12. The Obesity Prejudice With Harvard Medical’s Dr Fatima Stanford

Harvard Medical’s Dr Fatima Stanford recently published a study on the impact of systemic racism on obesity. Today, she discusses the alarming results and what we can all do about it.



Bill Ferro: Okay, so welcome to the Quacks and Hypochondriacs Podcast. I’m your host, Dr. Bill Ferro. I started my career as a chiropractor at health clubs, turned into a gut health expert. So, if you wanted to call me a quack, you probably would not be the first. On this podcast we’re going to give you the inside scoop on the so-called quacks of the world. The quackery claims who you should and shouldn’t listen to and why sometimes hypochondriacs have every right to be paranoid about their health. With me, with I think an alcoholic beverage in hand, my co-host Erin O’Hearn.

Erin O’Hearn: It’s been a long week.

Bill Ferro: You deserve it. I’m drinking kombucha, I think she’s drinking a martini.

Erin O’Hearn: But kombucha has alcohol in it, so we’re on the same playing level and it’s only because I have had all my kids virtual this week because they were exposed on Sunday for reasons that they shouldn’t have been. And, it’s just been a tough week, but the good news is, is we just got the results back and they are negative. So, I am thrilled about that and I did a little happy dance and I’m going to do a sloppy dance in about an hour. 

Bill Ferro: Well, my cohost is an ABC news anchor, fitness fanatic. Relevant to this conversation, she is the hypochondriac. So, we’re always looking for different things. So today without further ado, Dr. Stanford has 29 letters of acronyms finishing her name and I think 18 or 19 total letters in your first name. So, like that alone gives me carpal tunnel syndrome if I had a write you an intro. 

Fatima Stanford: That is hilarious.

That is so funny. Actually, I received, I was asked to do an awards presentation. I received an award today and I was so shocked that they were able to fit everything on the plaque. It like brought joy. I’d also probably for the hypochondriac here might appease to you. I may have to show it to you guys before we sign off today. I think you’ll really, find it.  Lovely to look at it, I guess. 

Bill Ferro: Well, if anyone was feeling a little bit quacky or hypochondriac about their place in this world, looking at all your accolades would definitely make them feel very, very inferior.

Fatima Stanford: I’m so down to earth to, it’s so funny that like, I mean, those things just, you know, have come and, you know, I’m thankful, but I don’t know if it like matches up to the personality, so we’ll see. 

Bill Ferro: When I see that type of stuff, it just seems I see an inquisitive mind. I see someone who can incredibly curious and people that are incredibly curious just give you the greatest insights. So super excited to talk to you. This is a topic that, I don’t think people normally bring the two together. So, we know we have this obesity epidemic, which was more of a, you know, kind of set us up for what’s happening with COVID and our mental health crisis. And then when you bring the fact that the racial inequality and potentially the race, you know, the racist part of this, or the systemic racial issues there, that’s what you’ve really been studying and talking about.

So, we’d love to hear, you know, A, what you do kind of in your day job. And then, and then that’ll be funny. And then what you’ve learned, and how it relates to obesity and, you know, systemic racism. 

Fatima Stanford: So as mentioned by Bill I’m Dr. Fatima Cody Stanford, I’m a fellowship trained obesity, medicine, physician, and scientist. I’m also an internist, I mean an internal medicine physician and also a pediatrician because why not do two residencies. and so, I care for patients between the ages of two and 90, with the disease of overweight and obesity, and have dedicated my life to this work.

So, after doing my residency in internal medicine and pediatrics, I came to Boston, to Mass General, to Harvard, to do a three-year fellowship, to learn all the ins and outs of caring for patients with obesity. I’ve been a researcher for the last 25 years. So, my research, I’ve published over now a hundred peer reviewed articles and medical journals, like New England Journal, the Journal of The American Medical Association.

Annals of Internal Medicine, et cetera. And a lot of this work revolves around, I would say two key themes, number one, overweight and obesity within both the pediatric and adult population. And looking at treatment strategies, policy issues, treatment strategies that range across from behavioral and lifestyle modification to medications, like pharmacotherapy, and then to surgical interventions.

And then also this other umbrella of the work that I do that has really made a big collision within the last year and a half is looking at issues surrounding racial and ethnic disparities and care. And I think that when we talk about what I call the three pandemics and what I just recently did, my TEDx talk on was the collision of three pandemics and they include obesity, COVID-19 and racism. and so, when we look at this idea of how these interact, because people are kind of confused, first of all, they’re like, what is she talking about obesity? She said disomic factor in obesity. What does that even mean? I think the reason why people usually kind of have that response to obesity for example, is because we see obesity is a lifestyle choice instead of the disease that it actually is.

There are reasons why some people can eat, you know, one thing and gain zero pounds and then another person walks past the pizza shop and they gained 10 pounds just by visualization. Now, of course that’s a bit of an exaggeration, but there are reasons why different people store more and hold more. And a lot of that really just has to do with how their brain, the hypothalamus particularly, how it interacts with the environment and how it interacts with their genetics and how it interacts with many different things.

So, when we look at this collision and why talk about COVID and obesity as a collision. As obesity is characterized by chronic inflammation. And so, if I were to have a patient as a new patient coming in with obesity and measure different inflammatory markers in their blood, we’d see them elevated. Not universally, different people would have different levels of elevation, but they would have this underlying kind of chronic inflammation.

We know, as we all have seen with almost 600,000 dead here in the United States, that COVID-19 presents with acute inflammation, right. Something acutely happens. So, when you put an acute one, a chronic process, you can imagine that those two don’t jive well, right. They just don’t interact very well. And so, the reason why we see the highest or the most common reason for death, for those of us that are under the age of 60 to COVID is unfortunately obesity.

Now, so let’s look at the racial and ethnic piece of that. 42.4% of us adults have the disease of obesity, that was based on 2018 estimates. The average weight gain based from the American psychological association during the pandemic for adults – 29 pounds. So, we can maybe say that that shifted a bit. Millennials actually, on average, I think their weight gain, 41 pounds during the pandemic.

And we can, we can delve into that a little bit later. I’ll let you guys bring that in. But what we do know is that racial and ethnic minorities have higher rates of obesity in the country. I’ll focus on the demographic that I represent, which is black women. And when we’re looking at black women, about 60% of black women have obesity, and then another 20% have overweight.

