Around Doctors

I was prepared to write my knickers into a twist about this:

http://www.xojane.com/issues/obesity-guidelines-weight-loss-drugs?utm_source=FBPAGE&utm_medium=post&utm_campaign=Issues

Until I actually read the article it referenced:  http://press.endocrine.org/doi/pdf/10.1210/jc.2014-3415

There is no doubt that pathologizing fat has not helped fat people any more than stigmatizing it has. There is also no doubt that the medical profession, generally, has a huge case of The Blind Dumb on the subject of weight and cholesterol. Further, there is no doubt at all that Big Pharma is hard at work trying to keep it that way.

There are passages in the actual medical article, especially the stuff about using weight loss drugs (which, no matter how efficacious, are NOT going to work long-term, and may be very dangerous in the short term), is The Usual Blather. It’s awfully hard to figure out why the article was even written/published (be interesting to know who funded it…there seems to be a sort of double-speak in the Financial Disclosure section…), because there’s nothing new in it. As near as I can tell, all it really offers is some convenient lists and charts, and mostly rehashes old info. Its main thrust seems to be that some drugs for some of the conditions associated with obesity (including psychological issues) have the side effect of causing weight gain, and that it would therefore be good clinical practice to try everything else first. That, and to push phentermine and its various cousins. Down near the bottom of page 5, there is a passing acknowledgement that permanent weight loss is extremely rare and very difficult to achieve without bariatric surgery. Which is neither entirely safe, nor always a long-term success. They talk some about Orlistat and how few side effects it has, and note that it is the only weight loss drug generally available in Europe. Interesting thought, that, since European countries tend toward speedier and less insurance-obsessed drug approval processes than those in the U.S. Maybe we don’t want to be taking anything even the weight-obsessed French won’t prescribe?

And, of course, Orlistat does have one side effect: famously, it makes you poop yourself. It works. You lose weight like crazy, but what dignity you might gain by being thinner, you definitely lose in bowel control. There’s also the teeny, tiny problem that all that weight inevitably comes back, thereby straining the very system its loss was designed to benefit. I’ve also never heard anyone talk about the immune system issues tied to taking a drug that mucks up your digestive tract, which someone ought to look into, given our increasing understanding about how crucial gut bacteria are to immune function.

Nonetheless, the article does not advocate for postponing other critical medical treatments or procedures until patients lose weight, as the xojane piece suggests. That being said, the writer does have perfectly good reasons for finding it fear-inducing. I have been told by a reputable doctor that I had flu because I was fat. I have met a woman who was, I’m guessing, 200 lbs whose doctor would not sign off on desperately needed knee-replacements until she “lost all the weight.” I suggested that she get a new doctor. We weren’t close enough for me to expound on her doctor’s sadism, but I’ll say it here. Doctors have absolutely been taught to treat fat as a catastrophic disease in and of itself. Combined with the cultural conversation about fat people consuming more than our share of resources/space/tax dollars/air, and the other thread that sees fat as a function of laziness/stupidity/greed/all of the 7 Deadly Sins, and the third thread about fat being repulsive/contemptible/threatening/invariably disabling/low-class, its no wonder that docs are so often such assholes to their fat patients. When you add in a pharmaceutical industry much more interested in selling drugs, and its legions of charming, persuasive, sample-spewing sales reps, you get a five-strand knot of considerable complexity. It explains; it does not excuse. There is no excuse. There is a ton of research out there about the dangers of weight loss drugs and surgeries, questioning the purpose and efficacy of cholesterol-lowering drugs, and affirming that treating fat people like we’re a lesser species tends to make us get fatter. Because knowing that you can’t trust a whole profession that is supposed to be dedicated to your welfare isn’t going to leave you feeling battered and frightened and panicky at all. Nope. Nuh-uh. Not at all.

Doctors who see their fat patients as human beings aren’t worth their weight in gold, they’re worth their fattest patient’s weight in gold. They’re rare and wonderful creatures. And they are out there. We just have to look a lot longer and sometimes farther to find them.

Whitney Thore, the star of “My Big Fat Fabulous Life,” spoke recently of finally finding an OB/GYN who didn’t lead with her weight after years and years of one after another who walked into the room (where she had her feet in stirrups–an already terrifically vulnerable position from which to have a conversation) and started in on her weight immediately. I’m of mixed mind about the show. On the one hand, she’s parlayed a kickass youtube video into an income-generating career in which she has a platform from which to speak sense and sanity about fat life. Good things. On the other hand, reality TV.

