Undisciplinary
Undisciplinary
Summer Edition: Re-post of 2023 conversation with Patty Thille on Obesity, Weight Stigma and Big Pharma
**Below is AI generated**
This episode discusses weight stigma as a systemic issue deeply rooted in healthcare practices, often leading to misdiagnosis and mistreatment of individuals based on their body size. Dr. Patty Thille highlights the dangers of medicalization and pharmaceuticalization - especially the popularity of drugs like Ozempic - in addressing obesity and encourages a more holistic approach to health that considers broader societal contexts.
• Weight stigma as both a personal and systemic issue
• The impact of bias in healthcare settings
• Personal experiences leading to critical perspectives on healthcare
• Medicalization redefines societal problems into medical concerns
• Pharmaceuticalization shifts focus to drug interventions
• Ethical implications of funding in medical guidelines
• The need for a broader understanding of well-being and health
• Encouraging holistic, weight-neutral approaches to healthcare
Undisciplinary - a podcast that talks across the boundaries of history, ethics, and the politics of health.
Follow us on Twitter @undisciplinary_ or email questions for "mailbag episodes" undisciplinarypod@gmail.com
Undisciplinary is recorded on the unceded lands of the Wadawurrung peoples of the Kulin Nation in Geelong and the Gadigal peoples of the Eora Nation in Sydney. We pay our respects to Elders, past and present.
Speaker 2:The world's first high-strung plant has been performed.
Speaker 3:Medical history has been made in South Africa.
Speaker 2:Reports of systemic racism in the healthcare system, and COVID-19 has made the issue even more urgent, characterized as a pandemic.
Speaker 1:Welcome to Undisciplinary, a podcast where we're talking across the boundaries of history, ethics and the 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?
Speaker 2:I'm going pretty well this morning, thank you. I am hiding away in a room with a COVID-y home. I do not have COVID myself.
Speaker 1:Well, it's a good thing we're on Zoom, so.
Speaker 2:I'm fine, but no one else is.
Speaker 1: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, it 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, is around weight stigma, obesity, and the current politics and the current, I think, focus on pharmaceuticals Ozempic I keep on getting these ads. I got one about the Ozempic butt recently. That wasn't an ad so much, but it was an article about a side effect of this weight loss drug, as they're so called. And so today we are very fortunate to have a special guest from Canada who has been here visiting in.
Speaker 1: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, patty.
Speaker 3:Great to be here.
Speaker 1:So before we sort of get right into it, it would be good to introduce you. That would be good yeah.
Speaker 2:And also I'm going to introduce Patty. I also want to hear a bit more about her Zempic butt, though, because I don't get those ads.
Speaker 2:Anyway we'll get the business end of the way. So Dr Patty Thiel 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 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 in 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.
Speaker 3:That's me in a very quick nutshell.
Speaker 1:And thank you for coming and congratulations, Jane, on the Saskatoon in Saskatchewan.
Speaker 2:I was impressed.
Speaker 1:Yes, I know someone from Saskatoon oh wow, 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, we already heard, I guess, a bit 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, say, some people do have a straightforward answer, straightforward story for that. Uh, but we also like to hear those more uh, divergent and roundabout ways people end up where they are roundabout is a good word to use for how I got to where I got to.
Speaker 3: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. It was clear I was going to go into health healthcare. I didn't. There's a whole lot of medicine I never wanted to even go near. Physiotherapy seemed like a good fit.
Speaker 3: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 Went on to 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 prof was like you know that you're three classes away from a degree, right? So that's how that starts. And the thing that really captured my attention in gender and health seminar with a medical sociologist was around just very basic manifestations of sexism in healthcare and I distinctly remember the way that sort of prescribing practices around heart disease and women were very much based on studies exclusively with men and we're talking about an example that was studied probably 30 years ago. So yeah, so that sort of opened up the path.
Speaker 3:And then I just was very concerned, I think, with some experiences I had in healthcare, so as a patient and for the record, just for context, I'm actually a straight size 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.
Speaker 3: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 helped me open up those ideas. 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. 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 intersection. But I see myself as a person who can bridge in both ideas from activist and advocate communities into healthcare, as well as social science theory and methodology. So that's sort of my story, 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.
