What does weight stigma research reveal about why people are taking GLP-1 medications like Ozempic?

Weight stigma researchers, including social psychologists who apply social identity theory to body size, argue that the surge in GLP-1 medication use cannot be explained by health need alone. Social identity theory proposes that people derive part of their self-worth from membership in social groups. When a group is socially devalued and a person believes they can leave it, most will attempt to do so. Fatness, unlike race or other fixed identities, has long been perceived as changeable, which is why weight loss attempts are so persistent. The rise of GLP-1 medications made weight loss feel achievable again for many people, and the reframing strategies of the body positivity movement quickly gave way to renewed pursuit of thinness. Researchers describe this as the fragility of acceptance that was never tied to genuine structural change.

Internalized weight stigma is identified in research as the primary behavioral driver behind harmful coping strategies, including the pursuit of weight loss through medical and non-medical means. Internalized weight stigma develops when individuals absorb societal anti-fat attitudes, apply them to themselves, and devalue themselves because of their body size. It originates in externalized weight stigma, the systemic, cultural, and institutional devaluation of fat people, but it is the internalized form that drives behavior. People who have done sustained, intentional work to reduce internalized weight stigma and build identity-level self-worth show greater resilience to cultural pressures, including GLP-1 cultural pressure.

The public health picture is complicated by data access problems. Clinical trials used to approve GLP-1 medications through national health systems have shown that these drugs did not improve cardiovascular health outcomes in people with higher BMI, older people, women, or people of colour. This evidence was placed in supplementary materials rather than the main body of published papers, meaning it was not peer-reviewed by the same standard and was not widely read by clinicians or policymakers. Researchers have raised concerns about undisclosed financial interests in the bodies approving these drugs for public health use.

A new dimension of medicalized weight stigma is emerging alongside widespread GLP-1 prescription: fat people who refuse GLP-1 medications are increasingly being treated as making irrational or non-compliant choices in clinical settings. This shifts the locus of stigma from cultural and social contexts into the examining room itself. Weight stigma researchers and weight-neutral practitioners note that this creates a significant clinical burden for fat people who have done the work to understand these medications and choose not to use them, and who must now defend that choice to healthcare providers.

Transcript 

Stephanie: I’m going to introduce you, I’m going to read a short bio on you and then we’re going to deep dive in the topic of weight stigma because I am a geek in that and I have so many questions for you. So, Dr. Angela Meadows is a social psychologist, researcher specializing in weight stigma and how it operates at the individual, relational and systemic level and we’ll cover each one of those in today’s interview. She’s also the founder of the annual International Weight Stigma Conference. So I’m going to open us up with a very broad question and then we’ll start diving into the various aspects of weight stigma but you’ve spent your career studying weight stigma and how it operates. And now we’re in this new era of, call it GLP-1, where it’s dominating nearly every conversation surrounding health, wellness. What are you seeing? What’s your take on this that most people are missing?

Dr. Angela Meadows: Oh, that is a broad question. Yeah. I think in terms of most people, if you mean the general population, I think many of them are blissfully unaware of weight stigma to begin with. It’s so normalized in society that it generally goes unrecognized by, certainly by thin people, but by very many fat people as well. So if somebody tells a fat person, you know, they could have a boyfriend if they just lost weight or if kids point and shout at them and say, you know, you’re so fat, you’re disgusting or whatever like that, a lot of them are telling us in research and online that people are just telling them the truth. They’re not actually recognizing it as a systemic fat phobia because it’s so ingrained in them. So I think in what did you call it, the era of GLPs, I tend to use it because it’s catchy. I think what’s really happening is we’re seeing under the cover of what has for the last sort of five to ten years or so been a rise in so-called body positivity. We’ve seen people say, oh, bodies are great and we need to accept more diversity. And when they say all bodies, they don’t mean all bodies, they mean thinner people who have a slight tummy. They don’t really mean very big bodies. But there has been this veneer of acceptability of not being model sized. And it’s the Ozempic era, for want of a better word, is just really blasting that out of the water. It’s just showing how shallow that acceptance was. And I think that’s very much based on the idea that people have kind of worked out that diets don’t work. But despite trying, and despite this, it’s not working. And there is actually a psychological theory that explains what’s going on here, if you’re interested in it.

Stephanie: Yeah, absolutely.

