Horrible New Medical Guidelines for Fat Patients

Bad DoctorWhen reader Vivian asked me what I thought of a piece from Medscape called “New US Obesity Guidelines: Treat the Weight First”  I geared myself up to read something terrible.  I didn’t imagine just how horrible it would be.

In the article Dr Caroline M Apovian discusses a paper, of which she was the lead author, that suggests guidelines about how to care for fat people who have actual health issues:

The guidelines advise treating the weight first with lifestyle modification and medication and then managing the remaining comorbidities that have not responded to any weight loss, including hyperglycemia, hypertension, and dyslipidemia.

She also recommends that if patients are taking medication that has a side effect of weight gain (including those for depression, epilepsy, and schizophrenia) including “insulin, sulfonylureas, thiazolidinediones, beta-blockers, or certain specific selective serotonin-reuptake inhibitors (SSRIs) like paroxetine”  they should be tapered off of them – even if the medication is working for their health issue and even if the tapering process may cause unnecessary physical and mental health issues – and put them on “alternative agents that don’t increase weight.”

So what these guidelines are actually saying is that only thin people should get evidence-based treatment for their health issues.  But don’t worry, because according to Dr. Apovian, they’ve really got a handle on this whole weight loss thing:

In the end, you’re going to give the best guess of which drug the patient should go on….If the patient doesn’t lose 5% of their weight in 12 weeks, stop the drug and try another. Unless you can really get a clear idea of what you think the patient is going to do best on, you’re going to be prescribing by trial and error….This is the question I get asked the most often. Unfortunately, the research isn’t there to help us beyond that.

Oh yes, this definitely has the ring of good evidence-based medicine, and doesn’t sound at all like completely uncontrolled experimental medicine. Not to mention that weight loss drugs cause everything from uncontrolled anal seepage to addiction and death and all for a minimal weight loss (4.5 pounds in a year!) which their own studies show patients begin to regain almost immediately.

She goes on to lament that the drugs aren’t covered by insurance and that doctors aren’t prescribing them enough (I’m thinking that’s perhaps because doctors know about their lack of efficacy and horrible side effects, but I’m just spitballing here.)

“Certainly, insurance coverage will help tremendously, but if we don’t have doctors out there who are trained to deliver the treatment in the manner we indicate in [both the 2013 and the current guidelines], we are not going to be able to utilize them even if they are covered by insurance….We’re trying to get a cadre out there of doctors who can use these medications. Once that happens, insurers will start covering them. The disadvantage now is the price.”

I would think that the disadvantage is the uncontrolled anal seepage, addiction, death, and total failure of the drugs but hey, what do I know? If you’re wondering how in the world a trained doctor could put people’s health and lives at risk while trying to sell them expensive dangerous drugs that don’t work, then you might consider this:

Dr Apovian serves on advisory boards for Amylin, Merck, Johnson & Johnson, Arena, Nutrisystem, Zafgen, Sanofi, Orexigen, and Enteromedics. She has received research funding from Lilly, Amylin, Aspire Bariatrics, GI Dynamics, Pfizer, Sanofi, Orexigen, MetaProteomics, and the Dr Robert C and Veronica Atkins Foundation.

Hmmm, she’s on the advisory boards of companies that make weight loss drugs, and she’s written guidelines that recommend a massive increase in the use of weight loss drugs.  That’s curious. I think that this is what happens when healthcare for profit and a cultural hatred of fat people collide.  This is the real “war on obesity” they want us thin, but they don’t mind if we die, as long as we’re not fat and they stay rich.

If these guidelines are adopted it means that fat people will have to fight even harder to get evidence-based medicine instead of “interventions” that are bought and paid for by diet companies. We’re going to have to wonder if our doctor is prescribing us a subpar medicine because they are following guidelines that tell them they should be more concerned about our body size than our actual health.

We’ll have to worry that they are withholding treatment that a thin person would be offered, unless and until we are able to manipulate our body size to their satisfaction.

Those who agree to take the diet drugs will have to worry that their ability to get actual healthcare rests on expensive, dangerous drugs with a poor track record that are being prescribed to them on a trial and error basis, and that 12 weeks from now when the drugs don’t work they will be prescribed a different expensive, dangerous drug, and again 12 weeks later, all while still being refused the evidence-based healthcare that they would have been prescribed 24 weeks ago if they were thin.

Those who agree to take the drugs will have to wonder what will happen when, as all the research shows is a near certainty, they regain the weight – will their doctor cease any evidence-based interventions to start another yet another trial and error weight loss drug?  We’ll have to wonder how many weight loss drug companies have our doctors on payroll (unless, of course, Dr. Apovian is our physician, then we know that it’s basically all of them.)

To me this is justification for my approach to dealing with healthcare practitioners, which is to constantly ask questions, ask for the research upon which their treatment suggestions are based, ask to be given the same interventions that a thin person would be given, and doing my own research.  I claimed the leadership role position in my personal healthcare and treat doctors as people who support and work with me on that, and not as gods who are above providing me with an explanation.

Of course my being in a position to do that is also a reflection of my various privileges. As long as I can do that I will, and I will continue to fight for those who aren’t in a position to question this sort of bought and paid for medical malpractice, because the alternative is just far too terrifying.

If you want some suggestions on how to deal with this at the doctor’s office, check out this post!

If you want to share your thoughts with Dr. Apovian:

Find her on Facebook:  https://www.facebook.com/drapovian

Or on Twitter:  https://twitter.com/drapovian

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Published in: on January 21, 2015 at 9:06 am  Comments (123)  

123 CommentsLeave a comment

  1. Holy fucking hell. Is it getting worse out there, Ragen?

  2. Holy Crap! I think I need to go back upstairs and hide under my covers. I think this lady went to the same medical school as my last horrid doctor who seemed to think I was hiding my diabetes from her. Nope, no diabetes here, although, if that had been a problem that would have been lovely to have diagnosed and work on a treatment plan. Can you, maybe, notice that my B12 levels are almost in the holy-fucking-hell-you-should-be-in-a-coma level and figure out what all my other symptoms meant? No? Ok, lemme find another doctor.

