This episode is part of “Health Equity Heroes,” an editorially independent special project that was produced with financial support from Takeda Pharmaceuticals.
Rachel Feltman: According to data from the Centers for Disease Control and Prevention, at least one in five U.S. adults in each state are categorized as, quote, unquote, “living with obesity.” But for many of those people, having physicians focus on their size is far from helpful. In fact, there’s research to suggest that our fixation on weight could be preventing us from actually helping people live healthy lives.
For Scientific American’s Science Quickly, I’m Rachel Feltman. Today we’re talking about a topic that might sound totally radical to some of you, but I hope you’ll listen with an open mind. My guest today is Ragen Chastain. She’s a speaker, writer, researcher and board-certified patient advocate. Her Substack newsletter, Weight and Healthcare, meticulous, evidence-based information on, you guessed it, weight and health care. Today she’s here to talk to us about how weight stigma—in other words, a systemic bias against bigger bodies—could potentially be to blame for many of the negative health outcomes we’ve been taught to associate with gaining weight.
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Feltman: Ragen, thanks so much for coming on to chat today.
Ragen Chastain: Oh, thank you for having me. I’m so excited.
Feltman: I’m really excited. I’m a big fan of your newsletter. I find it super helpful, so—really looking forward to chatting about it. But for folks who aren’t already familiar with you, how would you describe what it is you do?
Chastain: Yeah, so my area of expertise is at the intersections of weight science, weight stigma and health care practice. And so I teach health care providers about best practices for working with higher-weight people. I help higher-weight people navigate weight stigma in the health care sphere, and I analyze and contribute to the body of research around weight-neutral health and weight science in general.
Feltman: Awesome. And I do want to pause before we go further just to talk about, like, words we might end up using and words we might not use that might surprise some listeners. Could you tell me a little bit about the word choices you use in your newsletter and the work that you do?
Chastain: In terms of language around higher-weight people, the terms obese and overweight are terms that were literally made up for the express purpose of pathologizing bodies based on shared size rather than shared metabolic profile or cardiometabolic status like we would see in a typical disease diagnosis.
And the idea of pathologizing higher-weight bodies is rooted in and inextricable from racism and anti-Blackness. And I absolutely urge people to read Sabrina Strings’s Fearing the Black Body and Da’Shaun Harrison’s Belly of the Beast to learn more about how not only are these things rooted in racism and anti-Blackness but they’re continuing to disproportionately impact those communities.
Feltman: Absolutely. Yeah, I really appreciate that because I think a lot of really well-meaning people and publications and institutions—I mean, probably also some very not-well-meaning institutions, but some of them are well meaning—you know, say, oh, we’re going to focus on person-first language.
And, you know, as a self-identified fat person, I don’t know any higher-weight person who ever was like, “‘Person with overweight’—that’s what makes me feel good.”
Chastain: As if weight stigma doesn't give me enough problems, let’s make me grammatically problematic as well. Yeah, the thing about person-first language is that it’s being marketed as antistigma language, but it didn’t come from weight-neutral health community, health-at-every-size community, fat activism.
It came directly from the weight loss industry as part of their campaign to have simply existing in a higher-weight body, again, regardless of actual health status, be seen as a chronic, lifelong condition that requires chronic, lifelong treatment from them. And so it’s being pushed through, quote, unquote, “patient advocacy groups” that they fund.
This is person-first language for higher-weight people. First of all, they co-opted it from disability community, where there’s a lot of conversation and transformation and nuance. And again, urge people to listen to folks from that community to understand those nuances. But absent those nuances, the weight-loss industry sort of took it and plopped it onto higher-weight people.
And the, the problem is, to me, it’s more stigmatizing because we don't talk about other bodies that way. I’m not like, “Oh, I hope my friend with tallness can come over so I can change that light bulb,” or, “I think that man affected by thinness on the bus—I believe I know him.” That’s not how we talk about bodies.
And so when we suggest that it’s so stigmatizing to simply accurately describe a higher-weight or fat body that we need a semantic workaround, that actually creates stigma. It doesn’t reduce it.