So, we’re talking about 80% of black women with overweight and obesity here in the United States. And so, then we wonder why are we seeing, in addition to the fact that we have these racial inequities and care, but this high preponderance of obesity within the population. And we’re wondering why we’re seeing the numbers that we were seeing, not now as we’re starting to ramp up on vaccination.

So, I’m going to stop there cause there’s so much to say, but I think this kind of yields itself to understanding why I’m excited to share my voice today. I’m thankful to have this platform to speak about this work. And, you know, I think I was put here at this given time to do this work, to really shift the narrative regarding those three different domains of obesity, COVID-19 and racism.

Bill Ferro: Yeah. And to call something out for our listeners is the inflammation piece, which I think many people would be shocked to hear that as the root cause. Most people, and I resonate with that. We take people through a gut health, low inflammatory, food is medicine protocol for 30 to 60 days. And what did you know it, insulin resistance goes down, their A1C is dropped. They come off blood pressure medication, mental health gets better, sleep gets better, but when you position it to most folks and say, well, there’s 40% of us or more obese, which is just mind boggling, right. Cause I remember when I started this crusade, that number was 17 or 18%, just 20 years ago, thinking about where it’s gone, it’s just unbelievable. And so, people always point, you know, and I think in your view, people are either racist for your color. Or wait, those are the two biggest ones, right? 

Fatima Stanford: Well, those two forms of bias, right? The two biggest forms of bias, race bias, and then weight biasness country. And racing definitely leads the way. I mean, we can just turn on the news at any given point and understand that, but the weight bias it’s right there behind it. And then you imagine if you happen to be a black person with obesity, right. And one key thing I’m going to change, Bill that you said, I don’t ever use the word obese, although I’m saying it just to correct you, that obese is a label in obesity as a disease.

So, that label can be seen as stigmatizing. So, what I would say is a patient with obesity or a patient with mild, moderate, or severe. I also don’t use the word morbid to explain obesity because we don’t call it like morbid COVID. Or morbid diabetes or morbid heart disease. All those things can kill us. Morbid cancer.

But you can see that even in how we, we reference obesity when someone has severe state that we have our biases that are entrenched and it’s like, it’s super entrenched into medicine. We fail, we fail patients with obesity every single day, but we fail patients that look like me that are black also every single day. And that, you know, that is a recipe for disaster.

Bill Ferro:  Absolutely. You know, generally when we, when I talk with folks, I say, you have a lot more potential energy than others, and I’m going to help you liberate it. I’m going to help you tap into that energy source because really that’s all it is. It’s just a barrier to that expression.

And that barrier to expression is the mechanism of inflammation and insulin resistance. But yet most people, when you look at the common biases, as you mentioned, so a color of your skin or being overweight, right. Having too much adipose tissue and skin of the two biggest biases. Well, what’s almost a little bit worse about the obese bias.

You know, the being overweight biases, they think, well, you could do something about that. I can’t do anything about the color of my skin, but you should be able to do them about that. And then they always go to, man, if you, you just must be lazy and unmotivated, so now you get this extra. And really, it’s no, I have so much stress, so much toxicity, so much inflammation that I can’t, I’ll never do this. When you’re under those conditions the human craves poor food, and then it gets into that vicious cycle.

So, when you talk about the systemic part of this and the racism, is it more so the systemic racist part or the amounts of stress and demographics, right? So, someone who’s more demographically challenged financially, emotionally, and of course they’re subjugated to racism. Is it the stress of that environment that is leading to this?

Fatima Stanford: Yeah, no, I’m going to actually reference I, and I love referencing this study cause it’s the best study that’s ever looked at it. The Black Women’s Health Study, which I’m not an investigator on. So, I, I’m not tooting my own horn. I’m tooting other people’s horns.  But the Black Women’s Health Study really investigates middle-income to high-income black women.

So, all college educated black women. And then the study back in 2014, Dr. Yvette Cozier and her colleagues at Boston University Medical Center actually looked over time, over like the 20-year period, at both instances where the women would report with these over 4,000 of black women. either every day or a lifetime racism, heightened levels based upon the Bayer self-report. 

And what they found in those individuals that reported more every day in lifetime racism. Keep in mind, we’re talking about middle to upper income black women, all college educated. So, a certain different demographic that they, those that experience more internalized more actually had higher levels of inflammatory markers at baseline and higher levels of adipose tissue or fat tissue, stored particularly in those areas we don’t like in the mid-section. And so, I would say that even if we take the, you know, that socioeconomic piece out of the way, we’re still seeing those same issues. And interestingly enough, I’m going to, for the men that are out there that are feeling left out, if we flip the coin and we look at just men in this country, and we look at white, Black, and Hispanic men, based upon the data that we have from the CDC, we actually find that as Black men and Hispanic men, as they climb the socioeconomic ladder.

So those at the highest levels actually have the highest obesity rates. Now, interestingly enough, that differs from what we see for women for both white, Black, and Hispanic women. As we climb on average, our obesity rates decline, which seems to kind of fit the narrative that we want to put in our brain, but it deviates from men. And the reason why we think that is, or the hypotheses that we posit for this is that there’s this idea of John Henryanism. And I don’t know if you guys remember John Henry, like his heart worked hard. Basically, as black men or Hispanic men climb the ladder, they’re no longer just responsible for their nuclear family.

They’re responsible for a large swath of the community. Everyone’s looking to them for financial resources, support, emotional support, and that leads to more stress and more burden on them as they continue to climb. Where for white men is that as they continue to climb, they are able to just more so focused on their nuclear family. And don’t have those additional stressors that are brought in that lead to that increase in inflammation and stress and storage. So that’s, what’s being posed as a reason, but it shows you how complex this question is. They also find that there’s some genetic differences. So, for example, there was a big, what we call genome wide association study that came out of the NIH actually back in about 2018.

So, this is one of the studies and they looked at like 30,000 individuals and they looked at white individuals, Asian, those that were Black, meaning of African descent here in the United States. And then they looked at three different countries in Africa, Nigeria, Ghana, and Kenya. And then they looked, you know, kind of on the genome level to see if they saw any differences that would account for changes in body mass index or differences.

