The Fat Man Sings
Nearly All Americans Will One Day Be Overweight, Researchers Predict.
-Associated Press headline,
May 29, 1998
May 1, 1998: My doctor tells me - without me asking - that "maybe I should think" about a new obesity drug. Name: Meridia. "They're not hyping it like they did Redux," he says. "It's maybe best thought of as part of a health-improvement program. It's not for everybody. But, eh, you definitely qualify." I tell him Meridia sounds like the name of a car Ralph Nader wouldn't like and then leave, squeezing through his door and heading directly to the doughnut shop.
That weekend, I go to the local nursery and park my car on a busy street. I open the door and almost behead a passing cyclist. "Watch it, fatso!" he yells with a scowl. I smile and give him a modified parade wave. I slam a Kit Kat bar and think about what a spoilsport Ralph Nader is anyway.
I listen to my voice mail. It's my doctor. "Listen," he says, "I went ahead and called in that prescription, but before you take it you need to weigh yourself." He goes on to enumerate various side effects: hypertension, dizziness, "blotchy skin," sleeplessness. "If you get any of those, stop taking it and call me right away.
"You'll know it's working if you lose four pounds the first month. Okay?"
I get a call from my pharmacist. My insurance plan won't pay for the Meridia unless my doctor details my weight problem. So he calls them and gives them the basics: I'm 5'7" and have gained 45 pounds since going on antidepressants eight years ago. I imagine the conversation:
Insurance stooge: I mean, how big is he?
Doc: Believe me, he's exactly the profile, heh heh, you're looking for with this drug.
Insurance stooge: And it's because of his eating and not just a low metabolism?
Doc: I'm saying you don't want to get stuck in a plane crash in the Andes with the guy.
I get a call from my pharmacist. "Your insurance approved the Meridia and five refills," he chirps merrily. I pick it up, along with a Cherry Coke and some Fritos, and jump in my car. I notice for the first time that my ass is still getting into the car five seconds after I turn the key.
Day 1: I get up and have a cup of coffee and read the Times. In the business section is an article about how Knoll Pharmaceutical Company, maker of Meridia, is having a tough time selling its new miracle drug. The reason is that, ever since Redux and Fen-Phen were pulled off the market because they caused heart problems, the medical profession hasn't exactly rushed to prescribe the stuff. It also doesn't help that Meridia works on the same neuro-receptor system as Redux, the main difference being that it doesn't jack up serotonin levels but, rather, simply stabilizes them. Hmmm . . .
I go to the bathroom and look in the mirror. After I back up about 10 feet so as to squeeze my full face into the mirror, I reach for the bottle and make the folks at Knoll very, very happy.
An hour later: It's not working. I have a bowl of cereal with bananas and milk.
Two hours later: Not working.
Three hours: Still not working. I turn on public TV and watch my cooking shows. Today, I do not watch Paul Prudhomme's Cajun Country Cookin'. That wheelchair of his - that's not funny. Molly Katz is cuter anyway.
Hour 4: Lunch time! I make some Japanese rice and heat up some cold roast chicken. There's a box of Oreos on the counter. Why do I know there are exactly seven in the box?
Hour 5: Minor ringing in ears. Still chubby.
Hour 7: Onset of minor heartburn. Chocolate milk a medical necessity.
Hour 9: Dinner. My wife and I go to a highly recommended Islamic Chinese restaurant. I pick at my food; she devours entire small animal. We walk around the mall and look at some stylish clothes. Have minor flashback of my grandmother, who liked to buy me new clothes, whispering to my mother as I struggle to fit into my "age-group size," "Maybe we should try the Husky section." Sweat pops out on my brow.
Day 2: Easter. Not working.
Night 2: A dream. I am riding in my car with my friend Dan, a Melville scholar (naturally). As usual, I am telling him about my decision to try the latest pharmaceutical wonder. Also as usual, he is telling me I am completely full of shit. "Look," he says, as we we drive under a huge doughnut-shaped freeway underpass. "You just can't get it through your head. You can't really change just by taking a drug. It's a huge dodge of the real issue, and it's only because you're affluent that you can even play at it like you do."
He pauses and we zoom by a semi with big hamburgers for wheels. "You . . . you just want a magic potion. A . . . silver bullet!"
