Subject: Weight Loss & New Diet Medication on the Markets

From: PJM

Message: 

Reply from Dr. Bazos:

Thank you for your question PJM. Firstly, if PJM is short for pyjama man then already you're off to a poor start in dealing with weight loss management.

You have asked a very important question which very much reflects the Western "quick fix" philosophy and attitudes amongst our consumer-patient oriented way of life. Before I answer your specific concerns and situation, I really must address the topic of Weight Loss and more importantly Weight Management below. You will see why as you read on.

Obesity has become a global epidemic. This is most ironic in that the number 2 global epidemic is famine.

In Canada the economic burden of obesity well exceeds 2 billion dollars per year. This represents over 3% of the total health care expenditures for all diseases spent in Canada. Sadly, most obese persons will not lose weight. Of those who do lose weight, most will regain that weight (and then some) within the following 5 years.

A further irony is that many people with high risk obesity are not trying to lose weight while many normal weight, or even underweight individuals are trying to lose weight. High risk obesity implies persons at risk with developing comorbid diseases related to obesity which will be discussed below.

Before I go any further you must be aware of some medical terms used in dealing with this topic:

1. Body Mass Index (BMI) is defined as your Weight (in kilograms) divided by your Height (in meters) squared.

So, for example if your 5 feet 5 inches in height and weigh 172 pounds you first convert this to 65 inches x 2.54 cm per inch = 165 cm = 1.65 meters in height. Now 172 pounds x 1 pound per 2.2kg = 78 kg weight.

Plugging in the above values we arrive at:
BMI = 78 kg / (1.65 meters) squared = 78 / 2.722 = 28.7

2. Waist Circumference measured in inches. Centrally distributed weight places you at higher risk for obesity health problems. In the past, waist-hip ratios were used. Today the waist circumference is the accepted measure:

For men > 102 cms = 40 inches
For women > 88 cms = 35 inches

The World Health Organization (WHO) has classified one's weight risk as follows:

Classification BMI Risk of co-morbidities
Underweight < 18.5 Low (but risk of other clinical problems)
Normal Range 18.5 - 24.9 Average
Overweight >= 25
-Pre-Obese 25 - 29.9 Increased
-Obese class I 30.0 - 34.9 Moderate
-Obese class II 35.0 - 39.9 Severe
-Obese class III >= 40.0 Very Severe

The co-morbid diseases mentioned above related to obesity include:

- Diabetes mellitus (type 2)
- Hypertension
- Coronary heart Disease
- Lipid Disorders; namely high triglycerides ( > 2 mmol/L or 177 mg/dl)
- and low HDL cholesterol
- Arteriosclerosis
- Obstructive Sleep Apnea
- Osteoarthritis or other forms of arthritis (gout etc..)
- Stress Incontinence

Each of these carry with them their own symptoms, morbidity and health care costs.

Now PJM, when you see your doctor initially to help you deal with your weight problem he/she will/should rule out the following medical problems prior to dealing with treatment: 

1. Do you have a thyroid problem? A low thyroid (hypothyroid) certainly can cause a weight problem.
2. Certain medications can cause weight gain. Some of the common culprits include:
   -Antidepressants (mostly the old tricyclic class and some of the newer SSRI class agents)
   - Lithium
   - Major Tranquilizers ( the old Phenothiazine class and some of the newer agents, most notably Zyprexa)
   - Glucocorticoids (especially Prednisone used in many chronic conditions, severe asthma, lupus, certain arthritis..)
   - Female hormones supplements (notably oral estrogens and progestational products)
3. Depression
4. Undiagnosed Obstructive Sleep Apnea
5. Some 'rare bird' hormone disturbances ( hypothalamic disorders, Cushing's disease, and pancreatic tumors)
6. Binge Eating Disorder / Bulimia Nervosa

GOALS FOR WEIGHT MANAGEMENT

Successful Weight Loss is a reduction in body weight of at least 5% that is maintained for at least one year. We no longer rely only on the BMI tables, unless it's over 30. Remember, even a small reduction of maintained weight loss is associated with significant improvements in obese related complications, especially hypertension, diabetes and lipid problems.

Remember that rapid weight loss consists mostly of water and muscle -- the wrong kind of weight to lose. To avoid this, set more reasonable goals, such as one pound per week.

THE MENTAL APPROACH TO WEIGHT LOSS

Human behavior is governed by 2 directing forces. The avoidance of pain and the seeking of pleasure. Of the two, the avoidance of pain is a far stronger driving force than the latter. With this in mind, then, the most important step is to make up your mind to lose weight. This process must include a sincere commitment and be done with a positive attitude. Losing weight can be quite a challenge and downright tough. It takes time, practice and support to change lifetime habits. You and you alone are the one who has the power to lose unwanted pounds.

I cannot overemphasize the importance of having a positive attitude. Remember that emotions are like muscles and the ones you use most grow the strongest. Avoid attitudes such as " Why am I fat??. . . .  I'll never lose all that weight. . . ."  Rather, be positive and constructive in training your mind to control your body. "How will I lose weight?" Better still "How will I lose weight and enjoy the process??"