    What is wrong with these people that they want to experiment with weight loss drug after weight loss drug and *gasp* DISCONTINUE the use of other drugs EVEN IF THEY ARE WORKING if they could possibly cause weight gain?

    • I take a beta-blocker to help control congestive heart failure. It works. And yes, I’ve gained weight while taking it. SO WHAT???? I am alive, stable, doing well, and walking at least 45 minutes a day; when I was first diagnosed I was so weak that I could barely walk a hundred yards. But this idiot wants to taper me OFF the beta-blocker so that I’ll lose the weight … ? WTF?????

      • Makes no sense. If the drug works and makes your life better, isn’t that the purpose of medicine?

        • But- but, it made you fat! That’s not making your life better! That’s making your life worse! *eyeroll*

    • I had that problem with a doc too, about the B12 levels. My dad also had abyssmally low B12, but the doc did nothing. He diagnosed me with tendonitis when my hands were killing me (and the fingers). I decided to take B12 on my own, since I rarely eat meat, or enough of it. After 9 months I was doing the best in my whole life!

  3. From a personal standpoint, what I find truly terrifying about this is the recommendation to taper off weight-gain-inducing drugs needed for other conditions. Bipolar disorder medications are notorious for weight gain. They also prevent suicide. For untreated bipolar disorder, the suicide rate I’ve seen quoted is in the neighborhood of 15%.

    • That’s the piece that boggles my mind. Medications have saved me from severe depression that would have led to suicide….this woman is really essentially telling fat people to kill themselves….how on earth is that part of the Hippocratic Oath??

      • This is “One less fatty” syndrome. The drugs are keeping you alive, but you now undesirable, so this is to make way for a more desirable person. Eugenics in action. 😦

    • I definitely agree that this is terrifying. My husband as moderately severe bipolar disorder; I’m pretty sure he’d be dead or completely incapable of functioning in society without his meds. Yes, he’s gained weight! But he’s sweet, hard working, and STABLE!

    • I know this school of thought is what caused my fibromyalgia doctor to want to prescribe me Cymbalta for my fibro. He tells me this is the one he wants, and I have to have my blood pressure checked like once a week and keep an eye on yourself in case any suicidal thoughts come up, but it’s the best choice for you because it has less chance of gaining weight… When he finally stopped to take a breath from all the horrible things that might happen to me while I was on Cymbalta I asked him if I could have something other than an Anti-depressant because I don’t like them or how I feel when I take them. He asked me to explain, then he tells me well my second choice is Gabapentin, stepping up weekly to 600 mg a day, unless when you increase your dose you are too tired the next day. And that was it. No 5 minute discussion of all the ways the medication could kill me. He simply chose Cymbalta because it might cause less weight gain. Might make me want to kill myself, or cause my blood pressure to try to kill me, but at least I won’t be even more fat than I already am. I went with Gabapentin and I am very happy I stood up to him. I don’t care if it makes me more fat. I’m happy and I’m fat, and what’s another pants size if I’m happy and have less pain, less headaches and I’m sleeping better?

  4. Is this the first time this formal recommendation has been put down in so many words, to the best of your knowledge, Ragen? Because my blood is running cold to see it in print like that. Dr. Apovian said that she wants to officially escalate the war on obesity to a holocaust.

    • Wow, someone already said what I was thinking, this almost feels like genocidal-level thinking, either we fall in line or they let us die of easily treatable illnesses.

      • It really is an escalation of the “War on Obesity” to holocaust levels. If you want to make sure you don’t have to see fat people anymore, and you can’t make them not be fat, then risk making them plain just not be anymore.

        I get that she’s a diet shill, and while I find that disgusting, she’s entitled. What I don’t see is how she’s entitled to promote medical malpractice as a solution for obesity.

        • Yep, the “none is too many” approach. This was the response to a boat of Jewish refugees coming to Canada in the 1940s. They were turned back and all were gassed. There’s a book about it, with the same name.

          It’s appearing that the same prejudice, but with a diff. target, is now the order of the day.

          • And just like racism against Jews was at that time, fatphobia is considered openly acceptable and justifiable. (The term “anti-Semitism” pre-dates the word “racism.”) The difference is that violent hatred towards Jews has existed for thousands of years, whereas fatphobia of this degree is far, far younger–the worst essentially dating in infancy to 1947-48, and the creation and debut of Christian Dior’s New Look.

            (I’m a history dork, medical nerd, and fatshionista dating the most amazing woman ever, who happens to be Jewish and an MD/PhD student, so this is kind of the great Calvin-and-Hobbes-esque massive explosive catastrophe of my skill set.😄 )

            • I saw that show that someone pointed out here, the BBC doc, called “the Men who made us Thin” and the whole cultural move towards thinness. Yes it did indeed start with Dior. Pretty scary.

              Hope your gf can fight against mainstream fatphobia.

  5. As patients I think we need to learn a very important medical term and use it early and often when dealing with doctors who think this way: MALPRACTICE.

  6. My psychiatrist would FREAK if my primary care doc changed any of my medication, weight gain or no weight gain. Even adding a short term antibiotic has to be called in to him to make sure it won’t affect my drug cocktail or destabilize me. And here’s this lady saying, “Oh, just add a weight loss drug.” HA. Could it be that these drugs aren’t covered by insurance because they’re DANGEROUS and DONT WORK? I hope they’re NEVER covered. Most people wont take drugs not covered by insurance because of the expense.

    • We do the same for my husband. His primary MD changed his hypertension medication. The change was totally in line with current recommendations and intended to protect kidney function. However, Primary MD and pharmacist both missed that this drug can interact with Lithium, which he was on at the time. His kidneys shut down & he very nearly died. He can also never take Lithium again (which turned out to be OK, when we finally got a new stable regimen he has had less side effects). He doesn’t take an aspirin without clearing with his psychiatrist.

