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.'"
mechanisms that are not yet fully understood (Score:2, Interesting)
shucks, ive no idea, either that or because someone is paying someone else more for something else
Re:No, they don't work (Score:3, Interesting)
One Thing Is Clear (Score:2, Interesting)
Re:before anybody pops pills (Score:5, Interesting)
I lost 40 pounds by drastically increasing my saturated fat intake while reducing my refined carb intake.
Weight isn't the problem, it's a symptom (Score:5, Interesting)
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.
pills work, but only short term (Score:5, Interesting)
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.
Re:before anybody pops pills (Score:4, Interesting)
I should have clarified. I try to only eats fats that are made through old processes. So meat, dairy, lard, fish and cold pressed plant vegetables like olive, nut, and Avacado oils. Most are high in saturated fat. But unsaturated fats are mostly the byproduct of industrial processes requied heat and solvents. No thanks.
Re:They are scared (Score:5, Interesting)
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.
Tons of food (Score:4, Interesting)
You can eat tons of stuff that isn't so good for you, right? Cool. And, how old are you?
I was underweight for much of my life. Around age 25 or so, I FINALLY "bulked up" to 160 pounds. I stayed near that weight right up to about age 47.
Age has some nasty surprises for some of us. One day I looked down, and realized that I had a pot belly. Wow, man! That ain't me!
At the same time, my knees started giving out on me. I don't run any more, can't run. Oh - to be honest, I CAN run, but a quarter mile jog is going to leave me suffering for a week or more.
So, I got a pot belly, I'm far less active, and that pot belly now tips the scales at ~195, has actually reached 200 a couple of times.
At six foot tall, 200 pounds isn't "obese" - but it's unhealthy. For me, at least, YMMV depending on your body build.
When you're over 50, getting close to 60 years old, let us know how easy it is to lose those unwanted pounds. If taking a pill could reduce the number of fat cells for me, I would seriously consider getting some.
However, I do understand the equations very well. Those pills aren't going to do anything good that is permanent. About the only way to remove fat permanently, without serious exercise and diet, is surgery.
I'm NOT willing to go that route.
Re:before anybody pops pills (Score:4, Interesting)
or whatever the next fad diet to come along is
It is funny how for every fad diet there are tons of people who say it worked for them. That seems to be proof right there that whatever it is that works must be common to all of the diets. My guess is that simply being on a diet makes people more aware of what they are eating and that consciously or unconsciously causes them to eat less. Some people probably find it easier to do that with a specific type of diet, but the underlying mechanism is still the same.
Re:Fasting (Score:2, Interesting)
This, really! :)
I have done exactly this when I discovered I had diabetes type II.
I was extremely lucky because I discovered as it started setting on.
I decided to change diet. In 1 week I moved from a 3500kcal diet to a 1500kcal diet, cutting basically all sugars.
In 3 months my glucose levels where normal.
In 6 months I lost 80+ pounds (yeah do that math, it was crazy), and I had to change all my pants and shirts
This was *hard*, I had the motivation (scared shitless by diabetes), but I did it w/o any drugs.
Now I am on a healthier 1800-2000kcal diet, and with little control I move no more than 3 pounds up and down the scale.
I do not know if drugs would have helped me or not, but what I know is that obesity is primarily a mental condition, a failure to realize that changing your habits is vital. For me it really was a food addiction, I ate because I fucking loved the tastes I was putting in my mouth and I always wanted more, way, way, waaaaaaay past the point my body had "appetite". I would eat until I was full and then it some more, because that dessert was sooo delicious. I am sure some days I topped 6000kcal easily. That's insane, that's a food overdose, and is pure and simply psychological addiction.
Obesity is a hard problem because involves changing habits, something the average person (and in particular Americans) do not want to do, no matter what. They'd rather get a device implanted surgically that allows them to remove excess food from their stomachs (true story, but can't find the link now) than stop over-eating.
My fear would be that if the drug substitutes hard work either you end up using it forever or you'll go back and forth with an even worse effect.
Here's another thing that works: (Score:5, Interesting)
Re:before anybody pops pills (Score:4, Interesting)
Not true at all. An extreme example would be 1 teaspoon of sugar, and 2 lego bricks. Both contain a fairly similar amount of energy. Only one of these will actually make it into your body if consumed.
