‘What Happens Next?’: Should We Change How We Think About Fat?

Dr Susan Carland: Welcome back to What Happens Next?, the podcast that examines some of the biggest challenges facing our world and asks the experts, what will happen if we don't change, and what can we do to create a better future? I'm Dr Susan Carland. Keep listening to find out what happens next.

Dr Hilary Offman: What should your size matter if you’re healthy and you're enjoying your life?

Dr Michael Cowley: I think we need to not strive for perfection here. We have to accept ourselves as we are.

Dr Ahmad Aly: That's where we are using treatments like surgery, or like medication, which helps suppress the appetite, helps control or modulate that drive, that hunger that tends to cause the weight regain.

Dr Susan Carland: In our first episode on weight loss, we looked at the obesity crisis, the stigma attached to being overweight, and how losing weight and keeping it off is much harder than we think.

In this episode, our experts dig deeper into the way we talk about weight, and ask if we're putting reasonable expectations on our own bodies. And I promise, this time I will ask our experts the best ways to achieve weight loss. It's all coming up on part two of our look into weight loss on What Happens Next?.

Dr Hilary Offman: For most of my life, or a lot of my life, I was very fat. I am a lot less fat than I used to be, and so I have lived this experience… very much so.

Dr Susan Carland: Dr Hillary Offman is a psychiatrist and psychoanalyst, and lecturer at the University of Toronto. She's interested in weight and gender, and the idea of ‘otherness’ in general.

Dr Hilary Offman: And I think that's the best place from which to speak, having the experience oneself. And also as a physician and a psychiatrist who treats people, I have the other side of the experience as well, which is, what are we supposed to do about this? What does it mean?

Dr Susan Carland: Now, ‘fat’ is a very loaded term. Some people don't even like to use it. They think the term itself is pejorative. Where would you stand on the use of the term?

Dr Hilary Offman: I choose to use the word fat because I'm aware that it is a word with a lot of pejorative connotations, and there are all these words that people use to cover up what they're trying to say that, in my mind, even make things worse.

And it's a bit of activism, a taking back of the word, a reclaiming of it as something that can be said, like a descriptor, like ‘tall’ or ‘short’. There's something about speaking to something as it is, and forcing people to meet you right there instead of sliding away from the implications of the word.

Dr Susan Carland: When you use the word, do you find that people get uncomfortable?

Dr Hilary Offman: Yes, I do. And it's funny, I stopped… I personally am not uncomfortable when I use it, and I think that's because I've been practising using it. And I think I don't mind that it's a bit disarming.

Dr Susan Carland: Mm.

Dr Hilary Offman: I think that in order for people to take the topic seriously, I think they need to be a little bit disarmed.

Dr Susan Carland: Well, I wanted to ask you about this idea that we see a lot in advertising, particularly on social media now, of “healthy at any size”. Talk to us more about that. Do you think we are accepting of this concept, or as accepting of this concept as we should be? Do you think it's too flat a message for people to really grapple with? What's your take on it?

Dr Hilary Offman: Well, I would like to believe that there's been an uptake in society for health at every size, because it makes sense. I mean, what should your size matter if you’re healthy and you're enjoying your life? But sadly, I feel like there's a lip service paid to that. We might say it, but we don't really believe it.

Even people who are fat, because of what becomes an internalised stigma, believe it too. It's very hard. Even the people who are fighting against the stigma also believe in it. They believe that they are to blame. They believe that there's something wrong with them and that they should work harder. You'll have your family saying, “Oh, I want you to lose weight because I care about you.” There's this part that's like, “Well, yeah, but that's not really what this is about. Right? This is about how I look and how it interferes.”

So I truly believe that is absolutely possible, but I don't think we're there yet. I think we have a way to go before people will really embrace that idea.

Even healthcare professionals have trouble with that concept. They tend ... There's a sense that fat people get blamed for everything that's wrong with them. If you go to the doctor and you're fat, they'll say, “Well, you better go lose weight.” And you're, “Well, yeah, but I have an extra leg sticking out of my head. That's nothing to do with it.” [Laughter]

But this is what happens, and so people feel dismissed. They stop going to their doctors, and things get misdiagnosed. If you don't go to your doctor, you can't be diagnosed. And if you're always being told that everything wrong with you is because you're fat. And I can say that's pretty much my experience.

Dr Michael Cowley: I'm Michael Cowley. I'm a physiologist at Monash University. I work in the biology of weight control, and I work developing drugs to treat obesity and metabolic disease.

