetings, she would tell me how she was struggling with a lot of frustration and anxiety. She had stress because she was not losing weight in the way that she wanted or at the levels that she wanted. We always discussed realistic weight loss, but she had been very quiet in these groups for a long time.

When I met up with her recently, this patient shared with me that seeing all the other people posting allowed her to understand that she was doing really well herself. She was putting these unrealistic expectations on herself because she was comparing herself with someone in her life who was on a different journey. Everybody is on an individual journey. So the patient realized this when she started paying attention to how she was feeling and the nonscale victories that other patients were sharing. She realized that she had so many of her own nonscale victories, which started changing her whole mindset about her weight and health. When I see her now, I can see that I am talking to a completely different person. I can tell in her voice that she just has so much hope and positivity. I love that changing her perspective has helped her do that.

I had another patient who was struggling with losing weight, and we always work on a comprehensive approach. I tell my patients that weight loss requires more than just diet and exercise. It is more than what they are putting into their body. And sometimes patients need to hear that message from other people to understand it. In the sleep-focused support group, lots of patients are post about their struggles or successes with sleep.

This patient, who had totally been ignoring her sleep, realized through that chat that she also had these bad sleep habits. “Yes, I am also doing that. Maybe I do need to change my sleep habits,” she said. Once she started changing her sleep habits, she saw the weight effects as her sleep started improving. That happened because of the other patients. Yes, it originally came from me, but she did not listen to me as much as she listened to her peers.

Unlike with social media, where people are listening to others and receiving poor advice, this was advice from other patients about what they are doing, which is resonating with others. We also ensure patients are not sharing something that is totally off the charts or that could be very detrimental to other patients. But I love that they are learning from each other, too.

Joseph Kim, MD, MPH, MBA:
As the one organizing and running these virtual support groups, what have been the challenges that you have faced?

Sejal Desai, MD, DABOM:
As with anything, there are always challenges, which can be great learning opportunities, too. In my case, there were several. First, I started this intervention off a little too big and had too many support groups. Then I dialed it down to only have the 5 we have already discussed. It is better to start small and scale up rather than do too much right at the start. Along with this was the challenge that I was trying to do it all by myself. I was the moderator, poster, and listener. I had to make sure that I was in the support groups every day and checking in. It became too much for me to do as 1 person.

I am thankful that I did not have to hire anyone new to help me. My manager is the moderator in these groups now. She initially was the one who was excited about hosting the support groups. She participates in other online chat groups and feels that they are beneficial. And since, she has been a fantastic moderator. Because I handed that responsibility to her, I do not have to log in to all group chats every single day.

That was a huge lift for me because my practice is a smaller boutique-style practice where I feel like I am doing all of the work. So one of the biggest lessons I learned is to ask for help, and my manager’s assistance has been tremendous in making these virtual support groups successful.

Joseph Kim, MD, MPH, MBA:
As you think about the future and the sustainability of these support groups, where do you see things going and what do you think might be some factors that will change in the coming years?

Sejal Desai, MD, DABOM:
I have lots of visions for growing these support groups. One of my biggest commitments to my patients is to help them feel supported, heard, and empowered. I cannot do that in 1 office visit. Even though I do see patients about once a month, we often spend that single visit talking about their medications, lifestyle, and personal, one-on-one things. Therefore, I cannot get to a lot of the different things the virtual support groups can.

I want to have more interaction, support, and collaboration with patients in different ways. I want to incorporate larger groups and maybe have different groups where we can open the conversation up to everyone, not just the patients at my practice. I want to open it up to other people who are on their obesity management journey and need support.

One thing that I started doing recently is hosting a live, online talk every Thursday at noon. That is open to the public and completely free. I host these talks through an app called Goodself—a free social media app with vetted experts—where people can join in and ask questions. Each talk is recorded, so those who cannot join live can watch the recorded version afterward.

I want to do more of this type of work that is open to the public. I may perhaps create a Facebook group in the future. There are many different Facebook groups out there. I could create online courses that are made available in certain areas where I can dive deep into topics like liver health, menopause, or sleep health. Patients could take a course from me and complete it at their leisure.

I also would love to collaborate with and bring in other specialists, therapists, dietitians, and different people in the field. We could collaborate to make content that is available to everyone, not just those in my practice.

Joseph Kim, MD, MPH, MBA:
What advice do you have for those who might be interested in implementing something similar or  replicating what you have done?

Sejal Desai, MD, DABOM:
The first thing is to keep it small and simple to start. You can always change as you grow. I am constantly changing and doing new things that work for my patients, but it is easier to do that if you start small and keep it simple. This could be a private chat group, a monthly Zoom call, or weekly email check-ins; anything that is small and HIPAA compliant.

Setting clear expectations at the beginning is crucial. Really think about it. What do you want to achieve? Who is your target audience? How do you want to get your message and information out? How are you going to sustain that? Do you have the staff to support you, and who exactly is going to do what?

You also need to be consistent and hold yourself up to a better standard. If you are doing weekly sessions, make sure that you are doing those. Do not make plans or set goals that are unrealistic. Ensure that you have the time to deliver what you set out to do.

Establish ground rules at the beginning so everybody understands the rules. Then there will not be as much need to reprimand or delete chats. Establishing ground rules and fostering a supportive and judgment-free space can really prevent misinformation from spreading.

One thing I have not done myself that I would encourage people to look into is using technology more, including artificial intelligence (AI). I think that AI can certainly help in many different ways. Technology use can be challenging in healthcare because we have to be HIPAA compliant. We cannot just create a WhatsApp group. One, I do not know how to do that, and 2, it does not seem HIPAA compliant. But there are ways that AI and other technologies can help interventions like this. Perhaps there are platforms where AI could be a moderator or help generate questions. There is a lot of possibility out there. It is a future goal of mine and something where I need to become more educated.

Joseph Kim, MD, MPH, MBA:
As we get ready to wrap up, do you have any final thoughts or anything else that you would like to mention?

Sejal Desai, MD, DABOM:
The biggest thing for all healthcare professionals who are helping patients lose weight is to understand that obesity is a chronic disease. It is a lifelong journey. We need to help patients manage this disease and we should want to do it in an engaging way that uses evidence to help them improve their long-term health outcomes. We also should want them to achieve sustainable weight loss in a safe and effective manner.