And they found this variant called a SEMA four D variant that was only present in Black individuals here in the United States, you know, descendants of slaves here in the United States. And in those that were in either Kenya, Nigeria, or Ghana, they did not see this variant that accounted for five BMI point difference in anyone that was white or Asian, for example, which was the other group that they evaluated 30,000 individuals.

So, we have some issues that are related to like just the environment, some that are related to the genetic level, some that are heredity, right. Genetics, epigenetics, et cetera. And it makes my job really complex, but really exciting. Right? Like if you go back to that thing of saying, being an inquisitive and trying to continuously learn more because every day, like even in the research that I’m doing or that others are doing, we’re finding something new about this disease that happens to be obesity that happens to disproportionately affect communities of color. 

Erin O’Hearn: Doctor. So, there’s so many questions that I have right now. But I can’t, I don’t articulate things nearly as, as well as you do, but the first, so coming from my background, because I know, Dr. Bill just talked about the inflammation piece and, you know, my history as being a reporter in Philadelphia, you know, I’ve seen a lot.

Right. And probably, speaks more to the socioeconomic piece of this and what I have been repeatedly told and what I’ve witnessed is, you know, just because someone is obese doesn’t mean that it could absolutely a hundred percent mean that they’re going hungry, but they are suffering from hunger in this country because, you know, we have a major problem with food deserts in Philadelphia.

And I mean, I’ve seen it firsthand. There’s just no access, you know, it’s corner stores.  But I guess my question is like in your research and, you know, as we’re listening to you and learning and trying to understand as best, we can, where do you even start? Because there’s so many things coming into play and I, you know, you’re looking at it as, okay.

Obesity is a problem for, for everyone for this entire right there, there are, we’ve identified that certain people, are more prone to this disease and I don’t even know. I mean, it comes a lot from what you’re, what you’re talking about. And I do believe it comes from systemic racism because of that stress, and what I’m going off course here.

But I think when you answer this, if you could just address, people need to understand what systemic racism even is, because I think people have a misconception thinking that, oh, they’re victims of racism. That’s not necessarily the same thing. It’s that we just live in a culture that has dotes itself economically and socially off making other people be disadvantaged.

Fatima Stanford: Absolutely. Well, I think you actually defined it so well, I will try to add, I think you did a really good job. I think that that’s exactly, when we’re talking about systemic racism, is that our society is built up, I mean, one of the backs of slaves.

So, you know, people ask me, and this is often an uncomfortable conversation when people ask me, oh, where are you from? And I’m like, well, I’m from Atlanta, Georgia. Okay. But no, but where are you from? And I’m like, you know, I was born and raised there. My parents were also born and raised there, but where were you from?

And so, this is the response that often draws significant pause and maybe not further questioning. I say, this is my response, via some slave ship to the southern portion of the United States. That’s where I’m from, and so I don’t know, somewhere in Africa via a slave ship. That is the reality. I mean, that is the reality of, of being born and raised in the South and being a black person in this country, which means that for centuries, you know, the labor that my people did, went uncompensated and went unvalued., even as we look to medical school, I talk about this story, which is going to be shocking to you. So, I went to the medical college of Georgia for my medical degree. And if you look in the early archives of this medical school founded back in 1828, there’s a black gentleman and all of the pictures and you’re like, well, wait a minute.

It’s 1828. There’s the emancipation proclamation. There’s slavery. There’s the south, it’s Georgia. So, then you start putting this all together. I was present in the class and when the historian took me on this tour, it was like, well, who’s that guy? And she said, well Fatima. I’m so glad you asked. That was Grandison Harrison.

He was a slave purchased by the medical school for the anatomy and physiology department. His sole role was to rob the grave sites, particularly the Black grave sites, for the early medical students to be able to learn anatomy and physiology. So, he was purchased by seven of the faculty members. Eventually his wife and his son were purchased. And eventually he became free because he outlived the seven people that purchased him. But that was his role. That is how our country is built. Those are stories that when you bring them up, they burn, they sting, but they’re the reality of where we are. 

One of my earliest memories in life was the Klan burning a cross on my lawn at the age of three, we talk about when it’s too early to teach kids about racism. Well, you know, I don’t know if my parents wanted to start having the conversation at three, but you know what they have to explain to their daughter, who’s very inquisitive, who’s three, like, wait a minute. I thought the cross, is supposed to be a good thing. I remember, I don’t understand why is it burning? Why are these people in sheets? What’s, I don’t understand. we don’t have the luxury of being able to get older to learn.

 So, when we go back to this idea of systemic racism, it’s knowing that just because of who you are, you’re at a disadvantage, right? Because of how you look, we are seen as less than. Even with all of these letters and titles that I’ve accumulated in my lifetime, when I walk into a hospital, if I have on a hospital gown I’m seen as just another black body. And I know that cause I’ve been in a hospital and been treated as if that’s just what I am. It’s entrenched that people that look like me aren’t as good as, aren’t as successful as, aren’t capable as, despite the fact that we were behind a lot of what is, that’s the best way I can think to explain it. 

Erin O’Hearn: Or were put in the place because of.

Fatima Stanford: Oh, I love that, Erin. Now you’re speaking my language. 

Erin O’Hearn: I guess my point just to bring this full circle is that, in itself, living with that, is an enormous stress on the body, which when you tie that into stress being a big contributor to obesity and inflammation, that’s kind of where I was going. I want people to understand that you have all these degrees, right. This wonderful education, but that stress of still living with that or those assumptions is really, I don’t know if that is what accounts for that incline that you were talking about with men with black and Hispanic men.

Fatima Stanford: It’s this constant need to prove that I belong in this space.  Obviously being at Harvard, right? The creme de LA creme, you know, we presume that it’s, you know, the pinnacle of the ivory tower. I mean, we still have our issues. the reality is that even though it was founded, Harvard Medical School, for example, in the 1700’s, there have been only six black women in the history of Harvard medical school to become a full professor.

To date you know, literally six people. What does that say to people like me that are coming through? What it, what does that say? My CV currently is 132 pages. But obviously you have to continue to do more. What does it have to be 500 before I finally become a full, I don’t know. But that’s the reality that even in the places that we hold in high esteem, it’s built on the backs of systemic racism.

It’s built on the backs of not acknowledging, not promoting. Not valuing people that look like me. That leads to poor chronic disease. They did a study that actually that came out of Yale Medical School, I think about a decade ago. And they looked at the health outcomes of individuals that were finishing med school.