      As it happens, my husband had lap band a number of years ago. For him the issue is keeping his weight high enough. When he is manic it plummets and when he’s hospitalized it’s impossible to get someone to take the saline out of his band to make eating easier. Weight gain from his psych meds has actually been a blessing.

      • Jeezus friggin’ Krist! That is terrible!

  7. I feel so bad for this woman’s patients. BTW, apparently she has written a book called “Overnight Weight Loss” and has appeared on Dr. Oz-Hole’s show. Yeah, her credentials rock. /sarcasm off.

    While the “guidelines” are positively terrifying, the comments following the article are somewhat encouraging. The folks there identifying themselves as doctors and other health professionals (but of course, there’s no proof) are responding with, basically, WTF??? Yah, there are some of the typical comments and tinged with the usual fat-hate. But there are some kernels of sanity in there too.

    JAC above is right. I would walk away from any doc who tried this crap on me, and call the nearest lawyer. I’m not the litigious type, but this stuff has to stop somehow!

  8. This is super scary stuff…

  9. I’m calling bullshit on this alleged doctor’s suggestions – BULLSHIT!!! This is not treatment of patients; it’s mistreatment. End of story.

  10. This would only be formalising what many doctors already do, sadly. When I emigrated to Australia in 2012, I was no longer able to get the Claritin D that I used for my year-round allergies. I showed up at a chemist begging them to find something else that would stop me from drowning in mucus, and was handed a corticosteroid nasal spray. It worked *amazingly* well. When I went back to the chemist for a refill, I asked if this wasn’t available in the States? (Though that seemed hard to believe.)

    Very matter-of-factly, the pharmacist looked me over, and then told me, though this isn’t an exact quote, “No, they have it. But you’re on the big side, and it causes weight gain, so I find that sometimes US doctors won’t have prescribed it to someone your size.” I think my jaw hit the floor and stayed there for at least ten seconds. Keeping me from gaining weight was more important than keeping me able to *breathe* without trouble, or keeping me from being miserable every morning until the pill kicked in and my eyes stopped itching and running, or from having my allergies trigger an asthma attack. Good to know, right? At least if it’s out in the open, there’s a prayer of fighting it.

    • That’s my hope (that this will help spur fights against this kind of treatment!)

    • This makes me so sad. I’ve never had a doctor specifically prescribe weight loss to me, but now I have to wonder whether doctors are just hiding effective treatments from me because they might cause weight gain. How would I even know? It’s scary.

      • Very scary. It destroyed my trust in my doctors, and basically means that every visit to the doctor comes with a research assignment wherein I have to try to figure out what *might* be going on, and then the proper treatments for all those possibilities, and follow up if what the doctor diagnoses and prescribes is different from what came up in my digging. And, of course, aside from the stress and time spent on that, it doesn’t make for a very pleasant doctor-patient relationship. I try to be non-confrontational, and luckily my GP now isn’t the type to be offended easily, but how much patience does a doctor have for someone who is constantly pushing and questioning?

        • What a waste of time!

        • “..how much patience does a doctor have for someone who is constantly pushing and questioning?”

          So true, and you’ll just be chalked up to what many doctors (according to a recent survey) already believe about fat patients, that we are uncooperative and difficult (among other not so pleasant things). All the while many of us HAVE TO BE in order to get evidence based medical treatments – something most thin people get automatically. It’s a nasty vicious cycle that would just end if doctors would, say, i don’t know, hmmm maybe provide us with Evidence Based treatments.

      • I’ve had 3 doctors, including 2 family docs (who I’ve tossed) prescribe weight loss as the first line of defence against disease and looking “ugly”. One is the same doc as my parents, and I’ve read reviews on ratemymd.com that he is short with elderly and fat patients. Plus he’s statin happy. My mom is suffering the side effects of the statins, but he won’t take her off them.

        This is the same doc who didn’t catch my B12 deficiency. Apparently he’s like the old school “if it hurts, don’t do it” thinking, rather than actually looking for a solution.

        • Let your mom know she can take herself off statins if she wants to. It’s still a free country.

        • “Statin happy”?
          Hmm, kickbacks?

          Makes one wonder, doesn’t it?

    • Huh. I would have thought there’d be other reasons for not using corticosteroids long term, but apparently they’re quite commonly used that way and it doesn’t seem to be a problem.

    • Excuse my ignorance, but I thought it was illegal to immigrate to Australia if your BMI is too high? I’ve read news articles where ppl had to lose weight before they could work there, and sometimes “the other half” couldn’t get down enough, so they were effectively separated.

      • There is a pretty thorough medical examination necessary before they grant a partner visa, but I don’t have any co-morbidities, I’m just fat. Maybe that makes the difference. It wasn’t an issue anyone raised with me, in any case.

  11. I read this the other day and was, pardon my language but it just requires it, fucking furious. I meant to share in RNT and forgot.

    It made me curious, though, about the 4 new FDA approved meds. So using http://www.epocrates.com, I looked up the side effects, and I did screenshots, which I saved. This is fun (except not really).

    Qysmia (so long it requires two screengrabs):

    Contrave:

    Belviq:

    And the most recently approved drug is called Saxenda. It’s essentially a higher dosage of a medication – Victoza – which is already being used to control diabetes. This was so recently approved (late December) that Epocrates doesn’t even have it yet. But I went to the Victoza page instead. Remember… this is the list of side effects for a LOWER dosage of this medication.

    Sooo… at a LOWER dosage this medication is linked to cancer, but hey we should lose weight so we’re at a lower risk of cancer, right? What is wrong with this picture?!

    I also “highlighted” the side effects I found most curious, since they’re all similar to the things we’re supposed to be trying to avoid by virtue of being fat. Sooo… if we wind up hypertensive because of a weight loss drug, that’s okay, right? Because we’re trying to be smaller? Wtf.

