“You Just Have to Keep Buying”: How Diet Culture Profits from Fatphobia

Summary

The Money with Katie Show: “You Just Have to Keep Buying”: How Diet Culture Profits from Fatphobia

Release Date: January 22, 2025

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Introduction

In the episode titled “You Just Have to Keep Buying”: How Diet Culture Profits from Fatphobia, host Katie Gatti dives deep into the intricate relationship between diet culture, fatphobia, and the burgeoning weight loss industry. Building upon the foundation set in Part One of the series on the economics of weight loss drugs, Part Two explores personal experiences, medical perspectives, and the broader socio-economic implications of GLP1 agonists like Ozempic and Wegovy.

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Background: Part One Recap

Katie begins by recapping Part One, where the show examined the inverse correlation between income and weight predominantly affecting women in high-income countries. The discussion highlighted how weight stigma adversely impacts women's earning potential and drew parallels between societal attitudes toward wealth and fitness. Notably, the episode referenced Tressie McMillan Cottom's assertion:

“Being fat can be hell. Selling to fat people is profitable.” (Timestamp [03:00])

The episode also touched upon the rise of telemedicine and compound pharmacies capitalizing on the weight loss drug shortage, and introduced Lily, who shared her personal journey with GLP1 agonists.

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Lily's Experience with GLP1 Agonists

Lily provides a candid first-person account of her ordeal with GLP1 agonists. Initially optimistic about rapid weight loss, Lily's enthusiasm turns to distress as severe side effects emerge after the third dose.

Key Highlights:

• Rapid Weight Loss and Side Effects: Lily reports losing 11 pounds in approximately two weeks, leading to extreme muscle fatigue and difficulty walking. She recounts:

  “I lost 35 pounds. I love bread.” (Timestamp [02:14])
  “Nothing's ever worked this quickly. This is a magic bullet.” (Timestamp [14:25])

• Medical Challenges: Attempts to seek medical help were met with dismissive responses from healthcare providers, attributing her symptoms to potential COVID-19 or other unrelated issues. Lily narrates the frustration of feeling unheard and unsupported by the medical system.

• Emotional and Physical Toll: The inability to maintain normal activities, coupled with emotional strain from worrying family members, culminates in Lily’s realization of the drug's adverse effects.

  “I didn't go to medical school, but I'm pretty sure this is not Covid.” (Timestamp [11:14])

• Final Decision: Ultimately, Lily decides to discontinue the medication due to the detrimental side effects outweighing the benefits.

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Dr. Mara Gordon on Diet Culture and Medicalization

Dr. Mara Gordon, a weight-neutral physician, offers a critical analysis of diet culture and its medical manifestations. She defines diet culture as:

“The cultural influences that make us feel like we always need to be shrinking our bodies.” (Timestamp [04:35])

Key Insights:

• Diet Culture as a Scam: Dr. Gordon vehemently criticizes diet culture, emphasizing its role in perpetuating the multi-billion dollar diet industry. She states:

  “I hate being a part of it as a doctor. That's not why I went into medicine.” (Timestamp [36:54])

• GLP1 Agonists and Diet Culture: While acknowledging the potential benefits of GLP1 agonists, Dr. Gordon warns against their commercialization as diet tools, advocating for their use in treating genuine health conditions rather than as solutions for societal fatphobia.

• Impact on Women: Dr. Gordon discusses how weight stigma uniquely affects women, intertwining with misogyny to influence areas like workplace earnings and societal perceptions.

  “Women are judged on their appearance in a way that men are not.” (Timestamp [38:28])

• Size-Inclusive Medicine: She advocates for a shift from weight-focused healthcare to a more holistic approach, emphasizing actual health metrics over body size.

  “What makes you feel like you need to lose weight? Or what are your goals in trying to lose weight?” (Timestamp [41:11])

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The Economics of Thinness and Accessibility

Katie and Dr. Gordon delve into the economic dimensions of thinness, discussing how societal pressures and economic disparities influence access to weight loss solutions.

Key Points:

• Class Signifiers: Body type often serves as a proxy for social class, with thinness associated with affluence and moral virtue.

  “The ideal itself is manufactured and that the goal of inclusivity should ultimately lead us to neutrality.” (Timestamp [67:00])

• Access Disparities: Despite the high cost of GLP1 agonists, those who theoretically benefit the most from them—individuals facing weight-related stigma—are often the least able to afford or access these medications.

  “Many people who can absolutely benefit from medications cannot access them because of insurance issues and because of cost.” (Timestamp [51:53])

• Comparative Analysis: Drawing parallels with other medical conditions like prediabetes, the discussion highlights how medical definitions can be influenced by economic interests, leading to over-medicalization and unnecessary stigmatization.

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Historical Perspectives on Fatphobia

The episode incorporates scholarly perspectives to contextualize current fatphobia within historical frameworks.

• Kate Manne's "Unshrinking": The book traces the medicalization of fatness to the early 20th century, intertwining it with racism and misogyny. Manne states:

  “Fatphobia wears a lab coat because it's dressed up as a medical fact in ways that I don't think reflect the complex relationship between weight and health.” (Timestamp [25:00])

• Sabrina Strings' "Fearing the Black Body": This work connects the aversion to body fat with the transatlantic slave trade, highlighting how thinness became a marker of racial and social superiority.

  “Middle-class and upper-class white women, they needed to watch what they eat... to show their Christian nature and also their racial superiority.” (Timestamp [27:09])

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Medicalization of Fatness and Conflicts of Interest

The discussion transitions to the problematic medicalization of fatness, exploring how economic incentives can distort medical practices.

Insights from Dr. Mara Gordon:

• Selective Medicalization: Dr. Gordon distinguishes between medical needs and societal pressures, emphasizing that GLP1 agonists should address bona fide health issues rather than enforce societal beauty standards.

  “The real issues are... access to fresh foods, walkable cities, safe green spaces.” (Timestamp [53:26])

• Physician's Role: She advocates for doctors to focus on objective health metrics and support patients in defining their own health goals, free from societal pressures.

  “My goal as a doctor is to help my patients, sort through the different variables, interpret the different data, but ultimately it's their decision.” (Timestamp [55:59])

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Final Thoughts and Analysis

Katie concludes with a critical examination of the notion that democratizing access to thinness through medications will alleviate cultural obsessions with weight.

Key Conclusions:

• Hierarchical Inclusivity: Allowing more people to attain thinness does not dismantle body hierarchies but rather reinforces them by making thinness more accessible to specific demographics.

  “They don't neutralize or challenge their accordant beauty or body hierarchy.” (Timestamp [65:08])

• Socioeconomic Indicators: Thinness continues to act as a class signifier, with access to weight loss solutions being intertwined with economic status.

  “The most important qualification for meeting the ideal is often just affluence.” (Timestamp [71:42])

• Health Implications: Stigma associated with body weight contributes to adverse health outcomes, often more so than the physical aspects of obesity itself.

  “The stigma itself can be as dangerous as, if not more than, the thing that it is stigmatizing.” (Timestamp [75:00])

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Conclusion

“You Just Have to Keep Buying”: How Diet Culture Profits from Fatphobia” offers a profound exploration of how societal pressures, economic interests, and medical practices intertwine to perpetuate fatphobia. Through personal narratives, expert insights, and historical analyses, the episode underscores the necessity of rethinking our definitions of health and the role of medicine in combating, rather than reinforcing, harmful cultural norms.

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Notable Quotes:

“Diet culture is a scam. I hate being a part of it as a doctor. That's not why I went into medicine.” — Dr. Mara Gordon [04:35]

“Being fat can be hell. Selling to fat people is profitable.” — Tressie McMillan Cottom (cited by Katie Gatti) [03:00]

“The stigma itself can be as dangerous as, if not more than, the thing that it is stigmatizing.” — Katie Gatti [70:00]

Transcript

[Katie Gatti]

Everybody.

