Empowerment, Advocacy & Media Training

My name is Ximena and I’m the Managing Director of the Canadian Obesity Network in Edmonton, Alberta. And the reason why I’m here is because Dr. Sharma and I have been working with the Canadian Obesity Network’s Patient Engagement Committee to try to integrate the science of obesity into our advocacy efforts in Canada. So what we want to make sure is that patients feel that they have the scientific knowledge and understanding of obesity plus their own lived experience of living with obesity when they go out and do advocacy, whether it is with a politician, whether it’s they’re talking to the media, or they’re talking to somebody who wants to know more about obesity in general.

Like it could be your doctor, it could be anybody. But basically what we found at the Canadian Obesity Network was that when patients learn more about what obesity is and what obesity isn’t, they feel better prepared to talk about the key messages that they’ve developed for themselves. So what we did in Canada was that we had a two-day training workshop.

And the first day it was all about learning about obesity and Dr. Sharma did some training with patients talking about all the studies we have about obesity and the misconceptions about obesity and the bias and all of that. And then we had advocates from other communities from HIV, AIDS, and mental illness who came in and taught us about what they had done to advocate for change in those areas. And then the second part was the second day was where we did media training.

So Dr. Sharma and our Director of Communications then talked to the committee about how do you talk to the media and how you convey those key messages. But before we got to that point, the committee worked for about a day to develop their own key messages. As a committee, what are patients living with obesity advocating for in Canada? And so we have about five key messages and then the media training involved the incorporation of those key messages into the role-playing that Dr. Sharma did with them during the training.

So today we wanted to do a mini version of this. We have one hour and basically Dr. Sharma will speak briefly about obesity and I know you all have your own lived experience with obesity, but he will speak more from a clinical and scientific perspective and then he will introduce a role-playing exercise. How does that sound? Great.

Yes? Excellent. So Dr. Sharma. Okay, all right.

So I’m not the expert in obesity. You guys are the experts in obesity, right? Because you have personal experience. I don’t have that experience.

But what I do know, because I’ve been working in the field for a while, is that there are a few things that we want the public to understand. So whenever you talk to the media, you’re talking to an audience, right? And so the first thing you want to know is who’s the reporter writing for? Who’s the audience? Are you going to talk to a television audience that is very general and it’s the evening news and there’s a small news item, so a lot of people are going to be seeing this? Or are you talking to a more specialized audience? Is it a women’s magazine, so only women are going to be reading? Is it maybe a fitness magazine, so that’s only going to be read by people who already have an interest in fitness? So you have to always kind of know who’s the person writing for. That does not change the message.

That has been my experience. My experience has been that whether I’m speaking to my professional colleagues or whether I’m speaking to lay people, the message is always the same. The words I use are different and the language I use are different, but the messages are always the same.

Now I don’t want to give you the key messages because we’ve done key messages. It takes a long time to think about it, but when I speak to reporters, what are the things that I like to convey? The first thing I like to convey is that obesity is much more than simply diet and exercise. Diet and exercise is important, but it’s not for most patients, especially the kind of patients that I see, it’s not diet and exercise that is the main problem.

So we want to move away from the simplistic thinking, oh obesity is all just fast food and lazy people not moving or people who don’t know how to eat healthy, to making people understand that no, this is actually much more complex and every patient has their own story. Whether it’s a mental health problem, whether it’s the social determinants of health, it’s food insecurity, everybody has their own story. We know that genetics is very important and we know that there are many reasons.

So that’s my first thing is to get people to appreciate that obesity is not as simple as just it’s just diet and exercise. We want to move away from that. So that’s kind of the first topic that I always try to talk about.

The second topic that I feel very strongly about is that once you get obesity and it doesn’t really matter why or how you got obesity, it generally becomes a lifelong problem. It’s not a condition we know how to cure. We can manage it, we can treat it, we can maybe even with bariatric surgery lose some weight, maybe keep the weight off, but it’s going to be a lifelong problem.

So it’s really a chronic disease. So what I’m trying to do there is move away from this acute intervention, how do I get fat people to lose weight, to saying no it’s not about losing weight, it’s about managing a chronic disease pretty much forever. So that is my second message if you want.

And my third message is that yes it is a lifelong chronic disease, but we are not doing a good job of managing it. And there are many reasons for that, but overall we are not doing, we don’t have the kind of treatments for obesity that I would love to have when I compare the treatments we have for obesity to say the treatments that I have for someone who has diabetes or the number of treatments I have for someone who has heart disease or someone who has you name any other chronic disease. We usually have more effective treatments, better treatments, safer treatments, and more accessible treatments than we have for obesity.

So if I break this down for me and I say okay these are what do I want people to understand. The first one obesity is complex, multifactorial, it’s not a question of shame and blame and whose fault this is. The second one is when you get obesity for whatever reason it generally becomes a lifelong problem and it becomes a chronic disease and so we have to think about obesity as a chronic disease.

And my third point is we need better treatments and better ways to manage obesity because what we do right now for obesity is not working, not enough, not good enough. Okay those are my three messages. Now I can go on and I can have four and five and six and seven messages of course but what I’ve learned from media training is you want to keep things very simple and usually when you do an interview if you can just get one of these messages across I consider that already to be a very successful interview.

That’s my perspective. In the many years that I’ve been doing, does anybody work with the media here? Media people? Has anybody had formal media training? Okay so you guys know what I’m talking about. The first thing you learn in media training is never answer the questions.

Okay forget about the question. It does not matter what the question is, you have to know the answer that you’re going to get and that takes training right. So when I go into an interview I don’t care what the question is, I don’t care what they want to know but I go into an interview with what I want them to know and there are teachable and learnable skills that you can use and that’s what we’ll do in the workshop.

We’ll do that in a minute. Okay so you have to know what you want to say and then you go into the interview. Don’t go into an interview saying you know I don’t know what the interview is going to be, we’ll see what questions he asks.

Okay it doesn’t matter, don’t worry about the questions and don’t waste time answering the questions right. Do not waste time answering the questions. Give them what you want them to know okay.

That’s the first thing that I would say to anybody going into any media interview is ignore the question okay. You can and you kind of know this, it is irritating because who are the people who do the greatest job of ignoring the question? Politicians. Politicians, why do they do that? Because they all have media training.

They all have media training. They ignore the audience anyway. Huh? They ignore the audience.

Ignore the audience, ignore the reporter, you say what you have to say. Yeah. Okay that’s the first thing.

The second one is and I know a lot of people are very shy about this. You have to control the agenda and the best way to control the agenda is live. So when you have the opportunity and here I’m talking largely about public media so we’re talking about radio and television here.