Dr. Angela Meadows: So it’s actually the social identity theory, which says that people get part of their self-worth from the value of the groups that they belong to. So the groups that we identify with, whatever they are. So, for example, I identify as white, cisgender, British, and so on. And part of my self-identity and the self-worth attached to that comes from membership of those groups. But I’m also a member of the group fat and neurodiverse and disabled for various reasons. And part of my identity is tied up with those groups as well. The theory being that if you, historically, if you belong to a socially devalued group, you would have lower self-esteem. And actually, once they start researching it, they found that wasn’t necessarily the case. People actually get a lot of benefit. But that kind of depends on the nature of the group. If you belong to a socially devalued group, the theory goes, if you can lift the group, generally, that’s what people will try to do. So if the boundaries of the group are permeable, if you can get out, so, for example, if you’re poor, low socioeconomic status, you could maybe pursue education or try and start your own company, notwithstanding how the system is biased against you, but you can try to leave the group. Whereas if your group is based on, for example, skin colour, then you can’t. Now, this is interesting because it depends very much on your perception of how accessible weight loss is as a goal. So if you think that weight loss is achievable, then most people will go for the upward social mobility. They will try and lose weight and leave the stigmatised group. But the theory also says if the boundaries are permeable, if you can’t get out, people will do one of two things. They will either try to reframe the group. So, you know, black is beautiful from the 60s and 70s, body diversity in the 90s and noughties, or depending on how engaged they are with that group as part of their identity, they might actually fight and resist societal stigma and say we demand better rights. So that’s sort of at the most extreme level. So I think what we’ve been seeing for people that are not particularly and don’t want to be identified as fat, they’ve kind of felt helpless to leave the group. So they’ve had this reframing, size diversity and bodies are beautiful and that kind of thing. And all of a sudden, Ozempic and its friends come along and weight loss is apparently suddenly achievable again. And all of that reframing just went out of the window and people are trying to leave the group. And somebody asked me the other day, how would it be for people who have done all the work on body acceptance to see all of this hoo-ha about, you know, these GLP-1s? And based on no research whatsoever, but just based on my own experience, my thinking is for those of us that have done the work and have genuinely bought in, those of us that are most identified with our fat identity, our fat community, it shouldn’t have that too big an effect on our self-worth because it really, our self-worth is now protected for internalising the value of the group. Whereas for the people that were just paying lip service to that, all of a sudden that’s blown out of the water and they’re really struggling to sort of find their self-worth again, which is not to say for those of us that are activists and resisting weight stigma that it’s easy. It’s horrific to see how everybody is suddenly deserting this idea of body diversity. And it kind of proves just how socially constructed this whole sort of everybody is beautiful kind of thing is and thinness is the ideal. There’s no inherent truth in any of it. It really is driven by our culture.

Stephanie: Wow. There’s so much to unpack there because it explains what I see in practice. Right. So I work mainly with body image and what I see in practice is people who are not, who have not done the work at the identity level because you talked about, which is for me, the belief level and the thinking pattern level. That’s where the GLP-1 era gets to them. And you’ve explained with the theory what I see is they’re diverting back to attempting again to lose weight so they can belong to the group that’s socially acceptable. And while this is happening, I also have my long term people I’ve been working with myself and people who have done the work at the identity level where, yeah, there’s a level of questioning. But for me, it’s not a questioning, should I do it or not? It’s more questioning, why am I not being affected by this? Like, what is different with me? And you’ve just explained it for me, my work and the work that I try to do with people is at the belief level, right, it’s like altering your belief and reshaping your belief so that you can access confidence, what is called in my, in the world that I sell, but it’s the self worth. And it’s fascinating to see that there’s an actual theory behind that. So thank you very much for sharing that with me, because that’s the clinical work that I do and what I see in people. So for the audience who may not be as acutely aware of the psychology behind weight stigma, can you share in layman’s term, what is weight stigma from a psychological perspective? And where does it play in our brain and our nervous system?

Dr. Angela Meadows: And for the second half of that question, I actually can’t because I’m not a neuroscientist. I work very much at the whole person level. I don’t know if anybody else is actually doing that work, at least not in terms of weight stigma. I’m sure somebody is, you know, looking at some of the other more and longer studied prejudices, you know, someone’s bound to have looked at that in terms of racism or homophobia or something like that. But to my knowledge, no one’s actually doing that for weight stigma, which is a really interesting question. Every time I speak to someone about this, I get, oh, that would be a good study. I need to find someone to collaborate with on that. I have all these ideas, too many ideas, not enough time. But in terms of what is weight stigma, it kind of depends who you ask. I think for a lot of people who don’t really understand the structural nature of weight stigma, they think of it as people being mean to fat people, you know, calling them names very much on the interpersonal level, you know, rejecting them socially, again, on an interpersonal level. And we see a lot of the big weight stigma researchers who are saying health professionals need some training in this. And it’s what I call the be nice to the fat people approach. So it’s like smile to them, use the right language, that kind of thing. But it’s because it’s not an interpersonal problem and you can’t tell somebody that they are worthless and need to be eradicated whilst smiling and being nice to them and make it OK. As long as you are trying to eliminate the group, as long as you are valuing society, it’s never going to be OK with that approach. It’s a structural problem. And an interesting stigma was originally it comes from the Greek and a stigma or stigmata was actually a mark of body. It was a visible mark that they put on to identify people who are deviant in society. So a slave or, you know, a political traitor or something like that. So it was a visually deviant identity mark. And it’s very interesting. One of my big bugbears for weight stigma research is that a lot of it is being done in thin white people because most of it is being done in psychology departments where the easiest source of participants for your studies is psychology students who are on average thin, white, young women, obviously with exceptions. But that is the majority. So, for example, some of the scales that measured weight stigma, especially internalised weight stigma, could be — because I’m overweight, I don’t understand why anyone attractive would want to date me. That was an item on a traditional internalised weight stigma scale. And they changed it to instead of because I’m overweight, because of my weight, I don’t see why anyone. So the reasoning behind that is that they can now use it for people who aren’t fat. And there’s a lot of research that’s actually based on thin people and it drives me mad as a reviewer of studies when journals contact me to review the studies and they’ve been done on a population of thin people who dislike their bodies. That’s not weight stigma because they are not a socially devalued group in society. Now, that’s not to say thin people can’t have body image problems. Of course they can. It’s not to say thin people can’t be teased because of their weight or names because of their weight, especially if they’re very thin or if they have a slight pooch, there’s so much stigma generally that, you know, a loved one or a boyfriend or a parent could say something untoward, a kid at school could tease them. Absolutely. But if those people stop doing that thing or if the person themselves came to terms with their own body image issues, their own disorderly image issues, they would then be fine. For a fat person, that’s not the case because we’re being treated differently in society as a whole, we’re treated differently in employment, we’re treated differently in education, we’re treated differently in the health care system. And the phrase that I like to use the most is you can’t love yourself out of oppression. And so weight stigma to me is the systemic devaluation of a group in society who are treated as lesser because of it.