Negative thoughts unfortunately last longer than positive ones and do extensive toxic damage to your psyche. When one creeps into your mind, try to replace it by reminding yourself that you are somebody special, with self-worth, are unique with special strengths and talents. 

DIETS

I hate this word. It sounds so negative with "die" in it seemingly impossible and terminal. Rather I prefer "Healthy Eating." Some of the commoner "diets" include:

All of the above are good. Some are more expensive than others. There are of course many more. Diet and weight loss programs are much more flexible today than they once were and there are many prepared foods already portioned out. Low fat and low calorie foods are on shelves everywhere. You will need to learn newer, wiser eating skills. If you've mastered this, than honestly you will not need any of the above support groups.

The National Research Council recommends eating 5 or more servings of fruits and vegetables each day. Fruits and vegetables are the ideal diet foods for several reasons. They're relatively low in fat and calories, yet often high in fiber and rich in essential vitamins and minerals.

Carbohydrates are high octane fuel. They provide energy for movement and help raise internal body metabolism. They're also satisfying. The key is not adding high fat toppings to your carbohydrates.

Investigate for yourself which program appeals to you. Discuss the options with your doctor as to which if any plan is right for you. Choose a program that gives you some control, rather than imposing on one rigid system. Look for one that offers a variety of different eating plans, so you can choose the one that's best for you. But again most important is your positive mental frame of mind and your level of commitment.

EXERCISE

People who diet without exercising often get fatter with time. Although you may initially lose weight while dieting, this weight usually consists mostly of water and muscle. When the weight returns, it comes back as fat. To avoid getting fatter over time, increase your metabolism by exercising daily.

The benefits of exercise include:

The greatest pitfall of exercise is that one often rewards oneself with food that has more calories than those burned off in exercise.

Most people who are sedentary and begin to exercise make the mistake of trying to do a lot right away. If you are under 30 years old you might be able to do this. Maybe not. Starting any exercise program brings on aches and pains in muscles and joints. You can also sprain something. Most people stop exercising and never restart. The safe and sure way is to exercise for less than you feel you can do for about 2-3 weeks. You are not rushing to reach a goal but to establish a pattern of healthy activity you can live with for the rest of your life. 

Walking is one of the best and safest exercises. Walking will strengthen your bones, control your weight, tone your leg muscles, maintain good posture and improve your positive self-esteem. To lose weight, it's more important to walk for longer time rather than speed. Walking at a moderate pace yields longer workouts with less soreness -- leading to more miles and more calories spent on a regular basis.

Other aerobic exercise include jogging, swimming, bike riding roller blades and many others. Select an exercise that you are comfortable with. Check with your doctor what your safety cardiac tolerance is as well as advising you regarding proper footwear and safety devices where appropriate (e.g., helmets, wrist pads, knee pads etc.).

DRUG THERAPY FOR WEIGHT LOSS MANAGEMENT

There are of course many appetite suppressant drugs with amphetamine-like actions in the existing market. I will not mention these in this discussion because their use is generally frowned upon in the medical community. They are to be used for short periods if at all, no longer than 3 months and must be closely monitored for side effects: elevations in blood pressure, tachycardia severe mood swings, dry mouth, insomnia and have been found to have addictive tendencies. I have seen rebound weight gain as well as rebound depression on persons on these agents as well and for that reason will not even mention them by name.

Now PJM, you mentioned 2 new drugs recently released in the North American markets, they are Xenical and Meridia.

1. XENICAL (Orilstat)

XENICAL is an important and welcome tool in the physician's armamanterium in weight loss management. It is manufactured by Hoffman-Roche Pharmaceutical.

XENICAL is indicated for obese patients with an initial body mass index (BMI) of greater than or equal to 30 or greater than or equal to 27 in the presence of other risk factors, such as high blood pressure, high cholesterol and diabetes. Body mass index (BMI) is the most widely accepted measurement of obesity. 

Mode of Action:
XENICAL (120 mg) is a blue capsule which is taken just before you eat a meal. With this medicine in your gut, an enzyme (intestinal lipase inhibitor), which breaks fat down so it can be digested, is partially turned off. This results in a 30% reduction in fat absorption. This is what results in the side-effects. If you eat a low fat diet you will be unlikely to have disturbing side-effects.
XENICAL works in the gut and less that 1% gets into the blood stream. All the appetite suppressing medications work in the blood and the brain. No one has tested if a combination of Xenical and other medications are safe if taken together.

Side-Effects: 
Intestinal symptoms (stomach upsets) are the most commonly observed side effects associated with the use of Xenical and are primarily a result of its mechanism of action. These effects are generally mild and short acting and may include oily spotting, flatulence (farting) with discharge, fecal urgency, fatty or oily stool, oily evacuation, increased defecation and fecal incontinence. Maintaining the recommended dietary regimen -- containing no more than 30 percent of calories from fat -- may minimize the occurrence of these events. In studies the GI symptoms diminished over time and the patients quitting, because of adverse events, was similar among both medicine and placebo groups. 

