Poynter Lecture Healthcare for Every Body – Best Practices for Caring for Higher Weight Patients

April 04, 2024

April 2, 2024

Poynter Lecture

Healthcare for Every Body – Best Practices for Caring for Higher Weight Patients

Sponsored by the Program fro Humanities in Medicine

The Anlyan Center Auditorium

Ragen Chastain

Speaker, writer, researcher, Board Certified Patient Advocate, multi-certified health and fitness professional, and thought leader in weight science, weight stigma, health, and healthcare.

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ID: 11541
To Cite: DCA Citation Guide

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00:00OK. Oh, there you are.
00:02OK. Hi, everybody.
00:03Welcome. I'm Anna Reisman,
00:05director of the Program for
00:06Humanities and Medicine and
00:08very pleased to be here with you
00:10for this point to lecture. Healthcare
00:12for everybody, Everybody.
00:13Best practices for caring for higher
00:16weight patients Featuring Reagan Chastain.
00:19And this talk is happening.
00:22Thanks to medical student Chinya Jelly.
00:28And so I will introduce Chinya and then
00:30turn it over to Chinya to introduce
00:33Reagan and to lead the rest of the hour.
00:37So Chinya is a fourth year
00:38medical student here at Yale.
00:40Her research and career interests include
00:42HealthEquity and Health Policy.
00:44Through her participation in many
00:46extracurricular activities, she acts
00:47as an advocate for medical trainees
00:49and patients from backgrounds
00:51underrepresented in medicine.
00:52She recently matched into the
00:54Family Medicine Residency program
00:56at the University of Pennsylvania.
00:58Thank you, Jing.
01:05Hi, everyone. Thank you so much for coming.
01:07Just gonna adjust this mic. Yeah.
01:10So I now have the honor of introducing
01:13our speaker, Reagan Chastain.
01:15She's got many accolades,
01:16and I'm just trying to go
01:18through as many as possible.
01:19Reagan Chastain is a speaker,
01:21writer, researcher,
01:22board certified patient advocate,
01:25multi certified health
01:26and fitness professional,
01:27and thought leader in weight science,
01:29weight stigma, health and healthcare.
01:32Utilizing her background in research,
01:33methods and statistics,
01:35Reagan has brought her signature mix
01:37of humor and hard facts to healthcare,
01:39corporate,
01:39conference and college audiences from
01:42Kaiser Permanente and Nationwide
01:44Children's Hospital to Amazon and Google,
01:47to Dartmouth, Caltech,
01:49and ICAA.
01:50Author of the Weight and Healthcare
01:53Newsletter co-author of Haes
01:55Health sheets and editor of the
01:58anthology The Politics of Science,
02:00Reagan is frequently featured
02:01as an expert in print, radio,
02:04television and documentary film.
02:06In her free time,
02:07Reagan is a national dance champion,
02:09Tri athlete and marathoner
02:11who holds the Guinness World
02:13Record for the heaviest
02:14woman to complete a marathon.
02:16Reagan lives in Oregon
02:18with her fiance Julianne,
02:19and a rotating cast of foster dogs.
02:22Please give her a warm welcome.
02:25Thank you so much.
02:28Thank you so much for having me.
02:29The worst part about being a
02:31professional speaker is hearing
02:32your bio read over and over again.
02:33So thank you so much and thanks
02:35for all the work to bring me here.
02:37These things are no small feat to put
02:39together and I hugely appreciate it.
02:41So we're gonna talk a bit
02:42about healthcare for everybody.
02:43A couple things to start off with.
02:45First of all, I'm not a doctor.
02:46I don't play one on TV.
02:47My area of expertise is the research.
02:49I've been researching the intersections
02:50of weight science, weight stigma,
02:52and healthcare for about 20 years.
02:54And so my goal is to bring my research
02:56knowledge to help you in whatever you do,
02:58including if you're a practitioner,
03:01I may talk about things that are
03:03different than what you have learned,
03:06than what you have taught other people.
03:09And so in the 20 years that
03:11I've studied weight science,
03:12I can tell you I've had all
03:13the feelings right?
03:14Anger, defensiveness, denial.
03:15And so if that comes up,
03:18I just want to say that's incredibly valid.
03:20And also if it does, Ioffer that
03:22as an as an invitation to explore,
03:25right, to dig deeper.
03:26And I'm happy to help with that.
03:28That's my e-mail,
03:30reagan@wadeandhealthcare.com.
03:30You're welcome to e-mail me anytime.
03:31I pretty much live to talk about this stuff.
03:34I also want to say that when I talk
03:35about mistakes that are made around
03:37weight science and weight Sigma healthcare,
03:39I have typically made each and every
03:41one of these mistakes personally.
03:43And I don't think that people are making
03:45these mistakes typically out of malice.
03:46But I do think that there's a lot
03:48of misinformation that floats around
03:49and I do think that we've sort of
03:51built a paradigm on research that
03:53doesn't necessarily support it.
03:54And so that's what I'll talk about today.
03:56Most of my work,
03:57I think a lot about the Galileo
03:58story and we all know the whole,
04:00like, figured out the earth,
04:01revolved around the sun,
04:02put under house arrest,
04:04forced recant, terrible.
04:04The part of that story that most
04:07interests me is that Galileo's
04:08contemporaries are said to have
04:10refused to look through the telescope.
04:12So it's not that they were saying this
04:14telescope is poorly made or your math is off.
04:16They simply wouldn't look.
04:17And so a lot of my work is just asking
04:20people to look through the telescope.
04:33Got it? Well, we can click this way.
04:37There we go. OK. All right.
04:38I want to start about,
04:39start off talking about language.
04:40And I also want to say this is going to
04:41be about a 20 minute talk and then we're
04:43going to do an interview and AQ and A.
04:44And so this talk can go from
04:4620 minutes to four hours.
04:47So I'm really like condensing
04:48down to the high point.
04:49So again, there's a lot more to unpack
04:51here and I welcome you to reach out to
04:53me if you'd like to ever discuss this.
04:55So obese and overweight.
04:57These were terms that were literally
04:59created for the express purpose of
05:01pathologizing bodies based on shared
05:03size rather than shared symptomatology
05:05or cardio metabolic profile.
05:06The origin of pathologizing
05:08bodies based on size,
05:09the origin of weight stigma in general,
05:11the origin of the body
05:12mass index in specific.
05:13These things are rooted in an inextricable
05:16from racism and anti blackness.
05:18And I that's not my scholarship,
05:20that's what I've learned.
05:21And I absolutely recommend
05:23reading Sabrina's Strings,
05:23Fearing the Black Body and Deshawn
05:25Harrison's Belly of the Beast to learn
05:27more about how not only are these
05:29things rooted in racism and anti blackness,
05:31but they continue to disproportionately
05:33impact those communities today.
05:35So the impact of this idea of
05:37pathologizing higher weight bodies has
05:38been a tremendous amount of profit to
05:40the weight loss industry who have been
05:42the primary architects of this paradigm.
05:43A lot of stigma and oppression to
05:45the people in these classifications,
05:47a lot of separation between higher
05:49weight people and health and healthcare
05:51and healthcare practitioners,
05:53and basically no decrease in the
05:54number of higher weight people.
05:55In fact,
05:56there's been a consistent increase in
05:58the number of higher weight people.
06:00So then there's person first
06:01language and you may have heard
06:02this idea as anti stigma language,
06:04the idea that saying a person
06:05with obesity or a person with
06:07overweight is less stigmatizing.
06:09And the first thing I want you to
06:11know is that this did not come from
06:13weight neutral health community,
06:14it did not come from bad activism community.
06:15This again,
06:16came from the weight loss industry and
06:19through the advocacy groups that they fund.
06:22And so this the problem
06:23with person first language,
06:24besides the fact that it makes
06:26us sort of unwitting marketers
06:27for the weight loss industry,
06:28is that it's actually more stigmatizing
06:30because it means we talk about
06:31higher weight bodies differently
06:32than we talk about any other body.
06:34We're never like,
06:35oh thank goodness my friend
06:36with tallness is here.
06:37Now we can finally change that light bulb,
06:39right?
06:39Or my friend with blondness is
06:40going to sit next to me or oh,
06:41that man with thinness getting on the bus.
06:43I believe I know him right.
06:44That's not how we talk about bodies.
06:46So when we suggest that higher
06:48weight bodies that simply accurately
06:49naming them is so stigmatizing
06:51that it requires A
06:52semantic work around,
06:53that in fact is stigma.
06:57And so Person first language is roundly
06:59rejected by both weight neutral health
07:01community and fed activism community,
07:03anti stigma language.
07:04What we're looking for are terms that
07:06accurately describe these bodies without
07:08medicalizing or pathologizing them,
07:10and that we're not used as a taunt or
07:11slur in a way that could be triggering.
07:13And so those can be terms like
07:15higher weight people of size,
07:16larger bodies then we have fat.
07:19Fat is my preferred personal
07:21descriptor for a lot of reasons,
07:22but fat is a reclaiming term with all of
07:24the complexities that come with that.
07:26So there are people who could be defined
07:28as fat who reject that term completely,
07:30and that's totally valid.
07:31I like it because it's one of
07:33the ways I tell my bullies.
07:34They can't have my lunch money anymore,
07:36right? You can't offend me by
07:38accurately describing my body.
07:39And also, again,
07:40it doesn't medicalize or pathologize my body.
07:42Now, I'm not suggesting that
07:43you chart people as fat, right?
07:45But what I am saying is if someone
07:47describes themselves as fat in
07:48a neutral or a positive way,
07:50then we must never,
07:51never correct them.
07:52You're not fat.
07:53Don't call yourself fat because
07:54they in fact are fat no matter
07:56what we're calling them.
07:57So suggesting that again,
07:59accurately describing yourself as
08:01somehow offensive again is stigma.