"No I don't," I reply, my eyes spinning like pinwheels. "I just want a chocolate cupcake!"
Day 3: This morning, through my bedroom window, I hear the happy, innocent chatter of neighborhood kids merrily going to school. "Hey, fatso. Faaa-tso! Fattyfattyfatty!" I figure they must be the children of the bicyclist I almost decapitated the other day. I look out onto the street and see two skinny kids cheerily teasing some poor fat kid waddling in front of them. I briefly consider running across the street and telling the poor kid that the kids who called me that when I was his age still talk in very, very high voices.
Oh, forget it - gimme that maple bar!
Day 4: Gas. Headache. A surprisingly light dinner. I feel like the woman in that episode of The Twilight Zone - the one told from the point of view of a plastic-surgery patient waiting for her facial bandages to be removed. You know the one. At the end, the bandages come off. The doctors, whose faces you can't see, drop their stethoscopes and cry in despair: "No change!" You see the woman's face. It is Grace Kelly gorgeous; her surgeons have the faces of frogs.
But I have to remember: I'm trying to lose weight for health reasons only. Yes. That's it. Health reasons.
Day 5: Is it possible, really, to be indifferent to food? I ask this because it seems that the only people I know who can eat all they want and still not gain weight are people who are just that. Two of the slimmest, trimmest and most drop-dead attractive people I know eat nothing but those Lean Cuisine meals. Not because they're low-cal, but because they're so easy to make. This couple actually refers to them as coming in various "flavors," as in, "Oh, we stayed home and had the lasagna-flavored one."
I zip over to the local bakery for the "cherry-cheese-doughnut-flavored one."
Day 6: Something is happening. I meet a friend at a favorite Italian restaurant and order the baked trout, which comes with a giant side of pasta. I eat only half of it. I get in the car and notice that my stomach feels tight, sort of the way it does before a big fart. Is this how Meridia works its magic? I resolve to wait a full month to jump on the scales to see if it works at all.
Later, I surf the Net in search of Meridialia. This is supposed to be medicine's future: technologically "empowered" consumer-patients getting their own data about drugs and treatment. I hit one site called "Pharmo First," which includes an advice column hyping Meridia. I send a query to the columnist and ask about my specific situation. I get back a boilerplate telling me to look for chat groups dedicated to diets.
I go on. I get the Web site for Knoll Pharmaceutical. There's lots of Meridia data there, and frankly, it's presented with more caution than that of the
so-called consumer columnist. I read down the chart of side effects. Nothing
I don't know about. Except for a little something called "taste perversion." What the hell is that? I note that 2.4 percent of all Meridians get it.
I decide to call the liars in Knoll's PR department, who of course are too cowardly to call me back directly. Instead, after I leave another prodding message, I get a call from a sunny-sounding woman in the "Medical Communications Division" of the PR giant Fleishman-Hillard. Her name is Heidi. I tell her I'm a journalist and that I want some more information about Meridia. Of course, she says. I then tell her I am also taking the drug and am writing a journal about it. "Oh . . ." she says. "Eh . . . have you been in touch with the Meridia hot line?" I tell her no.
She goes on to tell me how Knoll has set up a comprehensive support line, "with real health-care representatives,"
"Heidi," I say before I hang up.
"Do you know what taste perversion is?"
"Taste perversion. It's one of Meridia's side effects."
"You'll have to ask the hot line," she says after a pause and a giggle. "But, eh, like, yuk!"
Day 7: Breakfast is the usual - cheese Danish and coffee. I notice two slender fellows discussing some blueprints at the next table. They are having black coffee and . . . bread sticks. Why is that? I mean, if nature can't, Metamucil will, guys.
Lunch is a falafel sandwich and lemonade. I eat half - then it starts to taste like my thumb.
I call the living dead at the FDA and request side-effects data. I make a Freedom of Information Act request, as any citizen can, requesting the staff scientists' comments on Meridia. I will get them in seven years.
Day 8: A major parade of fatties at the doughnut store today. It's only 8 a.m., and already I see my future - and see it and see it and see it . . . All right, just one choco-bar.