    Saxenda is also only approved in patients with a (ugh gag me) BMI of 30 or higher, OR patients with a BMI of 27 or higher IF they also have a so-called “co-morbidity” of obesity… like diabetes, although Saxenda sounds like a VERY questionable choice for people with diabetes, and in fact, the FDA fact sheet says it is not to be used in the “treatment of diabetes, as the safety and efficacy of Saxenda for the treatment of diabetes has not been established.”

    Oh. Oh, yeah and Saxenda is an injected medication. Fun times. Let me inject myself with something linked to thyroid cancer. Or not.

    This whole article pissed me off. I have fibromyalgia, something a very thin, clearly fatphobic rheumatologist did not want to diagnose me with, despite a preliminary diagnosis from my PCP. In fact, said doctor wouldn’t even friggin’ touch me long enough to do the gold standard exam for diagnosis fibromyalgia (commonly called the “tender point test).

    Nor would she prescribe Lyrica, because, and I quote, “one of Lyrica’s most common side effects is weight gain, and you don’t want that.”

    Actually, bitch, if it means I get to NOT live a life of daily pain? Yeah, I do want that. Sign me up. I ultimately wrote her an absolutely scathing letter about how poorly she treated me as a fat patient (she sent me out with prescriptions for medications I’d already clearly stated did not work for me, and in fact, were bad for me). She called my PCP and said “I’m worried about the mental health of your patient” in response to my letter. To my credit, my doctor basically laughed at her and assured her I was fine. And then she prescribed me Lyrica, and I didn’t gain any weight at all. Sadly, nor did it work for me. But at least I got to try it.

    So this Dr. Apovian, who would take away medications that, presumably ARE working for fat patients, simply to try to reduce weight gain? That is preposterous. Especially when you start to talk about meds like SSRIs, which often take a HUGE amount of trial and error to get right… but hey, if it might be making you fatter, we’d best wean you off even IF that might make your mental health worse. Because who cares if you wind up suicidal or deeply depressed just so long as you might – MIGHT – lose weight!

    *STABS THINGS*

    ~Jessica Lynn

    • contrave – homicidal ideation. a shame that would be directed at someone undeserving, unlike that charming doctor.

      • Contrave is a combination of the anti-depressant Wellbutrin with the opioid-addiction treatment drug Vivitrol. It inherits the side effects of both the component drugs, unfortunately. Suicidal ideation and homicidal ideation are both known adverse effects of Wellbutrin.

        • I’m glad you explained what Contrave is. My doc once gave me Wellbutrin to help me sleep, and weeks later I finally realized due to timing it was why I was an emotional mess AND suffering weird gastro issues as well. I weaned myself off it and was back to normal in a week.

          I’m suspicious of diet pills anyway, but I’d really hate to think I could have been put back on that merry-go-round without realizing what I was getting into.

          • I can’t imagine how Wellbutrin would help you sleep. I was under the impression that it is a stimulant!

        • I was given Wellbutrin for depression. I was okay on the half dose I started off with, but within days of going onto the therapeutic dose I became very, very angry. (It also affected me like an upper — I couldn’t sit down, couldn’t sleep, and I cleaned every inch of the house in an obsessive — think scrubbing the floor with a toothbrush — fashion.) Everything made me angry. Calling it “rage” would not be an exaggeration. I phoned the doctor to ask if I could stop taking it cold turkey (a previous attempt to go off Paxil without slow weaning was a nightmare) and waited days for the doctor’s office to call me back and let me know. I was so irrationally angry that in the end I stopped taking it without medical confirmation that it was okay to do so. Even after explaining what had happened to my doctor, I was not told that this could be an expected adverse affect of the medication! All this time I’ve thought it was just me.

    • Nice research there!

      This is a link to the actual Journal article:

      http://press.endocrine.org/doi/pdf/10.1210/jc.2014-3415

      Article is quite long. I skimmed it.

      Given your list of side effects, I noted something potentially scary in the Journal article. It looks like they are going for lifetime consumption of their weight loss meds.

      During weight loss: The guideline acknowledges that losing weight is hard. Losing weight involves lifestyle change and reduced calorie intake. Hence, it encourages prescribing weight loss meds to patients to more easily achieve weight loss goals.

      After weight loss: Guideline acknowledges that long-term weight loss can be difficult to maintain-because-body BMR slows due to the weight loss, forcing patient to under consume calories to maintain the loss. IOW, deck stacked against patient. The recommendation here is for patient to continue to take the weight loss meds to maintain the weight loss.

      How long must patient take weight loss meds? I didn’t see any end date suggestions. However, as meds lose effectiveness over time, the guideline recommends “dose escalation” (from article): If medication for obesity management is prescribed as adjunctive therapy to comprehensive lifestyle intervention, we suggest initiating therapy with dose escalation based on efficacy and tolerability to the recommended dose and not exceeding the upper approved dose boundaries.

      Um, won’t increased dosages increase the chance/severity of side effects? I love you too, dr.

      Not keen on any of the side effects listed above-although right now, homicidal ideation –under the Contrave list- sounds mighty tempting to me. Just sayin’!

    • For Qysima, it says “seizures, if abrupt D/C”. Does that mean, “don’t call” as there is no treatment for drug induced seizures? Crazy.

      Also, let’s go on a murder spree!!!!

      • Forgot to add that the cancer one will sell real well.

      • “Seizures, if abrupt D/C” means don’t just stop taking the drug; you have to taper off slowly to avoid the nasty withdrawal. “D/C” in this means “discontinue”.

      • Hey! I’m there!

    • SEROTONIN SYNDROME????????

      If a plant had the “side effect” list of any one of these drugs, or half the list, it would be considered deadly toxic. As in, eradicate on sight, or avoid at all costs. WHAT THE FUCK, MAN?

    • I happened to notice one of the “serious reactions” to Belviq is priapism. This is considered a medical emergency (according to wiki). It stems from the Greek god Priapus who had an enormous penis. The uncovered art from Pompey that features him, is hidden in the back room so that women won’t be turned on/offended.

