Undisciplinary
Undisciplinary
Weight Stigma and Pharmaceuticals in Healthcare: talking with Patty Thille
Prepare yourself for an enlightening exploration as we traverse the complex intersections of weight stigma, obesity, and the pharmaceutical industry with our distinguished guest, Dr. Patty Thille, an assistant professor in the Department of Physical Therapy at the University of Manitoba. Dr. Thille shares her unique insights into the insidious presence of weight stigma in healthcare, offering a fascinating narrative that spans from her formative years in women's studies to her current research at the crossroads of healthcare and social sciences.
We shine a light on the far-reaching implications of weight stigma in influential sectors such as healthcare, education, and legal systems. Uncover the disturbing realities of how this stigma can result in status loss, discrimination, and, at times, misdiagnoses within healthcare.
We discuss medicalization and pharmaceuticalization of weight, examine the historical perception of weight as a social problem, and dissect the rhetoric surrounding the modern 'obesity epidemic'. This paradigm shift has cleared the way for pharmaceuticals to position themselves as the magic bullet for weight issues. As we navigate this complex landscape, we reflect on the potential repercussions of this pharmaceutical-centric approach.
In the last leg of our journey, we discuss Canadian and Australian obesity strategies, highlighting their shortcomings in addressing social factors while overemphasizing lifestyle changes. The role of financial conflicts of interest between pharmaceutical companies and medical professionals in shaping obesity guidelines is another area we delve into. Our conversations extend to the marketing strategies of weight loss drugs and their potential implications on public health. Prepare to have your perceptions challenged and your understanding deepened, as we unravel the intricate tapestry of weight stigma and obesity in healthcare with Dr. Patty Thille. Join us in this thought-provoking episode.
Undisciplinary - a podcast that talks across the boundaries of history, ethics, and the politics of health.
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Undisciplinary is recorded on the unceded lands of the Watarong peoples of the Kulin nation in Jilong and the Gadigal peoples of the Iroha nation in Sydney. Welcome to Undisciplinary, a podcast where we're talking across the boundaries of history, ethics and politics of health, co-hosted by Chris Mays and Jane Williams. Okay, so welcome to another episode of Undisciplinary. Jane, how are you going this morning?
Jane Williams:I'm going pretty well this morning, thank you. I am hiding away in a room with a COVID-19 home. I do not have COVID myself.
Chris Mayes:Well, it's a good thing we're on the same page.
Jane Williams:So I'm fine, but no one else is.
Chris Mayes:Ah well, stay protected in your bunker. So, as I have been doing lately, it would be debasing myself at the start. If you would like to like or retweet or send us a review would be lovely. We always appreciate that. But today we are going to sort of return to a topic which we've circled a few times but I don't think have really gone to the sufficient depth that we should or could, which is around weight stigma, obesity and the current politics And the current, i think, focus on pharmaceuticals ezempic. I keep on getting these ads. I got one about the ezempic, but recently that wasn't an ad so much, but it was an article about a side effect of this weight loss drug as the so-called. And so today we are very fortunate to have a special guest from Canada who has been here visiting in.
Chris Mayes:Australia, dr Patti Thal, and we look forward to having a more in-depth conversation around some of the topics we've already touched on. So welcome, patti.
Patty Thille:Great to be here.
Chris Mayes:So, before we sort of get right into it, it would be good to introduce you. It would be good.
Jane Williams:And also I'm going to introduce Patti. I also want to hear a bit more about his ezempic butt, though I don't get those ads.
Jane Williams:Anyway we'll get the business end of the way. So Dr Patti Thal is a research intensive assistant professor in the Department of Physical Therapy at the College of Rehabilitation Sciences Rady Faculty of Health Sciences at the University of Manitoba in Canada. She's a physiotherapist, sociologist and a feminist who has many questions about why we do what we do in healthcare. So after training and working as a clinician and Saskatoon, saskatchewan, she pursued further training in the social sciences. Her MA and PhD used a range of qualitative methods to help highlight how weight stigma is embedded in healthcare. She continues this work now, using community engaged methods and intersectional approaches to study how to disrupt stigmatizing and discriminatory practices.
Patty Thille:That's me in a very quick nutshell.
Jane Williams:Thank you for coming.
Chris Mayes:And congratulations, jane, on the Saskatoon in Saskatchewan.
Jane Williams:I was impressed. Yes, i know someone from Saskatoon.
Chris Mayes:Okay, so part of this podcast and the focus on undisciplinary and undisciplinarity, we'd like to sort of hear a little bit about the backstory. I mean, you already heard, i guess, a bit you coming from physiotherapy as well as sociology, but yeah, how did you sort of end up doing the kind of research that you're doing, being in the position that you're in? And yeah, as we say, some people do have a straightforward answer and straightforward story for that. But we also like to hear those more divergent and roundabout ways people end up where they are.
Patty Thille:Roundabout is a good word to use for how I got to where I got to. So I'm from a small town, like a 1500 people, a farming community, and I went to university to get a job, to get a good job, and so that's how physiotherapy enters the picture. I was, my mother was a nurse and asked me never to become a nurse. I was going to go into healthcare. I didn't. There's a whole lot of medicine I never wanted to even go near. Physiotherapy seem like a good fit.