So here, again, going back to Bill’s question of how do we control for that socioeconomic? So, these are all doctors and what they found was that for the Black doctors that were finishing Yale Medical School, so well-known name, that there were dying sooner, they had significantly more health issues, higher weight status than their peers.

Even though when you looked at them at the time of while they were being educated, there were some similarities between the two groups. They begin to deviate pretty quickly. All doctors, but seeing significant differences. And I think it’s when we have those studies like that, which where you try to control for things that can cause significant differences and outcomes that we really begin to see how prominent racism plays a role in health outcomes and health disparities.

Bill Ferro: How often do you, Dr. Stanford feel that glare, that burden, that thought of these people think I’m less than, the systemic racism, because now you’re studying this and you feel that you’re part of your study, right? You’re part of this. How, if you had to guess, like how often is this running through your brain?

Fatima Stanford: All day, everyday 

Bill Ferro: I had a feeling that was the case. So, my point is there’s a physical stress and then there’s emotional stress.  And how your body responds and mind response to that stress really depends on where you are on your foundation, right?

So, do you have the right nourishment? So, some like you can go to boxing and if you’re in the right spot, boxing will work well for you. If you’re not in the right spot, it will give you tons of cravings. You’ll actually gain weight. And because you are prepared and thinking of this, maybe that all day, every day, is it as much stress because it drives you to do better and drives you to do more just like most right?

Because the people that I come across with we’re covered by about 40 health plans, as you know, and we do it digitally. They come to us from all walks and seasons of life, and these folks are stressed, so in one way it could be, they’d be focused about systemic racism and the other way, they’re just focused that their kid has issues at school or their relationships falling apart.

Like most humans in our society just waking up stressed and, and they’re stressed about anything and everything, and 

Erin O’Hearn: by dying from a runny nose. 

Bill Ferro: Yeah, exactly. The hypochondriac.

Fatima Stanford: There’s COVID, that’s why, you know, going back to that COVID, remember how much weight people gain. The key thing that everyone always says when they hear that number, they’re like, Oh, because everybody was inactive.

And I’m like, yeah, maybe there was a change in activity, but let’s talk about the stress of being in a pandemic that we don’t know the end date to, right? Like that affected everyone. You can, whatever your gender identity, your race, whatever, anywhere, if you lived in the here, on the earth, you know, planet earth, and some of the time during this pandemic, you felt that. There’s a sense of uncertainty of like, okay, we met we’re now at like 30% vaccine.

So, when do we like, can we like go outside? Can we, I mean, these things are, they may seem minimal, but when you think about it all every day, and you’re thinking about, Erin O’Hearn, my kids, I got to make sure they’re fine then, I mean, these are just, these are things we didn’t think about. Right? Like we thought about, we had stress, don’t worry.

We all had stress, right. We had stress, but then you added this layer of like a pandemic that Bill Gates saw coming because he recorded, he knew it was coming somehow, he knew, but the rest of us were like, what is Bill talking about? He’s he said, he’s. Microsoft, what does he know?

And somehow, you know, we had a pandemic that completely changed the course of how we do everything. so, I really think that stress of the pandemic and not knowing, and still not knowing to this day, like, what does life look like in this, whatever this post COVID world looks like? What does that, I don’t know.

I mean, I’m a doctor that studies this and I don’t, I can’t, I can give you like a guesstimate of potentials, but I can’t give you a date. And the people are like, well, what happens when I’ve had COVID? And two years later, I don’t know. Cause no one’s had COVID and had two years later to study, we don’t, we don’t know the answers. There is so much uncertainty surrounding the thing that looms over us.

 That’s what I think is the most major contributor to that weight gain, that big number that I threw out.

Bill Ferro: And that’s why I think the answer as, much as we. Unpack this and say, there’s so much more questions, so much more questions. The answer is just the awareness of all the things that could take us down as a human. Knowing that the antibiotics in our food, the overuse of antibiotics, we just had a doc on from Ohio.

She was amazing talking about, you know, she goes out and trains doctors stopped giving out antibiotics all the time. It’s not great. It’s in our food. It’s in our water. It’s stress. The awareness that yes, actually the systemic racism could be predisposing you to obesity. Not that you’re a bad person.

Similarly, if you are a white person dealing with this, it’s also not your issue because. You have, there’s other things, right? So, let’s leave them off the hook. 

Fatima Stanford: I’m so glad you brought about medications. I didn’t, wasn’t planning on bringing that up, but I would be remiss not to do this.

Right. We know that medications are a huge contributor to weight gain. Meaning we, as docs cause the problem. And we think 20% of the weight struggles in the United States today are due to meds that we prescribe for other issues. And I like to, like rattle off this laundry list. Cause it’s these are just the ones I can think of.

So, you ready? You guys ready? You’re going to think that should just be an auctioneer and leave my career in medicine. Okay. You’re ready. So, Lithium, Depakote, Tegretol, Celexa, Cymbalta affects your Zoloft, Paxil, Prozac, Ambien, Trazodone, just to name the ones I can think of, right that second. So, it says to me that if we, and sometimes we need to use them, right? Like sometimes we have to use these meds, but. I’m putting you on a med that I’ve seen some patients gained 80, a hundred pounds, and you can see it. I’m looking at their weight graph and it’s like steady, steady, steady, drug. 

But then they have bipolar disorder, or maybe they have some type of psychiatric disorder or they have some type of heart disease. And if I try to take them off, I’m no longer treating that, but then I’m blaming them for this. But I put them on the med that caused this. And I published a paper that just came out in last week when the journal national medical association.

And it looks at all of the medical boards. They’re 24 medical boards in the United States. And we looked at how well are we teaching about obesity? I guess I’m sure you guys probably know that we learned nothing about obesity in medical school.

Erin O’Hearn: Or nutrition or yeah, we’ve had a few doctors that say there’s like an hour.

Fatima Stanford: No there’s, there’s not even really, you know, like if you look at it, there’s no universal curriculum. And I actually did a study before that, that I published in the International Journal of Obesity to see like, not just what are we doing in the U S cause maybe we just aren’t great. What are we doing the whole world?

So, I looked at the entire world, everything that’s ever been published in the literature for the last 10 years to see like, Oh, maybe like Sweden is doing a great job. Or, you know, like you want to be able to lift one country up. No one, no country is teaching medical students, residents, or fellows about the disease of obesity.