When you have the opportunity to go live on television, live on radio, always go live. A lot of people don’t want to go live. They say oh no let’s free record it because then we can edit it and then if I say something wrong then I can say it again and we can or I can prepare for it or so my time.

The problem with that is you don’t have control. The only time you have control over what actually gets broadcast is when you’re live on television. Otherwise they’ll record your statement and you don’t know which, how many of you have actually done media interviews have been taped? Yeah they spent 30 minutes of recording and then it’s seven seconds on television right.

You don’t know what seven seconds they’re going to take and they usually take the seven seconds that are the least important or not the ones that I wanted. Okay so by going live I have control but if he likes it or not he’s going to have to listen to what I have to say and they can’t cut it out because it’s live. Okay so always go for a live interview if you have the possibility of doing live right.

Always better than pre-recording but in many situations pre-recording is what happens. In most pre-recordings you have to know that they will probably be editing it. So when you have a pre-recorded interview and because you don’t know what they’re going to use from that interview you have to not give them choices which means if I have one message that I want to get across the interview pre-recording can be 20 minutes but I will spend over 20 minutes I will see exactly the same message over and over and over and over again so that the only thing that they can actually ever use is going to be that message.

So it doesn’t matter which minute out of the 20 minutes they take they will always get the same message. That’s a bit harder to do but it can also be done without making it sound too stupid and again we can practice that right. So that is the trick around media interviewing is basically they are a very important channel right because they’re multipliers but it only works if you are using them rather than they using you and so what I want to do for this exercise now is we don’t have a lot of time but we can do it for a few people is I want you to spend maybe two minutes and actually take out a pen and paper and write down for yourself what is your most important message around obesity that you would like the general so if you had the possibility of standing up on the street tomorrow and there’s 100 people standing around you and you could say one thing to them about obesity what is that one thing that you think is going to change their perspective or get them to better understand obesity or something that you would like them to know just one sentence it can be a long sentence but just one sentence okay so I want you to do that right now.