[Dr. Mara Gordon]

These are violent criminals, so they're not.

[Lily]

Gonna go down easy. ABC Tuesdays Cops. Let's get this done. The rookie is back. We have two new rookies starting today. Howdy.

[Dr. Mara Gordon]

Being a cop is stressful.

[Katie Gatti]

24 7.

[Lily]

Every year on the job is different.

[Katie Gatti]

And training day, we have a serial killer at large.

[Dr. Mara Gordon]

Never ends.

[Lily]

We need an ambulance. The rookie. All new Tuesdays on ABC and stream on Hulu.

[Dr. Mara Gordon]

Diet culture is a scam. I mean, it's that simple. I think I sort of use a working definition of diet culture, which is amorphous and sort of constantly evolving. It's wily. But I think of it as the cultural influences that make us feel like we always need to be shrinking our bodies and that diet culture sort of depends on its inefficacy to exist. Diet culture is the multi billion dollar diet industry is a manifestation of diet culture. And by definition, all of these diets, Weight watchers, Noom, the keto diet, all the cookbooks, whatever. And in certain circumstances, I put GLP1 agonist in that category. In some circumstances I don't. I want to be really clear about that. But I think GLP1 agonists are and are not manifestations of diet culture. And we can get into that in a little bit. But all of this stuff, you just have to keep buying, literally. And if you stop being vigilant, if you stop paying for the app, the threat is that the weight will come back and you will face fat phobia.

[Katie Gatti]

Discover the power of rico.

[Lily]

Have you always had trouble losing weight.

[Katie Gatti]

And keeping on and you may lose weight.

[Lily]

Adults lost on average up to 12 pounds. I lost 35 pounds. I love bread.

[Dr. Mara Gordon]

And some lost over 46 pounds.

[Lily]

I love bread.

[Dr. Mara Gordon]

If you're one of the 70% of adults struggling with their weight, the problem isn't you. It's your health.

[Lily]

It's your health care. 70% of adults is struggling with their weight purse. There's the path to a range of personalized treatment options and compounded GLP1 injections.

[Katie Gatti]

Real change starts here.

[Dr. Mara Gordon]

It's your health care.

[Lily]

Welcome back to the Money with Katie show. I'm Katie Gatti. Toss in before we dive in, this is part two of our series the economics of weight loss drugs. And in part one, we talked about the relationship between wealth and thinness. We talked about how in high income countries, the inverse correlation between income and weight is borne almost entirely by women, indicating that weight stigma impacts women's earning potential. We also explored the parallels between our attitudes about wealth and fitness and how A deeply internalized belief in individual morality guides our attitudes toward everything from poverty to fatness alike. We reviewed the blockbuster success of the pharmaceutical companies who create these drugs. And we quoted a whole lot of Tressie McMillan Cottam, which I'm going to do again right now. To summarize the business portion of last week's episode, quote, being fat can be hell. Selling to fat people is profitable. End quote. We heard from a drug policy expert about the compounding pharmacies and telemedicine companies that are seizing the shortage moment. And we started to talk to a woman named L. Lily, who got on then off Mounjaro for weight loss and wrote about her experience for Jenny magazine. If you haven't heard it yet, we will link part one in the show notes for you. Today we are picking back up where we left off in conversation with Lily. Then we will talk with Dr. Mara Gordon, a weight neutral physician who deals with GLP1s. And lastly, I will give you my final thoughts and analysis on where I see all of this going. So Lily was just telling us why after a couple of weeks, her excitement about her GLP1 driven weight loss was beginning to sour.

[Katie Gatti]

I know that an egg is like 78 calories. If I cannot finish a 78 calorie egg for those are my two meals, like a half an egg and then a half an egg for lunch, that's starvation. Like that's not healthy. That's not everybody's reaction to the drug, but that was mine and like it could be dangerous.

[Lily]

You're a little bit like, feel like I should be able to eat more than this. So what happens next? You're physically having trouble eating. What were your other symptoms? If you had other symptoms?

[Katie Gatti]

I did. You know what's strange is I think because I had this kind of experience of having done the intermittent fasting. So I was doing things that were my, was my normal life. I was exercising as much as I had. I was going to work. I was doing all of the things and trying to force down whatever food I could and I thought it was okay. And then one day, like I said, I do like my normal long walk is a five mile walk. And I was at probably what I based on the time probably was about two miles into it. And suddenly the muscles in my thighs felt like I just run a marathon. And I've had similar feelings before in the summer and you're dehydrated and maybe you haven't been very conscientious about how much you, you know, water you've Drunk or how much food you've had before, you go and work out. And I. You feel weak. And that's what I thought I had done. I thought, like, ugh, I must not have had enough water. Let me stop. Let me slow down. I'll get some water and then continue on my way. And I kind of cut that walk short and went home and tried to, like, eat as much as I could. And then the next day, it happened even worse. I had walked a half a mile, and I felt like I wasn't sure I'd be able to get back home, which is a really scary feeling for somebody who's used to, you know, walking hours and hours and hours a day. That's my main mode of transportation. It felt suddenly very scary.

[Lily]

So what do you do next? You're like, okay, I don't think this is normal. I, like, can't go on daily walks. I'm not really feeling super healthy right now that I can't walk. What did you do next?

[Katie Gatti]

Well, I started to panic.

[Lily]

I think it was my first. My first response back to the subreddit.

[Katie Gatti]

Exactly, exactly. And I did, like, I really did do that. You know, people said things like, you have to make sure you're drinking an ounce of water for every pound you weigh. And that's a lot of water. A lot of water on a daily basis. And if the. The problem is I felt like I couldn't eat much, filling my entire capacity with water, then felt like I was playing a tricky game there. Like, am I drinking enough water? And. But am I taking all the space up in my stomach for food that I need? I called my doctor because I thought, like, you should not just be here suffering. Call your doctor. And I got through to him, and I explained what I was feeling. I had this, like, really extreme muscle fatigue, and I was starting to feel really unwell. And he. His response was, you know, well, have you vomited? And my answer was no. Do you have any pain in your. I feel like it was like they're. What they're worried about is pancreatitis. So it's like, you know, in your stomach, are you feeling any pain? And I wasn't feeling any pain. And then his response was, well, you're probably fine. And I thought, okay, well, maybe I am fine. Like, maybe I'm having a little bit too much panic about this. And maybe I felt, like, really worn out, and my brain is, like, taking this to a level that is panic and not reality. So I soothed myself with that a little bit, and I live in New York. I happen to have a car, and my best friend doesn't. And I was going to move my car for alternate side parking, which is something we have to do here. And so I texted her. I was like, hey, I'm gonna drive the car to the grocery store with the parking lot. Do you want to come? Just, you know, as a. As a friendly thing to do. And luckily, she said yes, and she came with me and we drove to the grocery store. And as I got to her house, I was feeling really shaky. And I let her know. I was like, hey, I feel a little bit funny. I'm just letting you know, like, what's going on? And we got into the grocery store, and I felt like I couldn't walk without holding onto the cart. I felt like I wasn't going to be able to stand up. And she quickly, like, ran around the store and got me a Gatorade. And I'm drinking it in the store, and I sit down for a while, and it's, you know, really starting to feel like I was going to pass out. And she took me home and, you know, put me in bed and, you know, set me up with all kinds of electrolytes. And we luckily were at the grocery store, so, you know, got some Power bar kind of things. Like, try to, like, get some protein and some calories in me with some hydration. Because at the time, I felt like I must just be dehydrated. That's got to be what's going on here. And I waited that day out. And I remember making dinner for my kids that night and trying to eat something, and my eyes filling with tears because I physically. I mean, little sliders, they're. They're teeny tiny. And I couldn't finish one. And my daughter noticed me. You know, they're teenagers. She noticed me being upset. She's like, you felt wrong. And at that point, I thought, like, okay, it's now. Like, I don't want her to worry about me. I don't want my kids to worry that something's wrong. Like, tomorrow I'm gonna go to the doctor. And the next day, I did. Like, I let them take themselves to school. And I tried to get myself to the emergency room. Cause it felt urgent at that point. I couldn't. It's a mile away, and I couldn't walk there. I couldn't walk myself there. I took a cab 1.1mile. And it was so busy and looked like it was gonna be hours and hours till I was seen. And I wasn't serious. So I ended up having that same friend come and meet me and walk me the four or five blocks to an urgent care instead. And the doctor there also said, oh, must be Covid.