Patty Thille:I happened to take a women's studies class prior to starting my physiotherapy degree. It was not direct entry from high school and that class was so intellectually engaging I didn't get my physical therapy degree but I didn't feel done with that type of learning. So I ended up practicing and doing one class a semester in women's studies and eventually a profit is like you know that, your three classes away from a degree right. So that's how that starts. And and the thing that really captured my tension in gender and gender and health seminar with a medical sociologist was around just very basic manifestations of sexism and healthcare. I just distinctly remember the way that sort of prescribing practices around heart disease and women were very much based on studies exclusively with men. That's the end. And we're talking about an example that was studied probably 30 years ago. So, yeah, so that's sort of open up the path.
Patty Thille:And then I just was very concerned, and I think, with both some experiences I had in healthcare. So as a patient I'm and for the record, for just for context, i'm actually a straight sized woman, meaning at the time I would have been probably a size four, but I had a doctor say to me like I don't want you putting on any more weight, and I was very confused by this. So that's the start of a whole story. But eventually it really got me thinking about how we think about weight and feminist studies of the body really help me open up those ideas.
Patty Thille:And yeah, it was just very clear to me that I I see myself as kind of a way I can bridge between the social sciences and the health sciences, because I have this clinical background. In sociology I'm considered an applied sociologist. In healthcare I'm seen as highly theoretical, so it's an interesting tension to live at, that, that intersection, but I see myself as sort of a person who can bridge in both ideas from activist and advocate communities into healthcare, as well as social science theory and methodology. So so that's sort of my story, and and it was to my great surprise that I ended up back in physical therapy. But here I am, this amazing position opened up for me, and it just fit Yeah.
Chris Mayes:And so while you were doing those classes and practicing as a physiotherapist, we also sort of seeing residences and problems concerns in the sort of physiotherapy practice as well, or describing of heart for heart conditions. But yeah, well, there are things going on in physiotherapy.
Patty Thille:Yeah, i had a chronic pain focus and I worked in a public practice that had a chronic pain focus in particular, and we didn't have the equipment for certain to go above certain body weights And so people, if they had a higher body weight, we actually couldn't give them the same privacy as we gave to other patients And and this was an intensive rehab space, so it's not like people coming in just for their single appointment, it's that people are there for whole days and for weeks on end, like on and six to 12 weeks, and I there was also. I mean, there's one person who really stands out because I wasn't there the day that we decided who would take in, take on the new patients, and at the time I'm like I'm a small person, i'm five foot one, i you know. Again, i've sort of given a body size I'm, and instead of the 200 pound muscley physio that I worked with, taking on this man who has body weight over 400 pounds we do speak in pounds in Canada. Still I was given him And so not only do we not have the equipment, but I'm actually just not as strong and wasn't able to offer him the same treatment, and I just remember being very like something is very wrong here, and then, at the same time, having my own experiences and then starting to talk with other people and using actually one of those undergrad assignments to begin to explore this, and then I was just kind of like what's happening there? so so I did have clinical experiences And I also have some patients who were really interested in this women's studies stuff I was doing.
Patty Thille:I'd have these. Really. Some people like to chat when your hands are on them and some people don't, and so it ended up chatting with some of them about it and they would share their stories as well. So that's what opened it up. And then I went into my master's thinking I was going to be writing guidelines for sensitive practice. You know how ambitious of me in 2002 to think that's what we meant when we said guidelines, but I it was very clear to me that there actually wasn't really good guidance and literature at that time, and if you wanted to do something differently, it wasn't clear how. So that's really that like how that opened up for me. So that's what I think is the most important part of this topic and this and the focus on trying to make a change, which is that applied sociology on a bent Yeah.
Chris Mayes:Yeah, and that's a good lead in an example, i guess, of weight stigma and its sort of prevalence in clinical contexts and the subtle way it can just come in as to sort of who's assigned what patients, etc. But yeah, what, what effects of what, what? what do you see as, i guess, a definition of white stigma and then also some of the effects that that can have in both the clinical context and then, i guess, in people's lives?
Patty Thille:So I'll start with the description. So weight stigma is actually kind of a euphemistic term for fat stigma. It's not really used applied on the on the more on the thinner end of the scale. That's not really how we use that word. So weight stigma is about fat or bodies in particular, and it is, stigma is a process where stereotypes are added to people based on their in this case a body characteristics, so personality kind of characteristics are ascribed to people. That group of people are then come to see as be seen as a problem that have to be fixed, which results in status loss and discrimination. And this can only happen stigma can only happen if powerful institutions like healthcare, education, legal systems etc. Are reproducing these ideas.
Patty Thille:So weight stigma is specifically the negative stereotypes applied to bodily fatness and therefore people with higher, with more body fat. That manifests in loss of status and discrimination in things like healthcare and the example that I gave of my being assigned someone, though someone was like stronger and bigger and better, more appropriate. But it's also in the things like the lack of equipment we had, so that person didn't have the same privacy and and equipment and structural manifestations of stigma is also one of the parts of it so. So it can also show up in terms of how people see themselves, that's more the internalized stigma. Stigma can show up in interactions between people bullying, shaming, lots of language for that, exclusion, excluding but it can also show up in structural forms so people have the same type of treatment they don't have. You think of university lecture halls? who are those seats for? who? are they not? for all these ways that those, the like physical structures as well as other type of structures, can say that you don't belong here or you are devalued. Okay, so that's my description. Now tell me, it's a little bit of clinical manifestations.
