[PREVIEW] "That's Unethical as Hell."

Hello and welcome to another audio version of Burnt Toast!

This is a newsletter where we explore questions, and some answers, about fatphobia, diet culture, parenting and health.

I’m Virginia Sole-Smith. I’m a journalist who covers weight stigma and diet culture, and the author of The Eating Instinct and the forthcoming Fat Kid Phobia.

I’m so excited today to introduce my guest, Marquisele Mercedes, or Mikey. She is a writer and doctoral student from the Bronx who is completing her PhD at Brown University School of Public Health, specializing in weight stigma, racism and critical public health studies. And oh my goodness, we need her work so much.

I’m putting Mikey’s Patreon right here at the top of the transcript, because I hope everyone reading/listening will check it out and support her work.

Welcome, Mikey. Thank you for being here.

Mikey

Thank you for having me!

Virginia

The first thing we have to talk about is the piece you did a couple weeks ago, a brilliant, searing takedown of Wegovy, the newest FDA-approved weight loss drug. Honestly, anyone who hasn’t read it yet, go read Mikey’s piece.

One of the things that really jumped out to me is how the diet industry finances these drugs, because whenever we see these headlines, it’s presented as unequivocally good news. People may sort of know that scientists are required to disclose whether they have a financial stake in the research they’re doing, but—I have been reporting on this stuff for a really long time and I don’t even totally understand all the ways that the financial disclosure on a study does not tell the whole story. So why don’t you walk us through that a little bit.

What does a financial disclosure do? And what does it tell us? What does it not tell us? And why, in the case of Wegovy, is there just so much more money at stake?

Mikey

The first thing to know is that to publish in most journals—especially those that have biomedical research—any journal that you try to publish in, if it’s peer reviewed, will ask if you have any financial conflicts of interest. But people who aren’t familiar with that process usually don’t understand that there isn’t a point at which the journal editors will say, “Oh, you have too much of a vested interest. We’re not going to take this article.” That doesn’t really happen. So, for example, there are three different authors on that Wegovy study that are employees of Novo Nordisk and then there’s also two that additionally hold stock, and that was not enough to not have this paper published.

Virginia

So it’s like: We’ll disclose it, but we’ll go right ahead and report this as unbiased science.

Mikey

Honestly, with a lot of areas of research, especially pharma or biomedical tech or whatever, having corporate ties is not a thing people really question. It’s definitely not a thing that journal editors question because it’s normal. So people are like, oh, okay, you’re a stock-owning employee of this of this pharmaceutical company. And you also receive fees from whatever and you invest actively in these companies, okay, we’ll note it at the bottom of this article. But it’s not like we’re not going to take your research, especially when it’s something like this. So there’s a lot of publication bias at work here too where, the medication had such distinct results, you know, an average of 15% loss of weight from participants’ initial weights, and a lot of people lost a third of their initial weight. When you have a result like that, it’s almost impossible for that to not get published, even in a journal like the New England Journal of Medicine, which is one of the most prestigious journals in the world.

So you have publication bias on your side, because you got positive results, and no one in this area is really going to question whether or not to publish this on the basis of your financial conflicts of interest, they’re just going to note the conflicts of interest, and then go on and publish it anyway. On top of that, you have this culture within medicine, especially in biomedical sciences, where, you know, there are just certain forms of research where corporate influence is seen as okay. And a lot of the time, pharmaceutical companies are part of that culture. And definitely when it comes to weight loss.

I’ve said this before: In science, there are some things that we get outraged about in terms of corporate influence, and others not. Like with tobacco. If a tobacco company tries to start an organization or a research foundation and do studies on the health outcomes related to smoking that may portray cigarettes in a less negative light, then people in public health especially are going to be pissed off about that. And they’re going to raise the alarm. But when it comes to Nestle funding research foundations, everyone’s like, oh, cool, private-public partnership, when it’s really private influence over what should be public work.

Virginia

Why that double standard? Why are we outraged that a tobacco company would do science to try to make their products seem safer, but not outraged that a pharmaceutical company will do science to make a drug they can sell and profit off of?