But it’s the most prevalent chronic disease then the entire world. It’s not just a US issue. I think, Oh, only those people in the US – false. I get asked to speak all around the world on obesity, because it’s a worldwide issue. I mean, there are certain places where there are higher levels, but it’s not like no country is like sitting there not dealing with it as an issue.

So why are we not teaching the people they tell you? Right. So, then the commercial would be like, they’ll do all that fast talking and I’m like, go see your doctor. But if the doctor doesn’t know that’s problematic. Why are we teaching about everything else? And we somehow forget the disease of obesity. I think it’s a travesty for people that are seeking care from docs and the doc knows nothing.

Erin O’Hearn: When we look at magazines and we’re looking at ads right now for Athleta, or, I mean, I don’t want me to point out Athleta, but anything, Maybelline, whenever you’re talking about, right. And I’m more talking about women because it is, women have been fed this idea that they have to be perfect a lot of different ways, right? Proportionally, their bodies, their faces, their skin color, their hair, whatever. So obviously things have gotten advertisers have caught onto the fact that no one really looks like the people in the magazines and they are more inclusive of, people who look, 

Fatima Stanford: Who deviate from the norms…

Erin O’Hearn: Yeah. So, but my question to you is that the representation I think it’s wonderful too, to make sure that we define, that beauty is defined as you know who you are, not what you look like. At the same time. I do see these images of people who do suffer from obesity. Okay. And what I, I guess my question is if it’s a disease and if it’s detrimental to your health, should we be saying, because this is what, how I take it. It’s okay. But we’re just going to accept you how you are.

Fatima Stanford: I have an answer for you. So, this is the thing, and hopefully, I mean, I’m going to use this illustration to help paint my, my response. 

Bill Ferro: Dr. Stanford, if you could dumb it down. Cause she went to Cornell.

Erin O’Hearn: That was in 1995. It was a lot easier to get in there. 

Fatima Stanford: That’s so funny. All right. So let me tell you, let me tell you how I’m thinking about it. When I first moved to Boston, I lived on the North shore.

And for you guys that don’t know that, but you take like this commuter rail, which is kind of like an Amtrak style train into the city every morning, at 7:13, I got on that train.  And I saw this gentleman who had very severe obesity, very, very, very severe obesity.  I didn’t know his weight until later, which I’ll tell you just in a few seconds.

Anyway, he was one of the conductors on this train. He was taking the tickets, he’d move up, he slowed the things, he climbed things. I was like wow, you know, he secretly was like my dream patient. Cause I could see him in action, but I could see this incredible degree of obesity that he was carrying around.

And so, I thought it would be a little bit presumptuous to hand them my business card. So, I didn’t, although I really want it to, and every morning on my way into the city, I thought about this. I want you to fast forward, three years later, I walk into my office and I just see a name, right. I go in as a new patient and my, like my face lights up and I’m like, Oh my gosh, you’re the conductor on the train.

My dream patients sitting here, no, I didn’t, you know, just kind of showed up in my office. His mom, he’s 45 years old, his mom is in the office with him. He has no cognitive deficits, so I want you to think about his mom, a 45-year-old man bringing his mom to the doctor’s appointment.

She immediately starts crying. She says, you’re the first doctor in his entire life that believed that he did anything other than just sit around and eat and be lazy. And she cried for the first 15 minutes of our hour-long appointment. Like literally I could not get her to stop crying. She was at that appointment to be there to support and say, hey doc, I know you think he’s this and this and this, but let me tell you, my son does X.

She didn’t have to do that with me. Cause I had, I’d been watching this guy. I secretly wanted to see him. He’s in my office. When I saw him in his initial visit, he was 550 pounds. And that’s obviously quite a bit of mass, like I mentioned.  And we have worked together since then. We’ve been able to get off 250 pounds.

So, he now has been stable for about the last four or five years, about 300 pounds. Now, if you were to see him. And so going back to your question that you asked, if you were to see him walking down the street, you might be like, oh my gosh, he let himself go. He needs to work harder. His brain defends the set point at 300 pounds, which is way better than 550.

I think we can agree, but it’s not maybe 200 or 210, which may be more ideal for his frame. And so, when I see these ads, I support them being there because I don’t know from whence, they came and I know that everyone has a gradation of where they are. So, I never conformed to the BMI scale. First of all, the BMI scale didn’t have me involved.

Meaning there were no black people when the BMI scale was configured and it wasn’t configured by doctors. It was configured by the metropolitan life insurance tables company, I’m sorry, back in the 1930s when blacks didn’t matter. I think we still don’t matter because you know, the whole Black Lives Matter movement kind of supports that, you know, I think we matter, but you know, whatever.

I think you matter; we think you matter.

No, but you understand what I’m saying? So, we just weren’t, we weren’t put in that. So, I actually redrew the BMI chart back in 2019 for the Mayo clinic proceedings. And I used real data from real people that are here, like now, and actually interestingly enough, for black women, particularly the BMI curve shifts up, ever so slightly somewhere between 31 to 33 as being the normal cutoff.

But it goes to show you that this confirmation to a number or a size is different for all of us. And this is I’m going to use, this may sound a little bit of a shred, but just bear with me for a second. When we think about different breeds of dogs, you know, a bulldog will always kind of look like a bulldog they’ll carry more mass, right?

A Chihuahua will always kind of be this little lean, little, little cute little thing. That’ll be a taco bell dog, right? I mean, all of these things, there’s some of it just how they are, the cards they’re dealt, you know, kind of how they will be shaped. You can mix like a, you know, a Chihuahua and a pit, and maybe that looks a certain way, but you can understand that some people have different levels of where they’ll be.

And my goal is telling my patients, I never given them a target number. They always want me to give them a number and I never do. And if they’re listening to me, they will agree with this statement. And they, they keep still asking 5, 10 years later. Well, what number I’m like, you know, I’m not going to do that.

I want to get them to the happiest, healthiest weight for them. So, for that gentlemen, going back to him, I think that 300 is where his happiest, healthiest weight is. He has no limitations. You imagine he had no reputation somehow at 550 and he’s able to like, literally do everything at this point.

That’s where his brain is like, Nope, this is where we are. This is the happiest healthiest for him. So, when I look at those ads, I think we can celebrate people across the domain, but recognize and treat the disease for what it is. So, his disease is being treated as best as we can, based upon the current tools we have available.

