It is estimated that about one-half of the US adult population are overweight (a body mass index, or "BMI," greater than 25), and about one third of adults are clinically obese (a BMI greater than 30). BMI is calculated by taking your weight in kilograms (kg) and dividing it by your height in meters (m) squared (kg/m2). Sounds complicated, but most doctors have a chart in their office.
Obesity is a big problem in our culture. And I am not just talking about the societal effects-- the prejudice against the obese, the physical difficulties associated with being overweight-there are very serious health considerations as well.
Obesity can lead to high blood pressure, high blood fats, and diabetes, which in turn are very serious risk factors for heart attack, stroke, and Alzheimer's Dementia. It is even becoming clear that many cancers are obesity-related.
Well, if the problem is so serious and so widespread, why aren't there more things that medical science can do to help these patients, many of whom have tried (and failed) various diets, over-the-counter weight-loss medications, exercise routines, and the like?
It is because the causes of obesity are complex. For example, what role does genetics play? And how important are environmental/cultural/lifestyle factors? Studies indicate that all are important. Consider genetics (family heredity)-some people are quite obese despite living a pretty darn healthy lifestyle; others seem to be able to eat anything (and any amount) and never gain weight. So genetics clearly plays a big role (that is only one of the reasons why we should not judge obese people).
However, environment factors (i.e. our culture, eating habits, lifestyles) also play a major role. Studies of twins show that one twin raised in a home with an obese parent is likely to be obese himself, while the other twin, if raised by normal weight parents is more likely to be normal weight himself. This seems to put more weight upon environmental causes.
And then we have the question of exercise. Some people love to get up and go-walking, jogging, tennis, basketball, hiking, etc. Others are quite content to sit and read a good book, watch TV, or play a video game. Why the difference?
There appear to be many factors operating in the causation of medical obesity. So developing one strategy, the so-called "magic bullet," is probably not realistic. But having said that, there are effective treatment options available for the medically obese patient.
Before proceeding I would like to point out some myths about obesity and its treatment:
Myth #1) Obese people are obese because they are lazy, slothful people who could lose weight if they really wanted to.
To be sure, some obese patients are to blame for their situation. But would you be surprised to learn that medical studies do not show that lifestyle changes alone help the majority of patients? Obviously something else must be done to help our obese patients. We physicians (especially we skinny docs) sit in our exam rooms and tell our patients to simply quit eating so much; quit eating unhealthy foods; get off the couch and start exercising. All good advice-but it doesn't work for many patients. Something else must be done to motivate the patient, and to help the patient with his or her food cravings. Just asking a patient to change his lifestyle does not work for a large number of patients.
Myth #2) Prescription obesity medications are too risky.
Yes, there are some side effects and risks associated with prescription obesity medications. But almost all medications have side effects and calculated risks-we just hope that physicians are weighting the risks (usually very low) against the benefits (usually very high). And in the case of obesity, the potential benefit for a patient who loses just ten pounds is tremendous.
Myth #3) Prescription weight loss medications don't make you lose a lot of weight, and therefore aren't worth it.
As I mentioned, losing just ten pounds can really help reduce one's risk factors. So yes, it is worth it!
Medical Treatment for Obesity-OTC Preparations
The over-the-counter compounds and supplements promoted for weight loss generally do not work. Let me tell you about some of these OTC compounds and the theories behind their use.
There are several mechanisms whereby we can theoretically induce weight loss:
1) Chemically increasing the body's energy output, which in turn burns calories. This works well in theory, but unfortunately the medications which perform this function are dangerous (OTC examples are ephedra and caffeine--they are too dangerous to advocate for use by the general public).
Some physicians have used prescription thyroid supplements for this approach as well-this too is dangerous for the person who has a normal thyroid. Do not do it.
There are also several OTC herbs, which claim increased energy output-bitter orange, guarana, country mallow, and yerba mate-they do not work.
2) We can preferentially burn off carbohydrate. Compounds purported to do this are chromium and ginseng-studies indicate they don't work.
3) We can take compounds which make us feel full (i.e. "appetite suppressants")-examples of OTC meds claiming to do this are guar gum, glucomannan, and fiber supplements such as psyllium-they don't work either.
Prescription meds which operate as appetite suppressants include the amphetamine-like drugs such as Fastin, Ionimin, Adipex, and Preludin-the "Phentermine compunds". They are effective, but have risks and they do not seem to work for the long term. More on these later.
And by the way, many patients who take serotonin anti-depressants like St Jon's Wort, Prozac, Paxil, and the like, state that they lose their appetites. We had hoped that this anorectic effect might help obese patients. Unfortunately this effect is very short-lived for the vast majority of patients; thus very few patients benefit in the long run.
4) We can increase the preferential burning-off of fat stored in the fat cells-the compounds which claim to do this include carnitine, hydroxycitric acid, green tea, vitamin B5, licorice, linoleic acid, and pyruvate-they too do not work.
5) We can try and block fat absorption in the intestine-chitosan has been tried, and has failed. We will discuss later a prescription medication which works this way and is effective.
6) We can increase water loss (i.e. the diuretic effect)-cascara and dandelion have been tried, and both have failed in this area. Prescription diuretics used for this are harmful and dangerous and not worth the risk.
