Overrated Medications Series: No.1 Weight Loss Medications
This is the first in my series on overrated medications. I am not trying for a definitive ranking of these medications, but rather I am simply trying to show my readers some of the most hyped and overrated drugs on the market. It will help people make better decisions, avoid waste and improve their health.
For number one I choose weight loss medications. The reasons are:
1. Weight loss medications are ineffective in the long run.
2. If they are ineffective, then by definition their therapeutic index (margin between safety and effect) is suspect.
3. Some are outright scams.
4. They are rarely needed (there are perhaps a few exceptions).
The most successful weight loss medications were fenfluramine and phentermine (Fen/Phen). This combination made a huge impact in the 1990s. Weight loss clinics sprang up and small fortunes made. I admit to taking the medications myself and to prescribing them. I bought into the hype.
The Fen/Phen studies were by Michael Weintraub and published in Clinical Pharmacology and Therapeutics. Initial results for some patients were astounding. Weight loss of 50 pounds the first year was fairly common. By year 3 of the study, study subjects were regaining lost weight and average weight lost was only 11 pounds. More than 50% of the patients had dropped out. I might add that this 11 pounds includes the medications plus diet and exercise. The United States Preventive Services Task Force guidelines for obesity cite 6 studies showing only diet and exercise resulting in up to 9.9 pounds of weight loss over 24 to 84 months. So medications add little to the small amount of weight lost by diet and exercise alone.
The Fen/Phen boom ended when fenfluramine patients developed valvular heart disease and pulmonary hypertension, both potentially lethal.
There are only two drugs currently approved for long-term use for obesity: Orlistat (Alli) and Sibutramine (Meridia). Neither of these drugs is more effective than the Fen/Phen combo. Orlistat is probably safe. It blocks the absorption of 25% to 30% of ingested fat in the intestine. Side effects are gas, bloating and loose oily stools to a degree that many users soil their underwear. You can decide if those side effects are worth it for the small weight loss effect.
Sibutramine is prescription only weight loss medication. I consider it unsafe. In this respect I disagree with the FDA, though they are conducting a safety review. The European Union has suspended Sibutramine stating risks do not outweigh benefits. It does not result in more effective weight loss than Fen/Phen and can raise blood pressure and increase cardiovascular risks.
Other weight loss medications include Phentermine alone. It is generally safe if patients are carefully selected and monitored. But why bother with this medication? It is approved only for short-term use. Weight is regained once the medication is stopped. The medication’s weight loss effects, just like those of Fen/Phen fade over the long run. It is of the amphetamine class and has some addictive and abuse potential. Side effects are high blood pressure, anxiety, palpitations, fast heart rate and in rare cases seizures.
Lastly I will mention the hormone Human Chorionic Gonadotropin (hCG). Marketed as Releana, it is a scam. Click the link to their slick site, scroll down and read the FDA disclaimer at the bottom of the page: FDA has not approved hCG for weight loss and there is no substantial published evidence hCG is effective in obesity treatment. Then click their “Help and Support” tab and then “Clinical Studies.” Open the second PDF file and go to page 5, under the results section you will read “Regarding weight loss, similar results (with/without hCG administration) were obtained.” You have to dig for it, but at least they are honest. The hCG does nothing. It is the 500 calorie per day that gets the job done. If you want to pursue a 500 calorie a day starvation diet, that’s your business. But you need medical supervision. It can be unsafe. It can rarely result in electrolyte abnormalities and sudden death. You will lose lean tissue, that is muscle as well as fat, and you will regain lost weight. Releana is a scam.
Do you need to lose weight? If your body mass index (BMI) is greater than 35 weight loss would probably improve your health. A BMI of 35 would put you in the fattest 3% of the population. A BMI from 18.5 to 24.9 is considered normal. Surprisingly, to those not well-informed on obesity, a BMI of 25 to 35 carries no increased risk of death. Until BMI exceeds 35 (and that includes 35 and up to 60+) there is simply no mortality risk associated with obesity. In fact, mortality is lower in the overweight until BMI exceeds 35.