      Basically this is a condition that could be called biggus dickus, or the eternal erection. Erections lasting longer 4 hrs cut off blood flow to the penis, and gangrene is an outcome of it.

    • I know this school of thought is what caused my fatphobic rheumatologist to want to prescribe me Cymbalta for my fibro. I was lucky that he did diagnose me and do a tender points test. On my second visit after all my blood work came back negative he tells me Cymbalta is the one he wants me to try, and I have to have my blood pressure checked like once a week and keep an eye on yourself in case any suicidal thoughts come up, but it’s the best choice for you because it has less chance of gaining weight… When he finally stopped to take a breath from all the horrible things that might happen to me while I was on Cymbalta I asked him if I could have something other than an Anti-depressant because I don’t like them or how I feel when I take them. After he had me explain how I feel when I’m on them, he tells me his second choice is Gabapentin, stepping up weekly to 600 mg a day, unless when you increase your dose you are too tired the next day. And that was it. No five minute discussion of all the ways the medication could kill me. He simply chose Cymbalta because it might cause less weight gain. Might make me want to kill myself, or cause my blood pressure to try to kill me, but at least I won’t be even more fat than I already am. I went with Gabapentin and I am very happy I stood up to him about that. I don’t care if it makes me more fat. I’m happy and I’m fat, and what’s another pants size if I’m happy and have less pain, less headaches and I’m sleeping better?
      Of course he continues to prescribe weight loss and an 1800 calorie diet as treatment for my fibro too, but as much as I’ve been able to tell him I have never dieted, I haven’t been able to tell him I’m not going to diet. I’ve only had two visits, and the second one was when he prescribed my meds, so part of it was just trying to not seem obstinate to where he won’t prescribe me anything. My next visit I’m going to try to discuss it with him. When he tells me he’s going to put me on an 1800 calorie diet I make noncommittal nonverbal sounds. I don’t disagree, but I don’t agree either, and then I go home and do what I was doing before. I’ve been on it for a month and I think it is helping me. I don’t know if I’ve gained any weight because I only weigh myself at the doctor, and I usually make sure any pants and clothes I own have room to move in them, so gaining weight isn’t going to make anything not fit.

      • Also I have a fat friendly Fibromyalgia Facebook support group. It’s a closed group so you can find it but nobody can see who is in it or what is posted unless they are in the group. If you are interested in joining search for us ‘Fibromyalgia Body Positive Support Group’

  12. PS. If you’re as appalled by this “doctor” as I am, here’s her facebook page. She proudly boasts of her work on these “guidelines,” and I called her out on them. I expect my comment to be refuted or outright removed (probably the latter), but it still might be worth commenting.

    https://www.facebook.com/drapovian

    • Gee, what a shocker, she has a diet book to hock.

      • Yes, the “Overnight Diet,” which doesn’t sound at ALL like yet another fad diet with a catchy name. Oh, wait…

        • It’s not even particularly highly-rated. I mean you’d think being an expert and all she could craft something with a solid base and evidence…sorry, couldn’t keep a straight face.

          • Dr. Apovian also sells diet foods. On the facebook page, scroll down to the 07 Jan entry. It reads: My Caramel Nut Proti Bars are an excellent snack or dessert.

            She (and other doctors) developed the Protidiet:

            http://www.protidiet.com/en/index.php?option=com_content&view=article&id=30&Itemid=184

            So she’s got a financial stake in promoting dieting. That’s in addition to whatever ‘compensation’ received for being on advisory boards for various big pharma companies.

            There ought to be a law against doctors shilling for causes that are simply fronts to line their own pockets.

            I haven’t pulled up the article yet, but there ought to be a disclaimer as part of it indicating her financial stake at promoting the viewpoint she did.

            Crook.

            • I’ve said it before, and I’ll say it again: the only difference between the tobacco industry and the diet industry is good publicity.

      • why is it that every one with these “GOOD IDEAS” is always trying to make a quick buck? Its like they just can’t help but try and profit from people who already have low self esteem and body image issues?

    • which is yr comment? i would like to vote it up.

      • I am Jessica Lynn on facebook, kafkette.

  13. Reading this, I was extra-grateful that my doctor doesn’t practice medicine this way — largely because I might have had a stroke reading it if he wasn’t amenable to treating my hypertension without me needing to lose weight. Not that it would work, anyway, because the high blood pressure predates the fat, but I’m sure in her world that’s just me making excuses.

    I noticed she doesn’t say what doctors are supposed to do when no drug works for the weight loss and they’re out of obesity drugs. Just keep prescribing random things the patient doesn’t need until something sickens them enough they lose weight? Even if takes escalating to, say, chemotherapy drugs to get the job done?

    And all the while it’s okay to ignore real disease like hypertension, diabetes, and most likely broken bones until the weight is forced off. What in the actual hell ever happened to “first do no harm”? Did she skip that part when she took the hippocratic oath? Grrrr.

    • Just keep prescribing random things the patient doesn’t need until something sickens them enough they lose weight?

      Tapeworms?

      grrrrr.

  14. I couldn’t even finish reading this, I got so upset. I’ve been taking anti-depressants for years – they’ve saved my life and I feel normal and functional because of them. The idea that someone is saying I should be taken off them because I’m bigger…. I’m speechless. I mean, I guess when I get so depressed I kill myself that would be one less obese person in the world right? Is that the goal?

    How about treating the person rather than the fat.

    • Christa, that’s exactly what I said in reply to her post on facebook…

      “This is not evidence based medicine. This is fat phobia, bias and fear mongering at its absolute worst, under the guise of “helping” fat patients. And if a few of us die in the process of “being helped” by so-called “medical professionals” like you, who cares, right? Just casualties in the War on Obesity, and HEY – bonus… a few less fat people in the world.”