And if something else comes about and I can continuously treat him, I will, but that’s where he’s come to. And I value him at 300, even though it’s not maybe exactly where I would prefer him to be, but that’s where his body has responded. So, I know it’s a long-winded answer, but hopefully that helps yo€ur understanding.

Erin O’Hearn: No, that makes me understand that a lot better. And I have to tell you, I think that what we have to get over. It opened my eyes a lot because I can’t say that I wasn’t looking at some of those images and thinking to myself, but that’s not like being pre-diabetic is not healthy. Right?  

Fatima Stanford: Interesting for him, he had no issues with his cholesterol, no characteristics of inflammation, no high blood pressure, no diabetes.

So, some people, even at that, you know, with that significant amount of excess mass, which he’s had for most of his life, which is why his mom still comes to his appointment, well she doesn’t come anymore, she trusts me now. She feels like I get it.  But she did. I mean, a grown man. How many grown men do you know take their mommies to the doctor with them to prove that they are who they say they are.

I had never seen it before in my life, but I got it immediately when I came in and I responded with like this jubilation. Like my God, this is the guy like, this is, this is my dream guy and not, you know, my dream guy,

Erin O’Hearn: I know what you mean. 

Fatima Stanford: And my husband is listening to me. So, I’m like, he’s probably like what she say, but my dream patient. And I’m like, wow, I can make an impact. And I have, and now his mom doesn’t have to come to his appointments and he is his living his best life. So, yeah. 

Erin O’Hearn: Thank you. 

Bill Ferro: The reason why no one gets trained in obesity is because we just think it’s easy. Oh, they just need to move more, eat less, or it’s education. Right? If someone doesn’t know that a cheeseburger is bad for them. But then why, as you pointed out, why do all these medical students have this? Why are they CEOs of companies having obesity issues?

Because it’s copious amounts of stress and inflammation. So, I just focus on the internal, reducing the inflammation and as much stress as I can, like chemicals on their skin and the environment. And then the elimination reintroduction, they figure out what works best for them. And then they get to, as you said eloquently, what is the healthiest for them?

What did they feel good? Never give them the number on the scale or whatever, let them get there.  And now that the gut is healthy, and just when I say the word cravings, when you gut is healthy and diverse, you actually start to crave healthier foods.

When we get on the calls, people say, it’s so crazy. I used to walk past the sugar bowl and I felt like I had to dive into it. Now it doesn’t appeal to me, and I find myself eating an apple with some almond butter on it. And it’s not because I told them they have to; they have to watch their weight. It’s just that they’ve made an increased diversity in their microbiome.

So, they actually start craving diverse foods and more healthy foods. When they’re under stress and the adrenal glands have been firing and all that, they are more apt to crave sodium, potassium, and sugar to fill that need. And so just by reducing inflammation alone, I don’t have to do a lot of psychological counseling because physiologically, I let them off the hook. And not to belabor with people, oh, well, we got to spend so much time with Tony Robbins and bring in Oprah and Dr. Phil and talk to you about your bad relationship with food. It’s like, no, we have a poor relationship with our environment and that’s the first place to start.

And to be aware of the things you’re talking about, about the systemic racism that could play into that, some of the parts of the genetics, but to solve for this for 42% of Americans, we better do something quick and swift that can let everybody off the hook, give them the resources. They need to see this success, and then empower them long-term because we won’t have the ability to follow through with them. Year two, year three, year four. If I’m still following along with you at that point, I haven’t done much. I haven’t empowered you yet. I got to empower you. 

Fatima Stanford: No, I disagree with you. Obesity is a chronic disease, just like diabetes. It’s just like saying, Oh, I only take care of your diabetes for a year, and then if you’re not empowered then your hemoglobin A1C. So, the thing is just managing and monitoring for most of my patients. And I can tell you this because I’ve done, you know, a lot of work with them. They change, you know, where their set point is, and we continue to keep and make sure that they’re there.

Maybe we need to add medications. Maybe we need to modify those medications. Maybe they’re getting pregnant. I have to adjust things that are, you know, maybe they’re postpartum. I mean, my goal is since I work with people between the ages of 2 and 90 is to meet them where they are at that moment and make sure that whatever phase of life that they’re in, that I’m maximizing where we are based upon the confines of where we are.

If you’re someone that’s coming into me for the first time to see me at 80, that’s a different conversation in terms of what I might utilize, what strategies I might address along the continuum from lifestyle to surgery than someone that’s coming in the age of 25, in terms of me having a certain tool bag of, things available based upon evidence-based medicine to treat that individual.

But I don’t want them to run away. If you’ve had metabolic and bariatric surgery, for example, and you leave, I’m no longer able to check your vital minerals. I’m not able to handle that inadequate weight loss or weight regain if you’re in that camp.  I don’t know any of those things. And then you come back 10 years later.

And then you’re, you know, not very far from where you started as the body weight cycles and goes back to defend what its initial set point is. So that if I keep you in check along the way. So, most of my patients, 95% that I’ve seen chronically for 10 plus years here that lost weight during the pandemic, I told you that most people gained 29 pounds.

My patients, 95% of them lost during the pandemic. It’s because they, I was managing their chronic disease, which is obesity. And maybe in their chart now they no longer have obesity. I take pride. I told my patients; my favorite diagnosis is to put history of obesity in adulthood. There is an actual code for that.

I love to put that, I love to delete hypertension and obstructive sleep apnea and diabetes, right. We know in three to four days of metabolic and bariatric surgery, you haven’t lost much weight, but 90 or between 85 and 90% diabetes is gone within three to four days of surgery. I mean, it just is what it is.

It’s the best treatment we know of for diabetes, but. That doesn’t mean I don’t follow them and don’t monitor them 5, 10, 20 years later to make sure they’re still in an optimal state. It’s a chronic disease. I have to manage the chronic disease. Hence me being an obesity medicine physician. 

Bill Ferro: What are the, what are the most common chronic comorbidities that you see? Is it hypertension with obesity? Is it anxiety, depression, digestive issues? 