At lunch, I get a chicken salad at my favorite Mexican place. It's the usual two-kilo snack: Chicken, avocado, cheese, olives, more avocado, even some lettuce. I dive in. Mmmm. Then, about halfway through, the same thing as yesterday. I sort of, well, lose interest in it, almost as if the usually pleasant backing-and-filling operation with my two forks isn't worth the effort. Well, this is a novel effect. I wonder if this is "taste perversion." But then, how could I know, since Giggling Heidi With Spin Control hasn't sent me that information yet?
Dinner is fettucine Alfredo at my mother-in-law's, followed by homemade cream puffs. (I am not making this up.) Today's score: Meridia 1, mother-in-law 1.
Day 9: Discovery of actually tasty no-fat food - Double Rainbow brand chocolate sorbet. Later, the mirror test. No change!
Day 10: I visit, out of sheer boredom, an Internet Web site dedicated to Meridia. I note, again out of sheer boredom, that the molecular configuration chart for sibutramine hydrochloride looks like the seating chart for a typical sushi bar. I also note, in The New York Times that day, the release of a study. It is headlined: Prozac Found To Aid Clams in Spawning. (Not kidding again.) Meridia and Prozac are both serotonin enhancers. I make a note to investigate Knoll for possible connection to sushi-bar chain. I mean, it makes sense.
Day 11: Breakfast - cinnamon toast and coffee. Followed by chocolate sorbet. Lunch - the chicken-rice thing. Followed by chocolate sorbet.
Day 12: Why, exactly, do some people (like me) have food problems and others not? Well, since you ask, let me count
the teary-eyed, Sally Jessy Raphael big-necked-bad-hair-it's-all-gonna-be-different-this-time ways.
1. As a child, you experience unqualified love only from an immigrant grandmother who believes that if you are not eating you might contract the Black Death.
2. As a child, you would rather read than play sports, leading to development of a big ass, leading to people calling you "Big Ass," leading to conclusion that you are unacceptable, leading to use of food as your "best friend," leading to even more creative nicknames.
3. As an adolescent, you learn to experience "control" of tormenting cruel world of impending adulthood by eating whenever and whatever you want.
4. As an adult, holding the belief that you must be achieving constantly, you eat to "fill in" periods of nonproductive time.
5. You have genetic connection to parent with above resume.
6. You have an imbalance of brain chemicals that control satiation - the feeling that you are "full."
Add to these:
7. The knowledge that the above reasons are not very interesting or profound.
8. You do not exactly feel like laughing when you talk about items one through six.
Got it, skinny?
Day 13: After a breakfast of chocolate sorbet, I finally get the PR package from Knoll. In it are the usual charts, studies, oversimplified scientific explanations and colorful diagrams of brain cells stuffed with, in this case, Meridia.
Unlike the usual pharmo press kit, however, it includes an actual description of Knoll's marketing approach. The ingenious core of it is, basically, "Meridia: It's Not for Everyone!" Or, as Steven Freeman, VP of marketing and medical for Knoll, says, "We are putting into practice Knoll's commitment to consumers - helping ensure that MERIDIA is used by the right people, in the right way, for the right reasons."
The plan includes much of what has become standard in medical marketing: letters to specialists, phone hot lines for prescribers and patients, special educational videos for doctors, even an "obesity sensitivity-training video" for Knoll's own employees, about which I will not make cheap speculative jokes.
But the most impressive aspect of it all is what Knoll calls its "customized, integrated care approach." This they have named "Point of Change." I decide to give it a call tomorrow.
After all, I am the right kind of guy.
Day 14: Meridia keeps me awake most of night; finally finish The New Yorker's special "Fiction Issue With No American Writers."
At breakfast, run into friend, who upon learning I am on Meridia lets me in on a "big secret."
"You gotta remember," he says. "Chin down, eyes up."
"Chin down, eyes up," he repeats, dunking his bread stick in his no-fat latte. "It makes your face look longer. Skinnier. They all do it. Some say Princess Di actually weighed 300 pounds, but she perfected that look, so you'd never know . . ."
"Oh." I spend the day looking at many different kinds of ceilings. Jaw hurts.
Later, I get around to calling Knoll's "Point of Change" program. Woman named Veronica with a slight Southern accent takes my call. She asks me a long list of questions about my eating habits, exercise patterns, stress levels. This is so Knoll can send me a "customized" series of newsletters and menus that will help me "reach my weight-loss goals," she explains. "It's kinda like we're in partnership with you on this." I muse that since Knoll is a $630 million giant, partnership is a good thing.
