Morgan Stanley has projected the weight loss medication market to reach $150 billion globally by 2035. The use of GLP-1s, such as Ozempic, have increased drastically since 2019. At the same time, new research shows that the use of these drugs still comes with the risk of judgement and social pressures that all relate to weight stigma.
An Oregon-based group, Body Liberation for Public Health, wants to help end these stigmas. The group is advocating for body liberation, which is a movement aimed to dismantle the systems that have created weight stigmas and bias, as opposed to the body positivity movement, which encourages acceptance of all body types. Debbie Kaufman is the creator of the project. She joins us to share more on what body liberation is and why it’s important to incorporate it into public health.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. Debbie Kaufman spent nearly 20 years teaching at Portland State University and the OHSU-PSU School of Public Health. Over the course of her career, she became interested in calling out and reducing weight stigma and bias in public health. She is a founder of the Body Liberation for Public Health Project, and she joins us now to talk about it. Welcome to Think Out Loud.
Debbie Kaufman: Thanks for having me.
Miller: When you were starting out your career in public health or public health education, how did you view body size?
Kaufman: I think, like most people do, seeing it as a problem if people were too large and you had to be thinner to be healthy. And now it’s very painful for me to think about how much I promoted that in my courses. And what I know now is that it causes harm.
Miller: What are the ways that you promoted that in what you were teaching?
Kaufman: That the goal was weight loss and we needed to do things to lose weight in order to be healthy. And I now know that we can do healthy behaviors and that can help us improve our health, whether we lose weight or not. So if we get exercise, generally that’s really good for us and it’s good for our health, even if we don’t lose weight.
Miller: How would you describe your own journey then? If you started with what I think it’s fair to say is still the dominant messaging from either health care professionals, doctors, nurses or public health authorities, and now you’re, in some ways, in a different space, what was your journey like?
Kaufman: Well, for me personally, I had the experience of doing all kinds of exercise programs. And I didn’t lose weight, so I thought …
Miller: Were you trying to lose weight?
Kaufman: Yes.
Miller: Because you had been told by your own doctors that you should or because it was more societal?
Kaufman: No, I actually was pretty thin most of my life, but society, it’s like, no matter what, even if you’re thin, it needs to be a different thin, different shape. So I did a lot of different exercise things with the goal of losing weight and felt like a failure because I didn’t lose weight and quit them. When in reality, all of those exercise things would have been good for me to continue in terms of my overall long-term health.
Miller: So it started actually as a very personal experience that then changed the way you thought about the messages you were putting out professionally?
Kaufman: Yeah, and I couldn’t have worded it. I couldn’t have articulated it the way I just did, just feeling discouraged and negative about my body. Then quite serendipitously, I went to an event at PSU that was put on by a group of students in a course called “Embracing Size Diversity.” They had an event and I don’t even know why I decided to go … just out of curiosity. And I heard a presentation there by the folks at the Center for Body Trust and it changed my life. It’s like light bulbs went off and I’m like, oh, this is why we’re struggling so much with these messages and these ideas that we must lose weight in order to be healthy. It’s just like so many things fell into place.
I had one experience early on in a course where I talked about this. And a student came up to me – a student in a larger body – afterwards and she said to me, “Now, I feel like I belong in public health.” And I knew I was on the right track. So, yeah, I was going to this event and hearing about it, and then I undertook this course of study. Taking training at the Center for Body Trust, reading, going to conferences, all these different things and started talking to students about it. And we were getting complaints from students about content in our courses that were weight stigmatizing. Students were demanding that we do something different.
So the impetus for the course that I taught at PSU at the School of Public Health, that was by students wanting this information and thinking that we needed to have a different perspective.
Miller: I mentioned the name of your project is Body Liberation for Public Health. What does body liberation mean?
Kaufman: The way we’re using it, freeing ourselves or liberating ourselves from these expectations in society that you have to have a certain look, certain size, certain shape, certain abilities in order to be acceptable in our society, and just freeing ourselves from these expectations because they cause a lot of harm. And they come a lot from the weight loss industry.
Miller: Which I should say I actually hadn’t realized just how much money we’re talking about. I knew with weight loss drugs, which we can get to, that they’ve been unbelievable blockbusters that changed the economy of Denmark. But in an article, partly about you, in Portland Monthly recently, it had the figure of a nearly half a trillion dollar industry. What does that much money mean in terms of the way we talk about weight and weight loss globally?
Kaufman: Well, it means that there are a lot of people who have a big financial stake in us hating our bodies and feeling like we need to “fix our bodies.” And they do a lot to perpetuate that and to make sure that we have this dissatisfaction, or we feel like we have a disease, or we’re unworthy, and all of these things so that we will keep spending this money.
To the public health part of it, a lot of institutions in our society promote this perspective and public health has, for many years, done that. And what we’re hoping is to help public health people, whether it’s academics, educators or practitioners, see the harm of the weight-centric paradigm and shift to weight inclusive.
Miller: What are some of the actual health risks of an anti-fat bias in a health care setting?
Kaufman: In a health care setting, as you can imagine, people in larger bodies get a lot of advice to lose weight, and often symptoms are actually ignored or they’re even denied care. There are sometimes weight limits for gender-affirming care for things like knee replacements. People will just say, “We won’t do this for you until you lose weight.”
Once you go to the doctor enough times where you feel like you’re ignored or they don’t have the right size gown for you, they don’t have the right size blood pressure cuff, they don’t have the right size needle for injections, all of these things, you start avoiding health care. And that is also bad for your health, if you’re not going to preventive appointments or you’re waiting till something is an emergency before you go to get care for it; and then people’s body size is blamed for their worst health outcomes. Really, the stigma and the discrimination in the health care system is discouraging them or preventing them from getting health care early on, when you could have had a better outcome.