      • I’m glad people are saying that to her – it’s so outrageous that a medical “professional” is behaving this way. It’s no wonder going to new doctors makes me nervous.

    • That is it exactly. “One less fatty”.

  15. And the hits just keep on coming. This one is about a new device that sends electrical signals through the vagus nerve to dampen your appetite! Ugh. http://www.latimes.com/science/sciencenow/la-sci-sn-fda-device-weight-loss-20150114-story.html

    • Oh, yeah. I saw Caroline Apovian is pimping that device, too. She links to her Today show appearance related to that on her facebook page.

      She is just up to her elbows in that weight loss industry honey pot, isn’t she?

    • Didn’t they try electric shocks over a decade ago, and *shock* it led to weight gain?

      • I just wrote a blog post about that thing. http://www.bigbadbuddhist.blogspot.com What I found most hilarious was the part where the manufacturers assume you won’t eat if you don’t feel hungry.

  16. (weeps uncontrollably)

    I can’t even string words in the face of this one today.

    Shit.

    • Hugs.

      • Thanks, much appreciated.

  17. One question to the background of this paper, where on the scale from “law of the land” to “opinion piece” does is fall?

    (Blog sees to be blacklisting not only my mail account but also my webpage???)

    • I want to know this, too. These are “suggested guidelines” — suggested TO whom? Is this something that’s being considered for formal endorsement by (say) the Surgeon General, or is it just the opinion of the Endocrine Society (and what professional status does that society have)? In short, are doctors going to be required or strongly encouraged to follow these guidelines, or are these just basically another set of suggestions out there competing with all the other suggestions?

      Either way, it’s infuriating and horrifying, but it really matters a lot if these are poised to become formal government-endorsed recommendations or not.

      • I had the same thought, Elizabeth… however, I do know that “doctor” has worked for the government, which makes it a bit more concerning that it might be otherwise. Hopefully, these “guidelines” aren’t anything more than one organization or so-called study writing up shit that bears no real weight (no pun intended) in most of the medical community.

        • I wondered this, too. I’d be relieved to know this is just one fatphobe fantasizing about what she’d *like* to do to us as opposed to something people in power are seriously attempting to get done. Either way, it should outrage every decent person on this planet anyone would suggest denying an entire group of people life-saving medicine because she doesn’t find them attractive.

  18. This is horrifying. Someone very close to me takes some pretty heavy duty psychiatric drugs which have allowed her to function normally, go back to school, hold down a job, and regain her life. They have also caused her to gain 30 lbs. The idea that she should be taken off of those drugs in order to lose weight is truly horrifying, because I have seen what she was like before she started them and it was scary. Really scary. But who cares if she can function, as long as she’s thin, right? WTF?!?!?!?!?!?!

    • I wonder if the idea is that once she’s thin, all her other issues will resolve themselves. Seems it either has to be that or this woman hasn’t considered exactly which conditions would have to go untreated to promote weight loss.

      And frankly, either explanation is terrifying.

      • Well, the weight loss industry (which I think it’s clear is the industry Dr. Caroline Apovian works for) is trying to sell us an idea: Lose Weight and Magically Become Healthy/Happy. If we as a society refused to buy into that idea, the industry would collapse.

        • What about all the thin ppl who aren’t happy? Oops no treatment there, they might get fat.

          It also disproves that thinness is a guarantor of happiness.

  19. And this this shows up on the Oncology RN feed. http://n.ons.org/17BhB9G
    Really, I’m sorry that weight loss rather than proper nutrition is being supported by my professional group.

    • That really sucks.

  20. How can this be taken seriously? This is the website of the Endocrine Society — I don’t have time right now to research all of these people, but I wonder about its legitimacy: http://www.endocrine.org/about-us/leadership-and-staff

    I just posted a comment on Apovian’s FB page.

    The reason you can’t post a comment on the original article is because commenting is restricted to “medical professionals.”

    • Well, this goes back to 2003, but the list of companies with ties to said society is quite eye-opening. It includes Abbott Laboratories, who created Meridia, Aventis, which created Acomplia (a fun little weight-loss drug that induced suicide and psychosis), and Genentech, who created Xenical. Hmmm…

      http://www.cspinet.org/integrity/corp_funding.html

  21. Left this comment for the good (sic) doctor: “These “guidelines” are a disaster for higher-weight people, and show that medical doctors are perfectly willing to hold actual medical care hostage to nonsensical demands for weight cycling. The evidence is clear that pursuing weight loss (rather than sustainable practices for health) leads to worsened mental and physical outcomes for the majority of people in the long run. Add now the delay in treatment and/or the withdrawing of effective treatments for diabetes, bipolar disorder, depression, asthma, eating disorders – I fear for us all. Please, Dr. Apovian, surely your long years of medical training qualify you to be an actual medical doctor rather than a marketer for the weight cycling industry.”

    • We need more like you.

    • Thank you for writing what some of us can’t.

      I am too angry right now to write anything not dripping with sarcasm and fury on that FB page. Sarcasm and fury are wasted on people like Dr. Apovian. Plus, I suspect I’m going to need all my energy in the months ahead.

  22. “Dr Apovian, who also served on that writing panel, pointed out that the 2013 guidelines covered lifestyle, medications, and surgery but didn’t go into detail about pharmacotherapy because there were few drugs available in the United States at the time it was written.

    But in the past 4 months, the US Food and Drug Administration has approved bupropion/naltrexone (Contrave, Orexigen Therapeutics) and liraglutide (Saxenda, Novo Nordisk) for weight loss.”

    So what she is recommending is that doctors prescribe first one, then the other drug… but what happens at the end of 24 weeks if neither drug has worked (or if the side effects make the drug impossible for an individual, or WHEN the drug is proven to cause some horrible issue like cancer or heart damage)? This whole “blueprint” horrifies me.

  23. Horrific

  24. Seriously?! I’m epileptic, and anticonvulsants are notorious for causing weight gain. The one I’m on now doesn’t, but if I had a choice between gaining weight and being seizure free or staying the same weight and still having seizures? I want to be able to drive! I want to be able to leave the house unaccompanied, to be able to work full time! There are lots of epileptic people who make this choice.