Dinner: Two tacos and a Coke, then choco-sorbet time again. Watch Law & Order and decide Jamie, the assistant D.A., is losing too much weight in her face. Perhaps she's trying for the Jill "Tiny Head" Hennessy look. Stop that, Jamie.
Day 15: Many bad meals. Even my own cooking, usually quite decent, seems yicky. Thank God for choco-sorbet, which seems unaffected by powerful force of taste perversion.
The Meridia is definitely doing something. I seem to eat a lot of half-meals. Also, I tend to wake up around
2 a.m. and stay up until 4. The combination leaves me in a defiantly self-loathing state.
Day 16: Sleep patterns totally screwed again. I blow off a speaking engagement to get some rest. Feel very bad.
Then the mailman comes and I get the first part of Knoll's "Point of Change" program. It's a brochure covering all the basics of weight control, a sort of "Obesity 101." In it are some tips about "how to think" about weight loss. Also, stuff to do with your mouth instead of eating ("Gargle with mouthwash," etc.). There's a newfangled weight-height table with the curious information that "BMI [Body Mass Index]=30kg/m2." The company promises me an "individualized menu plan" soon. I can't wait.
Breakfast is Danish and latte. Yum-yum. No "taste perversion" here. I
decide this is not something I am willing to give up yet. Note: Not hungry again until 3 p.m., and then settle for
There's definitely a pissiness that goes along with being on Meridia. The cause, I think, is simple. It's all that anger that we fatties stuff back into our face on a daily basis finally coming out in short bursts of meanness. A guy I know named Willard, a 6'2" black queen from Brooklyn, sees right through me.
"Your jokes, Greg. I don't laugh at them," he tells me one evening. "They're all at your own expense. You're not really laughing, either. I know. I can sense it."
"So, you want me to make jokes about you?" I say.
"No, I want you to deal with it, baby."
"Deal with what?"
"Don't give me that shit. You know what. It's your pain."
I get a little teary-eyed, but not enough for him to see.
Day 16 1/2: Guess at what time I'm writing this? A few more thoughts on the meanness-fat connection. How about a diet that emphasizes anger? I can see the advertisements already: Gals! Cuss your way into that size 6! Guys! Character-assassinate your way to washboard abs!
Do it, asshole!
Day 16 3/4: Sit bolt upright in bed. Realize the FDA hasn't gotten around to sending me the side-effects data yet! Decide to call FDA Commissioner Michael Friedman at home. Something must be wrong. I must tell him.
Day 17: Finally a decent night's sleep. And, for the rest of the day, only minor food slip-ups: at the grocery store, a half-bag of M&Ms (the half thing again). Milk before I go to bed. God, I live fast.
No "individualized" menu from Veronica yet, which in itself doesn't piss me off, because I know the basics of meal planning. (It's the parallel-world meals I consume between them that're the problem.) But I hate the idea of Knoll's marketing scum having all that information about me. Oh, I can see them now, sneaking those files out from under the bed, calling each other up on the phone and giggling about it like a bunch of CAA agents, and then, eventually, using it to sell some damn thing - even if they just sell the data to another marketing group.
But I could have worse troubles. I see in the Times today that Pfizer Pharmaceuticals is having a terrible time getting insurance companies to pony up for its new blockbuster impotence drug, Viagra, a.k.a. the "Pfizer Riser." The insurers want to limit the drug to clients who have a documented history of physical problems causing the, uh, trouble. Pfizer - and many, many short, bald Jewish men on the Upper East Side - were counting on getting Viagra because of psychological problems causing the, uh, condition. The result is that lots of doctors are under lots of pressure to "be creative" in describing a patient's diagnosis.
Also, note the process: The drug creates the market, the market creates the diagnosis, the diagnosis creates a bigger market, which . . . Isn't capitalism funny sometimes?
The choco-sorbet hour approaches . . .
