Episode Transcript
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Welcome to Nutrition For Mortals, the podcast that says life is too damn short to spend your time and attention worrying about your food choices.
So let's take a deep breath and then join us two registered dietitians and friends as we explore the world of nutrition with a special focus on cultivating a healthy and peaceful relationship with food.
My name is Matt Priven, and I am joined as always by my co-host and the best dietitian on planet Earth, Jen Baum.
Hey, Jen.
Hey, Matt.
And just a couple of quick reminders.
If you are enjoying the show, we do have a Patreon where we do an extra bonus episode every month.
A portion of our Patreon does go to support The Hunger Project, which is just a fabulous organization.
And I think I'll also say today that we are actually real live dietitians.
And so if you or someone you know thinks that working with a dietitian would be helpful, the time of this recording, you could actually work with us and you could head on over to oceansidenutrition.com to request an appointment, because at this time we have new patient openings, which is pretty rare and pretty exciting.
Yeah, you can work with Jen Baum, believe it or not.
It's possible.
You too can talk to me.
Or me, yeah, sure.
So let's get into it.
Yeah, Matt, what are we talking about today?
Or what is the episode about today?
Yes, today we're going to be hearing my interview with the wonderful Ragen Chastain.
I'm so excited to share our conversation with our listeners.
And I was actually not part of this interview, which in some ways was kind of cool because I got to listen to this episode like a listener would.
And I absolutely loved it.
I learned so much from your conversation with Ragen.
And I think it's just going to be a really valuable conversation for our listeners.
I missed you.
I missed you too.
I was a little jealous, but I was okay.
I kind of like, I handled my jealousy.
Okay.
Well, I'll set this up a little and then we'll jump right in.
So I guess what I want to say here is after we recorded that BMI episode that I hope most of our listeners have checked out, I was thinking a lot about the language that we use to describe people's bodies.
These words like overweight and obese, how they became inscribed in our way of talking, either in everyday life or in healthcare and scientific research.
I was kind of ruminating on this idea of language, and I wanted to have a more detailed conversation on our show.
And I thought, you know what?
The perfect person to talk to you about this would be Ragen Chastain.
And if you don't know Ragen, you're in for a treat because she was kind enough to join me for this chat, and she'll tell you more about herself when we get into this.
So let's just jump right in.
Let's do it.
All right, Ragen, welcome to Nutrition For Mortals.
I'm so excited you're here.
I am so excited to be here.
Thanks for having me.
So I have so many things I want to talk to you about today.
I know you are a wealth of wisdom.
And so I'm going to ask you a lot of questions, but I just want to start by introducing you to folks who might not know you.
So if you could just share a little bit about your background, your area of research and expertise, and what you've been up to recently, and then we can kind of jump in.
Yeah, so my area of expertise is the intersection of weight science, weight stigma, and healthcare practice.
It's something I started studying about, well, a little over now 20 years ago.
And at the time, I personally was studying it because I was looking for the best diet.
And I had been yo-yo dieting for years, and my background is research methods and statistics.
And so I decided that I would do a literature review to find the best diet.
And like, I was not in school, I didn't publish this, I had a corporate job.
This is like just the kind of mega nerd that I am as a person.
And so after finishing the literature review, I was so surprised that I went back and I did the whole literature review again, hundreds of studies, hours and hours, because what I found was that there wasn't a single study where more than a tiny fraction of people actually succeeded at significant long-term weight loss.
And that's what got me interested in studying these things.
And so then for the past 20 years, I've been studying.
In 2009, I started a little personal blog about them and started writing and speaking.
And in 2012, I started writing and speaking and speaking about this full-time.
Currently, I co-write the Health At Every Size Health Sheets and the Weight and Health Care Newsletter on Substack about these subjects.
So is finding this information out, is that sort of the origin story of who you are now, sort of this voice for fat activism and sort of the fight against the health care establishment pushing weight loss on us?
Is this where it all started for you?
It is.
I had been, so my mom says that I sort of like came out of the womb as a protester, as a kid.
I was always, you know, if I saw something that I thought was not fair, not just, I was gonna get people together, complain about it to the most powerful person I could find like in elementary school.
And so I had done that work in college.
I had done a lot of queer and trans activism.