Fatima Stanford: All of, all of the above, all of it. We know of at least 200, about 14 different cancers are related to obesity, osteoarthritis, idiopathic intracranial hypertension or pseudotumor cerebri. All of, you know, non-alcoholic fatty liver disease, which is, you know, not far behind obesity in terms of its prevalence, all of these things, are derivatives or spring offs from obesity.

The problem is as docs, we learn how to treat all of those things. We know how to treat fatty liver. We know how to treat diabetes. We know how to treat high blood pressure. We know how to treat all of those. And when you ask a doc about how to treat the disease of obesity, you’re often left with like kind of a startled look.

I can ask them how to treat something like Bechet’s disease, which you guys don’t even know. But I tell you, if I ask any doctor walking down the street right now, they would rattle off exactly what Bechet’s disease. Oh, it’s characterized by ulcers and such, such, such. I’ve never seen it in my career.

I don’t know if I will see it in my career. I see obesity every day, all day. And even if I weren’t someone that’s specializing in this as a field, if I chose to be a pathologist, I would still see obesity all day, every day, just because of the sheer volume. So why is it that we don’t learn how to treat the disease that causes all the other diseases?

We basically don’t treat the elephant in the room. We treat around it. We’re like, Oh, let’s treat the elephant’s nose and Oh, their trunk, or sorry, the trunk. And let’s treat their like left foot or whatever. We have to treat the disease that’s causing the disease.  Then we’re going to do much, much better as a society in terms of our health outcomes.

Bill Ferro: And we’re saying that the increase, the rapid rate of this obesity pandemic. It it’s incredible, right? The growth curve of this, and then of course, all these associated conditions, and just the last 20 to 30 years, if you ask me, 

Fatima Stanford: Our bodies, aren’t meant to be in this obesogenic environment. The things that we always talk about, our diet quality and exercise, those two are great, okay, but those are just kind of really small pieces of the pie. Sleep quality and duration, we know, play a large role in how the body regulates weight. Circadian rhythm disturbances, I am lauded, applauded for giving lectures in Melbourne Australia, at three in the morning because, oh wow, she’s an internationally known expert.

Our bodies aren’t, I’m not supposed to be up giving a lecture at three in the morning that deviates from circadian rhythm, the hypothalamus controls weight. When we deviate, we affect the superchiasmatic nucleus. We are now deviating from what our bodies are supposed to do. We’re supposed to be awake during the daytime and sleep during the nighttime.

When we turn the nail on its head, which is why night shift workers way more, it’s because their brain is dysregulated with the normal status of affairs. You start seeing that major shift from the night shift workers to the day shift workers in weight status over time. People think oh, it’s the night shift people, they’re eating horribly. No, if you look at their diets, it’s the same. It’s just that they’re not supposed to be awake, you know, we, we don’t want you, 

Erin O’Hearn: I can attest to that because I worked the morning shift for a long time, just like Bill’s wife did, and it’s horrible.

Bill Ferro: Most of the time when you’re converting fat to energy it’s while you’re sleeping, would you say doc, you’re seeing people come in, like you said the example, you know, you’ve got a guy that’s 500 pounds. Traditionally people will just start exercising. 

Fatima Stanford: He had been exercising. If you see the amount of activity he’s doing, that’s all he does. 

Bill Ferro: Not only that, he’s carrying around an extra 200 something pounds, right? So, he’s got the lean muscle tissue and sometimes on those folks, exercise can be counterproductive because it just creates more insulin.

Erin O’Hearn:  When you were rattling off those medicines and I’m being honest. Cause I don’t, I’m not embarrassed about this, but you know, I’m on Prozac and reason I,

Fatima Stanford: Well Prozac is the most weight neutral of the SSRIs. So, if you’re picking one out of that category, that’s the best one. So, whoever did that, thank your doctor. 

Erin O’Hearn: Okay, that’s not what they told me, they said we were surprised you were given Prozac because it causes weight gain. I probably gained like three pounds, like probably like three or five pounds heavier than if I wasn’t on it, but it really helped me.  What I want to understand from you is when women feel like they need that, or their doctors say you really need help because you can’t go through your life miserable and you can’t like, if there’s something that’s. Cause for me it was two concussions and it was, you know, probably a whole bunch of other stuff. But anyway, it has helped me. Do I need to go off it? 

Fatima Stanford: No, no, no, no. So, this is the thing it’s about weighing the balance. So. Prozac, thankfully is the most weight neutral of what we call the SSRIs. So those are the selective serotonin re-uptake inhibitors, and it is the most weight neutral in that category.

So, if I find that someone responds to an SSRI for depression, for example, I’m going to try Prozac in that category. The only antidepressant that has been shown to actually cause weight loss and is actually approved by the FDA in combination with another drug called naltrexone for weight loss is bupropion or Wellbutrin.

So, for patients that struggle with obesity, actually this is real talk, my hairstylist. I went in to see her and she was like, yeah, gained weight. And I was like, Oh really? And then she was like, yeah, my doctor put me on Mirtazapine.

I was like, why did they choose that? She was like, what do you, why did you say it like that? And I was like, that’s like one of the worst offenders for weight gain and the antidepressants. And I wrote on a card, my card, and I said, go take this to your doctor, tell me you want to go on bupropion on you’re going to do this.

And she took it to her doctor. She got switched. When I came back to see her two and a half months later, she’d lost 18 pounds. Now I feel like she should have done my hair for free. So, I’m still debating that a bit because I felt like she got free advice, but she changed nothing except the drug.

Right. The drug changed, her weight went back to what her normal was, but she didn’t know, the doc didn’t know. I told them to change it, and well I didn’t tell them, I suggested to her to tell them to change it. And that brought her back into her normal realm.  That’s a significant change. Now the three to five pounds is not Erin, but you feel good, you’re still within good range. 18 pounds within. Yeah, yeah, yeah,

Bill Ferro: Dr. Stanford to knock us out of here. So, your 10-year vision, what dent you want to make in this obesity and where do you see it coming from? Like if you what would you see 10 years from now? 

Fatima Stanford: Number one, from a policy perspective, we have to prioritize it. There’s a diabetes caucus. They’re all kind of caucuses in Congress, no obesity caucus, despite the fact that it’s the most prevalent chronic disease. I think we had a missed opportunity with the recent COVID-19 bills, as we’ve seen that obesity is the major risk factor to not address it. No one on Biden’s current team is someone that has any knowledge or expertise in obesity.

