The Bizarre Impact of Fatphobia in Medicine

Photo by Mathew Schwartz on Unsplash

It takes jumping through countless hoops to get treatment for chronic pain, and I had one psychiatric nurse practitioner tell me I couldn’t possibly have ADHD because I held a four-year degree and was in grad school at age 22. No Adderall or Percocet or Modafinil or B-12 injections, not even testosterone or a few days’ supply of Ambien, but weight loss drugs? No problem.

One of my favorite TED talks is by a guy named Russ Altman. Altman tells the story of how he and his student discovered a surprising interaction between pravostatin (cholesterol) and paroxetine (Paxil, an SSRI) by leveraging data.

I think about this a lot. I’m currently taking several medications, and although I’ll probably never need a statin, the point of the story isn’t those two drugs, or even those two classes of drugs.

It’s hard to test for drug-drug interactions, especially during initial clinical trial phases. But in the real world, people often do take multiple medications that may interact with one another, and not just pairwise. Consider the following list:

  • Wellbutrin XL (bupropion, 24-hour extended-release, 450 mg)
  • Effexor XR (venlafaxine, 24-hour extended-release, 225 mg)
  • Topamax (topiramate, 50 mg, twice per day)
  • propranolol (10 mg, twice per day, as needed)
  • benztropine (1 mg)
  • Truvada (PrEP)
  • testosterone (injection, 100 mg, weekly)

They are for depression, depression, weight loss, anxiety, excessive sweating, it’s complicated, and gender dysphoria, respectively. Truvada has a beneficial effect on my mood, possibly in combination with one or more of the other things I’m on.

Now, bupropion has a mechanism of action not wholly dissimilar to that of amphetamine drugs, such as Adderall, Ritalin, and so on. I did try a non-amphetamine ADHD drug at one point, Strattera, but all it did was make me constipated. And I gave it plenty of time, about six or eight weeks, but the side effects didn’t improve, and I saw no appreciable cognitive benefit. What’s more, I had to add laxatives and stool softeners to my daily medication regimen. Aside from that period of time and when I was first trying to recover from my eating disorder shenanigans, I haven’t been constipated in over a decade. (Veganism and hydration for the win!) So I knew it wasn’t just garden-variety digestive trouble.

Topiramate is indicated for migraine, which I do not have. What I do have is extremely frequent tension headaches, and my doctor acted like it might help those, but it didn’t. (Good bet, since migraines and tension headaches are, and this is true, not the same thing. It’s possible she was hoping for a placebo effect.) I can’t take ibuprofen or aspirin; drugs that thin the blood give me nosebleeds. Every time.

But topiramate is also, especially when combined with bupropion, prescribed for weight loss. Given my (very long) history of eating disorders, I had expected a lot more push-back when I asked about medication for weight loss. The fact that I happened to be overweight in terms of BMI when I made the request shouldn’t have mattered; given my stress levels and what we know about eating disorder relapse, it was arguably an irresponsible choice on the part of my doctor.

And that’s the point: it was so easy to get. I have chronic pain, ADHD, and a sleep disorder, among other things; all of these are unmedicated, because the medications needed are controlled substances and hard to get, due to the strong potential for abuse and chemical dependency. Those are traits of the drugs themselves, not traits specific to me.

Also, my problems are well-documented. I didn’t just wander in off the street and start picking medications to ask for, like I’m throwing things against the wall to see what sticks.

This is important. I’m in pain, I have classic non-hyperactive ADHD, and you only have to look at the circles under my eyes to know I’m not sleeping well. But even assuming I’m faking everything, and even acknowledging that mine is a complex case and that there was no way to know for sure how this seven-way interaction would shake out, the topiramate’s addition to the mix (and the consequences) were somewhat predictable.

I’m disgusted by almost all food when the meds are in my system. I often have to take a day or two off just so I can take nourishment without a fight. How topiramate works took me by surprise in this way: it’s effective, in terms of weight loss by restrictive eating, but extreme calorie restriction, especially over long periods of time, is unsustainable at best and potentially catastrophic at worst.

The only way I can actually eat anything, other than by going off the meds for a day or two, is with THC. But I’m never not hungry.

That’s the problem. I’m never not hungry, even when I feel physically full. I’m constantly, continually being harassed by my body’s need for fuel and its refusal of it. One time, attempting to take a dose of THC concentrate mixed with water, I barfed a mouthful right back into the cup from which I was drinking.

The only kinds of food that appeal to me are what I think of as dopaminergic foods, things with high fat and/or high sugar content. Things that are calorie-dense but nutrient-poor. (In other words, things that are not going to help me feel better.) It reminds me of my mom’s eating habits, especially late in her life: sliced ham (one specific brand), barbecue chips, pudding, chicken nuggets (Burger King), fried chicken (Popeyes), pork fried rice and egg rolls from a specific local Chinese place, corn dogs, cup noodles, pretzels, and salt. Like, a really ridiculous amount of salt.

Now, I’m vegan, so my habits are perhaps not as nutritionally catastrophic in the same ways hers were. But I can say with reasonable certainty that I am frustrated in ways she very much wasn’t.

I’m not saying she couldn’t understand these things the same way I do, just that she didn’t. And at the time, neither did I. But my brain works differently than hers, with or without medication, and that’s largely due to my educational background. You don’t get a bachelor’s in philosophy without it influencing your thinking patterns, and I like digging for answers and understanding things. She would get insulted sometimes when I used (what she called) “ten-dollar college words,” because she thought I was trying to make her feel stupid. Nothing could be further from the truth, but she was quite insecure about her intelligence, and her mental illness was of the “with psychotic features,” variety. In other words, paranoia on a clinical level was very much on-brand for her.

But I digress. Disgust with almost all foods and highly specific food cravings? Sound familiar?

I’ve definitely lost weight, but at what cost? Doctors were so willing to give me a medication to lose weight, even though topiramate is known to be a less-than-ideal ideal solution in conjunction with venlafaxine or in individuals with anxiety disorders, and I’ve got both. But the whole world has to stop (and I have to pee in a cup) if I want effective treatment for pain, ADHD, sleep, anxiety, HRT…

Is it just because topiramate isn’t a controlled substance, because there’s no real way to abuse it for the purpose of recreation? Possibly. But I would caution people, especially those in the medical field, not to dismiss the role of fatphobia: many other medications are tolerated much better than topiramate, but doctors are reluctant to prescribe them. Yet, I only had to ask, “Can you give me something to help me lose weight?” And my doctor wrote a script for topiramate without even once mentioning side-effects, and refills have been granted without an office visit for over six months.

It just seems irresponsible, a total misplacement of priorities. If I weren’t worried about getting caught, and if my finances weren’t in such dire straits, I’d find a way to get meds on the sly and just say, “To hell with it. To hell with doctor’s offices and feeling like shit all the time.”

But this is not in the cards, so I guess I’ve got to keep pushing until I get what I need or feel better. Obviously, no one should have to, and this is all made much more difficult than it needs to be, because when you can hardly force yourself to eat, it hurts. It hurts like hell, and it hurts everywhere.

Like most things, it could be solved with money, and I live in a constant state of frustration over that fact.

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London Graves

London Graves

Queer vegan cryptid trying their best to survive late-stage capitalism while helping others do the same.