08:03And this is an issue that happens
08:04in a lot of weight stigma research
08:06where that weight stigma research is
08:08actually rooted in anti fatness, right.
08:10So what We'll start the obesity
08:13epidemic continues unabated.
08:14You know there will be X number
08:15of obese people soon.
08:16Anyway,
08:17let's talk about not stigmatizing them,
08:19right.
08:19So it comes from a point of view of
08:20like we don't want to stigmatize fat people,
08:22but we definitely want to eradicate
08:23them from the earth and make
08:25sure no more ever exist.
08:26That's not an anti stigma point of view,
08:28right?
08:29And so all of that gets
08:30rooted into this language.
08:31So throughout this talk,
08:32I'll use higher weight in people's size,
08:35larger body and fat interchangeably.
08:37I'll use quote obese and quote
08:38overweight when I talk about the
08:40research that uses those terms.
08:41And I will not
08:41use person first language.
08:43So in the 20 years that I've
08:45been studying weight science,
08:47there are some commonalities that I
08:49want to talk about within the research.
08:51The first basic premise error I see
08:52in a tremendous amount of the research
08:54is this idea that will have higher
08:55weight patients experience a health
08:57issue more often than thinner patients.
08:59Then it must be because they're
09:01higher weight and everybody knows
09:02from their first day in their
09:03first research methods class.
09:04This is a correlation causation error.
09:06And this is complicated in
09:08healthcare research because we
09:09use correlation all the time,
09:11but it's not responsible to do that without
09:14actually investigating confounding variables.
09:15What else could be affecting
09:18this relationship?
09:19And here we have weight, weight stigma,
09:21weight cycling and healthcare inequalities,
09:23which we'll talk about in a moment.
09:25And there's also surveillance
09:26bias and testing rate, right?
09:28So if higher weight people are,
09:30as we find in research,
09:31often have their blood pressure
09:33taken with A2 small cuff,
09:34which gives an artificially elevated reading,
09:36and then we say, wow,
09:37those people have a lot of hypertension.
09:39That's an example of surveillance
09:40or testing bias.
09:41If we test higher weight people
09:43early and often for type 2 diabetes
09:44and we don't test thin patients,
09:46that's an example of surveillance
09:48or testing bias.
09:49The second basic premise error is OK.
09:50Well,
09:51if higher weight patients experience
09:52a health condition more often,
09:54or if a healthcare intervention
09:55is less effective for them,
09:56then the solution is to make
09:58them into thinner patients.
09:59So using weight as a proxy for
10:01health becomes problematic really
10:02quickly because no matter what
10:04definition someone's trying to use,
10:05whether it's BMI, waist,
10:07circumference, you know,
10:09percentage of adiposity,
10:11we still have the same issue,
10:12which is that you can have people
10:14who have those exact same traits with
10:16vastly different health statuses and
10:18symptomatology and cardio metabolic profiles.
10:21You can have people with vastly
10:23different weight, BMI,
10:24waist, circumference,
10:25etcetera,
10:26with the exact same health status and
10:29symptomatology and cardio metabolic profile.
10:31Also,
10:31people experience weight changes without
10:33health changes and they experience
10:34health changes without weight changes.
10:36And So what this becomes is
10:37sort of like saying,
10:38well,
10:38we know that CIS male pattern
10:40baldness is incredibly highly
10:41correlated with cardiac incidents.
10:43So the obvious solution is to
10:44get these folks to grow hair.
10:46It's the obvious difference.
10:47Like we've got to have a war on baldness.
10:49We've got to fix this,
10:50and that's what happens.
10:52It sounds ridiculous,
10:53and it is ridiculous,
10:53but in many ways,
10:54when you dig into weight signs,
10:55this is exactly what is happening.
10:59So in looking at those confounding variables,
11:01there's often in this weight science
11:03research a deep failure to control.
11:06So the first is controlling for
11:08the effects of weight stigma.
11:10Munich found that experiencing
11:11weight stigma over time was
11:12associated with increased rates of
11:14blood pressure and type 2 diabetes.
11:18Sutentanol found that perceived weight
11:19discrimination was associated with an
11:21increase in mortality risk of nearly 60%.
11:24And Munich, in a separate study,
11:25found that the difference between
11:27actual and desired body weight was a
11:30stronger predictor of physical and mental
11:32health than actual body mass index.
11:34Right? And typically,
11:35weight stigma is often not even mentioned,
11:37let alone controlled for in studies
11:39that claim to find a relationship
11:41between weight and health issues.
11:44Then we've got weight cycling.
11:46So Gaysern and Gotti found that
11:48the risks associated with weight
11:49cycling are very much the same as
11:51those associated with quote obesity,
11:53bacon and AD for more found weight
11:55cycling results in increased inflammation,
11:57which in turn is known to
11:58increase the risk for many,
11:59quote UN quote obesity associated diseases.
12:01And it's important to understand that
12:03when we talk about weight related or
12:05quote obesity associated diseases,
12:07we're talking about diseases that
12:08people of all sizes have that get called
12:11weight related or obesity associated
12:13when higher weight people have them.
12:15Research also indicates that weight
12:17fluctuation or weight cycling is associated
12:19with poor cardiovascular outcomes and
12:21increased overall mortality risk.
12:22And in fact,
12:23Bacon and Aftermore found that weight
12:25cycling could account for all of the
12:27excess mortality that was associated with,
12:29quote, obesity in both the
12:30Framingham and the Enhanes.
12:34And this is important because about a
12:36century of research from Stunkred ET
12:37al in 1959 that actually looked at the
12:39previous 30 years of research to at
12:41least Gazer and Angadi in 2021 found
12:43that the most common outcome by far
12:46of intentional weight loss attempts is
12:48short term weight loss and then long
12:50term weight regain which is weight cycling.
12:53So for about 100 years we've been
12:55prescribing these healthcare interventions
12:57right where the majority of people lose
12:59weight short term and and regain it.
13:01So we've been prescribing weight
13:04cycling essentially and then finally
13:06we have lack of access to ethical
13:07evidence based healthcare.
13:09And so here we can talk about practitioner
13:11bias and that is of course both
13:13implicit and explicit is an issue.
13:14But it goes beyond that.
13:15Most research doesn't include
13:17higher weight people.
13:19I was just speaking at a conference
13:21for anesthesiologists and and looking
13:22at like 30 years of anesthesia
13:24research repeatedly.
13:25They would create guidelines and the
13:26guidelines would start by saying,
13:28you know,
13:28guidelines for higher weight people.
13:30And they would start by saying,
13:31well, we know that pharmacokinetics
13:33and pharmacodynamics are different
13:34for higher weight people,
13:35but we're not sure how because they're
13:37typically excluded from drug trials.
13:38Anyway,
13:39here's some guidelines, right?
13:41And so instead of saying,
13:42dear God,
13:43we need to do studies that actually include
13:45higher weight people so that we know
13:47how this medication works in their bodies,
13:49they simply sort of shrug it off.
13:51And this is an example of both weight
13:53stigma and the healthcare inequality,
13:55the outcomes of which will often be
13:58blamed on higher weight people's bodies.
14:00And then there's accommodation,
14:02right?
14:02Simply a chair in the waiting
14:04room that someone can sit in the
14:05correct size blood pressure cup,
14:06A correct size gown,
14:08a correct size MRI until healthcare actually
14:10accommodates people of higher weights,
14:12Until there's research so that
14:14the tools and best practices and
14:16pharmacotherapies that are developed
14:17through research are actually
14:19developed for higher weight people,
14:21we cannot possibly have equality.
14:23And blaming higher weight people
14:25for healthcare's failings is
14:26not just weight stigma,
14:28but it also then perpetuates weight stigma.
14:32So also there's an underlying tenant of
14:34a lot of care of higher weight people,
14:36including in the way that the FDA
14:38approves weight loss interventions,
14:39that it's worth risking higher weight
14:41people's lives and quality of life
14:42and attempts to make them thin.
14:43And it's particularly important to
14:45know that that's coming from this
14:47research that I was just talking about,
14:49where there's no control for weight stigma,
14:50weight cycling or healthcare inequalities,
14:53right?
14:53Where there's just a pile of
14:55research that correlates being
14:56higher weight with health issues.
14:57And then the conclusion is Oh well
14:59obviously it's so dangerous to be
15:01higher weight it's worth risking
15:02higher weight people's lives and
15:04quality of life to make them thin.
15:06So the bottom line here is that
15:07what are sometimes called weight
15:09related or quote obesity related
15:11conditions again might
15:12actually be weight stigma related
15:14conditions and or weight cycling
15:16related conditions and or healthcare
15:18inequality related conditions.
15:20And until these are controlled
15:21for we cannot possibly know or
15:23understand the relationship between
15:24body size or adiposity and health.
15:28So what we have currently is a
15:30blame game where healthcare and
15:32the weight loss industry create and
15:35perpetuate weight stigma and weight
15:37cycling and care inequalities.
15:39And then research blames the
15:41negative outcomes of that on
15:43higher weight people's bodies.
15:44And then those negative outcomes
15:46are used to justify additional
15:47weight stigma and weight cycling
15:49and healthcare inequalities.
15:50And we're caught in this loop.
15:52And again, I don't think people
15:53are doing this on purpose.
15:55I think often it's a matter of
15:58paradigm entrenchment, right?
15:59Not looking through the telescope,
16:00being so sure that this must be the way
16:02it is that we don't ask the questions.
16:06And so then I want to talk real quickly
16:08about one claim that's very common.
16:09We hear, OK, 5 to 10% weight loss leads
16:12to clinically meaningful health benefits.
16:14And the first thing I want you to know is
16:16that that number came through attrition.
16:17It started with the metropolitan
16:19life tight weight tables where there
16:21was very specific if you are this,
16:23this height and this frame,
16:24you should weigh this amount.
16:26But they couldn't get people to lose
16:28anywhere near that amount of weight.
16:29So they moved to 20%,
16:30not through clinical trials,
16:31but because it was a round
16:33Number and it seemed memorable.