[Lily]

They're like, I don't think so.

[Katie Gatti]

I don't think that's what it is, man.

[Lily]

You all not a medical professional.

[Katie Gatti]

But seriously, like, I didn't go to medical school, but I'm pretty sure this is not Covid. I was like, do the test. Fine, do the test. And he's like, nope, it's not Covid. I was like, I know it's because of this. And he's like, well that doesn't really happen. I was like, you don't know that that doesn't happen. Like, you know, I feel like I'm having this very, very strong reaction and I left there thinking I'm on my own. My own doctor thinks nothing's wrong, this urgent care doctor thinks nothing's wrong and I cannot physically walk. And I felt on my own.

[Lily]

We'll get right back to that conversation with Lily after a quick break. If you've got Those sweet, sweet RSUs or equity from your benevolent corporate daddy or you are just an extremely high earner, you might be dealing with what Jay and Maya faced before they started working with Domain Money. Their combined income was over $500,000 and despite their withholding, they still owed tens of thousands of dollars on their taxes. With the help of Katie Song at Domain Money, they came up with a three part solution. They found the real culprit which was their RSUs, they started a donor advised fund and they switched to pre tax contributions. All best practices for their specific scenario. So if you've got a complicated comp structure and you're not sure what to do, working with Domain Money's certified professionals will get you right and tight come tax season. Get started by booking a free strategy session with Domain Money and your flat fee advisor will create a step by step financial plan to help you achieve your goals. For clear advice, no hidden fees, and a trusted resource for all of your tax related questions, check out Domain Money and start building your financial plan [e-mail] domain money that's moneywithkatie.com domainmoney I'm a real client of Domain Money via Money with Katie. I receive compensation and have an incentive to promote Domain Money. These stories are based loosely on real scenarios of actual clients of Domain Money. We have changed some facts and circumstances for privacy reasons. Similar outcomes are not guaranteed. See Important Disclosures at DMNMNY co X and how long had you been on the drug by the time the symptoms had reached this level.

[Katie Gatti]

So you take a shot weekly. And I had taken the third one. And after the third one is when it started to get really feel this severe to me. Week one, great. Week two, still feeling good. And once I took that third one, it was really, that was it for me.

[Lily]

Interesting. And had you been losing weight?

[Katie Gatti]

Oh, yeah. And you know, after the fact, I've heard people say to me, that should have been a sign that you shouldn't have been losing weight as quickly as you had. I think I lost 11 pounds in 2 ish weeks.

[Lily]

Holy smokes.

[Katie Gatti]

I know. And I was excited. I was like, this is amazing. Nothing's ever worked this quickly. This is a magic bullet. Like, oh, thank God. Like in a couple of months, like I'll be down to, you know, my pre baby weight, you know, which was 17 years ago. But that, that should have been an indicator, I think, to doctors that either my dosage, even though I was on a starter dose, that my body was reacting to it in a way that was abnormal.

[Lily]

I see, I see. Okay, so you're on the starter dose, you're three weeks in when all this is happening. Clearly something has gone awry. This medication was causing you to lose weight really quickly. And at the same time, you know, you're becoming thinner, but you're also like, it was not like your health was improving. Does that make sense?

[Katie Gatti]

Yeah, no, it does. And there, there is that dichotomy because, you know, for me, I have polycystic ovarian syndrome. And one of the symptoms of that is weight gain and sometimes insulin resistan for a lot of people. And with that there's a whole host of symptoms that come, you know, as you gain weight, you increase your risk of heart disease, but is that it's a chicken or egg situation. And I was a skinny little kid and after my teenage years, probably, Yeah, I mean, 18 to 20, like after that, that time, you know, we just slowly, slowly gained weight over the years and then it kind of accelerated after I was 40. So I felt like the version of me that was that other body that I, that I, you know, in my head I still feel like I should be. Not that, you know, a 48 year old should be the size of the 20 year old you have in your head. But like, that feels like my normal set point. Whether I should or not. I'm not totally sure whether that should be normal, but it felt like my body is doing something Wrong. And I'm trying to fix it. Like, it doesn't feel like it's doing the right thing, but I. You. Your point is a good one. You know, there is. I'm not a huge. Not that I'm not a huge proponent of body positivity for anybody else, because I absolutely am for everybody else except myself, which I think is a really common thing.

[Lily]

I think that that's a common feeling, is intellectualizing these ideas, but being so steeped in a culture that has trained us to think differently to where we have internalized these ideas about how you should look, that the. It's like, well, the real me is like the hot, young, thin one. And they're just trying to get out. This me isn't the real me. That's the opposite. I'm just going to get back to her. I think that that that applies to so many things, too. Not just weight, but aging as well. And like, conventional beauty standards that we identify with our younger selves and then can sometimes walk down some damaging paths in our older bodies.

[Katie Gatti]

Absolutely.

[Lily]

Our fatter bodies. To be like, I want to get back to that person.

[Katie Gatti]

And there is a certain amount of, you know, accepting yourself as the older that you get that I'm hoping I get to that. Well, this is how my body is happy. I've. Everybody's kind of seen those memes about, like, my peasant ancestors died for me to have this, to be able to store this much fat and be able to survive the famine. And, like. Fair enough.

[Lily]

Oh, my God. So you. You mentioned in part three of this series that you were prescribed the medication without so much as a glucose test.

[Katie Gatti]

Yeah.

[Lily]

And that the ease with which you could get it. Which we've sort of covered.

[Katie Gatti]

Yeah.

[Lily]

Gave you the sense that this was, like, a breezy thing.

[Katie Gatti]

Yeah.

[Lily]

Because it wasn't. There wasn't some major gauntlet of health markers or indicators that you had to prove in order to qualify. I was just kind of like, yeah, let's try it. Here you go. I'm gonna pull it out of a fridge and give it to you. So I'm curious how you think about this experience now when you reflect on it.

[Katie Gatti]

Well, I definitely do think that it should be more difficult to get it. You know, I've talked to a bunch of people after I wrote the series, reached out to me also and said, oh, I'm on it, and I love it so much. And I'm glad for them. Like, if it's working for you and if you feel good, fine. But a lot of them are doing it through these, like, weight loss spas, like, med spas thing. Places are prescribing compounded versions of it. And that feels super dangerous to me. But it does feel like there should be some kind of check in, some kind of monitoring, some sort of observational data even that, you know, that a doctor has to, or a patient and a doctor have to talk together about, like, about how this is going. Like, if I had said to my doctor like, this is how much weight I've lost within those two weeks, like, maybe that would have been an indicator to him. Like, oh, wait a second. Like, actually that's too much. Like, maybe you're the kind of person who needs to only take it every other week. And when I went back for my physical this year and we talked about it some more, he said, oh, right, it's your reflux that probably caused that. Because we now know that people with reflux have, like, it exacerbates it and then it, you can't eat. Like, that would have been helpful to know, dude. Like, thank you.