And I came out at the University of Texas in the mid 90s, which was a really interesting time and place to be out and doing that work.
And so I had that experience.
But I hadn't, and I understood, like I had done solidarity, anti-racism work.
So I understood models of oppression, but I never thought of myself as a fat person, as oppressed.
I thought of being fat as like a me issue and the difficulties I faced in a society that has a lot of anti-fatness as a me issue.
And so, understanding that, oh no, this is a group of people who are being oppressed, that would be wrong regardless of what the research said about weight loss, right?
But additionally, the way we're told to escape our oppression is through weight loss, which we should never be telling a group of people who are oppressed that they should change themselves to suit their oppressors, but moreover, it wasn't going to work, right?
And it wasn't going to make me healthy, which is what my doctors have been telling me.
And so just that, when I realized that level of injustice, that's what got me interested.
And at that time, I didn't know that there had been this incredible thriving community of fat activists and weight neutral health activists who have been working on this since before I was born.
I found that later.
But yeah, that was sort of the origin of my shift to working on this particular type of social justice.
And I've read quite a bit of your writing over the years.
And I've learned a lot from you.
And I really wanted to reach out recently because Jen and I were having a chat.
We recorded an episode about BMI.
And in talking about BMI, we went through the history and we kind of came to this point in the mid-90s where we formalized these categories of BMI.
And it really, you know, we ended up using these words a lot in conversation, the words of overweight and obesity.
And I felt like there were so many places that I wanted to go in conversation that were so many different tangents that we could really go down.
And I said, you know what?
I think Ragen is the exact person to talk to about all these tangents I want to go down.
And so I'm hoping we can do that today.
And I think most specifically, I'm curious your thoughts about the language that we use, these words of overweight and obesity, how they sit with you, with your 20 years of experience, what thoughts come up for you.
So if we could just start maybe talking about the word overweight, sort of in the colloquial uses, not necessarily a BMI category, but just like generally, how do you feel when you hear the word overweight?
Yeah, I mean, the term is inherently stigmatizing, right?
It says there's a correct weight and you're not it.
That's what it was created for, right?
This term was made up for the express purpose of pathologizing bodies just based on shared size, rather than shared symptomatology or cardiometabolic profile, like you would see in a normal disease.
And so to me, the word overweight is a stigmatizing term.
I don't use it unless I'm talking about studies that use it as a category, and then I always say, quote overweight, or you'll see me write overweight with an asterisk just to point out that this is a term that is, one, junk science, and two, is being used to stigmatize people and to pathologize people based on how they look.
And it's a strange word because it is sort of baked into the healthcare system now, but it's also a word that's been used from, you know, before it even became a formal BMI category.
It's just a word people use to describe themselves, to describe others.
And I think we are almost at a point where we're kind of taking it for granted and people use it in a way where they don't assume it's going to sort of bounce off somebody else's ears as maybe hurtful or judgy, but that's very different based on who you're talking to.
Would you agree?
Oh, definitely.
And it's a word that people use to describe themselves.
It's one of those things where when people are named, rather than getting to choose their own name, often there's just an acceptance of that and there's not a thought about like, how does this word describe me and what does it say about me and how does it work in larger language?
And so I think that's a big part of it that, we were sort of named as overweight, like you're the wrong size.
And now that label has both been medicalized but also kind of sticks.
And I also want to say, I have a really firm view about bodily autonomy and naming autonomy, right?
So if somebody's preferred term is overweight, they're allowed that, right?
That's their right.
But I do think it's important to understand, like, where does this come from and how is it used and what does this word do when we're using it to describe people?
Yeah.
And it's one thing I've really appreciated from your writing is you're such a stickler for language and you want to get into the weeds of, are we using the right terms to describe what we're intending to describe?
But also you're very quick to recognize things like autonomy that people can kind of be, they can choose the way they want to be referred to.
When it comes to words like obesity, what comes to mind for you there?
I mean, is it similar to overweight where the story is the same?
It's a word that was imposed upon people, but what do you think about when the word obesity is used casually?
Like let's say you're at a dinner party and someone uses the word obese to describe somebody.
How do you feel?
What do you think?
I feel like I'm going to take a big breath and the person beside me is going to be like, here we go, like anybody who knows me.