Patty Thille:What does it do in health care? I think was your next question. Yeah, so it does a few things. So one that gets talked about a lot is that people who are repeatedly stigmatized in health care start avoiding health care, and that makes that's totally logical. If your health care needs aren't being met like why would you keep going? And but the other side of it is that when people receive care that's that's based on like discriminatory care right, that re reproduces weight stigma It's things like people not getting diagnosed at the same rate.
Patty Thille:So in Canada there's a very sad story of a woman who for years was quite unwell and she kept on being told it was her weight for for years. She was diagnosed with cancer. At the time point she was palliative and died 10 days later and used her obituary as a way to talk about this experience. So that's an extreme case. But the idea of people not getting the same referrals, the same assessment, the same treatment based on the same condition is another one of the ways that it manifests. So if, if people default in times of uncertainty we are not sure what the diagnosis is Weight and fatness kind of becomes a default, like that's going to help. You know, it's going to help your, your dizziness if you can be more active, or your fatigue if you can be more active, and so it sort of stands in as a way to reduce the I don't know what's happening here sometimes to, and instead of actually investigating what's happening, it gets used as a stand in that way.
Chris Mayes:Yeah, it's interesting, you bring up dizziness, like I remember I had a bout of vertigo and it's still unexplained and so I still sort of worry. You know what's going to happen. And then I went to the the GP, and he basically was like I don't know, but you could lose, you should lose some weight. Well, i haven't gained a bunch of weight or lost a bunch of weight in the time you know in, you know this period, and I don't usually fall on the floor and molly through dizziness. So you know, i think maybe something else is going on. Anyway, fortunately that has not happened again. The dizziness, but yeah, just that. And this is something in the fat studies literature, as you're well aware, that you know is talked about a lot, that you know anything can be reduced at all to someone's body weight or sizes. That stands in as a easy, easy descriptor or easy, sorry diagnosis for what's going on.
Jane Williams:I would imagine that misdiagnosis so common, which I won't go into.
Patty Thille:Touch on that, because that was what I did in my masters was collected stories of women's, openly defined, and a range of ages, etc. So experience is talking about eating, exercise and health and weight. Sorry, eating, exercise and weight in healthcare settings, And so I collected both strikingly positive and strikingly negative. And so, yeah, that example of, you know, joint pain etc. Everything comes down to weight at times when there has been an active injury or you know it's, it's yeah. So sorry, I just feel like I wanted to share that one more, but please go ahead.
Jane Williams:So I'm just going to chuck this in there, because it was one of those quite off the cuff comments that was quite revelatory to me. So I feel like if I say it on here, maybe some more people will hear it as well. But you were talking about the lectures, theater and the seats, patty and who. Therefore? And last summer I was trying to buy some outdoor furniture and I was chatting about that with my excellent friend, leanne and she said whatever you do, don't get chairs with arms on them. And I was like, oh, how come?
Jane Williams:And she said, because I look at those chairs and I just really worry about whether or not I'm going to fit into it, and it's such a simple thing And we don't need chairs with arms. But what it is, what you know, if I'm inviting someone to my house and we've got all these chairs with arms, and the first thing somebody thinks is, oh God, well, i fit into that chair. You know that's really shitty, yeah, and and obviously not a thing that I was intending to signal to my lovely friend, but would have done it unthinkingly all the same. So I'm putting this out there Think about the size of your chairs when you're buying furniture.
Patty Thille:Yeah, the size, the arms and the weight limit actually. So in Canada I use advisory groups like I, members of the public who experience weight stigma in health care, and I actually can only book a couple of places for us to meet in person, which hasn't really been happening during the pandemic but before it did, because so few places have appropriate seating. So, yeah, so usually the instruction that are the information that I share is a variety of chairs, because some people do need arms from mobility perspective, but different widths is really good, so benches with arms can be also helpful for some people. And and then knowing your weight limits, because a lot of chairs don't go much more than, let's say, 285 or 300 pounds again, pounds, sorry for you Australians. That properly made the metric.
Chris Mayes:Yes, In talking about stigma. I mean, one way that's often talked about is stigmatization, and so it's. One of these is Asian words, which is you've recently published a paper with Andrea bomback and Louise Adams called drivers of medicalization in the Canadian adult obesity clinical practice guidelines, and there's a lot of stuff in that, and we will share this article with our show notes, etc.
Chris Mayes:Yeah, it'll be really great to unpack all the different things that you talk about in this short but very interesting article, but before doing that, so you do have a couple of terms in their one, big medicalization, the other interesting one being the pharmaceuticalization, and the pharmaceuticalization of fatness is something you talk about, and then I'm going to throw in another one, pathologization. So these are station words. You know, sociology tend to talk about the processes of something being turned into something else, and so And this ties in with the comments I made earlier about Azenpic, i think I'm pronouncing that right.
Chris Mayes:But other drugs that are coming in and seeming to be talked a lot about in the media just in the past six months I've only noticed it myself but this pharmaceuticalization of fatness. So could you talk a little bit about the relationship between those two things, the medicalization and the pharmaceuticalization, in particular in relation to your article or just in general would be.
