There's Good News and Bad News. And Fat News.

(TW for discussion of depression)

I went to the doctor last Friday (I went to see a couple of my doctors, actually, but this post concerns my visit with my internist). She recently replaced another doctor who had been part of that practice for several decades, and had been the only internist I had seen more than once as an adult. This new one, Dr. L., has had the unenviable task of taking on a lot of patients who were very attached to the previous physician, and earning their trust.

I went to see her a couple of months ago for the first time, to request a blood glucose test. My paternal grandmother, whom I never knew but from whom I seem to have inherited some unfortunate tendencies, had Type II diabetes, an illness which my "lifestyle" is quite conducive to. By "lifestyle" I mean that I suffer from great fatigue, difficulty focusing on tasks, and a lack of motivation.

"Lack of motivation" is a generally misunderstood symptom of depression. It does not mean that I sit around thinking, "Oh, I'm so depressed; why bother to do shit I don't want to do anyway." It means not that I lack discipline, but that there is a mental disconnect between my conscious mind, which says I want or need to do X, and the part of my brain which actually initiates activity. It prevents me from doing things I would very much like to do, as well as things I need to do, rather than indicating simply a lack of interest in doing things which are not immediately rewarding.

If you want or need to go somewhere, whether somewhere you're eagerly looking forward to going, or somewhere routine, or to the dentist for a root canal which you may be much averse to but have nevertheless decided will leave you better off in the long run, and you get in your car, turn the key in the ignition repeatedly, yet the engine sputters but does not engage, this is not an indication that you don't really want to go anywhere. It's an indication that something is wrong with the equipment you need to transport you there.

I am fully capable of sitting for hours, thinking periodically, "I need to pee," then, "I really need to pee," and eventually, "Damn, I need to pee," before being able to jump start the part of my brain which engages with the task of getting up and walking the ten feet to the bathroom, and initiates the movement which allows me to do that.

The more complex the task, the harder it can be, because a more complex sequence of actions must be, in some sense, imagined and targeted before the actions necessary to bring them about can be initiated. Most people are unaware that this process even takes place, because in a healthy brain, it occurs swiftly and automatically. In my brain, it does not.

I also have difficulty disengaging from tasks. Physical tasks are self-limiting, because my normal state is one of fatigue, and it escalates rapidly with any exertion. I can get sort of "stuck", though, doing fairly simple things on the computer, because the fatigue factor is low and it can require more energy to disengage, or mentally change gears to engage another task, than it does to just keep doing what I'm doing.

One result of these and other symptoms of my depression is that I get no exercise and my diet is terrible. Much of what I eat is dragged out of the freezer and shoved in the microwave. Many days I eat pretzels, cheese and my staple diet cola for breakfast, because it's what I can manage. For a "healthier" breakfast, I'll have a piece of fruit with that — when I have any, which is only a few days a month.

I cook occasionally, simple things, and occasionally make a salad, but even chopping vegetables is often beyond me. Since I have no car and have been unable for some time to manage grocery shopping by a combination of walking and buses, I order my groceries on the net and have them delivered. Because of the expense, I do this only every 2.5 to 3 weeks, which is therefore how often I get fresh produce, and only as much as I am likely to be able to prepare and eat within a few days. So my diet, as I mentioned, is monumentally crappy.

I spent a lot of years fighting my limitations. That accomplished nothing of lasting value, and actually endangered my survival. So I've learned to do the best I can to work with them. It does not create a healthy "lifestyle" but it permits me to survive. This is why the scare quotes around "lifestyle". That word is generally used to refer to something seen as chosen, preferred, as if selected from a menu of possibilities (you know, like being gay. You know you just love it 'cause it's naughty!).

I did not choose to live this way. I generally refrain from speaking for others, but I can say with bone-deep confidence that no one would choose to live this way. Whatever minor advantages it may seem to have to someone who never has lived this way, are far outweighed by the disadvantages, and no, I and others are not too stupid or childish to figure that out. It is also not the result of weakness. No one who has lived it could doubt the tenacity and power of endurance necessary to do so.

I have also been on every class of anti-depressant, anti-psychotic, mood stabilizer and anti-seizure medication in existence, have been through cognitive therapy and several courses of electroconvulsive therapy (ECT), commonly known as electroshock. Only a couple of the drugs and the ECT provided any benefit, and it was short-lived. All of the preceding is meant to make clear that my "lifestyle" is not going to change.

I went to have my blood sugar tested because I like to see what's coming, even if I can't do anything about it. I prefer knowing what I'm dealing with. Not only was my blood glucose elevated (I'm "pre-diabetic"), my cholesterol and blood pressure are climbing as well. My doctor had briefly given me the usual recommendations about diet and exercise, which I listened to in silence, knowing she was obligated to provide me with that information, and after my follow-up visit two months later to check the progression of my various elevated numbers, (because this was the first time any of them had been elevated), had emailed me saying that medication was a possibility if lifestyle changes alone were insufficient.