Mikey

Fatphobia. It’s literally just fatphobia. Public health is very proud of how it’s solved tobacco. It’s weird. They’re like, yeah, like, we managed to cut the smoking rate and blah, blah, blah. It’s one of the main examples that people use in health communication classes or science communication classes, when we’re talking about how to encourage or discourage people from doing certain things. Tobacco is the main example, as well as that health communication campaign, “Verb: It’s what you do.” Which actually wasn’t that effective, but that’s a whole other conversation.

It mostly boils down to fatphobia. And I’ve found that’s amplified by the way that corporations have always been part of, the “obesity prevention” area. So it’s less jarring when something like this happens because it’s like, oh well, this is the way it’s always been done.

Virginia

Right, you don’t question this whole system. It feels very radical to say pharmaceutical research should only be government-sponsored or that there shouldn’t be a capitalist stake in this. When I say it out loud, it seems quite logical yet also anathema to the way we are programmed.

Mikey

If you were to say that in a room full of like, researchers, I think people would be like, whoa, hold up. That’s a bit much.

Virginia

These corporations do have huge amounts of money, they do directly impact people’s health. If we could get them to put that money towards useful things like that could be a good thing. The problem is, they’re only putting it towards—

Mikey

Profit-making.

Virginia

Right profit-making, and in this case, creating a drug that you and I both feel strongly is going to be more harmful than it could ever be good.

Mikey

Exactly. This is all aside from the fact that these corporations should not have the money they have anyway. So that’s a whole other thing, that we might not have enough time to get into.

Virginia

Yeah, that’s a whole separate conversation. But definitely worth noting.

So let’s talk a little bit more about the drug itself. I mean, as you said, it’s had these “positive results” and people are reporting more weight loss while on the drug then you usually see in these studies, but you also talked in your piece about our short-term memory when it comes to this industry, and specifically weight loss drugs. So tell us a little bit about what we’ve forgotten about this drug’s predecessors that’s clouding our ability to assess this drug?

Mikey

If the diet industry was held accountable for all of its past failures, and not-delivered products, then it wouldn’t exist. Let’s be clear about that. The diet industry—and when I say the diet industry, obviously, I’m talking about manufacturers of weight loss drugs, but also like, companies like Weight Watchers, or individuals who actively profit off of selling weight loss, not necessarily as a thing that happens, but as a dream.

Virginia

Right, a very important distinction.

Mikey

And that’s the distinction that I think is really core to this cycle. Somehow we are so drawn to the promise of weight loss, that we choose to forget that if you’re a fat person living in this country, you have probably tried more than one, more than multiple forms of weight loss, dieting, some kind of weird cleansing program. You’ve probably tried some of those things, if you haven’t, I think you would be in the minority of fat people.

Virginia

Minority of all people but especially fat people.

Mikey

And I think the normalization of that activity, engaging in this collective fat hate, paired with the fact that like, there are tangible benefits to being smaller—and then also the fact that this industry has so many resources to make sure that we never forget that weight loss is a good idea—obviously, we’re sort of slowly seduced into forgetting the fact that most of us have definitely tried to lose weight and it hasn’t happened or it’s sent us off into spirals of disordered eating, or has had other kinds of negative implications on our lives. I think it’s really hard to remember that these things don’t usually work the way that we’re told they work because all those other things are happening.

We’re constantly being reminded that fat is bad, constantly reminded that weight loss is good. And then we see that reified by all of this media explosion when something like this comes out. It’s being talked about as a game changer: “This is gonna change people’s lives.” There’s always, always, always, always a steady supply of people waiting in the wings to advocate for something like this on a large scale. Which, honestly, the application of a weight-loss recommendation or technique for community-level or population-level health, that’s fucking unethical. That’s unethical as hell.

We know that encouraging weight loss, encouraging body comparison, encouraging body dissatisfaction, does all kinds of messed up things to our health. And we also know that it’s incredibly rare that people lose weight and then sustain that weight. And we also know that the consequences of putting people into a cycle of weight gain and weight loss has serious implications on our metabolic health.

And yet, it is completely acceptable to recommend those things on a community level, on a population level.

And there are people in the medical community who will absolutely advocate for that. And there are lots of reasons why. And sometimes those reasons boil down to dollars, and it’s a really uncomfortable thing to sit with. Regardless of how much we complain about how bad healthcare is in this country, I think that a lot of us still hold on to the hope that the people who give us healthcare services have our best interests in mind. And being confronted with information that suggests the opposite, or suggests that the story might be a little bit more complicated, is incredibly uncomfortable.