Stephanie: Yeah, and I love the analogy from the Latin language, like a mark on the body. It’s a mark on the…

Dr. Angela Meadows: I think it’s actually Greek, but yes.

Stephanie: Greek. Well, it’s also a mark. That’s how I see it in clinic, right? It’s a mark on the brain, on the way people think. And it’s a mark on the nervous system, like it’s a deep mark on the nervous system. Even for me, like about a year ago, I had a recent medicalized weight stigma where a doctor prescribed to me GLP-1. And even though I’ve been doing this work for 10 years, professionally and personally, that mark in my nervous system was still being activated and I could feel it in my whole body, like it never truly goes away. I just learned to manage it better. And I learned to live with it and live my life with it in a way that makes me a happy person. But that mark is still there.

Dr. Angela Meadows: Such a great example. The cultural instances of weight stigma are so prevalent every single day. We get it everywhere. It’s not usually the macroaggressions, it’s the little things, it’s the microaggressions. If you’re traveling on the train and there’s, you know, nowadays, everywhere you look, there’s advertisements for GLPs. Or in the UK, you’re not allowed to advertise GLPs directly to the consumer or any medication directly to the consumer. So we get the awareness raising campaigns funded by the makers of GLPs about how your fatness is not your fault and you should speak to your doctor about it. But messages, you know, in television, the fat joke every time you open a magazine. And of course, it’s constant. And, you know, those of us that have done the work, we are not cured, if you like. You know, sometimes something will happen or you’ll read about some new wonder drug and you’ll think, I wonder. And then, you know, your common sense kicks in and all that training kicks in and you’re like, no, this is just another instance of eradication that is seriously problematic. And it’s not going to work because biology doesn’t work that way. And you said you get better at ignoring it and telling it to go away. But, you know, I still have my moments. I’m sure many of us do.

Stephanie: Yeah. And to me, it’s as a fat person in the way that I teach it to people, it’s about recognizing that that mark is there and the mark is in the system, the mark is everywhere and recognizing that we need to work to change that mark, not to be there. But meanwhile, we need to, again, the work is put on us to learn coping skills and to learn mindset tools to survive this environment so we can have a, quote unquote, happy life so we don’t spend our life suffering.

Dr. Angela Meadows: My background is actually in biomedical sciences, and when I moved into this area, I just discovered fat acceptance on the Internet and it was kind of — it must have been about 15 years ago, maybe a little less. And, you know, the fat activism or the fat acceptance was starting to hit the mainstream a little bit. The health at every size paradigm was becoming wider known, if not better understood. And I joined up with a couple of Facebook groups. That’s how long ago it was. We still joined Facebook groups. And what I was seeing in that was that once people stopped hating their bodies, as you will know from your work, they start treating themselves better. They will actually take their kids swimming for the first time because they refuse to be shamed from wearing a swimsuit. Whereas before, you know, they weren’t taking these healthier choices. And what we were seeing from the outrage and the moral panic was that we can’t have fat people accepting themselves, they’ll just get fatter and fatter and fatter and they’ll destroy the health care system and the universe and all the rest of it. And it wasn’t what I was seeing in practice. Once people started accepting themselves, you know, they actually became or started making moves towards being healthier. So when I started my PhD, my goal was to show that if we developed interventions to reduce internalised weight stigma, people would actually engage in more healthy behaviour. And about three months, heaven help me, after starting my PhD, I accidentally founded what is now the International Weight Stigma Conference and I became exposed to a lot more learning and research than I had previously seen in my very narrow field. And I became more aware of the sociological approaches and understanding of this. And it made me realise that what I was trying to do, what many people are still trying to do is, as you said, help the victims of oppression fend off the blows better. But what we really need to be doing is to stop the blows from coming. So I moved into a more macro level. Working with clients, as you do, you know, you are helping people to fend off the blows better. Maybe that will also better equip them, some of them, to fight the system more. And there’s a lot of privilege in being able to fight a system. It’s very, very difficult and you need a certain amount of other types of privilege to begin with because of that power dynamic there. And absolutely all the research on internalised weight stigma shows that more of it’s bad and less of it’s better. Not hating yourself is much better for your health and well-being than hating yourself. But it still doesn’t help when you can’t get hired for a job or you get fired more easily, you know, it doesn’t help with the systemic stuff.

Stephanie: I think we need to, and this is for anybody listening to this, the work needs to be done at two levels. There’s people like you in research that work at the systemic level and changing the system and influencing the system. And there’s people like me who work at the individual level to help people, quote unquote, fend the blows better and live a good life, a happy life, and continue to change the system at the same time. It’s not either or, it’s a both approach that needs to happen.

