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Psychologist Alexis Conason joins us to discuss her background in “obesity” research, how she came to question the conventional weight paradigm and move to a weight-neutral approach, the industry influence behind the American Medical Association’s decision to classify obesity as a disease in 2013, the mental-health effects of bariatric surgery, how to talk about pharmaceutical-industry influence in ways that don’t give rise to conspiracy theories or make it seem like we’re impugning the entire medical establishment, and more. Then, in the paywalled portion of the interview, we discuss how social media makes it hard to have nuanced conversations about these issues, the discourse around GLP-1 drugs, and the trouble with the research underlying weight-loss recommendations.
ALEXIS CONASON, PSY.D., CEDS-S, is a clinical psychologist and certified eating disorder specialist-supervisor in private practice in New York City. Her group practice, Conason Psychological Services, specializes in the treatment of binge eating disorder, disordered eating, body image concerns, and psychological issues related to bariatric weight loss surgery. She is the founder of The Anti-Diet Plan, a weight-inclusive online mindful eating program designed to help people stop dieting, eat more attuned with their body, and live more peaceful and pleasurable lives. She is the author of The Diet Free Revolution: 10 Steps to Free Yourself from the Diet Cycle with Mindful Eating and Radical Self-Acceptance (June 2021, North Atlantic Books), available wherever books are sold. Dr. Conason is a fierce advocate for helping people recognize and question the societal norms that encourage feeling not good enough about themselves so they can stop fixating on shrinking their bodies and reclaim the space that they deserve in the world. You can find her on social media @theantidietplan.
Resources and References
Contains affiliate links to Amazon and Bookshop.org, where I earn a small commission for any purchases made.
Christy’s second book, The Wellness Trap: Break Free from Diet Culture, Disinformation, and Dubious Diagnoses and Find Your True Well-Being
Subscribe on Substack for extended interviews and more
Christy’s online course, Intuitive Eating Fundamentals
Transcript
Disclaimer: The below transcription is primarily rendered by AI, so errors may have occurred. The original audio file is available above.
Christy Harrison: So tell me about your relationship with food growing up.
Alexis Conason: I, like most of us, grew up in diet culture. I grew up in a household where there was chronic dieting and binge eating going on. And I just learned from a very young age that what you did, especially as a girl, as a woman, was to try and shrink your body. So I had a lot of narratives around food and grew up very much trying to diet and thinking that if I could control what I was eating, I would be able to shift my body into something that would make me more desirable, more acceptable, more lovable.
And I grew up with that narrative for so much of my life. And I really went into psychology with the idea, wanting to focus on weight management and helping other people figure out what I was struggling with so much myself, which was, how to lose weight and keep it off. And it wasn't until, thankfully, I got all the way through graduate school. I was really planning for this career in weight management and, quote unquote, obesity research that I started being exposed to the weight inclusivity framework. And that was really completely life changing for me, both personally and professionally.
Christy Harrison: Do you feel like when you struggled to lose weight and stuff, was it disordered eating level? Do you feel like you ever tipped into eating disorder territory or what did that look like?
Alexis Conason: For myself personally, I wouldn't say I ever had what I think would have been diagnosed as an eating disorder. I think I struggled with what so much of the population struggles with, which is feeling that there were certain foods that were good or bad. I was either going to be good or bad that day. Stick to the diet, not stick to the diet, and would kind of go through these periods of depriving myself of certain things and then overeating and kind of going off the wagon, as I say.
So I certainly never thought of it, especially when I was going through it, I never even thought of it as disordered eating. Like I said, it was so normalized, first in my family growing up, it's what I grew up to know. And then it was also normalized by peers around me. This was the nineties, and everyone was on Atkins or trying to get six pack abs. Taped to my bedroom mirror, I had cut out pictures from magazines of women with these kind of ideal bodies that I thought I had to use for motivation or inspiration. But it wasn't just me. All my friends had the same thing. So I really never thought of it as disordered at all. I thought it was just what people did.
Christy Harrison: Yeah. That quote, unquote, normative discontent that is so common in our society and yet really does qualify as disordered eating. I think about those inspo pictures or whatever, and that is something that comes up so often in people with eating disorders, all kinds of disordered eating, really. It's so normalized that it's hard to question it when you're in it.
