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Melissa Harris-Perry: This is The Takeaway. I'm Melissa Harris-Perry. Just a month ago, many of us were cozying up with the family, watching Hallmark movies, eating leftovers and hopefully, taking it at least a little easy from work and the stress of the pandemic.

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As soon as the clock struck January 1st, it was all about the resolutions. New Year, New You. In the US, there's one goal that's often near the top of the list. According to the database company Statista, nearly half of Americans who responded to a 2020 poll said they wanted to lose weight as their 2021 New Year's resolution. Now, some of that mindset could be because throughout the year, we're bombarded with commercials about the best new diet trend, juice cleanses, weight loss supplements and exercise equipment.

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45 million Americans go on a diet each year and Americans spend over $70 billion a year on diet and health products. This isn’t new. Y’all remember SlimFast?

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Even if you're able to lose weight on something like SlimFast, a vast number of these fad diets fail to meet the elusive goal of long-lasting weight loss. Okay, pause. Put your phone down. Don't tweet at me just yet because this is not a conversation about how to lose weight. I promise if you stick with us, we're even going to talk about the weight related stigma, body shaming and fat hate that has real effects on people's lives.

We're going to start just for now with an assumption that weight loss is a journey that at least some people want or feel they need to take. It's a bit like some people are going to travel to the Grand Canyon or to Disneyland. Now I might think one of those destinations is better than the other. But I'm just going to start by first asking about the challenges someone might face while trying to get where they want to go.

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Right now, getting on the diet industry train to try to get to the Grand Canyon of weight loss is one expensive, uncertain and bumpy ride. For decades, pharmaceutical companies have been trying to develop medications that could make the weight loss journey more comfortable and direct. For the most part, weight loss drugs have been a little bit more like the hot mess express.

In the 1990s, the popular FDA-approved drug known as Fen-Phen was pulled from the market due to concerns over serious heart valve complications. Today, there are new options, a class of weight loss drugs called GLP-1s that could help patients lose from 5% to 15% of their body weight. These medicines are less invasive than surgery and they come without some of those red flag side effects of their predecessors. The problem? Many doctors aren't prescribing them and insurance companies aren't covering them yet.

I spoke with Emma Court, health reporter at Bloomberg News about this new weight loss drug. I asked her about some of the history and science behind weight and weight loss.

Emma Court: We know that obesity specifically is tied to higher risk of various other health conditions including things like diabetes. It's called all-cause mortality. It's essentially death from any cause. These are some of the data that have been used to draw this connection between higher weights using the BMI scale and concerns about health and desire to help people lose weight to help improve their health.

Melissa Harris-Perry: Yet, weight loss is not just hard. If I were looking at the data alone and saying, "Okay, is this a thing I should spend my time on? Because it's likely I'm not going to get the outcome I want by putting time, energy and effort into it." I'd have to say really climb a mountain instead. Do almost anything because it feels like meaningful and lasting weight loss, it does feel nearly impossible.

Emma Court: Meta-analyses, big analyses of multiple, multiple studies have found that-while actually many people can lose weight in the short-term, in fact, probably many listeners here are like, “Wait, I've lost weight, right, what's so hard about it?” it's extremely difficult in the long-term to keep that weight off. The vast majority of people end up regaining weight. We know from the research that this is not just a difficult thing, but you're almost defying the odds by succeeding and keeping weight loss often over a period of years.

Melissa Harris-Perry: When we have physical ailments, challenges, things that actually challenge our health, pharmaceuticals and surgical interventions are the Western medical gold standard for addressing those things that impact our health. Has that also been true for weight loss?

Emma Court: Many people by now are pretty familiar with surgery as an intervention for weight loss. Bariatric surgery encompasses a lot of different approaches but essentially, even that is pretty underused. It's something that many people qualify for, but for various reasons, especially the issue of cost. It's a surgery that can cost about $20,000 that insurance doesn't always pay for it, or it can require you to jump through various hoops in order to qualify, including by the way, like sometimes losing weight, which is interesting.

My piece really looks at pharmaceuticals, which are also very underutilized. In fact, a lot of people who struggle with their weight their entire lives and are told repeatedly by medical providers that they should lose weight, it would be better for their health, are not informed about. The very doctors who are telling them that way, there's an issue and could prescribe them medications in order to help are not doing that. We actually know that only about 1% to 3% of people who qualify for prescription medications for weight loss are actually getting prescribed them, which is a pretty stunning figure. Actually many overweight people and all people who are living with obesity qualify for prescriptions for these medications.

The disconnect between these two things can seem stupefying but the reality is that many doctors aren't necessarily aware of these medications, may not be comfortable prescribing them, are concerned about side effects, which is a totally valid concern. Another piece of this is the general lack of awareness about this. The broad feeling that weight loss medications are maybe a little bit sketchy. There's a history of safety problems with these medications. People may recall Fen-Phen. There was a safety scandal about this combination of medications causing heart damage in the '90s. There's a lot of different pieces that add up here to mean that people are rarely offered these medications and rarely take them.