Now don’t tell it to me write it down. I don’t want to know what it is just write it down and prepare for that and I’ll give you three minutes to do it. Can I ask you a quickie for dinner? So here’s what we’re going to do so Vicky and a lot of you probably don’t know this so Vicky is a reporter and she works for this lifestyle magazine where it’s all about healthy active living and fitness and you know following the latest diet trend and doing all the things and she works for that magazine and she wants to interview me because she has heard that I am you know one of the important people in this field and wants to ask me about what is the importance of fitness and lifestyle and what is the best way to lose weight and what’s the best diet that people should be on etc those are the those are the questions that you have for me because that’s that’s what you want to talk about uh and she has agreed to meet me and talk to me about these issues okay all right so Vicky you’re going to do the interview okay so Ari you are so very welcome it’s a pleasure to have you here today and I see in your latest issue that you have spoken an awful lot about your work that you didn’t do so much in Europe can you tell me more about that so my work is basically dealing with patients who have what you would consider severe obesity that’s my clinical work and I’ve been doing this for the last 20 years or so and I can tell you that when we think when we see patients with obesity we don’t have simple solutions that’s that’s what I’ve learned and it turns out that obesity you know is not only a chronic disease it’s also a chronic disease that is very very difficult and was this on your agenda in Europe this is what you went to speak about well I went to Europe talking exactly about the issue that obesity irrespective of how you get in there are many different reasons why people can put on weight the problem is once you’re put on the weight it generally becomes a lifelong problem and unfortunately we don’t have great solutions for helping patients manage their obesity I see that Slimming World and Hair for Life are one of your sponsors your main sponsors and and how do you feel about that so I feel very ambivalent because I think that patients who have lived with obesity for a long time recognize that it’s a that there’s no easy solution they should take care of life no and they’re desperate right and so they are trying to try whatever is out there and unfortunately in obesity because we don’t have very effective treatments and because patients are very desperate uh there is this huge industry that is trying to sell solutions uh you know whether there are shakes or powders or a new fat diet unfortunately what we have learned is that when you once you have obesity it really becomes a lifelong problem and these quick fixes and fat diets and things that cost a lot of money they don’t really work in the long run very much but you take their money as a sponsor see I take their money really to get the message out that what we need for obesity management is going to be more than what most people think but most people think you can fix obesity by losing the weight or by you know taking a supplement or going into some kind of exercise program unfortunately it’s going for most patients that is not enough and we really have to get serious about taking obesity as a chronic disease and we desperately need better treatment on a personal note I see that your marriage has recently broke up and you are now with the latest model and from the swimwear collection and can you tell me a bit about that because fitness is a big part of our lifestyle yeah yeah so so my wife left me because I was too skinny for her okay all right so you get you all right you get the idea right uh so I she has an agenda oh yeah which I was not interested in uh I always came back to my messages my message the chronic disease we need better treatments we need better solutions it’s complex right I so I stayed on message yeah I can tell you it’s very hard to do and when you have someone as skilled as Vicky trying to get you to say something and that’s actually what they do and they don’t and the reporters don’t do it because they’re trying to get you to do something it’s not that they have an agenda they’re you know those very often these are honest questions that they have because reporters very often like everybody else have the same ideas about obesity it’s self-inflicted it’s you just have to lose the weight you’re not motivated enough you’re not following the right diet and so so these are innocent questions but that doesn’t matter but you’re controlling the agenda okay so yeah so so why don’t we do a why don’t we do a couple of examples here and then we’ll you know and then we’ll talk it so I need a volunteer somebody who’s written down a message who wants to talk about it okay don’t tell me don’t tell me your message come right up here don’t tell me what your message is okay uh hopefully we’ll find out sit down okay Sven all right and I’m a I’m just going to play the reporter okay you guys um so so Sven thanks for having an interview so I have a question about and this is not a personal question but you know I look at you how important is healthy eating for for for preventing obesity it’s as important for obesity as it is for any other disease and life in general uh it’s not more important or less important but but isn’t it that that you know people who have a weight issue that they’re not eating healthy and if they eat better they will probably not have the problem see if if there was an element of choice in becoming obese there’s no element of choice in being obese you cannot choose to no longer be obese once you are obese the chronic disease is with you yeah but wouldn’t eating healthier you know help you lose weight and be healthier that’s for everybody else it’s as valid for obese people as it is for anyone else okay so you’re saying that that so what are you saying I’m saying healthy eating is a good idea okay but it’s not a solution for obese people okay because there is no solution to obesity there is no choice and I’m choosing to eat healthy so I can no longer be obese so so so so what is your solution there’s no solution my solution is to manage the chronic disease and to live healthy with it just as everybody else should okay so if you’re saying that diet is uh not so important is what I’m hearing that’s not what I’m saying I’m saying it’s important for everybody okay as for these people okay what about what about activity physical activity I mean can’t you exercise to lose the weight you can exercise to lose weight but you cannot exercise to lose the weight and you cannot exercise to become not obese okay so exercise doesn’t doesn’t exercise burn calories and help people lose weight yes and I could explain to you the biology and biochemistry of obesity okay but the fact is that once you are obese your body is different from normal people and exercise will not fix you you should exercise if you can you should exercise if you’re healthy enough to do it and you should pick the exercises that won’t ruin your joints or your legs okay all pause what was he trying to say what was his message don’t don’t tell us the message it’s obesity is not a choice does anybody hear anything else or it’s a chronic he did say chronic illness yes well while you should live as healthy as you can that won’t fix your obesity okay there’s no fear for obesity okay that was that was implied there yeah tell us your message so no matter if someone had a choice in becoming obese yeah there’s no choice about living with obesity as a chronic and you said that yes how did you how difficult was it to stay on stay on track not at all not at all but you knew what you were going to say and you and you he did a pretty good job of staying on message yeah but i’ll although he did somewhat answer my questions but uh i’d like i’d try to be polite well don’t worry about being polite don’t worry about staying on message be rude nice job who else wants to volunteer oh i guess i can yeah and again don’t tell us your message okay don’t tell us what you want to have but but have a clear message that you want to talk about okay so christina so we you know i want to talk to you about this whole obesity problem and i and i was i was just reading that there are that there are chemicals in the environment that can cause obesity and that maybe the obesity epidemic is because of all these chemicals that are out there and you as someone who has been living with obesity what do you what do you feel about that message what do you feel about those those findings well it’s interesting how people are trying to find out to come up with findings that are totally irrelevant but they sell papers so you so you don’t think that there are chemicals in the environment that can promote weight gain well there are chemicals in the environment that can promote just about anything and everything if you want them to so so what do you think is the is it is causing obesity i mean why are we seeing so many more people who have obesity today than before it’s more a question of how the whole society are dealing with food and how do we relate to to it okay so for you obesity you would say is the food is more important than the than the chemicals the general living is more important and that includes the chemical things but that affects everybody okay so so you think it’s food is so so so people gain weight because they eat too much is that is that the message or no i think the food is because everybody eats too much today okay it’s food is too accessible and it’s so much lifted up that’s important thing to have you relate to people okay so we could fix the obesity problem by by what teaching people to eat healthy or what what what what is the solution i think it actually is the uh trying to get to the self-confidence of the person to live in the place where they are at the time so people with obesity they have low self-confidence and if i make them more confident they eat better or what’s the relationship the relationship is very much that people are stigmatized they are held back the whole time they’re not allowed to be a good person as is because they’re always confronted with it’s a bad thing to be obese but could they not make better food choices and solve the