Dr Susan Carland: What do you think about the conflict between fat acceptance activists who have the healthy at any size argument, and some of the things that scientists say about the negative impacts of being overweight on the body?

Dr Michael Cowley: I think the health impacts of weight are individual. Some people are very obese and don't have health consequences for that, and that's the genetic fortune, I guess, of being able to bear that weight. I don't think it's right to be prescriptive about what people should look like. I think people have a right to be as obese or as lean as they choose to. I think there's an element of lack of choice in it for many people. It's just the genetic cards they got dealt. But again, I think it should be about metabolic health, not appearance. If you're healthy, then you're healthy. But even if you're not healthy, I don't think it's right to shame people for it. I guess we do shame people for smoking now in Australia, but there are a bunch of other risk-taking behaviours that people still indulge in without being stigmatised. I'm quite comfortable with the idea, this healthy at any size. Absolutely. There are people who are healthy at very large sizes, and there are people who are metabolically unhealthy who are lean.

Dr Susan Carland: Mm.

Dr Michael Cowley: Again, we're not worshipping them or congratulating them for managing to get sick while still skinny.

Dr Susan Carland: Yeah. [Laughter]

Dr Michael Cowley: That would be the flip side of the equation.

Dr Susan Carland: Yeah.

Michelle Bridges is Australia's most influential personal trainer. You probably know her from the hit reality television show The Biggest Loser. She's also the author of 17 bestselling books on fitness, nutrition, and mindset.

Michelle Bridges: Hi, my name's Michelle Bridges. I've been in the fitness industry for 30-plus years. I love this industry. I love empowering people. I love empowering women of course, into being the best version of themselves through great nutrition and exercise.

Dr Susan Carland: Is there such a thing as being healthy at any size, or do you think our culture has over-corrected and over-embraced that perspective?

Michelle Bridges: Look, it's a great question because I've found myself in some pretty hot water having this conversation because it's a sensitive conversation. It's a conversation that can easily upset.

I think if you look at it through the lens of common sense, the most important thing is your health. Now, if that means that by dropping a couple of kilos, let's say again back to the 5%, means that you're going to improve your cholesterol levels, your blood pressure levels and reduce the risk of heart disease, then for me it seems like it's a bit of a no-brainer.

So yeah, I think you can be healthy at many different sizes, but rather than looking at it through the lens of what size you are, let's just look at it through the lens of what's going on for you internally. How is your blood pressure? How is your cholesterol? Can we make some changes in order to improve that?

It's of no surprise and no shock, but it was at the time, when I very first started working on Biggest Loser, and we had some extraordinarily large people that came on that show, and that had a list as long as your arm of health conditions that came with it. We were having the doctors saying, “This is amazing. What we're seeing on their stats week by week, like literally week by week, is extraordinary. And we've always known that this could be possible, it's just often that we never get the chance to see it actually happen.”

So we know that by doing a little bit of exercise fairly regularly, improving your nutrition, reducing processed foods, reducing alcohol intake, increasing fibre, these are the things that can make quite a big difference to your health overall, but also to your mental health as well.

Dr Susan Carland: If you could change one weight loss myth, what would you correct?

Michelle Bridges: I guess, diet foods, diet drinks. Clinging to that – in my experience, again – it hasn't ever really been probably the most successful path for my… people that I've worked with.

The supplement industry is massive and makes a huge amount of money on offering up supplementation that can help you lose weight. I'm wary of that. I'm a believer in looking at your nutrition and getting some exercise into your day, and also doing the work mentally as well, and getting some support for that.

One of them that I've heard in many instances is that weight training will make you big. And that won't. I believe that weight training is the fountain of youth. Weight training is the way in which you can increase your lean muscle mass, assist with the onset of early osteoporosis, improve your posture, improve your overall cardiovascular system… improve everything, like weight training is it. I'm not going to buy into the one that it'll make you big.

But on that note, I've also heard the myth of, “Oh, I've started weight training, so that's why I've put on three kilos. I've put on three kilos of muscle.” I'm, “Well, you only started weight training a couple weeks ago.”

Dr Susan Carland: Yesterday. [Laughter]

Michelle Bridges: It's not possible. “But my PT told me it's alright, it's the weights!”

Dr Susan Carland: Here's Dr Michael Cowley again.

Dr Michael Cowley: As you get older, you want to put more focus on muscle-building, or muscle maintenance, than you do on cardio workouts. They're both important for sure, but the young people, 18 to 35, don't need to have that same focus on muscle-building. That said, most young people do have a strong focus on muscle building, the ones that engage in the gym.