16:35But they couldn't get people to lose 20%.
16:36So they went to 10%, then five to 10.
16:38And recently I've seen three to five,
16:40an amount of weight I could lose
16:42with a haircut and a loofah, right,
16:44But always attaching this clinically
16:46meaningful health benefits phrase to the end.
16:49And so Man and Tomiama, I'm sorry,
16:51Tomiama, Osterman,
16:52Man in 2013 tested this to see,
16:54do these small amounts of weight
16:56loss actually create clinically
16:57meaningful health benefits?
16:59And what they found was
17:00in correlational analysis,
17:01we uncovered no clear relationship
17:03between weight loss and health
17:04outcomes related to hypertension,
17:06diabetes or cholesterol,
17:07calling into question whether weight
17:09change per SE had any causal role
17:12in the few effects of the diets.
17:14Increased exercise, healthier eating,
17:15engagement with the healthcare
17:16system and social support may
17:18have played a role instead.
17:19And So what we might actually
17:20be seeing is that people,
17:21when they engage in these
17:23weight loss interventions,
17:24they make behavior changes.
17:25They experience health changes
17:27and they experience typically
17:29temporary weight changes.
17:31And even though the weight changes
17:33are both small and simultaneous,
17:34we tend to credit them
17:35for the health changes,
17:36ignoring the behavior changes
17:37that preceded the health changes.
17:41And this is supported when we
17:43look at research like Klein ET al.
17:45So they looked at OK will large volume
17:48abdominal liposuction create these
17:49same improvements and they found that
17:51in fact they did not that large volume
17:54abdominal liposuction basically fat
17:56loss without behavior change does not
17:59significantly improve obesity associated
18:01metabolic abnormalities and again
18:03caveat on the quote obesity associated.
18:06And then we have this body of research
18:09that looks at retrospective studies.
18:11So we'll start with the way at all
18:14they looked at 25,714 adults, CIS men.
18:17Now in this study,
18:18as in almost every study that
18:19I'll talk about,
18:20there is no trans and non binary
18:22representation and there is an under
18:24representation of people of color.
18:25And that is a consistent issue that
18:26should never have happened and certainly
18:28should have been solved before now.
18:30But we see this.
18:31So they looked at the relationship
18:33between relative risk of all
18:34'cause mortality and body size.
18:36And if you look at these Gray bars,
18:38these are quote UN quote normal weight,
18:39quote UN quote overweight and
18:41quote UN quote obese CIS men who
18:43were not participating in fitness.
18:44And we can see the rise in all
18:46'cause mortality as body size rises.
18:47Now we cannot say that is caused
18:50by body size,
18:51again because of the possible confounders,
18:52but we do see that it's there.
18:54These red bars are CIS men who
18:56are participating in 170 minutes
18:57of movement a week.
18:58And what we see here is that their
19:01relative risk of all 'cause mortality was
19:04essentially the same regardless of size.
19:06Matheson and all took this further.
19:08They looked at 11,761 CIS men and women
19:11and they looked at 4 healthy habits,
19:135 or more servings of fruits and vegetables,
19:15exercise more than 12 * a month
19:16alcohol up to 1 drink a day for
19:18CIS women and two drinks a day
19:20for CIS men and not smoking.
19:22And so here we have their graph.
19:23Y axis is the health hazard ratio.
19:25X axis is the number of those four healthy
19:27habits people were participating in,
19:28from none of them to all four.
19:32And then on top of each of those numbers are
19:34three bars for quote UN quote normal weight,
19:36quote UN quote overweight,
19:37and quote UN quote obese.
19:38We can see when people were
19:40participating in none of the habits,
19:41there was a pretty big striation
19:43among health hazard ratio.
19:44Once again,
19:44we cannot say this is caused by body size,
19:46but we do see that it's there.
19:48When people participated in just one of
19:50those habits that compressed significantly
19:53for those participating in all four,
19:54they had essentially the same health
19:56hazard ratio regardless of size.
19:58And this is what we see over
19:59and over and over again.
20:00If we actually take behaviors into account,
20:03they may well be a better predictor
20:04of current and future health than
20:06his body size or weight loss.
20:07So Gazer and Gaudi is the
20:09last study we looked
20:09at 2021. They looked at 225 studies,
20:12systematic reviews and meta analysis.
20:15And they were looking at the
20:16relationship between physical activity,
20:17cardiorespiratory fitness and health.
20:18And what they found was the mortality
20:20risk that gets associated with
20:21quote obesity is largely attenuated
20:23or eliminated by moderate to
20:24high levels of cardiorespiratory
20:26fitness or physical activity.
20:27They found most cardio metabolic risk
20:29factors that are associated with, quote,
20:31obesity can be improved with exercise
20:33training independent of weight loss
20:34and by a magnitude similar to that
20:36observed with weight loss programs.
20:38Which is really important because
20:39as we see with weight loss programs,
20:40the vast majority of people regain weight
20:42and lose cardio metabolic benefits.
20:45They found that weight loss,
20:46even if it was intentional,
20:47was not consistently associated
20:49with a lower mortality risk.
20:52They found that increases in
20:53cardiorespiratory fitness and physical
20:54activity are consistently associated
20:56with greater reductions in mortality
20:57risk than is intentional weight loss.
21:01They found, again,
21:02weight cycling is associated with
21:03numerous adverse health outcomes,
21:05including increased mortality.
21:06And they posited that adherence to
21:08physical activity might improve if
21:09healthcare professionals emphasize to
21:11their patients the myriad benefits of
21:13physical activity and cardiorespiratory
21:14fitness in the absence of weight loss.
21:16Because what higher weight people are
21:18told is exercise makes you lose weight,
21:20which makes you healthier.
21:22And so people start an exercise
21:23program and they either lose a
21:24little bit of weight and gain it
21:25back or they don't lose weight at
21:26all and then they quit because they
21:28assume it's not working because
21:29they've been misled about the likely
21:31outcome and also about the benefits.
21:33It's important to understand
21:34the benefits of these health
21:36supporting behaviors are direct.
21:39So then we've got an RCT.
21:41So there's not a lot of randomized
21:43controlled trials of weight neutral
21:46health interventions and a big
21:48part of that is that so much of
21:49the funding is earmarked only for
21:51quote UN quote obesity treatment and
21:53prevention which is a huge issue.
21:55But Lindo Bacon ET all did a
22:00randomized controlled style trial.
22:02They looked at weight neutral
22:03intervention versus a behavior
22:04based weight loss intervention.
22:05It was a six month RCT with
22:07two years of follow up.
22:09At six months,
22:1041% of the diet group had quit and only
22:128% of the weight neutral group had quit.
22:15At two years,
22:1650% of both groups returned for evaluation.
22:19Among the weight neutral group,
22:20they had maintained their weight,
22:22improved all outcome variables
22:23and sustained the improvements.
22:24Over 2 years,
22:25the diet group had regained their weight
22:28and little improvement was sustained,
22:30which is what the previous
22:32research would tell us.
22:33So what we're talking about
22:34here is a change in focus.
22:36Instead of focusing on manipulating the
22:37weight of fat patients and focusing on
22:39trying to figure out how to quote UN quote,
22:41treat existing in a higher weight body,
22:44we focus on supporting people's health
22:45at their current size in research,
22:47in tools and equipment,
22:49in practitioner training,
22:50from compassion and anti stigma
22:52to practice right.
22:53What do we have?
22:54What does the research actually tell
22:56us is the best thing for our patients
22:57who are higher weight to advocacy,
22:59which is advocating for the research
23:01We don't have right in advocating
23:03for equality in structural bias,
23:06including things like chairs and Mr.
23:08IS and blood pressure, cuffs and gowns.
23:11Best practices and informed consent
23:13around weight loss interventions.
23:14True informed consent.
23:17So best practices,
23:18sorry,
23:21best practices include weigh in only
23:24when medically necessary, right?
23:26Rather than routine weigh insurance
23:28between no 'cause patient disengagement,
23:31allowing patients to decline with no
23:33pushback, and considering signage,
23:34and absolutely never offering
23:35to guess a patient's weight.
23:37The first time this happened to me,
23:38I was so surprised.
23:40I literally said this is not the County Fair.
23:42You're not guessing my weight today.
23:44And now what I say is either a number is
23:46medically relevant or it's guessable.
23:47And since you've told me it's guessable,
23:49I know it's not medically relevant.
23:53Look for inequalities and solve them.
23:54In what ways are higher weight people
23:56not having the same experience
23:58in a space that you're in?
24:00Right? Are there chairs that
24:01would accommodate folks, sturdy,
24:03armless chairs in love seats?
24:05Are there gowns?
24:05Are there blood pressure cuffs?
24:06Is there only one thigh cuff?
24:09And so anytime a higher weight patient
24:11needs their blood pressure taken,
24:12everybody has to run around and try
24:14to find that one thigh cuff, right?
24:16That's a procurement issue that's
24:18pretty pretty easily solved if you're
24:20tempted to prescribe weight loss,
24:22asking ourselves, OK, well,
24:23what would we do for a thin
24:25person who has this health issue?
24:26And have we tried that for this patient,
24:30choosing medications based on
24:32therapeutic effects first,
24:33not necessarily just weight impact 1st and
24:36also making sure to get informed consent.
24:39I'm hearing from a lot of patients
24:41now who are being told to try the new
24:43GLP one agonist weight loss drugs and
24:45when they ask about side effects,
24:46they're being told, well all drugs
24:48have side effects and it's no big deal.
24:50That is not an informed consent conversation
24:53creating a list of accommodating options.
24:55If you know that your facility
24:56doesn't have a large bore MRI,
24:58find out proactively what facility
25:01does and have a list of these things
25:03so that instead of just setting
25:04the patient out and saying we can't
25:05accommodate you saying here's the space,
25:09that can't.
25:10All right, so I'll finish this up
25:11and we'll go to the interview.