    But apparently a person’s livelihood and independence don’t matter to this so-called ‘doctor’.

    • I’m an epileptic as well. I have finally found a medicine that works, and luckily gaining weight is not a side effect of this one. After one of my grand mal seizures on depakote (which just didn’t work), I had a doctor change my meds to Topamax (aka Dopamax) because “omgweightloss!” I literally couldn’t function. My speech was slurred, my brain was foggy all the time, I couldn’t drive, but hey, I lost 30 pounds. When I went to my doc in tears begging him to change, he commented on the weight loss. “You obviously need it, why would you want to change the meds now?” My mom, who worked at the same hospital, had to step in and demand that he do something because my brain was so messed up I could barely talk. Reading about this brought back those same feelings and makes me think of how helpless doctors have made me feel even without these guidelines in place. My heart just hurts about this. I couldn’t even find the words until today.😦

      • Yikes! Putting the scale number ahead of quality of life, astounding.

      • That’s horrifying. I’m glad your mom stepped in and that you’re doing okay now.

      • My doctor tried putting me on Topamax for migraines (I was already on Keppra for seizures) and about two weeks in I called them because of the same effect you are talking about, but what made me call was hallucinating. I didn’t even make it to Hallucinate before the nurse told me to stop taking it, the slurred speech and feeling drunk for that long was enough. Those are the serious stop immediately side effects if it lasts more than a few days. I can’t believe he would keep you on it like that. I’m so glad you got everything sorted out.

        Gotta say, it was good shit for the first week. It certainly made me feel good, until I started running into walls and not being able to speak.

  25. This is horrifying, especially considering my recent experiences!

  26. Maybe it’s petition time to call this person out? Publicly shame her?

  27. Thank you so much for this post, it gives me a really good idea about what might be driving my own doctor’s attitude toward me, and understanding that will help me to communicate better with him and ask better questions. As soon as my disability is approved, I plan to go back to my old doctor because she is more in tune with me and my body, and never ever threatened to withhold treatments if I did not show a continued weight loss. Also I will be researching natural treatments for my various issues so that I can rely less on the medical community for healthcare. Your blog has become a go-to for me, I am feeling stronger emotionally about standing up for my right to be viewed and treated as a whole person.

  28. This is amazing timing…I am convinced that my “world-class” psychiatrist who demanded me to keep a food log (becuase of the SUPPOSED correlation between binge eating disorder and depression and anxiety) is following these governement guidelines. I am sick to death.

    I have good news and bad news today, the good news is that I refused to keep a food log as a form of activism and he didn’t freak out. He just said that if I want to follow his guidelines on how to reduce my anxiety (massive crippling anxiety at that, lol) than we need to get to the bottom of the anxiety and he thinks that my “addiction to food” (his words, not mine, because I enjoy food, but certainly not addicted) needs to be addressed. He sent me to my next appointment with the request that I keep a food log for next weeks appointment. Well I said I would think about it but I will absolutely not be keeping a food log.

    • I certainly don’t mean to tell you what to do, and I don’t want to be discouraging, but I can tell you that my own experience with a “food log” — school assignment of all things, not even from a doctor — only ended in a confused look on the reviewer’s face and me being questioned as to its accuracy.

      And as for “food addiction” — well, yeah. Kind of addicted to oxygen, too, aren’t you? Probably overfond of having a place to live and clothes, too. How in the world can one be addicted to something that you have to have to survive. That’s always bothered me.

      • Laney, I was going to make the same point about oxygen. I detest the term “food addiction.” I reject the idea you can have an addiction to anything you NEED to survive, unless that’s how you’re defining “addiction.”

      • And therein lies the problem. What’s the point in keeping a food log when you know from experience that if you turn in a log that doesn’t include what the doctor has already decided you “must” be eating (ie, “Today I had six Big Macs, three ten-gallon drums of pork lard with extra butter, an adorable kitten, and a bucket of pasta boiled in thin tears for a grand caloric total of OVER 9000!”), he’s just going to accuse you of lying?

        • Sometimes I wish I really could down that much food in a day (excluding the adorable kitten), just so I could watch the Food Cops freak out about it.

          • I think most of us would actually puke on that much food.

            • Just make sure you’re facing towards Dr. Wonderful there when you let fly. :p

    • good for you! i loath keeping food records! and even if you do binge eat, that is not a cause of anxiety! If you are going to keep a record of anything, I would suggest you just write down what is going on when you do have an anxiety attack. This helped me and I only needed to keep writing it down for a couple of weeks before I was able to identify my anxiety triggers. It really has nothing to do with food!

    • Also not going to tell you what you should or shouldn’t do, but be aware that if you *don’t* keep the food log, your psych is likely to write you off as non-compliant and in denial about your “food addiction”. He didn’t freak out, and that’s good, but your treatment is stalled because HE is stuck on “must have food log”, and he’s not moving on. As frustrating as it is, and as discouraging as wasting your time on the food log will be, it might be worth it to you to do it so he moves on to something that has a prayer of HELPING you.

    • It’s nice to know that world class psychiatrists can’t tell the difference between “eats when depressed or anxious” and “binge eating”.

      Also, yeah, major side-eye to “addicted to food”. Yeah, I need food to live. I am so totally addicted. To food, to oxygen, to water. Maybe I should go cold turkey? After all, it will eventually cure my depression. However, I’ll come down with a major case of being dead instead.

  29. “If the patient doesn’t lose 5% of their weight in 12 weeks, stop the drug and try another. Unless you can really get a clear idea of what you think the patient is going to do best on, you’re going to be prescribing by trial and error”

    Isn’t that what she is prescribing: trial and error with a 12 week trial period?