Patty Thille:Well, yeah, okay, great, i'll start with medicalization. So medicalization is seen as the turning of a social problem, so something that in society is seen as a problem, into something that medicine acts on. That's how I would sort of try and explain that. So body size, specifically bodily fatness, was not always seen as a medical concern in the same way, actually, its roots in terms of treating it as a negative, the stereotype, et cetera, comes, precedes medicine taking it up. But so medicalization is the process of something, and a classic example that I point to for some things is homosexuality. So homosexuality and same sex attraction or same sex sexual activity was seen as a crime in a lot of societies. So that was the way it was criminalized instead of medicalized. Then it is medicalized as, treated as a psychiatric disorder, and we don't see the reduction of stigmatization by something becoming a medical problem instead of a crime problem, because it was constructed, at least in Canada. It is by the removal from the medical domain and the fighting against the idea that having same sex attraction or being queer is a pathology. So the rejection of that idea altogether. But what's been happening with weight? I mean, weight has been medicalized. We're not talking about a new phenomenon We are talking about a you know, probably near or around a century, that body weight has been seen as a medical problem to deal with, but we've seen this intensification through the language of, or the rhetoric of, the obesity epidemic. So that's a phrase that we are all very familiar with. It definitely has a rise at a certain moment in time, and so medicalization then can open the door to pharmaceutical intervention. So where something becomes seen as a target for pharmaceutical companies to develop drugs for or to market drugs for off-label use of pharmaceuticals And so pharmaceuticalization is about approaching a medical problem as one that pharmaceuticals can address Is sort of in my simple term, and this article is about these Canadian clinical practice guidelines released in 2020.
Patty Thille:And they were released by two organizations, so obesity Canada is the name of one of them, and the other one is a bariatric surgeons organization. So these are organizations that are deeply invested in the idea that this thing that they call obesity is a chronic disease, so they've really invested in that chronic disease language. And the new guidelines speak a lot about medications, and that's fairly new. So not new entirely, but attempts to have weight loss or fat loss drugs.
Patty Thille:In the past they have these drugs have been quite dangerous, and now there's a new wave of them coming in, and so pharmaceuticalization, if as a process, involves a number of things and including like expanding your market right, we're talking about a capitalistic model where you need to have a market And so that's done through both this promotion that you've started seeing in the last six months or so, chris, but also can be done through things like funding organizations that develop guidelines that are very friendly to pharmaceutical intervention. So so the pharmaceuticalization is, if we think about it as a process, so it's a process of turning fatness into something that can be addressed with pharmaceuticals at its most simple basis. And I might pause there and let you follow up, because I can say more.
Jane Williams:But yes, i got some questions. So one Well, you know you referred to the drugs that were taken earlier. Hey, so it's not new to take drugs to stay thin, or. But I'm curious about whether you think that drugs to stay thin are different from drugs to address obesity. Like I'm I'm only going off kind of vibes here of the, of the use of speed, basically in earlier, earlier generations, of mostly housewives, it seems, and I don't know if that's just an impressionistic thing or if it's born out in the literature.
Jane Williams:And then I'm thinking about other things that have happened, like remember Alestra was going to be there And it was going to fix all of our problems because it would just mean that we, you know if that wouldn't stay in us, or whatever that was about. And then the final question that I had, i guess, was I was I was googling semi-glutides this morning, which is the drug that is M pick is, and see that it was approved in 2012. I'm really curious about why we're hearing so much about it now And whether that is perhaps going to your article, patty, it being sort of taken up as a as a pharmaceutical solution to obesity rather than the blood sugar lowering drug that it was apparently intended as initially. So I've just checked a whole lot of ideas there, but there were the things I was thinking about while you were talking.
Patty Thille:Yeah, that's a lot to respond to And I feel like I'm not going to do quite an adequate job in responding. But I I mean some of these, the new drugs, right? I think of Wagovie. It's being called the skinny jab And it's being taken by people who don't have weight problems in the medical diagnostic sense to stay skinny. So we're already in that, like what is the? you know, it's already being used in these variety of ways And I also OK, i'm just riffing a little bit off of you here, jane, but it's also that like people smoke to stay thin, like that was definitely a thing as well, right?
Jane Williams:And sleep. I remember talking to some models once who said that they would drink and sleep, so the more they were asleep, the less they were awakened, therefore thinking about eating.
Patty Thille:Wow, the things that people will do to stay thin.
Jane Williams:I mean to be fair. The jobs would be thin.
Patty Thille:So yes, yeah, yeah, no, no, i hear that. I mean the why. Now it's a really good question And admittedly I'm a contributor to this paper and not the first author, so pharmaceuticalization isn't my focus per se in my research. So what I will say is that, for whatever reason, this is seen as, the ground is now ready in some way. So I think someone sort of traced out the series of studies, the way it sort of created the market for these. I mean it's interesting because the guideline recommends use of pharmaceuticals, including in populations that it's not well studied in. So it's clearly not all about evidence, and particularly some of a more recent guideline that came out around pediatrics care in the US has the use of these quite young, without any form of long.
Jane Williams:Including very atrix surgery. Right, yeah, it was on the 12 or 16. Yeah, it was young.
