Central  South  Dakota  Medical News
The Clinical View
by Phillip E. Hoffsten, M.D.
4 December 2003

AVAILABLE TREATMENT FOR OVERWEIGHT

     Last week’s column described a number of hormones that influence a person’s weight.  Like all hormone induced behavior enough will power can overcome the effect of the hormone.  As a general rule however, the will power wears out after time and the hormones don’t so the person reverts to the eating habit that they had “naturally” from the hormones.  Studies done in the past have demonstrated that fully 98% of the people that try to control their weight through dietary measures alone are on unsuccessful.  It is a sad commentary that our society continues to advocate “diet and exercise” to control overweight when only 2% of the population that tries this will achieve the normal specifications for weight.

     With the above piece of information one wonders about alternatives available to help control weight.  The early 1990’s demonstrated the “Phen-fen” epidemic in which a very successful weight loss program was practiced by millions of people.  Unfortunately, a few hundred developed heart valve abnormalities and one piece of the Phen-fen program was withdrawn from the market.  The other half of the program called Phentermine is still available and probably accounted for 60% of the appetite suppressing effect of that drug combination.  The official book recommendations are that Phentermine not be used for more than “a short period of time”.  In fact stopping the Phentermine for a person who is successful with it is rather stopping insulin for a diabetic.  Just because insulin is controlling the blood sugars doesn’t mean you should stop the insulin after awhile.  If the Phentermine is effective in helping control weight, there is not an intrinsic reason why it should be stopped.  In fact there is a good reason to continue the medication because weight control is so important to a person’s long term health.

     A second medication available to help control weight is called sibutramine (Meridia).  This drug seems to work on the same principal that the original Phen-fen combination worked.  It is not been shown to have any heart valve threat.  However, it is much less effective as an appetite suppressant as compared to what Phen-fen was.  It is also substantially more expensive and experience with this drug has not been a universal success.

     A third drug used by some individuals is called orlistat (Xenical).  This drug interferes with the body’s ability to absorb fat.  Thereby fat that the person eats is passed on through the stools having never entered the body’s metabolism.  The disadvantage of this drug is that it leads to substantial diarrhea and an inordinate amount of gas if the person eats fatty foods.  In my opinion, the real way that this drug is successful is that it discourages people from eating fat in order to avoid that side effect.  It is also substantially expensive and success has been infrequent.  There are several other medications that have been found to have the side effect of causing weight loss when they are used to treat problems such as depression, seizures, or diabetes.  These medications are still under study and do not have a clinical indication for use for weight loss.  As mentioned last week, there is a product called PYY that probably will become available on the general marked in the future.  It will be an injectable product very much like insulin.  While it appears at this time to be very effective, it will also be very expensive.

     Surgical intervention for overweight has been used for more than 40 years.  Currently, the gastric bypass procedure appears to be the most successful and is probably the method of choice of the young morbidly obsess individual.  Based upon the number of years of life lost because of morbid obesity, in addition to all the discomfort and social disability that comes from morbid obesity.  It is my person opinion, that strong consideration needs to be given to a definitive step in care at an early time when a person is facing a 2% likelihood of successful weight control with dietary means alone.  The gastric bypass procedure seems to work no only limiting the amount of food that can be eaten mechanically, it also has hormone modifying component that turns off the appetite stimulating the hormone called ghrelin.  Many insurance policies are now covering this type of surgery for individuals with a body mass index greater than 40.  My personal observations regarding this procedure have been favorable and well work the inconvenience and adjusts that it requires in the long run.  To my surprise, thus far, I have only seen individual who has to try to eat more to maintain a normal weight.  All of the other cases I have seen thus far (more than 20) have come in for a “soft landing” getting their body mass index below 30 over the course of over 2-3 years.  This is achieved without inordinate hunger.  This procedure would be especially recommended for those individuals who are diabetic.  Several of the cases that I have personally cared for no longer require any diabetic or any antihypertensive medication and they feel much better.

     As mentioned in last week’s column, overweight is an epidemic in our society at this time.  More than 1/3 of the population of the United States of America is considered to be obese.  This means the body mass index more than 30.  Morbidly obese means a body mass index in excess of 40.  These values are highly predictive for major health problems in the long run including diabetes, early development of heart attack or stroke, arthritic problems with requirement for replacement of knees and hips plus the many years of physical strain that comes from carry an excessive amount of weight.    On Saturday, December 06, there will be a discussion available at the Medicine Rock Café regarding the problems of overweight and the steps that can be taken to help deal with this major health problem in the United States today.