Today I interview Dr. Arghavan Salles, MD, PhD., and board-certified bariatric surgeon about the recently released covers of ...

doctors-react-to-controversial-cosmo-cover

Doctors React to Controversial Cosmo Cover

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

Dr.

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