Patty Thille:Yeah, and we're just in a place where I mean, the pharmaceuticals, pharmaceutical companies, were not always the funder, for example, but BCD Canada. So BCD Canada started as a federally federal grant funded, like federal government grant funded network, and so, as they tried to become independent, they looked to corporate funding, and so pharmaceuticals make that. You know, they start making that connection and they start off in the smaller projects and then become more and more embedded, which is something that we do talk about in the article. And so, yeah, the why. Now I'm sorry that I'm not giving a very satisfying answer, but yeah, i've got a hypothesis.
Chris Mayes:I mean, i think, that point you just made, though, about Canada. I think it's also important to bear in mind different contexts, like what you just said about the funding model for BCD Canada and how perhaps that's different to Australia. With the say there's a team at Deakin University who are now rewriting the Australian guidelines for the National Health and Medical Research Council. They all have positions at Deakin University. They've got a grant through the Australian government and through the NHMRC to write this, so they're not reliant on industry money, but also they are, i would say, very much within the episteme of nutrition and physical activity. That's the centre or the institute that they're from. So they are still on that, still on that approach to weight management, if you like.
Jane Williams:Yeah.
Chris Mayes:That term. It's something that has concerned me in, i guess, my own work And I think part of the problem is the critique of the ineffectiveness of dieting and lifestyle modifications. That critique, say, made by and we can talk about this a bit more later but say the health at every size movement or people who have said you know, dieting doesn't work, that kind of critique, making that critique in the absence of critiquing the underlying idea that fat equals bad and unhealthy, only sort of maintains weight stigma and then gives rise to more insidious interventions like bariatric surgery or this pharmaceutical approach. So you know these companies and I remember when I was doing my research on the sort of lifestyle stuff like the barrier. do you call them bariatricians?
Chris Mayes:I don't know bariatric surgeons were more than happy to accept the critique that dieting doesn't work. They were like, yes, dieting doesn't work, so let's get you under some general anesthetic and get get surgery. And then, likewise, i imagine that the pharmaceutical companies And again, i think this is a only one part of the picture, i think, the pharmaceutical industry and off label prescribing. We have some colleagues who Wendy Lickworth and NASA's Giddy who've done some work on off label prescribing, but I think off label prescribing would be another interesting area to explore as to and as you mentioned earlier, with capitalism and the pharmaceutical market is always looking for
Chris Mayes:a new market And this is, like I think you know, such a lucrative prospect for them, like when we talked about it with the articles in the Australian newspaper, and especially if they're still able to sort of talk about, you know, the overweight and obese, lumping everyone in together. So 66% of the population is a potential market for these companies, and so I think that's something that's been saying it's irresistible for them. But yeah, that idea though, of critiquing dieting and weight loss, but without taking that further, to sort of destigmatizing fat, i guess, and to say that fat doesn't equal bad or unhealthy, which I guess is where I brought in that other categorization, so being able to say that weight and fat is a pathology.
Patty Thille:Yeah, yeah, yeah, i know that. But okay, i have many responses. But the big critique of medicalization really is how it individualizes the response to something And it's really impatient at a time And, as opposed to getting, if there is, for example, we are less active. I'm a physical therapy prof. I mean I, you know, i those things do matter, but like what's driving that I can't look at the drivers of those kind of things and actually orient public health toward those things, like we're not. So this idea that we develop guidelines and clinicians are supposed to do this thing When people are, for example, in an environment that is or in a situation that is like deeply conducive to those things, it's, it's kind of a bait and switch, like what, what are the changes in our culture and our environment that are producing some of these increases, for example, of some types of health problems for some? And then we we don't really ever address them. So you mentioned the social determinants of health, chris.
Patty Thille:There's another piece that we published a few years ago around weight policy, weight related policy in Canada. It's in the CMA J And it really is like the sort of lip service to social determinants of health. It's acknowledged as a problem but we're still going to promote eating and exercise. and this is the tension. I actually looked up your Australian I haven't had a full chance to read it all of it, but your Australian. So it's called obesity national obesity strategy 2022 to 2032. And the subtitle is Australian enabling Australians to eat well and be active. And then when you, from what I've seen, it's sort of that same kind of we know that the problems are this other thing, but we're going to talk only about eating and exercise like we're. we're not going to talk about stress, we're not going to talk about sleep deficits and it's, you know, impacts on bodies. And I really lursons lurson did this really wonderful.
Patty Thille:Lars Larson did this wonderful comparison of health policy in Denmark and US over several decades and really showed how lifestyle has become in policy which originally understood very much a contextual, like how someone styles their life or the routines of their life are very much contextual on the environment and the community that they find themselves in. but we see the removal of that contextualization by the 1980s And we're still now. we see, i think in these reports we often see like some acknowledgement, but they're also not going to address them and guidelines are just never going to address those things, and I've written another piece about guidelines. there was a 2015 guideline in Canada and, and really the thing about guidelines is that the end product really reflects the assumptions and the boundaries put on the knowledge assembled from the beginning. And to understand a guideline is a knowledge brokering process. you are the broker of a number forms of knowledges and you're putting them together in a certain way. the knowledge is that you will and will not pay attention to shape the final result, and so I think that's that's a lot of of where rat with guidelines.
