Diet Drugs Work: Why Won't Doctors Prescribe Them? 670
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.'"
Re:Fasting (Score:5, Informative)
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....;-)
Re:before anybody pops pills (Score:5, Informative)
Cold pressed vegetable oils, avocados, and fish oils are (with a few exceptions) predominantly unsaturated fats. So it sounds like you mostly got the good kind of fat, you simply didn't realize what you were doing.
You're confusing unsaturated fats and partially hydrogenated vegetable oils; partially hydrogenated vegetable oils are really bad for you.
Re:before anybody pops pills (Score:5, Informative)
Re:No, they don't work (Score:3, Informative)
The more fat they have the less they need to eat.
Unfortunately it doesn't work like that. You'd think severely obese people don't need to eat at all; try that, and you'll end up with lots of dead people.
The human body can't live just on pure calories, there is a constant need for vitamins, minerals and such, without which it just starts dying. Stored fat has none of those, while at the same time using them up in order to get converted into usable calories. Meanwhile, food sources of this stuff are themselves laced with sugar and additional fats, so doing a minimum calorie while at the same time life sustaining diet, means the actual weight loss will be pretty slow.
Re:Type-1 Diabetic Here (Score:3, Informative)
Hi mate, I'm a type 1 diabetic in my mid thirties and I empathise completely with your comments and hope you're looking after yourself and keeping your HbA1c levels as low as possible.
In my experience I am constantly surprised by the lack of actual knowledge and education about diabetes. Sure, there's lots of awareness, which is good, but nobody seems to actually know anything. And unfortunately, I have to include doctors in that category. I've had the good (or bad) fortune to have my condition assessed in four different western countries (US, Canada, Australia and the UK) and found that only half the doctors I have seen could actually give me helpful and constructive advice for the treatment of the condition.
Having said all that, I also notice a massive difference between the advice from doctors regarding exercise, dieting, and losing weight. The problem (as I see it) is that the primary goal of diabetes care is to stabilise blood sugars. Which makes sense, and is obviously a good thing. But going beyond that, and wanting to lose weight or be an athlete, is not well supported by the medical field at all.
So, if I could offer some advice for you, don't give up hope and don't accept that you can't lose weight due to the diabetes. The comments you made about planning ahead tell me that you really know your stuff and you are very self aware of the condition and what is at stake. Which is great! Just try and take that to another level and build more exercise into your plan. Yes, your insulin requirements will come down, but you monitor this as you currently do normally, keep an eye on things and adapt. Something to be aware of is that exercise makes me more sensitive to insulin for about 24-72 hours. On top of that, after exercise my blood sugars are high. DO NOT treat post exercise high blood sugar with insulin, you will hypo within an hour. Instead, just chill and drink plenty of water and your sugars will come down quite happily by themselves. Of course, this is what happens to me, and your body may be different. Sorry if any of this is stuff you already know, I don't mean to be patronising, just helpful. Finally, my specialist is a huge fan of Metformin. It has protective benefits against heart disease, makes you more sensitive to insulin, lowers blood sugar over a nice long period of time, and helps to reduce apetite. I was told that 2g per day is the effective dose that's right for me and that patients should take as much as they can "handle". I say it like that because the side effects are stomach upsets, gastric pain and diarrhoea, which as you can imagine isn't the best of fun. So I take my full dose of Metformin and a small (10U) amount of Lantus each day and that keeps my basal blood sugar pretty much perfect. Most importantly I can go to the gym without eating anything and not have a problem with hypos. I only take Humalog for large meals that I have no control over: so a dinner party, or special meal, but in general I eat low carb meals and don't take any Humalog at all. I also gave up drinking about six months ago, which changed my life for the better, though have a glass of red wine every month or so since I love the flavour, and there is a protective effect against heart disease in those low amounts.
To be more active I would encourage you to be firmer with your own personal plans. I set a fixed time for exercise each day and it carries as much value in my day as a meeting with the boss or lunch with the girlfriend. I do not allow it to be moved or messed with, and so I get to the gym (or swim, or jog, or cycle: diversity helps!) every day for my little workout.
Anyway, I just wanted to reach out and say G'Day and let you know that you can do it and you can get your weight down, even with diabetes. Maybe my own experience has been helpful for you, or others here, but regardless, good luck with everything!
Re:The article is BS (Score:5, Informative)
Another factor that often gets overlooked in this debate is the role of sugar in our diet. [youtube.com] (Here's a written summary [nytimes.com] of the video.)