But I think, so yeah, obese is a bit more insidious I think.
It comes, it was specifically created as a, like a quote unquote medical term to describe higher weight people.
It comes from a Latin root and that root means to eat oneself fat.
And so a lot more stereotype there than science and it reinforces this idea that people are higher weight just because they, you know, of the way that they eat and we know that that's not true.
And the constant attempts to rename it, to create classes of quote obesity, to create new and different ways to define quote obesity so that that group of people has expanded to expand the market for weight loss products.
There's a lot of insidiousness that goes on behind that.
So if somebody uses that word, you know, at a dinner party, they're gonna get some information from me about where it comes from and how it can harm people.
Yeah, so thinking back to that sort of Latin etymology there, to eat until a point in which you've basically contributed to your body size, you're saying, and I agree with you, that this is something we know not to necessarily be true.
There's so many factors that go into body shape and size.
But speak a little bit more about that, because we do have some listeners here who are new to some of these ideas.
And so maybe they do have this sort of reflexive idea of like, if somebody's in a larger body, it has to be because of sort of this calorie math throughout their life.
So can you speak to that a bit?
Yeah, and that's certainly something that, you know, people have been told and taught, including doctors.
Most of the audience to whom I speak are healthcare providers.
And they are also having these ideas.
So just know if this is what you were thinking, this is not uncommon, but it's also not accurate.
The truth is there's a diversity of body sizes.
There's a diversity of heights.
There's a diversity of nose sizes, of hand and feet sizes, right?
Bodies are incredibly diverse.
There's also a diversity of weights, right?
Some people fall naturally higher on the weight spectrum.
Some people fall naturally lower.
And so there's this idea that, oh, if somebody is higher on the weight spectrum, it must be because they ate too much and they didn't exercise enough.
And in fact, there are tremendous outside forces that go into our body size.
There are good studies that show that weight is about as heritable as height, right?
So there's genetics that goes into it, and there's a lot more as well.
But the thing that I think is really insidious here is that we know that the most likely predictor of weight gain is actually intentional weight loss attempts.
Yeah, unpack that a little bit, because I know that to be true in practice, working with folks as a dietitian.
And I think some people hear that and they go, yeah, I recognize that in my own life.
But can you unpack that for folks who aren't familiar with that concept?
Yeah, so like a century now of data shows, like I said, that the vast majority of people who attempt intentional weight loss will lose weight short term and gain it back long term.
Up to 66% of those people will regain more weight than they lost.
And so then what will happen is those people will be told to try again.
And so they will try again and they will have that weight cycling, which is when you lose weight and regain it, with again, that likelihood that they regain more than they lost.
And I'm not saying there's anything wrong with being fatter becoming fatter.
I think there's something seriously wrong with something that's considered a healthcare intervention that's prescribed to about 70% of the population that has the opposite of the intended effect the majority of the time.
And that's what we're talking about with intentional weight loss.
And again, it's really insidious because what we hear is, oh, people have just been getting fatter and fatter, but what we haven't heard is probably because we keep putting them on diets over and over and over again, right?
We have no idea what fat people's body sizes or health outcomes would look like if they were not constantly subjected to weight cycling or weight stigma or healthcare inequality, right?
And so it's this industry that perpetuates this failed intervention and then blames people for the outcome of the intervention, and then blames their bodies for the negative outcomes that follow.
And it seems like a lot of this is being driven by the research that doesn't represent people in all bodies, but then uses the findings of said research to design public health interventions.
And the BMI is sort of the classic case of that.
Yes, absolutely.
The way that research is conducted around being higher weight.
First of all, predominantly all of the research about higher weight people, including stigma research, comes from a perspective of eradication, right?
We think that it's best to eradicate fat people from the earth to prevent any more from ever existing.
But perhaps in a non-stigmatizing way, which is not a real thing.
You can't, pathologization, eradication is stigma.
So you can't want to eliminate a group of people from the earth and do that in a way that doesn't stigmatize them.
But so we get this research that basically creates a cycle in healthcare that creates weight stigma, which we know is correlated with the same health issues that get blamed on fatness.
It creates weight cycling, which we know is correlated with the same health issues that get blamed on fatness.
