Transcript: Well+Being: Obesity and Stigma with Ruth Marcus and Susan Yanovski

MS. PARKER-POPE: Hello, and welcome to Washington Post Live. I’m Tara Parker-Pope, editor here at the Well+Being desk at The Washington Post.

About 70 percent of the U.S. population is overweight or obese. Joining me today to talk about the stigma of obesity and new weight-loss drugs that are helping many patients lose weight are Dr. Susan Yanovski from the National Institutes of Health and Ruth Marcus, a columnist here at The Post who recently wrote about her experience using one of the drugs.

Dr. Yanovski and Ruth, welcome to Washington Post Live.

MS. MARCUS: Hi. Thanks for having me.

DR. YANOVSKI: Thanks, Tara. It's pleasure to be here.

MS. PARKER-POPE: It's so nice to have both of you here, and I think this is such an important topic, and I know we've got a tremendous level of interest among our viewers.

Dr. Yanovski, let's start with just a really basic question. Why is it so difficult for people to lose weight and to keep weight off?

DR. YANOVSKI: Sure. I think that's a really important question. We know that once people develop obesity, there are a number of changes that go on in the body. Obesity itself leads to changes in brain function, in metabolism, so that people tend to defend the higher level of body weight. So when someone with obesity, they can work very hard and lose weight--and many people have done that, but they have these strong metabolic signals and brain signals that are telling them that they're really in more of a state of starvation, and so over time, the weight generally will come back on. That's kind of the Holy Grail for us, for those of us who study obesity, is helping people not only be able to lose weight in the first place but to keep that lost weight off.

MS. PARKER-POPE: So, Ruth, you wrote a really personal, very compelling essay about your experience. What has been the reaction from readers? What are you hearing from readers, and what did you learn from this experience?

MS. MARCUS: Well, the reaction has been actually overwhelmingly gratifying, both in the number of readers who have told me--shared their own personal stories with me, the number of readers for whom this resonated. And I have to say when you're writing about something as personal as your own weight and you're putting it out there as a columnist, you're going to get some meanness, and that goes with the territory.

But I've read all the emails I've gotten and much of the comments that were posted online, and they were surprisingly kind and human and mostly talking about people's own journeys and struggles with weight, with obesity and with overweight.

The one area in which I got some criticism that I will actually want to address up front has to do with the scarcity over times, mostly in the past right now, of Ozempic and whether I was using Ozempic, which is the anti-obesity and diabetes medication that I used. I used it for an off-label purpose.

There was a time when it was hard to get, and there was a moment when my pharmacy did not have it in stock, and I thought, huh, I am not needing this medication in the way that people who are using it to treat their diabetes need it. And I just went without for a period of a few weeks until it came back in stock at my pharmacy. So that's--I didn't want to put that in the piece because I didn't want to look like I was patting myself on the back, but I did want to share that with people because it was a totally legitimate question about whether I was elbowing the more needy out of line, and I was trying not to.

MS. PARKER-POPE: Well, I think you raise a really interesting point, and I'd like Dr. Yanovski to comment on this. We have this perception that these drugs are somehow a luxury for people who want to lose weight, as if it's a vanity play versus a really fundamental health issue. Should people who use these drugs to lose weight apologize for it? Should they feel like they're cutting in line against somebody else who might need the drug for a different reason? I mean, for some people, these drugs are lifesaving. Is that not true?

DR. YANOVSKI: I think that is true, and I really want to focus on fact, the fact that obesity is a chronic disease.

[Pause]

DR. YANOVSKI: I'm hearing some extraneous noise here.

But obesity really is a chronic disease. Fat cells, fat tissue, we used to think it was an inert storage organ that just, you know, stored extra calories. Now we know that--now we know that fat.

Can you hear me?

MS. PARKER-POPE: We can hear you fine.

DR. YANOVSKI: Okay. Now we know that fat tissue is actually an active endocrine organ, and it secretes the number of factors that act on the brain to impact your--impact your appetite, your metabolism, your physical activity, and obesity itself also--the fat tissue secretes a number of inflammatory factors. So people with obesity end up developing damage to almost every organ system in the body.

As I think you pointed out, type 2 diabetes is the one we think about most often. Now 11 percent of the adults in the U.S. have type 2--have diabetes. Ninety percent of them have type 2, and of those, 90 percent have overweight or obesity. So obesity is a major driver of diabetes.