Last spring, the convenience stores in my area started stocking fresh fruit, so I switched my habitual breakfast from coffee and a Snickers bar to coffee and a piece of fruit. Around the same time, I saw the video linked above, and started actively avoiding sugar whenever it's convenient. These are the ONLY changes I've made to my lifestyle, but since then I have lost about four inches off my waistline.
Sugar is toxic. Do yourself a favor and avoid it. (Did you know that a 12oz can of coke does as much liver damage as a 12oz can of beer?) And artificial sweeteners are even worse. They mess up your insulin response profile and impede the signals which tell your brain when you've had enough to eat. (If you have a diet coke with dinner, you'll likely eat more food.)
The BBC did a four-part series on the "weight loss industry" earlier this year. It does a pretty good job of exposing the hype and marketing BS behind our current situation. Worth a look. [youtube.com]
Re:mechanisms that are not yet fully understood (Score:5, Informative)
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.
Re:Good health in a pill? Sure, why not? (Score:3, Informative)
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
Health is something that isn't nearly as simple as almost everyone seems to love to believe. The truth, based on current medical evidence, is that something like 60% of "obese" people are by all metrics besides BMI perfectly "healthy", while something like 60% of the people who are part of the epidemic of diabetes and afflicted with massive amounts of cardiovascular disease are people of normal body weight who everyone assumes are "healthy" solely due to their "normal" BMI. It just plain isn't that simple.
Obesity, diabetes and cardiovascular disease have been proven in recent decades to not be nearly as well linked as almost everyone still believes. Getting the obese to lose weight with pills therefore will not necessarily result in a strict increase in overall "health" of our society. In fact most of the pills that help promote weight loss have been shown to cause rather extreme negative side effects. Such as fatal heart attacks.
Everyone still believes that you must stay away from saturated fats and cholesterol, even though it's been shown over and over again that increasing or decreasing "dietary" fats and cholesterols has almost no link whatsoever to increasing or decreasing levels of fats and cholesterol in the body and blood, most of which is created by your own liver. In fact, if I'm quoting Dr. Lustig correctly, the link between the ingestion of the fructose molecule and bad blood glucose, fat, cholesterol and triglyceride levels is about 50 times better than the link between those things and the ingestion of any kind of dietary fats. Yes, fructose. According to Dr. Lustig's research, fructose, and its close relative ethanol, may be the root cause of metabolic syndrome, obesity, diabetes and the explosion of cardiovascular disease. Not starches or dietary fats.
Also quoting Dr. Lustig, evidence indicates that approximately 99% of human beings cannot maintain any form of weight loss for more than a few years, if they even succeed in losing any weight the first place, which most people don't. Thus, no matter how long everyone continues to insist that obesity is a personal willpower problem that should be solved by the individual... THIS. WILL. NEVER. SOLVE. THE. PROBLEM.
EVER.
If we really want to solve the societal pandemic of obesity we need to completely discard the idea that it's caused by some personal moral failing (of the lower classes, no less). We went from 10% to 60% obesity over the last 40 years. If we keep relying on the magic pixie dust of "personal responsibility", 90% of our grandchildren's generation will be obese and 90% will have diabetes starting from early childhood regardless of body weight. There is a systemic problem in the modern diet that is causing this explosion of obesity and diabetes, and we need to find PRACTICAL solutions that fix it on a society-wide basis.
Linky:
http://www.youtube.com/results?search_query=lustig+sugar&sm=3 [youtube.com]
Re:mechanisms that are not yet fully understood (Score:5, Informative)
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.
Re:mechanisms that are not yet fully understood (Score:4, Informative)
Other people have pointed out that is not the case, but I thought I would address the pregnancy thing.
Pregnancy studies are a high risk/low reward proposition, unless you are talking about fertility, anti-miscarriage or other pregnancy related applications, since including pregnant women in a clinical trial has a really high settlement cost if there's a problem with the pregnancy, and an even higher cost if the baby comes out with a birth defect. As an example, women with hair loss get warned against finesteride, since it acts as a 4-5 reductase suppression agent, which, when it occurs naturally (5-ARD), results in conditions from hypospadias needing surgical correction, all the way to full blown X-Y females (sterile of course).
It's fairly common to warn pregnant women not to take a medication, even if in fact it might be perfectly safe because of the exclusionary nature of the studies. This is purely a legal liability/malpractice issue, not necessarily an issue with the medication itself.
Re: DIET OF THE POOR (Score:4, Informative)
I don't think the government should tell us what to eat, but I do think there is something wrong with the US food supply that calories doesn't cover because rice is horribly high in calories and carbohydrates
Portion size.
What are they putting in the food that most Americans eat that the rest of the world isn't eating?
Nothing really. Most of the world is getting fatter.