25:12I just want to say,
25:12even if I'm wrong and I have to
25:14say that right,
25:15every scientist has to say that even if
25:18higher weight patients could all become thin,
25:20even if by becoming thinner
25:21they would all become healthier,
25:22higher weight patients would still deserve
25:24equal accommodation and access to the world,
25:26including healthcare.
25:27Fat people have the right to
25:29exist without shame, stigma,
25:30bullying or oppression.
25:31It doesn't matter why they're fat.
25:33It doesn't matter if their
25:34health impacts of being fat.
25:35It doesn't matter if they could
25:37or even want to become thinner.
25:38The rights to life,
25:39liberty,
25:39and the pursuit of happiness are
25:40not and should not be size dependent.
25:44All right, so you're welcome to contact me.
25:46You can e-mail me, you can message me,
25:48you can find more resources.
25:49The Health at Every Size health
25:50sheets are weight neutral,
25:51diagnosis specific care guides.
25:52So you can literally download
25:54like Fatty Liver and see OK,
25:56what's the weight neutral
25:57option for caring for that.
25:58There's also a resource in research bank,
26:00so if you like me or a mega nerd,
26:02that's a good place to kind of dig in.
26:04And then Wade and Healthcare is
26:05my newsletter where I talk about
26:06these things pretty much endlessly.
26:07So thank you.
26:08I know this is a lot of information fast.
26:10Do please feel free to reach out to
26:11me with any questions or thoughts.
26:13And I'm looking forward to our interview.
26:38Can you guys hear me?
26:40Fantastic. Yours is working.
26:42I think. So. Can you hear me?
26:44Perfect. Thank you.
26:46So I want to start by saying that that
26:48talk was so inspiring and eye opening. I
26:51really appreciate it. That's why I was
26:53like you guys have to give her a hand.
26:54That's amazing. Thank you.
26:57And so I have a handful of questions
26:59I want to ask you and some of
27:00them you already touched on,
27:01but I'm going to give you the
27:03opportunity to elaborate.
27:04Thank you. So first,
27:06a topic that is probably
27:08on a lot of people's minds,
27:10and if it's not,
27:11it should be is the GLP one
27:15agonist that you mentioned,
27:17drugs like Ozempic.
27:18Can you talk about how the
27:20introduction of those drugs and
27:21sort of the frenzy around them has
27:23affected higher weight people?
27:24Sure. So I think they've really changed
27:27the conversation around the idea of
27:29weight loss and weight management and
27:30I think that's happened prematurely.
27:32Sort of a sub specialty of mine is
27:34the ways in which the weight loss
27:36industry works to influence and
27:38manipulate the healthcare industry.
27:39And I think there's a lot of that
27:41here to go back and just give
27:42a little bit of context.
27:43So Novo Nordisk and Eli Lilly,
27:44who are the two big players right
27:46now with the GLP One agonist,
27:47though there are more coming.
27:49We're also big players in insulin
27:51and price gouging on insulin.
27:54And they did that through
27:55something called shadow pricing,
27:56where they look and see.
27:57And as their competitor
27:58increases their price,
27:59they increase their price
28:00sometimes within minutes.
28:02And that's how the price of
28:03insulin went up and up and up.
28:04And so as they were forced to
28:06bring down the price of insulin,
28:07Novo Nordisk CEO said he was going to quote,
28:10take a bet on quote obesity.
28:13And so when Wagovi was approved,
28:15which is the Somali tide,
28:17the form of Ozempic,
28:19that's for weight loss,
28:20they promised their shareholders
28:22the fastest ever launch of the
28:24drug and they did exactly that.
28:25And so there's been a huge marketing
28:28push and everything from paid speakers
28:31who are doctors and researchers
28:33who are putting out research,
28:35who are advocating in the papers,
28:37often without disclosure,
28:38to their own marketing around this,
28:40to their advocacy groups that they fund.
28:43So there's been a huge push.
28:45And the thing about these
28:46drugs that's important,
28:47first of all,
28:48they are Type 2 diabetes drugs
28:49with a side effect of weight loss.
28:51And so they are dosed and titrated very
28:53differently when dosed for type 2 diabetes.
28:55The goal is to give the minimum dose to
28:57get glycemic management and to minimize
29:00side effects windows for weight loss.
29:02The goal is to maximize side effects and
29:05you can't do that without maximizing
29:06all dose dependent side effects.
29:08We only have two years of data
29:11on these drugs at that dose.
29:13For Ozempic until just a year,
29:15two years ago the maximum
29:17dose was 1 milligram.
29:19For the last two years the maximum
29:20dose has been 2 milligrams.
29:21Well,
29:22Govi is 2.4kg,
29:25so we've got a bunch of people on
29:26a mega dose of a type 2 diabetes
29:28drug with only two years of data.
29:30We know from their research that
29:31when people go off the drug they do
29:33regain the weight pretty quickly.
29:35But also even their own two year
29:36research shows that at the end of two
29:38years people who stayed on the drug,
29:39their weight is ticking up.
29:42Also about 10 to 15% of people
29:44don't lose weight on the drug
29:45and in the tirzepatide study.
29:47So there's a thing that happens
29:49in weight science research where
29:50words that mean things get new
29:52and interesting definitions.
29:54So in the tirzepatide study,
29:55maintained weight loss meant
29:57gained back less than 20%
29:59of the weight by the first year, right.
30:03So they did a 36 week treatment and then
30:05they observed for the next 52 weeks,
30:07some people went off, some people
30:08stayed on and so maintained weight loss
30:10just meant they were regaining slowly,
30:12which is a little bit questionable to me.
30:15And so I my concern with these drugs is
30:17that they do have serious side effects,
30:19sometimes fatal side effects.
30:20And I'm very concerned that we're
30:23headed toward another Fen ven
30:25where we're so and and I again,
30:28I don't think people are doing
30:29this to harm higher weight people,
30:30but I think people have spent their careers,
30:32we've got this paradigm entrenchment
30:34that like we have got to get higher
30:36weight people to lose weight.
30:37And we have absolutely failed at
30:39every intervention we've tried.
30:40And Oh my God,
30:41here's the thing that quote UN quote works.
30:42So put everybody on it And the drug
30:45companies are doing a really good job
30:47of working hard to expand their markets
30:49progressively older and younger populations,
30:51progressively lower BMI populations,
30:54often using this idea of quote UN
30:56quote weight related conditions.
30:58So I'm,
30:58I'm very concerned that we're not
31:00having a full discussion about this and
31:02we're really jumping the gun and that
31:03a lot of people are going to get harmed.
31:07Thank you so much, So much to unpack here.
31:09It's a lot. Yeah. So I want to
31:13sort of dig into the culture of
31:15weight loss and the war on obesity.
31:20Can we talk about when that started
31:22and I asked that question because
31:24you showed us some excellent studies
31:26that showed a lack of effect of
31:29dieting and weight loss programs on
31:31the health of higher weight people.
31:33And some of those studies are old.
31:36I mean from my perspective,
31:37you know, 2003, 2013.
31:41So the only reason why studies
31:44like that haven't taken hold
31:45and aren't more widely discussed
31:47must be a cultural reason.
31:49So can you tell us what is the war
31:52on obesity? When did it start?
31:53Why did it start?
31:54Yeah. So to go way back the when,
31:59the World Health Organization classified,
32:01quote, obesity as a disease,
32:03that meeting was paid for by the
32:06International Obesity Task Force.
32:07The International Obesity Task Force
32:09was funded by two drug companies who
32:11had weight loss drugs coming out.
32:12They asked The Who to have the meeting
32:14and who said we don't have money
32:15for that And they said no problem,
32:16they paid for the meeting,
32:17they drafted the statements and then
32:20they bypassed the Who's editorial
32:21review and sent it out to health
32:23ministers of over 100 countries.
32:25And then the committee for the NIH
32:28said that they felt pressured to
32:30conform to the Who's definitions.
32:32And also the committee for the
32:34NIH had nine people and seven of
32:36them had like huge financial ties
32:38to the weight loss industry.
32:40And that committee was chaired by someone
32:41who was a former executive director and
32:44current board member of Weight Watchers.
32:46So the weight loss industry has been in
32:48it since the beginning and continues to
32:50be in it in a lot of different ways.
32:52And then Richard Carmona,
32:54who was the surgeon general at the time,
32:58said that obesity was a bigger
33:01threat than terrorism.
33:03And so that was sort of what started
33:05the the whole war on obesity.
33:07We need this global war on obesity
33:09and and the ridiculous notion that
33:11you can want to eradicate fatness
33:14without stigmatizing fat people,
33:16right, which is simply not possible.
33:19And so this whole war on obesity
33:22at that point,
33:23that's when we saw the money get
33:25earmarked only for research around,
33:27quote UN quote,
33:28obesity treatment and prevention where
33:30it's incredibly difficult to fund
33:32anything that doesn't pathologize
33:34higher weight bodies and doesn't focus
33:35on manipulating the size of those bodies.
33:37That is when we started to see this
33:40huge global conglomerate of weight loss
33:43companies and the sort of astroturf
33:46organizations they funded, right?
33:48The Quote Obesity Action Coalition.
33:49When they were pushing the AMA to make,
33:51quote, obesity a disease.
33:53They had 10 platinum sponsors,
33:56all of whom were weight loss companies.
33:59Now they're down to 1 platinum sponsor.
34:01It's Novo Nordisk.
34:02They gave them about $600,000 last year.
34:05And the OAC lobbies heavily for
34:08insurance coverage of NOVOS drugs.
34:12Right?
34:12So you've got this incredible mixing often,
34:16not clearly,
34:18right.
34:19A lot of what Novo is doing with
34:20the GLP ones is taken right out
34:22of the playbook that Purdue Pharma
34:24used for its Oxycontin promotion.
34:26And it's tough.