But something else we don't think about, obesity is actually now--it's causing non-alcoholic fatty liver disease, which is now a leading cause of liver transplantation in this country. It also contributes, as you said, to heart attacks, strokes, and some forms of cancer. So I think it's really important when we're talking about medications to treat obesity to realize that obesity itself, it's not just a cosmetic issue. It's a real health issue.

And I think even when Ruth was talking in her--when Ruth was talking in her essay, she noted that even though she started these medications in large part because she didn't like the way she looked or felt, she had sleep apnea, which is a very serious disease where you stop breathing during your sleep, and it can lead to diabetes and heart disease. And she was actually able to discontinue her treatment for that when she lost the weight.

MS. PARKER-POPE: I think one of the challenges here is that we often expect people who are overweight-- before we offer them help or medical intervention, we wait for them to become obese. We wait for them to develop diabetes or another significant health problem.

I know people to qualify for surgery, maybe they're 80 pounds overweight, and I've actually interviewed people who have eaten more to gain 20 pounds so they can qualify for the surgery. I mean, this feels really messed up to me. It feels like we should be helping people sooner to prevent them from getting high blood pressure or diabetes or a more extreme weight problem. Would you agree with that?

Dr. Yanovski, you can answer it. Yeah.

DR. YANOVSKI: Yeah. I absolutely agree with that, and I know there's been a lot of controversy right now about the role of BMI, or body mass index, which is just a measure of weight for height. And I think it's important to know that BMI, it's just a screening tool. It's really important for people to talk with their doctor or their other primary care clinician who can actually talk to them about what's their history been with weight, what's their family history, do they have any ongoing health problems, and to not use the BMI as a be-all or end-all in what kinds of treatment to undertake.

MS. PARKER-POPE: Okay. So, Ruth, I think the question on a lot of people's minds is they really want to know what this experience of using one of these weight loss drugs is. What does it feel like? What's it like to poke yourself with a needle once a week? Can you talk a little bit about like when you--the first time you used Ozempic, what it felt like, and then how you felt as the drug began to take effect?

MS. MARCUS: Sure. And I want to preface that by saying that my experience was overwhelmingly positive and that other people have had much more difficulty in terms of side effects, not everybody or not even the majority of the people, and other people have had much more difficulty in terms of the amount of weight loss, the amount of weight loss that I experienced, which was 40 pounds, 25 percent of my body weight was really at the very high end of the numbers.

And also honestly, my experience was--and I'm very grateful for this, and it goes to what we were talking about before--is that my insurer--I was not technically obese, just shy of it, when I started taking this medication. I was overweight. I had associated conditions. My cholesterol was high. My blood pressure was getting higher. I was close to pre-diabetic, and I had a very serious case of sleep apnea. My insurer covered this. I'm very grateful both to the insurer and to my doctor for being willing to do something that wasn't a no-brainer. My doctor said, when she first prescribed this to me, "You'd be the thinnest person I ever prescribed it for."

My experience was this. First of all, for people who are put off by the notion of injecting themselves, I really think that overstates the experience. It's a little tiny pin prick with a little--with a little pin, almost entirely painless. You don't have to be on the tough end of stoic to think this is a no-big-deal event. That's number one.

For me, the side effects were mostly at the beginning, some nausea, a little bit of queasiness, like you were taking a ride and felt carsick at the end of it. Associated with that was an almost immediate diminishment in appetite. There were some longer lasting side effects, and just to be blunt about it, some constipation, sometimes some diarrhea with the constipation. I just want to lay that out there. For me, completely tolerable. For others, they've had a different experience, but I--the side effects were so de minimis for me, and the upside, which was not massive immediate weight loss, it was mostly--

I'm going to move because I think the light goes off in this room if I don't move.

It wasn't massive immediate weight loss. It was slow and steady weight loss that just was, you know, less than a pound a week on average. I've been doing this for 18 months. I have not lost any weight since January of 2023, but I've not gained any weight since January of 2023, and that for me is remarkable to be able to maintain it this way.

MS. PARKER-POPE: I think people have the perception that this is an incredibly rapid weight loss and that it's just, you know, super easy, but it does. It takes time. It's fairly slow weight loss, which is healthier.

Ruth, tell me a little bit more about how this affected your eating and your relationship with food. You put a plate of food in front of you or you had--I don't know--some favorite food in the fridge. How did it change the way you--the way you ate?

MS. MARCUS: I learned a new word and a new feeling, which is "satiety." I am a very good clean-plate ranger. I am a very good eater of pints of ice cream. At the beginning, especially, my appetite was way down. I just--I would like get an entree at a dinner at a restaurant and pretty much cut it in half, and I would be able to take that other half home. I could wave away the--

[Audio break]

MS. PARKER-POPE: Looks like we might have lost a signal for a minute.