[Lily]

Oh my gosh. But they're so new.

[Katie Gatti]

We're still, they're so new. Yeah.

[Lily]

Learning about them being used for this purpose at scale.

[Katie Gatti]

And I actually, one of the things that I did because it, because it is new and the, the only kind of side effects that are mentioned on the, you know, the pharmaceutical information or the, were the major life threatening ones is I reported my, all of the symptoms I had back to Eli Lilly because I thought, well, somebody's got to say something. Like, if somebody else has this same experience, I want them to know that it's not just them, it's not in their head. Maybe you should go to your doctor now if you've experienced and it's. Honestly, part of the reason I wrote the series was there weren't any negative stories. And not that I want anybody to not take it. Like, if it works for you and it, and you're happy and you feel good, take it. I, I, I still kind of wish I could, but I wanted people who weren't having a good experience to not feel alone because it's, it doesn't work perfectly for everybody.

[Lily]

Mm. Thank you very much. Or anything that you would like to say.

[Katie Gatti]

You can ask me if they change the drugs and you, you, you know, maybe it's something that you could get back on. Would you. Because I don't, because I don't know. Like, that is the, that's how ingrained the idea of like, you know, we were talking about the, the thinness healthy again, air quotes version of yourself. Like, I still feel like, man, because my body is messed up in this particular way. If there were a drug that could account for me having reflux or me being more sensitive to it, if I could have like a baby version of it, would I. And I don't know the answer. Yeah, if I can microdose a DLP one, like, would I. And the answer is maybe even though I've had like this terrible experience and I don't know what that says about me, but it's interesting.

[Lily]

I honestly think about that sentiment, first of all. I think it's very honest. So thank you for sharing that. And I think it's just evidence that it's incredibly hard to not be thin in our culture.

[Katie Gatti]

Yeah, it's. It's interesting. And I do, you know, I think that I've gotten a pass a lot. People have been always very kind to me. I'm incredibly outgoing and really social and like, gifted from my parents with like, looks that are approved of by society. And like, I've been always very. So I think I really do get like a pass. A lot of the times I'll say a pass from society because I, I know how to dress a certain way that hides, like, parts of my body that I don't want people to see. But the fact that I even do that, that like, that feels like something I have to do just to exist in the world feels so like I would just love to have the ease of just walking out the door and feeling comfortable, I think, in my skin.

[Lily]

That was beautiful. Thank you very much. When we come back, we'll talk more about the medicalization of fatness and the possible conflicts of interest therein. If you love iPhone, you'll love Apple Card. It comes with the privacy and security you expect from Apple. Plus, you earn up to 3% daily cash back on every purchase, which can automatically earn interest when you open a High Yield Savings account through Apple Card. Apply for Apple Card in the Wallet app subject to credit approval. Savings is available to Apple Card owners subject to eligibility. Apple Card and Savings by Goldman Sachs Bank USA, Salt Lake City branch member FDIC terms and [e-mail] Hot Take a Wireless plan's monthly bill shouldn't be jaw dropping. That's why Mint mobile has a 2025 resolution for you. Save some serious cash by making the switch. It's what I did. I made the switch to mint mobile in 2021 and I never looked back. Mint Mobile is dropping huge savings for the new year by offering any three month plan for only 15 bucks a month. Even their unlimited plan comes with this deal. All plans include high speed data and unlimited talk and text delivered on the nation's largest 5G network. You can even bring your current phone and number. New customers can also get half off an unlimited plan until February 2nd. To get your new wireless plan for just 15 bucks a month and get the plan shipped straight to your door for free, go to mintmobile.com that's mintmobile.com MWK $45 upfront payment required equivalent to $15 per month new customers on first 3 month plan only. Speed slower above 40gb on unlimited plan. Additional taxes, fees and restrictions apply. See Mint Mobile for details. So a complicated truth that emerged for me while I was learning about this topic is that for some people, access to a drug like Ozempic or Wegovy means access to health care. It means finally getting relief. And for others, its existence represents a barrier to proper care, or a barrier to and distraction from real vitality and health. This drug might be medically miraculous, and it also feels dangerous in a society that is as superficial as ours. And I wanted to know more about where our culture's obsession with thinness comes from. And I found feminist philosopher and author Kate Mann's work very useful for this. In her book Unshrinking, she writes about the history of the complex relationship between health and weight, and this part really jumped out at me. Quote, it wasn't until the early 20th century, when health insurance companies got involved, that there was this medicalization of having a fat body, which has often then been used as a pretext to justify racism and misogyny. Now fatphobia wears a lab coat because it's dressed up as a medical fact in ways that I don't think reflect the complex relationship between weight and health. It gives it a kind of legitimacy that makes it very hard to push back against. End quote. And there's a lot of interesting sociological work out there on the history and origins of fatphobia, like a book called Fearing the Black Body by Sabrina Strings, which uses meticulous research to trace an aversion to body fat, to the transatlantic slave trade, and a desire to draw a dividing line and build a hierarchy between white bodies and black ones. Here she is in conversation with Maddie Sofia for npr.

[Katie Gatti]

If you were like me, you might have assumed that there was some moment in between Marilyn Monroe and Twiggy in which, right, suddenly we suddenly became fatphobic in those three years.

[Lily]

But Sabrina started digging, looking at 19th century magazines like Harper's Bazaar. And what she found was troubling articles warning American women, well, middle class and upper class white women, they needed to.

[Katie Gatti]

Watch what they eat and they were unapologetic in stating that this was the proper form for Anglo Saxon Protestant women. And so it was important that women ate as little as was necessary in order to show their Christian nature and also their racial superiority.

[Lily]