34:27You can't talk about this for more than
34:28like 5 minutes without starting to
34:30sound like a tinfoil hat conspiracy theorist,
34:32because it is in many ways a conspiracy,
34:36right?
34:36And again,
34:36I think a lot of the people are who
34:39are part of this are well meaning.
34:40I think there are some people who are
34:43doing this for money and don't care much,
34:45right?
34:46We're talking about a company
34:47that price gouged insulin.
34:48So I think everything that
34:49Nova and artist does has
34:50to be viewed through that lens.
34:52And so now we've got people saying,
34:54oh the war on obesity isn't right, right.
34:56We don't want to stigmatize fat people,
34:58We just want to eradicate
34:59them from the earth,
34:59but like in a non stigmatizing way.
35:02So I think that that's sort of changing.
35:05They're also now.
35:06So many people are now falling
35:08all over themselves to say,
35:09oh, behavior based weight loss
35:12interventions don't work.
35:13People in my community have been screaming
35:15this from the rooftops since the 40s, right?
35:18And now the weight loss companies are like
35:21the last seven people to learn this fact,
35:23but only in the service of
35:24now we have more expensive,
35:26more dangerous interventions to
35:27foist on this population rather
35:29than maybe now is the time to
35:31actually start having weight neutral
35:33comparator groups in our research,
35:35right.
35:36One of the things that happens in the
35:38research is that like for Novo's drugs,
35:39they compared their drugs to a
35:41behavior based weight loss intervention
35:42that they said in the introduction
35:44of their study didn't work.
35:45Comparing your drug to a known
35:47poor intervention is like nice
35:49work if you can get it.
35:50But if they had had a weight
35:51neutral comparator group,
35:52then we could really see could these
35:54benefits be achieved without all the risks
35:56of these drugs and the enormous expense,
36:00right.
36:00Same thing with them,
36:01weight loss surgeries,
36:02often their comparator groups are
36:03people who wanted weight loss surgeries
36:05and were denied the surgeries,
36:06not like a galloping shock that this
36:08group of people would have worse outcomes
36:10than the surgical outcome group,
36:11right.
36:12But we don't.
36:13We're not digging into the research.
36:15And so I think to come back to your point,
36:18sorry to get off a bit but the this
36:21war on obesity has been something that
36:24people could sort of get behind easily,
36:29right?
36:29Oh these are fat people.
36:30And again that goes back and I,
36:31I absolutely do not intend to white
36:33explain racism, racism to anyone.
36:34But I'm the person with the mic.
36:36So I just want to make it clear
36:38like this goes back to to the fact
36:40that fatness is tied with blackness
36:41and with people of color in this
36:44way that it's easy to to just
36:46blend those two things together
36:47in ways that they intersect and
36:49that allows that to to flourish.
36:52Right. And I as I was telling you before,
36:55I'm kind of new to the
36:57study of weight stigma.
36:59But what you described in terms
37:01of the relationship between racism
37:03and weight stigma is something
37:06that I think black women especially
37:08have personal experience with,
37:09with, even if they can't name it.
37:12So I'm really thankful that
37:13you mentioned those two books
37:15earlier in the presentation,
37:17and I've only read one of them,
37:19so I'm going to read the other.
37:20Awesome. Yeah, yeah. Sabrina,
37:22Strings Fearing the Black Body
37:24and Deshawn Harris and Belly of
37:26the Beast are the two. Thank you.
37:29OK, so you, you mentioned how some
37:33studies attribute health issues,
37:36various comorbidities to higher weight,
37:40but they're confounders
37:41that we didn't look at.
37:42And one of those confounders is
37:45discrimination against higher weight.
37:46Folks, can
37:47you talk about the discrimination
37:50higher weight folks that happen
37:52specifically in healthcare context?
37:54Yeah, so there's within healthcare context,
37:58we first have practitioner bias,
37:59both implicit and explicit, right?
38:02So implicit is subconscious bias.
38:03And we live in a world with a
38:05tremendous amount of weight stigma.
38:06So again, not a galloping shock
38:07if we've internalized that.
38:09And so it can be very easy to see
38:11somebody who has higher weight
38:13and start making assumptions
38:14about them subconsciously, right.
38:16So we've got that and then
38:17we've got explicit bias.
38:18And these are people who have very specific,
38:20they're aware that they have
38:22stereotypes and negative beliefs
38:23about higher weight people.
38:24They're aware that they're acting on them,
38:27right. And I think part of
38:28what's causing this, ironically,
38:29is this whole war on obesity because
38:32doctors were trained for years and
38:33years and are still in some cases being
38:35trained that if people try hard enough
38:37they can lose weight and keep it off
38:38with behavior based interventions.
38:40There is literally nothing to support that.
38:42There is no reason in in the
38:44research to believe that is true,
38:45but that's what they've been told.
38:47And so they assume I give this advice to
38:49my patients and they don't lose weight
38:51or they lose weight and gain it back,
38:53they're non compliant.
38:53And so they think, OK,
38:55these patients don't want to help themselves.
38:57Why would I want to help them?
38:58And so it spins this kind of,
39:00you know, weight stigma in that way.
39:02So there's that there's bias.
39:04But then there's also,
39:05like we talked about research,
39:07research that doesn't include
39:08higher weight people, right.
39:10Research that only looks at how to
39:12make higher weight people thinner,
39:14not how to make higher weight
39:16people healthier.
39:17Research that specifically excludes
39:19any kind of intervention that
39:21doesn't involve weight loss, right.
39:23So you'll see guidelines created and
39:25one of the exclusion criteria was that
39:26the study looked at health and not wait.
39:28So when we exclude that from the research,
39:31when we say we're not even going to
39:32look at that, that's a huge problem,
39:35right?
39:35So you've got research bias,
39:36then you've got structural bias.
39:38And structural bias is when the
39:39things that higher weight people
39:41need either don't exist for them
39:42or don't exist in a specific space.
39:44And so we go back to, like,
39:45is there a chair I cannot fit.
39:47I cannot physically sit in any
39:49chair in this room.
39:50So if I were a student here and this was
39:52a room that I had to be in for a lecture,
39:55I would have to try to get my own chair,
39:57which isn't always something that
39:59happens because it's If people's
40:01weight is not considered a disability,
40:03then like,
40:04the disability services office
40:04doesn't have to help.
40:05I see this.
40:06I work with people a lot in spaces like
40:08this who aren't being accommodated.
40:10I went to the law student who took
40:12every test of law school sitting on
40:14the stairs because the testing room
40:15didn't have a chair that would fit her
40:16and they wouldn't make an accommodation,
40:17right.
40:18So it's the chairs,
40:20it's the blood pressure cuffs,
40:21it's the gowns, it's the Mr.
40:23is,
40:23it's the ultrasound,
40:24it's the research upon which the
40:26best practices and the tools in the
40:29pharmacotherapies were created.
40:30This research typically excluded
40:32higher weight people and then when
40:35their outcomes aren't as good,
40:36we say, Oh well,
40:37it's because they're higher weight.
40:38Obviously they have to be made into
40:40thin people rather than saying
40:42they're being treated in a healthcare
40:44system that wasn't made for them.
40:45There's an interesting study Sun
40:47ET al In 2012 looked at the 2009
40:50H 1N1 outbreak and higher weight
40:52people had much
40:53worse outcomes in terms of
40:55severe outcomes and death.
40:56And so at the time all of the
40:58studies coming out, we're like, well,
40:59what's wrong with fat bodies, right?
41:00Is it low grade inflammation
41:01due to quote, obesity?
41:02Is it that it's acting in the adipose
41:04tissue and what Sun and all found was
41:07simply that thinner people got earlier
41:09antiviral treatment than heavier people did,
41:11and that when that difference
41:12was controlled for,
41:13the difference in outcome disappeared.
41:16And so I wonder how often that's happening,
41:19right, that what we're seeing is inequality
41:21of treatment that gets blamed on fat bodies.
41:24So there's that kind of bias.
41:26There's a bias where if research
41:28shows that higher weight people
41:29have higher rates of complications
41:31than they're denied surgery, right.
41:33And we see this with BMI based denials
41:34which I would describe as healthcare
41:36held hostage for a weight loss ransom
41:37that most people will not be able to pay.
41:41And this is,
41:42I'm as a as she had said in my bio,
41:45I'm a certified patient advocate and
41:47this is typically the work that I do
41:49as an advocate is helping people who
41:50have been denied care that they need,
41:52often denied a surgery that they
41:54need or want,
41:55and then referred to weight loss surgery.
41:58Right.
41:58So your knee surgery is too dangerous,
41:59but we'll be very happy to take
42:01your perfectly healthy digestive
42:02system and create a disease state
42:04permanently that we're cool with, right?
42:06So there's a lot of that as well.
42:07So there's so many different layers
42:09of weight stigma,
42:10and structural stigma is one of
42:12those things that all stigma needs
42:14systemic changes.
42:15But weight stigma that is structural
42:18requires systemic change.
42:20You can have a fully fat affirming
42:22practitioner.
42:22You can have a fully fat affirming patient,
42:24but if the MRI isn't big enough,
42:26that patient will not get care.
42:29And I was just giving a talk to
42:30APA program where one of the the
42:32folks said when they were working
42:33in the emergency room,
42:34they had a patient pass away
42:36because they couldn't get an MRI.
42:38And that in a thinner patient they
42:40suspected there would have been
42:41no problem in getting the MRI and
42:42that patient would have lived.
42:43So these weight stigma can be fatal
42:47and it requires systemic change to solve.
42:51Thank you. And my next question.
42:53My next question falls directly from
42:55what you were just speaking about.
42:57And you've already mentioned
42:58some of these best practices,
42:59but I'll give you the chance to elaborate.
43:01In addition to the larger MRI machines,
43:04the larger blood pressure
43:06coughs and the thigh coughs,
43:07what can we do to better accommodate people,
43:12higher weight people?
43:15So I think there's a number of things.
