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; it’s 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 GLP-1 agonists in that category. In some circumstances I don't, I want to be really clear about that. But I think GLP-1 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 fatphobia.

Katie:

Welcome back to The Money with Katie Show. I'm Katie Gatti Tassin. 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 born 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 Cottom, which I'm going to do again right now to summarize the business portion of last week's episode, “Being fat can be hell. Selling to fat people is profitable.”

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 Lili 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 Lili. Then we will talk with Dr. Mara Gordon, a weight neutral physician who deals with GLP-1s. And lastly, I will give you my final thoughts and analysis on where I see all of this going. So Lili was just telling us why after a couple of weeks her excitement about her GLP-1 driven weight loss was beginning to sour…

Lili:

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

Katie:

You're a little bit, ah, I 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?

Lili:

I did. What's strange is I think because I had this kind of experience of having done the intermittent fasting, I was doing things that 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, 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 had 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 water you've drunk or how much food you've had before you go and work out and you feel weak.

And that's what I thought I had done. I thought like, oh, 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 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 walking hours and hours and hours a day. That's my main mode of transportation. It felt suddenly very scary.

Katie:

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

Lili:

Well, I started to panic. It was my first response

Katie:

Back to the Subreddit.

Lili:

Exactly, exactly. And I really did do that. And 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. That's a lot of water. It's a lot on a daily basis.

And if 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. Am I drinking enough water? But am I taking all the space up in my stomach for food that I need?

I called my doctor because I thought 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 really extreme muscle fatigue and I was starting to feel really unwell. And his response was, well have you vomited? And my answer was no. Do you have any pain in your, I feel like it was like what they're worried about is pancreatitis, so he's like 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. Maybe I'm having a little bit too much panic about this and maybe I felt really worn out and my brain is 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 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 going to drive the car to the grocery store with the parking lot. Do you want to come, just 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 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 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 really starting to feel like I was going to pass out. And she took me home and put me in bed and set me up with all kinds of electrolytes. And we luckily were at the grocery store, so got some power bar kind of things like try to get some protein and some calories in me with some hydration because at the time I thought 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 made little sliders. They're teeny tiny and I couldn't finish one. And my daughter noticed me, they're teenagers. She noticed me being upset. She's like, you feel wrong. And at that point I thought, okay, now I don't want her to worry about me. I don't want my kids to worry that something's wrong tomorrow I'm going to go to the doctor.

And the next day I left them take themselves to school and I tried to get myself to the emergency room. It felt urgent at that point. It's a mile away. And I couldn't walk there. I couldn't walk myself there. I took a cab one mile and it was so busy and looked like it was going to be hours and hours until 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.

Katie:

Like, I don't think so. I don't think that's what it is…

Lili:

Not a medical professional. But seriously, 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. 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. I feel like I'm having this very strong reaction. And I left there thinking I am 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.

Katie:

We'll get right back to that conversation with Lili after a quick break.

And how long had you been on the drug by the time the symptoms had reached this level?

Lili:

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.

Katie:

Interesting. And had you been losing weight?

Lili:

Oh yeah. And 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 two-ish weeks.

Katie:

Holy smokes.

Lili:

I know. And I was excited. I was like, this is amazing. Nothing's ever worked this quickly before. Hell yeah, this is a magic bullet. Thank God in a couple of months, I'll be down to my pre-baby weight, which was 17 years ago. But 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.

Katie:

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're becoming thinner, but you're also, it was not like your health was improving. Does that make sense?

Lili:

Yeah, no, it does. There is that dichotomy because for me, I have polycystic ovarian syndrome and one of the symptoms of that is weight gain and sometimes it's insulin resistance for a lot of people. And with that there's a whole host of symptoms that come 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 after that time, I 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 in my head, I still feel like I should be, not that a 48-year-old should be the size of the 20-year-old you have in your head, but that feels like my normal set point. Whether I should or not, I'm not totally sure though that should be normal, but it felt like my body is doing something wrong and I'm trying to fix it. It doesn't feel like it's doing the right thing. But your point is a good one is not that I'm not a huge proponent of body positivity for anybody else. I absolutely am for everybody else except myself, which I think is a really common thing.

Katie:

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 it's like, well, the real me is the hot young, thin one and they're just trying to get out. This me isn't the real me, that's the authentic, I'm just trying to get back to her. I think that that applies to so many things too. Not just weight but aging as well and conventional beauty standards that we identify with our younger selves and then can sometimes walk down some damaging paths in our older bodies.

Lili:

Absolutely.

Katie:

Or our fat bodies to be like, I want to get back to that person.

Lili:

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

Katie:

Oh my God. So you mentioned in part three of this series that you were prescribed the medication without so much as a glucose test and that the ease with which you could get it, which we've sort of covered… it gave you the sense that this was a breezy thing because 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 going to 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.

