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Introduction

The other day, two of my best friends texted me to say that Oprah was doing a special on weight loss medications. I figured the special would bring up questions for people, so I watched it and I’m giving you a breakdown from my perspective as a registered dietitian, certified intuitive eating counselor, and weight-inclusive provider.

Trigger warning, the special used lots of weight-normative language and repeatedly pathologized fat bodies, calling obesity a “disease.” I will be unpacking these aspects of the special and if that would be triggering for you, perhaps this is a blog post that you skip or come back to at a different point in your journey.

Note, I recognize that I hold several unearned privileges as a cis gender, white, heterosexual woman in a straight sized body. I continuously participate in supervision with folks who hold different identities than me in order to expand my perspective, but I am also aware that I might not always get it right. This breakdown on weight loss drugs is me trying my best while also acknowledging that I’m sure I won’t be able to capture all aspects of this conversation.

The special opens up with a montage of clips of different people sharing pieces of their personal struggles with food and weight.

Then Oprah comes on screen and shares about her own lifelong struggle with food and weight, she says, “For 25 years making fun of my weight was a national sport.”

Throughout the intro to the special, she reiterates over and over again that her hope is for people to stop being shamed for how they chose or don’t choose to lose weight.

We’ll come back to this in a little bit. Let’s dive into the guests featured in the special.

Oprah’s First Guest

The first person Oprah has out on stage with her is a woman who has lost a significant amount of weight from weight loss injections. They flash to a montage showing before and after pictures, and the change is quite dramatic. Then the woman shares about her history of being fat shamed as early as 5th grade. She talks about feeling alone her whole life so food became her best friend, and then goes on to share how she turned to food after her Dad passed away and after dealing with several stressors in her life such as Covid, marital issues, and having a newborn. At one point, the woman became emotional, reflecting on how she was so ashamed of her body that she didn’t like taking her kids out in public, had no friends, and avoided going to the doctor because she felt so much shame.This woman shared that her labs were terrible and she was diagnosed with diabetes.

Then Oprah asks about her labs now, that she’s lost all this weight. The woman proudly shared that her labs are all normal now. She also reflects on how she’s treated like a completely different human being after losing the weight. “People are friendlier, they are nicer to my children,” she says. 

Correlation Doesn’t Equal Causation

The way the story is presented, it seems like the reason this woman’s health improved is because she lost weight. But just because her weight loss was correlated with changes in her mental and physical health status, doesn’t mean that we can say that the weight lost was the CAUSE of these changes.

In fact, there are many pieces of this woman’s story that clearly point to other factors that were more than likely contributing to her health status before going on ozempic beyond her weight in and of itself.

Research shows that experiencing chronic weight stigma– aka feeling shame for your weight– is a greater risk factor for our health compared to the food we eat.  This is because chronic shame leads to chronic stress in the body which increases allostatic load leading to widespread physiological disregulation. High allostatic load is well-known to lead to worse health outcomes such as irregular labs and chronic illnesses such as diabetes (recall this woman had irregular labs and diabetes). 

Another factor that can lead to negative health outcomes that is not related to weight in and of itself is medical weight stigma. If people have negative experiences with medical providers– ie being shamed or berated for their weight– they are more likely to avoid doctors appointments. Avoiding medical visits can lead to poor health outcomes. Folks who avoid medical visits can end up with more serious progressions of disease states that could have otherwise been prevented with early intervention and screening from regular check ups. This woman clearly stated that she would avoid the doctor due to the shame of what they might say about her body.

Social and community context is one of the social determinants of health. The Social determinants of health (SDOH) are a group of social conditions that make up almost 50% of the overall factors that contribute to your health. 

Your social environment is the type of support system you have to help you work through some of the stressful times that might come up in your life. If you don’t have a good community to support you, you may not be able to mediate stressful events and this can negatively impact your health.

A great example illustrating the true impact of social and community context on health outcomes comes from a well-known epidemiological study called “the Roseto effect.” In this study, a community of Italian immigrants were curiously found to have very low incidences of heart disease despite having diets that were very high in foods that we normally associate with higher rates of heart disease (meat, lard, alcohol). Researchers studied this community and found that this group of people was extremely close knit, having really strong cohesion and the community acted as a strong support system. It was determined that these close social relationships were what lead to these low rates of heart disease in the community (PBS). Many people would likely be surprised to learn that community context can actually have a greater impact on health than one’s diet. There have now been various other epidemiological studies with identical findings: social and community ties is an incredibly strong predictor for health outcomes.

In the context of the first guest on stage on Oprah’s special, she shared that she was so embarrassed about her weight that she isolated herself socially. She said “I had no friends.”  She also mentions not wanting to leave the house. This woman’s lack of strong social ties likely contributed to her negative health outcomes (labs, diabetes). 

