New Obesity Guidelines Advocate Treating Fatness First, All Other Conditions Later — Including Mental Illness

According to these guidelines, my GP is supposed to sit down with me and tell me that I need to get off my psych meds to lose weight.
Publish date:
January 22, 2015
fat, crazy, obesity panic, medication, obesity, psychiatry, Diagnosis Fat

In college, there was a running joke that whenever you went to Student Health for anything, the first question out of the clinician's mouth would be "Are you pregnant?" followed by "Are you sure you're not pregnant?" if you answered in the negative. Those guys were really convinced that we were running around all over getting knocked up.

Now, of course, the new trend in medicine is telling people they're fat, from pretty much the minute they walk in the door. Every damn time I go to the doctor's office, it's "step on the scale," followed by frowning and scribbling as the nurse writes down my BMI, followed by my doctor stabbing her finger at the BMI index on the wall and haranguing me for being fat no matter what I came in for and what kind of medical attention I need.

"Bleeding all over the floor from a severed arm? You know, I'm a little concerned about your BMI. What are we going to do about it?"

Every fat patient endures it, to greater and lesser degrees — the fatter you are, the worse it gets. We've spent a long time blaming fat patients for everything that's going wrong, and now, thanks to some brand spankin' new best practices guidelines on the pharmaceutical management of obesity, things are about to get a whole lot worse.

Historically, you went to the doctor, tried to ignore the doctor insisting that if you just "worked harder" you wouldn't be so disgustingly fat, tried to avoid fat discrimination — like the stuff that kills patients. Need surgery, even for an urgent condition? Lose weight first. Present with symptoms of a potentially serious condition? Lose weight, that will solve your problem. Want any kind of medical treatment at all? Prepare to be shamed because you're a fatty mcfatty fat fatty, clinically fat, fat fat fat.

Now we get a whole new exciting level of fun: Doctors are supposed to push weight-loss drugs on their patients as part of the clinical management of fatties. That's right! If diet and exercise don't work, the new guidelines suggest, load on the weight-loss drugs, even if they're contraindicated or potentially dangerous. If they conflict with existing medications, drop the other meds, because losing weight is more important.

Let that sink in, if you will. Losing weight is more important than managing any medical condition you have, even if it is a potentially life-threatening one that requires complex pharmaceutical management. If your heart failure drugs cause weight gain, go off 'em. If the steroids you take for asthma cause weight gain, stop taking them. You're too fat, and that's the only thing that matters.

The guidelines basically say that we should treat the fat first and everything else later, positioning fat as a disease that causes comorbidities when fat, health, and disease are really complicated things and they have a very fraught relationship. (Like, starting with the fact that fat isn't inherently unhealthy and fat doesn't make you sick — in fact, sometimes gaining weight rapidly is a sign that you're very sick, but it's written off Because Fat and a potentially fatal diagnosis gets missed.) Putting fat first and treating it like fat people are sick and gross is not a whole patient approach to medical care.

But that's not where it gets personal for me.

Where it starts to get personal is where the guidelines start talking about psychiatric medications, and recommend that patients be treated with "weight neutral" medications or that they engage in a "shared decision-making process" where they're told that psych meds will make them fat and asked if they really want to be fat.

See, here's the thing: I am a fat crazy person, and I am fat in part because of my meds, and I like being alive a whole lot more than I would enjoy being less fat (sorry, pallbearers). I suspect the same is true for many, many people with mental health conditions.

The subject of weight gain already comes up pretty routinely in my psychiatry appointments, because my doctor can read my charts just like anyone else can. And there's always the "You're gaining a little weight" and "You'll feel better if you diet and exercise" thing that happens, while steam pours out of my ears and my fists clench under the table. You know what would make me feel better? Not being threatened with the risk of having my life-saving medications taken away so that I'll stop gaining weight.

Psychopharmacology is incredibly complicated. There's a reason that psych drugs are the purview of psychiatrists and specialists like the neuropharmacologist I see to manage my medications. It's because many of them are potentially dangerous and complicated, and because it takes time and precision to arrive at appropriate dosage levels. My doctor and I have been struggling with a meds adjustment for the last six months and we're still not sure the medication I switched to is working and will work.

But yeah, let's worry about my weight, because that's way more important than, like, my random crying jags or the violent outbursts or the compulsive shopping or the repeated poor decisions or the way one of the meds we tried made me so wobbly I could barely stand up — hey, that one was weight-neutral, so at least I wouldn't have gotten fat on it!

I'm currently taking two psych meds infamous for causing weight gain — and I've probably gained 50 pounds or so as a result. I have what some people refer to as the "psych belly" or variations thereof, where the weight associated with my meds has concentrated around my belly; people experienced with psych meds know exactly what it looks like and how it feels. I'm okay with this, because these medications keep me alive.

Being fat is totally not a problem with me in the first place, but it's definitely not something I would trade for my psychiatric well-being basically ever, no matter whether it caused comorbidities. No one should be faced with that choice and it shouldn't even be presented, especially to people who are in a vulnerable emotional state like untreated depression who are already struggling with a lot of complicated stuff. The last thing they need is fat shaming, especially if they have a history of disordered eating or other weight-related mental health conditions.

According to these guidelines, my GP — a doctor not trained in the administration and management of psych meds — is supposed to sit down with me, turn the fat shaming dial up to 11, and tell me that I need to get off those meds to lose weight. I'm going to be told that I should switch to different meds (newsflash: a lot of psychiatric meds cause weight gain, especially those for severe mental health conditions — if you have schizophrenia or bipolar disorder, you are pretty much going to have to take meds that will lead to weight gain) so I don't get any fatter, and, ideally, so that I lose weight.

She's going to shove a bunch of diet pills in my face — like the slew of pills that coincidentally were just approved by the FDA — and tell me to lose weight. If I still don't, I'll probably be threatened with weight loss surgery, an extremely invasive, incredibly dangerous procedure with very high risks of complications. Because she's supposed to treat the fat first, not the patient. If I don't agree with her treatment recommendations or bow to the demand that I lose weight, I become a noncompliant patient, I get a red flag in my file, and I'm more likely to face discriminatory practices whenever I seek health care. All because I don't actually think that becoming less fat will solve any of my health-care problems.

If my doctor tries that, I'd like to punch her in the stethoscope and run, but it's not that simple. These guidelines suck for fat patients and will endanger fat patients in a number of ways — not all medications that cause weight gain are psychiatric in nature — but I'm deeply troubled by the detailed suggestions that losing weight is more important than psychiatric health.

While there are obviously some corollaries between fat and mental well-being — like, I don't know, struggling with depression because you're fat and everyone hates your body and you're in a society that continually trashes people who look like you — psychiatric conditions really do need to trump BMI (which Lesley has already explained is a load of horse crap anyway).

My mental health is more important than my weight. My mental health is more important than best practices guidelines that tell my clinician to endanger me by pressuring me to switch psychiatric medications or drop them altogether. My mental health is more important than society's desire to not have to look at fat people. My mental health is more important than what I look like. My mental health is more important than any clinical findings or consensus on how fat patients should be "managed," like we're a herd of cows to be shifted from place to place.

You will pry my psych meds from my cold, dead hands, and if my clinicians enact these guidelines, that metaphor might turn literal.

But hey, at least my hands will be skinny.