Feltman: Yeah, I think that’s really well put. Well, and this is a great segue because I think some of our listeners probably assume that it’s common sense that being in a bigger body brings all sorts of health risks. But of course now many researchers are pushing back on that. So could you walk us through what the data actually says about higher weights and what it doesn’t say?
Chastain: Sure. So it—I’ve been studying this research for 20 years, and I came to it believing exactly what you’re saying, right, believing being higher-weight is a healthy issue and weight loss is the solution to it. And in digging into the research, I found that neither of those things were actually what the research was saying. And so what happens is we get this research that correlates being higher-weight to a health issue and, you know, so your first day of research methods class, they teach you correlation is not causation, right?
You can’t assume one thing causes the other because they happen together at the same time. And this gets tricky in medical research because we use correlation all the time, but it’s not responsible to do that without investigating what are called confounding variables, right? Basically, what else happens to higher-weight people that could lead to higher rates of these health issues?
And in terms of the research, there are three well-researched confounding variables: weight stigma, weight cycling, or yo-yo dieting, and health care inequalities. And these things independently are correlated to the same health issues that get blamed on body weight. And in these studies, they’re rarely even mentioned and never controlled for.
And so when we talk about, you know, quote, unquote, “weight-related” or, quote, unquote, “obesity-related” conditions, what we might be actually talking about are weight-stigma-related conditions, weight-cycling-related conditions and health-care-inequality-related conditions. For example, [Linda] Bacon and [Lucy] Aphramor [noted research that] found that weight cycling could account for all of the excess mortality that was attributed to, quote, unquote, “obesity” in both [the] Framingham [Heart Study] and the NHANES [National Health and Nutrition Examination Survey].
And so we’re talking about serious confounders that are not being explored at all in the research. And, you know, a big part of that, from my perspective, is that the research is often being conducted and funded by the weight-loss industry. And I have sort of developed over time a bit of a subspecialty in the ways that the weight-loss industry has and continues to infiltrate and manipulate the health care industry.
And this research is one of those ways.
Feltman: Yeah, well, I definitely want to get more into that because I think you do some really incredible work in that space. But for folks who are, like, maybe having their minds blown right now, you know, what do we know about where this conflation comes from? I know that you already mentioned some recommended reading on the origin of weight stigma, but I would love to hear a little bit more about that.
Chastain: Yeah. So, and I want to say, too, if you’re listening to this and you’re having, like, anger, denial, defensiveness, incredulousness, I have had all of those feelings in the last 20 years as I’ve been researching this. So I want to name that as valid and say, when you do have those feelings, I just offer that as an invitation to dig deeper and ask more questions.
But in terms of weight stigma, so the research on weight stigma shows that the experience of weight stigma and even perceived weight stigma is correlated independently with things like higher rates of type 2 diabetes, higher rates of hypertension, suicidality, substance use, lower health-related quality-of-life scores, almost 60 percent greater risk of overall mortality—so we’re talking about serious correlations here between experiencing weight stigma and these health risks and issues that end up getting attributed to weight.
Feltman: And what do we know about, you know, how this impacts, sort of public health overall?
Chastain: So at some point, public health became less about helping the public be healthy and more about making fat people’s bodies the public’s business, with the goal of eradicating higher-weight people and making sure no more ever exist, right—the, quote, unquote, “treatment” and “prevention” of, quote, unquote, “obesity.”
And it’s helpful, I think, to substitute higher-weight people existing for the term obesity to get a clear picture of how this impacts higher-weight people in public health. And I don't think most people were doing this from an ill-intentioned perspective, right, but what we ended up with is public health that is hyperfocused on eradicating higher-weight people and preventing higher-weight people from existing in ways that end up harming higher-weight people and make it almost impossible to support the health of higher-weight people directly.
And you get a co-opting and twisting of the concept of anti-weight stigma that ends up like, “We don’t want to treat fat people badly, but we definitely want to rid the Earth of them and make sure no more ever exist but, you know, like, in a nonstigmatizing way,” and that’s not actually possible.
And so, through public health, this focus on, this hyperfocus on manipulating body size rather than an evidence-based option to support people’s health based on their own priorities and definitions at the size that they are has ended up creating a public health system that is hostile and harmful to higher-weight people.
