Following on from last week’s ‘pill for every ill’ mental health piece, this week we look at obesity and the burgeoning obesity drug market. As we all know, obesity is currently one of the world’s largest problems (pun intended!), but are drugs really the answer? With Government strategies woefully inadequate, medical education failing to include adequate training in nutrition, and conventional dietetic advice lagging behind developments in nutritional research, nothing much is actually changing. People are getting progressively fatter and sicker whilst the ‘brains’ behind policy change seem to keep studiously looking in the wrong direction. Despite a wide body of evidence to the contrary, conventional health providers look to either decrease caloric intake and increase energy expenditure or prescribe pill-popping for weight loss. Obesity drugs are the new fertile, post-cholesterol, plains for the drug industry. The cholesterol myth may have exploded, but fat loss is definitely the new game in town.

Turning conventional weight-loss advice on its head

Widespread official weight loss recommendations from sources such as the National Health Service (NHS) in the UK, the National Institutes of Health and the American Dietetic Association in the USA, are based on daily calorie reduction of around 500 kcal per day. According to an August 2011 Lancet paper, this has erroneously been thought to result in slow and steady weight loss of about 0.5 kg per week. However, this rule of thumb was derived by a static model based on the estimation of the energy content of weight lost.

The Lancet published this study by a US and Australian team of scientists headed by Dr Kevin Hall offering an extremely important correction to the old model. They even made the paper free for download to help spread the word – but so far we’ve seen no evidence of the data filtering into weight-loss counselling. Hall and colleagues say the 500 kcal model ignores the way the body adapts physiologically to being over weight and this leads to changes of both the resting metabolic rate, as well as the energy cost of physical activity.  It also ignores the underpinning body composition of the person involved, particularly with regard to body fat percentage at the time of intervention. 

Unfortunately, despite this new model and a wide body of evidence on lifestyle management, mainstream medicine’s adherence to the simple ‘calories in, energy out’, ‘one-size fits all’, premise to manage the obesity epidemic sticks fast. The old model entices the public into short-term, fad diets – which simply don’t work in the long-term and are often more likely to do more harm than good. This results in the classic ‘yo-yo’ effect that most dieters experience, which is far more damaging and usually leads to greater weight gain down the road. 

The paper, gives several important insights. Weight-loss variability exists between people despite having the same intervention, caused by differences in the initial body composition between individuals, as well as uncertainty about baseline energy expenditure. The paper also shows that the timescale of human weight change is long and not a short-term measure.

Get ready to perservere

Weight-loss is about the long haul, 3-5 years to be precise, depending on how much needs to be shed. And, much larger changes are needed for obese individuals to return to leaner body weights than has previously been applied. For example, an adult with a BMI higher than 35, representing 14% of the US population, needs a change greater than 500 kcal per day.   

Hall et al’s findings, from complex mathematical modelling, show that every permanent change of energy intake of 24 kcal per day will lead to an eventual weight change of about 1 kg, taking about 1 year to achieve half of the total weight change and about 3 years for 95% of the total weight change. In practice, based on an “averagely overweight person”, we calculated that an adult weighing 107 kg (BMI 40), with a weight-loss goal of 42 kg, would need to consume 1000 calories less per day over 3 years. Whilst this won’t work for everyone, it is likely to work on a lot more people than the current conventional model. It also shows that this kind of calorie reduction needs to be incorporated more or less permanently into a person’s diet and lifestyle.

‘Quick-fix’ obesity drugs

While the drug companies have paid lip service to reducing calorie intake for weight-loss, surprise, surprise, they’re pushing for quick-fix pill popping instead. As attractive as a pill may be, no pill is ever likely to achieve the natural outcomes from effective dietary and lifestyle modification programmes. Outcomes such as restoring metabolic and hormonal balance, correcting insulin resistance, enhancing cognitive function and mood and increasing radiance, vitality and energy levels. For a patient to eschew such positive outcomes in favour of a suite of horrendous side effects that accompany most obesity drugs, the failure has to be one of education, and therefore communication on the part of the practitioner.

Take ‘alli’ from GlaxoSmithKline for instance. Side effects include “wind with or without oily spotting, sudden or more frequent bowel movements, fatty or oily stools and loose stools”. 

In past years there has only been one slimming drug available by prescription in the US and the UK - Xenical.  However, as our US team have recently reported, the US Food and Drug Administration (FDA) Endocrinologic and Metabolic Drug Advisory Committee has just recommended the approval of another slimming drug, one that has previously been rejected for safety reasons. The drug — Qnexa — is a combination of two existing drugs, phentermine (appetite suppressant) and topiramate (anti-seizure medication).  Side effects of phentermine include heart palpitations, dizziness, chest pain, edema, increased blood pressure, vomiting and diarrhea.  And if these side effects don’t make you feel suicidal, one of the 63 side effects of topiramate is the alteration of your mental health “in unexpected ways” that could lead you to become suicidal. Tempting isn’t it?

Enhancing compliance

Pill popping for weight loss creates laziness and a lack of responsibility for one’s own health, making it too easy to continue with poor eating habits. What's needed is a total rethink about the way in which approaches to healthy eating and living are communicated to the public.  It’s a real positive to see more emphasis being placed on exercise and activity, but still little is being done to tackle the problem about overcoming people’s resistance to dietary change on an emotional level. Compliance with nutritional programmes is very low. Most likely because food is so intimately linked with emotions and is often used as a comfort, a treat, a reward and related to passion and pleasure. Dietary change needs to be associated with positive gain instead of loss of all things fun and pleasurable before we’ll see significant adherence to 3-5 year programmes.  

A leaner future

As ANH-Intl’s executive and scientific director, Robert Verkerk, points out, “the scientific community at large is generally in agreement that inappropriate diet and lifestyle are at the root of the obesity epidemic. So we need to ask why it’s so alien to the vast bulk of conventional health providers to be looking at diet and lifestyle for a solution to the obesity epidemic?”

The most important take home message is that there is no short-term fix. Weight reduction programmes need to be individualised, based on body composition and long-term — ideally a permanent life change.

What you can do:

1. Be honest with yourself about whether you need to lose weight and whether you have the discipline and self-motivation to do it on your own. If not, make the commitment to seek professional support.
2. Cut out snacking and go for 3 balanced meals per day, making sure you’re eating a rainbow of vegetables and fruit daily. At least a third to half your plate should be vegetables at each meal, which helps to reduce your dependence on grains (wholegrain only) as your main carbohydrate source.
3. Include some high quality protein e.g. eggs, chicken, meat, fish or legumes at every meal.
4. Focus on healthy fats – extra virgin olive oil on salads and coconut oil for cooking as it’s more stable at high temperatures.
5. Ensure you’re drinking at least 1.5 litres of water a day. Tea, coffee and fruit juices don’t count!
6. Think about activity changes that you can make in your lifestyle. The journey that you could walk instead of drive, the escalator you could walk up instead of ride.
7. Healthy food can be a taste sensation! Get creative in the kitchen and if you don’t know where to start, the Internet is a great resource for new recipes.
8. Eliminate sugar, refined carbs, processed and fast foods from your diet. 
9. Get out in nature and let your body move naturally and breathe fresh air.
10. Make sure you get at least 6-8 hours sleep a night.
11. Love more and laugh harder!

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