I have the same mixture of feelings about S. E. Smith’s piece for xojane. The anger and fear are legit and righteous (https://fathealth.wordpress.com/. And calling the medical profession out on their prejudices is important and ought to be done more and more frequently and more and more loudly. For those of us who are middle-class, educated, cis-hetero, white, and insured, I think it is a particular duty, because if we’re dealing with this shit, then just think of how it is for women who don’t fall into those categories. All the knee-jerk fat-prejudice plus the huge range of stupidities and insensitivities to which those women are subjected almost autonomically. It’s abusive. It’s bullying. It’s ethically unacceptable. It’s mean. And considering how many fat people have abuse or assaults in their histories, it’s particularly vile.

But panic and approaching all doctors as though they were The Enemy isn’t going to help us, either.

round dragon

2 thoughts on “Around Doctors

  1. I am a doctor, a fat one, who has been on both sides of the prescribing desk related to treatment for obesity. I must respond to some of your comments on the initial article (Pharmacologic Management of Obesity: A Clinical Practice Guideline). First, the title tells you the purpose of the article and it is quite clear. These are guidelines for doctors to use in treatment of obesity. The guidelines are very specific. They are aimed at inducing weight loss, preventing weight gain, and maintaining overall patient health. They are based on data that has been obtained through good clinical studies, and they clearly state, for each piece of advice, just how strong the data is.
    Second, nowhere in the article does it say that weight loss drugs cause weight gain, and indeed nowhere in medical literature will you find that is the case. In addition, most weight loss medications currently on the market are safe for long term use, and are generally effective for long term use. The article notes that discontinuing the medications allows weight gain to slowly resume.
    Third, where the article notes that only Orlistat is used in Europe for weight loss, it also recommends that Europe study and then provide additional medications to obese patients to help decrease the morbidity and mortality from their disease.
    Fourth, the primary side effect of Orlistat, only occurs when a person exceeds a reasonable amount of fat in the diet, so it is completely under the control of the person using the medication. It usually occurs as leakage of an oily liquid; you don’t “poop yourself” as you so eloquently noted.
    I understand your frustration with society (and doctors particularly) in its treatment of fat people. I do not understand your offering a post that is grossly inaccurate and a thorough misreading of the article you cited.

    • fatmatters says:

      Actually, I did acknowledge, repeatedly, that the article was intended for use as guidelines, and that it was making perfectly sensible suggestions about not trying weight-gain-inducing drugs as first-line responses. I was specifically speaking against the sort of panic the xojane article was expressing, while trying to also acknowledge that that sort of trigger-response has its basis in the experiences of a great many fat people. What disturbed me most about the articles recommendations is that it recommends weight loss drugs (okay, I overstated the consequences of Orlistat–though I still question the long-term safety of drugs that muck about with the digestive system). Study after study makes it clear that these drugs, no matter how much weight loss they induce, do not produce sustainable weight loss, except in rare cases, and that the bounce-back is also very dangerous to the health. And there is a good deal of research (I did a blog on this early on in the series–I’ll try to find it and re-post it) suggesting that for a large part of the obese population, morbidity and mortality statistics are overstated. I’m not saying, and never have said, that it’s healthy to be fat (though I do think it’s possible to be healthy and fat), or that extreme obesity is not extremely dangerous. But there are a lot of unexamined statistics generated by research that too often has an agenda driven by drug companies for whom pathologizing weight is a potentially endless source of profits. But even where there is no corporate agenda, statistics can be “played,” and often are, to convince fat women (particularly, I suspect) that their weight is, in itself, a disease. My personal favorite example was my ob-gyn telling me I didn’t have the option to go to the birthing center to deliver my first baby because my pregnancy was “high risk” simply because of my weight. He assured me that the birthing center wouldn’t even talk to me, which I later found out was untrue. When I asked what made it high risk, he countered by telling me that 9 out of the last 10 mothers to die in delivery at the local maternity ward had been overweight. When I asked him if his statistics (which I now suspect were an outright fabrication, in any event) accounted for age, pre-natal care, income levels, secondary conditions, and overall health of the mothers, he put his hands in the air and announced that as long as I had the baby in a hospital, I could do the labor and delivery any way I wanted. I had a long, tough labor that ended with pitocin and a very healthy baby, but I know now that midwives would have probably known how to manage a shorter labor and no pit. I’ve also had an ortho tell me not to worry about wearing out my knee-replacements because I was not likely to outlive them–I was 55 and he was telling me that I shouldn’t expect to make it to 65. Of course, he was a toad (for a bunch of other reasons, though surgically competent). My issue with that article, for all of its basic good sense, was that it was re-hashing all the old medical tropes, albeit in a calmer-than usual tone. But the bottom of page 5 is worth paying attention to.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s