So today you're far less likely to encounter a ladies mag that will tell you explicitly that hey gal, this is the proper body type if you want everyone to know that you are an upper class wasp. No, today you're much more likely to hear about the idea of fatness as burdening the health system or costing the system money in order to justify public concern. And as we covered last time, the data around health savings associated with weight loss drugs was relatively small and growing slowly, estimated to be around $50 per person per year in 2026 and around $650 per year 10 years from now. But as Kate Manne points out, we don't typically stigmatize other behaviors that create health system costs in the same way, like drinking alcohol, for example. It seemed fairly obvious to me during the research phase for this show that something beyond a commitment to healthy living was fueling the cultural discourse. And the idea of medicalizing fatness seemed especially relevant as the classification of certain bodies as good or bad provides a framework for consumption habits. If you have a, quote, unquote bad body, you gotta pay with your time, your money, your energy, your mental bandwidth to, quote, fix it. For example, in 2019, journalist Charles Piller reported on the phenomenon of the pre diabetic label in medicine, how it actually began as a, quote, public relations catchphrase In 2001, the Chief Scientific and medical officer of the American Diabetes association at the time told Pillar that they started using the term pre diabetic in lieu of the old name for slightly elevated blood glucose, which was impaired glucose tolerance, because they felt like the latter didn't raise sufficient alarm in doctors and patients. In his story for Science magazine, Pillar writes, quote, in medicine, prevention is usually an unalloyed good. But in this case, other diabetes specialists argue medical and epidemiological data give weak support at most for increasingly dire prediabetes admonitions. Quote, nobody really thought at the time how pre is pre diabetes for all these people, says Richard Kahn, who was the former chief scientific and medical officer who left ADA in 2009 and is now at the University of North Carolina in Chapel Hill. The World Health Organization in Geneva, Switzerland, and other medical Authorities have rejected prediabetes as a diagnostic category because they are not convinced that it routinely leads to diabetes or that existing treatments do much good. John Yudkin, a diabetes researcher and emeritus professor of medicine at University College London, describes the ominous warnings about prediabetes from ADA and CDC as, quote, scaremongering, okay? End quote. That was the entire passage from Pillars, reporting in Science magazine. He goes on to say that the CDC's own data, he says, shows that progression rates from pre diabetes to diabetes, it's less than 2% per year and the effect of a naming change and perhaps a broadened diagnosis wouldn't necessarily generate complicated outcomes. But the financial conflict of interests here are noteworthy. Pillar argues, quote, to lower blood sugar, ADA has increasingly advocated more aggressive measures such as prescription drugs, a push that has opened it to charges of conflicts of interest. Science magazine found that the group and its experts who promote aggressive treatment of prediabetes accept large amounts of funding from diabetes drug makers. So far, no drugs have been approved specifically for prediabetes, meaning that doctors are limited to prescribing diabetes drugs or other medications off label to treat the condition. But drug companies are testing dozens of drugs aimed at prediabetes in hopes of tapping a potential worldwide market of hundreds of millions of people. Given the avalanche of questionable spending and the wave of anxiety it has unleashed, Khan now says. Remember, Khan is the former chief scientific and medical officer. Khan now says he rues the day he helped promote the term pre diabetes, calling it a, quote, big mistake, end quote. So again, that is From Charles Pillars 2019, reporting in Science magazine. And honestly, the entire story is fascinating and I think worth reading because he traces the money throughout the system and sees who the largest beneficiaries of this tide of medicalization have been. But I particularly enjoyed his conclusion about where public investment might actually change people's health outcomes by addressing the health impacts of, quote, social stratification and failures of urban planning, end quote. He cites a 2011 study that examined the health outcomes of women in low income housing projects. One test group received a voucher for better housing and help with moving. And over the next 20 years, the rate of diabetes in that group which received a path to affordable housing was 25% lower than the control. I went searching for this study to learn more, and I ended up finding about a dozen more from the last 20 years just on the first page of Google that established a relationship between increasing access to affordable, stable housing and lower rates of diabetes diagnoses. And so it made me wonder, you know, there's been so much talk of public investment in the GLP1 space, whether paying for these drugs more widely will improve health outcomes, the cost of providing them versus the savings expected, and so on. But. But what if our definition of health and what promotes it is just too narrow right now? At this point, I wanted to talk to a physician who speaks with dozens of real patients every day about what this embrace of GLP1 agonists for weight loss means. And so I called Dr. Mara Gordon, a family practice physician in Camden, New Jersey, who's been thoughtful and cautious about the euphoric embrace and their relationship to diet culture more broadly. Okay, so Dr. Gordon, you wrote for NPR. Quote, for every patient who seeks out my weight neutral approach, I have 10 who have been sold the lie that losing weight will fix every problem in their life. That myth is nothing new, but it's been newly medicalized in the era of Ozempic and WeGovy, a class of medications known as GLP1 agonists. And patients are showing up at my door eager for the promised panacea. End quote. Okay, so in your role as a medical practitioner, you have been openly critical of diet culture and the weight loss industry. And I'm curious if you can tell us why that is.

[Dr. Mara Gordon]

Diet culture is a scam. I mean, it's that simple. I think I sort of use a working definition of diet culture, which is amorphous and sort of constantly evolving. It's wily. But I think of it as the cultural influences that make us feel like we always need to be shrinking our bodies. And that diet culture sort of depends on its inefficacy to exist. Right. So diet culture is, you know, the multi billion dollar diet industry is a manifestation of diet culture. And by definition, all of these diets, Weight watchers, noom, you know, the keto diet, all the cookbooks, whatever. And in certain circumstances, I put GLP1 agonists in that category. In some circumstances I don't. I want to be really clear about that. But I think GLP1 agonists are and are not manifestations of diet culture. And we can get into that in a little bit. But all of this stuff, you just have to keep buying, literally. And if you stop being vigilant, if you stop paying for the app, the threat is that the weight will come back and you will face fat phobia. And so diet culture is all of these sneaky different sort of tentacles of this way of thinking that just sneak into so many aspects of our life. And it's Always telling us to quantify, to measure, to restrict, to tame ourselves. Right. To sort of treat our bodies as these unwieldy creatures to be tamed. I hate being a part of it as a doctor. That's not why I went into medicine. It's not therapeutic, it's not healing, it's not centered on health. And those are all the values that drove me into medicine. And they're antithetical to diet culture, antithetical to health.

[Lily]

And healing, I think, is a really powerful way to think about it because of the extent to which it has been medicalized, per that quote. Right. Like, we've been kind of taught to think about these things as being necessarily good for us. Like, if it makes me smaller, it must also be making me healthier. And I think challenging or interrogating that assumption that to this point is so internalized that I'm not even sure it's conscious. But I think one of the reasons that we wanted to explore this today, and to your point about fatphobia, there was this statistic that was brought to our attention that the long associated correlation between weight in poverty in rich countries, that fatness was a byproduct of being poor, that that was like the causal relationship, that it's actually a lot more complex than that. And that recent findings identified that the relationship between income and weight is actually relatively flat for men in high income countries and it's in women where we notice this downward sloping line where income is inversely correlated with someone's weight. And so the suggestion therein is that weight stigma is uniquely punishing for women. And I'm curious if that statement resonates with you, if weight stigma being uniquely punishing for women, does that, Is that reflected in what you see in your practice and when you speak with your patients?

[Dr. Mara Gordon]

Oh, absolutely. Just your point about how deeply we've internalized this idea that, you know, making our bodies smaller is synonymous with being healthier. I think just so many people, their idea of what it means to visit a doctor is a gauntlet. Right. Where you sort of walk through the office, you're publicly weighed, your weight is commented on like just that that weight is so central to the experience of interacting with primary care for so many people. And it's part of my activist work and my writing that I'm trying to undo that. Right. That primary care is so much more rich and complex and I hope healing, than simply an audit of your body size. And I think so many people have come to think of it that way. So much so that, you know, I have thin friends who tell me that they won't even wear boots when they go see the doctor, lest they creep up into a BMI of 26 and start getting yelled at by their doctor. Right. This affects all of us. It affects big people, small people, all body sizes. And I think it has really widespread harmful ramifications for the way that we conceptualize our health and well being. But to your question about weight stigma uniquely facing women, I absolutely think that's true. Right. And I think that has to do with the way that fatphobia intersects with misogyny. And it absolutely has ramifications, I think, for the workplace as well and sort of pay over time. I think of it as being reflective of that. Women are judged on their appearance in a way that men are not. Right. And it's just so much more fundamental to the experience of being a woman that we're aware of the male gaze. Right. And we're aware of the female gaze too. Right. The gaze of other women, but that's often informed by the male gaze. I see this clinically. Right. So I have more women see doctors than men, period. Right. So women are more likely to go to the doctor than men, which I think is multifactorial and has to do with sort of health care stigma amongst men. Women often intersect with the healthcare system in reproductive health care settings that men don't necessarily. But absolutely more women comment on their weight than men. Right. So women will come in to see me and say, oh, you know, I gained five pounds, or oh, doc, am I healthy weight? Or this isn't good. Like my scale at home said I was this. And now the scale, like people are just really zoning in and fixated on it. And there's some selection bias in the way that I think about that. In my experience, you know, as a woman doctor, I probably attract more female patients. So I don't have like a official validated statistic about it. But in my experience that's absolutely true.