43:18First, getting educated on the options
43:20for weight neutral care, right?
43:22And part of that is just if you're
43:24tempted to prescribe weight loss to
43:25say what would I prescribe to a thin
43:28person in the same situation, right.
43:29And making sure that you at least
43:31give that as an option to the patient.
43:33Real informed consent conversations
43:36that include things about data like
43:39for weight loss surgery, again,
43:40the comparator groups are really problematic.
43:42There's very little data more than 10
43:45years out and the data that exists
43:47often suggest that if a patient
43:48is below their baseline weight by
43:50any amount and they are not dead,
43:51they are a success.
43:53They typically only look at adverse
43:55events for the 1st 30 days,
43:57even though they're creating a situation
43:58where we know that people can experience
44:00long term malnutrition and long term
44:02serious significant side effects.
44:03So if you're only tracking adverse events
44:05for 30 days and you tracks, you know,
44:08improvements for a year and then you say see,
44:10this is a great idea,
44:11that's a huge problem and
44:13patients deserve to know.
44:15We don't really have much data after that.
44:18We're not sure what will happen,
44:20but we know, for example,
44:21that if you get this ruined,
44:23why you won't be able to meet
44:24your nutritional needs with food.
44:25I was recently on a panel with a woman
44:27who had that surgery and then very
44:31unexpectedly experienced homelessness.
44:32And so she knew she could not get
44:34the nutrition she needed without
44:35her supplements and she could not
44:36afford her supplements and there was
44:38literally nothing for her to do, right?
44:41So making sure that patients
44:42understand all of these things,
44:44there's I think sometimes what happens is,
44:46and again I think it comes often
44:48from a really well meaning place,
44:49but there's a paternalism that happens
44:52where the practitioner believes that
44:53this is the best thing for the patient.
44:56The practitioner perhaps has implicit
44:57bias that says if a patient is fat,
44:59then they're not smart enough to make
45:01decisions for themselves or obviously
45:02they're making poor decisions for themselves.
45:04So I've got to convince this
45:06patient to do what's best for them.
45:07And so maybe one of the ways I do that
45:09is I kind of hold back on that informed
45:11consent conversation and I say all
45:13medications have side effects which
45:14is both true and completely unhelpful
45:17in an informed consent context,
45:19right.
45:19So it's we've got to be having
45:21these conversations,
45:21we've got to be offering weight neutral
45:24options and we've got to be clear,
45:25look there are people of all sizes
45:27who have your exact same presentation
45:29and here's what we offer to people
45:32who are quote UN quote normal weight
45:34to whom we don't suggest weight loss.
45:36This is what we offer and offering
45:37those things to patients as well,
45:41excellent. So I want to take this time to
45:44open the floor to questions and
45:45for the people in the room,
45:47if you could just raise your hand,
45:48I'll bring you a microphone and we'll get
45:50some of the questions on Zoom as well.
45:55OK. We've got a couple questions. I'm coming.
45:58I'm so excited. This is my, I do the talk,
46:00so I can do the Q&amp;A. So this is awesome.
46:06Hi, thank you for coming to talk to us.
46:09I I'm curious for for patients who
46:11say that they do want to lose weight,
46:13is it like, is it ever ethical for
46:16healthcare providers to help them do that?
46:18That's a great question.
46:19I think the first thing to do if a patient
46:22wants weight loss is to ask them why.
46:24And they will probably be surprised
46:26because this has probably
46:27never happened to them, right.
46:28They say you won't weight loss.
46:29I I won't weight loss the practitioners,
46:31because of course you do and then you
46:32just go on and usually the answer to why
46:34will fall into one of three buckets.
46:36They're trying to cure or
46:37prevent health issues.
46:38They're trying to increase mobility
46:40or ability or they're trying to
46:42escape weight stigma and it may
46:43be one or all of those buckets.
46:45And so for the first two buckets,
46:47we can offer weight neutral options, right?
46:50For both of those things,
46:51there are people of all sizes who
46:53have the same mobility and ability,
46:55who have the same cinematology
46:56and cardio metabolic profile.
46:57So we have weight neutral options
46:59and we can offer those.
47:01We can also offer weight loss,
47:03but we have to be honest about things
47:05like failure rates and the possible harm.
47:08And then the third bucket, weight stigma.
47:10That's the tough one,
47:11because weight stigma is real and
47:13it impacts people in very real ways,
47:15and their life would be better if they
47:17were thinner because of weight stigma.
47:19The problem is we don't have real
47:21good ways to make people thin.
47:23And so,
47:23again,
47:24I think informed consent is really important.
47:26I think to the extent that it's
47:27within the scope of whatever you're
47:28practicing to let people know there's
47:30a whole community out there who are
47:31working and surviving and thriving
47:33outside of weight loss, right?
47:35There's the weight neutral community,
47:36there's the fat activism community
47:38and letting people know about
47:40those resources as well.
47:42And for me, so I'm both fat and gay.
47:44I came out in Texas in the mid 90s,
47:46which was a super interesting time to be out.
47:47And I did a lot of political work around
47:49queer and trans rights and at that time,
47:51in my personal experience,
47:52and this is still happening
47:53to way too many people,
47:55but that's when they told me
47:56like OK being queer as a choice,
47:57it's a bad choice,
47:58it's bad for you,
47:59it's bad for society and homophobia
48:00is terrible.
48:01So you should really try to be straight.
48:03And I never bought into that
48:04as a queer person,
48:05but I did buy into it as a fat
48:06person for a really long time.
48:08And So what I realized was that
48:09I had spent years fighting my
48:11body on behalf of weight stigma,
48:13and that what I wanted to do instead was
48:15fight weight stigma on behalf of my body.
48:17And that choice made all the difference.
48:19And so letting people know
48:21that that is an option,
48:22especially if that's why if
48:23they're saying like I want to
48:24lose weight because I want to,
48:25you know,
48:26shop at the normal clothing stores or I,
48:28you know,
48:29want to escape weight stigma in whatever way
48:30they're experiencing it,
48:31I think that's really important.
48:33In terms of ethics, it really that's
48:36I think a really personal question.
48:38And some people won't have the option
48:40to say like I don't offer weight loss.
48:42Right. But I think that at the very least,
48:44it has to be a serious informed consent
48:46conversation so that people know,
48:47especially if they're undergoing,
48:48for example, behavior based interventions.
48:51Look, 95% of the time people lose weight
48:53short term and gain it back long term.
48:54Up to 66% of people gain back
48:56more weight than they lost.
48:58If that happens to you,
48:59that is not your fault.
49:00That is what every piece of research
49:02we have says will happen long term.
49:04And so you're, you know,
49:05you're welcome to do that and I
49:08will be here if it doesn't work.
49:09And I want you to know it's not your fault.
49:11I think it's important to remember patient
49:14centered care is still fully rooted in
49:16ethical evidence based medicine, right.
49:18So if a patient said, oh,
49:19I saw on a TikTok that I can fly
49:20if I jump off my roof and I think
49:22that would really cure my knee pain,
49:23right 'cause flying will take the
49:25pressure like right off that joint.
49:27It's still not patient centered
49:28care to like endorse their plan to
49:30jump off their garage and flap their
49:31arms really hard right even though
49:33they believe it will help them.
49:35And so I think we still have to always
49:36be coming from do I believe that
49:38this is an ethical evidence based
49:40intervention and what informed consent
49:41do I need to offer to the patient.
49:45I actually have a question
49:47sure which I never ask.
49:50I liked your comparison
49:51for best practices
49:53worth and patients and as you referred to as
49:55fat patients. But
49:56my question is actually what could
49:59what would you say to fat haters
50:04the people that just for
50:06one reason or another
50:09don't see the comparison
50:10don't don't understand do
50:15you I'm sorry, can you elaborate
50:16a little bit people who well, I,
50:18I the one that came to my mind was
50:20the show that's on TV my 600 LB Oh
50:22yeah. And and or
50:24just people in general
50:25that will make a comment,
50:27those rude, horrible comments
50:30that they would probably
50:31not say to a thin person,
50:33but they will say or under their
50:35breath say to someone who is fat.
50:37Yeah, I mean, so no matter, again,
50:40no matter what people think about
50:42being fat and health, it does not
50:45justify poor treatment of fat people, right.
50:48And so to those folks, I say like,
50:50I hope you get some help to work
50:51out your issues and I hope that
50:53you learn to behave better.
50:59Hi, I don't have
51:01like a specific question,
51:01but I was wondering if you could
51:03talk a little bit more about larger
51:04bodies and reproductive health.
51:05I just think like
51:06in classes, I've learned that higher
51:09way and like higher risk of like
51:12gestational diabetes and also just
51:14in general the culture about like
51:17getting your body back like postpartum
51:19and all that. Yeah.
51:21So for this in general I recommend Nicola
51:24Salmon's work and I see Ola Salmon.
51:27She does incredible work around
51:29fat fertility and fat pregnancy.
51:30I've done some written some some stuff
51:32with her and done some workshops with her.
51:34So I think again when we
51:36go back to the research,
51:37often it doesn't suggest the risk
51:40is as high as it's believed to be.
51:43Also, again,
51:43there's not good research that
51:46shows like would behavior based
51:48interventions improve these outcomes?
51:50And so I just saw a study and I
51:52haven't broken it down yet,
51:53but it's like maybe you know quote UN
51:55quote obese pregnant people shouldn't gain
51:57weight at all or should maybe lose weight.
52:00And there's other research that says
52:01that's probably not the best idea, right.
52:03So it's always about breaking
52:05down the research I think and then
52:08managing the situation, right.
52:10People who have high risk for
52:11pregnancies for various reasons get
52:13pregnant and that is their right.
52:15And so, like,
52:15how do we manage and help those
52:17folks rather than saying, like,
52:18you shouldn't got a you shouldn't
52:20have gotten pregnant, you know,
52:21you shouldn't exist as a pregnant person.
52:24You don't deserve help any problem.