Patty Thille:we're still stuck in this cycle where we want to treat it as an individual problem To the extent we focus on lifestyle more generally for any number of health things we don't actually want to do. the bigger health, like the bigger environmental kind of work. And to your comment about the bariatric surgeons are like, yeah, we're happy for this to you know, to be not seen as a lifestyle problem. I really I think it's Karen Thrasby's work, but it might, it might also be one. I can send you the references just to be sure. but who did work around the way that bariatric surgeons in the US actively promote bariatric surgery like it's? like we know you are stigmatized based on your size. that is wrong and we can correct it. But then when surgery doesn't produce the results, it's the patient's fault again.
Jane Williams:Yeah.
Patty Thille:Right. So because, just like any other surgery, it creates a range of results, including no weight change for some, right, and so then that's, that's treated, it's, it's in in their language. It shifts from being, you know, we understand that there's a lot of things that affect weight and a lot of things that affect success in terms of being a successful thin person, if we want to use a bit more sociological kind of framing.
Chris Mayes:But it's, but, yeah, but they flip it like it's a marketing technique, right, it's interesting that you're saying that about the bariatric surgeon saying that they'll take away the stigma, like in that empathetic move, because that's similar to what you say here in your article about the pharmaceuticalization that, this recognition of stigma around weight. And here we're going to help you out with whether we're part of the good guys who are going to sort of take away weight stigma by providing this pharmaceutical solution.
Jane Williams:Take away weight.
Patty Thille:stigma by taking away weight Yeah so we're not going to deal with the root cause, which is personality characteristics being assigned to people based on a body characteristic. We're just going to change the bodies, and I actually okay. so to go back, we've talked about my undergraduate, my one class at a time I wrote a paper about cosmetic surgery, just because I felt like I had really no hand it was going to. I was going to do a paper that was looking at how medicine approached eating disorders versus cosmetic surgery, and I was told that was a master's degree, and so I had to pare it down And think I really struck me in that literature and this is again I'm writing based on stuff that's published in the 90s and even the 80s was that cosmetic surgeons some of them talked about themselves as being doctors of self esteem, and so this idea that we're not going to fix the problem at a social level, but we'll, we'll take away the problem for this one person I mean, that's the model, right, it's like, and what ends up happening is reinforcing, in their case, beauty, beauty standards.
Patty Thille:we reinforce beauty standards And by making more people conform to them with surgical means, and so it's the same thing here. we we help more people conform to expectations around body size through surgical means, and and the expectation is that people will take on both the lifelong change that some of these surgeries, particularly which I'm about, bariatric surgeries It's not like you have the surgery and then, like your life is the same. you have to do like all of this lifelong, your stomachs permanently altered, you have to eat differently, you have to take all these supplements, you have to like you. you can't be social in the same way with other people around. food like it's the actual lifelong work you know is completely ignored, let alone. you know people can die from these surgeries, cosmetic or bariatric depending, it doesn't matter which one. we're talking about, right?
Patty Thille:So the idea that people take this kind of risk is quite shocking. like for the possibility of this outcome, and and the thing about prior pharmaceuticals that were supposed to address weight is that they had all sorts of harmful effects. And and so I remember seeing I also have been on the receiving end of some of this promotional materials, and the Guardian wrote, published a piece about the, the orchestrated PR campaign around these, and and the one friend sent this to me and it was a video by a respirologist, so someone who deals with the lung and respiratory respiratory system. who was talking about? it's a game changer, and they used actually all of these language that comes out in this, this guardian piece, where they found like they actually had the documents around what the PR campaign is like. So your first red flag is why is a respirologist talking about this?
Patty Thille:And then, as he went on, it was like talking about a 10% serious side effect rate and it was like but this is so good and I just remember being like that's the serious side effects And the like, wow, like that's. you know, it's quite shocking the way that these things get promoted at times. Yeah, so, yeah, and so it's a different. these practices, yeah, so they. if, if they result in the in a thinner body, which is this, this and and, with this idea of concealer and this is like a face of that person, this is kind of a compliment or pretty much a of respect to this idea of makeup being done. Okay, let me finish that first sentence.
Patty Thille:If they result in a thinner body, yeah, that person may experience less weight stigma. It doesn't mean that their life isn't. A lot of studies have talked about people after those surgeries really like wondering why people treat like, how badly they were stigmatized is really visible to them, and there's some things with people really questioning like people approaching them now. So new friendships, new relationships, like what they still like me if I'm bigger, but it's just very different understandings of risk and what again, what kinds of knowledge matter? Okay, i'm getting a bit rambly, so you're probably going to cut some of that, no, no, no.
Chris Mayes:I mean on the what kind of knowledge matters, though, and this comes back to the guidelines. I think there is a newness and a shift that has happened, and you talk about this, maybe not necessarily as a newness or a shift, but that it's not just a matter of a bunch of people who are focused on nutrition and lifestyle changes, writing guidelines because they're committed to lifestyle changes And that's what they want to do And that's what I think is the correct approach.