problem but that’s not the important thing so so what do you think is important to gain self-confidence as a person uh and that doesn’t mean the result should be losing weight it should be that you are a worthy person who can live in the society in a good way okay cut what’s her message was there a clear message yeah yeah no yeah yes yeah oh who thinks who thinks there was a clear message at the end okay so what was her what was her her theme or her message stigma what are you going to take away from this that each person is working on each person is working you don’t have to be slim to do okay what were the words that we heard we heard this self-confidence we heard about stigma what else did we hear about live a good life quality of life quality of life we heard about that yes what were any any other messages that you that you heard out of christina tell us your message self-confidence self-confidence in what sense uh i have a good illustration i was working with people who were blind kids okay and we trained them one of the things that we did was train them to learn to drive a car double commando so that they wouldn’t go in okay and the reason for doing that was to get them to have self-confidence they knew something about what the rest of the world was doing so they had that insurance you know well i know how to drive a car and that’s part of what a person to feel better so the self-confidence the importance of self-confidence that came out she was trying to answer your question a little bit about the food he got you to talk about the food yeah and the uh his initial question was about the environment yeah but you didn’t answer that which is good i mean which is good you avoided the answer yes it’s good okay all right thank you let’s take someone else who wants to answer i can try it yeah come here need to remember what i wrote down yeah read what you wrote down and and why you stick on message okay my clear message yeah don’t tell us you might have to tell us later why you think that’s an important message but okay all right orly yeah how you doing doing good okay so i was thinking i was hearing about uh about stomach stapling that stomach stapling can cure obesity as someone living with obesity how do you feel about that i mean you know going to a surgeon and having your stomach stapled so you cannot eat anymore do you think that that is you know that should be a treatment i can’t say what i think should be a treatment because that’s up to the person to decide because the person living with obesity it should be the person’s choice and i know there’s a lot of alternatives that’s a percentage and yeah that’s one of them okay so uh do you think that there’s a danger of of you know getting people’s having bariatric surgery and i hear also they have a lot of problems after bariatric surgery so so so uh you know i know there are many doctors and surgeons who are lobbying for more surgery i mean you think that is the solution or i know there’s like a lot of like risk with it but i think that’s the information and the risk should be accessible for the patient so they can make the decision if they want to do surgery or not but isn’t surgery ultimately isn’t surgery just taking the easy way out right i mean you’re getting a stomach staple so you can i think i still still come down to the person i mean that’s the person’s decision uh it’s that the person living with obesity it should be the person’s call and i think that i mean the information about all the risk and all the information about the treatment and follow up that that is more important and for the person with obesity yeah to take that call so do you think it is really uh what country are you from sweden sweden so in sweden you have a public health system do you think it is good use of public money in the health care system to pay for you know getting people’s stomach stapled i mean why why why don’t those people going you know maybe we should be putting the money in in health eating on preventing obesity so what is your opinion on that my opinion it still comes back to all the persons i mean if someone wants to do the statement that’s up to them i mean i can’t really be sure the public health care system should my tax dollars pay for stapling common studies but is that a good use of money in the health care system i can’t really answer that i really think that you should like get all the money from the state to focus in one area because i mean all not not all the people are obese and see that that’s the problem so they maybe don’t want to spend the money on that but as if i want to do that and yeah then i pay taxes for it then it would be up to me i mean still still go back to that okay should be enabled thank you very much okay what was what do you have your piece of paper it didn’t go fast what was your message yeah it’s uh treat me like i’m a person not a sickness okay was that what you heard out of his answers no the decision is up to the person that was very that was very clear you managed to mix him up and you got into the money back then then he couldn’t respond and keep into that agenda yeah he did a good job of answering my questions which is a mistake that was my way yeah that’s only when you mentioned the money otherwise it was fantastic he kept the same message yeah he’s kind of stuck to the message right so uh let’s adapt so what did you find challenging no it was more of the yeah just like more like thinking about what everybody else should think because i think this is my really important question and just think like yeah i think that everybody should be treating this and i was thinking like it should be my decision and that’s okay how and you said that you said yeah okay because i because i don’t want to be treated like this okay yeah all right no good job all right uh does anybody else want to try anybody else has a message yeah come on up you have to actually sit in that chair to experience it’s uh okay all right so uh who are you i’m jack okay and you’re from belgium i live in belgium okay all right uh do you have a big obesity problem in belgium um okay okay um okay so uh actually it depends on how you want to uh how you want to define obesity so from our perspective in belgium there are many ways that you can become obese but depending on if you follow the wha definition or dr sharp’s definition as i understand it it’s going to be a difference between is obesity in terms of bmi affecting your life or are you carrying on at which point you may or may not be considered to be but what would you think would think that and i was looking at some statistics just before this conversation and what i’m seeing here is that that the the the obesity rates in belgium have been going on for the last two years so is that all beer beer and french fries or belgian fries or what what is what’s what is driving this actually as i said before there are many different ways how people actually arrive at obesity i think we need to take into consideration not only uh the food environment but we also very much need to take into account um mental uh factors and drivers as well as sometimes uh uh medical other comorbid medical conditions or epidemiology it may be allergies it could be autoimmune it could be anything but there are different pathways to arrive at that physical outcome okay so if you have to change the food environment in belgium to prevent obesity what how should we change the food environment should we be taxing fast food or what was your recommendation to the politicians how can we reduce obesity in belgium well actually i think you hit the nail on the head there because um food environment is something very important however it’s not the full story if i keep on having to emphasize that if someone for instance arrives at obesity because of a mental health uh complication that’s not necessarily the food environment that kick-started it so the food environment i would say is part of the maintenance regime but when you think of how different people arrive at obesity you need to start taking a more holistic look and in fact in the belgian context because of uh um uh health outcomes based healthcare approach that we’re now taking and this has been integrated into the various belgian health system reforms there’s an excellent opportunity to go to different ministries and different uh different uh stakeholders in the policy making world and actually make sure that we’re taking a holistic look so how would you make uh so so how would you address the fast food problem in in that would you would you increase taxes or or do you ban advertising how would you approach that as a solution for obesity i mean how do we how do we get people to stop eating fast food well again it’s not a solution i i don’t know how many times i have to repeat to you so so so you’re saying so you’re saying you’re saying fast food is not part that’s not what i said what i said was it is not the solution so depending on uh i think again you need to take into account a life cycle approach fast food comes into could it be could it have been a trigger as one of the pathways or more to the point once you’re there how do you deal with it how are the various uh influences around you actually supporting your management of a very long-term condition but it’s not necessarily the trigger as to how you got that so i’m not an expert at this but isn’t isn’t isn’t obesity just calories in calories out if you eat too much your weight goes up you know once again um as i say to the beginning of this interview as i say to the beginning um that’s one of the if you like the uh the demonstrable factors in terms of weight gain or not but again some people have autoimmune conditions some people have leptin uh scientifically proven leptin resistance as well i hear that is very rare um actually uh it depends on uh what the co-factors will be and again depending on your other comorbidities then that will affect positively well so we say neutrally or negatively and it’s just one of the other pathways to obesity so what would you be your tip be for belgians how they can eat healthier actually i’m going to take it away from the food and something which i personally do um in order to manage my obesity um is to meditate for 10 minutes every morning and make sure i get in what you have for lunch no not at all it’s actually um it’s a