Alexis Conason: Yeah, exactly. I mean, I think in retrospect, obviously, I was not in a healthy place around food or how I was feeling about my body. And I think that it was that, like you said, that discontent that the role that food and body played in my life that really led me into this career. So I can see in hindsight, it was certainly not healthy, but it was so normalized. And also, this was a time that there was no conversation at all, at least in the mainstream spaces. And we didn't have social media. So the way that we got information was through magazines, television shows, movies, kind of the mainstream media. There was no conversation about body positivity, weight inclusivity, body acceptance. It was just kind of being bombarded with all directions about all of these really fad diet kind of stuff was just completely pervasive.
Christy Harrison: Yeah, completely. I'm curious about your decision to go into psychology. Do you feel like it was always tied up with this desire to help people with weight loss and weight management, or was there other aspects of psychology that were interesting to you? And then it kind of morphed from there?
Alexis Conason: For sure, there was other areas. When I first wanted to go into psychology, it was not necessarily focused on food or eating. It was really this yearning to better understand people. And I think at the core of that, probably to better understand myself as well. I just have always been fascinated with why people do certain things and kind of what goes on in the inner workings of other people's minds. And I think that probably comes from being a child who was, in many ways, an introvert, and I still am, and who maybe doesn't naturally really kind of get that always about other people.
And it just has always been fascinating to me, and I feel really privileged to be able to do this work and to share with clients on their journey and for people to share with me kind of the inner workings of what's going on. So I would say that wanting to bear witness and accompany people through these difficult moments is really what drew me to psychology. And then it was in graduate school that I started to focus more, or even going into graduate school when I knew that not only did I want to study psychology, but I wanted to have my career be focused on psychology, that I started really thinking about food and body issues at that time, again, framed very much in this weight management context.
Christy Harrison: Yeah. And so your first career in psychology, or your first sort of research position at least, was in, quote unquote, obesity research. Can you talk a little bit about how you came to do that work and what that was like?
Alexis Conason: Yeah. So in graduate school, like I said, I went in really being very interested around people's relationship with food. I was seeing it through the only framework that I knew how to see that through, which was this lens of kind of overeating and weight management. But having struggled so much around my own relationship with food, having that be such a big part of my family life at home as well. It was something that I was so yearning to better understand.
And in graduate school, I started working in research lab that I was looking at obesity research specifically around bariatric surgery. That's what I was really interested in to understand for people who, of course, at the time, I assumed that everyone who had bariatric surgery must be struggling with their relationship with food in some way, because, of course, how else would you be in a bigger body? That was my understanding from this very diet culture, fat phobic lens.
But I got really interested in kind of understanding psychologically what happens to people as they undergo bariatric surgery. That's what my dissertation was about. Looking at substance use in people who undergo bariatric surgery was actually one of the first studies to find an increased risk of alcohol use in people following gastric bypass surgery. And from there, I really was primed to enter this career in obesity research and weight management. So in my postdoctoral work, I worked in a bariatric surgery center and also continued working in obesity research, and I did that for many years.
Christy Harrison: I'm curious to talk a little bit about that bariatric surgery research. What do you think that increased risk of alcohol use, which we now see replicated in multiple studies, what do you think that's about for people who've had bariatric surgery?
Alexis Conason: It's interesting. When you look at it, a lot of the research really points to that it's specific to certain types of bariatric surgery. And there is some thought that there are changes in the wiring of the reward mechanisms in your brain after you have bariatric surgery that can make you more primed to develop issues around substance use. Multiple studies have replicated the risk of alcohol use after bariatric surgery, but also they're starting to see issues with opiate abuse and I think some other drug abuse as well.
Interestingly, also, the way that, because bariatric surgery, especially gastric bypass surgery, alters the functioning and the mechanisms of your digestive system, it changes the way that you absorb food and alcohol and other drugs as well, and can actually speed up the absorption. So there is some thought that has to do with the alcohol is being absorbed very quickly into your bloodstream, making you feel more intoxicated with less alcohol, more quickly. And your brain is also primed for that to be more rewarding, which can be a little bit of a recipe for disaster.
Christy Harrison: Yeah, for sure. And that idea that things are absorbed more quickly is common to a lot of the side effects of bariatric surgery. As I understand it, like the dumping syndrome being that things are absorbed really quickly into the gut and you kind of can't handle all of that carbohydrate or whatever it is being absorbed at once. And so diarrhea as the result seems like multiple things that result from that sort of quick absorption in bariatric surgery.