Chris Mayes:But with the introduction of the pharmaceutical companies and sponsorship and people who have received money, there is a direct financial conflicts of interest between these people writing. I think, while I disagree with the guidelines written by people who are sort of wedded to the lifestyle modification model, I can kind of at least see that they have intellectual integrity in what they're doing. If you ask me to write the National Guidelines, it would probably be very fecodian and, you know, very focused on a social determinants of health and they're my commitments. So that's what's going to come through. But with these guidelines that you're talking about, with obesity, Canada, where there is financial contributions from the pharmaceutical industry, the whole question of the integrity of the people, as well as the guidelines, comes into question. And I think this comes as well to this broader questions of ethics and practice within medicine and medical research.
Chris Mayes:With the introduction of these commercial and capitalist incentives, The way, particularly in this country I don't know about the history in Canada, but you know advertising in medicine was something that was there were strong norms against and regulations against doing that And the way that there's been this soft creep of, particularly through social media.
Chris Mayes:But the way that you know whether it's the IVF industry, you know talking about egg retrieval as being like a bikini wax, you know, and just minimizing all of these harms that are associated with these. You know what they would term, as you know, very minimally invasive surgeries, but not talking about, and using social media to promote them, bariatric surgery. These drug companies, I think, are big shifts that are a continuation of what's been happening slowly, but perhaps an acceleration. And so, yeah, the thing that I thought was really interesting and disturbing is the this conflicts of interest and the intensification of the pharma influence in Canadian obesity organizations. And so these guidelines not only do they rule out other ways of looking at things, but they're also financially invested in looking at a particular way of things.
Patty Thille:And they would actually, i think people with conflicts of interest often want to downplay them. So it's there's actually a lot that I could say, a lot that couldn't make the article, But in short, this this guideline was published in the Canadian. These guidelines were published in the Canadian Medical Association Journal. They were published early in in in the year that they then were in a journal that was bringing in new conflict of interest guidelines. So I think they made it in just under the wire, like had they submitted six months later they may not have been able to be published in the Canadian Medical Association Journal. And so this, yes, and the article we're talking about does give examples from diabetes as well that have been studied right. So the conflicts of interest, yeah, they're very pernicious. And and obesity Canada, for example, has talked about their process, like that they had a process. They state that they had a process to manage conflicts, but there's no publicly available information about what that process was.
Patty Thille:And the thing that I I found myself thinking this earlier and I think it's still relevant to say, is that people's whole careers are on the line here. You know, if you've spent your life I mean if you're a bariatric surgeon these ideas, actually thinking differently, about risk thinking. How can we like weight neutral care as a as a way to destigmatize practice, for example? these are like career threatening. So we're talking about entrenched interests. Some of them are conflicts in the pharmaceutical funded sense and some of them are just people are going to be entrenched.
Patty Thille:It's going to be quite hard, if you've built your career on these ideas, to suddenly go. You know we have it all wrong And so that's what it's. That's where I think sociology can be so powerful Among other social sciences. Humanities is just really trying to highlight, like what's going on here, thinking bigger and broader about the, the patterns that we're seeing. You know, the fact that capitalism exists and these are its manifestations like that should surprise no one at this point. Right, they're going to try and build markets and by the part of building markets is deemphasizing the potential harms or the lifelong impacts that someone might have from pursuing a particular treatment.
Chris Mayes:Yeah, I mean to go back to the Azempic butt that and I didn't read the whole of this article that was promoted to me based on my, i guess, prior readings and but I mean that seems to be a. so from my understanding it's the weight loss drug causes your bum to sag and so people, so it's gotten aesthetic and then no doubt will be a so it's got an aesthetic and then no doubt will be a surgical or pharmaceutical intervention that can assist with that problem. But that seems to be a PR issue at the moment for Azempic is if it's been marketed for this aesthetic reasons as well as, obviously they would say, the health reasons, but if a primary driver is that aesthetic dimension to body shape if this is a you know outcome, then it may not be as lucrative as they hoped.
Chris Mayes:But that also reminds me and and yeah, just going to, i guess, some Ficotian language around successful failures and the way that with these drugs, when they do fail people, and the way you were mentioning before that it can just all with the bariatric surgery, that it can just be put back on the patient as their fault They didn't follow the right process after the surgery. Or, you know, in your article you talk about the lack of efficacy and safety for a lot of the drugs that have been introduced And you know some of them are things like cardiovascular disease, which no doubt can be reinterpreted as well. They probably they would have had an underlying condition already due to their obesity or body weight which only further.
Chris Mayes:And this is the successful failure that when they die, it just reaffirms this need for further intervention onto these people and their bodies.
Jane Williams:Right, can I go ahead, zane, yeah, oh yeah. yeah, i was just going to talk about the Azempic butt as being a successful failure. right, it's not sagging, it's because you're losing fat. You're only meant to. you know, your butt's the only body that's meant to have fat in it. So that is the drug doing its work, presumably Having only heard about it 20 seconds ago or whatever that was, but I see that as maybe a successful failure as well.
Chris Mayes:Yeah, and also perhaps shows just the lack of targeting. you know the sophistication of these things.
Jane Williams:You know we had a conversation offline about that, Yeah Of the way, oh, what the drugs meant to be able to target everything except your butt.
Chris Mayes:Well, no, the way that this idea of what is a weight loss drug anyway, they have some you could like is that just the primary thing that it does?
Patty Thille:You know you could talk about.