This example is obviously dumb, but it's true of all foods –varying amount of the energy in those foods will actually make it into your body. Worse, varying bodies will get varying amounts of energy from them. This can be caused by bacterial fauna, metabolic rate, genetic efficiency of processing, the body's current state and hence it's desire to store or dispose of foods, etc.
Re:No, they don't work (Score:5, Interesting)
There are so many aspects to why we're overweight as a society that it's stupid to cite any one thing as why. Sure, we don't move around enough, either at work or for our leisure time. We're taught that active, physical jobs are low-brow, and that the definition of success is to have others do things for us. We watch TV and sit at the computer instead of taking care of our homes and playing sports and working on things. We eat more than we should calorically. The kinds of things that we eat are bad for us. There aren't many rules about what companies are allowed to prepackage for food for us, and when rules do get passed, the public get pissed off and tries to reverse them.
This, "I don't wanna!" neoteny that our culture has fallen into, regarding getting out, being active, actually doing things is going to be our undoing. I actually support the idea of using medication to stimulate metabolism, at least enough to help us overcome the hump of inactivity, maybe if our metabolic rates were raised for a time before we get active, it'll be easier to get active in the first place.
I'm stuck in the same trap that we're all stuck in, it's Saturday morning and I'm sitting on my ass on the couch on my laptop, not really interested in fixing the compressed air distribution system in my shop or in insulating around the whirlpool bathtub or in putting new hatches on some of the openings to mechanical spaces, I'm warm and comfortable in my laziness. Yes, give me medication that makes it harder for me to sit still, and maybe I'll get my ass up and go do something. At least I finally accepted a few years ago that 99% of what's on TV is crap, so I have one less thing holding me here.
Re:The article is BS (Score:5, Interesting)
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.
Re:No, they don't work (Score:4, Interesting)
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.
This.
You can shovel pills down someone's throat all you want, and sure, they'll lose all sorts of weight, but if they're not building the life habits necessary to maintain their weight, they'll stuff their faces with shitty food all over again, and gain the weight back in a matter of months. The very fact that people want a Magic Pill to make them lose the caboose is evidence that they lack the skills, knowledge, and personal discipline necessary to successfully control their own weight. These people need to be told the truth: Losing weight takes work to achieve, and it takes real change of your lifestyle and habits to maintain, and most of all it takes stark honesty with yourself about what you eat and drink, who you are, and how you live your life.
Oh, and before anyone starts attacking me with the "thin privilege" and "fat hatred" crap: I used to weigh greater than 300 pounds once upon a time, had completely ruined my knees, and just didn't give a damn anymore. It took years, but I'm below 200 pounds, can leg press more than 3 times my bodyweight, and participate in a competitive endurance sport, and it was a damned hard road getting to where I am full of wrong turns and hard lessons, so don't sit there and tell me you've "tried everything", or "it's your genetics", or "it's impossible!", or any of the other excuses I see day after day after day. Don't sit there and claim you can be "healthy at any size", because that's utter bullshit. Stop trying to turn your sloth and lack of discipline into some sort of twisted virtue, because it most certainly is not! They say "Denial ain't just a river in Egypt", and your denial of the problem and it's implications is also going to wreck your children's lives as they grow up thinking it's OK to ruin their bodies, and being sabotaged by the poor dietary choices you make for them when they have no choice in the matter but to eat what is put in front of them.
So please, stop being in denial, stop ruining your health, stop ruining your bodies, and stop passing on your lack of discipline and poor choices to the next generation. It's all on you.
__________________________________________
Yes, I gave everyone both barrels with this one. Can't handle the truth? Not my problem. Deal with it.
Actually they do work. (I'm on one of them.) (Score:3, Interesting)
(tl:dr The drugs work. People think about obesity wrong.)
To those that say they don't work, I would suggest you look at the trials. One of the differences between these regulated prescription drugs and supplements or (most) diets is that there are actual double-blind placebo controlled studies behind them. They do work. There is very good research to show that they do.