It creates healthcare inequalities, which we know is correlated with the same health issues that get blamed on fatness.
So, it creates this cycle, and then it blames higher weight bodies for the negative impacts of what is done to fat people.
And then it uses those negative outcomes to justify more weight stigma and weight cycling and healthcare inequalities.
And I keep coming back to this idea of the language, right?
And at some point, the WHO gave us these BMI categories.
And I know BMI is not the whole story here, but it's something we were talking about recently.
And when we labeled these categories, we chose these words of overweight and obesity.
We could have chosen anything, right?
We could have called the BMI groups like group one, group two, group three, group four.
We chose these stigmatizing words.
What do you think that says about our society that we chose those words to describe literally half the population?
Like if you look at the category selection for BMI cutoffs, half of the population was instantly sort of put in this category that eventually became a diagnosed condition of overweight or obesity.
So what does that say about us that we chose those words?
So what it actually says is that the weight loss industry was massively involved in this process.
I told you that my area of expertise is the intersection of weight science, weight stigma, and healthcare.
My subspecialty, as it were, is the way that the weight loss industry infiltrates and manipulates the healthcare system.
And in this case, and I won't go too far into this because it gets to be a lot without charts and graphs, the World Health Organization's meeting around this was funded by the International Obesity Task Force, which was funded by pharmaceutical companies that made weight loss drugs.
They paid for the meeting, they wrote up the declarations from the meeting, and they were passed through a non-traditional method that the WHO typically has more review than was used for these guidelines.
And then the NIH team that replicated this were told that they were pressured, they said, to conform to the WHO's guidelines.
Yeah, that is not something I was aware of, sort of the money that was behind all of this.
I mean, it's not surprising to hear that.
So what is the motive here?
I mean, maybe it sounds obvious to you, but what is the motive behind including words like overweight and obesity to describe these categories versus naming them something that isn't stigmatizing?
Well, the point of these categories was to pathologize bodies based on size.
And so these terms, overweight and obese, these terms ended up being used because they sounded sciency, right?
They had sort of been floated around.
The term morbid obesity was created by a couple bariatric surgeons who were trying to get insurance coverage for their procedures.
BMI was the idea of like, oh, well, this is math, so obviously it sounds sciency as well.
So I think the idea wasn't, they didn't want to de-stigmatize fatness.
They wanted to pathologize fatness.
And so they chose terms that created a negative view of higher weight bodies.
And so once you pathologize different body shapes and sizes, which became very easy when we had these words at our disposal, and now we have ICD-10 codes, like insurance billing codes associated with these words, what does that do to the individual?
I mean, you talked about how this labeling, this whole system really can put a lot of people in larger bodies at a disadvantage from trying to seek health care.
What are some examples of that, that you see when you talk to people or that you sort of look at the literature?
Sure.
And I do want to preface this by saying that weight stigma and anti-fatness, including in health care, doesn't harm people equally.
It's always going to do the most harm to those of the highest weights and those who have multiple marginalized identities.
And I also want to say, and this is not my scholarship, this is the scholarship of people of color, but I want folks to know that the idea in general of pathologizing bodies based on higher weight, the BMI in specific, these things are rooted in and inextricable from racism and anti-blackness.
And I absolutely urge people to read folks like Deshaun Harrison's Belly of the Beast, Sabrina Strings Fearing the Black Body, to understand more about how these things are not just rooted in racism and anti-blackness, but they continue to disproportionately impact those communities.
Yeah, that's a really great point to make.
And so within healthcare, what happens is, and it's been an evolution, but the evolution has been that because we so extremely pathologize being higher weight, the focus of almost all healthcare for higher weight people becomes changing their body size.
And so I personally have been prescribed weight loss for strep throat, a separated shoulder, and a broken toe, right?
So you have what I call practitioner weight distraction where they're trained in medical schools to see higher weight patients as essentially a walking, talking pathology.
And they're trained in this idea of Occam's razor, right?
The simplest answer is probably the right one.
So if someone who's higher weight comes in with health conditions, they're like, oh, well, probably if we get this person to be thin, those health conditions will be resolved.
And if not, they'll still be better off.
So we'll do that first.
And then if anything's left over, we'll treat it.
