- Cosmopolitan UK put this on the cover
and it stirred a lot of controversy.
- But let's focus on whether obese people are healthy
because they're not.
- I sat down with Arghavan Salles,
a renowned bariatric surgeon and obesity researcher
to get her thoughts on the cover,
as well as the popular body positivity movement
known as health at every size.
Do you think overall,
the health at every eize movement
is an overall net positive, net negative or neither?
- That very line, health at every size
is not actually true.
Can there be people at any size
who are healthy at that moment? Yes.
But is it true that no matter what your size
you're always able to be healthy, like that's not true.
I am anti-weight bias, anti fat-phobia,
anti-fat stigma, definitely anti-fat shaming,
I've written about that,
but I don't think that being aware
of the consequences of obesity
is the same as fat shaming.
- What I'm hearing, and correct me if I'm wrong,
is you could be a patient who is diagnosed with obesity,
may have great cholesterol, may be not diabetic,
their blood pressure may be great.
The fact that their weight is above a certain cutoff,
it puts them at a greater risk down the line,
maybe not at this given moment.
- All those lab values also don't mean
that they don't have knee pain or hip pain
or ankle pain or lower back pain,
which are all things that we commonly see
with people with obesity.
Increased risk of endometrial cancer, for example,
increased risk of mood disorders,
like all of that is still there,
even if our lab values are normal.
- [Presenter] Speaking about the Cosmopolitan cover,
do you think that those covers send the right message
or wrong message during a time where obesity
in the United States and in the world
is becoming an epidemic of sorts?
With COVID-19 we see worse outcomes for patients
who are diagnosed with obesity.
Do you think those covers are problematic, basically?
- I think they're a little bit misleading.
I think that the story itself,
like the content that they wrote is very nice
and they talk about how each of these women,
what their relationship with physical activity is
and how they feel about their health and their body,
and it's not even about obesity at all.
There were a number of people criticizing,
saying that, well, especially when we know
that people with obesity have worse outcomes with COVID,
this is irresponsible.
And to me that feels a little bit of a stretch,
like I think they're just trying to say
that people of all different sizes can move,
can be physically active, can love their bodies.
And I think that's a really good message.
- I think they are ultimately sending the message
and I agree with you on that.
I just think they're doing it in a cheeky way,
where they're trying to create inflammatory conversation
or maybe - - Oh, for sure.
- Productive
inflammatory conversation. - Yeah.
No doubt.
I mean, they could have said this is loving your body,
or you know, everybody is worthy or what, you know,
there's a number of different things they could have put
on those covers that would have been pretty accurate
and indisputable.
- [Presenter] We frequently see on the cover of magazines
very slender bodies, thin muscular, six packs, et cetera.
It's led to true cases of disordered eating going up
and body dysmorphia.
The sort of rebuttal to this is to say
that's what's happening right now.
Let's put people of different sizes on magazines
and let's take someone who is diagnosed with obesity
and put them on a cover.
Is there a chance that that can lead to disordered eating
in the opposite direction
of people feeling it's okay for me to be this size,
I should continue my lifestyle, not make changes,
not think about going for bariatric surgery
because the celebrities I look up to are this way.
- I think there's a balance there.
I think that we can have the covers, like the Cosmo ones
and say, look, people who are a bigger size
can still be active and aspire to having a healthy body
versus saying, this is how we all are,
and we should just live with it.
You know, I think that's a different message.
In this country, about three fourths of people
have overweight or obesity.
And if there were no negative health consequences of that,
maybe that would be fine.
But the fact is, as we've talked about,
all of that excess weight brings with it risk
for very serious problems that are costly
to the individual that inhibit their lifestyles
and make it harder for them
to live the life they might want.
So I think we have to kind of acknowledge both sides
of it that no, we don't want to be stigmatizing people
who are bigger, but we also want to recognize
that obesity has a number of medical problems
associated with it.