Dr. Angela Meadows: Absolutely. We do need both of them. I would like to say that I really can’t take any credit for changing the system, despite all my best efforts. I think those of us that are doing the research and trying to influence policy tend to be banging our heads against a brick wall most of the time. And the change is happening from the full time activists that are just putting in all of the time and all of the effort and keep, you know, just banging on the right doors to talk to those people and making those alliances. It is a full time job. Groups such as NAFA, the National Association to Advance Fat Acceptance, are doing a ton of work. The campaign for size freedom is gradually leading to policy changes in cities and states across the US. I’ve done my little bit, but on top of my research, I’ve tried, I’ve spoken to parliament, our government a couple of times, and they all find it fascinating and nothing changes. I think I’ve been told several times that I need to start smaller and I just can’t do it because starting smaller is you’re still not challenging the system, you’re still saying the system is OK and the problem is systemic and it’s endemic. And I am actually about to found a non-profit organisation with a colleague where we can actually do this work as full time as two people with other lives can actually do. So hopefully that will change in the UK where we’re going to be working, but it’s very hard for people in research to actually make these changes unless they’re telling policy makers what they already want to hear. So, for example, the Rudd Centre that are based in the US are very much among the fat people group of researchers and they have quite a lot of influence in policy makers because, you know, the policy makers like to hear, oh, we can’t stigmatise people, it’s bad for them. But obviously, obesity, we still need to address, you know, deal with that. But if we train people to say people with obesity, then everything will be better. Of course, it’s nonsense, but it’s very hard to speak to people who are not ready to hear what you’re selling.

Stephanie: So let’s talk about public health, because that’s one of the areas I want to talk about. What do you believe currently, in your own personal forecasts, will be on this era of Ozempic, as you call it, GLP-1, is actually doing to public health? What’s your perspective on that?

Dr. Angela Meadows: Well, I can only speak to the UK context, but I think it is starting to have a huge negative impact. And I think in the next 10 years, we’re going to see it probably breaking the National Health Service, the NHS. At the moment, access through the health care system, through your primary care provider, through your GP, is very limited because of the costs. But the organisation in the UK who okays drugs for funding through the health service approved both Ozempic and Mounjaro for use in the UK on the basis of evidence of people with severe, very heavy financial interests in this narrative, some of which were not declared, and on scientific evidence that if they had dug a little bit closer, wouldn’t have actually supported the moves they were making. So, for example, it was approved for people with a BMI over 35, despite the fact that the so-called longer term trials, which means like two years, were showing that they don’t actually work terribly well for cardiovascular health in that group of people. They don’t actually improve health based on the data we have so far. In a large study, it was shown that overall there were some improvements in cardiovascular health, but not for people with higher BMI, older people, women, people of colour. And people are not looking at this evidence. And most of this evidence is actually buried in supplementary materials to journal articles. So most journals have a word limit on how many words you can include. So what people are doing is they’re putting all the positive stuff or so-called positive stuff into the paper, which is peer reviewed. And the fine detail, like it didn’t work in fat people, which is considered fine detail, gets hidden in supplementary materials that are only available online and aren’t necessarily subject to peer review. You have to work really hard to find this information. And I believe you’ve already spoken to Ragen Chastain, who’s done a lot of this work. And when I first got the opportunity to speak to the UK Parliament about GLP-1, she’s the person I turned to and said, explain it to me. And we’ve been working together. And at one point we were both sitting at our computer monitors with a ruler trying to work out from the graph exactly where the line was. The data was so hard, most people will not be seeing these data. So it’s actually quite hard to get these through your PCP. But the vast majority of people in the UK, it’s approximately 80 percent, they reckon, are getting them privately. So from online pharmacies, from health, from beauty salons, from their personal trainer, from a stranger. We actually were doing a study at the moment, a qualitative study. So we’re interviewing people and asking them about their experiences. And one person was telling us she saw a work colleague who had lost weight, asked her how she’d done it. And she said, oh, she had this lady that was giving her GLPs. So our interviewee went along with her colleague to this lady’s house, her house. The woman asked her how much she weighed, went into her fridge, took out a vial of something and injected her with it. I mean, these are the risks people are prepared to take. And the chance of them actually getting GLPs, what we’re hearing a lot is that some people are injecting insulin. And of course, if you’re not diabetic, then you pass out. This one passed out and broke her collarbone. But the things that people are prepared to do and we’re seeing all of these side effects, we’re seeing organ damage. We will see a rise in more serious problems, which will then have to be treated publicly. People are turning up at what you would call an emergency room in North America. What we call accident and emergency in Canada is emerge. I’ve learned to be hospitalized in lots of languages in my travels. And people are turning up with these problems. The health service is having to deal with them and pay with the fallout from them. And that’s always been the case. The health service has always been dealing with the fallout from dieting and the harm it does for our bodies. But the scale of this problem, the number of people who are taking these drugs is massive. And we’re going to see the harms played out in public health for decades to come. Meanwhile, the companies that make these drugs are laughing all the way to the bank and they’re not the ones dealing with the fallout. They’ll just come up with a new drug that they say solves this problem and then they’ll make more billions.

