No, Really, Treat the PROBLEM

A comment for Treat Weight First? that I did not approve, but found striking for its ability to completely misunderstand, was:

There must be some powerful drugs in that koolaid you’re drinking. You admit you are morbidly obese, you have multiple health problems directly related to obesity, yet you shun the doctors that are trying to help you and others like you to lose weight. Amazing!

I posted here before that I’ve recently been diagnosed with multiple conditions that cause fatigue, muscle loss, and weight gain.

I repeat: cause fatigue, muscle loss, and weight gain.

What I haven’t posting about is that it’s been TWO MONTHS since the test that confirmed I’m deficient in human growth hormone — and I haven’t started treatment yet.

(Why? Combine a rare condition with an expensive, injectable drug treatment and you get fun “Who’s on First?” times with the doctor, insurer, pharmacy, and the drug manufacturer. I am not thrilled to have the drug manufacturer’s help line in my cellphone contact list. On the other hand, I do have the drug manufacturer’s help line in my cellphone contact list.)

Because I try to be a good patient, I read up on this new condition.  It has fun, familiar symptoms like:

  • A higher level of body fat, especially around the waist  (Like the 30lbs I gained since my dad died? Or the 50lbs between 97 and 2001? Or, er, my entire life?)
  • Anxiety and Depression (I didn’t have a problem with anxiety until about 4 years ago. Uh…)
  • Fatigue (So, not just hypothyroid?)
  • Feelings of being isolated from other people (So…not just getting older and less patient?)
  • Greater sensitivity to heat and cold  (So… not just getting older or hypothyroid?)
  • Less muscle (lean body mass) (Yeah, my weight lifting hasn’t had results it used to, it’s harder to build muscle…)
  • Less strength, stamina and ability to exercise without taking a rest (Like how I could walk a mile a few years ago and now I need to rest after a couple blocks? YES IT’S VERY NICE TO KNOW WHY.)

And a symptom that’s very, very scary for me: hypothyroid can cause impaired memory.

So let’s go back to that “koolaid” I’m drinking. And about how weight loss is going to “help” me.  Because weight loss will obviously fix the “obesity-related” health problems I have.  Except, wait — those hormonal deficiencies are “obesity-related” in terms of “people who have this tend to be fat”, not “caused by fat”.  And they’re screwing up my life. 

  • Weight loss isn’t going to fix hormone deficiencies.
  • Weight loss drugs won’t fix hormone deficiencies.
  • Weight loss surgery won’t fix hormone deficiencies.

If I were to lose weight without treating those hormone deficiencies? My quality of life would not be improved.  FUCK THAT.  Or, to be precise I am going to continue to focus on improving my HEALTH.  Because THAT will improve my life.

(How RUDE to put MY priorities first!)

And if, in the course of improving my quality of life — things like restoring my former energy levels (horrors!) and my former stamina (eek!) and regrow my muscle mass (Aack!) and reduce my anxiety and depression (gasp!) — I may end up losing some weight?  That’s up to my body.

Treating Weight First?

The Twitterverse has been busy talking about some new treatment guidelines for fatties. Ragen Chastain posted about a piece from Medscape called “New US Obesity Guidelines: Treat the Weight First,” which also has quotes from the lead author.  I also clicked over to the guidelines themselves. They start with an extremely helpful objective, to wit:

Objective: To formulate clinical practice guidelines for pharmacological management of obesity.

That’s the goal here. That tells you what this is primarily about: weight-loss drugs.  Two more were approved in 2014, at least in the US – Europe has been slower to approve the drugs.

There are a few things in the guidelines that I like.

First: Some medications have weight gain as a side effect.  I consider this is a useful fact for medical practitioners.  It makes no sense to prescribe a drug that has weight gain as a side affect and then chastise patients for the resulting weight gain.

Second: Yes, it makes sense for medical practitioners to be aware that medications can cause weight gain or loss, and to discuss that with patients. A fat patient may prefer a drug that doesn’t cause weight gain. A slender patient may want to avoid drugs that cause weight loss.

Third: They’re measuring that a weight loss drug is “effective” if the patient loses 5% or more of their body weight in 3 months.  If that seems low? Yes, yes it is. Worth anal leakage? I think not.

Fourth:

Historically, patients and providers thought that weight loss medications could be used to produce an initial weight loss that could subsequently be sustained by behavioral means. The available evidence does not support this view.

