The Obesity Epidemic- Drug Treatment

Over the last 2 decades, obesity has become endemic in North America and is a major public health issue. It is estimated that more than half of American adults and 10-15% of children are obese. At least a quarter million Americans die each year from obesity related complications. The obesity epidemic is rising exponentially and it is predicted that obesity-related health problems will soon take over tabacco as the nation’s number one leading cause of preventable deaths. It has finally been realized that drastic changes are required to control the obesity epidemic. A newer breed of doctors, known as weight loss experts, has now been brought into the arena of obesity management. And of course when doctors get involved, drugs follow.

One thing that has been acknowledged is that drugs may not be the answer in controlling the obesity epidemic and a change in life style is mandatory. Therefore, along with these weight loss physicians, there has been an explosion of nutritionists, exercise gyms, herbal therapists, psychologists, spiritualists, yogis and a whole host of other experts- all who have been burdened with solving Americas number one health problem.  The majority of these so called experts are in the business to make money and Quack therapy is very prevalent in the obesity business.

As Americans continue to increase their waist lines, there has been a resurgence by the pharmaceutical companies to search for the ideal weight loss drug. Many new medications are currently being investigated and a few may be available in the next decade for use. However, there are some problems with drug use in the control of obesity. For the past decade, physicians have been reluctant to use weight loss drugs. This has mostly been due to the side effects and the legal hassles which follow when prescribing these drugs. Today, physicians have only a few drugs to choose from in the battle against the bulge. The FDA has approved two weight loss medications for long-term use—typically a year or more. A few other newer agents have been approved for short term use but this may not be enough to produce the weight loss required.

Despite these concerns, the new breed of weight loss physicians are taking a second look at these drugs in combating the obesity epidemic. It is believed that more that 25% of Americans are now eligible for short term drug treatment for weight loss.

Brief History

The control of obesity with drugs has been a major struggle for more than 3 decades. All types of drugs have been used in the past to treat obesity.

In the past, thyroid hormone and diuretics were often used inappropriately. Dangerous drugs such as dinitrophenol and amphetamines were prescribed, with serious side effects. With better understanding of obesity in the 1980s, different types of weight loss drugs were manufactured. Drugs like fen-phen helped individuals continue to maintain their weight loss. However, the drug was associated with serious cardiac side effects and its use has been banned universally.

Since then, two new drugs with different mechanisms of action have been approved for use by the FDA. Sibutramine (Meridia) is a serotonin-norepinephrine reuptake inhibitor acts on the appetite center in the brain, and orlistat (Xenical) is a pancreatic lipase inhibitor and inhibits the absorption of fat from the abdomen. However, these drugs do have side effects and their long term complications remain unknown. At present we have a huge gap in our armamentarium to treat obesity.

When does treatment start?

There are various guidelines and most recommend that drug therapy for weight loss should start when an individual has a body mass index (BMI) of > 27 or those who have obesity-related risk factors or co-morbidities, and in obese patients whose life style is severely affected. Under certain circumstances, weight loss drugs may also be effective for other patients. Some physicians also consider using obesity medications to patients with a BMI above 25 who have not responded to a rigorous program combining behavior modification, dietary changes and exercise.

Anti-obesity medications fall into two broad categories based on how they help patients fight fat. One group helps reduce food intake, while the other prevents fat absorption.

Appetite suppressants

Drugs which suppress appetite are the best choice for individual who have strong food cravings and have voracious appetites

The first appetite suppressant was Phentermine which has been available for about 50 years. It acts on the brain feeding enter. Over the years, a number of related drugs have been developed and include Ionamin, adieux and fasten. These drugs are only recommended for short term usage. The major problems with these drugs is that they can cause physical dependence after prolonged use. Other side effects may include an increase in blood pressure, palpitations, dizziness and insomnia. The major problem with these drugs is that they are often prescribed for longer periods without any medical follow up.

Even though the FDA recommends that these drugs not be used for more than 3 months, most weight loss physicians claim that with proper follow-up Phentermine is safe and effective for more prolonged use. To be on the safe side, most physicians get patients to sign a consent form acknowledging that they need to take the drug for longer than 3 months.

Recent anecdotal data suggest that combination of SSRI class of antidepressants like Prozac and Zoloft may be more effective in producing weight loss. However, none of these data have any scientific basis. Other less popular appetite suppressing agents include diethylpropion, phendimetrazine, sibutramine and mazindol.

Acomplia is the first of a new class of drugs that affect signals in the brain that influence appetite. This drug inhibits the appetite center in the brain.  As an obesity treatment, Acomplia may be best suited for people who are not only overweight but also have metabolic syndrome. Metabolic syndrome is a collection of symptoms, including high blood pressure, high cholesterol, large waist circumference, obesity and insulin resistance that can lead to diabetes and heart disease without treatment.           