Speaker 1:And so while you were doing those classes and practicing as a physiotherapist, those classes and practicing as a physiotherapist, were you also sort of seeing resonances and, I don't know, problems, concerns in the sort of physiotherapy practice as well, or because you use the sort of prescribing of heart for heart conditions?
Speaker 3:but yeah, were there things going on in physiotherapy that you 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, give them the same privacy as we gave to other patients, 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 end, six days, 12 weeks, and so 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, 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.
Speaker 3:And I just remember being very like something is very wrong here, 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 really what's happening there.
Speaker 3:So I did have clinical experiences and I also had some patients who were really interested in this women's study stuff I was doing. I'd have these. Really Some people like to chat when your hands are on them and some people don't, and so I'd end up chatting with some of them about it and they would share their stories as well, and so that's sort of 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 in 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 this topic and this and the focus on trying to make a change, which is that applied sociology kind of bent.
Speaker 1:Yeah, yeah, that's a, um, a good lead in an example, I guess, of weight stigma and its sort of prevalence, uh, in clinical contexts and the subtle way it can just come in as to sort of who's assigned what patients, et cetera. Um, but yeah, what, what effects, uh of what what? What do you see as I guess, a definition of weight stigma and then also some of the effects that that can have, um, in both the clinical context and then, I guess, in people's lives, in both the clinical context and then, I guess, in people's lives?
Speaker 3: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 thinner end of the scale, that's not really how we use that word. So weight stigma is about fatter bodies in particular. So weight stigma is about fatter bodies in particular, and stigma is a process where stereotypes are added to people based on their in this case, a body characteristic. So personality kind of characteristics are ascribed to people.
Speaker 3:That group of people are then come to 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 et cetera are reproducing these ideas 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 health care. So the example that I gave of my being assigned someone though, someone who is like stronger and bigger and better, more appropriate. But it's also in the things like the lack of equipment we had, and so that person didn't have the same privacy and equipment and structural manifestations of stigma is also one of the parts of it. So stigma can show up in terms of how people see themselves. That's more the internalized stigma. Stigma can 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 don't get access to 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 the physical structures as well as other types of structures can say that you don't belong here or you are devalued.
Speaker 3:Okay, so that's my description. Now tell me it's a little bit of clinical manifestations. What does it do in healthcare? I think was your next question. So it does a few things.
Speaker 3:So one that gets talked about a lot is that people who are repeatedly stigmatized in healthcare start avoiding healthcare, and that makes that's totally logical. If your healthcare 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 based on like discriminatory care, right, that reproduces weight stigma. It's things like people not getting diagnosed at the same rate of a woman who for years was quite unwell and she kept on being told it was her weight for years and 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.
Speaker 3: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 people default in times of uncertainty, where you're 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 too, and instead of actually investigating what's happening, the risk is that it gets used as a standard in that way.
Speaker 1:Hmm, 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 um, the gp, and he basically was like I don't know, but you could lose, you should lose some weight, and it's like, well, I haven't gained a bunch of weight or lost a bunch of weight in the time, you know, in this period, and I don't usually fall on the floor and vomit through dizziness. So, you know, I think maybe something else is going on. Anyway, fortunately that has not well aware that is talked about a lot that anything can be reducible to someone's body weight or size, as it stands in as an easy descriptor or easy diagnosis for what's going on.
Speaker 2:I would imagine that misdiagnoses are are so common which I won't go into.
Speaker 3:Well, if I can just touch on that, because that was what I did in my master's was um collected stories of women's, openly defined and a range of ages, et cetera, Um experiences talking about eating, exercise and health and weight. Um, 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, et cetera, everything comes down to weight. Um, at times when there has been an active injury or you know it's, it's yeah.
Speaker 2:So sorry, I just feel like I wanted to share that one more. But please go ahead. Yeah, the. 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.
Speaker 2:But you were talking about the, the lecture theater and the seats patty, uh, and who they're for, um, 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? 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. 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, will I fit into that chair? You know that's really shitty 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.
Speaker 3:Yeah, the size, the arms and the weight limit actually. So in Canada I use advisory groups like a members of the public who experienced weight stigma in healthcare, 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 or the information that I share is a variety of chairs, because some people do need arms from a mobility perspective, but different widths is really good, so benches with arms can be also helpful for some people.