This is an important admission. The human body doesn’t like to have its weight set point messed with.

The things I disagree with?  It’s hard to limit myself to just a few, but:

  • I disagree that patients need to be moved from drugs that control chronic health conditions just because the drug may cause weight gain. What are the side effects of the new drug? Is it as effective?  Does the patient have support during the transition?  That matters too — especially with psychiatric meds.
  • I disagree that patients should postpone treating conditions like hypertension until they lose weight. If the patient wants to try lifestyle changes first, fine — but it should NOT be under duress. The medical profession is already known to mistreat fat people. This can become another justification.

On the flip side, I was prescribed a drug that can cause weight loss (Levothyroxine) this fall. The endocrinologist was thrilled that I lost 3lbs after a few weeks of taking the drug.  I don’t care about that.  I care about FEELING BETTER.  Obviously I’m un-American.

Guidelines: Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline,

Medscape: New US Obesity Guidelines: Treat the Weight First

Medpage Today: New Guidelines: Treat the Weight First

A Hypothetical Doctor’s Visit

Jasmine is waiting in the exam room and her chart shows that her weight today is up five pounds from her last visit two years ago, putting her BMI at 32. Her blood pressure was borderline high in contrast to the normal readings in previous visits. Although Jasmine’s labs were normal in past visits, they are out of date. When Dr. Johnson greets her today, Jasmine seems anxious and tells Dr. Johnson, “I almost did not come in today knowing my weight is up from the last time I was here and you suggested a diet. I feel like such a failure. However, I need help for my migraines, so here I am.” Dr. Johnson and Jasmine look at each other, there is a beat of silence, and they both sigh.

Dr. Johnson says, “You know, Jasmine, I have been reading the research on weight loss interventions and weight-cycling and I’m realizing that if the same thing happens to almost everyone, it probably is not the fault of the person, it is probably more about the process itself. So, instead of focusing on weight loss, I’m encouraging my patients to think about what makes them feel better in their everyday lives; emotionally and physically. For example, do you feel better when you eat more fruits and vegetables, drink more water, take a walk with a friend, meditate to relieve stress, and get enough sleep? There’s good evidence that those behaviors are going to make you healthier and feel better even if your weight does not change.”

Jasmine is a bit surprised by Dr. Johnson’s shift and says, “Well, typically, when my weight loss slows down or stops completely, I stop doing any of those things you mentioned that would help me feel better and be healthier.” Dr. Johnson says, “I understand, but we’re going to turn the focus from your weight to your health. Because those behaviors are linked to health, why not do them anyway?”

Jasmine smiles at Dr. Johnson and says, “It sure would be easier to come back and see you the next time I’m supposed to if I did not have to lose weight first.”

Dr. Johnson replies, “I do not want anything to stand in the way of you getting your medical care, including worrying that I might scold you. Now that we have a better plan, I am going to have the nurse retake your blood pressure.” Jasmine and Dr. Johnson then discuss treatment options for Jasmine’s migraines.

— from The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss published in the Journal of Obesity.

Some Things I’m Learning

48 can be a little too young for menopause. Drat.

Occasional spotting can be a symptom of a problem. Well, that I knew. But it does lead into….

Vaginal ultrasounds don’t necessarily hurt.  But when the tech is having trouble seeing the right ovary, and keeps poking around trying to see it, fuck yeah, it’s going to hurt. For days.

Cervixes can have polyps! Cool! (I think.)

If you haven’t had kids, things like “uterine biopsy” can be bad news.  Why?  My cervix is, shall we say, not at all interested in this “open sesame” crap.

You can take tablets vaginally!  I did not know that, but you can.  Like, say, misoprostol.

Misoprostol causes uterine contractions, aka cramps.  It also “softens” & opens the cervix, like, for a biopsy. (Or, I would presume, an IUD.)

Even with misoprostol, my cervix is STILL not interested in playing nicely. It wants to be left the fuck alone, thankyouverymuch.  Perhaps I should name it Greta.

Don’t bother trying to go to work after said biopsy. Just no.

….yeah.  At the moment it’s been mostly gathering info, and so far no cancer has been detected.  So.  Joy.

 

Wheezing Around the Block

One of the recent rants I moderated out of the comments included something* about how “wheezing around the block doesn’t count as exercise.”

Wheezing is a symptom of asthma, bronchitis, sinusitis, pneumonia, and other illness. Deciding that wheezing is only due to weight and only will be treated by weight loss is DANGEROUS.