Stephanie: So, I mean, by the way, I have an interview coming up with an emergency doctor, Dr. Michelle Tubman, and we talked about the fallout that she’s seeing in emergency care of GLP-1. So I won’t extend myself on that. But what I’m hearing and what you’re talking is this two angle. There’s this idea why GLP-1 is integrated in public health was supposedly to save money long term by eradicating fatness in people. And that was supposedly going to save money long term, but what the prediction is is actually going to cost us even more money with the fallout of all the health consequences, but also people regaining the weight, which we talked about with Ragen, and regaining fat instead of muscle and all the side effects of that. But what do you think it will do to medicalize weight stigma? Because we didn’t dive on that, but we were kind of working into making medical weight stigma better as you talked in your opening in educating people, but now doctors or health practitioners are seeing GLP-1 as a solution, so what is your perspective on medicalized weight stigma long-term with GLP-1?

Dr. Angela Meadows: Yeah, I think it’s actually very similar for healthcare professionals as it is for the general public, because they’ve not been trained in this, they’re getting their messages the same way that everybody else is from the media and from the hype, and I think in terms of somebody coming into the emergency room, it’s as likely to be a thin person as a fat person, really, because everyone’s taking these drugs. So I think in that sense, it won’t necessarily be a backlash against fat people for that reason, as in, oh, here are fat people causing problems again because they’re fat, rather than recognizing it’s the interventions that we pushed on them that are causing the problems, because the problems are sort of more universal given the broad spread appeal of these drugs. But I think it used to be that you were stigmatized for being fat, whereas now with these supposedly easy to use, easily accessible, none of which is true, drugs that will supposedly make you thinner, and of course that means healthier, which we all know is not the same thing, then you’re stigmatized for not using the drugs, so you’re making bad choices. So whether you continue to use them and get sick, or whatever, you’re going to be stigmatized for using them, you’re going to be stigmatized for not using them. I think if anything, it’s actually going to make things worse.

Stephanie: That’s what I’m seeing in client work is they’re coming back when they’re refusing to tell GLP-1, I’m seeing a new medical weight stigma coming on, is the one where you’re now crazy, not functioning properly because you’re not making the decision to take GLP-1. I think there’s a new form of weight stigma that will be happening to fat people for refusing to take it.

Dr. Angela Meadows: Yes, definitely. And I think it requires an awful lot of self-care and knowledge to choose not to take these drugs, because without that knowledge, why would you not? So these are people that know these drugs are going to end up hurting them. They’re going to end up gaining back the weight for whatever reason. And they are having to fight against the system that’s telling them, you’re crazy for not taking these drugs. And they are having to fight on a whole other level. It wasn’t bad enough that we had to fight for our rights in every aspect of society. But now, I mean, there was already a lot of people have been treated very badly in healthcare. But I think this will just exacerbate that problem.

Stephanie: So I want to discuss a theory that I have with you. So we’re seeing the use of GLP-1, obviously, an expensive growth, and more people are taking it, as we’ve been talking for the last 30 minutes. But the vast majority of people taking GLP-1, in my opinion, is aesthetic. There is a small percentage of people that are taking it for documented health reason that have established use of GLP-1, like type 2 diabetes, for medication. In fact, I have a client who when the GLP-1 started, people started talking about it, she didn’t even know she was taking GLP-1. She had put type 2 diabetes for years on this medication, and then she realized it was GLP-1, because it never made her lose weight. It just helped her stabilize type 2. The vast majority of the people are taking it for aesthetic reason. And when I think about that, it’s just proved to me, and this is my theory, it’s weight stigma. Internalized weight stigma is the reason why we have seen this phenomenal growth of people taking GLP-1, and it just demonstrates the power of internalized weight stigma. What are your thoughts on my theory?

Dr. Angela Meadows: I think you’re absolutely right. To be clear, GLP-1s were developed for diabetes for the management of blood sugar. People who are diabetic produce less GLP-1 in their body than it is a naturally-occurring hormone. They’re fantastic drugs for that. They’re generally not first-line drugs for that, because of the cost of them and the side effects. But if other things aren’t working for you, that is something a doctor can try, and they can be life-transforming. Even the thing with diabetes, if you’re taking them for diabetes, the idea is to stabilize and manage your blood sugar at the lowest possible dose. I’m guessing you spoke about this with Ragen, because this is how she explained it to me when I first went to her. It’s all about the dosage. What they noticed in these trials with these low doses, very low doses, is that some people were actually losing weight on them. As the pressures on these companies were increasing, as governments were fighting back against price gouging on insulin, which is where they were making all that money, here was a brand new market that was suddenly available to them if they could sell these drugs for weight loss. In order to make the figures as attractive as possible, it was all about increasing the dose to as high as a person can tolerate, which is a very different approach to the way that it’s used in diabetes. That’s the first part of your question. The second part of your question — well, I’m not entirely sure about that, because I think we can all say that fat is everywhere in society. And I think for a lot of these people, achieving that sort of model figure, so let’s just say they’re slightly above the upper end of so-called normal weight range, and we all know how garbage BMI is. But, you know, let’s say they’re a little bit, just a fraction heavier than the ideal. Getting to that ideal is rewarding, it’s rewarded in society for people who look like that. And fear of becoming bigger, fear of becoming fatter, is like a lot of people, especially women, although that’s increasingly changing, but a lot of women and girls in particular, fear of becoming fat is a major driving factor behind disordered eating and the development of eating disorder. And it’s a real fear. You know, it’s not just that you dislike your own body, it’s that society is going to dislike you and treat you worse. And I can totally understand why people can be tempted to do these things, because if they do get thin and stay thin, their life probably will be better in many ways, in terms of external stuff, what it does to their long-term health, what it does to their psychological well-being, what it does to their self-worth is a whole other question. But in many ways, certain aspects of their life will be easier, and that’s because of external fatphobia.