Speaker 1:And and then knowing your weight limits, um, 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, yes, um yeah, so in talking about stigma, I mean one way that's often talked about is stigmatization, and so it's one of these ization words, which is you've recently published a paper with Andrea Bombach 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, uh, with our in our show notes, etc but, um, yeah, it'll be really great to unpack all the different things that you talk about in this short but very interesting article, uh, but before doing that, so you do have a couple of terms uh in there one big medicalization, the other interesting one being the pharmaceuticalisation, and the pharmaceuticalisation of fatness is something you talk about.
Speaker 1:And then I'm going to throw in another one, pathologisation. So these isation words, you know sociology tend to talk about the processes of something being turned into something else, and so, um, and this ties in with, uh, the, the comments I made earlier about a zempic. I think I'm pronouncing that right.
Speaker 1: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, uh, myself but, um, 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, um, uh, in in relation to your article or just in general would be well.
Speaker 3:Yeah, okay, great, I'll start with medicalization. Um, 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. It was actually its roots in terms of treating it as a negative. The stereotype, et cetera, comes, precedes medicine, taking it up. But so, so medicalization is, is the process of something, and, and a classic example that I point to for some things is, um, is homosexuality.
Speaker 3:So homosexuality and same-sex attraction or same-sex 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, as it was constructed, at least in Canada. It is by the removal from the medical domain and the fighting against the idea that, you know, having same-sex attraction or you know, 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, 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.
Speaker 3:Is sort of in my simple term, and this article is about these Canadian clinical practice guidelines released in 2020. 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 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. In the past they have.
Speaker 3: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 were 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 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.
Speaker 2:And I might pause there and let you follow up, because I can say more but yes, I've got some questions, so one well, you know you referred to the drugs that were taken earlier, so it's not new to take drugs to stay thin.
Speaker 2: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 um, of the use of speed, basically in earlier um, earlier generations, of mostly housewives, it seems, and I don't know if that's uh, just a um, an impressionistic thing, or if it's borne out, uh, in the literature.
Speaker 2:And then I'm thinking about other things that have happened, like remember Olestra was going to be the thing that was going to fix all of our problems, because it would just mean that we, you know, fat 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 uh, semaglutides this morning, which is the drug that ozempic is, and see that it was approved in 2012. I'm really curious about why we're hearing so much about it now, um, and whether that is perhaps going to your article, patty, um, 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 chucked a whole lot of ideas there. They were, uh, the things I was thinking about while you were talking yeah, that's a.
Speaker 3:There's a lot uh 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 Wagovi. 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, um, to stay skinny. So we're already in that, like what is you know? It's, it's already being used in these variety of ways, and I also okay, 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, um and sleep.
Speaker 2: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 drink and sleep. So the more they were asleep, the less they were awake and therefore thinking about eating.
Speaker 3:Wow, the things that people will do to stay thin.
Speaker 2:I mean to be fair.
Speaker 3:their jobs were to be thin, so yes, yeah, yeah, no, no, I hear that. I I mean the the why now? Um, 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, like any any surgery, right?
Speaker 3:yeah, it was like 12 or 16 and yeah, it was young yeah, and so we're just in a place where, I mean, the pharmaceuticals, pharmaceutical companies, were not always the funder, for example, of Obesity Canada. So Obesity Canada started as a 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 with smaller projects and they 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.
Speaker 1:I've got a hypothesis no-transcript 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 approach to weight management, if you like to use that term.
Speaker 1:And so I think 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. Um, that critique so 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, yeah, when I was doing my research on the sort of lifestyle stuff like the barrier. Do you call them bariatricians?
Speaker 1:I don't know bariatric surgeons, 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 only one part of the picture, I think, the pharmaceutical industry and off-label prescribing.
Speaker 1:We have some colleagues who Wendy Lipworth and Narsis 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 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. I mean, 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 ization of the pathologization. So being able to say that weight and fat is a pathology, yeah, yeah, yeah, no that, but okay, I have many responses.
Speaker 3:But, um, the big critique of medicalization really is how it individualizes the response to something, so it's like one patient at a time, um, 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? Um, if we can't look at the drivers of those kinds 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 a situation that is like deeply non-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 don't really ever address them. So you mentioned the social determinants of health, chris. There's another piece that we published a few years ago around weight policy, weight-related policy in Canada. It's in the CMAJ 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 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 its impacts on bodies. And I really, larson did this really wonderful.