Lili:

Well, I definitely do think that it should be more difficult to get it. 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 if it's working for you and if you feel good, fine. But a lot of them are doing it through these weight loss spas like med spas, 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 a doctor has to, or a patient and a doctor have to talk together about how this is going. If I had said to my doctor, this is how much weight I've lost within those two weeks, maybe that would've been an indicator to him like, oh wait a second, actually that's too much. Maybe you're the kind of person who needs to only take it every other week. 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, it exacerbates it and then you can't eat. I'm like, that would've been helpful to know. Thank you.

Katie:

My gosh. Oh my gosh. But they're so new. We're still, they're so new. Learning about them being used for this purpose at scale.

Lili:

I actually, one of the things that I did, because it is new and the only kind of side effects that are mentioned on the pharmaceutical information or the major life-threatening ones is I reported all of the symptoms I had back to Eli Lilly because I thought, well somebody's got to say something. 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. If it works for you and in you're happy and you feel good, take it. I still kind of wish I could, but I wanted people who weren't having a good experience to not feel alone because it doesn't work perfectly for everybody.

Katie:

Thank you very much. Anything else that you would like to say?

Lili:

You can ask me if they trained the drugs and maybe it's something that you could get back on, would you, because I don’t know, that's how ingrained the idea of we were talking about the thinness healthy again air quotes version of yourself. I still feel like, man, because my body is messed up in this particular way, if there were a drug that it could account for me having reflux or me being more sensitive to it, if I could have a baby version of it, would I? And I don't know the answer. Microdose. Yeah. If I could microdose a GLP-1 would I? And the answer is maybe even though I've had this terrible experience and I don't know what that says about me, but it's interesting.

Katie:

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.

Lili:

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

Katie:

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.

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 healthcare. 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.

I wanted to know more about where our culture's obsession with thinness comes from. I found feminist philosopher and author Kate Manne's work very useful for this. In her book, she writes about the history of the complex relationship between health and weight. And this part really jumped out at me: “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.”

And there's a lot of interesting sociological work out there on the history and origins of fat phobia 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 Sophia for NPR:

NPR Clip:

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

NPR Clip:

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 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.

Katie:

So today you're far less likely to encounter a ladies mag that will tell you explicitly that 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 “bad body”, you got to pay with your time, your money, your energy, your mental bandwidth to 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 public relations catchphrase. In 2001, the chief scientific and medical officer of the American Diabetes Association at the time told Piller 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, “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 pre-diabetes admonitions. ‘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 pre-diabetes 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 a DA and CDC as scaremongering.”

Okay, that was the entire passage from Piller’s 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 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 pre-diabetes accept large amounts of funding from diabetes drug makers. So far, no drugs have been approved specifically for pre-diabetes, 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 pre-diabetes 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—now says he rues the day he helped promote the term pre-diabetes, calling it a big mistake.

So again, that is from Charles Piller’s 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 social stratification and failures of urban planning.

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, there's been so much talk of public investment in the GLP one 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 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 GLP-1 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 GLP-1 agonists and patients are showing up at my door eager for the promised panacea.”

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. So 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 GLP-1 agonists in that category. In some circumstances I don't, I want to be really clear about that, but I think GLP-1 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 fatphobia.

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.

Katie:

Antithetical to health 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. We've been kind of taught to think about these things as being necessarily good for us. 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 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, 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 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 where you sort of walk through the office, you're publicly weighed, your weight is commented on. Just 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 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 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.

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 wellbeing. But to your question about weight stigma uniquely facing women, I absolutely think that's true. 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. And it's just so much more fundamental to the experience of being a woman that we're aware of the male gaze and we're the female gaze too, the gaze of other women. But that's often informed by the male gaze. I see this clinically, so I have more women see doctors than men, period.

So women are more likely to go to the doctor than men, which I think is multifactorial and has to do with sort of healthcare stigma amongst men. Women often intersect with the healthcare system in reproductive healthcare settings that men don't necessarily, but absolutely more women comment on their weight than men. So women will come in to see me and say, oh, I gained five pounds, or oh doc, am I healthy weight or this isn't good. My scale at home said I was this. And now the scale—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 as a woman doctor, I probably attract more female patients. So I don't have an official validated statistic about it, but in my experience that's absolutely true.

Katie:

What do you say when a woman says, oh, I gained five pounds. 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 GLP-1 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 that a BMI over 26 means you're unhealthy. So when a patient comes in to see me and makes a 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.

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 achieving wellbeing in my life that aren't fixated on sort of achieving a specific number on the scale 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, oh, 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.

Katie:

Holy cow.

Dr. Mara Gordon:

So that's not an uncommon story, and I think even for many, many people who don't meet criteria for a clinical eating disorder who aren't experiencing the severity of a clinical eating disorder, but I still think so many of us have disorder eating habits, and I think a lot of the origins of that kind of internalized fat phobia often start in the doctor's office, and that's the work that I'm trying to undo.