way of being mindful um to be sure that actually i’m focusing on my day and centering myself so that food becomes fuel and actually it’s my mental capacity to be able to control or at least manage um an ongoing uh i would say an ongoing multi-faceted condition but but you would agree that making fast food more expensive would also help no because once if you have gone through that particular pathway to obesity um actually you won’t care will you say to a drug addict for instance if i um if i up as a drug dealer if i up the price um for your daily fix you will still come to me but that has worked with tobacco they’ve increased the price of tobacco of cigarettes and so people are smoking less well actually what they’ve done is not only increase uh the price they have done a whole slew of measures which took a holistic approach targeted different audiences had very clear campaign messaging and in fact acknowledged that there are different pathways to people starting to smoke and continuing to smoke and what the different potential effects on their health and lifestyle and pockets can have so it’s just part of a holistic campaign which is what we should be doing in the case of obesity as well so banning fast food would be a good start right that’s what you say um my message was um there are many routes to obesity both mental physical and epidemic okay did you hear the message i can be a bit of a pain but how did you feel in this situation was it realistic to you or not actually um it was the first time i wasn’t afraid because i’m normally really really afraid of journalists okay why were you not afraid because it was something that i live every day and it wasn’t just something that you know you have to learn for work or whatever and i didn’t feel that i actually felt genuine about it so it was much easier did it help to have a message very much so very much so and and also the briefing that you gave before to not care what they’re going to ask me but just keep going to because before i’d be like but it’s impolite it is very impolite so it was it was it actually and because it also it was in english whereas um so that’s my first language but if i had to do it in another language then it would have been more challenging for sure because i’ve got to do the nuancing in my brain as well at the same time yeah very good one more yes yes so carlos it’s very interesting that you’re here so i’m hearing a lot about uh the obesity problem in portugal and i was reading about uh and i was actually listening to a talk about that it is bacteria in the stomach which is making obesity is that is that the your experience or is that what do you think about that i never heard nothing about bacteria and for me the obesity is uh biological disease is not a comportmental disease this is the main main message that i want to tell you and all the other people because we know that 87 of the people with obesity has a resistance to leptin and and a little part don’t produce leptin and they can solve this problem quickly okay and there are another part of people who produce not enough leptin to life but can solve this problem too but the biggest part has a resistance and they can’t solve yet this problem so why so we need we need increased research about this about leptin about not leptin but about how can you uh control yeah go around this resistance okay okay that is the main problem that you have in obesity in this moment okay so uh so does this eating you know eating a healthier diet is that will that not help eating is only one of the way to control the obesity not not for the treatment what about exercise exercise is the other way to control that’s all we talk about control but when we talk about control we talk about eating exercise surgery uh some medicines that are in the that we have now to to to help us yeah but we talk it’s a very dangerous but but we talk about control only treatment okay you only have in research in this moment and you have three centers uh four centers working in this area is one is portuguese is the bull banking uh science center the other one is hockfeller in new york the university of cambridge and the an australian uh university i don’t remember the name so but but let me ask you so i understand i mean research is very interesting but uh but we have results now but isn’t isn’t obesity ultimately just you know to be honest it’s too much and not moving enough right no because that is the problem that you have with this the disease biological disease if that thing don’t arrives to the brain what what you do if if your the the meter from gasoline of your car is stopping zero and you need to drive what you do you go several times to the gas station even with the with gas in the car and you don’t drive and you don’t drive so much because you don’t know if you have sufficient gas in the in the tank this is the the main reason of obesity if the signal said you that you have the sufficient energy in your body to leave don’t arrive to the brain what brain said okay you need to eat and you and don’t use because you don’t have energy don’t exercise because you don’t have it okay but i’m slightly confused because if i eat too much yes my weight goes up yes that isn’t the best way to lose weight if i stop eating or eat less than my weight goes no so why why no you must control but you are talking about control you you are don’t talk about the the treatment so control so you’re saying is more willpower or willpower people have to have more willpower for eating controlling their food and things no control obesity you can control obesity with several from several ways but my message is not about control obesity because all people talks about control obesity okay my message is we need research to the treatment of obesity it’s different okay but we can start by eating less we can start now my message is this one the obesity is a biological disease and not a comportmental disease all right so and when you were saying control versus treatment are you saying that we need a cure now we say that in this moment we can make a really treatment for some people who don’t produce leptin or produce leptin in not enough quantity right but we need improve the research in all these centers these international centers because what they understand what they they discover is there are out neurons in the sympathetic tissue outside the brain they connect to the you’ve already lost you’ve already lost me like i i agree what they find they find out out neurons in the sympathetic tissue connect to the to the fat cells they can be activate without came to the brain and they can do the same work that if leptin arrives to the brain and control your and the energy you have in your in your body okay good job all right so i’ll put you guys in the hot hot seat which is unfair yeah uh i want to put myself in the hot seat so i’m going to ask uh the lady here the professional to come and interview me about uh obesity whatever it is that you want to talk about you can just come over and i’m the i’m not my first language so english is not my first language it’s quite challenging for me now well that’s okay so so you’re the you’re the journalist you’re i’m the obesity expert uh i work in a very limited field of obesity uh but that doesn’t matter so ask me ask me some of your questions yeah good to show me welcome in here yes how are you today i’m very good how are you oh fine thank you so you are here in vienna at the oppositological conference right now i’ve heard your lecture yesterday it was really interesting but uh i’m not a scientist i will need your help now as our viewers will as well so would you be so kind and tell us tell the audience what is a way to treat obesity today because obesity it’s called a new um epidemic the epidemic of the 21st century so it’s clear that we need some cure we need some treatment yeah so what’s the way to treat obesity yeah so so you know treating obesity is you know is interesting but really i think we have to focus on prevention i think we our focus has to be i mean there has to be you know there is a reason why in the last 20 or 30 years we’re seeing so much more obesity and so our talk about obesity has to talk about prevention and we have to think about what is it that we can do to prevent obesity and i think that is much more important than going find to find which diet etc because if you can prevent obesity then we don’t need treatment is of course you are totally right if you can prevent the illness then you don’t have to treat it exactly that i agree but we have a lot of people who need that treatment already because we didn’t do enough of prevention for them so now we need a treatment what do you do with this well yeah well you know i think that if you if you focus on prevention and we improve the food environment and we improve the physical activity and mental health i think everybody will benefit also people who have obesity will benefit so i think we have to really go upstream and focus on the social determinants of health we have to you know improve the nutrition of the population and you know that will also that will help everybody but i think that is where our focus has to be yes sure i totally agree again but you are not answering my question i asked what can you do to people who are living with obesity there is a prevention there is information of course but they need a treatment right now so is there anything you can offer to them well i mean they will also benefit if you make if you make good food cheaper and easier to access and the physical activity the social norm i think everybody benefits also people who have obesity will benefit and i really think that there’s a lot of opportunity of you know changing the food environment and changing the activity environment that is going to benefit everybody of course of course but how do you offer those things with those changes to people who need a change and they need treatment oh absolutely and i think we should be starting with children if you prevent because you start treatment of the children but how do teach children to live differently if their parents are living with obesity and they need treatment see and that’s where i think that some of the policies we can discuss for prevention will be very helpful we can uh you know we can start with the sugar tax uh we can because