Alexis Conason: Yes, as well as a lot of the vitamin deficiencies and malnutrition issues that we see in people after surgery.
Christy Harrison: What are some of the other mental health effects of bariatric surgery that you found?
Alexis Conason: About five to seven years out after surgery is where we start seeing a lot of the negative psychological complications following surgery. And one of those risks that we do see is an increased risk of suicide.
Christy Harrison: That's really important to know. And I think bariatric surgery is one of those things that's presented in a way that sort of minimizes the risk. And I see that a lot across the diet and pharmaceutical weight loss industry. It's like the actual risks of interventions are maybe downplayed or not presented at all in some cases. Or if they are presented, it's sort of like but the, quote unquote, risk outweighs the benefit. And the risks of staying a higher weight are worth taking on all these potential risks of physical and mental health complications.
And I think it's so insidious because it's not really a fair comparison, I think, in that weight stigma is associated with and is a risk factor for all of these conditions that get blamed on weight itself and may perhaps explain, along with weight cycling and disordered eating and other issues that higher weight people are more likely to face may explain a lot of that difference in risk for chronic health conditions and mortality in people who are higher weight.
But it sort of gets painted, of course, in diet culture, as causation, as like, higher weight causes all these things, and therefore you're at risk staying higher weight. And it's worth taking on all these sometimes pretty extreme risks, even if they're relatively unlikely to happen. But things like an increased risk of suicide or an increased risk of alcohol use disorders or other substance use disorders, it's not something that many people would take lightly, I think, if they really thought about the risk benefit analysis.
Alexis Conason: Exactly. And I think that we're seeing a similar conversation coming up around GLP-1 medications. And I think that it's this idea that weight loss at any cost. That the most important thing is to lose weight, and that's always going to improve your health, even if there are really serious health risks and complications to taking these medications or having surgery. And people may not be in poor health to begin with. The assumption that everyone who's in a larger body must obviously be on death's doorstep is we. We know that so clearly from research is not accurate. So I think that's definitely something that we're seeing.
And I know certainly with bariatric surgery, I agree, there's a huge minimization of the risk of surgery. And I think even when we look at, for example, the risk of death, this is an area that I've been interested in and really want to dive in on the research, but I haven't had the time to do it. But the standard for something being classified as a death related to bariatric surgery, of mortality as a complication for bariatric surgery, is only recorded, I believe, if it happens in the first 30 days after surgery. And the responsibility is on the surgeons to record that and report it. And they report it to the Bariatric Surgery Association. So the Bariatric Surgery association is the holder of all of that mortality risk of surgery.
And most people don't die on the table when they're having bariatric surgery. They have complications. They kind of go in and out of the hospital for some time. And if they sadly do die, it's typically not within the first 30 days. But very much is related to the fact that they had bariatric surgery and none of that is captured.
Christy Harrison: Wow. Yeah. That is really insidious and shows so much of the profit motive at play and how that can make otherwise ethical providers perhaps not report the things that need to be reported.
Alexis Conason: Yes. Yes. I mean, I think that we need independent oversight with all of these things.
Christy Harrison: Right. And I'm so curious how that would play out. I'm also curious to hear about your experience working in, quote unquote, obesity research and that whole field. And there's a connection for sure to be made to the conversation that's happening now about GLP-1s and the medicalization of higher body weight and all of that. So I'd love to go back in time to when you started working in that field and as you got further into that research too, what you came to understand about both the research underlying weight loss recommendations and how industry played a role in creating and disseminating information about weight loss.
Alexis Conason: Yeah. So that was one of the things that was really eye opening to me as I spent time in the, quote unquote, obesity research and the obesity industry was that intermingling of money from companies that have very clear motives to be incentivizing weight loss, and kind of the medical recommendations that were passed down to doctors and the research that was being carried out. So one example that I'll share, well, two examples that I'm thinking of, but one was an organization, a non-profit organization, that appeared to be fighting against weight stigma. But when you look into it, it was very clearly funded by the Bariatric Surgery Association, as well as kind of an obesity organization.