52:25And this is what I hear people say,
52:27like, yeah,
52:27I was getting an epidural and my
52:29doctor said that if I had any problems,
52:31it would be my fault and that I
52:32should never have gotten fat.
52:33Like, while they were giving the
52:35epidural out of scope.
52:37Inappropriate, right?
52:38So there's the way that weight
52:40stigma also impacts.
52:41Do people get all of their care?
52:42Do they skip prenatal visits,
52:43'cause they just cannot deal with
52:45another weight lecture, right?
52:46So there's all of that.
52:47And then the culture around getting like,
52:48pregnancy body back is like that bit
52:52of diet culture is so, like odd to me.
52:55Like you made a whole person, right?
52:57And all we're like is do you look
52:59like you looked when you were 18?
53:00Who cares?
53:00Like that diet culture thing is
53:02a whole extra separate trip.
53:13Uh, huh.
53:22Now it's on.
53:24And so for me as a
53:24second year medical student,
53:26I'm thinking a lot about the sort of
53:28long term consequences of patients
53:30who are under insured or uninsured.
53:32And I think if you look at the landscape
53:34of the American Insurance you know,
53:36scheme, one in 10 people are not insured.
53:39And if you look at you know the sort
53:41of breakdown of who those people are,
53:43they tend to be people who are you know,
53:44from lower socio economic groups,
53:46you know face you know different barriers,
53:48social determinants of health etcetera.
53:50And I guess my question is when
53:53you are charting and you write
53:56the word obesity in a chart,
53:58insurance companies from what I
54:00understand have sort of limited,
54:01my limited knowledge is that they do often
54:05elevate rates for people who are obese
54:07or those those sort of rates are are in,
54:10you know,
54:11they're informed by the charts.
54:13But I want my patients to be
54:15insured because people who are
54:17insured have better health outcomes.
54:19So you see the issue here, right?
54:20Like, what is the purpose of documenting
54:22that in a chart that then might,
54:25you know,
54:25affect someone's insurance status to the
54:27point where they are no longer insured
54:30and then they're jeopardized further by
54:32a system that they can't support them.
54:34So I'm curious, I guess,
54:34as a comment, how does charting,
54:37you know,
54:38maybe affect people's insurance status?
54:40And how does insurance status
54:42affect people's health as as
54:43people who present with obesity?
54:44So I don't know.
54:45Yeah,
54:46that's a great question.
54:47This has gotten a lot better
54:49since the Affordable Care Act.
54:50Prior to that when insurance
54:52companies were allowed to deny
54:53people for pre-existing conditions.
54:55You may or may not remember
54:56when that was the case,
54:57high BMI was considered a
54:59pre-existing condition.
54:59I personally could not get
55:01healthcare for 14 years because my
55:04body was considered a pre-existing
55:05condition that insurance companies
55:07were not required to cover.
55:09And so that's not the case anymore.
55:10They're not allowed to stratify
55:12based on body size.
55:13It's just smoking in age at this point.
55:16If they're under an Obamacare
55:18and Affordable Care Act plan,
55:19if they're doing the like independent
55:21private plans and they can,
55:22it's they can do whatever they want.
55:23Unfortunately for me,
55:25the the charting around,
55:27quote UN quote, obesity,
55:28first of all,
55:28it can trigger a lot of like
55:30communications with the patient
55:31that that patient may not want.
55:33Especially let's say the patient
55:34is higher weight and experiencing
55:35an eating disorder, right.
55:36And they're getting all of this
55:38weight loss stuff that can be
55:40incredibly triggering and problematic
55:41also like life insurance and
55:43long long term care insurance.
55:44Those things are deeply impacted by weight.
55:47I cannot get either because of
55:51my BMIA lot of people can't.
55:52So that's a huge problem.
55:54So, yeah,
55:54I think the the way that we chart
55:56size and the fact that it's been
55:59put into requirement like the MIPS,
56:00if you're working with with Medicare,
56:03one thing to know is that with
56:04MIPS if the patient refuses weigh
56:06in or declines weigh in,
56:07it removes them from both the numerator
56:09and the denominator of the miscalculation.
56:11So it does not count against
56:13the compensation.
56:14If that is removed,
56:15of course you have to have an
56:16EHR that will do that,
56:17which is a whole other thing.
56:19So I think in terms of like
56:20their health insurance,
56:21it doesn't necessarily cause an
56:23immediate problem in terms of
56:25like their cost of insurance,
56:27it doesn't make it go up,
56:28but it can create barriers,
56:30it can create step programs with
56:32certain insurances where like they're
56:33expected to try different things.
56:35And this is one of the huge concerns
56:37with the big push right now.
56:39Novo Nordisk and Eli Lilly are in
56:41a huge full court press to mandate
56:43Medicare coverage of their weight loss drugs,
56:46which is odd because Medicare is
56:48almost entirely people 65 and up.
56:50And that's a group of people where
56:51there's a large body of research
56:53that shows that they that weight
56:55loss creates increased mortality.
56:56So I have some concerns about that.
56:58They're also pushing.
56:59I just want to point out that access
57:01to these drugs for black and brown
57:04communities is a social justice issue.
57:05But black and brown communities were
57:07vastly underrepresented in their trials.
57:09Meaning this is basically just
57:11replicating a history of experimental
57:13medicine on people of color.
57:14And I think that's something that
57:15we need to keep pointing out.
57:17So I think that that in terms of charting,
57:19that's the bigger issue to me.
57:21I also just want to point out like there's
57:23there's the thing where they say, oh,
57:24people of lower socio economic status
57:26have a higher chance of being fat.
57:28But I also want to point out that
57:30people who are fat have a lower,
57:31have a higher chance of
57:33being lower economic status,
57:34right higher way people are hired less,
57:36paid less and promoted less than
57:38similarly qualified than people.
57:39One study found that higher weight women,
57:41the penalty was about $19,000
57:43over very thin women.
57:45So it's not like a small amount of money.
57:47So I think that we also always
57:48need to be looking at like the
57:49chicken and the egg problem there,
57:51which is way more than you asked for,
57:52but that's what I got.
57:55I thank you for a wonderful
57:56talk and advocating for patients.
57:59Could you please clarify a little bit
58:02the statement that you made about the
58:04increased risks of the GLP one medications?
58:07I think you had compared it to the Fen
58:10Fen from from Eris prior because you know
58:14there there's not as much long term data
58:17on the obesity dosings of the GLP ones.
58:21But there's plenty of long term data
58:23and big study data is using the same
58:25agents in diabetic trials and they,
58:28you know mostly for all agents have shown
58:31improvement in three or four point Mace.
58:33It's being used in heart
58:36failure kidney disease.
58:37So you know,
58:38those seem like they're quite beneficial
58:40for patients who have comorbidities.
58:42But what,
58:43what is the concern about the higher
58:46doses for obesity management?
58:49Yeah, so there there's a couple of concerns.
58:51The 1st is just that it's
58:53more than the maximum dose.
58:54So while we have data on the diabetes doses,
58:56that titration and dosing is very different
58:59for weight loss because the goal of
59:01that is to maximize side effects, right.
59:02So it has good health benefits and I
59:04agree that it's a solid type 2 diabetes
59:06drug and has other benefits as well,
59:08like the idea that we wouldn't
59:09give it at that dosage,
59:10but that we could keep cranking up
59:11the dosage to produce weight loss,
59:13to produce the side effect means that
59:16we're going to increase the rates
59:18of all those dependent side effects.
59:20So there's that piece of it
59:22that's concerning.
59:23There's also the concern that we don't know.
59:24Now one of the chief benefits of these
59:28drugs in terms of type 2 diabetes is
59:29that they only act when glucose is high.
59:31So there are fewer hypo incidents
59:33on these drugs.
59:33However,
59:34people who don't have type 2
59:36diabetes do have glucose spikes.
59:38And what we don't know and what some
59:39endocrinologists are asking is what
59:40happens when we give people a mega
59:42dose of a type 2 diabetes drug and
59:43they don't have type 2 diabetes.
59:45So when they have a normal blood sugar spike,
59:47does that then like hammer the beta cells,
59:50exhaust them sooner and create an
59:51earlier presentation or presentation
59:53that never would have happened of type
59:542 diabetes in that patient, right.
59:56We don't have an answer to that
59:58question because we don't have
59:59a long term data on of people on
01:00:01these high doses of the drug.
01:00:02So that's the concern in general.
01:00:04My Fen Fen concern is that
01:00:07it's not just the side effects,
01:00:08but the fact that we've got a medication
01:00:10that shows short term weight loss,
01:00:13right,
01:00:13that in two years weight loss levels
01:00:15off around like that 58 to 62 week mark.
01:00:17And then sort of studies with TIRZEPATITIS,
01:00:21studies with Novo Nordisk at 68 weeks,
01:00:23sort of a weight cycling.
01:00:25Thing happens with the mean weight
01:00:26loss and then at the end of two
01:00:28years weight is is going up and
01:00:30that's when the data stops.
01:00:32So that's a concern.
01:00:34The fact that their own 100 year
01:00:36patient adverse data shows that
01:00:37every 25 years people are looking
01:00:39at three serious adverse events and
01:00:42one adverse event serious enough
01:00:44to discontinue the medication.
01:00:46And again,
01:00:46because this is the same as weight
01:00:48loss drugs have always been,
01:00:49when people go off of it,
01:00:49they regain the weight.
01:00:51And Novo notice unbelievably
01:00:52profitable solution is will people
01:00:54just stay on this drug for life.
01:00:55And that's why we're seeing this redefinition
01:00:57of obesity isn't just a disease,
01:00:59it's a chronic lifelong relapsing remitting
01:01:01disease which covers all of their bases,
01:01:03right.
01:01:04If people weight cycle on the drug,
01:01:06well that's the relapsing remitting nature
01:01:07of the quote UN quote disease, right.
01:01:10It's chronic and lifelong like asthma.