Even though controlled clinical studies do show it to be an effective weight loss drug, the drug does have major side effects of concern. Severe depression nausea and vomiting are common. The drug has not been approved by the FDA for use in humans.

Amphetamines like drug

Some weight loss physicians are returning back to using the amphetamine-like agents which were used in the 1980s. These drugs fell out of favor decades ago because of their potential for abuse and causing physical dependence. Some physicians have been using dextromethorphan in relatively small doses in longer acting forms, closely monitoring patients and having them take the medication consistently every day to reduce the possibility of dependence. The individuals taking these types of drugs require frequent monitoring by the doctor.

Fat-busters

There are many individuals who are obese because they just can’t stop eating. The food craving and the binges are strong and preoccupy the mind. In such cases, another type of drug class may help. These drugs help by preventing the food from getting absorbed in the body and may even bust the fatty food which does manage to get absorbed.

Orlistat (Xenical) is the only medication besides sibutramine that has been approved for long-term weight loss use. This drug acts by preventing the body from absorbing a moderate amount of dietary fat. Weight loss from these drugs usually amounts to about 5% to 10% in four to six months. Both drugs have side effects. Xenical often causes diarrhea, abdominal cramps and loose stools. Some individuals may not tolerate these side effects for too long. The drug can also inhibit the absorption of important vitamins and so additional vitamins are recommended.

To ensure that these drugs work, the individual must adhere strictly to a low fat diet. Eating fatty food and taking these drugs defeats the purpose of these drugs.

Using other off label drugs

Other unorthodox weight loss experts claim that other not recommended drugs may also help in the weight loss program. These drugs are not approved for use in obesity. These drugs include thyroxin, diuretics and the anti diabetic agent, metformin.

The anti diabetic drug, metformin is an effective weight loss reducing agent and has been used by non diabetic individuals. However, in non diabetic individuals, the drug can cause profound drop in blood sugar and lead to coma. Thus daily blood glucose monitoring is mandatory.

The antidepressant bupropion (Wellbutrin) has also been associated with weight loss. When the drug is prescribed to patients with depression, weight loss has been a noticeable side effect.

Temporary weight loss can also occur with diuretics and thyroid hormone. However, these drugs have potent side effects but still are frequently abused by athletes and boxers.

Results

There is no doubt that no matter what weight loss drug is prescribed, most patients will initially lose 5-10% of their starting body weight. This is significantly more than any conventional behavior modifying treatments. The most important rule for success is that individuals have to have realistic goals. Setting sights at losing 10-15% of body weight in a year is reasonable but the majority of individuals are unrealistic and loose hope after a few months. For the physicians, it is essential to educate patient on a reasonable amount of weight loss. Physicians who promote 25-50% weight loss in a year are setting up all patients for failure.

Most weight loss experts now feel that it is essential to help patients lose 3-10% of body weight. Results indicate that medications plus aggressive life style changes can produce dramatic results. An important part of that strategy includes educating patients to stay on low-calorie, low-fat maintenance diets and continue to exercise. While losing 3-5% of the body weight may not sound too impressive and may not be the patient’s goal, these results combined with life style changes have shown a significant reduction in the risk of developing type 2 diabetes mellitus.

Follow-up therapy

The idea about treating obesity should be understood in the overall context of medical health. Treating obesity means one treats numerous potential risk factors and preventable disease at one time. Obesity is the genesis of a whole lot of other potential problems

One of the major complaints most individuals have after using drugs to lose weight is that they re-gain the weight once they stop taking the medications. This suggests that further therapy with nutritional and behavioral therapy is essential to help maintain the initial weight loss. The drugs do provide a boost but they are not enough to cure the problem.

After 30 years of trying drug treatment therapy for weight loss, most experts believe that drug therapy alone is not adequate to control the obesity mania. It is unlikely that a perfect magical drug for losing weight will ever be developed and even if the drug is developed, it will not be the magic pill. Diet and exercise will always be the corner store therapy for weight control.

Drugs probably will end up being most beneficial to people who have a genetic propensity to being overweight. The majority of people who are obese today are as a direct consequence of their lifestyle and nothing to do with their genetics. These people better start walking and eating more vegetables.

The history of drugs for weight loss has taught us something- that these drugs have potent side effects and their long term complications are unpredictable. So far, drugs have not had a bigger success and have always come out on the shorter end in comparison to the food industry campaigns of “supersize”.

The last 30 years has seen a major erosion of our life style. We have abundance of food, which is cheap, readily available and the concept of supersize is now imbedded in us. We are always looking at how to make our lives easier with energy saving methods. A sedentary lifestyle is now a major preoccupation of more than 70% of North Americans. Even simple walking around the block has now become a burden for majority of individuals. New drugs may be another treatment for obesity but they will never be a replacement for a drastic change in our life style. Drugs will help lose a few pounds but beyond that, it is going to take a lot of hard work and exercise.