Well, I gave that some thought. Dr. L. had engaged in no fat-shaming, no blaming of any kind, and seemed like someone with whom a patient could have a mutually respectful conversation. Also, Shakesville.

I spent the first three decades of my life hearing that all my problems, as well as those of the people close to me, were All My Fault. I saw, throughout my teen years, a series of therapists who were no help at all, who did not even provide me with a diagnosis, and generally treated me as if I were simply a rebellious teenager who wasn't smart enough to see that the person whose life was being destroyed by my inability to function was my own.

I only returned to mental health treatment in my thirties when it was clear that I would not live much longer without help. It was that which made me desperate enough to ask for the help I had always been told I did not deserve. I didn't find treatment which worked, but I did find a psychiatrist who treated me like a person with an illness who deserved whatever he could do to help, and that was enough to allow me to survive, although it has been touch-and-go at times. This doctor has been extraordinary, in my experience. I have had to deal with other mental health care providers as well, over the years since he became my doctor, which has only confirmed that view.

So I don't expect a lot, from anyone, including health care professionals. I learned somewhere along the way to say to people, "I won't accept that." I'm not sure I ever learned to say, "I expect this," or even just, "Would this be possible?" But I think the view insistently expressed at Shakesville that fat people are entitled to the health care they need, not only that which they earn by meeting the expectations of others, including health care providers, also influenced my decision to have a conversation with my new internist about whether medical treatment would be appropriate, given my unchanging "lifestyle".

So I went to see my doctor again. (She is aware of my history of depression, because I get all my health care from various departments of the physician's practice within my HMO, and they all have access to my complete medical record.) I told her that my diet is terrible and I get no exercise at all. I further told her that I have lived as I do for many years, well aware of the likely health effects, especially given my family history. (That diabetic grandmother? Also bipolar*. Thanks**, unknown Granny, for all the diseases!).

I told Dr. L. that realistically, none of that is going to change. I asked her if, given that reality, there was any value to my taking either of the medications she had suggested might be possible "if lifestyle changes were insufficient." She said matter-of-factly, "Well, medication is appropriate when lifestyle changes have been maximized." I said, "So there's no point in my taking any." She said, "Oh, no, I meant that if your lifestyle changes have been maxed out, and the condition remains, then medication is appropriate." So we discussed the nature of the medications she had in mind, and I left with two prescriptions. Deathfatz was not mentioned.

She knows how much I weigh. I was weighed each time I went, without fuss, and the result duly noted on my chart. Also, she can see me. I am "morbidly obese". But then, I'm generally pretty morbid. (Ha-ha! Little depressed person humor there! Yes, we have our own jokes, too. I will spare you them.) At no time did I get any fat-shaming, lifestyle-blaming, or air of disapproval from her. Most importantly to me, when I told her that I can't change the way I live, she took me at my word.

My allergist had previously tried to convince me how simple changes to my diet would be, based on how when he was divorced he used to just throw some stuff on the grill on the days when he had his kids. He's a nice man, really. His manner wasn't patronizing, and I actually appreciate his willingness to take the time to talk to me about something outside his own direct responsibility but which was intended to better my health, given that many people have doctors who rush in and out with barely a chance to discuss anything with them. But, doc, I'm not a divorced man who never learned to cook because a woman had always done it for him. I'm chronically ill. No, really. They are not similar conditions.

So telling a doctor that this is how I live, and that my own assessment based on the knowledge accumulated in living my particular life tells me that it's the best I can do under the conditions of my life, and having her accept my judgment on that point, and matter-of-factly go on to discuss what can be done, was . . . startling.

I have read the horror stories here at Shakesville and throughout the fatosphere, about health care professionals who appear to believe that fat people don't deserve to be healthy, and are by jiminy not going to get any help from them in becoming as healthy as they can be until they earn it by losing weight. I know I am really lucky to have the doctor that I do. Hell, I'm lucky to have the broad access to health care that I do, which is provided by a combination of Medicare and MediCal that I am very fortunate to have, and I don't forget that.

But having access to a building where health care is provided and a staff who provide it to those they feel are deserving (the right weight, the right gender, the right gender presentation, the right sexual orientation, the right religious beliefs, the right sexual habits — being the right kind of person, i.e., like me, the provider) is one thing, and having access to health care you can use, provided by professionals who respect the autonomy and judgment of the patient, is a whole other dimension. I have both, and I know that, in this respect, I am very fortunate.


*My depression is unipolar; unipolar depression is quite often also found in families where bipolar disorder is present.

**I couldn't resist the sarcasm, but obviously no one is responsible for the genes they have, much less who among their children and grandchildren inherit them, and given that these conditions certainly caused her suffering as well, unknown Granny merits only sympathy from me.

H/T to CaitieCat and eastsidekate, who jump-started my motor to write this post. :)