01:01:11So you have to take it forever,
01:01:13except that it's not like asthma or
01:01:15type 2 diabetes because there's no
01:01:17real definition of obesity that is
01:01:21separate from other conditions, right.
01:01:23They. So there have been, if you look,
01:01:26there's no clear definition.
01:01:27We've had the BMI definition.
01:01:30But the the new definitions are like,
01:01:32oh, well, it's excess fatness that
01:01:34impacts health, which is not really the
01:01:36way you diagnose the disease, right.
01:01:37Because it's like saying, well,
01:01:39if you're 6 foot seven, you're just tall,
01:01:40but if you're 6 foot seven with hypertension,
01:01:42now you're medically over tall, right.
01:01:45And so the the thing with these,
01:01:47with these drugs that is concerning
01:01:49to me is that we're almost 70% of the
01:01:52population is eligible for them and
01:01:55they're pushing really hard to get
01:01:56insurance coverage for Medicare so
01:01:57that they can get private insurance.
01:01:59They're pushing really hard to get
01:02:00them formularies in other countries.
01:02:01And we don't have a lot of data.
01:02:03There are serious and including
01:02:05fatal side effects of these drugs,
01:02:07and we don't know what that will
01:02:08look like at this dose.
01:02:09And we are racing to get them to people.
01:02:12And that is what concerns me
01:02:13about another fan event.
01:02:17So we have time for one
01:02:19more question from the room.
01:02:24Anyone else have a question?
01:02:28Yes, Doctor Hall. Really
01:02:40loud. Karen's going to give
01:02:41it to you. I'm sorry. Yeah,
01:02:43they're bringing the mic.
01:02:43We are. We do have a bunch of
01:02:45people on Zoom. So hi Zoomers,
01:02:55can you hear me Perfect.
01:02:57Thank you for that,
01:02:58that very informative talk.
01:02:59I was wondering if you could
01:03:00speak a little bit more about,
01:03:02you know you mentioned the
01:03:04intersection between anti between
01:03:06weight related stigma and racism.
01:03:09But you also touched a little bit on
01:03:11how that may intersect with sexism,
01:03:13particularly with respect to,
01:03:15you know, I would say sort of the,
01:03:18you know, get your pre pregnancy
01:03:19body back and just this idea that
01:03:21you know somehow women are vessels
01:03:23and you know you have to gain weight
01:03:25to produce the the pregnancy.
01:03:27But then afterwards you know you better,
01:03:29you better get that body back in shape
01:03:31so that you can be desirable because
01:03:33otherwise like what's your value?
01:03:35Obviously I'm exaggerating,
01:03:36although sadly not that much.
01:03:39And then you know also you,
01:03:41you reference the correlation
01:03:42between weight and socioeconomic
01:03:44status and certainly you have more
01:03:46expertise in this area than I.
01:03:47But the what I've read on that
01:03:49actually that that's pretty gender
01:03:51specific and that for men the
01:03:54correlation between weight and
01:03:56earnings does not hold particularly.
01:03:58Whereas with women,
01:04:00there's a stark difference in terms of pay,
01:04:03in terms of what,
01:04:05you know,
01:04:05weight stigma and how like economically
01:04:08there's a huge advantage to being
01:04:10thin because the stigma is so great
01:04:12for professional women in particular.
01:04:15So I was wondering if you could
01:04:16just speak a little bit more
01:04:17about that and some of the work
01:04:18that's been done in that area.
01:04:19And and what are you,
01:04:21what do you think are some of
01:04:22the underpinnings of of of that?
01:04:23Because I think it's,
01:04:24it's really salient to
01:04:25this conversation as well.
01:04:27Yeah. So I'll do the last one first.
01:04:29A new report has just come out that has
01:04:31found that in fact the wage penalty
01:04:33for higher weight men is much worse
01:04:36than was recently believed. Right.
01:04:38So up till now there's been the general
01:04:40belief that the penalty isn't as bad
01:04:41for CIS men as it is for CIS women.
01:04:43And while that's true,
01:04:44it seems that it is much steeper for CIS men,
01:04:47especially if you start to
01:04:49striate by education.
01:04:50So the more education someone has,
01:04:52the the bigger the penalty is.
01:04:55So that data was for the for a
01:04:57long time was what was believed.
01:04:59And now it's seeming that that may not
01:05:01be true and that if we really striate
01:05:03there is a significant difference.
01:05:05And in general,
01:05:06I mean the weight loss in the beauty
01:05:09industries have made billions of dollars
01:05:11by creating the Sisyphean task, right?
01:05:13You have.
01:05:13We have a solution to sell you.
01:05:15So you have a problem, right?
01:05:17You should spend as much time and
01:05:19energy and money as you possibly can
01:05:21trying to attain a stereotype of
01:05:23beauty that is firmly rooted in thin
01:05:25white CIS het currently able bodied youth.
01:05:29And you will probably never get there.
01:05:30But that is not a good reason not to try,
01:05:33right?
01:05:33That has been the underpinning.
01:05:35And it's also why intersectionally,
01:05:37it creates so many problems for people
01:05:39with multiple marginalized identities,
01:05:41right?
01:05:41Because you've got all of these
01:05:43different aspects of the stereotype
01:05:45of beauty that will be unattainable
01:05:47for you and even people who attain it.
01:05:49It hurts people who attain that
01:05:51stereotype of beauty because then they
01:05:53live in terror of losing that right,
01:05:55the privilege that that creates,
01:05:56the opportunities that that creates for them.
01:05:59And so they tend to spend a ton of
01:06:01time and energy and money trying
01:06:02to maintain that privilege.
01:06:03So that's been the underpinning of
01:06:05diet culture for a really long time.
01:06:07And it's, you know,
01:06:08we can see it and pull it apart
01:06:10in each aspect.
01:06:10And the whole pregnancy body for
01:06:13people who can get pregnant is
01:06:14certainly a huge part of that, right.
01:06:16It's this market that they have
01:06:18of people who, you know,
01:06:19now you need to get your pregnancy
01:06:21body back and this, you know,
01:06:23this whole diet culture piece of it.
01:06:25But I think it's all sort of based
01:06:27on that Sisyphean idea of attaining
01:06:29that stereotype of beauty and that
01:06:31that's our responsibility and that
01:06:32we owe other people aesthetically
01:06:34pleasing by their own definition.
01:06:37And I think that that one of the
01:06:39things that I looked at in my own
01:06:42journey was what if perceiving
01:06:43beauty was a skill set?
01:06:45So if I don't see the beauty in someone,
01:06:46that's on me because we're not asked
01:06:48to develop that skill set, right?
01:06:49We're told this is beauty.
01:06:50Everything else isn't.
01:06:51This isn't beauty done easy.
01:06:53So what if the ability to perceive
01:06:54a beauty is
01:06:55a skill set that we don't develop?
01:06:56And so then it's my responsibility.
01:06:58And if somebody can't see the beauty in me,
01:06:59that's not on me, that's their
01:07:01responsibility to develop that skill set.
01:07:03And maybe they never do, but I don't
01:07:05take responsibility for that, right?
01:07:07I don't owe people aesthetically pleasing
01:07:08based on their definition and the same thing.
01:07:11I think often this gets intertwined
01:07:15with the idea of health, right?
01:07:17So whatever the current standard
01:07:18of beauty is is also what quote,
01:07:20UN quote, healthier fit looks like.
01:07:22And so I think it's really important
01:07:24that we're always saying health
01:07:25is not an obligation, right.
01:07:26Which I know because there's a the
01:07:28whole NFL where the goal is to risk
01:07:30your short and long term physical
01:07:31and mental health in the hope that
01:07:33someday your team will score enough
01:07:34points to win a shiny piece of jewelry.
01:07:36You're allowed to do that,
01:07:38but it does not prioritize the health.
01:07:40The sport of skeleton in the Olympics,
01:07:4180 miles an hour down an ice
01:07:43chute on a sled face first,
01:07:44does not prioritize the health, right.
01:07:47So there's that piece of the
01:07:48health is not an obligation,
01:07:50it's not a barometer of worthiness.
01:07:51It's not entirely within our control.
01:07:54And it's a really gooey,
01:07:55amorphous concept, right.
01:07:57And just like beauty,
01:07:58we tend to act like health is as simple,
01:08:00like you could throw a dart and hit it.
01:08:01That's healthy, right?
01:08:02It's a simple definition.
01:08:03I put people in and out of it.
01:08:04But when we look at individuals,
01:08:07it's so different.
01:08:08If you take for one example,
01:08:09somebody who has no chronic
01:08:11conditions versus someone who's just
01:08:12developed a chronic condition versus
01:08:14somebody who's been dealing with six
01:08:16chronic conditions over a decade,
01:08:17their concepts of what health and Wellness
01:08:19look like will be very different.
01:08:21But that doesn't make any of
01:08:22them wrong and just say, well,
01:08:23some people are healthy and
01:08:24some people are not,
01:08:25doesn't do a service to anybody.
01:08:28Rather than saying,
01:08:29OK,
01:08:29based on this person's personal
01:08:31goals and priorities and situation,
01:08:33what is it that they're looking
01:08:34for in terms of health?
01:08:35And I think that also can be
01:08:38ascribed then over to the idea of
01:08:40this beauty standard that is used
01:08:42and abused within the healthcare
01:08:43system and within the greater world.
01:08:48So we are unfortunately over time.
01:08:51But I just wanted to take the
01:08:52opportunity to thank you, Reagan,
01:08:54for coming to speak to us.
01:08:56It takes a lot of courage to try
01:08:58to push back against a cultural
01:09:00paradigm like the war on obesity,
01:09:02but that is the work of activism.
01:09:03So we appreciate you doing that work.
01:09:06And please give her a hand.
01:09:10Thank you very much.
01:09:13And again, thank you for
01:09:14all of the work you did.
01:09:15Thank you all for coming.
01:09:17It's been an honor.