She also talks about how people were friendlier to her after losing weight. Though this might not seem like much, these little interactions with people in everyday life can positively impact our mental and physical health, contributing to a more positive social environment.

It’s not fair that people noticed her less or were rude to her when she was in a bigger body, but her larger body wasn’t never the problem…

The problem is our weight-bias, fatphobic society that values people differently based on the size, shape, color, and/ or ability of their body.

Finally, this woman shares that she’s been struggling with her weight since she was a young child. She speaks about trying to lose weight several times in the past, only to gain it all back. This phenomenon of losing and gaining, losing and gaining is very common and it’s called weight cycling. The research clearly shows that weight cycling is an independent risk factor for diabetes along with other chronic illnesses. This means that it’s likely that this woman started experiencing negative health outcomes not because of her weight itself, but because of her history of weight cycling. 

So to recap, though this woman lost a bunch of weight from the GLP-1 inhibitor injections, a bunch of other things changed in her life too:

  1. She gained thin-privilege therefore was no longer experiencing chronic societal weight stigma
  2. She no longer felt shame about going to the doctor and likely stopped avoiding regular medical appointments. (It’s possible that doctors also started taking her more seriously as a result of her being smaller as research shows this often happens).
  3. Her social environment improved. She stopped self- isolating and started having more pleasant interactions with strangers in her daily life. 

We cannot say that the weight loss in and of itself is the reason for her improved health outcomes, when various other things shifted in her life when she got smaller.

Correlation doesn’t equal causation. I have a podcast breaking this down even further if you’re interested, it’s called, “the real reasons being higher weight leads to negative health outcomes (it’s not the weight).”

To be very clear, I don’t blame this woman for pursuing intentional weight loss through injectables. It sounds like she’s endured several years of weight stigma, beratement from medical providers, weight cycling, and isolation because of her body size. As someone who holds unearned thin privilege, I can truly only imagine what it’s like to navigate the world with this kind of constant marginalization. It’s so unfair and this woman deserved better.

I also believe in body autonomy which means that all people have the right to make their own decisions about their body, including the decision to pursue intentional weight loss. But I can’t help but wonder… would this woman have been as compelled to pursue intentional weight loss if she wasn’t existing inside our culture of anti-fatness? 

I agree with Oprah that we shouldn’t be shaming people for their choices, but what Oprah left out of the conversation is…

We shouldn’t be shaming people for having bodies that exist outside of the thin ideal. Body diversity is inherent in humans. And for those people thinking, “but what about their health! You can’t be saying people in much larger bodies are healthy!” We know that weight actually isn’t an indicator of health. There are people in small bodies with abnormal labs and chronic illnesses like diabetes. And there are people in larger bodies in perfect health. 

In my own practice, I’ve worked with women with “normal” BMIs who have diabetes and I’ve also worked with women who are technically “obese” by BMI standards, yet they are in perfect health. Our weight isn’t linked to our health in the way diet culture has always led us to believe

The Featured Doctors’ Perspective

Oprah had several other guests on stage throughout the special. The next guest was a Doctor who has been studying “the disease of obesity” for nearly 2 decades. This is important to note because this person’s entire profession is built around pathologizing fat bodies.

He explains that when you lose weight, your body slows your metabolism down, to get you back to your previous weight. The body is built to maintain our weight. Some people have a higher weight set point. He goes on to use this metaphor saying Dieting is like holding your breath under water, you have to eventually come up for air and that means your weight coming back to where you previously were.

I completely agree with these statements! Our bodies do try and get us back to our set point weight range after losing weight. The body IS built to maintain our weight. Some people do have a higher weight set point! Dieting is like holding your breath under water! For a second there, I was really nodding along with this doctor. But where he lost me was when he was asserting that weight loss injectables like Ozempic would somehow be different…

If our bodies do everything in their power to keep us at our set point weight range, why would Ozempic be any different? Being on Ozempic, like dieting, would still be like holding your breath underwater… And as soon as someone gets off the drug, we see rebound weight gain, which continues to perpetuate the weight cycling, which we know is in and of itself a risk factor for poor health outcomes.

Oprah summarizes to the doctor on stage to make sure she’s understanding correctly. She stumbles through trying to explain what she is hearing: “so many people have the disease of obesity but everyone who is overweight doesn’t necessarily have the disease. If you don’t have the disease, you can lose weight and maintain it through diet and exercise, if you do, you’re going to end up regaining it.”

We know from extensive meta analysis done over the years that 95% of people who pursue intentional weight loss end up regianing all the weight (and often more) back within 5 years of losing it. Following Oprah’s logic, this would mean that 95% of people have “the disease of obesity” in my own story, I’ve attempted intentional weight loss only to gain more weight back. That would mean that, according to the logic Oprah and this doctor are presenting, I have the disease of obesity. Even though my bmi has been within the “normal” range my whole life.