Day 18: I finally get the New Drug
Application for Meridia from the FDA - 300 microfiche pages of statistics, clinical trials, laboratory studies, chemistry panels and scientific reviews. The importance of the document is thus muted; the NDA process, which in this case took two and one-half years, is designed to carefully weigh the risks and benefits of a given compound before deciding whether or not to turn the American citizenry into 270 million lab rats. This particular NDA is a sobering document; after spending a day reading it, I emerge from the library microfilm room feeling like the school wise-ass who's just been dressed down
by somebody a whole lot smarter. How,
I wonder, did Meridia ever end up on
According to study after study, Meridia is only moderately more effective at causing weight loss than a sugar pill. (So moderately that FDA scientists, describing the drug, were moved to outright irony, repeatedly putting quotation marks around the word effective.) And,
according to study after study, there is worse news: The drug had such profound and potentially dangerous or fatal side effects that FDA scientists twice
recommended it for "non-approval."
The main worry is that sibutramine seems to induce high blood pressure and increased pulse rates, particularly at night, when they usually decrease. After reviewing more than a dozen studies, the scientists concluded that Meridia is a paradoxical drug: While it may help people become less obese, it does nothing to eliminate - and may actually increase - many of the obesity-related illnesses that, well, make obesity so dangerous, which is why you are taking the drug in the first place. In other words, a perfectly healthy fat guy might lose weight with Meridia and in the process get less healthy.
There is another worry: The government, the drug company, the researchers and the scientists are still not quite sure what sibutramine is. Dozens of NDA pages are given over to a debate about whether or not the stuff chemically resembles amphetamines (like the old-fashioned "bennies") or hallucinogens (like the once-popular street drug MDMA). After finally concluding that it is neither, the report presents a long and a detailed argument about whether or not Meridia causes addictive behavior.
Unfortunately for Mother Nature, resolving this issue requires the "cooperation" of many members of the animal kingdom. In a test substituting Meridia for cocaine, several lab monkeys proceed to dose themselves silly with the stuff. This is not always pleasant for the monkeys; at least one died, and several others became so sick with blood in their urine that researchers had to terminate the experiment. But the finding this time is conclusive: Sibutramine is classified a Schedule 4 drug. To Knoll's chagrin, its label must carry the very uncheery warning, "Physicians should carefully evaluate patients for history of drug abuse and follow such patients closely . . ."
Nevertheless, Meridia wins approval. In return, Knoll promises to eliminate the powerful 20mg version of the pill, which prompted the most pronounced health concerns. The company also promises to carry out an extended series of post-marketing follow-up tests. But my reading of the document leaves me wondering, as it did one prominent FDA scientist, whether sibutramine has "an unsatisfactory risk-benefit ratio."
Certainly it curbed my appetite today.
Day 19: Eyes open at 4 a.m. - I can't stop thinking about that monkey.
In fact, I can't stop thinking about a lot of things in that NDA. Those charts that showed why various human subjects dropped out of the studies flicker past my sibutro-eyes. I remember: One guy dropped out because he cut off his finger in a work mishap; a 30-year-old woman experienced "sudden deafness in right ear." There were instances of epileptic seizures, severe depression and severe gastric pain. There were three instances of "serious cardiovascular events." A 37-year-old man with a history of coronary artery disease died of a heart attack 14 days after being pulled off the study because of stomach pain. Of course, causality could not be established or ruled out - the study populations, being obese, were already susceptible to such maladies.
But the fact that so many sacrificed so much for a drug with such lukewarm commendation gives me pause. Is it really worth a finger, an ear, or even the legions of rats, bunnies, dogs and monkeys that were "sacrificed" for it? It's something I'll definitely think about the next time I give the finger to that guy on the bike who called me fatso.
Day 19 1/2: Is it me, or have I really been eating yogurt and fruit for lunch? Just to make sure my taste hasn't gotten too perverted, I go down to my favorite Mexican eatery and order up a taco, some rice and a Diet Coke - about half what I normally consume. While I wait, I see that Mrs. Garcia, the owner, has already assumed her usual postprandial position in front of the TV, watching those wonderfully gaudy telenovelas. Her giant head lolls on her chest as her eyes battle Morpheus. One of her hands holds her cheek while the other rests on her thigh, supporting her upper body. Mrs. Garcia weighs an easy 280. If there was ever a candidate for Meridia, she is certainly one.