And so you get this situation where a thin person goes in with a certain set of symptoms and they get an ethical evidence-based intervention.
A fat person goes in with those same symptoms and they get a diet, right?
So there's healthcare inequality created by that.
There's the idea that if healthcare inequality is due to body size, then it's acceptable, right?
So you'll see people argue like we shouldn't have tables that accommodate higher weight people.
What we need is for people to lose weight, right?
So we get this healthcare system that isn't made for higher weight people.
We get a system where higher weight people are excluded.
I recently spoke at an anesthesiology conference and in reading decades of anesthesiology studies to prep for this talk, there was a common thread among guidelines where they would say, oh, well, we know that pharmacokinetics and pharmacodynamics are different if people have higher rates of adipose tissue, but we don't know how because those people were excluded from studies.
And then they'd say, well, so anyway, here are some guidelines, right, for decades, including the most recent guidelines.
So instead of doing studies that included higher weight people to figure out how can we be better at anesthesia for higher weight patients, what we do instead is deny higher weight patients medical procedures because they may have more negative outcomes in anesthesia, for example.
So it creates a health care system that wants to make people thin and is in fact willing to risk people's lives and quality of life to make them thin rather than wanting to make them healthy to their definition and priority.
Yeah, it sounds like an area where the list just keeps going on and on when I talk to people all the time, clients of mine who share challenges that they run into going into just a primary care office or a specialty provider and being told to focus on weight loss or sort of being grilled about what they've been eating in sort of an odd way, when they're going in for things like you mentioned, like a strep throat or knee pain or whatever it might be.
It always seems to come back to weight loss for folks that are perceived to be, quote unquote overweight or obese, right?
And it's strange how the language kind of splintered where we use overweight and obese as adjectives to just sort of describe body types.
And we also are maybe vaguely implying that we're guessing at their BMI category.
But do you ever think about how weird it is that we just use these words so interchangeably that we can throw around words like overweight and obese?
And we kind of have this essence that it might be related to BMI, but there's so much gray area with this language.
It just bothers me.
Yeah, because it's really nonspecific, right?
Because we know, like Kate Harding's BMI project, even Kate Harding did incredible work, and this is part of it, just showing different bodies, and people would guess, like, okay, this is their BMI, and then it would come up what their actual BMI category was.
The fact that we know that a lot of professional athletes are quote unquote obese, because all we're talking about here is a ratio of weight and height, right?
Your weight in pounds times 703 divided by your height in inches squared.
That's what we're talking about.
It's not scientific.
It's not a health measurement of any kind.
It's just a simple ratio of weight and height.
Yeah, and so our listeners don't get confused.
That is the same as kilograms over meter squared.
It's just metric versus imperial.
So per our BMI episode, you can do it in pounds too.
Yeah, sorry.
I'm in the States.
And so as they say, we'll do anything to avoid using the metric system.
And I am in this moment guilty of that.
But yeah, so yeah, tossing around these terms, which are used as medical diagnoses as also common labels for people walking down the street where their size is none of our business is really problematic as well, right?
So it really sort of meshes this thing where people just trying to like live their best life are being pathologized by randos at the grocery store and the gym and stereotyped and treated poorly.
And so there we get this medicalization, this pathologization, this focus on the eradication of people existing in higher weight bodies then becomes a societal issue as well.
Yeah, and it gets into this question of like concern trolling by like quote unquote, well-meaning family members, right?
Or doctors, frankly.
And so, you know, it seems like people feel like they have license to give recommendations.
And that's where I think a lot of the harm seems to stem from.
And I think one of the challenges is we don't really have alternative language to use to describe bodies.
And, you know, caveat being, you know, don't just go randomly describing people's bodies to them, you know, get to know people and understand how they want to be referred to and all that.
But I read a post that you shared maybe in 2018 where you kind of went through some of the ways in which we could change our language away from words like overweight and obesity to kind of get to a new place in terms of how we describe body types, body shapes and sizes.
And maybe you could speak a little bit to how you like to be referred, how you tend to refer to other people when you're speaking generally about body sizes, like larger body sizes specifically.
How do you think about this?
Sure.
So when we think about non-stigmatizing terms, to me, that is a term that accurately describes these bodies without pathologizing them and that was not used as sort of a slur or a taunt that could be triggering to someone.