That would also mean that every single client I’ve ever worked with “has the disease of obesity” since every client I’ve ever worked with has tried to maintain intentional weight loss without long term success.(note when I say success I mean maintaining long term wt loss while maintaining a healthy relationship with food/ without having disordered eating or an eating disorder).

Oprah says this line, “obesity is complex which is why it’s so wrong to be shaming people  because you don’t understand the complexity of their situations.” Again, I agree with Oprah that we shouldn’t be shaming people for their weight… and I understand the sentiment of her saying that the reason we shouldn’t shame people is because we don’t understand the “complexity of their situation.” But I’d love to see us not demanding that someone has “a complex situation” in order to justify their weight.

Some folks live in larger bodies without health conditions or trauma or “complex” situations. Just like some folks live in tall bodies without justification other than genetics… body diversity exists in the human species, and we shouldn’t demand an explanation for why someone lives in a fat body, just like we likely wouldn’t demand an explanation for why someone lives in a thin body.

Another doctor comes up as Oprah’s next guest and states that, “the data support that you have to be on it for the rest of your life. When  you go off it the “disease” comes right back.”

Aka the body desperately tries to restore it’s set point weight range after a period where food intake was threatened and therefore – as the brian perceives it– survival was threatened

I just thought it was interesting how this doctor explicitly said that the data shows that the weight comes right back after going off the medication.

Which brings up the question as to whether or not it’s safe to be on these drugs long term…

Before unpacking that piece, it’s important to note that after these two doctors left the stage, a message appeared on screen saying 

“Both doctors disclose that they are involved with the makers of the medication and participate in paid consulting with them.”

This is, for obvious reasons, important to keep in mind as a conflict of interest. 

Speaking of conflict of interest, Oprah stepped down from her position as a board member at WW and donated all her shares in the company specifically so she wouldn’t be seen as having any conflicts of interest for this special (since WW now uses weight loss injectables as part of their protocol).  Though Oprah didn’t have that conflict of interest, there were other cases of conflicts of interest reflected through her guests, specifically these first two doctors who came on stage.

The Teenage Guest and Her Mother

Her next guest on stage was one of the most heart wrenching parts of the special for me to watch.It was a teenage girl and her mom, who together, reflected on the child’s long history with trying to lose weight. The mom says, “I took her to obesity clinics and weight loss camps but nothing worked long term. 

Now before going any further I want to again be clear that I do not judge this mother. I can only imagine how scary it must have been for her to repeatedly hear from medical providers that her child would die early if they didn’t address her weight.This mother was clearly doing the best she could with the resources she had.

Speaking of resources, this teenager grew up in a small farm town in middle America. She had bariatric surgery at 13 and remembers constantly being told she was fat by peers and doctors.

Eventually she was prescribed a Semaglutide approved for kids called Victoza.

The family emphasized the financial strain of paying for this medication several times. Also, the mom shares that she struggled with her own weight her whole life as well. This clueless off that being in a bigger body was likely part of the genetic blueprint going on in this family.

Again, we can imagine that if this teenager was dealing with health issues, they could be related to other health determinants,  not necessarily her weight… 

Financial stability and social community context are 2 of the social determinants of health that specifically come to mind. We don’t know much about her family’s financial situation, but in telling the story of this teenager, they make a point to say that they lived in a small farm town in middle America, and they also say affording the medication wasn’t accessible for their family unless they could get it covered by insurance. These details suggest perhaps her family dealt with some stress regarding financial stability, but we don’t know for certain.

We can also reasonably assume that she dealt with some social isolation related to her body size, aka  weight stigma. Which, again, is known to be a risk factor for negative health outcomes.These are just some examples of other factors that could’ve been going on to contribute to her health outcomes that are not her weight in and of itself. 

What made this segment of the special so hard to watch is that the teenager was clearly so uncomfortable on stage– and I don’t blame her! Here she is on national television discussing her weight. Being a teenager is awkward and embarrassing enough on its own, and now add on top talking to Oprah Winfrey about your weight… I can only imagine how that felt for her. She was shifting awkwardly in her seat the whole time, truly seeming so nervous and uncomfortable, and again, I don’t blame her. 

The teenage daughter reflects on how people treat her differently now that she’s lost weight. She was no longer afraid to try out for cheer and she made the squad, and she feels more noticed in general. Then Oprah added, “and I hear you’re going to the prom!!” in a very excited, sing-songey tone.

The Wrong Message

I am sure Oprah’s intentions were to cheer her on and hype her up, but the way this whole conversion landed for me was: A person in a fat body can’t be on the cheer squad and go to prom. One must lose weight  in order to be deserving of those experiences. It was so heart wrenching to see Oprah promoting the idea that life starts when you’re smaller. Thats when you can play the sports you’ve always wanted to, go to prom, and do all the things…

This sends the message that one should put their life on hold until they lose weight. And unfortunately, for many people, that means putting your life on hold forever because as we know from the research, sustainable weight loss is very rarely attainable. 