And it was, the whole idea was to create this group that seemed like a patient advocacy group, but was actually advocating for the alleviation of weight stigma, so that patients would feel comfortable going to their doctor, so that they could be recommended weight loss and bariatric surgery, and not feel stigmatized about engaging in those surgeries. And they framed insurance companies not covering those surgeries as, quote unquote, weight stigma, and spent a lot of money lobbying Washington to get insurance coverage for bariatric surgery. But this was all done under the guise, if you looked at this organization on face value, you would not know that it was connected to the Bariatric Surgery Association. So that was one place that I saw it.
And then another thing that comes to mind is just, I was involved in that world when, I think it was in 2013, when the American Medical Association decided to classify obesity as a disease. And as many of us in the kind of anti-diet world know, that was a controversial decision made by the AMA. They had put together an independent advisory council, to research the topic and come up with recommendations. Their recommendation was actually not to classify obesity as a disease. And what was at the time, a very rare decision.
The AMA went against the advice of the advisory council and decided to classify it as a disease anyway. And it was interesting timing, because it was the first time that there were two new weight loss medications that were being FDA approved, coming into the pipeline, entering the market. And the decision to have obesity classified as a disease meant that these medications would now be eligible for insurance reimbursement, so they would be far more profitable. So I don't think the timing of that was coincidental.
And I will always remember being at one of these obesity conferences and having the president or someone kind of in administration for the organization get up on stage and very openly said, everyone was kind of celebrating this decision from the AMA to classify obesity as a disease, and they got up and said we want to thank our friends at the Endocrinology Association because for obvious reasons, we couldn't be behind the lobbying efforts to get obesity classified as a disease to the AMA. So we had our friends at the Endocrinology Association lobby on our behalf because the financial interest was less obvious coming through the Endocrinology Association, then coming through the Bariatric Surgery Association.
Christy Harrison: That is so nefarious. And so it just really shows how much intent goes into these decisions, how much wheeling and dealing goes on behind the scenes to try to get these things done and push through, and it's incredibly unethical, and yet there's no oversight to that. And especially when they can kind of pass it off to their friends in endocrinology, where it doesn't necessarily look like as much of a conflict of interest. Even though there is rampant weight stigma and pharmaceutical industry money going into endocrinologists pockets to push for these, quote unquote, treatments, surgery and medication, diet, drugs and all that stuff, it just seems like there's no real oversight of those kinds of decisions.
Alexis Conason: Yeah, I think there's no oversight, and it's all very normalized and accepted within the industry. Again, that comment that I heard was not made at some high-level, small group, closed door meeting. It was to the general conference at the president's address.
Christy Harrison: Yeah. So it's not like they're trying to hide it. It's not secret. I've noticed that in some of the conversations around these new weight loss drugs as well, where, in the Oprah special, which aired recently at the time we're talking, she has two people on who are paid consultants to Novo Nordisk, which makes Ozempic and Wegovy and other GLP-1 weight loss drugs. And these paid consultants are going on about the benefits of these drugs and why obesity is a disease and all this stuff.
And then there's one little moment where she's like, "You're both paid consultants to Novo Nordisk. Why is that?" Or something. Or "what does that mean?" I think she says, "What does that mean?" And one of them says, it means that they see my expert opinion as valuable or something, just ridiculous. And then the other one says, it means that I've gotten consulting money from them to do continuing education talks, and I've also taken money from them to do some research on upcoming obesity medications or something, and then Oprah's like, "Okay, cool. When we come back, we're going to talk to someone else about something totally different." That's it.
When I see any of these disclosures happening in newspapers or other media outlets, there is often very rarely I think, as compared to the volume of coverage about these drugs. But there is occasionally a nod to this person is a paid consultant to Novo Nordisk or to Eli Lilly or to someone else who makes weight loss drugs, as is common practice in the field among obesity experts. And that's considered sort of all they have to say, and then they move on and there's no real effort to dig into why is that so normalized in the field? Why is it considered, okay, why is it not a massive conflict of interest, which I think it is, and I think you probably agree. Many people listening to this will probably agree.
Why is that sort of conflict not discussed more and sort of shown a light on in popular press? And why is there no real investigative journalism going on in this country? There is some in the UK. The Guardian and Observer did a series on pharmaceutical industry influence around the adoption of those drug to the UK formulary. And I think that was really interesting. But here, there's just not a real effort to do investigative reporting. Even when I've talked to journalists and sort of pointed them in that direction, it doesn't seem like anybody really wants to follow that up.