So in general, if I'm talking to larger audiences, I tend to use terms like higher weight, larger body, person of size.
Plus size is a term that gets used, but it's been pointed out that that term can be really gendered in problematic ways.
So I don't typically use that unless I'm talking about like specific clothing.
But so yeah, these sort of generalized terms, right, that accurately describe these bodies.
If for myself, I prefer fat.
Fat is a reclaiming term with all the complexities that come with that, right?
But for me, fat as a reclaiming term, using it kind of, first of all, it tells my bullies they can't have my lunch money anymore.
Right?
It takes that power back for me.
You cannot harm me by accurately describing my body because there's nothing wrong with my body.
And also, again, it doesn't medicalize or pathologize my body.
So I like the term fat.
As I said, it's a reclaiming term.
So there are people who could be described that way who do not align with that term, and that's completely valid.
There are people who could be described that way, who consider that term a slur, and that's completely valid.
And so I don't recommend, like if I'm talking to a group of doctors, I'm not like, start calling people fat.
Even though ideally, I think that would be great if we could just do that.
But what I want to make sure people do is if someone is describing themselves as fat in a way that's neutral or positive, that we don't correct them.
Right?
The number of people who say to me, oh my gosh, you're not fat.
I super am, first of all.
But don't correct people who are choosing to self-label in that way using a reclaiming term.
And so that's what's important to me, that people be allowed to call themselves what they want.
And going back to terms, I can't think of a term I would like to be called less than fluffy.
Right?
There is nothing about that that appeals to me.
But there are people for whom that is their preferred descriptor of their body.
And I will call that person fluffy all day long.
Yeah.
That's super helpful.
There's no one universal way we should be speaking about people's bodies and the language that we choose to use.
But we want to make sure we're focused on being accurate with what we say, but also recognizing that some words are interpreted as a slur or a taunt.
And that's going to be different for different people.
So, you know, fat as a neutral descriptor would be ideal, but that's going to get interpreted as a slur for some people.
But for yourself, the word fat, it sounds like it's your preferred adjective.
So, you know, this is super helpful just to talk out because I don't think this is a conversation we have enough.
But now I want to switch gears a little bit away from discussing language specifically, because you have an area of expertise here that I want to tap into.
So if we look into the scientific research that leads to weight stigma, I want to dig a little deeper.
And I guess I want to ask you a tough question, which is, you know, what, in your opinion, is the number one problem in the research when it comes to the methodology of studies or the interpretation of findings that ends up leading to so much weight stigma that then fans the flames of sort of weight-centric healthcare?
Any thoughts on that?
I'm going to try to keep this to one, but it may be compound.
That's why I did it, because I feel like we could do an hour on this, because I would also love to nerd out on study design.
But yeah, let's try to think, what's the biggest one?
The biggest one is making purposeful correlation versus causation errors.
So the first thing you learn, your first day of research method class, correlation does not imply causation, right?
Just because two things happen at the same time, we can't assume that one causes the other.
This is the cardinal sin of research.
And this is also complex, because in healthcare research, we use correlation all the time, because the body's complicated, a causal mechanism can't be found.
But it's not responsible in any way to use correlation when you haven't explored what are called confounding variables.
What else happens to this population that could cause this outcome to happen more?
So let's say we say, oh, higher weight people have a higher incidence of high blood pressure.
So the next thing we have to ask if we're going to be any way responsible in our research is, well, what other factors happen to higher weight people that also are known to cause high blood pressure?
And I can tell you three of them are weight cycling, weight stigma and healthcare inequality.
I can also tell you that the use of a smaller blood pressure cuff creates an artificially high reading and that mis-cuffing of higher weight people is rampant.
And we have research to back that up.
And so we would have to look at all those things and say, like, is this high blood pressure really related to their weight?
Or is it related to the weight stigma they experience, the weight cycling they experience, the mis-cuffings they experience and other healthcare inequalities?
Yeah, it's a little surprising that the research community hasn't caught on that you should at least ask people about their history of dieting, because it's gonna, I mean, we know so much about the metabolic impact of restriction.
And so to have two people with the same BMI, one who's never engaged in dieting or restriction, and one who's done it many, many times, we know them to be, you know, unique, and that would be a confounder.
