Tag Archives: fatphobia

Weight Loss for Its Own Sake: At What Cost

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Several Ozempic pressure applicators, arranged loosely on a background of Rx labeled wallpaper

Laurie and Debbie say:

Ozempic: it’s a diabetes drug which also works for weight loss; it’s a wonder drug that will solve the obesity epidemic; it’s a rich people’s drug that will ensure that only poor people are fat; it’s a scam; it’s all things to all people.

We’ve been very skeptically watching Ozempic’s trajectory through the news since it started being regularly available (to some people) about two years ago. Weight loss wonder drugs tend to appear, fail, and vanish. Ozempic (also called Wegovy when it’s prescribed for weight loss) is lasting longer than most. So, the problems it causes are getting very obvious.

As we know so well, the vast majority of doctors believe that fat is, in itself, a disease and health risk which must be eliminated at all costs–and now the doctors have a drug that will actually “work” to meet the doctors’ goals–whether or not those are the patients’ goals. Angelina Chapin, writing for The Cut, has a heartbreaking set of stories of patients (generally women) pushed by their doctors into taking the drug. Chapin cites five examples–different stories, same underlying medical myth:

Marcy was diagnosed with lymphedema, a condition that causes fluid to build up in her legs, in 2021. The 53-year-old from Queens wanted to work with a nutritionist to follow an anti-inflammatory diet that she hoped would lessen the pain and swelling. Her primary-care doctor made a referral last year, but the callback came from an office administrator at a hospital weight-management center. The person told her that she’d need to be evaluated and then choose between having weight-loss surgery or going on Ozempic. Marcy, who describes herself as “visibly plus size,” told them there must be a misunderstanding. Her goal was to develop better eating habits, not to lose weight. But the administrator said that in order to work with a nutritionist, Marcy had to join the weight-loss program, which a nurse reiterated in a follow-up call.

It felt to Marcy like these health professionals had seen her BMI and made the assumption that “All fat people are unhealthy.” Though her medical chart says she’s obese, Marcy doesn’t have diabetes, high cholesterol, or high blood pressure. The swelling from lymphedema has made her gain weight, but she doesn’t eat regularly because the pain “kind of curbs my appetite.” And yet, medical workers are “focusing on the number on the scale,” she says. “You’re ignoring my diagnosis. How am I supposed to get better?”

Another example in Chapin’s article has high cortisol levels which the doctor told her “don’t matter.” More than one have eating disorder histories and are afraid of the psychological consequences of limiting their food intake.

This is bad enough. If Chapin found five examples, there are probably 5,000 people out there dealing with this right now. Or, there were about that many until last month, when Medicare approved the drug. Dylan Scott, writing for Future Perfect at Vox, has a powerful analysis of what Medicare approval means. Please note that Scott has a wide-eyed naive acceptance of the “obesity epidemic,” and thus of the medical value of Ozempic. Despite this shameful assumption, he comes away with major reservations about widespread prescription of Ozempic:

there is growing data that these drugs also reduce heart disease risk — one clinical trial involving more than 17,000 patients found Wegovy significantly reduced the chances of an adverse cardiovascular event such as heart attack or stroke. Just 6.5 percent of participants who received Wegovy experienced an acute cardiac emergency, compared to 8 percent of patients who took a placebo. …

The medications are extraordinarily powerful at controlling patients’ appetite and therefore aiding weight loss; in clinical trials, patients lost an average of 15 percent of their body weight in little over a year.

But that’s only as long as patients continue to take them — once a patient stops the drug, the benefits go away. And medication adherence is a struggle across the US health system.

And even if people do adhere to regular doses, taking Wegovy or Ozempic long-term may prove prohibitively expensive. Even Medicare enrollees can pay up to $2,000 out of pocket annually for their prescription drugs, depending on their specific plan.

The available evidence suggests patients will gain back some or all of the weight they had lost if they stop taking semaglutide. The whiplash of losing and then regaining weight may even be worse for a person’s health than if they had never lost the weight in the first place, Stacie Dusetzina, a health policy professor at Vanderbilt University, told me. Doctors call it “weight cycling.”

