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Diet Drugs Work: Why Won't Doctors Prescribe Them?
Hugh Pickens DOT Com writes "Suzanne Koven, a primary-care doctor at Massachusetts General Hospital in Boston, writes in the New Yorker that the FDA has currently approved four drugs that will help patients lose weight but few primary-care physicians will prescribe them. Qsymia and Belviq work by suppressing appetite and by increasing metabolism, and by other mechanisms that are not yet fully understood. 'But I've never prescribed diet drugs, and few doctors in my primary-care practice have, either,' writes Koven and the problem is that, while specialists who study obesity view it as a chronic but treatable disease, primary-care physicians are not fully convinced that they should be treating obesity at all. The inauspicious history of diet drugs no doubt contributes to doctors' reluctance to prescribe them. In the nineteen-forties, when doctors began prescribing amphetamines for weight loss, rates of addiction soared. But in addition, George Bray thinks that socioeconomic factors play into physicians' lack of enthusiasm for treating obesity because obesity is, disproportionately, a disease of poverty. Because of this association, many erroneously see obesity as more of a social condition than a medical one, a condition that simply requires people to try harder. Louis Aronne likens the current attitude toward obesity to the prevailing attitude toward mental illness years ago and remembers, during his medical training, seeing psychotic patients warehoused and sedated, treated as less than human. 'What the hell was I thinking when I didn't do anything to help them? How wrong could I have been?' Specialists are now developing programs to aid primary-care physicians in treating obesity more aggressively and effectively but first primary-care physicians will have to want to treat it. 'Whether you call it a disease or not is not so germane,' says Lee M. Kaplan. 'The root problem is that whatever you call it, nobody's taking it seriously enough.'"
Your diet is a perpetual thing, not something you do for a little while to lose weight. Eat healthy, be healthy. Drugs and short term adjustments in what you eat aren't going to do shit.
Ask yourself the following:
(1) Are you cooking most of what you eat yourself?
(2) Have you cut all sugar, pasta, bread, and other starchy foods, and most saturated fat and meat from your diet?
(3) Have you been tracking your calories and weight daily for the past month?
If the answer to any of these questions is "no", you haven't seriously tried losing weight, and nothing is likely to help you.
The previous post is a fine example of the problem: treating obesity as a moral failing. If you were a "good person" you'd have the willpower, eat right, etc.
Sure, modern lifestyles and diets are a contributor to the problem, but not the entire cause. There is ample peer-reviewed validated research out there that shows that some people are more efficient at metabolizing food, and that you can exercise as much as you like and eat as little, and still not lose weight as much (and suffer a variety of undesirable side effects in the process).
Bear in mind also that the underlying biochemistry of the "average adult" has changed as the result of food and activities during childhood. A travesty to be sure (juvenile onset diabetes, for instance), but now that you have that 20 year old with the screwed up biochemistry (in terms of comparison to 1900s man), you're not going to fix it by changing diet and activity.
And then, there's the practicality problem. If your job, which pays for the food you eat, requires you to sit in a cube with a headset on and a keyboard, no amount of Outside magazine inspired "get out and get fit" exhortation is going to provide an opportunity to "live a healthy lifestyle". Companies talk the talk, but when it comes to adversely affecting productivity, they do not walk the walk: that's why company wellness programs emphasize things like smoking cessation.. it's something you can do on your own time that saves the company money (yes, it's a good thing, but the real point is that the employee is doing the heavy lifting).
And so, after sitting in the cube all day, or inspecting people at a checkpoint, or whatever task there is, you ride the bus to your second job, so you can make the rent on your apartment in the food desert. Not a whole lot of time to prepare that nutritious meal from non-existent ingredients.
So, before exhorting "good healthy ways to eat", let's talk about paying people enough so they can afford to do so (in terms of time available, etc.)
Hello,
I'm a weight loss and weight long term control success story, more or less. But having done it, I know exactly how hard it is.
I'd love it if the US population could dump their extra pounds by taking a pill. It'd just be a win for everyone, and the only people who'd "lose" are those who feel superior because they've managed to do it without the pill.
And even THOSE people will be paying lower health insurance premiums because the population is healthier in general.
If the pills really work, BRING 'EM ON! Who knows, if I can't exercise some day (I'm currently taking a few weeks off because I got rear-ended in my car!), then I'll need them myself!
--PeterM
i am sorry this is not biochemistry this is made up "science". When ketosis is entered (by depleting ready carbohydrate resources) the body can metabolise fat into ketones (via the liver). The reason this myth persists is because for decades medical researchers couldn't imagine the brain running without glucose, which is a necessary condition of ketosis. Then some bright spark pointed out that the Innuit have been living like that for millenia and (shock horror), it works on western folks too!