Feltman: Yeah, absolutely. Well, and I think again, for our listeners who are, you know, maybe very new to this, let’s talk about some of the ways that, you know, sort of, um, health-based interventions can be decoupled from, you know, weight-loss and weight-based interventions and sort of the kinds of health care that people have difficulty accessing or [are] even outright denied because they’re in a higher-weight body.
Chastain: Yeah, that’s a huge, like, area of concern. So there's a lot of ways that this happens. There’s implicit and explicit bias from health care providers, right, where, either subconsciously or consciously, they’ve got these stereotypes and preconceived notions about higher-weight people that lead them to treat, you know, us differently—either give us less time, fewer recommendations, make assumptions about our behaviors.
There's also structural bias. And this happens when the things that higher-weight people need simply don't exist for us in the spaces we are. And that could be anything from a chair in a waiting room to an MRI machine. And all stigma requires systemic solutions, but structural bias can only be solved systemically.
Because you can have a fully fat-affirming provider, a fully fat-affirming patient, but if the MRI is too small, that patient cannot get care. And so, within the health care system, those are all issues that face higher-weight people on a daily basis.
There’s also, as you talked about, accessing health care. So as a patient advocate, often what I’m working on, and as a researcher and writer, is the idea of BMI-based health care denials. And this is when a person is refused a health care procedure that a thinner person would get unless or until they become a certain BMI or they lose a certain amount of weight.
And this is holding health care hostage for a weight-loss ransom that most patients are not able to pay. And it can sort of float into the ridiculous, where—I had a patient who was denied the gender-affirming care that they wanted but then was referred to weight-loss surgery. And that’s an actually a pretty common thing, and in this case, I don’t expect this to ever work again, but the argument we made was, you know, you’re saying that you’re denying this surgery because of anesthesia risk, but you’re now going to offer this patient weight-loss surgery. Whoever’s going to do the anesthesia for the weight loss surgery, could they just, like, come down the hall and do the surgery this patient actually wants and needs?
And they ended up agreeing, but I’m not sure that will ever work again. But, like, this is where we’re at in terms of health care for higher-weight people—that it can be a fight just to access basic care. And then the other piece of that is what I call provider weight distraction, where the provider becomes so hyperfocused on the patient’s weight and manipulating the patient’s size that they’re not listening or responding to the patient’s actual complaint presentation, why they’re there, what they want in health care.
And so this can really lead to patients who disengage from care or patients who simply can’t access the care that they want and need.
Feltman: And how do you think that drugs like Ozempic are impacting this, you know, weight-centric health paradigm? And then, you know, how is weight stigma impacting the way that we talk about these drugs?
Chastain: Sure, I, now, I take a very firm view of bodily autonomy. Right? So I think people can do what they want. But I think people deserve good information, and in terms of health care, they deserve ethical, clear, informed consent.
Feltman: Mm.
Chastain: I have done breakdowns of the research on these weight-loss drugs since they started, and I am not nearly as excited as the people who are reading the marketing language versus the research.
For example, uh, Wegovy, or semaglutide, Novo Nordisk’s drug, their four-year outcomes have just come out, and they claimed that people were able to maintain 10 percent loss. But if you look, they started with almost 9,000 people, and they ended with only 900 in four years. So that’s massive attrition that did not make the headlines, right?
So I think these are—first of all, I want to be clear, these are solid type 2 diabetes drugs.
Feltman: Absolutely.
Chastain: Right. They work well for people who are contraindicated on other drugs. They work well for people who couldn’t get the glycemic management they wanted on other drugs. and they have benefits in terms of only working when blood sugar goes high, so there are fewer hypoglycemic episodes.
But so what happened was they realized that these drugs had a small side effect of weight loss. And so what the drug companies asked was, “Well, if we gave people megadoses of these type 2 diabetes drugs, would that increase the weight loss?” And they found out that yes, it would, and that’s how these turn into, quote, unquote, “weight-loss drugs.” And so there’s a big titration difference because with type 2 diabetes, the goal is to give the smallest dose necessary to achieve the glycemic control that somebody wants and reduce or minimize side effects. But with weight loss, they’re just trying to get people to take as much as they can for the express purpose of maximizing side effects.