MS. MARCUS: Okay.

MS. PARKER-POPE: There, now you're back.

MS. MARCUS: Okay, good. You know what it is? The--I'm going to--if you--if I am back to you guys, can you let me know if I'm back?

MS. PARKER-POPE: Yes, you're back.

MS. MARCUS: Okay, good.

DR. YANOVSKI: You're back.

MS. MARCUS: I was able to wave away foods, and actually, there were some things like the greasy pizza that comes on Wednesdays, so we're going to get it in the office, it did not sit well with me. And so it's easy to, you know, be trained. If it doesn't make you feel good, you don't want to eat it.

But it was mostly this feeling of I don't have to eat everything in sight or I'm not looking longingly at the French fries on your plate in order to see if like--and it just--not craving food in the same way, not constantly thinking about food.

I will say in about the last six months, my appetite has come back, but it has come back in a way that is still much more under control than it was previously. And that was what led me to ask my doctor about Ozempic, which was I had always been able to lose weight and control my appetite previously. If I really put my mind to it, I could lose the weight. I couldn't keep it off. But all of a sudden, I couldn't even do that. And now while I'm eating like a completely normal person, I am eating like a normal person and not like a person who can't stop eating.

DR. YANOVSKI: And I'd like to make a comment about that, if I can, Tara--

MS. PARKER-POPE: Yeah. Please.

DR. YANOVSKI: --because Ruth really brings up such an important point. One of the things I hear from people is concerns of this is the easy way out, right? People with obesity, they're just lacking in willpower and need to push away from their plate. And what Ruth has said and so many people say is "I have been able to do this for some periods of time. I have willpower. I have extreme willpower." People with obesity are really successful at many things, and they may have given up smoking, and they're successful in their jobs and in raising their families. But they just, over the long term, have this one difficulty with food that--and repetitive behaviors that really don't let them sustain those behaviors because it is such a struggle every day.

So it's not really the easy way out in that you take a pill or you take an injection and you don't have to think about your eating or your physical activity. It actually allows you to make the healthy choice, the way most people can, without medications.

MS. PARKER-POPE: Well, I think that raises, you know, the conversation around we have this perception that we should be able to lose weight with grit and determination, and yet we don't have that same expectation for someone with cancer or someone with diabetes. We recognize that medical intervention is needed. Can you talk a little bit about willpower? It's essentially a limited resource, right? I mean, is willpower--should that be enough to help somebody lose weight? Dr. Yanovski?

DR. YANOVSKI: Yeah. Yeah. Again, I think that people can do this over the shorter term, but we're learning so much more about what happens once you develop obesity. So I think you need to separate out prevention from treatment. We need to work. You know, people say, "Oh, it's our food environment. It's, you know, the physical activity," and those are critically important, and we need to work on those to get people--to prevent people from developing obesity in the first place.

But once you have developed obesity, you have physiologic changes. You have changes in your brain so that you are feeling when you lose that weight, you have you have--you have metabolic changes and behavioral changes that make you struggle every day. People report that they're thinking about food all the time at work. They can hold off for a little while, but eventually, all of us have times when our defenses are down.

And so I think that people who haven't struggled with this don't really understand the degree to which your brain and your body are trying to defend the higher level of body weight.

MS. PARKER-POPE: And aren't there brain scan studies showing this? I've read about studies where patients who are obese look at different images, and we see different--we see changes in their brain, right, when they see a certain type of food? Can you talk a little bit about that?

DR. YANOVSKI: Yeah. We really are learning more about the physiology, and in fact, at NIH, where I work, we're doing this study. We're just getting started with a study that are trying to look at why some people do really, really well when they lose weight, have no problems, and others, probably the majority, really struggle. And we think there are a number of adaptations, again, in the brain, in the muscle, in the fat tissue that lead people to regain weight. So we're actually starting a study where we will have 200 people lose weight with behavioral treatment like they are supposed to do, and we're going to study them very carefully before they lose the weight, after they lose the weight, and then over the following year. And we're going to be doing brain scans and studies of reward systems and muscle and fat biopsies to see if we can really get a handle on what are the physiologic responses to weight loss and so how can we get in there and help people keep that lost weight off long term.