Stephanie: That’s an interesting perspective. So for you, it’s the pressure of the externalized weight stigma, externalized fatphobia is greater than the internalized weight stigma.

Dr. Angela Meadows: Yes and no. So internalized weight stigma doesn’t develop in a vacuum. So the criteria for defining internalized weight stigma traditionally have been, first of all, that you are aware of societal negative attitudes towards fatness. Secondly, that you apply those negative attitudes towards yourself, because of your body size. And thirdly, that you devalue yourself because of it. So for example, I’m aware of the stereotype that fat people are lazy, which is obviously a stereotype, it’s not true of everyone. Some fat people are lazy, some thin people are lazy. I myself am extremely lazy, despite living in a fat body. But I don’t think that makes me worth any less as a person. So I would score low on a measure of internalized weight stigma. However, all of those processes begin with a devalued identity in society. Now, what we see in the research in terms of people’s behavior is that internalized weight stigma is the major driver of all of these unhealthy, maladaptive coping strategies. It is internalized weight stigma, not externalized weight stigma. So you’re right in that respect. However, that internalized weight stigma comes from the externalized weight stigma, the anti-fat attitudes in society. So when we see that people who have experienced weight stigma have health problems, or they’re engaging in unhealthy coping strategies in society, it’s usually internalized weight stigma that is the intermediary of that. So they experience stigma or they’re aware of stigma in society. They anticipate they’re worried about stigma, they internalize all of these negative messages. And it’s the internalized weight stigma that’s driving the behavior. However, there is also a codicil to that, in that to some extent being exposed to a hostile environment, even without internalization is extremely bad for your health. And what we see from all of the literature, not just the weight stigma literature, but the racism literature, the homophobia literature, the sexism literature, is that the major driver of ill health is not a single major instance of prejudice or discrimination. It’s the little everyday things, the microaggressions, we call them, that tell you that the environment is hostile to people like you, and that there’s something wrong with you and that you don’t belong. And that is a form of stress. You’re living in a state of hyper anxiety, hyper vigilance, whether you’re experiencing these things directly or not. And to some extent, we’re all experiencing them indirectly, you know, in the media and everywhere else, but also anticipating it. So we’ve got all that going on. So it’s a form of stress on our bodies. And our bodies have evolved to respond to stress in very particular ways. They increase stress hormones. And those then have a series of biological, physiological effects on our body that enable us to deal with stress. And the way we evolve, those stressors were acute stressors. We’re supposed to respond to the stress, it enables us to run away or whatever. And then all of those internal signals and those biochemical messengers, they all calm down and you go back to normal. But when the stress is constant, you never go back to normal. You are in a heightened state of arousal, which has long term negative impacts on your health, psychological and physical health, metabolic health. So we see people with all of these stigmatized identities, regardless of whether or not they internalize that stigma, have worse long term health outcomes because of being exposed long term to a hostile environment. So there’s those two routes. So you’re getting it directly and then you’re getting it indirectly because of you internalize it and then you engage in unhealthy, unhelpful coping behaviors that also worsen your health. So in terms of behavioral processes, internalized weight stigma is the bigger driver. If you experience stigma and don’t internalize it, you don’t tend to engage in those maladaptive behaviors. You’re still having the negative effects of being in a hostile environment. So there’s the indirect route and the direct route, but it all originates in societal attitudes towards fatness.

Stephanie: That was brilliant. And my question, as you were speaking from a theoretical perspective and explaining, and I’m like, it really tells about me because I work at the behavior level. That’s where my focus is. So for me, the mediator is internalized weight stigma. And my mind needs to be reminded that it comes from the external. But it leads me to have the next question. Is there people who are exposed, like that lives in society that are exposed to externalized weight stigma that do not internalize it?

Dr. Angela Meadows: Well, I think originally, probably no. I think the rise of the fat liberation movement, the fat activism movement, I think there’s many of us that are fighting very hard not to internalize it. I think the damage was largely done when we were younger. I think the fat liberation movement has been around for long enough that there are probably some people who are lucky enough to have grown up in households where their parents had already accepted this and were coaching them from a very young age that they were not the problem, that society was the problem. And hopefully there will be more and more as generations come. But I think they’re the minority. I think most of us, including myself, grew up disliking our bodies, internalizing all those messages from the magazines and the TV shows and the movies, dieting, becoming fatter because that’s what happens when you diet, and internalizing that hatred more. And then we have to learn to deal with that. So that’s where you’re coming in. And as you said earlier, this work is really important and it needs to be done because nobody — think of it on the aeroplane, when you have to, if it’s an emergency, you have to put your own mask on before you help anybody else. Nobody with that much internalized stigma can fight the system. We need to fix the individual level at the same time as the people that are able to are fighting, and then more and more people will be able to join that fight.