And these drugs have serious, sometimes fatal side effects, and so that’s not a small issue.
Feltman: Right. And how are you seeing the prevalence of these drugs, you know, with the goal of weight loss, impact the way mainstream physicians talk about and treat higher-weight patients?
Chastain: Yeah, so, and sort of to continue from your other question about how weight stigma is involved, it’s important to understand that the approval of these drugs by the FDA was based on a risk-benefit analysis that suggests that it’s worth harming or killing some higher-weight people to make others a bit thinner.
And that’s a view that’s based in weight stigma, right, often to cure or prevent health issues that thin people also get but from whom these risks are not asked. So there’s that piece of it, and the weight-loss industry, and in particular the pharmaceutical companies who make these drugs, are now falling all over themselves to say, “Oh yeah, behavior-based weight loss interventions don’t work long-term.”
Right? And they’re, like, the last 15 people to figure this out. We’ve been, people have been screaming this from the rooftops in my community since before I was born, right, that at this point, 100 years of research show that almost everyone will lose weight short-term and gain it back long-term because these behavior-based interventions physiologically change our bodies, making them into sort of weight-regaining, weight-maintaining machines.
And so now doctors are sort of being honest with themselves about this, right, because this is what they had, so they would just tell every higher-weight person who came in, like, “Eat less and exercise more,” without typically asking even what we ate or how much we exercised. And now they’re saying, “Oh, well, now there’s a drug, so, like, it’s so much easier, and you just get on the drug.”
And I’m hearing patients who are really being pressured to take the drug and/or who are saying, “These side effects are intolerable to me” and are being pushed to tolerate them.
Feltman: Wow. Yeah.
Chastain: Right? And being given an unclear picture of the likelihood of long-term success. The sort of best-case scenario is that at 65 weeks, people will have lost kind of whatever they’re going to lose.
And if they go off the drug, all of the research shows they’re going to gain the weight back and lose the cardiometabolic benefits that they got. And so this is, basically they’ve invented every weight-loss drug that ever existed. This is how weight-loss drugs work. But their marketing is that, oh, well, again, because of this idea that, quote, “obesity” is a, quote, “chronic condition,” you just have to take these drugs for the rest of your life.
Now, their research doesn’t support that this will work. In tirzepatide’s study, 10.5 percent of people who stayed on the drug had gained back 20 percent of the weight just in one year. So we don’t know that that’s even gonna work. Right? But that’s the messaging. And so I think doctors are getting a view of this that is vastly overstating the research.
And that’s because a lot of the communication is coming from the companies themselves, who also have taken incredibly active roles in creating and running the research. Um, and again, in doing the breakdowns for these, they have strayed so far from what would be considered appropriate best-practice research methods and statistics in order to get these results that they’re publicizing. And so I think that it’s putting doctors at a disadvantage because they’re being misinformed, and then they’re misinforming their patients. And there’s just, again, so much focus on the idea of making fat people thin rather than supporting their health directly that doctors and sometimes patients feel like “it’s worth risking my life and quality of life for this.” And that also is about not just health but escaping weight stigma, which is another piece of this, right: that we’re trying to change ourselves to suit our oppressors so that we can be treated better.
And while individuals can make that decision, as a society, to say you should change yourself to suit those who, you know, oppress and bully and harm you is a dangerous, dangerous road to go on.
Feltman: Yeah, absolutely. You know I think it’s so interesting how little medicine is expected to innovate to be better at, say, performing surgery on a person at a higher weight, you know, as opposed to having these BMI requirements for sometimes extremely necessary surgery.
And as a science journalist, I’m also just so struck by, like, the credulity I see in people talking about this class of drugs.
Everything I learned in, you know, science journalism grad school tells me to be extremely skeptical of, like, these, quote, unquote, “miraculous” drugs, you know, in the words of the companies selling them. And it just feels bizarre to see not all but a lot of the media treating these drugs, like, completely differently than they would any other class of medication.