There are several drugs in the pipeline for obesity. I will review them in the future. Preliminary reports show some promise, but weight loss is modest as it has been with all past drugs. Except for those rare patients that truly need to lose weight for health reasons I recommend healthy eating (not dieting) and exercise and for patients to accept their current weight. I recommend that my fat patients read Health at Every Size by Linda Bacon.
Dear Dr. Lemmon, I’ve been taking Alli for about 5 weeks now, with good results so far (about 10 pounds) and have to admit I was relieved to read on your post that Alli is one of the safest weight loss medicines available. However in response to your comment “You can decide if those side effects are worth it for the small weight loss effect” I would like to clear up this one huge misconception about Alli. The side effect of gas or loose stools IS COMPLETELY OPTIONAL. If you choose to eat more than 15 grams of fat per meal while taking Alli, you will probably experience that side effect. End of story. I have intentionally not experienced that lovely side effect because, even though I eat pancakes and pizza and ice cream and Philly cheesesteak and whatever else I like, I count how many grams of fat are in each meal and have never had an issue. Ever. And, not whining here, but to only give Alli credit for “small weight loss” is not exactly correct, by the end of May I will have lost my goal weight of 40 pounds which for me and many other women is enough to change my life.
Also, in response to your reason #4 above, “[Weight loss medications] are rarely needed” to lose weight, I totally agree. Physically they are not. But there’s more to it than that. (You must be skinny or you would know this…) It’s your frame of mind that can make or break any challenge. When you fall off a diet it’s always the mental part that failed you. The secret weapon of Alli is that even if you’re weak on will power, just start taking Alli BEFORE you sit down to eat or enter the restaurant. Once it’s in your system, you’re stuck. You’re now obligated to eat right “or else.” The threat of one of these “stinky” side effects is usually enough to keep most people on track.
And finally, the best part of taking Alli (which I didn’t see coming) is that I have gotten into the habit of eating smaller portions of my favorite “unhealthy” foods, which is good because it’s unrealistic to think I would ever give them up completely. By the time I reach my desired weight I will be the poster child for “everything in moderation.” Finally.
Good luck to you, I hope your practice flourishes. Your article and research is incredibly educational and interesting and I look forward to reading more of your posts.
Jennifer
Jennifer,
Congratulations on your weight loss and success with Alli.
I have been fat since childhood. I know what it’s like. I decided to give up on dieting as the term is commonly used. My approach is to eat healthy foods and exercise and simply accept my weight where it falls. If my weight gets to far out of hand I make extra efforts, yes. I believe it is possible to be healthy and fat. They key is eating healthy foods and exercise. I have lowered my LDL to 100 from over 130, raised my HDL to over 40 and lowered my triglycerides from close to 300 to 135 with exercise and healthy eating. My blood pressure is about 115 / 65 (formerly over 140 / 90). Yet I weigh well over 200 pounds at 6 feet 2.5 inches. I just don’t think the evidence shows that drugs get the job done. I have lost 60 pounds with my method, though I do bounce around.
I do have an open mind though and might consider the new drugs in the pipeline for myself or my patients if the evidence looks good and risk is reasonable. By the way, I too have tried Alli. I think every fat person goes through a period in their life when they will try anything.
Try reading Health At Every Size by Linda Bacon. You might be surprised by what you read.
I appreciate your comments.
I think diets are the problem and those of us who have struggled to lose weight through dieting have wrecked our metabolism. I do have to disagree with you about HCG though.
I urge you to read the manuscript called “Pounds and Inches” by Dr. Simeons. It explains that HCG doesn’t cause you to lose weight, but it does allow you to be comfortable on 500 calories a day while you are in phase 2 of the protocol for 6 weeks at a time. Phase 3 is a maintenance phase. When done correctly, the weight does stay off. It’s not a miracle fat cure and it is not easy, but it is effective.
I don’t think it does anything based on the trials that have been conducted. But I have never tried it and I know at least three doctors that have. They tell me it works. Diets as spartan as 500 Kcals have been associated with sudden death.
It worked for me and my sister and mother. I would hate to think we risked our lives to lose the weight though…
500 calories is basically nothing, but when on HCG (and we used a homeopathic version) some days I wasn’t hungry at all and didn’t even want to eat the 500 calories. I wanted to do one more round this fall, but the risk of sudden death may have just changed my mind.