Dr Susan Carland: Mm.

Dr Michael Cowley: I think there are a variety of ways to pursue that muscle growth kind of exercise. It doesn't need to be lifting metal in the gym. I mean, swimming's a terrific way to do it. There are lots of approaches that are not what you typically think of as muscle-building exercises too.

And by itself, exercise is just so valuable anyway, irrespective of weight changes. And we know exercise isn't a good way to lose weight.

Dr Susan Carland: Mm.

Dr Michael Cowley: In many cases, people exercise more and see no weight change, and they’re disheartened by that. But the health benefits of exercise are tremendous, and outweigh any lack of effect on body weight.

Dr Susan Carland: The best measure for weight loss is calorie intake versus calorie burn?

Dr Michael Cowley: Yeah. But you need to do both to be effective. If you just food-restrict, then you'll recalibrate your metabolism and you'll just be more efficient on less food.

Dr Susan Carland: Do you feel slightly panicky about this in the same way that I do?

Dr Michael Cowley: No.

Dr Susan Carland: As an expert? How do you reconcile all this within your head as an individual?

Dr Michael Cowley: Yeah. I'm in my 50s now. I'm never going to have the physique I'd like. I am as active as I can be, I exercise regularly, and I try to eat healthily, and that is enough that I feel better. It's not going to make me live forever.

But I think we need to not strive for perfection here. We have to accept ourselves as we are, and do as much as we can. But again, my focus is on more exercise rather than dieting down to be able to count the muscle fibres in my abdomen.

Dr Susan Carland: For the average person at home who maybe wants to be healthy and is just seeing every diet that’s being thrown at them on Instagram, how do they know what is healthy and makes sense, and is a good idea, and what's just a fad that in a year we'll all be embarrassed about?

Dr Michael Cowley: This is a great question, and I've got I think a good answer for it. I mean, one of my favourite authors is a guy called Michael Pollan, a journalist out of the US. And he's written a series of books around food and around, I guess, the food industrial culture. One of my favourites is A Natural History of Four Meals. But he gets asked this question regularly as a prominent journalist, and his answer is, “Eat food”... as opposed to chemicals. And when he says food, it's something your grandmother would recognise as food. “Much less of it, and mostly plants.”

Dr Susan Carland: Mm.

Dr Michael Cowley: I mean, it's a message everyone can understand. I mean, if you can't understand the ingredients in the processed food you're buying, he recommends against it, and I think that's a reasonable ... I mean, that's a message that everyone can grasp, I think.

Dr Susan Carland: Right. “Eat food. Mostly plants. Not too much.”

Dr Michael Cowley: Yeah.

Dr Susan Carland: Mm. That's the easiest way to do it.

Dr Michael Cowley: And it seems to work.

Dr Susan Carland: The formula's a good one, but given the enormous role our genetics play, eating the right food may not be enough. I asked Dr Ahmad Aly, Head of Upper GI Surgery at the Austin Hospital, about a more drastic lifestyle change.

So if you can't help your genetics, and it sounds like for the vast majority of people, if they are obese, keeping the weight off is almost impossible. Is surgery really the only feasible long term option?

Dr Ahmad Aly: Surgery is a very effective treatment, and of all the treatments that we have at the moment, it still remains the most effective for medium to long term weight loss. It's not the only treatment.

In fact, I think we have to really think about obesity as a chronic disease in the same way that we treat many other diseases that are chronic, like arthritis. We don't necessarily immediately jump to surgery for an arthritic knee. We might start with some physiotherapy. We might add some anti-inflammatory medication. We might do an arthroscopy and clean up the knee joint, and eventually we might need a knee replacement. It very much depends on what stage of disease we are at.

Obesity is a similar situation. If someone is suffering obesity and their obesity is a life-threatening condition – and more than likely they will have tried other means of weight loss in the past – well, no, the appropriate treatment for that patient may well be surgery. On the other hand, there may be another patient who, yes, is suffering obesity. Perhaps it's not affecting them from a medical illness point of view so severely, and perhaps we haven't tried other therapies to their fullest extent, in which case we might avoid surgery in that patient and use some of these other treatments.

The fact that they're not quite as effective, or maybe don't last as long, isn't necessarily a bad thing or a reason that we must always jump to surgery. It's about using the right treatment, in the right person, at the right time.