Alexis Conason: I agree. I think that it's too normalized. And I think that even the fact that some of these specials, the Oprah one, which I haven't watched yet, but there was also a similar one, I think, last year by 60 Minutes, where all the medical experts were paid consultants for Novo Nordisk. And why aren't we finding independent experts instead of the people that the drug companies are saying, here, talk to this person. This person obviously has a specific agenda to promote. And it just kind of blows my mind that why aren't we finding people that don't have a conflict of interest? There's many, many doctors out there.
Christy Harrison: And why is it so normalized in the field that these people can have a talking point of like, oh, that's just how it's done in our field. And it's pretty true, too. If you find anyone who's a significant, quote unquote, expert in obesity, they're likely going to be on some consulting panel somewhere or have done continuing education work for a pharmaceutical company. And sometimes it's also Weight Watchers International or Jenny Craig or whatever, some sort of financial tie in their history. And I just think it's really important to dig into why that's happening, and nobody seems to be in that industry. Do you have a sense of why when you were in that field, what was sort of the discourse around industry relationships that you heard?
Alexis Conason: I think that by and large, it was very normalized. There were certainly researchers and people that I worked with who were opposed to taking any kind of industry money. But to be frank, I think it's very appealing because being a researcher is not an easy way to make a living. And I think a lot of people need the money, to be frank, is what the motivation is. And I think it gets into all kinds of issues around the value that we put as a society on medical research. The average person doing medical research, putting aside people who are discovering a new pharmaceutical or a new device or something where you can make a lot of money, you're reliant on grant money. There's an instability in some of that profession. And I think a lot of people do feel, just from a capitalistic perspective, that if they can have a stable position working with pharmaceuticals or industry and get a kind of fat paycheck from them, it's appealing.
Christy Harrison: I mean, I get that as a dietitian in private practice and an author and journalist, like independently, freelance sometimes for some publications. And I have my own stuff. It's a tough way to make a living, and it's kind of up and down and it's not super stable. And when you have a family, that's not great. And I can totally see why people do that. And I sometimes wish I didn't have, I feel like I've painted myself into a corner in a way of being so critical of industry relationships for everyone else that I'm like, well, I can't do that now. But part of me wishes I could. Part of me wishes I had that option because it would be nice to have more money.
Alexis Conason: Yeah. So I think that's a lot of the motivation for people. I don't think the average doctor or researcher is nefarious in trying to carry out some diabolical plot. I think most people are just day to day trying to get by.
Christy Harrison: Yeah. And it sort of is a systemic issue, actually. This lack of stability in capitalism in general for most workers, and with researchers specifically being so dependent on grant money, I can see why that's, it's appealing to have something that's a little bit more of a stable source of income.
Alexis Conason: I'm also really taken a lot of the time by how hidden the disclosures are. I'm just thinking as we're talking about an article I read recently that was talking about that weight management programs do not increase the risk of eating disorders and actually can help treat eating disorders. And I'm like, wow, what an interesting article that really goes against everything that's common knowledge in the field of eating disorders.
And I was reading through the article, it's maybe a ten or twelve page article, and it wasn't until I read through the entire article that I get to a little sentence at the end that I only saw because I was looking to copy the citation for something because it was like hidden in the addendum. That said, this researcher is a consultant for Novo Nordisk, and this other researcher is a consultant for Weight Watchers and this other person for Slimming World. I mean, I think that there has to be a way for people to be aware because that obviously would impact the way that I was reading the article in the first place. And to not even have that knowledge until afterwards is kind of problematic.
Christy Harrison: Yeah. You were not reading it with a sort of critical eye or the distance that you might have been with that knowledge ahead of time. For someone to go through the entire article and get to that tiny disclosure at the bottom takes, A, access to the full article, which I think journalists and other people who cover nutrition and health and weight and all that stuff don't have access to or don't have time to read the whole article and maybe don't have the knowledge and the training.