7) We can try to block hormones which cause fat cell growth (hormones like cortisone, estrogen, testosterone, and growth hormone). These approaches do not work because the OTC compounds are not strong enough and the prescription medications are very risky.
8) Finally we have the miscellaneous group of products, which do not even try to offer a mechanism for effectiveness-they just claim to work. Examples are laminaria, blue green algae, guggul, and apple cider vinegar-they do not work.
Now, I know you are feeling really frustrated and hopeless at this point, because you have tried (or were planning on trying) several of these approaches and have failed. Don't lose heart! There are options available.
Prescription Medications for Obesity
One answer for the obese patient who has tried and tried to lose weight without any long-term success might be prescription medications specifically designed for weight loss. I know, I know, some of you out there will think I am getting a kick back from the drug companies for advocating this, but trust me--I am not!
Now, let me categorically state at the outset that obesity medications are not for those persons who are just trying to lose a few pounds-you must be medically obese to qualify (i.e. greater than 30 on the BMI index--your physician or dietician can measure you, but a general rule of thumb is this: if you are a woman whose waistline is over 36 inches, or if you are a man whose waist is over 40 inches, you probably qualify).
Now, let me suggest two FDA-approved medications that might help you if you are medically obese (yes, I know, the FDA seal of approval is in question these days, but these medications I am going to suggest have been around a long time and we have very good experience using them).
Meridia (Sibutramine). This medication works by making one feel full. It might also speed up energy expenditures and burn calories, but this latter effect is questionable and not proven. However, the medication works. When compared to placebo it was more effective, with the average weight loss (when taken over several months) being anywhere from 5% to 10% of total body weight (usually 10-15 lbs). The medication is generally safe but must be administered by a physician; and the patient must be monitored for increases in blood pressure and pulse rate. Other common side effects are not serious and include nausea, insomnia, dry mouth, and constipation. Meridia is expensive and most insurance companies do not cover it. But it just may jump-start a person by helping them get started with a strict low-calorie diet the first few months.
Xenical (Orlistat). This medication works by inhibiting a fat-absorbing enzyme in the intestine. The blocking of the enzyme is not total, so the medication is safe (you do need to absorb some essential fats in your diet). The effectiveness of Xenical was like that of Meridia: a loss of weight of about 5% to 10% of body weight. Because some fat is blocked from being absorbed in the intestine, side effects center around this mechanism and are predictable: fatty, greasy stools, minor diarrhea, and occasional fecal leakage (rare). Reducing the fat intake in one's diet can lessen or even eliminate the side effects. Xenical must be taken three times a day (kind of a hassle), and is also expensive, but effective.
As you can see, neither of these drugs is a magic bullet-yet both can help a person lose 10-15 lbs over a few months and make dieting an easier experience.
Other Prescription Medications
There are other prescription medications used for weight loss, but as I will mention below, all have some drawbacks.
Glucophage (Metformin). This is primarily a diabetes drug which works by making your fat and muscle cells more sensitive to the effects of insulin (they promote carbohydrate absorption into the cells and out of the bloodstream). Glucophage also shuts down the synthesis of sugars by the liver. Diabetics who take Glucophage lose weight better than placebo. When tried on normal subjects however, the studies are conflicting-some show modest weight loss while other studies do not confirm this. Glucophage has some side effects, some of which can be serious. I do not recommend it for the non-diabetic.
Fastin, Ionimin, Adipex, Preludin (Phentermine). These are an amphetamine-like medications that make one feel full, and might also speed up energy expenditure. They works, no question about it, but unfortunately they have many side effects, some of which can be serious. And one major problem is that some patients are susceptible to addiction, just like amphetamines. They are all controlled substances.
Now for the big drawback: studies show that the medications lose their effectiveness over a few weeks to a few months, and then the weight comes right back. The generic form (Phentermine) is relatively inexpensive, but must be prescribed and monitored by a physician. I do not recommend it.
Surgery for Obesity
To qualify for a surgical approach to clinical obesity one must have a BMI greater than 40 (usually these people are at least 100 lbs overweight). The reason that the weight requirements for surgery are so high is that obesity surgery has risks, many of which can lead to disability and even death. It is estimated that the mortality rate from gastric bypass surgery is about 1%; but the complication rate is as high as 25%. One should not consider surgery for obesity without getting all the information one can get (2nd, 3rd opinions, talk to other patients, read the available literature!).
Surgery is quite effective, however. The average weight loss varies from 45 to 95 lbs. Unfortunately many patients who have this type of surgery have some type of gastrointestinal side effect afterwards, which can last indefinitely. Surgery must be considered a last resort for the morbidly obese patient whose life literally depends on it.
It is the holidays! Come January we will all be wondering why we ate so much! Many people will be looking at their waistlines and committing themselves to losing 5 or 10 lbs. This article is not for you. You can quickly and safely lose that holiday weight just by increasing your exercise and by doing some common sense dieting. I suggest you try and limit your sugar and white starch consumption for a few weeks. Watch your fat intake as well, concentrating on high quality, lower-fat proteins and complex carbohydrates (brown, fibrous starches like whole wheat breads, rice, and pastas). I have addressed this diet in other articles. It works.
But for the obese patient who has tried diet after diet without much success, consider seeing your physician about medication options tailored for you.