Diet and exercise works every time. Guaranteed. There are no exceptions. If you are not exercising , a good chance you will lose some "lean mass". Loss of muscle through maintenance also occurs, so these statements are no helpful.
*however* biology is all about homoeostasis. When you look at your paunch and flabby bits, ask yourself the question "why does biology hang on to them". The body stores excess sugars as fat, as sugars in the blood are toxic. The hormone insulin causes this sequestration of the sugars into fat cells. If you go on a crash diet , the body is happy to burn up the fat. But the cells are still there. Returning to previous over-caloried state just fills the cells up again. Only by a gradual change onto a *lower* calorie diet will you lose the weight "permanently". Think 6 months minimum. Believe it or not 2lbs/week is a pretty good rule of thumb as the body gradually reallocates the cells. If you want to get "cut" that requires some more extreme measures...;-)
Recent research is showing that being overweight and diabetes are connected, although the data stretches back decades. The biggest FUD of the 20th century is the daily calorie limits. If they ever applied it was to a population that was more active, but modern folks spend way too much time on computers(!).
Biology is very complicated but the rules are simple. Everything in moderation....;-)
My wife is morbidly obese. She for years has tried to lose weight with various diets and drugs. These had temporary weight loss effects, but all ultimately failed.
Why? Was my wife of inferior moral fiber and simply unable to follow through? Is she simply someone who needs to eat from a smaller plate, sit further away from the table, exercise more, eat less sugar, eat less carbs, eat more carbs, follow some arcane points system?
Nope. None of that works.
I'm a software engineer. Failure is a daily occurrence, and when we fail and study the failure, we learn the underlying problems and then we have success; and I've constantly encouraged my wife to keep trying. And she has; for over 10 years.
Two years ago, she contacted a weight counsellor / psychologist in Florida. In that time, they have peeled back the layers of her life, looking for the real, underlying problems. And, they found them. Who knew, for example, that being sexually abused as a 4yo child for years would cause problems? Who would have thought that when the attacker (a family "friend" next door) said things like "you would look prettier if you lost a bit of weight", it causes problems like gaining weight to try and make the pain go away? Why on earth would a narcissistic mother cause problems - especially when a 4yo comes to her bleeding from the vagina and covered in semen, and the mother simply wipes it away and says it never happened?
My wife's weight is far from something to be ashamed of. Instead, it's the mark of a person who came through some of the most horrendous things you can imagine - and lived.
The reason all the diets and drugs failed? Denial of the past and the problems in it. Simply becoming an adult doesn't mean the past will not affect you.
The future? Looking good. Since breaking through and working through all of her past, the underlying need to eat compulsively has gone. Guess what? She's loosing weight without a restrictive diet, drugs, surgery - whatever.
Obesity isn't a "disease" or anything like that. It's the symptom of something else. Medical dollars are best spent for people who are ready to lose the weight AND deal with their pasts by supplying them with competent psychologists, not the latest diet pills.
As a primary care physician, I gave in years ago. I now prescribe assorted appetite suppressants whenever some one asks me, it saves me lots of arguments, and a lot of time.
However, I get them back monthly for weigh ins. The drugs work great for a couple months, losing 4~8kg a month, then tapering off to nothing. Folk then realise that this is not a wonder cure.
The only stuff that works long term is eating less +/- exercising more, or surgery to shrink your stomach (actually the latter works pretty well, better than pills long term, in my experience. little change out of $10K, but probably worth it)
Pills are short term appetite suppressants. The following year, you are back to your previous weight, but your wallet is much lighter. Look to advice that you already know about for long term losses.
Nah, as a doctor (in Australia, but i suspect most places are the same), we prescribe them only when a patient goes on & on, "but honestly, I dont eat much...", especially when the waiting room queue is getting longer.
We know they work, for a few months, before becoming less and less effective.
I'm guilty, I prescribe them to turn off a patients demands and get them out of my room, knowing they will see that the response is poor after the first few months.
Eat less, do more. That is reality, everything else is bullshit, or very temporary.
After 3 or 4 months, when the drugs stop working, some are ready to face reality. Those I can work with.
What's so funny about this (and reinforced by the other replies to your post) is that people really object to the morality of other people "getting away with something" -- eating too much of the wrong food and not exercising enough.
I'm surprised they don't object to people with infections being treated with antibiotics, since if they had better hygiene they wouldn't get sick.