Chris Mayes:You know marijuana as a appetite inducing drug, but it also does a whole bunch of other things. And yeah, just the way that drugs do have lots of effects and what we call the side effect or the primary effect seems up for debate.
Patty Thille:Yeah, and that gets. I've worked a little bit with the concept of framing right, and so this is a very particular frame that you're talking about. Right, that this thing is a weight loss drug but it has all these other effects and what gets named? what gets named, what gets foregrounded, what gets advertised and what gets de-emphasized or ignored in advertising.
Chris Mayes:So it's called the internal bleeding drug.
Patty Thille:Yeah, no, and it's your work about. Okay, is MPEG bucks, but is also new to me. So you know I'll go with that. But this also brings me back to Karen Thrasby, who I mentioned earlier, and she did a piece called the obesity. Obesity, multiple And skin is a thing Like after bariatric surgery those people who have a significant reduction in fat. Then their skin really changes And their skin becomes a point of distress for some people, and then that's yeah, then you can go for the cosmetic surgery. There we're making the link complete, you know, yeah.
Patty Thille:Yeah, the idea of frames, though, like the reason that I talk about this on the whole, is because this way of thinking, this way of framing, this way of understanding, closes down the potential for others, and that's Foucaulti in a discourse sense. Right, this is the way that we understand this thing at this time and place and this culture, and it's not to say that it's forever and it can shift, of course. Maybe even talked about some of the shifts, right, these organizations, pharmaceuticals and et cetera, taking up the weight stigma as a problem frame right, they've shifted their frame, but the big challenge is that they make it harder To talk about other ways of approaching, so they close down alternatives. So you know the idea that there is no alternative. This is, this is the way versus there are many alternatives And and having an active conversation among them And even get funding for some of the other ways to approach this topic. Right, it's Dominant ideas.
Patty Thille:And let's be clear medicine and pharmaceutical companies still hold a lot of power in our society to And I'm not being very for Cudi and for Cudi and in my name use of that term for Cudi and there's the right word But pharmaceutical companies and medicine are still quite powerful institutions in terms of shaping the way we think about things. You know media will take up their framing. For example, i'm going to give an example. When the guidelines were first released, a few of us wanted to write a conversation Canada response So I know you have the conversation here in Australia as well And we wanted to talk about this.
Patty Thille:But the actual weight stigma part of the guideline writers had written their own conversation Canada piece And when we proposed our alternative, the editor was like was not there for it And because we were going to talk about the pharmaceutical influence etc. And and the editor's response was like well, of course, pharmaceutical companies are going to find things that align with their interests, as sort of this idea that they're the conflict of interest is not so much an issue. But then we have something like the conversation Canada, which is supposed to promote academic dialogue, including on contentious things, kind of shutting it down and promoting a particular frame, which is the way that obesity Canada and these guidelines frame their approaches destigmatizing, and it's actually gotten quite aggressive over time.
Patty Thille:So, in terms of just not the conversation, but I mean just the way that this, the obesity world, has responded to critiques has become more aggressive. That's what I want to say. So initially they just ignored alternatives and we've sort of danced around the health at every size. They just don't cite it, they don't acknowledge its existence. I remember talking to a physician who was quite involved at one point and I said, well, there is an existing model, you know, it's health at every size, because, well, we're healthy at every size. And I was like, sorry, that's a trademarked term, no, you aren't. And so like.
Patty Thille:So there was like some of it, i think, was. I mean, if you're doing a literature review, you have to choose not to read and cite those things. Right, and obesity Canada and its foundation didn't read and cite those things. They went across Canada, did focus groups to establish yes, weight stigma is a problem in Canada. It's like we already knew that you didn't, you could have cited.
Patty Thille:So there's citational practices that used to ignore. But as we've moved on, as it's, i would notice in the last two years, for example, some very aggressive promotion of the idea that, like, if you're not with us, then you are promoting weight stigma And and like hit pieces on health at every size that pretend it's something that it's not So it's. I mean, it suggests that they see health at every size as a threat and so they need to discredit it. But it's also in terms of a process or a tactic. It speaks to the work being done to preserve a very particular frame and in public discourse, yeah, and so I think that's one of the examples right there, sorry, yeah, well, that just makes me want to do.
Chris Mayes:I want to do an episode on health at every size in the future, jane, and I want to do an episode on the conversation.
Patty Thille:I'm not really sure if I'm going to be able to finish with the conversation again, but yeah, i think that I have. I just want to. I want to encourage you, though, because health at every size Next week, the Association of Size, diversity and Health, which is an American organization that holds the trademark to health at every size, is like relaunching it. They've been doing a lot of work to reconfigure the principles to more deeply integrate anti racist and anti oppressive principles, so it's actually a good time to do an episode, because it's both. It has a legacy as being a contrast to these obesity related frames, but it's also itself going through a big transformation, so that strikes me as a really good topic for you folks.
Chris Mayes:Yeah, thanks a lot for coming on. It was really interesting.
Patty Thille:Yeah, thanks so much for this chance to talk and while I'm in Australia, you know I head back to Canada in a week, so it's nice to.
Chris Mayes:And, yeah, we'll share this article which is called Drivers of Medicalization in Canadian Adult Abyssinian Clinical Practice Guidelines in the Canadian Journal of Public.
Jane Williams:Health. Thanks, Patty.