Because XENICAL partially blocks fat absorption, it has been shown to reduce the absorption of the fat-soluble vitamins A, D, E and K as well as beta-carotene. Therefore patients are advised to take a daily supplement that contains fat soluble vitamins and beta-carotene.

Positive effects of XENICAL besides weight loss management include improvements in:
- blood pressure
- cholesterol
- triglycerides in patients with central obesity
- glycosylated hemoglobin-A1C in diabetics

Contraindications:
XENICAL should not be taken by patients with chronic malabsorption syndrome or cholestasis. 

Dosage:
120 mg capsules to be taken before meals 3 times daily.

XENICAL Summary:
I am very glad to have another weight control medication available to my patients. This drug has done well in the clinical trials reported thus far and has an impressive safety record. This is certainly worth a try in anyone with a BMI > 27 who is motivated, committed and decided to take serious their decision to lose weight and keep it off.

2. MERIDIA (Sibutramine)

MERIDIA is also an important and newer agent in the physician's tool in weight loss management. It remains under investigation in the Health Protection Branch in Ottawa and is not yet available in Canada. It is manufactured by Knoll Pharmmaceutical and no one knows when it will be released in Canada. It is however available in the US of A.

Does MERIDIA Work?
In the 17 studies presented to the FDA taking in 6000 patients the successful results were 50% to 65%. This means that any individual patient just starting MERIDIA has a 50-65% chance of losing weight because of it.

Indication:
In the USA MERIDIA is approved for use in people who weigh 30 BMI or more. While 58% of our population weighs a BMI of 25 or more, only 33.4% or our population is 30 BMI or more. 

Mode of Action:
Meridia works to suppress the appetite primarily by-inhibiting the reuptake of the neurotransmitters norepinephrine-and serotonin. The anti-obesity drug dexfenfluramine also-inhibits the reuptake of serotonin. However, dexfenfluramine, unlike Meridia, also causes an increase in release of serotonin from the nerve cell.

Side Effects:
The most common side effects associated with MERIDIA include dry mouth, headache, constipation and insomnia. The drug causes a small increase in average blood pressure, and causes a higher increase in some patients. FDA recommends patients taking MERIDIA have regular blood pressure evaluations. People with-uncontrolled high blood pressure should not take MERIDIA. No cases of pulmonary hypertension, a rare but serious side-effect associated with the anti-obesity drugs fenfluramine and dexfenfluramine, have been reported in clinical trials of-sibutramine. Echocardiograms on patients taking Meridia did-not show more valvular disease than those on placebo.

Results:
Studies so far show that patients lost an average of 5% to 10% of their body weight and maintained the loss over the course of a year.

Dosage:
MERIDIA will be taken once a day without regard to meals. It will also be available in multiple doses (5, 10, and 15 mg), enabling physicians to individualize therapy for their patients. The recommended starting dose of MERIDIA is one 10 mg capsule per day. Patients with inadequate weight loss should be titrated to a 15 mg dose.

Contraindication:
MERIDIA should not be used in patients with a history of stroke, coronary artery disease, congestive heart failure, or uncontrolled hypertension.

3. PLACEBO AGENTS

Many false hopes have been raised by people peddling placebos as active medicines. Just as placebos can have real effects on our bodies, so can people lose weight with them. When an active medicines effects are no different from a placebo, then that medicine is a placebo. Some of these products out there on the market are;

4. STARCH BLOCKERS

The "Sleep Off Your Weight" pills 
All of the various vitamin products in the many multi-level marketing schemes. 

People who claim metabolism disorders account for a large percentage of our weight related problems. Blaming food intolerances, medications, hormones, and thyroid imbalances for the majority of these "disorders". Some strange people claim food intolerances are responsible for at least three out of four "metabolic" problems. This is bad science and I have never seen any reference to any of the medical journal articles I have read. The above are usually terms used when someone is trying to sell you something and uses these nonsense terms to confuse you with scientific sounding words. 

"BUZZ WORDS"

Buzz words - Certain words and phrases which are used frequently and have come to have enhanced, and sometimes misleading, meanings. Whenever you read or hear any of the following words you should be very careful. Someone may be trying to sell you on something which has not been tested at all, or they may have misunderstood what they heard. 

Chromium Picolinate - A food additive which has never been tested on human beings to see if it adds energy or helps to lose weight. I read in one of the newsgroups that it had been tested on pigs. It can be found for sale at most "health food" stores. 

NATURAL - There are many "Natural" things in the world which are bad for you and this is one of the most misused words in our language. Any time anyone wants to talk you into spending your hard earned money they call something "Natural."

OVERALL SUMMARY

So PJM, losing weight is not something one can do overnight. Remember, there are no quick fixes with lasting results. See your doctor to determine your BMI, any secondary causes of weight gain (hypothyroid, depression, other medication, etc.) and assess your level of risk and suitability to any of the existing medications listed above. Pay particular attention to your heart murmur as it should be diagnosed and managed accordingly. 

A carefully planned weight loss program requires common sense and certain guidelines. Unfortunately, there's a lot of misinformation floating around and people are easily duped and ripped off.

Thank you for your question and a happy summer! Remember to use sunscreen.

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