I've talked about this a lot on both podcasts about how going into my career as a journalist, I was coming out of an undergraduate degree in rhetoric and French literature. I did not have the training on how to read a scientific study. I sort of learned on the job, but I didn't get a complete understanding of how to do that until I went to graduate school. And mostly I was reporting based on a press release and abstract and then some conversations with an expert. A, quote unquote, expert who was the researcher, one of the researchers affiliated with the study, or maybe another researcher who was not affiliated with the study to give a counterpoint or whatever it was. And I think that's what a lot of journalists and reporters do. They're not looking in depth and combing through the disclosures and the fine print to see what sort of influence is there and how that might affect how their source is reporting and what sort of other sources they might want to get to have a balanced perspective or some critical input.
So what gets disseminated in the media, whether it's about eating disorders and weight management, or about these new diet drugs, or about weight loss and nutrition and health in general, I think is so skewed and so biased, and it's really tricky. And it's tough to have these conversations because I'm aware from my reporting for my second book, The Wellness Trap, that there's a whole anti-vaccine industry, and to a certain extent, the wellness industry more generally, that relies on this narrative about the corrupt pharmaceutical industry and the corrupt conventional medical industry, and how you can't trust doctors and they're just out to get you for profit, and they don't care about the public health. And so come over here to the anti-vax movement, or come over here to the wellness industry where we care about you and we'll help you and we'll do everything, quote unquote, naturally and trust us. And then they're selling you snake oil.
I think it's important to have nuance in these conversations and sort of not let yourself get conspiratorial in your thinking about the entire healthcare system and the entire pharmaceutical industry, even though there are these pockets of real problems and real ways that the bias influences the research and the reporting on the research that is very skewed towards the interests of industry.
Alexis Conason: I couldn't agree more. I think it can be a slippery slope and it can be hard to understand what to believe. But I think that in research, we look for replicability. So when we start to see results over and over again, it starts to speak to something. And I think that it's important to be critical when we're looking at research. It's important to be critical when you are interfacing with doctors or understanding medical guidelines or recommendations that healthcare professionals might make.
And it's also important not to throw away the entire paradigm and to understand I think that most doctors are truly in it to try to help people. They're doing this because they care. And I think that when we can kind of try to purse out, this is one of the reasons that I think it's so important that disclosures be made more prominent and that we're able to understand how industry influences recommendations and research, because otherwise it does create kind of a more widespread mistrust. When I think it is kind of these pockets that we have to be cautious about.
Christy Harrison: I know, I wish there was more science education in schools, from teaching people from a young age how to understand, influence, and look for signs of something maybe you don't necessarily have to throw away the results entirely, but you could see it as this is an outlier that may be influenced by this special interest that is behind the financing of it, or the authors that are writing this research or whatever.
Alexis Conason: Exactly. And I think so many of us are getting lots of our health information from social media, which is somewhere where all nuance is lost. So we're kind of only taking in the most extreme perspectives.
Christy Harrison: Totally, yeah. And that's what the incentives of the algorithms do, is it actually incentivizes extreme perspectives and things that provoke moral outrage and misinformation. And all of that does well from the algorithms perspective of keeping people engaged and keeping people on the platforms getting served more ads. So it doesn't behoove the social media companies necessarily to change those algorithms in favor of helping us have more nuanced conversations. And the kinds of things that really sell are the controversial takes, unfortunately.
Alexis Conason: Exactly. I think that we see the most extreme viewpoints and they're presented to us as if everyone feels this way. And I think it can be really hard to digest and to understand that the truth is probably somewhere in the middle.
Christy Harrison: I will say, as someone who wrote a book called Anti-Diet and who's part of an anti-diet movement and was for a while earlier in my career, very strident about these sorts of things, I do feel like I was pushed in a more nuance free kind of direction by the instruction incentives of social media. And I started to write in ways that just stripped out some of the qualifying language and the uncertainty of it all. And writing from a place of sort of black and white certainty sometimes. And that's not really who I am. And I think I got pushed there by the pressures of social media and this sort of media environment more generally.
And now I'm trying to think through how to continue to have anti-diet values in the sense that I don't promote diet culture, want to help people think critically about diet and wellness culture, and not succumb to all these false promises and the harms that can be associated with that. And I also want to speak with more nuance and think in a less black and white sort of way about all of these things. I'm curious if you have any thoughts on that coming from a similar place. I mean, we'll talk in a minute about how you got to the anti-diet perspective in the first place. But just since we're on this topic of social media nuance, I'm curious if you've had any sort of thinking around this issue.
Alexis Conason: Yeah, I'll just say same.