[Lily]

What do you say when a woman says, oh, I gained five pounds, like, can we talk? Am I a healthy weight? Am I healthy? In the same context of I gained five pounds, how do you then respond in that situation? What do you reorient their attention to?

[Dr. Mara Gordon]

Totally. Yesterday I saw patients for 12 hours, I probably saw about 30 patients. Probably had this conversation 10 to 15 times. And I will note, as a size inclusive doctor, I tend to not initiate those conversations. I always say, never say never. Clinical medicine is very. It's all about the patient in front of me and there are scenarios where sometimes I'll bring up a patient's weight, often in the context of rapid weight loss. But the way that I define size inclusive medicine is that I don't yell at my patients to lose weight. Which is not to say that I'm against using pharmacologic treatments for comorbidities that are often associated with weight. But I want to be really clear that GLP1 agonists are amazing medications. I'm very grateful to the researchers who developed them. I've been prescribing them since I graduated Medical School in 2015. They're very, very useful medications and they've helped many of my patients with glucose control, protecting their cardiovascular health, protecting their kidneys, protecting their liver. So, yeah, I'm not against them, but I am against this immediate assumption that any kind of weight gain is Pathologic and any BMI over 26 is Pathologic. I definitely encourage my patients to try to deconstruct some of those assumptions that they've learned over time, often in healthcare settings. Right. That a BMI over 26 means you're unhealthy. So when a patient comes in to see me and, you know, makes an often comment about their weight, I'll sort of gently pause and I'll say, what makes you feel like you need to lose weight? Or what are your goals in trying to lose weight? Or sometimes I'll say straight up, I'm a body positive doctor. I don't care about the number on the scale. I care about your labs, I care about your blood pressure. And I'm not able to undo the harms of medicalized diet culture in my 15 minute appointments with my patients. But I like to think that maybe I'm planting a seed, just that, hey, maybe this is more complex than meets the eye, and maybe there are more holistic ways I can think about sort of achieving well being in my life that aren't fixated on sort of achieving a specific number on the scale because that causes a lot of harm. And I think doctors really underestimate the harm that it causes. I can't tell you how many patients I've talked to, often people with clinically significant eating disorders who say, the day it started was when my pediatrician gave me a huge printout about how I was too fat and I needed to lose weight.

[Lily]

Holy cow.

[Dr. Mara Gordon]

Yeah, so that's, that's not an uncommon story. And I think even for many, many people who don't meet criteria for a clinical eating disorder. Right. Who, yeah. Aren't experiencing the severity of A clinical eating disorder. But I still think so many of us have disordered eating habits. And I think a lot of the origins of that kind of internalized fat phobia often starts in the doctor's office. And that's the work that I'm trying to undo.

[Lily]

Man, that's. Yeah, that's really something. You must feel like you're kind of swimming upstream a little bit or like swimming against the tide.

[Dr. Mara Gordon]

I do at times. And I kind of think of it as, like, slow and steady work. As I started talking about this publicly and working as an advocate about this work publicly, I went on TV last year, which was a new experience. That was wild. Yeah. I went on CBS Sunday Morning and I was talking about size inclusive medicine. And I had a whole influx of patients coming to see me after that. And I was sort of so excited. I was like, yes, we're spreading the gospel. Like, we're going to end fatphobia. And so many of those patients came in specifically asking for ozone back. And I was like, oh, I don't know if you were listening, but I realized over time and in conversations with many of these patients is that people are sort of having this cognitive dissonance. Right. Like, they want a doctor who doesn't judge them. They often still want to be smaller. Right. And I don't fault them for that. We live in a really discriminatory fat phobic society. And so for me to try to talk an individual patient out of attempting to lose weight through pharmacologic measures when we have widely available medications, it just. It isn't therapeutic. Right. And so I hope that slowly and surely I might be able to say, like, let's see if we can explore some broader definitions of health. Let's see if we can just open our minds collectively a little bit. But yes, it does sometimes feel like I'm. I'm swimming upstream for sure.

[Lily]

Yeah. Well, you know, part of what we were exploring in this episode is the business side and what we've started to colloquially call, like, the cottage industry of telemedicine and like, pharma startups that have sprung up around this phenomenon and the lengths to which somebody will go to get their hands on this stuff. And at first when we were talking about it, I was like, man, I can't imagine, like, mail ordering a syringe in a vial and injecting myself without having interface with a physician or without having, like, the quote unquote proper medication or like, the. More of a. What would feel like a legitimate medical touch point, like just Injecting myself with this stuff. And then I thought about it more and I was like, I think the fact that that is so popular and so widespread is actually more evidence of just how hard it is to live in a fat body in our culture. Like, just how much you would feel willing to do to ease that experience. And so I've heard this sense of internal conflict, ambivalence almost about this in pretty much every source I've found where it's a first person account of someone describing this decision to take the drugs. Because, yeah, there is a little bit of cognitive dissonance. There is a little bit of. I'm not sure that I should want to be thinner, but I do. Like, I would. I feel like my life would be easier.

[Dr. Mara Gordon]

Totally. I have some patients who are, who seek me out, who drive an hour and a half to come see me because they are radicalized towards body liberation and they want a body liberationist doctor. And some of those patients want to take Ozempic, right? Like that they are deep in an online culture of fat positivity and yet they still want to use these meds. And I totally respect that. And I have some patients who have never heard of body positivity or if they have in very broad strokes and have no ambivalence at all, like, why wouldn't I take this medication? And then I have some patients who live in bigger bodies who don't want to take the medicine or who try it and feel really sick when they use it and decide to stop it. I have one patient I'm thinking of who was very healthy by many sort of objective metrics. Young person, had normal glucose control, normal blood pressure, no evidence of hyperlipidemia. Very active, but had a BMI of about 30 who wanted to try the medications. And she was throwing up every day and she said, you know what? I'd rather be fat than feel terrible. And I get that too. Right. So I think that it sort of comes down to an individual's definition of what it means to be healthy. And I don't say this as some super abstract, like semantic talking point. Like, I, I think it's really practical. And sometimes I say this to colleagues and they're like, oh, don't be so, like politically correct. And it's so. It's not that I'm a total relativist, right? Like, I, I do think that if you're hemoglobin A1C, that's a measure of glucose control, right? It's how we diagnose diabetes. If your hemoglobin A1C is 12. You are very likely to develop significant complications from diabetes that can cause you a lot of harm. So I'm not trying to be all touchy feely, right. Like, I'm not a total relativist, but I do think that, that some people, they might say, hey, you know, my ability to enjoy food is really important to me. And food is so cultural, it's so social. And to feel like you can't eat with your family or to eat and practice sort of cultural traditions can be a source of real psychological harm to people. And so I think with that patient who decided that she was throwing up all the time, that she said, my mental health around food is so much more important to me than losing £15. And she got to make that decision, Right. Like, that was how she defined health. And so it's my goal as a doctor to help my patients, like, sort through the different variables, interpret the different data, but ultimately it's their decision. And for some people, losing 10 to 15% of their body weight through use of a GLP1 or GIP, GLP1 slash GIP agonist is how they define health. And I respect that. Right. That's, that's up to them.

[Lily]

Yeah. And there's this other layer or complication. I think that when I think about this question, there's the two money angles. The one money angle is like, how weight stigma impacts what somebody is able to earn. And therefore, as like the economist put it, this crazy sub headline which I think was absolutely clickbait, but it was like, it is economically rational for an ambitious woman to want to be as thin as possible. And I was like, well, that's bleak. As there's that money angle of this story. And then there's the money angle of, like, these drugs are very expensive, and therefore there is a certain class of people that will find it much easier to attain them than others. So access is a huge question around these drugs. And so I think when you, when you put those two puzzle pieces together, what you get is something very interesting where those who would theoretically, in this perfectly economically rational framework, those would theoretically, quote, benefit the most from access to them, are actually the least likely to have access to them.