I appreciate the focus on COVID, but I think. Focus on COVID without focusing on obesity is really missing the ball there. 

Erin O’Hearn: I nominate you, by the way. 

Fatima Stanford:  I just talked to the white house this week and I basically told them they were missing that, literally. 

Erin O’Hearn: I have an in.

Bill Ferro: Erin knows everybody.

Fatima Stanford: Number two, I think that we, as healthcare providers need to do better. It is unacceptable. The lack of education that doctors, and it’s not just doctors, nurses, physician’s assistants, across the board, no education about obesity. And yet, what do they tell you to do? Go see your doctor, go see your healthcare provider to talk about your obesity.

No one knows. I mean, we have now over 5,000 physicians that are board certified in obesity medicine, but that doesn’t touch the 110 million adults. I mean, really that doesn’t divide out very nicely. We need to do better. And those people don’t really need to. I mean, we need to have frontline providers being able to care for these patients that have the disease.

 Number three, we have to reduce our weight bias and stigma. We cannot continue to assume that patients will want to see us, be in our setting, even go down to the walk down the street if they know that they’re going to be judged, just because of the way they look, just like we would talk about race.

Weight bias is a significant importance and we have to do better. We cannot assume that because that person’s walking down the street that they’re lazy. They’re slothful, they don’t exercise that eat horribly because you don’t know. And you’re judging the book by its cover. Just like you could, if I just because I’m black. And that’s just unacceptable, so we have to do better. 

So those are the three, the three big things that I would love to see change. And I think if we see those, see those screeching shames, the policy perspective, our education, or lack thereof, you know, improving that in health care as a whole, and the bias issue that will begin to make major strides in this disease. But until then, unfortunately, we’re here to continue to see that gradual increase. As our, our is, our bodies are just not meant to be in this environment that we’re in. 

Bill Ferro: Absolutely. In that last question you’re walking down the street and your theme song is playing. What’s your theme song? 

Fatima Stanford: You know, that’s interesting. I, my, I just gave a talk and so I’m going to use  this talk. This was my intro, they had me come into a song. It was funny cause I was sitting here, so I don’t know if I really walked in. It would have been nice if I were in person, but it will be Jill Scott’s Living my Life Like it’s Golden.

And I think that it reflects really how I choose to live my life and how I, I think of the work I do with my patients, my students, everyone that I work with. I want everyone to live their best healthiest self for them, whether it’s weight or whether it’s in their profession. I want to somehow be a contributor to them being their best self.

And so, Living my Life Like its Golden. Jill Scott, Jill, if you’re listening, I adore you. Um, and that’s how, that’s my theme song. Well, 

Bill Ferro: I would just like for our, you know, as a request from us and the rest of the world and the listeners, can you do more please? 

Fatima Stanford: You know, cause I’m just such a slacker, right? I mean, to step it up, just like, I mean, I have to work harder.

I finished my fifth and what I’m calling fifth and final degree on May 11th.  But I’ve said fourth and final and you see how that turned out.  The reason why I keep doing this is because I feel like there’s so much more to learn. And the more that I can learn in the more that I can teach, the better that I think the people I encounter will be. To do the best work they can do. And so that’s, that’s really what drives me. And this is what keeps me going. And it allows me to hang out with you guys today, so.

Erin O’Hearn:  I really thank you for taking our questions and, and I want to encourage everybody. There are uncomfortable topics to talk about. I think obesity is one of them because people have insecurities about it because there’s that stigma, systemic racism is certainly one that people don’t want to talk about because they don’t want to reflect internally on what, you know, may reflect poorly on them.

 We have to feel comfortable with being uncomfortable and that is the biggest thing that I, you know, took away from this conversation is that, you know, there were a lot of sensitive topics that you touched on and, you know, I try to tell myself, and I know Billy, you do this too, is you have to give up some of your own personal insecurities. Like the fact that I was like, I’m on Prozac. Like, I need to know about this. If you’re, if we’re all comfortable talking about things that are taboo or that you should, that should be kept private, we all can learn a lot and we can feel better about ourselves. 

Fatima Stanford: You’re a hundred percent correct. And that’s what I liked about it. I said, I didn’t see anything as you know, for me, I picked it really the two most sensitive topics that like my whole life is with the work I do. Right. Obesity, racism, those two. Are like, people were like, wait a minute, you chose both. Some of it was by choice. IE obesity, you know, the racism piece was not something personally that I chose to be the work that I do, but has been a big part of, of the work I’ve done for, you know, more than two decades.

And so, I tackle the hard things, you know, if it’s easy what’s the point, let’s go home. You know, we can just go home. And we learn and we learn, and my patients teach me so much. So, if you guys are listening and if you’re one of my patients, thank you for teaching me.

And thank you for allowing me to tell your stories.  Because they really informed me and I think informed the work. 

Bill Ferro: Absolutely. Thank you, Dr. Stanford. We appreciate you.  You are amazing. Have a great weekend. 

Fatima Stanford: Okay. You guys so great, so great meeting. I sent you LinkedIn invites.  Okay. Bye. Bye. Have a good day. 

Bill Ferro: Thank you, Erin. That was a great conversation. Thanks for all listeners and everyone at Quacks and Hypochondriacs podcast. Dr. Stanford was amazing. If you’d like to show, be sure to rate, review, subscribe, do all the things that help us and help you find the next show and the next episode.

And don’t forget our sponsor. What is our sponsor again? Oh, that’s right. betrhealth.com. That’s betrhealth.com. This episode was edited and produced by us because Jason didn’t show up on time, so thank you so much Earfluence. Hope you have a great day. 

Full Episode Transcript

Dr Stanford’s study, “Is obesity a manifestation of systemic racism?

Ending the Obesity Shame Game

Fatima Cody Stanford, MD, MPH, MPA, FAAP, FACP, FTOS is an obesity medicine physician scientist, educator, and policy maker at Massachusetts General Hospital and Harvard Medical School. She is a national and international sought after expert in obesity medicine who bridges the intersection of medicine, public health, policy, and disparities.

Visit our sponsor, BetrHealth.com, a gut healthy, effortless, food-as-medicine approach to whole person health . Try BetrHealth risk free at https://betrhealth.com/risk-free-trial/.

Quacks and Hypochondriacs is hosted by Dr Bill Ferro and Erin O’Hearn, and is produced by Earfluence.

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