When we talk about patients suffering obesity, we're talking about a level of weight, usually genetic-encoded, where it either has the potential to significantly affect health, or it already is.

That's where we're using treatments like surgery, or like medication, which helps suppress the appetite, helps control or modulate that drive, that hunger that tends to cause the weight regain, to help patients lose weight and then keep it off.

Let me make it very clear: If these patients did not have any discipline, well, they wouldn't have yo-yoed, because they wouldn't have lost weight in the first place. It's extremely hard to lose weight. It's virtually impossible to keep it off if you're suffering from that genetic predisposition.

Dr Susan Carland: Mm. Give us the most simple explanation or description of what happens in bariatric surgery, and then the process of the surgery. And then what happens in the patient's body afterwards? Why does it change things for them?

Dr Ahmad Aly: As we said, the genetics tends to code for an appetite setting, if you like, that's high. They've got a high appetite. They're driven by hunger most of the time. They may not feel full easily.

Often these patients will tell you they eat a large volume of food and they say, “And I'm still hungry. I don't know why.” Whereas others that aren't suffering obesity say, “Well, you know what? I eat a sandwich and that's it. I'm done. I just don't even want to look at food anymore.” It's not a choice. It's just a feeling. Right? It's a sensation.

What surgery fundamentally does is, it modulates that appetite. By altering gut structure, often people think of it as, “Oh, we make the stomach smaller”. And technically, yeah, that's true, but it isn't about size. What happens when we manipulate the stomach or the small bowel in certain ways, what happens is it changes appetite, and it changes that sense of fullness. So when we do the surgery, what then happens afterwards is when patients eat a small amount of food, like half a sandwich or something like that, they just feel full. They just feel disinclined to eat. They don't want any more.

Similarly, the hunger is suppressed, so they don't get hungry quickly. And for many patients, actually, yes, they love the weight loss, and the improvement of health, and so on, but many patients tell us, “You know what? That lack of hunger, that no longer being incessantly driven by hunger, that's actually the biggest benefit, because I suddenly feel like I've got control again. I feel like I am me again. I feel like I can manage things. I'm not dominated constantly by this hunger.”

I mean, you think of it yourself, Susan. If you're really hungry, for whatever reason you haven't been able to get breakfast or lunch, and you're hungry. You're driving along the street. Suddenly every shop you see is a food shop. Even streets you've driven down before, you've never noticed the pizza shop before, but now you do.

That's what appetite does to us. It switches all of our senses on to go looking for that food. To go wanting it. Until you eat, you're going to be driven, and driven, and driven to go and do it. It's all biological, and it's all survival. It makes sense. Yeah.

What we do is surgeries, we modulate that. We alter that. Medications that treat obesity do a similar thing. Most of them are aiming at reducing that appetite, increasing that sense of fullness. In fact, most of the newest medications are derived from hormones that we discovered were important in regulating appetite, and we discovered that through studying surgery. So the medications these days are trying to mimic what surgery does.

Dr Susan Carland: Do you think perhaps those medications might be a future direction? Surgery may no longer be needed, which is obviously quite invasive and no small thing, and perhaps it would just be the medication instead?

Dr Ahmad Aly: Well, I think certainly there is a drive to develop medications and other treatments. Absolutely. And that's right and proper. And we should, because as I said, this is a chronic disease, which will require treatment – a multifaceted treatment, and often combinations of treatment. We're now combining surgery with medications sometimes in some patients. I think we'll need all of these treatments.

I don't think necessarily that surgery will be replaced. I think the biological mechanisms are just so sophisticated and complex that it's going to be very difficult to replicate it in a single pill or a single injection.

What happens in the body with appetite and appetite control, and when you eat, it's like a symphony. It's not just one hormone. It's hundreds of hormones that are going and flowing and ebbing in different ways. People with different genetics will have a different symphony to others, and so I don't think that we're going to find one single critical key. I think it's going to be multiple points that are going to help.

Dr Susan Carland: There's something beautiful about listening to that internal symphony. It's almost like looking at that much smaller picture of hormones and genes, opens our eyes to a much bigger picture. There's more to weight loss, gain, and body type than what's on your plate and who's teaching your next gym class.

The next time you step onto that scale and start to despair, remember that internal symphony. Remember to reframe the way you think about fat. And if that doesn't work, blame your parents.

Thank you to all our wonderful guests on this series for their valuable insights. If you're enjoying What Happens Next?, why not give us a rating – five stars only, please – and review on your favourite podcast app? I'll see you back here next week with a brand new topic.