That may be changing now and part of the reason for that is that makers of weight loss medications are now starting to see some much more promising approaches to these interventions. Some older medications in this space are thought to only help people lose about 5% to 10% of their body weight using these medications. Now, newer drugs like one drug from Novo Nordisk that's called Wegovy that was approved by the FDA last summer is actually able to help people lose about 13% of their body weight on average.

Melissa Harris-Perry: Here we have prescription medications that do seem-- even the ones that there's been a critique about, we're still talking about potentially 5% of body weight, which could be game changing when we're talking about comorbidities like for example, diabetes. In that space, is it like a moral and ethical like you should just be able to get on that Peloton and lose that weight by working hard, or is it legitimate fear on the part of physicians about over-prescribing?

Emma Court: Well, an important context for having this discussion is the fact that obesity hasn't traditionally been thought of necessarily as a medical issue. This got a lot of attention about eight years ago. The American Medical Association declared obesity a disease. While it's been described as a disease for many years, including by a group of experts convened by the NIH back in the '90s, this isn't something that's necessarily permeated our collective understanding of weight.

In general, I think many people continue to think of it as an issue of willpower and that many people includes, by the way, medical providers. We're all human beings, including people who went to medical school. It wasn't necessarily a part of the way that they were trained and you're starting to see more doctors come out getting these certifications in obesity, but there's still not that many of them relative to how many people might benefit from seeing an obesity doctor.

Melissa Harris-Perry: I can remember- -in the ‘70s and ‘80s that much of what was presented as weight loss drugs were these over the counter non-prescription, and what they were was like uppers. This was a lot of caffeine in a small pill and the notion was take this and it will make you less hungry.

I can remember folks feeling jittery and unable to concentrate and all of those kinds of things, but that's really different than what's going on with, for example, Wegovy. You want to talk a little bit about how Wegovy ends up out here on the market as a prescription weight loss drug because it's not how it started?

Emma Court: Wegovy is part of a broader group of medications that are known as GLP-1 Receptor Agonists and they are named that because they replicate the effects of the satiety hormone that's known as GLP-1. These are drugs that are actually best known for their applications in diabetes. What they do is prompt your pancreas to release insulin and help bring blood glucose levels down. This is how they've been used for a long time.

The first of these class of drugs was approved by the FDA in about 2005. They also knew even as they were developing these drugs, that they did seem to help people lose weight as well. Some of the earlier generation of these diabetes drugs, they were helping people lose weight, but only a little bit, like a couple percentage points. As they started developing different formulas of that of higher doses, they saw that they were able to produce more weight loss.

Melissa Harris-Perry: It's my understanding what's going on with Wegovy at the moment, is that it's available to be prescribed and that there is a huge demand for it. That demand is actually having some trouble getting filled in part because of all the supply chain problems, but also that the nature of the availability of it also is that health insurance plans are currently not covering it. Is that right? I'm just trying to think about some of the other barriers here. Because it's my understanding it's quite expensive and health insurance isn't covering it and yet we still have this big demand.

Emma Court: The kinds of results that Novo Nordisk has gotten with Wegovy in these research trials, the 15% weight loss, it's gotten a lot of people interested. You saw a lot of demand from that initial launch, and that's one aspect of this. Another piece of this puzzle is the fact that insurance companies generally haven't been covered weight loss medications. That hasn't been such an issue for some of the older drugs that are actually used off-label. They are medications that are widely prescribed by obesity doctors that are pretty cheap generic medications and they don't cost all that much.

They haven't been explicitly approved by the FDA for weight loss, by the way, but they're used and they're generally considered pretty safe, and obesity doctors say they know how to prescribe them. This is actually drugs like phentermine, which was part of that Fen-Phen equation back in the day, and is actually the most commonly prescribed weight loss medication up to this point.

These are pretty cheap medications. Wegovy is not a cheap medication. It's about $1,400 for a month’s supply. It's a weekly shot, so that's about four of these injectors that they sell. How exactly insurance coverage is going to shake out for Wegovy is still to determined. They used to think of it as a lifestyle medication alongside stuff like erectile dysfunction medications and smoking cessation products. How that changes is very much up in the air. I'd spoke with insurers and it did seem like they were watching this.

Melissa Harris-Perry: Fascinating, all of it. Emma Court is a health reporter for Bloomberg News. Thank you for joining us on The Takeaway.

Emma Court: Thank you so much for having me. It's been a delight.