[Dr. Mara Gordon]

Yes. And I sort of think about that from a medical framework. Right. I do think that many people who can absolutely benefit from medications cannot access them because of insurance issues and because of cost. I guess I, as a physician, like to think of it less as like, oh, what's their earnings? Good for you. Good for you.

[Lily]

I'M glad to hear that.

[Dr. Mara Gordon]

Yeah. I mean, that headline is kind of silly. And I mean, another way of putting it is like, yeah, it's rational to be as male as possible. Right. It's rational to be as white as possible. And so I think that angle there's. Honestly, yeah, we don't need to get into it because this is sort of outside my area of expertise. But, like, there are ways to make yourself more male, make yourself more white passing or white appearing. And what a bleak view of human diversity. I take a little issue with that. I do think that many people who would benefit from these medications are not able to access them. And the way that I think about it as a doctor is I think these medicines are really useful for treating a very narrow range of problems. Right. And they're important problems. Cardiovascular disease, kidney disease, diabetes, liver disease, risk of heart attack, risk of stroke, risk of heart failure. These are all really important. I really want to help my patients avoid them. And these medications can really help with that. They can help people lose 10 to 15% of their body weight if they take a high dose of the medications and they take it consistently. That's often not physically, in appearance terms, like the sort of Oprah transformation that people come to expect. I think that this idea that it's going to transform our economy, that it's going to close the gender pay gap, which is what's sort of implied by that article in the Economist. Like, people just.

[Lily]

That's good news, ladies. This one simple trick. All you have to do is be super hot.

[Katie Gatti]

Yeah.

[Dr. Mara Gordon]

And as long as we have a hierarchy of bodies, as long as we have a fat phobic society, that's the problem. It's not the fact that some people are going to lose £10 with this medication. Right. And I have patients coming to me sort of asking about versions of that very phenomenon all the time. They're like, oh, my marriage is bad. Like, I want Ozempic. And I'm like, this doesn't treat marriage conflict right? Or just, you know, people feel tired all the time. And I'm like, welcome to the club. They work in an Amazon warehouse and they're just so treated so terribly at work. They work crazy hours, they work night shifts. They're just expected to work in a way that's not compatible with human physiology. And Ozempic is not going to fix that. So I think people come in blaming everything on their body size. And really, it's the culture at large that we need to fix, rather than sort of shrinking, shrinking their bodies. Right. So in the sense, to return to your original question, I do really, really think that many people who don't have access to fresh foods, who don't have safe spaces to exercise regularly, who don't live in walkable cities, who don't have safe green spaces for their kids to play, those are the real issues, right? But often those people we see, cardiometabolic disease that is most likely related to those factors. It's also probably genetic, it's also epigenetic. But not being able to access vegetables is, is a, is a part of it for sure. And so if Ozempic can help them, I'm game, right? Even though the problems are much bigger. But often those are the very patients who can't access it, right? So the people who end up taking it are people who have a BMI of 26, no evidence of cardiometabolic disease, and just want to be thinner because they think it's going to help them get paid appropriately to work. Right? Or whatever reasons they have. So again, that's diet culture talking, right? That's diet culture telling us that everything is the fault of our bodies being unwieldy. And really there's so many complex issues at Play. And a GLP1 agonist will address a very narrow slice of them, which often have to do with risk of cardiovascular disease, kidney disease, which are real and important, but not the whole story.

[Lily]

It's so American to be like, let's construct a society that degrades your humanity at every turn. And then when you barely feel human, we're going to sell you a drug that we're gonna tell you is gonna make you feel like this situation that you're in is tenable again. But I appreciate the way that you put it of for some of your patients. You're not gonna say, well, yeah, you don't have access to these things that you need. And yeah, you're being treated like shit in an Amazon warehouse. And yeah, you're at now risk of car, but because, you know, those are the real problems. So I'm not gonna give you this drug that could help you. I mean, obviously that's not a rational response either. I'm curious then, for the patients that you've seen kind of experience getting on the drug and having it quote, unquote work, right? Like they don't have side effects that are causing them to get sick and they don't want to get off of it, and maybe they do have insurance that will cover it and like all the boxes are being checked of, like yes. Access. Yes. It's working. Yes, whatever. For those who are able to access it and use them for weight loss, what do they come back to you and report, like what happens next?

[Dr. Mara Gordon]

You know, So I must say it's really variable. I have a very general primary care practice. I practice in Camden, New Jersey, which is a low income community of color. And I would say the majority of my patients who are taking a GLP1 agonist are like older adults. Many of my patients are from the Dominican Republic, Puerto Rico, Spanish speaking. And I would say my typical patient is like a 70 year old lady who doesn't particularly want to lose weight, has diabetes. We'll have a sort of moderate bmi. Right. I have some patients who are on it who actually have a low BMI and the reason that they're taking it is for their diabetes. People with a moderate BMI between you know, like 26, 31 and they're often on lower doses, that's not necessarily causing a lot of weight loss and they can really help. That's great. It gets their diabetes under control, helps prevent their risk of developing cardiovascular disease from diabetes. Yeah, I would say like the vast majority of stories are not like Oprah style, before and after People magazine kind of thing. I do have some younger patients with. I'm thinking of one young man in particular who probably had a BMI of maybe 55, 60 when he started the medication and contrary to what all the public health messaging would have you believe, actually did not have a diagnosis of diabetes or hypertension. And he was one of the first patients I who was able to start taking the medications that I took care of, who asked about it specifically for the purpose of making his body smaller. He didn't have any medical conditions that we might also use the medication for. He's lost a fair amount of weight, I think. I asked him point blank the other day actually if he felt like it was a success and he said yes. He felt like he was more able to exercise regularly, which was. Has been really positive in his life. He has had some sort of mental health concerns around the way that people treat him differently now that his body's smaller. I think has been really dysphoric for him and has been challenging to grapple with. So that's something that we're working on together. We're treating his depression, he's in therapy. And that's sort of at one extreme. I have a lot of people who lose a little weight, 15 pounds, something like that. I some people who stop the medicine because they can't tolerate the side effects like that patient I was telling you about, people who feel like it makes them really sick to their stomach, and they don't feel like it's worth it. It doesn't actually make them feel healthier. Right. And so they feel like they want to discontinue the medications. That's a somewhat common scenario, too. So it's really all over the map. Again, the way that I think about it with my patients is I want to treat the objective evidence of disease that people have, right? So if they have a diagnosis of diabetes, if they have a diagnosis of fatty liver disease, if they have cardiovascular disease that's often associated with diabetes, I'll say, let's use this medicine for this purpose. And we'll define success by your hemoglobin A1C coming down. Or we'll define success by reduction of adipose tissue that's visible in your liver when we do an ultrasound. And those patients often aren't sort of. They don't read as fat to the world. Sometimes they do, sometimes they don't. Right. And I think I've really come to conceptualize sort of two forms of fatness, right? Like, one is sort of adipose tissue, often what we call visceral adipose tissue, which means sort of surrounding the internal organs, the liver, the heart. I mean, the liver is a really big one, and that can cause cardiometabolic disease. It can cause metabolic dysfunction. Often those people don't feel fat. They don't look fat. They say, oh, my body size is fine. Or like, I feel sexy, I feel good. And then there are sometimes people who sort of read as fat in different contexts, and they often have no evidence of cardiometabolic disease or sort of dysfunctional adipose tissue in their internal organs. And again, I think that sort of cultural fatness, as I call it, is often contextual. So that somebody might not be. They might be considered fat at, like, sorority rush, but they might not be fat at Thanksgiving dinner with grandma. And I think in medicine, we've really confused the two in a way that can cause a lot of harm, Right? And so I want to find better ways to help my patients diagnose those problems related to dysfunctional adipose tissue and treat them and take great care of them, and then try to shed all of the noise about, oh, I feel fat at the pool, but I don't feel fat when I'm at my postpartum yoga class, right? Like, it's. It's so contextual. And I think it really shifts based on the context in a way that people have a hard time understanding that that's separate from the medical conditions.