Katie:

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

Dr. Mara Gordon:

I do at times, and I kind of think of it as 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. 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 so excited. I was like, yes, we're spreading the gospel. We're going to end fatphobia. And so many of those patients came in specifically asking for Ozempic, and I was like, oh, I dunno 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. They want a doctor who doesn't judge them. They often still want to be smaller, and I don't fault them for that. We live in a really discriminatory, fatphobic 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 isn't therapeutic. And so I hope that slowly and surely I might be able to say, 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 swimming upstream for sure.

Katie:

Yeah. Well, part of what we were exploring in this episode is the business side and what we've started to colloquially call the cottage industry of telemedicine and 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 mail ordering a syringe in a vial and injecting myself without having interface with a physician or without having the proper medication or the more of a what would feel like a legitimate medical touchpoint, 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. 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. I feel like my life would be easier.

Dr. Mara Gordon:

Totally. I have some patients who seek me out who drive one hour and a half to come see me. They are radicalized towards body liberation and they want a body liberationist doctor, and some of those patients want to take Ozempic 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, 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 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.

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 semantic talking point. I think it's really practical. And sometimes I say this to colleagues and they're like, oh, don't be so politically correct. So it's not that I'm a total relativist. I do think that if you're hemoglobin A1C, that's a measure of glucose control. 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, I am not a total relativist, but I do think that some people, they might say, hey, 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 pounds, and she got to make that decision. That was how she defined health. And so it's my goal as a doctor to help my patients sort through the different variables, interpret the different data, but ultimately it's their decision. For some people losing 10% to 15% of their body weight through use of a GLP-1 or GP GLP-1/GP agonist is how they define health. And I respect that, right? That's up to them.

Katie:

And there's this other layer or complication, I think when I think about this question, there's the two money angles. The one money angle is how weight stigma impacts what somebody is able to earn. And therefore, as 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.” I was like, well, that's bleak as ****. So there's that money angle of this story, then there's the money angle of 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 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 benefit the most from access to them are actually the least likely to have access to them.

Dr. Mara Gordon:

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

Katie:

Good for you. 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, yeah, it's rational to be as male as possible. It's rational to be as white as possible. And so I think that that's such a good angle, honestly. Yeah, we don't need to get into it. This is sort of outside my area of expertise, but there are ways to make yourself more male, make yourself more white passing or white of hearing and what oblique 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. 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 implied by that article, the Economist, people just that—

Katie:

Good news ladies, this one simple trick. All you have to do is be super hot.

Dr. Mara Gordon:

As long as we have a hierarchy of bodies, as long as we have a fatphobic society, that's the problem. It's not the fact that some people are going to lose 10 pounds with this medication. And I have patients coming to me asking about versions of that very phenomenon all the time. They're like, oh, my marriage is bad. I want Ozempic. And I'm like, this doesn't treat, that's really marriage conflict or just 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 shrinking their bodies.

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. 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 a part of it for sure.

And so if Ozempic can help them, I'm game even though the problems are much bigger, but often those are the very patients who can't access it. 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 at work 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 GLP-1 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.

Katie:

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 going to tell you is going to make you feel like the situation that you're in is untenable again.

But I appreciate the way that you put it of, for some of your patients, you're not going to 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 cardio—but because those are the real problems, so I'm not going to 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 experience getting on the drug and having it work, 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 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:

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 GLP-1 agonist are older adults. Many of my patients are from the Dominican Republic, Puerto Rico, Spanish speaking, and I would say my typical patient is a 70-year-old lady who doesn't particularly want to lose weight, has diabetes, will 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 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 the risk of developing cardiovascular disease from diabetes.

Yeah, I would say the vast majority of stories are not 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 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 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 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 a one extreme, I have a lot of people who lose a little weight, 15 pounds, something like that.

I have 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 'em really sick to their stomach and they don't feel like it's worth it, it doesn't actually make them feel healthier, and so they feel like they want to discontinue the medications. That's a somewhat common scenario too. So I'd say 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. 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, they don't read as fat to the world. Sometimes they do, sometimes they don't. And I think I've really come to conceptualize two forms of fatness, right? 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 I feel sexy, I feel good. And then there are sometimes people who 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 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.

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. 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.

Katie:

And it sounds like how I would summarize this philosophy is 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 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 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 really don't think most doctors go to work each day 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, when I was in training, I would tell people to lose weight all the time, and I thought I was helping them get more active. And going into the visit with the assumption that with clear communication, that hopefully your doctor will be open to what you need. 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. It 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, I really don't want to talk about weight. And they often come to me, they know 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 X, Y, Z 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, 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 physicians will be more respectful and responsive than you might imagine.

Katie:

Thank you so much. I think that that's really helpful 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 a follow-up piece was written labeled quote, “the Ozempic edition.” It attempted to reanalyze this question in the age of the GLP-1 agonist and suggested that by democratizing access to thinness, which is how I would characterize their argument, and therefore making it 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 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 it 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 Macchi 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. 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, et cetera, 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.

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 of 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 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. 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.

Katie:

That is all for this two part series. Thank you so 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 Henah Velez and me, Katie Gatti Tassin, 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.