Again I think about the NDA. Because in all of those 300 pages there is no Mrs. Garcia. This is because older women do not figure greatly into the pharmaceutical industry's plans for obesity medications. Nor do ethnic Americans in general. Or men of any age. The world of the NDA is white, female and middle-aged. Embarrassingly so. Only once does it mention Asian-Americans, using, instructively, the charmingly Kiplingesque term "Oriental." Latinos are completely absent. African-Americans, the report concludes, "should be studied more."
"I finally found a doctor," I hear Mrs. Garcia say to a friend a little later on. She arches her brow and shrugs. "Maybe another operation."
I try to imagine what Mrs. Garcia looked like as a young girl, before biology and genetics and a rough life took her slender figure away, but I can't.
I can, however, finish that taco. Weirdly, one is enough . . .
Day 20: Breakfast - latte and involtino de formaggio at Il Fornaio. I've been coming here for weeks now, seeing the same revolving crew behind the counter. Mainly young women of all sizes and shapes. Why is it that the chubby ones are the least friendly to me?
I think it is because, in America, chubby men can stay chubby and not worry about being rejected. I trace this phenomenon not to the growth of patriarchal capitalism, but, rather, to the great and very wide trail blazed by two men: William Howard Taft and Jackie Gleason.
Regarding Taft, who weighed in at more than 355 pounds: Have you ever been in a town in which at least one prominent citizen or institution (usually a men's club or a library society) doesn't claim to have a chair that "was made especially for President William Taft when he visited during the campaign of 1908"? I think this fact is branded in the head of every 20th-century American male. The message of Taft's chair is this: If you are male and successful, you don't have to worry about being huge - people will simply build new chairs for you.
Regarding Gleason, who weighed in at more than 310: Have you ever seen a picture of an unhappy Jackie Gleason? Most likely, no. This is because Gleason publicly lived out the private fantasies of every Playboy-reading young husband of the late '50s and early '60s. The Great One drank and danced and ate and caroused with every leggy "broad" around. Did he care if people made fun of his ass? Perhaps, but it never showed.
Day 20 1/2: I stop by my favorite Italian deli and pick up some supplies for a meal I'm cooking tonight. I go home and make myself a ricotta sandwich and soup. No taste perversion - perhaps it only kicks in when I'm eating the same thing too often.
The mailman comes. I finally get the "customized weight-management plan" from Knoll. It's another four-page brochure, filled with boilerplate pep talks and exhortations to "keep a physical-activity journal" and "make a grocery shopping list and follow it." About the only sign that it has been personalized is the fact that my name has been laser-printed into the upper right-hand corner. I think of it as the pharmaceutical version of those "Mr. John Smith You Have Won!" mailings from the felons at Publishers Clearing House.
The brochure, however, does serve an important business purpose. This it does by stressing, repeatedly, the importance of having "realistic expectations." Charitably interpreted, "realistic expectations" can be read as just another of the many (somewhat effective) cognitive techniques used in mainstream talk therapy and parroted in countless self-help books. Not being the charitable type, however, I can't help but wonder if it's not just another way to get the patient's eye off the performance of Meridia.
"Close your eyes and imagine how you'd feel if you weighed 175 pounds" (which is still above my safe weight, according to Knoll's own "BMI Chart"), the brochure advises.
Well, for one, I'd finally be able to see whether or not I need Viagra . . .
Then I read on: "Ask yourself, 'Might I begin to feel the same way at 185 pounds?' How about 195 pounds?"
But that's only 10 pounds less than I weigh now! I think.
"As you can see," my personalized program concludes, "you're not far off the mark!"
Day 20 3/4: I make a big dinner - pasta in red sauce with saffron, grilled sausages, fennel and endive salad with pears, biscotti. I pick at it while everyone else chows down. It's a kind of sulky-picking-at-it, because I know I'll soon feel full. I skip dessert and lie down on the couch, exhausted. My stomach feels tight - gas-bubble tight.
Later that evening, though, I disappoint myself by snacking on too many cookies and milk. I'm no fun anymore . . .
Day 21: Watching the new kid at the bakery scooping up my cornetto di mandorle from the glass pastry case, I can tell he's a man of size before I even see his face. It's his . . . forearms. Because unlike the ass, the gut, the thigh and the chin, the forearms are the private shame of the obese.
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