I'm just so surprised, I keep scratching my head going, why is nobody asking about this?
But I'm sure you have a lot to say about why that is the case.
What you've already said, sort of the vested interests is really the problem.
Yeah, it's sort of reached these ideas, like if a health care issue happens more commonly in higher weight people, then obviously their weight is to blame.
And then the second step, obviously making them thinner will solve this, which is also not scientifically supported, right?
We can't say, it would be like saying, oh, well, cis male pattern baldness is incredibly highly correlated to cardiac incidence.
Obviously, we've got to get these people to grow hair.
Yeah, I take it personally too, Ragen.
Oh, sorry.
You should know I can't see Matt in the video.
But there is a lot of stigma around baldness, right?
But if, from a healthcare perspective, if we were like, well, if these folks have higher rates of cardiac incidence, then we've got to get them to grow hair so they can look like the people who have less, like that would be seen as ridiculous, right?
But that's exactly what we do with weight.
And I think the reason why is because it's reached what I call everybody knows status, right?
So I will go, and it's getting better, but especially in the early days, in like 2009, when I was giving this talk to healthcare audiences, I would give an hour and a half of just nothing but evidence-based points about this, right?
Here's a bunch of studies, here's a chart.
And at the end, somebody would be like, I mean, everybody knows that being higher weight causes health issues.
And that would be their entire argument against my hour and a half of research.
And people would not have, yes, you're right.
There's a, we all know sort of the story of Galileo, right?
That he made a telescope, figured out that the earth revolved around the sun and they put them under house arrest and it's terrible.
The part of that story that interests me because of the work I do is that Galileo's contemporaries are said to have refused to look through the telescope.
So they weren't like this telescope is poorly made or dude, while your math is way off, they just wouldn't look.
And that's what I see a lot within greater society and healthcare in particular, when it comes to questioning this research, to saying, look, any freshmen could tell you what's wrong with the study.
Any freshmen who took a research methods class and yet it got peer reviewed and now you're citing it and now you're defending it when there are obvious, obvious methodological errors here.
And that's, I think, a huge problem.
I'd also, I'll just throw this in.
What I'd really like to see is if weight loss studies had to have a weight neutral comparator group, right?
So, okay, this is the group that tried the weight loss intervention.
Here's the group who did weight neutral health supporting behaviors.
What were their outcomes differences and what were their risk differences?
I think that would really open a lot of eyes to what's happening here.
Unpack that a little more, just so people are clear on what you're saying.
A weight neutral comparison group.
What do you mean by weight neutral in that context?
So research shows, again, understanding a lot of things impact our health, that weight neutral interventions, things like social connection, quality sleep, movement, nourishing foods, et cetera, these health supporting behaviors are better predictors of current and future health, health hazard ratio, risk of all cause mortality, than our weight and weight loss.
And so if one group was put on diets and one group had their health supported directly, we could start to see the differences.
Because one of the ways that these studies are manipulated is they create comparator groups either who do nothing, or in the case of weight loss drugs, their comparator groups are often people who are dieting, which we know to be a failed intervention.
So they're stacking the deck to say, yes, our drugs are at least short term, more have higher efficacy and weight loss than this thing that we know doesn't have high efficacy and weight loss.
But if we actually looked at health outcomes, and if we actually looked at the risks versus benefits of weight neutral health supporting interventions and diet drugs, we'd see a very different picture of what people's options are to support their health.
Yeah, that's a really good point.
I mean, this glaring omission from the research really speaks to a society wide issue of how we value certain people and how we perceive others.
And it's just really reflected in the research more than anything.
And everything we're talking about today, our language that we use, what happens in research, where money flows in the health care system, it all has to do with this sort of systemic issue.
And so I guess for you, what are some things that are giving you hope for the future?
Things that make you excited that things are trending in the right direction?
Yeah, there's a lot of things that are giving me hope right now, including just the growth of people who are aware of these issues in the world in general, the growth of the fat activism community, the weight neutral health community.
I've been doing this, like I said, since about 2009.
There are people who have been doing it since before I was born.
And one of the things we talk about is just how many more weight neutral providers you can find now, how many more people are in social media talking about these issues in the world, in conferences talking about these issues.