[Lily]

And it sounds like how I would summarize this philosophy is like you want to focus on real health outcomes and that you get better health outcomes when you aren't hyper fixated on this number that like sometimes correlates and sometimes doesn't to those health outcomes. So I assume you would recommend weight neutral healthcare to other people. But I know that insurance networks can be very limited and sometimes someone might feel sort of stuck with the options that they have based on the insurance coverage that they currently carry or can afford. And so I'm curious, are there any pointers that you have as a physician for making the best out of a relationship with a healthcare provider who may not see it this way, who might disregard all else in favor of hyper fixating on that number on the scale?

[Dr. Mara Gordon]

Yeah, that's a great question. I will start by saying by defending my profession a little bit. And I, I just, I really don't think most doctors go to work each saying, I really want to make some fat people feel terrible. I think that they want to do the right thing. I think that many doctors think that they're helping people by bringing up weight. I used to, I used to, when I was in training, I would tell people to lose weight all the time and they, I thought I was helping them get more active. Right. And going into the visit with the assumption that like with clear communication, that hopefully your doctor will be open to what you need. Right. And I think being honest about what you're looking for is often a great starting point. Right. And it can feel scary. I totally get that. Can feel scary to talk about body size in general, but in particular it can feel scary to talk about body size with a doctor. I have so many patients who come to me and say, you know, I really don't want to talk about weight. And they often come to me because they know I'm, I'm talk publicly about this. They just aren't sure exactly what I mean when I say I'm a size inclusive doctor. And they advocate for themselves in a way that's really exciting and I think many people can learn from. So I think if you start the conversation by saying, I'd really like to avoid discussions about weight today. I want to focus on xyz, other issues and sort of set ground rules. I think many, many doctors will be more responsive to it than you might imagine. You don't need to be weighed. There are certain scenarios where I need to weigh patients and I'll talk about it with them. Many offices won't require it. And if you just say, hey, you know, I really prefer not to get weighed during your intake, you may find that it's much more within the realm of possibility than you imagine. And that can be a starting point for sort of those advocacy discussions with the doctor around saying, here are my expectations, here's what I'm looking for in a doctor, and I hope that many, many physicians will be more respectful and responsive than you might imagine.

[Lily]

Thank you so much. I think that that's really helpful. Yeah, and thank you for joining me today to talk about this. So where does this leave us? If you recall at the beginning of part one I told you about Casey who sent me an economist article about the economics of thinness and well, wouldn't you know, a follow up piece was written labeled quote the Ozempic edition. It attempted to reanalyze this question in the age of the GLP1 agonist and suggested that by democratizing access to thinness, which is how I would characterize their argument, and therefore making it, quote, easy to be thin, we might actually see a cultural obsession with thinness fade. And I have to say I find this logic pretty dubious. Whether you think it's fair to classify the effects of these drugs as making it easy to be thin, which in itself itself is an objectionable claim given the typical weight loss associated and the side effects, they still uphold a hierarchy of body type. They don't neutralize or challenge the desire or cultural preference for thinness. They simply attempt to make it slightly more accessible and as we've covered, not all that accessible. For a useful analogy, think about the way in which the invention of Botox did not make the cultural obsession with youth any less powerful. Just because it was now possible to freeze one's face medically did nothing to diminish the premium that we put on youth. If anything, it meant the opposite. In other words, neither Wegovy nor Botox fundamentally challenges their accordant beauty or body hierarchy. And anything that sorts people into a pyramid of value will always lead to punishing consequences for the majority because by definition very few will sit at the top according to the same piece. Weight loss drugs will probably be responsible for the next big change and it will not be the creation of Stepford Dystopia. Thinness is desirable now because it sends a signal that one has the time to work out the money to afford healthy foods and the education to know what diet to follow in low income countries. Where food is scarce for poorer people, obesity is more desirable, as it was in the pre industrial West. A study by Elisa Mackay of Brown University carried out in these countries manipulated images attached to loan applications and found that applicants who appeared obese had better access to credit than thin people in those places. End quote. And so I think the author of these economist pieces and I are in agreement that body type is ultimately a class signifier. We just disagree that any drug, Ozempic or otherwise, will change that fact. What's happening here is conflation of one type of inclusivity with another. The first says the ideal itself is manufactured and that the goal of inclusivity should ultimately lead us to neutrality, which flattens hierarchies. The other type of inclusivity says, hey now everyone can be included in our preference for thinness. The thing that indicates proximity to capital or a high social class will always be the thing that is perceived to be most desirable. Which is why you see the difference in a country where food access indicates poverty versus affluence. When you think about things like diet culture or beauty culture not merely as natural systems of preference, but hierarchies designed with the express purpose of stratifying people with body type, hygiene, beauty, etc, just serving as proxies for social class, the whole story starts to make a lot more sense. As long as there's still something specific worth aspiring toward, there will still be a premium status associated with it and punishment or shame awaiting those who do not meet that ideal. And as I think we've learned, the most important qualification for meeting the ideal is often just affluence. And on the topic of health, there are real health consequences to that punishment and that shame that we just talked about. For example, Aubrey Gordon has written about how she used to enjoy swimming and competitive sports as a kid. But once she began to understand that her fat body was something to be ashamed of, she no longer wanted to wear a bathing suit. So she stopped swimming, she stopped playing sports. And this is a shame, because we know that while exercise does not always lead to weight loss, it does always promote health and vitality. And paradoxically, weight stigma can discourage exercise size. All of these ideas about who's worthy and whose life has value contribute to an extraordinarily narrow definition of health, one that views thinness not as just one form a human body might come in, but as the form that signals a certain socioeconomic standing and moral righteousness. Per Scientific American quote, many studies show that the stigma associated with body weight, rather than the body weight it itself is responsible for some adverse health consequences that get blamed on obesity, including increased mortality risk from workplace discrimination and poor service at restaurants to rude or objectifying commentary online. The stress of these life experiences contributes to higher rates of chronic mental and physical illnesses such as heart disease, diabetes, depression and anxiety. End quote. Put another way, the stigma itself can be as dangerous as, if not more than, the thing that it is stigmatizing. And no miracle drug can fix that. Ready to talk GLP1 weight loss with lemonade Health. You're not alone. Introducing weight loss by him we're here for your GLP1 questions and care. No insurance needed Personalized prescriptions and including.

[Katie Gatti]

GLP1 injections and oral medication kits designed to help you lose weight so you can gain confidence, feel healthy. I don't deny myself bread every day.

[Dr. Mara Gordon]

No insurance.

[Lily]

Don'T take with go through your family have v thyroid cancer multiple intermediate places of impact do or the L2 stop and go.

[Katie Gatti]

Who was that?

[Lily]

That was my doctor at Weight Watchers. Weight Watchers doctors people with type 2 diabetes especially if you take medicines that is all for this two part series. Thank you so much much for tuning in. We will see you in two weeks for our next episode of the Money with Katie Show. Our show is a production of Morning Brew and is produced by Henna Velez and me, Katie Gattytosan with our audio engineering and sound design from Nick Torres. Devin Emery is our Chief Content Officer and additional fact checking comes from Scott Wilson.