Stephanie: The way that I’m seeing what you just said is it has to be intentional work, intentional work when you raise children. So the women who are doing their personal work today will raise the next generation protected to a degree to lesser internalization or no internalization of it. But that person has to be intentional in learning the skill set to protect themselves, unpack your current internalized weight stigma and protect yourself from incoming one. That’s the way that I’m seeing in clinical application.

Dr. Angela Meadows: Yes. I don’t think anyone could go through life and accidentally not internalize these messages. I think you’re absolutely right. It has to be intentional work to fight back because the messaging is just so pervasive and so constant that you have to critique it, question it, challenge it in order to not be affected by it.

Stephanie: Yeah, because it’s human nature to absorb it, like the way the brain functions, the socialization, the brain is made to absorb the message of society to supposedly protect you. That’s like a very primal viewpoint on the way the brain works. So you have to like, it’s like an umbrella and you’re like dodging it. Like you have to be very intentional to dodge that socialization. And it’s not just weight stigma. It’s all the various intersectional form of oppression. I want to talk about another angle because and this is something that I’m observing. People who do lose weight through GLP-1 are now being stigmatized for having lost quote unquote easily the weight on GLP-1 versus exercising and restricting food. What’s your take on that?

Dr. Angela Meadows: Yeah, the effort effect. Absolutely. There’s been some very interesting work done on this. And it just shows you that, you know, society doesn’t want thin people. It wants fat people to suffer, basically. You know, if they really cared about your health, they’d be happy that you are now thin and supposedly less a drain on society. It’s very much the moral judgment of the person. And, you know, ignoring all the horrific side effects that people have had to deal with the supposed easy way out. They haven’t suffered enough. They haven’t put in the effort to pay for their sins of excess and sloth that led them to being fat in the first place. I think that’s the sort of societal message. We need to have done the work. We need to have suffered for our sins. It’s very moralizing, very judgmental. If you like, it’s the new religion.

Stephanie: Yeah, the suffering piece. And I think that explains it very well. Like, it’s, we have to have suffered for having been in that fat body and GLP-1 makes it too easy. Let’s talk about your conference, because I think it’s important to give it a platform for people to understand. Tell me how you came up with that conference. I’m sure there’s a good story behind that. And what is, what do you see it playing a role in the work we’re doing here?

Dr. Angela Meadows: Oh, yeah, I could talk for a whole hour about the conference. It actually started, I was a baby PhD researcher. I was about three months into my PhD, which I’d originally signed on to with the idea of doing something quite different before discovering the fat acceptance movement and saying, I want to study internalized weight stigma. And at the time, there wasn’t a huge amount of literature out there. There was some, but not a lot. And most of it was coming out of one or two main labs in the United States. The big one being the Rudd Center, who’ve been doing this work for a while, not from a fat liberation perspective. But I was a few months into my PhD and our university put out an email saying, there’s some money for PhD students to put on an event. It was a transferable skills kind of thing to help with our development in academia and as researchers. And I thought, OK, well, as far as I know, nobody in the UK is doing this work. So it might be good for me and the maybe six people in the UK who care about this stuff to, you know, get together and get to know each other. So I applied for this very small amount of funding and I really didn’t know anybody else in the UK that was doing this work. My husband and I spent an entire weekend just listing in an Excel spreadsheet all of the universities in the UK, every single department at each university that might have something to do with weight stigma, which is like most of them, except possibly maths and physics, but pretty much all the others might have an interest. And finally, a contact email address for somebody in that department. And we sent out a call for abstracts to all of these people saying, please share it with your researchers. And for reasons that I won’t go into, the event was three months to the day after I was told I had the funding. And three months later, over 100 people showed up to this event, which wasn’t supposed to be a conference. It was just a little get together event. And it was standing room only. And at the end of the day, two people said, I can host this next year if you like. And that’s how the weight stigma conference was born. And I get the credit quite a lot for this. And I will admit, I do a lot of the work on this. But every year we’ve had a host in wherever we’ve hosted it. And a lot of people have supported this conference and done a lot of the work for it. And it wouldn’t have continued without them. And how it helps with the work we’re doing. I think, to be honest, without trying to sound like I’m boasting, I think it’s been transformative for the field. It’s brought people together. It’s shared best practice. It’s changed minds. There’s so many research collaborations and initiatives and amongst healthcare practitioners, not just researchers and policymakers that are doing things differently because of their exposure to this conference. A lot of people, especially healthcare professionals and some researchers, have initially come to the conference because they’re aware that stigma is bad, but obesity, you know, they still want to address obesity, but they want to do it in a nice way. And they’ve had their ideas challenged. And a lot of people, the ripples from this, we’ve been going now for 13 years, we lost a couple of COVID, but this year will be our 12th international weight stigma conference. The ripples are massive. And I’m prouder of this conference than anything else I’ve ever done.

Stephanie: So it’s happening. So we’re recording today on June the 5th. So it’s happening in two weeks, you said at the beginning when we’re chatting?