we know that taxing changes behavior we have seen it for tobacco and i think we have reduced the tobacco smoking we can reduce obesity uh but we have to focus on public policies for a moment it works for for tobacco industry of course yeah because you don’t have to smoke but you have to eat but and if you are a person living with obesity and you need some treatment you still have to eat so the taxes are not the answer yeah but we can change the kind of food that we believe if you make fast food more expensive and healthy food cheaper then we can change what people believe how do you change it how do you change it because how do you persuade people to do it to change their habits absolutely that’s the first thing and my second question is how do you help them to be treated so they can uh change their life and then work on the prevention not to get back yeah i i you know i think as you agreed we have to start very early in childhood because if we can prevent obesity i mean that is for me that is the only solution i see okay sure okay all right so uh so so what we wanted to do so thank you very much so so what we wanted to do was uh just give you a taste for how easy it is to fall into the trap of answering questions and how important it is to actually know what you want to say before you go to an interview right uh this does not mean you should be shy of interviews no you have to welcome interviews you have to welcome you have to look at every media contact as an opportunity to get your message out but it has to be about the message that you want to get out there so so you have to think very carefully about what is it that you want people to know about obesity and then you can think and then the more often you do it the more you know the more fluent you become in your message and the better you will you will get at it but do not answer questions okay that’s the most important message here so one of the things that we tried to do in canada was that to make sure that the messages that the patient engagement committee was releasing to the media uh were evidence-based yep and we’re strategic in terms of our advocacy goals and and so when this committee I know that you have your strategic plan and so you have strategic goals and if those goals are aligned with your messages I think if you’re representing this committee or talking about advocacy and what your goals are then the messages are ready for you right like we need whatever your goals are like the messages need to be around your goals and I think from uh when you they interview you you can talk about your lived experience and your journey but I think it has to match with what the overall mission goal is like what are we trying to get changed and in in canada we decided that the mess the key first thing we need to do is get obesity recognized as a chronic disease right so every patient that is being interviewed in canada right now will say obesity is a chronic disease in every single interview 20 times right because we need to get that message in there so I think it would be helpful for all of you to talk about what are the key messages that EASO EASO patient council wants to get out there and then you contextualize that message with your personal experience you know like in my perspective obesity is a chronic disease because I’ve lived with it for this long or I’ve tried this and I’ve tried you can contextualize whatever with whatever experience you have and you can answer the question um that they’re asking you but bringing that key message back and I think that’s what the patient engagement committee in canada liked about practicing this with you because you tried to you knew the key messages but you didn’t know what the individual patient had selected for the role model for their role play but we all worked very hard for like hours to make sure that everybody could actually get their key message out and by the end of it it was very they got very good at it and now they’re all practicing out there like they’re all doing media interviews and I think it’s helpful to just for all of you to think about that what is your key message from the EASO patient council perspective Jimena that was a two-day workshop wasn’t it we had a two-day workshop we need some time it does it does but this is very I mean it was kind of like a teaser yeah this was more like a like an introduction to uh to some of the issues but you can do it it’s more complex you can you can record it you can look at the recording you can analyze it and say okay what did you say there and then of course there are other issues around body language and posture and oh yeah how you speak the kind of words that you use uh the length of sentences working with analogies those are all things that you can that you can practice and they’re all very teachable so it’s all learnable if somebody tells you and you practice it you can do it there’s there’s no rocket science it’s not magic it doesn’t you know take a lot of uh you know complicated thinking but somebody has to tell you and you have to practice it you have to practice it because that gets you better otherwise uh you you probably are not taking full advantage of the opportunities that you have to communicate your message and your and the issues that you want the public to understand and so don’t don’t depend on this on on the reporter asking the right question they don’t know what question to ask no that’s right when they have their questions they have their questions but their questions but you you can use their questions to get to what you want to talk about i’m in no rush so uh all right well thank you everybody for coming for the well i came so you guys but i’m i’m happy to take questions yeah sure yes when you were talking in the beginning you mentioned your three messages that you also mentioned that um when a person becomes obese then the body changes and it’s going to be chronic life-long disease and is that at any level of obesity that you are referring to or is it that for example morbid no it’s it’s not even at any level of obesity it’s at every any level of body weight at my body weight if i wanted to lose five kilos and keep them off i would have as much of a problem as someone with severe obesity was trying to lose 20 kilos and keep them off this is not a problem of obesity this is a problem of how the body regulates its body weight and defends its body weight we are all in a different set set point my set point is my current weight uh but if i put on 30 kilos then that becomes my new set point right right now my body is defending this weight so uh it’s not a question so this is not a special physiology of people who have obesity no this is this becomes a chronic life-long well it becomes it becomes if somebody puts on five kilos it becomes a chronic yes because now your body because what happens is that your body will then defend the higher weight so when you get to 120 kilos your body is going to defend 120 kilos and your body will always try to defend 120 kilos no matter what you do when you try to lose weight you go diet exercise get your stomach stable take medication do whatever you want when you stop any of those things your body will go back to 120 kilos that is what makes it a chronic disease right that’s why every single diet that you go on it doesn’t matter everybody has lost weight over and over and over again they always end up at the same weight or they go even even higher and so the first the first thing that i tell my patients and i tell my patients is you know right now what was your highest weight ever and they say it’s 130 kilos i say that’s good because you’re fighting 130 kilos you don’t want to fight 150 kilos or 170 kilos so you’re lucky you’re only fighting 120 kilos let us make sure that is the heaviest you’ll ever be because what we don’t want is this level going up because that’s going to make it more and more difficult but unfortunately i cannot change 120 kilos your body is always going to want to be 120 kilos so we have to find some way of managing it you want to be so i use my rubber band example i often explain this noise like your body wants to be here you want to be down you’re pulling on a rubber band we have to find ways for you to pull on the rubber band but whatever you do it will always be a rubber band you can have bariatric surgery that’s pulling on the rubber band well what bariatric surgery does really if you think about it is it it loosens the tension in the rubber band so now it is easier to pull and it is easier to sustain the pull on that rubber band but even after bariatric surgery it is still a rubber band which means even after bariatric surgery if you’re not pulling you go back to 120 kilos right so surgery doesn’t doesn’t cure obesity it makes managing obesity easier because it removes the tension in the rubber band and that’s why you’re more successful but it’s always going to be a rubber band i cannot change the rubber band and it’s always going to be 120 kilos so or whatever the high speed is how long you would have to be at particularly probably probably depends on that i mean and we know that from very short-term gpa changes so if you take somebody like tom hanks and he gains 20 kilos for a film role and he you know they film the film in in four weeks and then he loses the weight and comes off and he never has a problem maybe four weeks is not enough right so the question is how long do you have to be at a certain weight before that becomes your new weight uh and i think that there’s going to be a lot of variability for some people that can happen very quickly so some people it happens very slowly for some people maybe it never happens but in generally speaking generally speaking we have to assume that the highest way that you’ve ever been is probably the way that your body would go back to if you did nothing right how does this help people knowing there’s a point okay what it helps what it helps people so it helps people in two ways i think well the first of all it’s very depressing and it’s a shock and everybody’s oh my god you know no hope i i you know i i don’t think that’s true i think the first thing it helps you to understand why it is important to not get heavier so if your lifetime maximum was 120 kilos then please don’t make it 130 140 because that’s going to be so if you can just you’re 35 