So that gives me a lot of hope.
In terms of language, I think pushing back against pathologization and medicalization.
And the weight loss industry is very, very good at what they do.
And so recently, you may have heard them just falling all over themselves to say, yeah, you're right, intentional weight loss almost always does lead to weight gain, which is after decades of people like me screaming this from the rooftops for them to finally be like, oh yeah, we just noticed today, because we found these much more profitable drug interventions that we're going to try to sell.
We have to be really careful because we're at, I think, a really critical moment right now, where companies like Novo Nordisc and Eli Lilly are trying to co-opt anti-weight stigma language and indeed anti-weight stigma activism and turn it to be something to sell weight loss drugs.
And that's really dangerous.
So when Novo Nordisc launched Wegovy, they also launched a program called It's Bigger Than Me, which is supposed to be an anti-weight stigma program.
And I'm like, really?
Because bigger.
Because fat people.
I'm like, if your program sounds like it was named by a sixth grade bully, you probably aren't an expert at anti-weight stigma work.
But they've got researchers on their payroll, right?
They've got the whole, the Red Center just partnered with Eli Lilly on this, what's supposed to be an anti-stigma project, but it's really just putting out the language of the weight loss industry.
We don't want to stigmatize fat people, but we absolutely want to eradicate them from the earth, prevent any more from existing and make billions of dollars doing that, is what the message really is.
But it's not what we hear.
So I think people pointing that out is really important.
And I do see that happening.
The campaign for size freedom, which was created by NAFTA and Flair, funded by Dove and full disclosure, for which I am the legal fellow, is working to get height and weight protections against discrimination across the country.
And I think that's really important.
Like whatever is happening with the weight loss industry and the medicalization of body size, the idea that discrimination against higher weight people is okay, but because it's perceived that they could be thinner if they tried, is always going to be wrong, right?
And so the idea that people aren't protected from discrimination because they're perceived to be able to leave the discriminated against category is never the right argument from a social justice perspective.
Yeah.
Well, I'm learning so much from you.
I mean, I do a version of this work all day long in being a dietitian who provides weight-inclusive care and really changing the narrative in the nutrition world away from a weight-loss-centric, calorie-centric model to what is actual holistic health?
How can we eat in a way that makes us feel good?
How can we eat intuitively?
How can we move our bodies in a way that brings us joy?
How can we sort of change the conversation?
But you're really helping me realize, as you have in your writing for so long, that there's so much to the social justice side of this work that I am just scratching the surface of.
So I really appreciate you explaining all this.
Oh, thanks for asking and listening.
And I think the work that you do is so life-changing, life-saving, and critical.
Because higher weight people are constantly told that the best path to health is intentional weight loss.
And there's so much great research that shows that health-supporting behaviors, understanding that there are so many things that impact our health we don't have control over, writing that health is not a barometer worthiness entirely within our control or an obligation.
But if we had correct information about the ways that health-supporting behavior could support our health, rather than a focus on manipulating our body size, people could make their choices from an informed perspective.
And the work that you do is so important to that.
And, you know, exponentially, you never know how many people are gonna be impacted when that client of yours goes out in the world and spreads that information as well.
But yeah, it's tough, because I work on the health side predominantly, but social justice should never be predicated on health.
Fat people have the right to exist.
Without shame, stigma, bullying or oppression, it doesn't matter why they're fat.
It doesn't matter if there are health impacts of being fat.
It doesn't matter if they could or even want to become thin.
The right to life, liberty, the pursuit of happiness, the ability to live in peace, those things shouldn't be size or health dependent.
Amen.
Well, thank you so much, Ragen.
And, you know, as we wrap up here, could you just share with our listeners where they can find you and your writing out there on the internet if they're looking for you?
Yeah, so you can find my Weight and Health Care newsletter.
It's just weightandhealthcare.com.
And that's my sub-stack where I write about these things.
And then my speaking site is sized for FOR success.
So if folks are interested in the speaking that I've done, I also have there a repository of the various freelance writing I've done and that kind of stuff.
So you can check that out as well.
Great.
Well, thank you so much for being on the show, Ragen.
Thank you, Matt, for having me.
And for all the work that you do, it's been an honor.
Likewise.
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