- The way that someone like you
goes about treating individuals
who are diagnosed with obesity
or at least morbid obesity
would be through a procedure known
as bariatric surgery, right?
That is your specialty.
You obviously don't think that is recommended
for all patients, but it's certainly one of the best
treatments out there when it comes
from an evidence perspective of not only losing weight
but keeping weight off long-term.
And then also even getting rid of some other diagnoses
like diabetes, like high cholesterol, et cetera.
Why is it that bariatric surgery has better
long-term success in keeping the weight off
than let's say traditional diet and exercise recommendations
that your family medicine doctor can give you.
- [Arghavan] One thing we know about losing weight
with diet and exercise is that only about 5% of people
who lose weight that way are able to maintain
that weight loss.
So all of us know people who've had incredible success
with diets and exercise, and that's amazing
and something to be really proud of
because they've really beaten the odds.
For the majority of people, no matter how hard they try,
it's very, very hard for them to get to a healthier weight
and size on their own.
And that's where bariatric surgery comes in
and is really really helpful.
We don't a hundred percent know
in terms of the weight loss, why it's more effective.
We think that it helps reset people's kind of set point
if you will.
A lot of us believe that everybody
wants to be around a certain number
in terms of weight or a certain size in terms of BMI.
We don't know how that develops
but that seems to be what happens.
One of the most magical things
about bariatric surgery is its effect on diabetes.
Especially when we talk about specifically
the gastric bypass, we have many, many patients
who have diabetes, are on insulin,
maybe other medications for it
and then they have surgery today.
And then today their blood sugar is normal
and they no longer need those medications,
so that's really magic.
- Absolutely, I mean anytime you can cure
what we consider to be an incurable illness,
it's absolutely amazing.
Talk about the challenges that your patients face,
and actually my patients as well,
in trying to get bariatric surgery covered
from an insurance perspective,
'cause right now, I believe in the past,
you've mentioned that only 1% of eligible patients
actually do end up getting bariatric surgery.
Why is that number so low?
Can we impact it in a meaningful way?
- I think the obstacles are multiple.
One is people in the past have thought
that bariatric surgery is dangerous.
It turns out that's not true anymore.
The risk to dying of dying within 30 days of surgery
is less than it is for having your gallbladder taken out
which people do every day in this country.
Another is the perception that it's the easy way out,
that if you have bariatric surgery,
then you have no willpower,
you can't do it on your own, et cetera.
And really that's not it at all.
I think the people who come to us for surgery
are some of the strongest people
because what they're acknowledging and realizing
is that they have tried all these other things
that don't involve surgery and nothing has worked.
And rather than just giving up, they're saying
what else is out there?
What else can I do?
Because I want to take control of my health
and I want to have a healthier life.
Another issue is time.
I believe you would know more about this than I do
but in your office, you're the one
who's seeing these patients
before they come to see someone like me.
And you're often managing, you know, diabetes,
high blood pressure, high cholesterol,
maybe a mood disorder, you know, all these other things.
I think sometimes it can be hard to talk about obesity.
And also, you know, I think you've mentioned this
in some of your previous videos,
there's a lot of sensitivity around obesity
and how do we talk to people about it
in a way that is engaging and brings them to the table
and makes everybody feel like we care,
that we as physicians care about their health
as opposed to judging or blaming or shaming.
And then the last like maybe biggest issue
is insurance coverage.
I believe, as many of us do, that part of the reason
most insurance plans or many insurance plans
don't cover bariatric surgery
is because of weight stigma and obesity stigma.
Basically people think it's not a health issue
but can you imagine if there were a plan that said,
no, you can't have a coronary artery bypass graft.
You have heart disease, but you're stuck.
Good luck with it, it's a lifestyle you've chosen.
- Not only is it beneficial to the patient, very clearly.