years old your highest rate was 120 if at age 50 your highest rate was also only 120 you have been very very successful in managing your weight that much i can tell you okay so that’s the first thing i tell patients so that’s that’s what you get from here so if your set point is 120 let us let’s make sure that’s the highest you’ll ever be the second thing that i think why the model is helpful is because it tells you that i’m going to need a long-term strategy here right it’s not about how much can i pull for next two months because what happens in the third month and third month i start going back right so what it really means is we are going to have to find a strategy for you and that is different for every person on how much can you pull on the rubber band in a way that you can sustain the pull if you cannot sustain the pull then you’re pulling too much and for some people the only pull they can sustain is this much then that’s a four kilo weight loss okay that’s what you’re going to get okay thank you so much right so that’s that’s the conceptual idea so so and that’s how i explain why obesity is a chronic disease because i don’t care how you got to 120 once you are there you’re going to be fighting 120 forever yes sir scientific references for this model yes uh well yes and no so there are uh if you look at all of the intervention studies all of the lifestyle intervention studies or any type of study we know that weight regain happens in every single study when you stop the treatment or when you follow people over time they tend to regain their weight so if you take the biggest loser study those guys they lost a ton of weight i know that’s right everybody goes back to almost not everybody almost everybody goes back to where they started right and that is the rule and that is all over uh and and that is the rule so the people who lose weight and can keep it off for a long time uh the longer you go the fewer and fewer people you will find who can actually do that right so they’re the exceptions the rule is that whatever amount of weight you lose the relapse the chances of relapse which means the chances of putting the weight back on is almost i would say 95 percent for most people so that that tends to be a lifelong problem so if i say that whatever diet you go on should be something that you can sustain sustained for the rest of your life yes that’s something that i can claim that scientifically absolutely yeah and it’s not just whatever diet it is it also it also applies to lifestyle it also applies to medication it also applies to bariatric surgery so that’s why for example getting a gastric balloon which you can only have for six months is not going to cure obesity you can put in a balloon you can lose the weight and i take out the balloon what happens the weight goes right back up the same would happen for medication if i say if i start here on the raggy type the injection the glp1 hormone it also loses the rubber band and you lose the weight but i stopped of course you go back right so when you stop and that is the definition of a chronic disease the chronic the definition of a chronic disease is a condition that i cannot cure where if i stop the treatment the condition comes back or becomes worse again so whether you’re looking at diabetes or high blood pressure or whatever the chronic disease is that you look at when the treatment stops the disease comes back okay and that is exactly how obesity behaves when you stop the treatment for obesity it doesn’t matter you can be running marathons for your obesity i don’t care when you stop running the marathons guess what happens right you could be doing mindful eating when you stop practicing mindful eating guess what happens right it doesn’t matter what the treatment is the point is you have to do that treatment for life and the day you start doing that treatment whatever that treatment is your weight will start coming back all right may i interrupt just for one sec sir i’m mary forehand i work with the canadian obesity network one of the things and i i’ve worked with aria a long time i’m not a medical doctor so when i first started doing interviews i tried to talk really technical to sound like i really knew what i was talking about and what it did is it made my interviews really bad because it wasn’t natural for me to try to pretend to talk really technical so how aria was just talking at the end that it doesn’t matter what i do i have to do for lifelong because it’s a chronic disease that’s as much detail as you need to put the pressure on yourself to be able to to say unless you have that background and really understand the technicality of it because the more i try to use all the right medical terms and all the technical explanation the worse my interview was and i think i forgot i’ve forgotten your name when you said it’s very natural i the interview was very comfortable because i talked about what i knew and what i was comfortable with that was bang on so i just i just want to bring the stress level down a little bit if it’s there to not feel obligated my first ones already used to go mary that was terrible they were terrible yeah yeah it actually helps to say you know sorry guys i’m not the expert on this but the way that i look at it or my personal experience or what i see in my patients you know i’m not the expert but i see in my patient uh i mean although it is it looks like false humility but actually it’s a very effective speaking technique to say you know what you know i don’t know you know that of course there might be somebody who can do it but you know what i look at my patients they’re not going to do that i look at myself i’m not going to do it right so you bring this down to a very personal level uh that also makes for a better interview because the one thing you want to do in an interview is you want to be relatable like when somebody’s watching the interview you’re looking at the person who’s the interviewer so if you’re using a lot of fancy language and you’re using kind of thing then you’re not relatable they say who’s this guy right i’m like you know i don’t believe him uh so there’s a little bit of an art so the more you can keep it personal use your own language and and and stay at the level of comfort right uh so i was going to mention what what happened to doug one of our patients that was part of the training so doug lives in halifax in Nova Scotia where there’s very little access to treatment in fact the clinic that he was a patient of was canceled about six months ago so he has no support in his um in his city so he came to this training is it was his first in-person meeting with the public engagement committee and he heard arias talk he spoke you spoke about two hours about the science of obesity uh that first day you talked about the brain set point you talked about this canyon medical association defining obesity as a chronic disease and he had never heard this and he came back to me after his presentation and he said jimena i nobody has ever told me that i have a chronic disease nobody my doctor didn’t tell me i’ve been through an obesity management program and nobody told me that i was living with a chronic disease and he said i need to absorb this i need to think about this what this mean and then an hour later he keeps like jimena i’m still thinking i’m still processing this information like this is very difficult for me and then the next day he came back and he’s like i know what i can do now he’s like i’m gonna go and talk to my minister of health in nova scotia i’m gonna say this is unacceptable i have a chronic disease the canadian medical association the carolina disease if 2015 why is this that i don’t have access to the treatment that people with diabetes have and so it became an empowerment for him to understand this is a chronic disease that it was not his fault and that he’s not alone and that he doesn’t need to manage this on his own and that there are evidence-based treatments because i already talked about the treatments as well and and that he he has a voice now he i am a person and i have a chronic disease and i am a taxpayer and as a taxpayer i have i want access to evidence-based treatments so i think the hopelessness it went over it was in it was immediate like he felt oh my god i’m gonna have this forever i don’t know what to do but then after a couple of hours he processed that information and then it became an empowering thing for him so i think i just want you to think about that because when you say that to somebody a friend who has obesity or somebody else and they have never heard this before they’re going to look at you and say what what do you mean there’s no cure what do you mean what i mean i have to do this forever right and so that’s the opportunity we have to educate the media the public and everybody that yes you can live with obesity it is manageable it’s not entirely hopeless but we do need evidence-based treatments and i think that’s why you come in because you are living with it and you are managing your disease and you are healthy and you have good quality of life it’s possible to live with obesity but you need support and you need evidence-based support why is diabetes always mentioned it’s by the medical professionals as if it’s sexier yeah yeah i mean it’s difficult to live with diabetes and there’s also prejudice i guess i know that’s actually with type 2 diabetes because you don’t know if it’s your fault yeah yeah one person told me that uh patients with type 1 diabetes will especially say to you i have type 1 diabetes yeah right because type 2 diabetes is those things yeah it’s okay to have type 1 diabetes real diabetes wonderful fantastic manner and diabetic patients have no problems at all so yesterday i was at their world health organization the meeting that they had and somebody said you know i’m not sure i’m comfortable calling obesity a disease because i think it will increase stigma and i said when we declare cancer a chronic disease did that increase stigma for people with cancer but cancer was never declared a chronic disease but it’s a good it’s an ncd of non-chronic disease by who yes it’s an ncd europe as well yeah um so i have a question because one of the biggest challenges that i’ve been facing i mean i can’t meet advocacy for obesity but a lot of people keep saying to me well