Chastain: Yeah, that’s such an important perspective, and it has been really frustrating to me. Things like the New York Times—there was an article by Gina Kolata ... that every single expert quoted had taken money from the drug manufacturers.
And there was no disclosure of that.
Right? I’m seeing a lot of that, and, for example, there was a study that looked at the effect of Wegovy (semaglutide), Novo Nordisk’s drug, on major adverse cardiac events. And instead of releasing the study, Novo Nordisk released a press release saying that it had been a 20 percent reduction [in relative risk] in adults with, quote, unquote, “overweight” and, quote, unquote, “obesity.”
And that spread like wildfire through the international media. Novo Nordisk’s stock went up by 17 percent that day. But when the study came out, what we learned was actually a 1.5 percent reduction [in absolute risk]. The problem is, I don’t want to put this all on reporters because we’ve got a 24-hour news cycle; there are fewer and fewer reporting jobs; people who never intended to be science reporters are being asked to report on science.
So there’s a lot of issues that put reporters at a disadvantage, but I think it does the public a tremendous disservice when reporting is not more critical in the way that they look at these headlines and these press releases and this research.
Feltman: And when you think about a more equitable health landscape, particularly with regards to body size, what does that look like, and what needs to change for us to get there?
Chastain: Yeah. So we have a good body of research that shows that behaviors are a better predictor of current and future health than is weight or weight-loss attempts. And obviously, much more impacts our health than simply behaviors, right? But when we're talking about “What would a doctor recommend to a patient?” there’s an interesting study on this.
[Traci] Mann, [Britt] Ahlstrom and [A. Janet] Tomiyama looked at this claim that 5 to 10 percent weight loss creates clinically meaningful health benefits and found in correlational analysis that they couldn’t correlate the actual weight loss with the health issues, and they posited that it was, in fact, the behavior changes instead.
[Eric] Matheson et al. looked at four behaviors. They looked at five or more servings of fruits and vegetables a day, exercising more than 12 times a month, up to two drinks a day for cis men and one drink a day for cis women and not smoking. And they found that people who participated in all four of those habits had the same health hazard ratio, regardless of size.
So I think what we need in general is a change in focus that, rather than trying to manipulate the weight of people, that we’re trying to support their health directly.
Feltman: I definitely recommend that folks go check out your newsletter. We’ll absolutely link to it in the show notes. but if you could give just, like, one major takeaway to folks who aren’t going to go do that, what would it be?
Chastain: I just want to say that even if I’m wrong about everything, right, even if all fat people could become thin, even if by becoming thinner, they would become healthier, fat people would still deserve the right to exist without shame, stigma, bullying or oppression and would still deserve the right to complete access to society, including health care.
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 want to become thinner. Fat people deserve equal rights and access to the world, again, including health care.
Feltman: Ragen, thank you so much for coming on to chat today. This has been super informative, and I really appreciate your time.
Chastain: Thank you so much for having me and for talking about this and for all the work that you do. I’m honored to be a part of this.
Feltman: That’s all for today’s episode. Check out Ragen’s Substack Weight and Healthcare if you want to learn more—like, seriously, so much more, because she cites all her sources. We’ll be back on Monday with our usual news roundup.
By the way, we’re still looking for some voice memos to help with an upcoming episode. We’ll be taking a look at the science behind earworms, those songs you just can’t get out of your head, and we’d love to feature some of your favorite—or maybe most infuriating—examples. If you’d like to share an earworm with us, make a voice memo on your phone or computer and send it over to ScienceQuickly@sciam.com. And, yes, we do want to hear you singing, or at least humming, the earworm in question. Make sure to tell us your name and where you’re calling from, too.
Science Quickly is produced by me, Rachel Feltman, along with Fonda Mwangi, Kelso Harper, Madison Goldberg and Jeff DelViscio. Emily Makowski, Shayna Posses and Aaron Shattuck fact-check our show. Our theme music was composed by Dominic Smith. Subscribe to Scientific American for more up-to-date and in-depth science news.
For Scientific American, this is Rachel Feltman. Have a great weekend!