I strongly believe that people are the best experts of their own bodies. We live in these bodies every every damn day. We know when things don’t feel right. We know when we’re content. And when we’re at ease. The fact is that most doctors don’t know what to do with fat bodies. There are plenty of studies that suggest that doctors do not feel equipped to deal with patients that are “obese.” [Virginia Note: I summarized a lot of that research in this article.]

They don’t know how to do nutrition education, they spend less time giving health education to people who are fat. A lot of the restrictions that fat people face, especially when they’re looking to get life-saving surgical procedures or transplants—there’s this idea that at a certain weight you are less able to get through that procedure. That is also something that I’m very sure is born from doctors just straight up not knowing how to deal with fat bodies. In medical school, a lot of cadavers when they’re fat, people are just like, “Oh, I have to, like, cut through all of this. Oh, my God.”

Virginia

So dehumanizing.

Mikey

And it also just turns treating fat patients into a burden from the get go. So, yes, people are absolutely, probably the best experts on their own bodies. But also, a lot of doctors don’t know what the fuck they’re doing when it comes to fat patients.

Virginia

It’s so important to highlight that. With this drug in particular, it had this initial 15 percent weight loss or up to a third weight loss, which sounds like some brand new achievement. But let’s talk briefly about what are the concerns about Wegovy?

Mikey

Someone who engaged in the study and was receiving Wegovy, is quoted in multiple articles about the medication, saying that she ended up gaining back most of the weight that she lost while she was on the medication, and then also lost some of it and then also gained some of it back. That’s the textbook definition of weight cycling. The fact that this medication is being heralded as this game changing diet drug—there’s nothing game changing about it. When you’re on it, it fucks with your pancreas enough that you are sent into a process of losing weight that probably is not healthy or organic or makes sense for your body. And then once you’re off the drug, you gain it back.

Novo Nordisk has sort of perfected the playbook of taking one drug and finding that it has a side effect of weight loss and then just like, selling it in bigger dosages so that weight loss happens more quickly.

They did this with another drug, Saxenda is just Victoza at a higher dosage. The only difference between them is the dosage and Saxenda is also specifically marketed as a weight loss drug whereas Victoza is not.

Virginia

Right, it’s a diabetes medication.

Mikey

Right, it’s a type two diabetes medication, and it is very effective at doing that. But it’s not meant for weight loss. And then you have Ozempic which is the drug that they amplified the dosage of, to get Wegovy.

So Victoza was the subject of a major 2017 federal case against Novo Nordisk. Novo Nordisk was ordered to pay $58.65 million to the federal government and state Medicaid programs for intentionally minimizing the risks of developing a rare form of cancer to physicians who would be prescribing this medication to their patients.

I’m not saying that what happened with Victoza is what’s going to happen with Wegovy, that doesn’t even need to be the case for this to be just a failure and hazard to everybody’s health. The point is that if a company has a history of doing things for profit that intentionally did endanger people’s lives, maybe that company should not still be making things that people will ingest. Moving on from that, if we know that a medication has risks, like serious risks, even in small doses, and then you rebrand that medication into a weight loss medication…like, why, how was that allowed to happen?

It’s really hard to find out if people from the FDA have taken corporate money. I’ve tried to figure that out, because I really didn’t see any other way for Wegovy to have been approved. It’s been a few years since a drug has been approved for weight loss by the FDA. So this is a big deal and I don’t know. I’m not sure if the FDA has ever approved a potentially risky medication, especially after a corporation has been found to have intentionally mislead physicians. I don’t know if that’s something that has happened before in history. But clearly, this is something that we should be worried about.

Virginia

There’s so many red flags, except none of them were being reported in any of the mainstream media.

Mikey

I’m sure you saw how the American Academy of Pediatrics like came out supporting bariatric surgery for tweens, and it’s the same thing. I was like, damn, NPR should be ashamed of itself, because—

Virginia

That story was a travesty.

Mikey

Like, how is it that the only risks focused on in that piece were like, trisks of promiscuity following weight loss? They were like, she’ll be socially relevant. Are you fucking kidding me?

Virginia

The girl’s mom was against her getting it, but not because she was worried about the risks of the surgery, but because she thought she hadn’t tried hard enough to lose weight. And that was completely unexamined.