you’re not an obesity patient anymore because you’ve lost your weight so you will be an obesity patient for life right exactly i mean that is like telling someone who’s diabetes whose blood sugar is well controlled or you no longer have diabetes no you still you’re still a diabetes patient who’s well controlled so how do you counter that when you’re dealing with the media who basically sees you as a bit you know quite you know but you tell them because you’re not living like a normal person you’re living like a person who had obesity who has lost weight yeah right you’re not living like a normal person if you went to live like me you’d be twice your size i’d be very ill i’m dietic surgeon right yeah exactly right so you’re not you’re not sure right you you you have found you have found a treatment that has helped you control the disease but you’re not you’re still a patient with obesity you have treated obesity and you still live it and you could go back to obesity tomorrow if you went back to your surgeon and asked him to unstable your stomach right or something else happens right so so but that’s because people think obesity is a size yeah so there are big people and there are people who have obesity there are people who are big who don’t have obesity the mental scars of obesity stay with you yeah you still walk into a room and see can i fit through that gap even though you’re thinner you still judge the seats you still immediately scan and think what can i do here because obesity is still in here it doesn’t go but there are people who live in bigger bodies who don’t have any health impairments because of their weight which is what aria talked about yesterday so i think we need to distinguish between being a big person but having a big body so being a big person is not a disease but having obesity is a disease but how do you decide well the difference is whether or not your size is affecting your health when you’re sometimes you’re healthy you have obesity when your size does not affect your health you’re just a big person you’re just a big person right so there’s nothing wrong with like i’m a small person or a short person its size is not a disease but size is not a disease even though even the amount of body fat is not a disease because you can have people who have a lot of body fat and they’re pretty healthy and they don’t even feel bad about it if you lived in a culture where i mean remember a lot of the stigma and the uncomfortable that comes is because of the social construct yes right you live in a fat phobic society yes right and because you live in a in a fat phobic society there was a lot of pressure to be thin but if you lived in a society where people look down upon the skinny people and if you lived in africa where they’ll actually send you as a bride oh and my wedding is next year i need to gain 20 pounds otherwise in my you know my wedding night my husband’s not going to touch me uh if you live in that kind of a society well then you’ve got the other so now the skinny guys are running around trying to gain weight because they are not right so we are living in a fat phobic society and so you have to kind of differentiate between what is the fat phobia stigma part of this problem and what are the actual health implications now of course the fat phobia problem the stigma can lead to health implications in two ways first of all they get a huge mental health burden so we talk about the mental health burden of being stigmatized if you’re living constantly in every single situation from the minute you wake up in the morning to when you go back to bed you’re conscious of your size you’re ashamed of your size you’re not comfortable you’re afraid to go out on the street because people are going to look at you you have to get on the plane you don’t know if you want to sit you have to ask for the extender uh that is a constant stress level right your stress levels are over here constantly the whole day that cannot that cannot be healthy right and so even if you don’t have any health problems you are going to get health problems just from the stress okay so and that is why the you know the Canadian Obesity Network says we have to work against fat phobia as number one problem to to destigmatize the condition because although we are not changing people’s sizes at least we are trying to reduce the amount of stress that comes with this condition right it’ll never go away completely because you know but after you lose the weight it’s still there it’s always going to be there so so so my definition of obesity or the obesity definition that I like is that when your body fat and it’s not the amount of body fat but it’s when your body fat affects your health it becomes a disease if it’s not affecting your health it’s not a disease it’s just just too much fat right and that’s what there’s a difference between being fat and having obesity being fat is like being short or being tall or being blonde or being whatever right that’s that’s being fat right yeah I’m fat but I don’t have obesity how can you decide well for example yesterday I was attending one of the talks and you mentioned the study yeah is that a good a good route to take to try and do the questionnaire and yeah I mean I ask my patients when patients come to me come to me in my clinic and I every every time I mean my average patient that comes to me in the clinic is BMI 50 but they’re all big patients right so my question to them is also so so how is your size I mean have you always been big etc but how’s your size affecting your health I mean tell me specifically and it could be I cannot tie my shoes I cannot cross my legs I cannot get on the floor to play with my grandchildren or it could be I have diabetes or I can’t lie on my back because I can’t sleep or my legs swell up or I have reflex disease or whatever the problem is but you tell I don’t know what your problem you tell me what your problem is right and then sometimes the problem you’re telling me you know what this problem we cannot solve with weight loss because no amount of weight loss is going to fix that problem right so somebody might have told you and and self-esteem is one of those issues right no amount of weight you know if you have a significant body image issue my experience has been that for most patients losing weight does not fix that but they will not be happy with their body image so they disappear okay so I can’t fix that but you’re going to be very very unhappy because you’re going to have bariatric surgery you’re going to lose 60 60 kilos and you will still be unhappy yeah right so so we have to also be realistic is losing weight even going to fix that problem because if it’s not going to fix that problem then maybe losing weight is not the solution here and so but I can’t decide that I have to you know that’s where you have to have a conversation that’s why I’m saying you cannot define obesity based on a chart or a table or a measuring tape or a scale you have to get to know the patient I have to do a physical exam I have to talk to the patient I have to look at the laboratory values and then I can decide okay is this affecting your health or is it not so so I don’t know I don’t want to keep you guys here forever but my my I said obesity is like obesity obesity is like having a big nose have you ever thought about it okay if you live in a society where everybody has a big nose and a big nose is seen as being something that is very attractive then everybody wants to have a big nose and that’s a good thing but now imagine if you live in a society if you have a very big nose and you live in a society where the good thing to have is a small nose and people with big noses they are looked down upon and we don’t like people with big noses you could be very conscious about your nose and now your nose is going to affect your ability to your confidence is all built on you know they’re looking at they’re not looking at me they’re looking at my nose so you get very conscious about your nose so is that a medical problem well it can be a medical problem if you’re if you’re so conscious about your nose that you can no longer function in society you’re no longer leaving your house you’re already always wearing a mask you have no friends because you don’t even put your picture on a social media because you’re so conscious it can become a medical problem in the sense that it is now impairing you or it can be a real medical problem if your nose is actually making it more difficult for you to breathe or you’re always getting sinus infections because of the size of your nose it can become a medical problem so now the question is when does the public health system pay for your nose job right when can you go in a public health care system go to a plastic surgeon and get your nose corrected right is that just you know i don’t feel comfortable you know i prefer smaller noses so i want to get a nose job or is there a medical reason for getting a nose job so when does a big nose become a disease when it starts impairing you when it’s impairing your health and functioning well i i’m afraid it’s listening i’m struggling with my own struggle with the nose no no no i’m struggling with uh the difference between what when you allude to when you mentioned medical problems actually you then give a list of physical no so medical so i’ve saw uh i think very holistically so so my definition is health and the health and physical mental physical and social well-being okay yeah right and social well-being is the hardest to fix right the physical health i can fix mental health you can do you know psychological counseling or whatever social health is very difficult because social health i’m dealing with society i can’t fix society right so that is the most difficult aspect of this to help right i mean yeah uh but that’s my definition of health so when i say health uh i’m not just talking about whether you have diabetes i’m also talking about social functioning uh you know job opportunities and you know can you find a partner right that’s all part of health right so it’s a very broad definition of health now when does that become enough of a problem to warrant medical care and medical intervention that’s a whole different problem and that depends on resources and access to services etc right let’s thank our guests and our participants.