No reader of Body Impolitic is likely to be unfamiliar with the medical dangers of “weight cycling,” or “yo-yo dieting,” or whatever you want to call it. Scott apparently never heard of it. But look!

Given the evidence that people struggle to maintain weight loss over time, some experts have called for putting less emphasis on losing weight for people who are obese or overweight and more on improving their access to medical care.

Holding Chapin’s article next to Scott’s, we immediately see that Medicare’s coverage of this drug will result in tens of thousands of people being pushed by their doctors into taking it. Some of them will be aware enough to understand that their weight is not their problem, and at least try to push back. Others–the vast majority–will buy into the combination of the social conviction that fat is always and forever bad for you, and the pressure from their medical care team, and will not even have the tools to examine the recommendation.

At the end of her article, Chapin returns to Marcy:

Marcy, the woman with lymphedema, tells me she recently found a nutritionist who has agreed to discuss an anti-inflammation diet without pushing weight loss. She’s excited to finally work with a health professional who won’t jump to conclusions based on her size. “I’m not on a couch, eating a half-gallon of ice cream,” Marcy says. She now hopes to become more active with the help of a pump to massage the fluid in her leg and compression leggings. “I want to do Alaska next year,” she says, “and I want to be on a dog sled.” It’s something most doctors she’s been treated by didn’t see in her future.

The United States (and much of the world) is culturally incapable of separating fat from health, acknowledging that in some situations fat contributes to health issues and in other situations it does not. This country is medically incapable of expecting doctors to listen to patients’ concerns (such as wanting to be on a dog sled) and address them rather than jump to a sometimes completely inaccurate conclusion. It is also politically incapable of reining in Big Pharma and requiring affordable drugs and drug plans (although the Biden administration is addressing that issue with moderate success). Until all of these things change, Ozempic should be administered cautiously, to people who both need it and are not threatened by its side effects, and in ways that break no one’s pocketbook.

Fat chance.

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Debbie has deleted her Twitter account. Follow her on Mastodon.

Follow Laurie’s Pandemic Shadows photos on Instagram.

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Brilliant Essay on “SF’s Big Fat Problem”

classic science fiction image with fat astronaut

Laurie and Debbie say:

First, it’s good to be blogging together again. We’ve had good reasons to be writing separate posts, and we’ve missed the synergy of our two minds.

Second, it’s great to find someone we don’t know writing an incisive analysis of fatphobia in written and filmed science fiction. R. K. Duncan’s “SFF’s Big Fat Problem” is thorough, thoughtful, and moving. (In case it’s not your world, SFF stands for “Speculative Fiction and Fantasy.”) He frames it very carefully for what it is and what it isn’t:

This is going to be a Jeremiad, not a hopeful essay. If you want the good news about fat protagonists in SFF, look at this lovely piece from Meg Elison. If you need education about fatphobia and the ways it harms fat people mentally and physically, try these episodes of Maintenance Phase on anti-fat bias, eating disorders, and the obesity epidemic.

If you are fat, stay if you need righteous anger, but please don’t make yourself read this if you need something soft right now. This essay is for thin SFF fans and creators.

That might be the only place we disagree. We both know (and we’re sure Duncan does) fat SFF creators who nonetheless flavor their work with fatphobia. Sometimes this is internalized self-hatred, other times it’s simple sloppiness, or unawareness, but it certainly happens, and deserves to be named.

Duncan begins by framing casual fatphobia and the depth of social stereotyping before he moves to SFF, and there he explains why he designed the essay for thin fans and creators:

I want to believe it’s only that writers and editors without access to a fat perspective miss fatphobic passages, that they would change them if they recognized them, that we all agree that it is bigotry, that it is violence to treat fat people like that. I want to believe it enough that I’m stripping myself raw to reach everyone who reads this.

We’d like to believe it too, but evidence points in the opposite direction. From that point on, however, Duncan starts hitting high points and never stops.