Mikey

Portraying that doctor that helped her get the surgery as a kind of savior, especially since that particular doctor is like, honestly, I want to I want to start like, I don’t know, I want to gamble basically on the chance that this specific doctor shows up in an article about weight stigma, because she’s always always always around. And she’s heralded by medicine as this crusader for dismantling weight sigma. And I’m like, what the fuck is so different about her from the people who are just more obvious about hating my body? I honestly find it more dangerous, that someone would hide their disgust for fatness in like, not genuine concern for my well being.

Virginia

The tell is always when they come around and say we’re helping these kids lose weight to avoid weight stigma. It’s like, that’s not how you fight stigma. You don’t fight stigma by taking the marginalized person and making them assimilate. That’s the opposite of fighting the stigma, that’s reinforcing the stigma.

Mikey

And then we can’t really rely on most journalists, at least to give us the the real on what is happening with these. I mean, a colleague of mine tried to write something about Wegovy, they really tried to get something published. And they were told that it was just too controversial. And I’ve pitched this to no less than 15 places and no one will get back to me. It’s ridiculous. I think that with how pervasive weight stigma is, it makes it seem like there’s no one that gives a shit about it at all. But there are people like you, like me, like my colleagues, like fat activists, people that really do this every single day. They’re constantly thinking about weight stigma, how to dismantle it, constantly working to do that, but they get shut down at every single angle. And, it’s exhausting.

Virginia

I often run into this attitude of “yes, we’re very worried about weight stigma, I guess it’s this terrible problem, but oh my God, ob*sity equals death. And that’s the real danger.” It’s almost like we have to sacrifice people’s mental health to fight this public health war. And I think that discourse comes out of the public health world. And it really is about how the diet industry has infiltrated public health discourse. So talk a little bit about that, how you see diet culture and fatphobia showing up in public health and how these two things got so enmeshed?

Mikey

In terms of public health, I mean, I don’t see an area of research that is not impacted in some way by diet culture, by the diet industry. I’m doing my PhD in a behavioral science department. I’m surrounded by people who do behavioral interventions on obesity, and it’s just the most whacked shit ever. A lot of people are completely disconnected from how certain areas of science really come to be, how certain areas of public health really come to be. And so when you try to say like, “Oh, hey, maybe what we’re doing in public health is shitty. Like to a lot of people.” When you bring that up, they’re just like, what are you talking about?

This is research that I’m currently doing now for my own book proposal. Like, how deep do obesity prevention initiatives really go? A year ago I was reading Fit to Be Citizens? by Natalia Molina, who talks about Mexican Chinese and Japanese immigrants in the 19th century, late 19th century, early 20th century, and their experiences being actively marginalized by the Los Angeles county and city public health departments. And it’s a really good read, I recommend that people pick it up. It’s very accessible language. Molina is a really, really good writer. But even in those health interventions that they would target towards Mexican moms in the early 1900s, late 1800s, a lot of that was critiquing their diet, and the way they ate. So even that falls into the parameters of an obesity prevention initiative. And that’s something wouldn’t necessarily be classified as one because it falls into the realm of maternal and child health, which is honestly one of the most fatphobic areas of research I’ve ever seen in my life. But I mean, it’s the same reason why that survey returned that ob-gyn is one of the most fatphobic areas of medicine. These things are not a coincidence.

Virginia

We like to police women’s bodies, mothers’ bodies, mothers of color’s bodies. It all needs to be policed and controlled as much as possible.

Mikey

We have to understand that critiquing people’s diets—especially people from other cultures—critiquing people’s diets, critiquing the way they feed their kids, critiquing their cultural foods, really became bolstered by public health initiatives justified by the faulty science that they put out to justify their bigotry. And now it’s a whole area of research. Now, that’s not just critiquing immigrant mothers, that’s obesity prevention research. Like that’s a thing like that has journals, that has grants, that has clout. So it goes really, really deep. And it's not just relegated to the areas of research that look at eating, it’s also about physical activity research. And also people who do research on racial health disparities often fall back on like fatphobic racist logic for why some people are healthy and why others are not.

Virginia

Say more about that.