Dr. Angela Meadows: Less than two weeks. Yes, less than two weeks. And there’s still things that haven’t been done. So it’s the 13th and 14th. I don’t know if this will air in time, but it’s the 13th and 14th of June, which is not this weekend, but next weekend. And it’s Friday today. Oh my goodness, just over a week. And so much work today in Oslo in Norway, but also online. We’ve been fully hybrid since 2023. And if you’re interested, if this goes out in time, but also if you’re interested in attending future years, our website is at weightstigmaconference.com. And please do check us out if you want to submit an abstract. Even if you’re not a researcher, we’ve had people over the years that are sort of like running positive businesses. We have somebody this year that’s doing that. And although it’s run as an academic conference, since the very early days, when we had fewer abstracts and weren’t in a position to turn people down, I’ve been mentoring people. So if you have a good idea, submit it and I can work with you. And sometimes if it’s not my area of expertise, I’ll get somebody else to help you to make it more suitable and help you integrate into this environment. That might seem a little bit scary for some people, but it’s a really, really nice conference. And for those of us that are engaged in weight stigma work, most of us are not fortunate enough to be working in a very fat positive environment. Many of us are working within universities or in health care facilities or services that are still very fat phobic. And we are constantly, whenever we say anything, having to defend the work that we’re doing, provide references and annotations. And to be in a room full of people that get it, it’s just incredible. It’s an amazing experience.

Stephanie: I will put the link of this in the show notes. So for anybody listening, I don’t think we will hear it in time, but it’s on the radar for next year for people who want to see it. And thank you for doing this work, to putting together an event where people can network in such a small community. That’s how we do systemic change. So when you were saying at some point in the interview that you weren’t working at the systemic level, I want to say, in my opinion, you do because you’re putting events like this.

Dr. Angela Meadows: Thank you. I forget that sometimes. I forget sometimes that this counts. I know my failures to get through to our MPs and our legislators. And I tend to focus on that. And I forget that this is systemic work too. So thank you for reminding me.

Stephanie: Yeah, you are doing systemic work. That’s how we’re going to change long term. It’s not going to be next year. It’s not going to be in 10 years. But this is the groundwork that needs to be done. And the academic world is the groundwork that I need to be able to go on social media and talk about this. So I think we all have a role. We’re all doing work at the systemic level that will change in the future. And I keep having hope because I cannot be hopeless. Something will change in the future. And this is my last question to you. I think as little as can come out of the GLP-1 era, something positive may come out long term for weight stigma. I don’t know what it is, but I keep hoping there will be. So here’s my question. I’m going to close on that. If you look forward to 5 to 10 years from now, from your area of work, where do you see weight stigma, weight neutral health being in 5 to 10 years from now?

Dr. Angela Meadows: I have to try very hard in the GLP-1 era to remain as hopeful as you’re doing and how hard you’re trying to do it, looking at that. In terms of weight neutral health, I’m a little more hopeful because there’s now a generation of people who are doing this work. There’s more research networks. There’s more health care networks. And more and more people are trying to integrate this into their practice and in countries like the UK into their services. And they’re getting a lot of pushback. But I think, you know, the building mass of evidence will eventually change things. And every one of us that can fight this point talks to our colleagues, talks to our students, talks to our patients, and they go away and they talk to other people. And I think the critical mass is, I think the weight inclusive health care space is probably the most exciting. It’s the one where I see real change happening. Obviously, it’s not the norm mainstream, but so many more people are doing this work now. And I think at some point, obviously, hopefully, we’re going to reach a critical mass where it becomes the norm. Five to 10 years, probably not. But hopefully, within my lifetime, we’ll look back and say, you know, we were on the right side of history on this one.

Stephanie: And what’s your perspective on your academic circle with weight stigma, five to 10 years given the GLP era? What would be the impact?

Dr. Angela Meadows: Well, there’s a lot of people who have jumped on the bandwagon of this new social phenomenon who weren’t originally doing weight stigma work. They’re very interested in how GLP ones are showing up in society and what that’s doing for interpersonal relationships and behaviors. And so I’m seeing a lot more people doing this work. And I hope, pretty much has happened to me, before the GLP era. I actually have a master’s in weight management. I’ve come from the other side. And I stumbled across this literature by accident, and it blew my mind. And I’m doing what I’m doing. So I wonder if it’s actually a way in for people to actually discover the systemic nature of these problems, and maybe change sides and come at it through a different lens. And we can only hope.

Stephanie: Yeah. And when I say I like I’m hopelessly hopeful, I think my perspective is that, as we know from science, people will lose the weight to regain the weight and most likely will not regain the weight in a way that will be supportive of their health, as we know, weight cycling, it will be impactful on their health. And I think five to ten years from now we’ll be dealing with the other side of the GLP-1 era, which will bring back all that we know about weight stigma and say, “See? We told you.” And that’s where we’ll be able to change the narrative.

Stephanie: But thank you very much for having shared your time with us and having gone deep into the world of weight stigma with me on the angle of GLP-1. I think it’s gonna help a lot of practitioners and women looking to support their decision in this whole GLP-1 era. So we’ve got two audiences, and I think you’ve helped both of them. So thank you very much for your time. It was a pleasure having the opportunity to ask you these questions.

Dr. Angela Meadows: Thank you. Yeah. It’s been great.

Stephanie: And we’re also going to put in the show notes the informed consent from the physicians in weight-inclusive care for people to get more information. You can find that at sizeinclusivemedicine.org.