MS. PARKER-POPE: So, Ruth, one of the most painful parts of the story when I read it personally was when you were talking about discussing your weight loss with other people, where you maybe said, oh, I'm eating less, you didn't really want to tell people that you were using a weight-loss drug, and at one point, you said, "Well, I cheated." And I want to talk a--I want to hear from you where that was coming from, that you felt almost a sense of maybe guilt or embarrassment to talk about relying on medication to help you lose weight versus I guess doing it through just sheer willpower. Do you want to talk a little bit about that part of the story and the emotions that you were feeling?

MS. MARCUS: Yes. Well, one thing is--and I've noticed it's become much easier to talk about this over time as people have become aware of Ozempic--I started Ozempic, and there's obviously other medications on the market that have been--excuse me--approved for weight loss, which Ozempic hasn't. But when I started it, this was not in any way a household name. People would look quizzically, and you would have to say, "I'm taking this medication. This is what it's called. This is how it works."

Now everybody--it seems like everybody on the planet, certainly everybody on social media, has heard about these weight-loss drugs. So it became easier to talk about it for that reason.

But it's really much more, as you say, much more fundamental than that. When people said, "You're losing weight. How did you do it?" I first--my first answer was, "Oh, I ate less," and this was technically correct, but it was really misleading, and so I felt like I was not being honest with people.

But interestingly--and this goes to the question of stigma. This goes to the question of we take drugs for our cholesterol, and we don't feel embarrassed that we're taking them to deal with our cholesterol. We take drugs for our high blood pressure. Saying if we take medications for--to deal with our obesity or our overweight, we feel like we are cheating. I felt like I was cheating because I knew how to do it the old-fashioned way. I knew you could do it. I knew I could lose weight with diet or exercises, though honestly, for me, I was either at an age or at a weight or at a what--I had been at that weight for so long that my body was just rebelling against the normal things that I would do to try to lose weight.

And we believe that if we simply have the discipline, we can get the weight loss done on our own and, more important, keep it off on our own. And so when I told--when I started to tell people I was on Ozempic, the way I originally got into that was to say I'm cheating. And it was a kind of lighthearted way to introduce the topic and excuse myself. And I have to say it was only when, many months ago, I started researching this article and speaking to experts like Dr. Yanovski that I got myself better at just saying Ozempic. Now I can just say Ozempic, and it's a shorthand--and got more comfortable with that notion, but it really did take quite a lot out of me.

MS. PARKER-POPE: I know there's--it's so interesting to me how much judgment there is, not just in culture, in society, but within ourselves, right? We often blame ourselves for weight gain or for not losing weight or not keeping weight off, and yet if we were diagnosed with another medical condition--I think if you were diagnosed with osteoporosis or, you know, high blood pressure, I'm not sure we would have as much self-blame. Would you agree with that, Ruth?

MS. MARCUS: Not--we wouldn't have anywhere--it's just so completely clear. We wouldn't have anywhere near as much self-blame. But on the other hand--and I'm going to say something that Dr. Yanovski is going to, I suspect, want to push back on a little bit. High blood pressure is a phenomenon that's measurable for--so is weight and obesity, obviously. But what I mean is I know I can--I'm not going to say--I'm not saying this very well. There is an element of cosmetics that's involved in pushing for weight loss. It is--for me, I just--I say this in the piece just very much up front. I did not go to my doctor and say I would like to try Ozempic because I'm concerned about my health. I went to her and said, "I would like to try Ozempic because I cannot get this weight off. It doesn't seem like I can get this weight off any other way." And so there is a cosmetic element that, at least for me, just speaking for myself, was built into this desire, even though it's had phenomenally good health effects for me, that is a piece of how, yes, obesity is a chronic disease, but did I have that disease? I wasn't technically obese, and yet I'm so glad and I'm so much healthier having done this.

MS. PARKER-POPE: Well, I don't think anybody should apologize for doing something that makes them feel better, makes them feel well.

Ruth, we have a couple questions from readers that I want to ask both of you, but I'm going to start with Ruth. We have an audience question from Virginia in Connecticut: "How do we confront internalized self-hatred for being overweight." Can you relate it all to that question?

MS. MARCUS: Oh, yeah. I decided when I started writing to name this essay that I was writing, as I was doing it in our internal system, "Fat Columnist," and it was a little bit kind of poking fun at myself and also just trying to own the situation. I think we can just understand, as Dr. Yanovski has said, that we are heavy or heavier than we want to be because of internal genetics and internal propensities, because of the obesogenic environment that we live in with so many fat-saturated foods, unhealthy processed foods all around us, and there are some people for whom being thin comes easily. And there are some people, myself included, for whom being thin comes much--with much, much more difficulty, and we need to accept that and also recognize that if there is a medical intervention that can help us along the way, there should be no shame in that either.