Mikey

I mean, so first of all, there's the enduring, long-lived fallacy that race is biological, which it is not. But when you make race biological, and you essentially make culture something inherent to an individual, then you can make the case that their way of eating and their way of cooking is an inherent pathology. And some people don’t even bring race into the picture, they’re just like, oh, you know, some cultures are just so unhealthy, and we need to help them. And all of its bullshit, because of how malleable and subjective it is, like, now quinoa and avocado are seen as super foods like, now it's okay that people of color were the ones who like, really eat them.

Virginia

And collard greens..

Mikey

And kale and collard greens. Yeah, like, fuck off, like, whenever I see something like that, I'm just like, this is how I know that none of this is really rooted in anything but our internal hatred for certain kinds of people. When you start to look at things through that lens, it’s a really depressing lens. I don’t recommend doing it all the time. But it’s often the perspective that I use when I’m thinking of things like Wegovy, because I’m like, who is benefiting from this drug being approved? Who is benefiting from what it does in the meantime, and also, who was benefiting from what happens afterwards? Because I remember, someone made such a wonderful comment when I first put out my article, and they were just like, this is going to lead to a whole generation of diabetics, the way that this messes with people’s insulin production. That’s a consequence that I think will happen. Even if a few years from now the FDA is like, this is not a thing that should have ever been approved, by that point, the damage is already done. And since it’s fat people that are going to be prescribed this drug, right, that just feeds into the idea that fatness is inherently inherently pathological. Thus the cycle begins again.

Virginia

The last thing I want to talk to you about is the how all of this stuff plays out in food culture. A lot of my listeners are parents, so I get a lot of questions around kids and processed foods, and there’s a lot of fears around processed foods. I want to hold space for the fact that parents are under a huge amount of pressure to feed our kids perfectly. But I think it’s very useful to unpack how much the anti-processed food argument is rooted in fatphobia and racism and classism. There are a bunch of new studies that came out this week looking at processed food and kids’ diets and then immediately linking them to health problems. There’s this never ending onslaught of research in that area, much like with the weight loss drugs, and we see these headlines and we think, Okay, well, there it is, salt, sugar and fat is so bad for us. You know, processed foods, the ultra processed foods are so bad for us...

Mikey

This is more of a new thought, but I wonder about the utility of making certain kinds of foods that are more widely available to people of color, especially Black people, low-income black people, I think about the utility of marketing those foods as something health conscious, respectable people shouldn’t be eating. Who benefits from that? A lot of the discourse that demonizes certain foods over others is honestly some form of marketing ploy to push some kind of new form of eating, whether that's clean eating or, or being like, oh, we all have to be vegan, or we all have to eat clean, or we all have to buy organic foods, you know, whatever that means. The way I see it, the more we impose hierarchies on food, there will always be certain foods that we have a fixation on, because those are the foods that we shouldn’t be eating. In terms of parenting, I feel like that is so relevant.

When I was younger, my fixation on eating more and more, first originally stemmed from hunger, because like, I was restricted, you know, in terms of my diet. I have always lived in a fat body at any age. And so when it came to the point where restriction was an enforceable thing, that was when I became most fixated with food. I didn’t become fixated with, you know, ultra processed food, or like, that wasn’t the thing that I really even gave a shit about. When I was a kid, I was like, I want to eat more of the food that I had for dinner, because I was still hungry. And I live in this body, and my body is telling me that it needs food. And eventually, that fixation moved away from being something that I physically felt was necessary, and more a compulsion that I had to fulfill. Because if I didn’t have it, it meant that I had let some kind of need go unfulfilled. And that caused me a lot of distress.

So when we talk about ultra processed foods, I feel like especially in areas of parenting, we’re just like, how do we make kids less fixated on these foods? How do we make kids like these foods less, you know, like, marketing for these foods is all bright and colorful and draws people in. And kids are always told not to eat them. So you know, they might like them more, but I honestly tell people to start with their relationship with the food they eat on a regular basis. The idea that food abuse starts with foods that are, you know, “unhealthy” I feel is misinformed and incorrect. But it’s something that so many of us feed into. And it’s extremely prominent in literature that is targeted towards parents, because just because of the way that a lot of these foods are age-coded. Is there a reason why Lunchables and other forms of prepackaged ultra-processed foods are so bad? I think that’s a conversation worth having. But I also think that a lot of the time, it’s a distraction.