Speaker 3: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 as 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 have written another piece about guidelines. There was a 2015 guideline in Canada 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. So, if we understand, a guideline is a knowledge brokering process. You are the broker of a number of forms of knowledges and you're putting them together in a certain way. The knowledges that you will and will not pay attention to shape the final result, and so I think that's a lot of where we're at with guidelines.
Speaker 3: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 Throsby's work, but it might. It might also be Juan. 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.
Speaker 2:Yeah.
Speaker 3: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, um, you know, we understand that there's a lot of things that affect weight and a lot of things that affect success, um, in terms of being a successful thin person, if we want to be as a bit more sociological kind of framing, but it's, but, yeah, but they flip it like it's a marketing technique, right for it's interesting that you're saying that about, um, the bariatric surgeons 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, that this recognition of stigma around weight, um and here, we're going to help you out.
Speaker 1:We're the, we're part of the good guys who are going to sort of take away weight stigma by providing this pharmaceutical solution take away weight.
Speaker 3:Stigma by taking away weight yeah 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. Yeah, 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 actually wrote a paper about cosmetic surgery. Just because I felt like I had really no hand. I was gonna. I was gonna wrote a paper about cosmetic surgery just because I felt like I had really no hand. I was gonna. I was gonna 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.
Speaker 3:And the thing that 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 right 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's like, and what ends up happening is reinforcing, in their case, beauty, beauty standards. We reinforce beauty standards 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 we're talking 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. You know your stomach's 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? So the idea that people will take this kind of risk, so the idea that people will take this kind of risk, is quite shocking like end of some of this promotional materials um, and actually the guardian wrote published a piece about um, the, the orchestrated PR campaign around these.
Speaker 3: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 system who was talking about. It's a game changer. And they used actually all of these language that comes out in this, this um guardian piece, where they found like they actually found the documents around what the pr campaign is like. So your first red flag is why is a respirologist talking about this?
Speaker 3: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, I just remember being like that's the serious side effect. That's not even the like wow, yeah, and so it's a different. These practices, yeah, so they if, if they result in the in a thinner body, which is okay. Let me finish that first sentence. 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 they and there's some things with people really questioning, like people approaching them now, um, so new friendships, new relationships, like, would they still like me if I'm bigger? You know? Um, but it's just very different. Understandings of risk and again, what kinds of knowledge matter.
Speaker 1:Okay, I'm getting a bit rambly, so you're probably going to cut some of that out I mean on that, on the what kind of knowledge matters, though and this comes back to the clinical guidelines I think there is a newness and a shift that has happened, and you talk about this, um, maybe not necessarily as a newness or a shift, but um, that it's not just a matter of um. You know a bunch of uh, 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 you know, and that's what they think is the correct approach introduction of the pharmaceutical companies and sponsorship and people who have received money.
Speaker 1:There is a direct financial conflicts of interest between these people writing like 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. You know, if you ask me to write the national guidelines, it would probably be, you know, very Foucauldian 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.
Speaker 1:With the introduction of these commercial and capitalist incentives.
Speaker 1: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 were strong norms against and and regulations against doing that and the way that there's been this soft creep of um, particularly through social media. 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 they're. You know, and just minimizing all of these harms that are associated with um, 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 um 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 this conflicts of interest and the intensification of the pharma influence in Canadian obesity organisations, 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.
Speaker 3:And they would. Actually, I think people with conflicts of interest often want to downplay them. So there's actually a lot that I could say, a lot that couldn't make the article want to downplay them. So it's it's. There's actually a lot that I could say, a lot that couldn't make the article Um. 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 um, in the year um that they then were, uh, in a in a journal that was bringing in new conflict of interest guidelines. So I think they made it in just under the wire, like I had they submitted. Six months later they may not have been able to be published in the Canadian medical association journal, and so this, yeah, so, and the, 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 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.
Speaker 3:And the thing that I found myself 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 way to destigmatize practice, for example? These are like career threatening. So we're talking about entrenched interests.