MS. PARKER-POPE: Now, I want to get to another reader question, but real quick, you mentioned in the article that an age-old boyfriend made kind of a rude comment to you, and that really stung and stayed with you, right? It had a big effect on you.

MS. MARCUS: I remember every mean thing that every single person has said--and I won't name them here--about my weight over the years. But that was the first time. I had been a tiny, tiny, skinny child, and I got on the scale at my--at our house, and it said 113 pounds, and I--which happens to be a pound more than I weighed this morning. And I said to my then boyfriend, "Do you think I'm fat?" and he said, quote, "Everybody knows you could stand to lose a few pounds." And it was like a slap in the face. It was the first time but not the last time that I thought of myself as a person who needed to worry about her weight. And it really stuck with me.

MS. PARKER-POPE: Yeah. So people should not make comments about other people's weight. That is a lesson from today.

MS. MARCUS: I invited it, but yeah.

MS. PARKER-POPE: Dr. Yanovski--

DR. YANOVSKI: If I can--

MS. PARKER-POPE: Sure, go ahead.

DR. YANOVSKI: If I can just say about what Ruth has been talking, about the stigma. I mean, people with obesity face stigma from their employers, strangers, a lot of times their doctors, and this stigmatization can actually lead to more weight gain. It impacts, as you said, how people feel about themselves. It can make people embarrassed to exercise. It can actually increase their stress hormones, which can lead them to eat more and to deposit more unhealthful types of fat. So I think addressing weight stigma is critical in helping improve people's health, regardless of what they weigh.

MS. PARKER-POPE: So I want to quickly get to two more reader questions, Dr. Yanovski. First off, can we talk a little bit about--this is a question from Natalie in Washington who wants to talk about the social determinants of health and how they affect obesity prevention and treatment. So there are other factors, right, besides how much food you put in your mouth that can affect obesity, correct?

DR. YANOVSKI: Oh, oh, absolutely. And I think--I'm really glad that someone brought this up because it's so critically important. You know, there are a lot of health disparities among certain racial and ethnic groups in diabetes and obesity, and, you know, in many cases, for example, highly processed foods, foods high in fat and low in other--in sugar and low in other nutrients, they're the cheaper foods. And people also who are living in poverty don't have access to good health care. They're under more stresses. They may sleep less well. All of these then go towards contributing to more obesity, and of course, these are also the people who are at least likely to be able to afford high-quality care for their obesity, including medications.

So I think we really need to address that in order to help prevent people from developing obesity, to give them access to treatment and really just to make the quality of their lives better.

MS. PARKER-POPE: So I want to get in one more audience question before we have to wrap up. This is from Ellen in Missouri who asks, "Is there a way to help the obese live healthier lives without stigmatizing them?"

So, Dr. Yanovski, tell me quickly what your advice would be to address the issue of stigma and to help people who are obese cope with it.

DR. YANOVSKI: Yeah. Yeah. Well, I think we need to better educate people, especially health professionals, about what their biases are actually doing with their patients. And I think for everybody, regardless of weight, you can try and eat a healthful diet. You can try and be more active. And, you know, also I think get your other health problems taken care of. Even if you can't do anything to lose weight, make sure you're working with your doctor to help address any other health problems you may have.

MS. PARKER-POPE: And, Ruth, I want to give you the final word. Now that you've written this amazing article and you've heard from people, what is the takeaway?

What do you want people to remember, and how do you want them to feel after they've read your article? What's the message you want sent?

MS. MARCUS: Obesity and overweight are just chronic diseases and chronic illnesses, and you should think about what you can do for yourself to feel healthier and look better along the way. And you shouldn't--you shouldn't be shy about raising it with your physician, and you shouldn't be shy about taking control of it, because I really do think we have new mechanisms and new opportunities, medical opportunities to deal with this condition, which is, you know, 70 percent of the people in the country are dealing with it. We need to get it under control for ourselves and for our public health.

MS. PARKER-POPE: Well, we're out of time, unfortunately. I want to thank you both for your concern and your compassion and your commitment to this issue. It's so important to so many people.

So, Dr. Yanovski from the NIH and Ruth Marcus, columnist for The Washington Post, thank you so much for joining us.

MS. MARCUS: Thank you. Thanks for all the good questions.

MS. PARKER-POPE: And for everybody watching today, a reminder that Ruth's essay can be found at the WashingtonPost.com website, and to learn more about our upcoming programming, please go to WashingtonPostLive.com.

I'm Tara Parker-Pope. Thanks again for joining us on Washington Post Live.

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