Qsymia, which I am on, gives an average of ten percent body weight loss beyond placebo, and the weight stayed off out to two years, which was the end of the study. I went from 269 to 253 in my first six weeks (13 pounds or 4.8%.) I feel much better now, and I have taken up weight lifting again. My weight isn't dropping, but I am clearly losing fat and gaining muscle. My weight is pretty stable, but I can feel ribs that I haven't felt since the nineties. None of my leather belts fit anymore. I'm wearing a belt with a friction buckle until I stop shrinking.
I also just got my quarterly labs back and my A1c is down 1.2% and my lipids are great. I'm getting lightheaded when I stand up too fast (orthostatic hypertension;) I have an appointment next week to talk to my doctor about reducing my blood pressure medication. You don't just lose weight, but the comorbidities go away with about 5% weight loss.
The main problem with obesity drugs can be seen in the comments here. People for whom obesity is not a disease don't understand what it is like to fight the disease. I'm old enough to remember when depression was treated the same way as obesity is treated now. Polite people said "try to think happy thoughts." "Just snap out of it" was a more common response. Today most people understand that some people have broken brain chemistry, and telling a depressed person to work harder at being happy isn't going to work. The researchers understand that obesity is a disease, and telling people to work harder at being healthy isn't going to work either. But most people don't understand that yet.
To the person who said diet pills are short term only, you are right and wrong. When a person who is on medication for a chronic condition stops taking their medication, the condition returns. That is how you know the medication is working. Obesity is a chronic condition. Because obesity was once thought of as something that could be cured, like an infection, pills used to be given for a short period. People would lose weight on the meds, the doctor would pronounce them cured, they would stop the meds, and they would regain the weight (and the high blood pressure, and the diabetes, and the dislypidemia, and all the other fun stuff that goes along with central body fat.) The researchers and educated doctors now understand that obesity is a chronic condition that responds well to medications. (It also responds very well to *intensive* lifestyle modification and surgery. Most doctors miss the word "intensive" in that sentence, which is the subject of another rant.) The current expectation is that you stay on the drug the rest of your life, possibly with drug holidays.
For me, Qsymia has been life changing. I had lost about 100 pounds of fat over about six years, but I was stuck and I still had type 2 diabetes, high blood pressure, and horrible lipid numbers. I was working out, hard, at least eight and a half hours a week plus two 50 minute weight lifting sessions with a private trainer. I watched what I ate, but I was still obese and I still had the health problems. Eventually I got discouraged and stopped working out hard. I still did 300 minutes a week on a treadmill, but I wasn't killing myself in the gym or lifting. Interestingly, I lost muscle and gained a little fat, but it made very little difference to my overall health. With Qsymia my eating changed dramatically, I lost a bunch of fat, and my lab numbers got better.
Whether you prefer anecdote or data, the result is the same. Qsymia is a game changer.
(Some disclosure. I'm a computer guy with no medical training. My girlfriend is an MD wh
Re:No, they don't work (Score:3, Interesting)
I wish /. had a like button.
I remember when I realized that not only had a chosen to take the stairs because the elevator was taking too long, but I had run up the last flight.
I disagree about only allowing special people to get treatment, but I can totally validate the intangible of losing a bunch of weight after having been stuck for a couple years.
It is all very subtle and nuanced. Slashdot, alas, is not a good forum for intelligent discussion.
The problem, as I see it, is that we are all speaking from our experience. As an obese person, who has struggled with the disease all my life, it is easy for me to understand that it is a disease. I also have the benefit of having seen the research and spoken with the researchers. I have the experience and the knowledge, so the truth is obvious to me.
But I confess I have little sympathy for people with chronic pain. If I take the time to think about it, I can imagine what it must be like to be in agony all the time, but in the moment I just think "suck it up, we all have crosses to bear."
Seeing the uninformed here is a good reminder for me.
False recovered memories. (Score:0, Interesting)
Your wife is a likely victim of false memory syndrome [wikipedia.org]. In other words, the psychologist planted those memories in her through suggestion. It's a really nice setup, your wife gets absolved of all personal responsibility for her obesity and the psychologist gains a patient who will be dependent on them for the rest of their life.