Why should you care if someone else is healthier by taking a pill?
Your personal physiology is identical to everyone elses', and so what worked for you will also work for every single other person on earth? Great! Spread the news! With this astounding insight, the obesity epidemic will be cured in no time!
Wait? What's that? You mean the metabolic pathways for storing and releasing energy are complex and very different from person to person? You mean that the body actively fights to retain fat stores when less energy is available resulting in crippling pain, headaches, listlessness, inability to cocentrate and insomnia? You mean to say that obesity is caused by numerous interrelated factors that each require corrective action in concert to be effective? It even says so in TFA? Well shucks!
Who'd have thought an illness that 100 million people are unable to cope with might actually be difficult to cure?? No, no! That can't be it. Let's just say they're lazy gluttonous porkchops so we don't have to find solutions to a difficult problem. So much easier for us to sleep well at night.
Scientists point out problems, engineers fix them
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Here are two more 100% correct assertions: you can live forever as long as you avoid death, and you can be wealthy by earning more money than you spend.
During World War 2, the "Minnesota Starvation Experiment" was conducted. 30 healthy men had their maintenance level of calorie intake measured for a month or two, and then had that calorie intake cut in half with no changes to their daily minimum half an hour of exercise. At the end of the study, the participants had an average drop in resting metabolism of 30%, and that's not 30% lower than when they were heavier, it was 30% lower than predicted for someone at their new skinnier sizes. Most of the men had developed an eating disorder, a mood disorder (bipolar, depression, etc...), an obsession with food, or all three.
The devil is in the details.
Perhaps doctors don't prescribe them because:
- they don't work very well in the short term and not at all in the long term
- they are expensive
- they have lots of bad side effects:
Qsymia has particular risks for pregnancy, as it can cause birth defects if taken in the first months of pregnancy, even before a woman knows she is pregnant. Women of childbearing age must use effective birth control to keep from becoming pregnant while taking Qsymia.
Qsymia should not be taken by:
Pregnant women
People with glaucoma
People who have been told they have an overactive thyroid
People taking a type of antidepressant called a MAOI
People allergic to phentermine or topiramate
Belviq should not be taken by:
Pregnant or nursing women
People taking drugs linked to valvular heart disease, such as cabergoline (Dostinex)
Belviq should be taken with caution by:
People taking certain medicines for depression; migraine; the common cold; or mood, anxiety, psychotic, or thought disorders
Men with conditions that predispose them to erections lasting more than four hours. These conditions include sickle cell anemia, multiple myeloma, and leukemia
Men with a deformed penis
Qsymia and Belviq each come with a long list of important safety information, but this list is different for each drug.
I don't read your sig. Why are you reading mine?
You might want to review the full research before posting.
> - they don't work very well in the short term and not at all in the long term
Qsymia gives about 10% weight loss beyond "placebo" (which was a diet and exercise program that all treatment arms got.) Weight loss was maintained out to two years, which was the end of the study. Qsymia is a combination of two medications that have been on the market for a long time. Weight loss docs have been prescribing them together for quite a while and I haven't heard any talk about them not working after a certain point. Qsymia just takes two existing meds and makes one pill out of small amounts (if you want to match the Qsymia doses with generics you have to chop tablets as small as an eighth) and uses a time release formula so the side effects (carbonated drinks taste funny and tingling in the fingers are common. I have the change in taste) aren't as bad. There is no research on Qsymia past two years, but there is experience with the components. Belviq is a 5-HT2C receptor agonist, and I'm on a SSRI. I haven't paid much attention to it, but I assume it has data out two years also.
> - they are expensive
True dat. And not covered by a lot of insurance. I buy mine out of pocket. About $170 per month. It's worth it to me.
> - they have lots of bad side effects:
Other people have pointed out that is not the case, but I thought I would address the pregnancy thing.
First, if I, as a 45 year old man, get pregnant on Qsymia it will be news. Much bigger news than a birth defect.
Second, obesity also increases in risk of birth defects.
Third, this is why they have a program to tell people that if you take Qsymia in the first few months of pregnancy there is an increased risk of cleft lip/palate. This is because Qsymia contains topiramate, a medication prescribed about 10,000,000 times a year. Interestingly you can take 400mg a day of topiramate for neurological conditions without a warning, but if you take 23mg a day for weight loss you have to be warned of the risk. Not that there is a bias against obesity or anything...
I think I have posted more in this one topic than in all the rest of the time I have been on slashdot, but this drug has made such a difference in my life.