Speaker 3:Some of them are conflicts in the pharmaceutically funded sense and some of them are just people are going to be entrenched. 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 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 part of building markets is de-emphasizing the potential harms or the lifelong impacts that someone might have from pursuing a particular treatment.
Speaker 1:yeah, I mean to go back to the ozempic butt, um, that and I didn't read the whole of this article that was promoted to me, um, based on my uh, I guess, prior readings and but I mean that seems to be a. So from my understanding it's um, the weight loss drug causes your bum to sag, um, and and so people, so it's got an aesthetic and and then no doubt will be a surgical or, uh, um pharmaceutical intervention that can assist with that problem. But that seems to be a pr issue at the moment for um, a zempic is, if it's been marketed for this, aesthetic reasons, um, as well as, obviously they would say, the health reasons, um, but if a primary driver is that aesthetic dimension to body shape, um, if this is a you know outcome, then it may not be as lucrative as they hoped.
Speaker 1:Um, but that also reminds me and and yeah, just going to I guess, some uh, fecodian language around successful failures and and the way that, with these drugs, when they do fail people, and the way you were mentioning before that it can just, or, 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 that will. They would have had an underlying condition already due to their obesity or body weight which only further.
Speaker 1:And this is the, I guess, successful failure that when they die, it just reaffirms this need for further intervention onto these people and their bodies.
Speaker 2:Right, go ahead, jane. Yeah, oh, yeah. Yeah, I was just going to talk about the ozempic butt as being a successful failure, right? So if your butt's sagging, it's because you're losing fat, you're only meant to failure, right? So if your butt's sagging it's because you're losing fat, you're only meant to. You know, your butt's the only bit of your body that's meant to have fat in it.
Speaker 2:Uh, so that is, uh, the drug doing its work, presumably yes having only heard about it 20 seconds ago or whatever that was, but I see that as maybe a successful failure as well.
Speaker 1:Yeah, and also perhaps shows just the lack of targeting. You know the sophistication of these things.
Speaker 2: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.
Speaker 1:Well, no, the way that this idea of what is a weight loss drug anyway, they have so many you could like is that just the primary thing that it does?
Speaker 3:you know you could talk about um.
Speaker 1:You know marijuana as a? Um appetite inducing drug, but it also does a whole bunch of other things um and yeah, just the way that uh drugs do have lots of effects and what we call a side effect or the primary effect seems up for debate yeah, and, and that gets.
Speaker 3: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?
Speaker 1:um, in advertising, so it's the uh internal bleeding drug yeah, no, and it's your work about.
Speaker 3:Okay, is mpx, but is also new to me. So you know, go, I'll go with that. But this also brings me back to Karen Throsby, who I mentioned earlier, and she did a piece called the obesity. Obesity, multiple and skin skin is a thing like after bariatric surgery those people who have a significant reduction in 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, then you can go for the cosmetic surgery. There we're making the link complete, you know, yeah, yeah.
Speaker 3:And so 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 Foucaultian 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, we've even talked about some of the shifts. Right, the, these organizations, pharmaceuticals and etc. Taking up the weight stigma is a problem frame, right, they've shifted their frame. But the big challenge is that they, they make it harder to talk about other ways of approaching, so they closed 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. 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 Foucaultian in my use of that term, foucaultian, 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.
Speaker 3: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. 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, et cetera. And and the editor's response was like well, of course, pharmaceutical companies are going to fund things that align with their interests, as sort of this idea that 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, 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. Not the conversation, but I mean just the way that the obesity world has responded to critiques has become more aggressive. That's what I want to say.
Speaker 3: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. She goes well, we're health at every size. And I was like sorry, that's a trademarked term, no, you aren't and so like. So there was like some you aren't and so like. 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.
Speaker 3: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. 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 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 in public discourse.
Speaker 1:Yeah, there's a lot of examples right there, sorry, yeah, well, that just makes me want to do.
Speaker 3: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 because I've got lots of things to maybe we'll never write or publish with the conversation again, but but yeah, I 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.
Speaker 1:Yeah, thanks a lot for coming on. It was really interesting.
Speaker 3: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.
Speaker 1:And, yeah, we'll share this article which is called Drivers of Medicalization in Canadian Adult Obesity Clinical Practice Guid guidelines in the canadian journal of health.
Speaker 2:Thanks, patty. ©. Transcript Emily Beynon.