Dr. Fatima Stanford on what obesity really is

Dr. Fatima Cody Stanford, MD, MPH, MPA, MBA, MACP, FAAP, FAHA, FAMWA, FTOS, does not just treat obesity. She studies it, publishes on it, teaches it at Harvard Medical School and advocates loudly for the patients who have spent their lives being judged because of it. As an attending physician in Obesity Medicine and Nutrition at Massachusetts General Hospital and the author of more than 275 peer-reviewed publications, she is one of the most trusted voices in the country on a disease that is still widely misunderstood. Rolling Out’s Health IQ sat down with her for a conversation covering brain biology, weight stigma and why black market weight loss drugs are putting lives at risk.

What are the three most important things communities should understand about obesity?

Number one, obesity is an actual disease. A lot of people think this is a matter of willpower or something you chose to have. It is far more than that. It is based on stress and the stressors present in our communities, on genetics, development and environment, and all of those things come together to predispose us to this chronic disease governed by how the brain communicates with our genetics and surroundings.

Number two, it is treatable, but we have to use all the tools available. Our community often shies away from options beyond lifestyle modification. Diet and physical activity matter, but we now have medications that can treat obesity. The most underutilized treatment for severe obesity is metabolic and bariatric surgery, which remains the best option for that group. For many patients we combine surgery, medication, dietary changes and psychological support.

Number three, weight bias and stigma are real and damaging. We judge people by how they look. If someone carries excess weight we assume they are not taking care of themselves. I want us to stop that. Do not judge anyone by their size.

How should we talk to family members living with obesity?

Start with the words we use. We call people fat, morbid, obese. None of those words invoke warmth. When we are talking about family members at reunions or at church, we have to ask whether the way we are approaching them is the way we would want to be approached. Lead with love and care.

The same applies in medical settings. If you go to the doctor and feel judged rather than cared for, find another doctor. There are physicians who will help you feel seen and receive the right treatment. That is what every patient deserves.

Why is mental health support so critical in treating obesity?

Mental health professionals are essential to this process from the very beginning and throughout treatment. A patient coming in on day one may have been judged or bullied their entire life. That internalized bias shapes how they interact with everything around them. Now add being Black and having obesity on top of that, and you begin to understand what these patients are carrying before they ever walk into a clinical setting.

Even after reaching a healthier weight, a patient’s sense of worth can still be tied to who they were before. That is where body dysmorphic disorder comes in. They still see themselves in the original frame even as others see them differently. I have had patients tell me they do not feel they deserve to be a smaller size. Mental health support helps patients understand that their value is not tied to their size, and that is foundational to the entire treatment process.

What does the Black community need to understand about movement and weight loss?

We have to set realistic goals. Physical activity is excellent for weight maintenance but does not typically lead to significant weight loss on its own. Think about Steph Curry. He has played professional basketball for years, running constantly through full seasons. His weight has not dramatically changed because the body defends its set point. Activity keeps weight stable, but once activity stops, weight tends to climb.

Every January people flood gyms with weight loss goals, and there is actually a day called National Quit Day marking when most people stop. That happens because their bodies have not responded the way they expected, because exercise is for maintenance, not significant loss. For most people, lifestyle modification alone changes weight outcomes about 5% of the time. For those who respond strongly, that is great. But for the other 95%, additional strategies are needed, and understanding the biology removes a lot of unnecessary shame.

What do women need to know about weight changes across their lives?

There are three major times in a woman’s life when significant weight shifts occur. The first is when menstrual cycles begin in adolescence. The second is pregnancy, whether or not it results in a child. A woman who experiences multiple miscarriages may still go through major physical changes with no visible outcome, and that can be deeply difficult. The third is menopause, which is the number one reason women seek care for obesity. All three moments are driven by changes in estrogen that are largely beyond a woman’s control. Having an obesity medicine physician involved during those times can be critical in managing weight gain and identifying the right interventions.

How do eating disorders connect to obesity?

The number one eating disorder in the world is not anorexia or bulimia. It is binge eating disorder, and most people do not know that. Binge eating involves an intense, difficult-to-control desire to consume food, followed by a sense of calm once enough has been consumed. That entire pattern has to do with brain pathology in the hypothalamus, which regulates two key pathways. The anorexigenic pathway suppresses appetite. The orexigenic pathway drives eating and fat storage. When the orexigenic pathway dominates, the desire to eat is not a willpower issue. It is biology.

Medications can help regulate that imbalance. The only medication approved specifically for binge eating disorder in the United States is Vyvanse. GLP-1 medications can also reduce what patients call food noise, that constant preoccupation with eating. Recognizing that different people have different neurological regulation around food is what allows us to remove the judgment entirely.

What do people need to know about black market weight loss medications?

This is something I address regularly in national media because it matters. Approved medications have known side effects documented through rigorous clinical trials. We can monitor for them. There is zero published data anywhere in the world on off-label weight loss medications sold through black market channels. No dosing data, no safety data, nothing.

Last year there were nine reported deaths linked to off-label medications. The causes are not fully understood because there is no data to analyze. As a physician-scientist who has served as a principal investigator on major trials, I can tell you that no data means no protection. Patients who use these products and end up in an emergency room leave their physicians with nothing to work from. The two approved medications from Novo Nordisk and Eli Lilly have been through extensive trials. That is what safety looks like. Please do not run the risk.

For someone living with obesity, where do they start when seeking help?

Start by looking at who is available in your area. The American Board of Obesity Medicine has a free search tool on their website to find verified physicians. If you want fellowship-trained specialists, the Obesity Medicine Fellowship Council maintains that list, though there are fewer than 120 fellowship-trained physicians in the country for the 200 million people living with this disease.

Decide what setting works for you. A large academic center will have a full team including dietitians, psychologists and surgeons. A smaller community practice may feel more accessible. At Massachusetts General Hospital my colleagues see roughly 8% Black patients. I see 45%, and that difference comes down to patients feeling that someone genuinely has their best interest in mind. That trust is not a small thing. Obesity is a chronic disease requiring long-term care. Most of my patients have been with me for 12 to 15 years. The goal is not a quick fix. It is getting you to the healthiest, most sustainable weight for you over the course of your life.