As a child, I got used to reading past fatphobia and not noticing the hurt. I got used to thinking of myself as ugly, as undesirable, as obviously lesser than my thin, visibly fit classmates. I left Harry Potter behind long before I was cognizant of being stung by its disgusting fat caricatures, but the damage remains. I was a little more aware by the time we all watched and read Game of Thrones, and historically literate enough to be offended by the nonsense of stigmatizing fat in a medieval setting. We have enough records and enough armor made for them to know fat knights weren’t somehow out-of-shape for battle. Even Tolkien, who I re-read for comfort, doesn’t shy from using fat as a pejorative synonym for lazy and soft, and Bombur is one reason I re-read The Lord of the Rings more often than The Hobbit.

In newer works, the vocabulary of fatphobia is different, but it’s still there all too often. Less likely to be sniveling fat villains or cowardly knights, more likely to be workouts, diets, the casual fear of getting fat. It’s the word “obese,” which you should expunge from your vocabulary unless you’re engaged in activism around how the medical system treats fat people, popping up next to the smell of diabetes, whatever that is, in M. John Harrison’s The Sunken Land Begins to Rise Again. It’s fat children being as unathletic as their bullies say they are. It’s Sarah Monette’s The Goblin Emperor’s taking time to mention the grace and balance of a fat character when it doesn’t bother to be concerned about those things in anyone else. It’s authors being very clear how worried they are about gaining weight when they post on social media about meals and workouts.

That’s a spectacular point buried in there, that taking the time to note the grace of a fat character is fatphobia. Duncan is extremely generous to the books that trouble him:

I don’t cite these specific books for being particularly egregious …. I cite them because they’re the ones I’ve read recently enough to remember the hurt in detail. Indeed, I would, and will come December, still recommend The Goblin Emperor wholeheartedly. I wasn’t kidding when I say this all blends to white noise. I don’t keep an inventory of all the places I met a little fatphobia and flinched at it and moved on. I remember the worst of my childhood reads, occasional clear flashes from the vast library of my teens, and what I’ve read in the last few months and discussed with fat friends and partners and colleagues. The hurt of most fatphobic moments remains as hypervigilance when a fat character appears, as tension waiting for the whip, not memory of every slight and injury.

He goes on from books to discuss popular films, including one of Debbie’s pet dislikes–“fat Thor from Endgame,” with the same care and precision.  He has some very pointed comments about fat suits in movies. Writing about Denis Villeneuve’s Dune (which he has chosen not to see because of the fat suit issue, he says:

Stellan Skarsgård is a brilliant actor. I have loved his work in many films. He could, without a doubt, have portrayed the evil and depravity of the Baron without a fat suit. Or, if Denis Villeneuve’s directorial vision required a fat Baron in keeping with tradition, he could have chosen a fat actor, and perhaps gotten a performance with the authenticity and power of Vincent D’Onofrio’s Kingpin.

Because it’s tor.com, and moderated, the comments are intelligent and worth reading. We were especially struck by digenis’s thought:

It seems silly to imagine futures for our planet, let alone for life beyond the planet or on completely fictional fantasy worlds, that just reproduce the exact same body shapes, plugged into the same biased hierarchies of value…

In addition to being harmful or unkind, it is also unimaginative and short-sighted. That isn’t to say that other (futuristic) societies won’t have their own hierarchies of value or biases; just that it would be nice to see authors imagine them in new ways.

Duncan ends with a call to action:

In my lifetime, SFF has become unimaginably more welcoming of my queer self than it was when I began to read. My fat self, not so much. This essay is a callout for everyone who feels they are a part of this community. Do better. Think twice before you consume or recommend a movie or show that uses fat suits and fat stereotypes. Notice where your favorites pivot to the monstrous fat villain, or shorthand a lazy, unfit coward with a swollen belly and a sweaty brow. Call out your friends and favorite authors when they do. Warn your fat friends before they blunder into stories that hate them. I want this to change.

So much of our work is about wanting this to change; we’re simultaneously warmed by finding such a skilled writer doing this work, and infuriated because he still has to.

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Follow Debbie on Twitter.

Follow Laurie’s Pandemic Shadows photos on Instagram.

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