It also should be beneficial to the entire system
because when a patient loses, you know,
a significant portion of their weight,
if they're a patient diagnosed with morbid obesity
they will have better outcomes,
will use the emergency room less,
will be less likely to need a stent, a cardiac cath,
will take less medications longterm.
So wouldn't that be even a cost-effective measure
for them to implement?
And I don't know why it is that a lot of insurers
don't look at it in that way.
- Yeah, I mean, I don't totally know either,
I haven't been in their shoes,
but what I think is happening is an artifact
of our healthcare system in this country.
Basically in our country, people change their insurance
every time they change a job, right?
And sometimes even when they have the same job, you know,
there's a new election period for their benefits
and they switch to some other company.
In order for one company to see the benefit,
that long-term benefit in cost savings
after bariatric surgery,
that means that patient would have to stay with them
for years and years
and many patients do not
because either they change their jobs
or there's something else that they need on their plan
and they switch.
The only way I think we would really reap those benefits
is if every plan from every insurance company covered it
and then they would all be seeing those cost savings
as patients move from one system to another.
- You know, it's unfortunate that we've come to the point
where we have to rely on a surgery
because we don't have a clear cut way
for 95% of people to be able to lose weight
on their own and keep it off long-term.
Why do you think that number, 5%,
of being able to keep weight off long-term is so low?
Is it something to do with adherence to diets?
Is it the lack of good information on nutrition?
The fact that there's a level of willpower that's involved
in this, where do you think that 5% stems from?
- I mean, just like anything else it's multifactorial,
there a number of different factors involved.
Like one, for example, is we know a lot of people
with obesity live in parts of towns and cities
where they don't have access to healthy food
or not easy access to healthy food.
We also know that healthy food
in a lot of cases is more expensive.
So that means people who are making less money
or lower socioeconomic class level
don't have access to healthier foods
and so even if they can get by for some period of time
and make modifications, you know,
there's real budgetary constraints that come into play.
- How do you talk to patients
that may not be candidates for bariatric surgery
because you're certified in obesity medicine as well?
How do you counsel those patients saying like, look,
maybe bariatric surgery isn't for you.
There's a 95% chance you're going to fail in losing weight
but here's how you can be successful
'cause it's a daunting task.
- I would tell anybody,
whether they're having bariatric surgery or not,
more or less the same thing
which is that there has to be a lifestyle change.
As long as we are thinking about weight loss as a diet,
as a temporary thing,
especially in a way that we're going to deprive ourselves,
that is not sustainable for anybody.
The only time that you will really be successful,
and this is true for those who've had surgery as well,
is committing to living life a different way,
committing to living and eating and moving differently
than you did before.
- There was a quote that I wrote down in my book here
from your Medscape article, someone commented,
I believe it was a nurse, an RN.
This person wrote body positivity is not about health.
It's about combating discrimination
against marginalized bodies.
And I think that's such a powerful quote.
The body positivity movement should be about fighting
this discrimination,
not about saying that diagnosis of obesity is a false one
or made up one, or it's a judgmental one.
It's an objective measure of someone's risk
and current health.
Now it doesn't mean that you're completely unhealthy
if you fall into one of these BMI categories.
No, 'cause again, spectrum.
But the fact that if someone discriminates against you
for being in this group,
that's what body positivity should really be focused on.
- I think it's like a yes and.
Yes, you should feel good about your body.
Everybody deserves to feel good about their body.
Everybody is worthy of love.
And there are negative health consequences for obesity.
Both these things are true and they are not in opposition
and anyone who tells you otherwise
I think is stirring up trouble.
- I would like for you to have the last word,
you're the expert.
Tell us what message you'd like to leave the audience with.
- I just would love everybody to understand
that when your doctor talks to you about your weight
it's most times not because they're trying to attack you
but because they want to help you.
If you're not ready to talk about it,
you can just say so,
but keep in mind that you can always come back
to that conversation.
And in the end, we're all in it together
to help us live happy and healthy lives.
(upbeat pop music)