Melissa Harris-Perry: There's another side of this conversation to consider, whether we should be pursuing weight loss as a goal at all. Large bodies are typically defined in our society as problematic bodies. The people with large bodies are assumed to be lazy, greedy, or just inadequately motivated. They're not working hard enough to look the way that someone else wants and expects them to look. Maybe you've noticed there is more than a little fat shaming going on around COVID-19, obesity and mortality, as if getting ill and dying during a multiyear global pandemic could be fixed with just a few more hours on the Nordic track.

Brittney Cooper: That is really part and parcel of how we think about people of size, about fat people in American culture. They are the one acceptable group that we still think it is widely okay to discriminate against, to say negative things about because we have this overarching idea that fatness is a choice and that it is an unhealthy choice that folks are making because they lack self-control.

Melissa Harris-Perry: Now that's Brittney Cooper, a professor at Rutgers University, an author of Eloquent Rage: A Black Feminist Discovers Her Superpower. Back in August, I spoke to Professor Cooper about the pervasiveness of body shaming and fat phobia, especially around Black women and celebrities like Lizzo. Today we didn't want to have a conversation about weight loss without also talking about a movement that reminds us losing is not always winning.

Paula Atkinson: The Fat Acceptance Movement is pretty simple. It's the belief that all humans, regardless of body shape deserve the same amount of respect.

Melissa Harris-Perry: Now that's--

Paula Atkinson: Paula Atkinson. I am a body liberation focused psychotherapist, and I'm a professor at George Washington University where I teach a course about body justice called Weight and Society.

Melissa Harris-Perry: Takeaway producers spoke with Paula about her work.

Paula Atkinson: I myself, am in recovery from an eating disorder. My body has been very, very large, and my body has been very, very small. I have done a lot of terrible things to my body in the pursuit of thinness and acceptance. I became a psychotherapist wanting never, ever to touch eating disorders or body hatred with a 10-foot pole. Then I found myself unable to stay away because I felt so strongly about the fact that I myself had been brainwashed to believe that I would be a more valuable person were my body a different size, and then to watch other people suffer within that same illusion made me crazy.

It turned out the only way to be sane was to get really angry and become an activist in body justice and helping other people free themselves from the belief that weight equals worth.

Melissa Harris-Perry: Paula works with other psychotherapists to help them look at their own biases and how those biases affect their interactions with their clients. She says mental health professionals need to take the lead to prevent a lot of weight related stigma.

Paula Atkinson: This idea that a large body is an indication of insufficient willpower, a lack of discipline, inability to make good choices, that a body shape indicates poor character, clinicians, mental health professionals tend to diagnose people in large bodies with more severe mental health issues. It's insane when you think about it, that a body shape would indicate somebody's mental health other than the fact that body shape does indicate somebody's mental health, because a person in a large body has to deal with the stigma of living in a large body every single day.

Melissa Harris-Perry: Visiting a doctor's office can also be traumatic for someone in a larger body. Medical equipment, gowns and chairs may not fit their bodies, and they may have to deal with weight bias from their doctor, too.

Paula Atkinson: The amount of betrayal and bias and hate that they receive from medical professionals, again, medical professionals who are supposed to be helping all people get “Healthier” is really sad. It's really awful. We have been taught that obesity again is a “Disease” that should be cured. However, there is no cure. There is no sustainable maintainable way to make a big body into a small body. Study after study after study shows that nothing can sustainably reliably turn a big body into a small body, and yet when somebody's in a big body and they go to a doctor's office, the doctor tells them, "Do it, make your body smaller." It's pretty insane.

Melissa Harris-Perry: If your New Year’s resolution, it's still about trying to fit into an old pair of jeans or just attempting to make choices that you feel are healthier, Paula has some advice on that.

Paula Atkinson: Study after study after study shows that if you actually want to be “Healthier”’, the best thing to do is to not focus on your weight, is to not focus on the number on the scale, it's to not focus on your body shape. Something that I talk about a lot is to shift the perspective from my experience, my internal experience of living in this body versus somebody else's experience of looking at my body. That's what's going to create the most amount of health. What foods feel good? What movement feels good? What rest feels good inside? My internal experience- -of living in this body is more important than your experience of looking at it. That's the best way to actually attain health.

Melissa Harris-Perry: It's also important to remember especially in this country, that there are many socioeconomic barriers to health. Rather than casting judgment, Paula suggests this approach.

Paula Atkinson: Health is not a characterological thing either, whether or not somebody is healthy quote or “not healthy" everybody deserves the same amount of respect. This idea that everybody has equal access to health is nonsense. There's a lot of people that cannot be "Healthy" no matter how hard they try or how they put their nose to the grindstone. Yes, fat people can be healthy. Of course, they can, and also maybe not everybody can be healthy but that doesn't mean that they don't deserve the same amount of respect, and love, and compassion.

Melissa Harris-Perry: That was psychotherapist Paula Atkinson, professor at George Washington University and this is The Takeaway.

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