  30. I won’t allow me to see anything, I need to log in.

  31. I’m in tears.
    The last month has been hell.

    I’m bulimic (in treatment… will an ED clinic) and of course I still can’t accept myself being fat. So, my doctor recommended phentermine, for when I was “no longer bulimic” so that it would help me “control myself” around food. The catch was, he’d only prescribe it if I slowly weaned off venlafaxine (for depression). I was so desperate that I crashed off them (over 20 days instead of three months) and ended up in the emergency room at midnight because I was so sick. Now it’s a month since this happened and I’m manic and have to take quetiapine every day.

    Oh but he still wants me to take the phentermine because he thinks my desire to lose weight is “admirable”.

  32. And this is why I avoid going to the doctor. So there’s that…

  33. GRADE Guidelines (see reference #2 – DOI: http://dx.doi.org/10.1210/jc.2007-1907) used in Apovian article:

    “GRADE describes the quality of the evidence using four levels: very low, low, moderate, and high quality. Recommendations can be either strong (“we recommend”) or weak (“we suggest”), and this strength reflects the confidence that guideline panel members have that patients who receive recommended care will be better off. The separation of the quality of the evidence from the strength of the recommendation recognizes the role that values and preferences, as well as clinical and social circumstances, play in formulating practice recommendations.”

    I just started reading this article. 1/2 of recommendations in both sections 1 and 2 rated as weak (“we suggest”). Will continue to read will low expectations…. What a bunch of garbage.

  34. All the while, the longer the real health problems are left untreated the more likely it will domino to other health issues. A healthy body can fight off a lot more than a body trying to tackle health issues that go on without proper medical care. You can be sure those other illness will be chalked up to their weight, and be added to yet more BS statistics about how unhealthy it is to be “overweight” or “obese”.

    The effects of leaving health problems untreated while trying to manipulate body size is just going to snowball into more “evidence” that what they are doing is “right”. By not treating the real problem they are just creating more statistics and “evidence” of how unhealthy it is to live in a non-thin body.

    Yeah, you better believe it’s unhealthy to live in a non-thin body, but not because of the body size, but because of the way our family, co-workers, bosses, complete strangers, and our so-called doctors treat us based on our body size.

    • This! You have summed up my feelings on this perfectly.

  35. I Didn’t even know about that crazy, but was pondering emailing you recently because I ran into this mentality suddenly in a doctor that has always been supportive before. I’ve been getting treated for a back injury related to an accident for the last year. Suddenly out of nowhere, my doctor refused my painkillers and muscle relaxants and said that she would represcribe them if I lost 10lbs to “prove that my morbid obesity is not worsening my condition” I went back ONE WEEK later, 10 lbs lighter, because, i emphasized, I was in so much pain I threw up anything I ate…. and she freaking congratulated me and gave me my meds back. Da fuq. I have been talking to her and have made it clear i will not be taking this BS further, so we have come to an agreement. but ugh.

    • Oh great. So you were constantly throwing up, thereby risking dehydration and electrolyte imbalance — and this frigging idiot of a doctor CONGRATULATES you???

      You can DIE from electrolyte imbalance. I was hospitalized a few years ago for hyponatremia (dangerously low sodium) caused by a bad reaction to a powerful diuretic that I was taking for my congestive heart failure. I went to the ER after I fainted. The stages of hyponatremia are confusion; weakness; fainting; seizures; coma; death. It can be caused by prolonged vomiting. Any doctor with any credentials at all should know that. The idea of a doctor *congratulating* a patient on prolonged vomiting that causes 10 lbs. weight loss in one week makes me so angry I can barely type this.

      We’ve passed through the looking-glass onto the other side, folks. This society is insane.

      • Yeah. Makes me wonder how these folks managed to graduate from med school.

  36. I have this sudden urge to dump 100 pounds of lard on her front steps with a note saying, “Here’s proof I lost weight. Can I have proper medical treatment now?” LOL

  37. Reblogged this on … but I digress.

  38. Wow, definitely pissed off by this. I take a beta-blocker to control chronic migraines and it has been one of the most effective medications. I can’t remember if I gained weight when I started taking it, but if I do- that’s well in the past now. So you want me to go off a medication that works me, that is not currently causing me to gain more weight, and no guarantee that if I go off it I would even lose weight? I mean, even taking the view that being fat is bad and weight loss is the better than anything else (which I do not agree with), what exactly would this be accomplishing?
    Weighing the benefit/risks of a medication is not universal and should fall mostly on patients. I’ve talked with my neurologist about how I would like to try things to reduce my migraines even more, but I won’t try any new preventative that has weight gain as a side effect (most of them do). I think this is very much a my body, my choice. I’m allowed to prioritize the potential benefit or a medication with the possible side effects however I want, and other people have a right to prioritize different.

    It really boggles my mind though the things people think someone being fat is worse than. Being fat is apparently worse than being in constant severe pain that prevents you from doing much at all. Being fat is worse than experiencing psychotic symptoms. And being fat is apparently even worse than being dead (psychiatric medications often cause weight gain and help people with depression not feel suicidal).
    As a fat person, those things are all definitely worse than being fat.

    • re-reading, besides my typos, I feel like I wasn’t clear about my point in the second paragraph- all people are different, our experiences and how we prioritize things are different. You cannot act like a side effect like weight gain is always worse than the benefits for all people who are considered overweight/obese. It’s fine to not want medications with that side effect, it’s also fine if that is not a deciding factor in if you try a medication to control a condition. These are individual issues.

  39. “This is the real “war on obesity” they want us thin, but they don’t mind if we die, as long as we’re not fat and they stay rich.”

    What struck me about this sentence is…if we die, it doesn’t matter if we’re fat. They will have their money, AND we won’t exist anymore for them to prescribe dangerous drugs to, and could just move on to the next fatty.

    I find it utterly ridiculous that doctors think that the worst thing about those who are obese is that they are obese. My doctor is constantly telling me to lose weight, because all my other issues will go away once I do. He’s a jerk, and I’ve told him as much. 😉


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