I do wheeze. I have asthma. Now that  it is properly treated I can exercise without wheezing. My treatment plan is greatly helped by insurance to cover the not-available-in-generic Advair & other meds. One of my asthma triggers is exercise itself. This means I need to medicate pre-exercise. I’m also affected by things like air pollution and pollen.

If you’re fat and wheezing while walking around the block, you may need to see a doctor about your wheezing. It’s not necessarily “just being fat.” Waiting til you’re thin? A, may not help, and B, YOU COULD DIE in the meantime.

The fat haters of the world would have you believe you only wheeze if you’re fat and should lose weight to cure it. The fat accepters think that if you’re sick, you should be treated for that without having to lose weight first. I’m on the fat accepting side.

*Paraphrased to remove profanity & improve readability.

QOTD: USian Healthcare

From currently unemployed teacher Diana Wagman, writing in the LA Times:

Some 700,000 Americans every year declare bankruptcy because of medical bills. The number in Japan? Zero. The number in Germany? Zero.

And the kicker?  It could be worse.

Thanks to the Affordable Care Act, my new insurance company can’t deny me because I had cancer.   […]  We’re not poor, I don’t want to suggest that we are, but we will have to make some hard choices if I’m not working and we’re paying $1,300 a month to an insurance company.

In my field, I could make more money in the short term, and probably have less stress, if I were to focus on temping (which includes overtime) instead of being a full-time salaried employee (which doesn’t).  But the full-time salaried job at a big company includes affordable access to better-than-average health insurance.  I have asthma & allergies, which means maintenance meds — and allergy shots.  I am also OMG FAT & have a history of depression, which makes me expensive to insure.  So yeah, I’ll do the big company salaried job if they want me.  At least they gave me a signing bonus (which helped make up for the overtime) and stock (which I try not to count on, because I’ve had employer stock become worthless).

You’re SORRY? Oh fuck you.

Dr. Peter Attia thinks about his former patient often, the woman who came to him in the emergency room at Johns Hopkins Hospital one night seven years ago.

She was obese and suffering from a severe complication of Type 2 diabetes, a foot ulcer, which required an urgent amputation. At the time, Dr. Attia admits, he silently judged her. If she had only taken better care of her health, maybe exercised more and eaten less, he thought to himself, this never would have happened to her.

But a few months ago, in a TED talk, Dr. Attia stepped onto a stage and offered a few words to his former patient: “I hope you can forgive me.”

WHAT THE FUCK?  Why should she forgive you?  You’re just another judgmental asshole in a nice long line of judgmental assholes.  Is it really such a stain on your self-image that someone might not worship you as the all-perfect person you want to be?  Why should she spend any pity or compassion on you?

“As a doctor, I delivered the best clinical care I could, but as a human being, I let you down,” Dr. Attia, his voice breaking, said in his talk. “You didn’t need my judgment and my contempt. You needed my empathy and compassion.”

Wow.   Just … wow.   He thinks his “judgment and contempt” did not prevent him from delivering the best clinical care?  Or is he admitting that the “best clinical care I could” might not be the best clinical care?

I still don’t see why he thinks an apology from just one doctor might MATTER at this point.  Maybe it would.  Maybe pigs would fly, I don’t know.

Apparently Attia’s now looking into research on whether “the precursors to diabetes cause obesity, and not the other way around“.  Interesting.  Did he read some genetic research on type 2 diabetes?

Dr. Attia’s insight was informed, in part, by the startling discovery a few years ago that despite paying close attention to his diet and exercising frequently, often for hours at a time, he had developed metabolic syndrome, a precursor to Type 2 diabetes. He had made all the right lifestyle choices, he thought, and yet he was overweight and on a fast track toward obesity and diabetes.

Oh for fuck’s sake.   Dr Perfect is SHOCKED, SHOCKED to discover his body is not 100% under his control at all times.  OMG, this is a REVELATION.

Sources:

NY Times article on Dr Attia, where I pulled most of the quotes from.

Dr Attia’s TED talk.

Why I Think Declaring Obesity A Disease is Harmful

It’s inaccurate:

It distracts from the real issues:

It’s a win for the weight cycling industry

Unfortunately, what’s good for the weight cycling industry isn’t necessarily good for patients: 

There is a Change.org petition on this – I’ve signed, have you?