So many of my clients share this feeling of having put their lives on hold for some future moment where they have finally lost weight.I’ve worked with clients who have put off applying to dream jobs, going on certain trips, dating, having children…  

Until they eventually realize through doing work on healing their relationship with food and body, that their life is NOW. That they can do the things that light them up now, in their current body.

And what happens as a result? They often start to feel happier and more fulfilled in their lives even without losing weight… but because they are actually living, doing the things they want  each day,  instead of waiting for the potential of future weight loss.

Again, I’m here for Oprah promoting confidence in young women, but I wish the message was that you can take up space and live your best, most unapologetic life in any body size. You don’t have to lose weight to attain confidence.

Keeping in Mind Oprah’s Lived-Experience

This whole special was put on Oprah, someone who has publicly battled her body for years. And again, I don’t blame her. I can only imagine the pressure Oprah felt as a person with multiple marginalized identities in the public eye during the heyday of diet culture. I could understand why she feels relieved to have found a weight loss injectable, as I imagine she feels relief that this is the answer to her lifelong struggles. 

So we have to remember that though Oprah has no formal conflicts of interest to disclose in this special, her lived- experience greatly impacts the lens of the special. Of course Oprah is going to curate guests in support of the very weight loss drug that she has found relief from. 

Lack of Airtime for Stories of Negative Side Effects 

One thing I found interesting was that conveniently, all the guests Oprah invited on stage had positive experiences with the drug. Surely there are many people who could have come on and spoken about their negative experience on the drugs, but this was not included in the special which felt unbalanced.

Later they shared that 17% of patients discontinue medications because  of side effects, mostly GI. I’d guess there are more people who experience negative side effects but try to endure through them because the desire for weight loss is so strong.

At one point, Oprah talks to an audience member who took the drugs then stopped because of severe nausea sending her to the ER. She shares how being on the medication was very hard for her and the side effects were scary. 

Then, they pan to a doctor in the audience (who was previously up on stage as a guest), asking her what she has to say about that and she goes, “it’s about managing the side effects. They are mild to moderate and they’ve been overhyped….” 

I found this moment incredibly frustrating. Here there was a woman bravely sharing her negative experience on the drug and this doctor sitting just a few feet away indirectly invalidated her experience by saying the side effects are “over-hyped” and you just need to figure out how to manage them….

Oh, then the doctor goes,” medicines have side effects” 

This woman in the audience– a literal stone throw away– legit ended up in the ER from the meds… Medicines aren’t supposed to have side effects that land you in the hospital…

Also interesting how she wasn’t called up on stage to have as deep of a dive on her story/ background, and was given comparatively much less airtime compared ot the guests who had positive experiences on the drug.

The Question of Longterm Safety

Then Oprah has a conversation with both the doctors who were previously on stage about the long term side effects (and recall that both these doctors have disclosed their ties as paid consultants to the weight loss medication companies). They say people are worried about thyroid cancer, pancreatitis, gallbladder complications, but  this has not been shown in human studies…

But if risk for these illnesses hasn’t been shown in human studies, then why has the FDA issued a box warning requiring that Ozempic clearly state the high risk of thyroid cancer associated with taking the medication?

And the other issue is that these medications haven’t been on the market that long, we don’t have long term data therefore we really can’t say for certain what the long term health effects are. 

Closing Thoughts

In some ways, I could appreciate the way Oprah ended the special. She said…

“For people who feel happy and healthy in their life celebrating life in a  bigger body and don’t want the medications– I say bless you!

For people who say diet and exercise is the only way to lose excess weight, I say bless you too.

For people who think this could be the relief, support, and freedom that you’ve been looking for your whole life, bless you too because there is space for all points of view.”

I like that she is emphasizing body autonomy and reiterating that we don’t need to judge others for their decisions about their body.But there are still some undertones of healthism in this closing statement.

What about people who aren’t healthy and never will be due to chronic illness or other circumstances? Why is it that people in bigger bodies need to be happy and healthy in order to get Oprah’s blessing?

Overall, I like that Oprah’s message throughout the special was to stop the shaming and blaming! It’s certainly true that our weight and our health are largely out of our immediate control, and therefore we shouldn’t blame ourselves. I think this is a great start coming from the traditional diet culture rhetoric which is all about personal responsibility.

Instead of her message of “let’s stop shaming and blaming ourselves and others for living in larger bodies … .now we have weight loss injectables to fix them!”

I wish the angle was geared more towards, “ lets stop shaming and blaming people for existing in larger bodies, period.”

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