Miller: The World Health Organization says that, “The health risks caused by overweight and obesity are increasingly well documented and understood.” They wrote that in 2021, “Higher than optimal BMI caused an estimated 3.7 million deaths from cardiovascular diseases, diabetes, cancers, neurological disorders, chronic respiratory diseases and digestive disorders.”
What are ways that you think health care professionals or public health authorities can safely and honestly talk about these kinds of risks without shaming, without doing everything you’ve just been talking about?
Kaufman: We have to take a look at the research because a lot of it is correlational – and this is a little bit of public health speak here. Yes, there are more people in larger bodies who have diabetes. But that is a correlation, that doesn’t mean that they’re causal. There’s much less research showing that there are causal relationships.
We know stress is also highly correlated with the things that you listed. If somebody is avoiding health care, being stigmatized and is living under chronic stress from the stigma of being in a larger body, those can also be contributors to poor health outcomes. And like the statement from the World Health Organization, it’s blaming it just on the weight. More and more research is also showing that weight cycling, the pattern of intentionally losing weight and then regaining it – which happens in the vast majority of cases if you go out long term, if you look at long term data – is particularly bad for cardiovascular health.
So we have to look at confounding factors rather than just saying, this person in a larger body has whatever health issue, not “the body size must have caused it.” It’s much more complex than that. And it just makes me so angry when I hear about, well, the data that is killing people and stuff like this, and not taking into account living with that stigma in society and not getting good health care, people ignoring your symptoms, people saying you should just lose weight – all of these things are harming our health.
Yeah, so it’s just not that simple, the way they’re outlining it. And newer research is showing that it’s much more complicated than weight equals health.
Miller: I want to turn to politics and the current cultural moment. If that line from the World Health Organization infuriates you, I think what I’m about to play might be even worse. This is audio from the Secretary of War, Pete Hegseth, from a speech about three months ago and this was to a bunch of Pentagon brass. And he very publicly talked about the way people look and this is part of what he said.
Pete Hegseth [recording]: It’s tiring to look out at combat formations or really any formation and see fat troops. Likewise, it’s completely unacceptable to see fat generals and admirals in the halls of the Pentagon, and leading commands around the country and the world. It’s a bad look. It is bad and it’s not who we are.
Miller: I wanted to play that because the sense I’ve gotten over the last, say, decade or so, it has seemed like there was a growing societal movement towards what you can call body liberation or against fat phobia. And I wonder now if we’re seeing a backlash, if we are seeing the political renormalization of anti-fatness.
Kaufman: Yeah, I think a little bit. Statements like that are really problematic, that the people in our military defending our country, the most important thing about them is how they look … actually would have different qualifications that I would want.
Miller: He went to talk about beards, clothing and all kinds of things that have nothing to do with national defense. But, he started by talking about body size. The president obviously has been talking about this for years and years. What effect do you think this kind of language has on culture?
Kaufman: It sort of depends on who the audience is. It’s harmful in terms of discouraging people. I go back to my not-being-able-to-lose-weight situation. And there’s been, in the past – I don’t think it’s so predominant anymore – in public health, if you shame people for their body size, it’s sort of like shaming people for smoking. That will help them to quit smoking or motivate them. And actually, there’s a lot of research that shows that shaming just doesn’t work.
Miller: In general, you’re saying shaming doesn’t work if you want to change someone’s behavior?
Kaufman: Right. It might be like a very short-term thing, but it’s not long term. I mean, it sort of makes logical sense. If you hate your body, you’re ashamed of your body, you don’t want to go out because people will make comments, all of these kinds of things, you can’t find clothing, you can’t get good health care. I would argue, and I think this is logical too, that people, if you feel good about your body and appreciate your body, and you want to do good things for it, that you’re more likely to do health behaviors that will improve your health, again, regardless of whether you lose weight or not. I think I’ve gone off the Pete Hegseth thing.
Miller: Happily, so. Let’s just turn to the broadest way of thinking about this right now. I mean, can you describe the society that you’re working towards, that you want to see?
Kaufman: That people in all body sizes can live fulfilling lives and thrive. That there are seating in theaters and airplanes. That you can get clothing without having to pay extra, or some people in very large bodies can’t even get clothing. That people aren’t discriminated against in the workplace and that they can get health care. In health care training and medical training, they generally just practice on thin bodies. And then they say, well, we can’t operate, do surgery on this person because they’re too large. And is that a failing of that person or is that a failing of the system? Because my guess is that we could learn how to do, for example, surgeries on all different kinds of bodies if we set our mind to it.
So it’s an equity thing. We just want to be able to live in this society and have access to the same things that other people do without the stigma and the shame.
Miller: When you make these arguments in health care settings, what kinds of responses do you get?
Kaufman: Well, I’m not so often in health care settings as public health and the difference is fuzzy for a lot of people. It’s interesting that people are generally positive. There’s a pretty good understanding right now that weight stigma is bad. And this has been co-opted by the diet industry or weight loss industry, because you’ll hear all over, weight stigma is really bad and everything. But if you take this drug, you won’t be fat anymore and you won’t suffer from the stigma, which is blaming the bullied rather than the bully.
So, yeah, that’s what I hope that we can have, a society where people in all different sizes of bodies can feel fine about their bodies and not feel shame, and can thrive because they have access to all the same things that other people do.
Miller: Debbie Kaufman, thanks very much.
Kaufman: Thank you.
Miller: Debbie Kaufman is the creator of the Body Liberation for Public Health project.
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