Virginia

I think you’re articulating a key tension I think about a lot which is: The processed food industry, much like the diet industry, could certainly use more oversight, could certainly stand to have someone coming in and saying hey, stop with the predatory marketing tactics, stop disproportionately marketing communities of color, stop disproportionally marketing to kids. All of that would be super, and is really important. But we often lose that nuance, and it becomes: these foods are bad. You are bad if you feed them to your child. And it’s so much more complicated than that, these foods in and of themselves are not terrible, it’s the excessive marketing and the way that’s done in this disproportionate way that is the problem.

Mikey

It’s the way that these foods give in to the fixation we already have about eating. Like, if I'm a child, and I am already thinking about food, and then I am suddenly bombarded by food marketing, those are things that feed into each other. It’s not like food marketing started my issues with food.

Virginia

Because if you hadn’t been restricted, you could have navigated the marketing much easier.

Mikey

Do not restrict kids. I hear things like, Oh, well, if I don’t restrict my kid, then they’ll eat whatever they want, until they’re sick. And, you know, sometimes we need to have that experience. You need to have that outcome in order to be able to learn from that experience.

Virginia

It’s part of learning how to navigate these foods. And if you restrict your kid around them, they will have that experience at a friend’s house on a play date or something, you know, they will, it’ll happen one way or the other.

Mikey

And we have to think about how the fixation that we have on ultra processed foods in general, and the insistence that we eat a certain way that’s cleaner, healthier, blah, blah, blah. All of those things just demonize other people.

Virginia

Right.

Mikey

That’s where a lot of that comes from, it comes from the inherent distaste that we have for poor people, for fat people, for Black people, who are often more often than not forced into a position to buy foods that fall into the category of processed or ultra processed, because of the fact that they have restricted access to resources to buy other kinds of foods.

This is literally just another way to push bigotry and enforce hierarchies. And the more we think about it like that, then the next time, you know, it’s easier for us to be like, well, this thing is telling me that unless I have this prepackaged meal, that will help me lose weight, then I’m a bad person, it becomes easier to unpack that and point out why that’s bullshit when we understand that these are not fueled by health promoting goals. They’re promoted, they’re fueled by profit seeking goals that are also amplified by division and bigotry.

Virginia

Something I often think about when parents are articulating these anxieties to me is: How much of this is honestly about your concern for your child’s health, and how much of this is about your concern for your perception as a parent? I’m thinking about kids lunches, and the standards for kids lunches have gotten just, you know, there’s supposed to be like four types of produce and a rainbow and you know, it’s insane. And it’s all white ladies on Instagram, performing their parenting in this way and performing their white savior lady thing, right?

Mikey

Performance is a crucial social tool, right? But it’s not a thing to base your lifestyle on. Like, it’s okay to be like, oh my god, I made this really cute lunch for my kids. This sandwich looks like a face and it’s smiling. And I can’t wait to talk about this with like, the other parents that I know. That’s totally cool. The thing that’s not okay is taking those values that you have around that sandwich and applying it to how you’re treating your human child.

Virginia

And that you’re then judging the other parents such as myself who are packing Uncrustables for our kids lunch, right?

Mikey

I have Uncrustables because as a semi-functioning adult, If I don’t have them, I might not eat anything. They’re amazing. I also want to say that just because you’re a parent doesn’t mean that you’ve resolved your own issues with food, so unpack that shit. Figure out your hangups around food and how you might be projecting those onto your child. Because, you know, a lot of the times, we’re guided by these conventional nuggets of wisdom, but those conventional nuggets of wisdom are just trauma that we’re still holding onto.

Virginia

Such a good point. Mikey, thank you so much. This was an amazing conversation.

Mikey

Thank you for having me. I don’t usually talk about this kind of stuff.

Virginia

Tell us all of the ways that people can follow you and support your work.

Mikey

On Twitter, which I spend way too much time on, I’m @marquisele. On Instagram I’m @fatmarquisele. I'm also on Patreon: patreon.com/marquisele. I’m currently working on a fat studies public health syllabus. So if that’s of interest to anyone, I break down a lot of what we’re talking about right now, in terms of how fatphobia became a thing, especially in the sciences. And if there are some concerns or questions that you have around fatphobia, I’m always always always taking questions through my website. And those are the subject of my semi bi-weekly newsletter I put out through Patreon as well.