Our Obesity Problem

I recently read to editorials on obesity. Both of these were written as thought pieces after the announcement of first new diet pill to be approved by the FDA in over ten years. I thought both were extremely poignant and I could not have written them better myself. I agree completely with their overwhelming sentiment that overcoming our obesity epidemic needs to be a concerted effort to change our eating habits and getting moving and not with a magic diet pill.

The first piece is an editorial from the most recent Lancet

New obesity pill: new hopes, old fears

On Dec 7, 2010, the US Food and Drug Administration (FDA) Endocrinologic and Metabolic Drugs Advisory Committee gave a positive recommendation for the use of Contrave in the treatment of obesity and weight management, signalling a potentially major shift in attitude towards the disorder. Contrave, if finally approved by the FDA on Jan 31, 2011, will be the first new weight-loss drug to be approved for 10 years. The drug is a combination of bupropion, an antidepressant used to help patients to quit smoking, and naltrexone, an opioid antagonist prescribed for alcohol and drug addiction, thought to affect the reward pathway (system in which behaviour is regulated by induction of pleasure).

The use of such a drug to tackle a complex problem like obesity is worrying, especially when the benefits seem modest (a decrease in bodyweight of 5%) compared with the potential risks. Albeit no serious side-effects were recorded in the four phase-3 trials for Contrave (one of which was published in this journal), there are indices of serious risks associated with bupropion, such as suicidal thoughts, seizures, and serious cardiovascular effects. The FDA committee and the drug's manufacturer, Orexigen, agreed that a large trial to assess the risk of major cardiac events associated with Contrave was needed, but that this study could wait until after the approval.

Research into obesity has been fraught with difficulty, with many drugs having been withdrawn from the market in the past for safety reasons. The flexibility shown by the FDA in its ruling on Contrave may be motivated by a desire to encourage pharmaceutical companies to commit more funding into obesity research, as rates of obesity continue to soar. More than a third of the US population is obese, and two-thirds are either obese or overweight. But this drug showed weight loss only when combined with lifestyle modification, and should not be seen as a magic bullet. Governments should address the obesity epidemic through a comprehensive approach, focusing on the underlying causes of obesity, and not promoting medication of a disorder that should be treated with modifications of lifestyle, diet, and exercise.

The second piece I read this morning on kevinmd.com

Is it the doctor's fault if an obese patient cannot lose weight?

By John Mandrola, MD

I need help.  In dealing with obesity as a medical problem, that is.

I am pretty solid at arrhythmia management, but as an obesity doctor, not so much.  If I was the teacher, and my obese patients were the students, I would surely be fired for poor student test performance. At least, if the core measure was the patient's BMI.

If a student does poorly on an achievement test, is it the student's or the teacher's fault? If the obese patient does not lose weight, is it the doctor's or the patient's fault?

Recently in the NEJM, I read about Arena pharmaceutical's attempt at creating the new "wonder pill" for obesity.  Lorcaserin is a novel serotonin re-uptake inhibitor which acts primarily in the brain centers that control hunger and satiety.  Theoretically, it provides a patient with the good sense not to eat too often, and as the skinny farmer advises, leave the table before you are stuffed.

Although, Locarserin had no major adverse effects, the weight loss was modest, up to 5-10% of body weight.  Thirty pounds is only the prologue for the 300 pound patient.

So, now we may have another pill for fatness.  Like we do for tiredness, and the low sex drive of male middle-agedness.

The study conclusion is worded with scientific precision.  The researchers say, in conjunction with behavioral modification, the drug was effective in weight loss  What people hear, though, and the drug manufacturer are really saying is: take this pill and be thin.

Cynicism is knocking at my door, and I am trying to ignore it.

It is clearly true that obesity is one of the developed world's most important medical problems.  Paradoxically, while the fury of modern medicine has lowered death rates from heart disease and cancer, the obesity epidemic continues unabated.  The more sophisticated we become as a society, the fatter we get.

As a doctor of the heart, it is crystal clear that lifestyle choices lie at the heart of health. No disease is more preventable by lifestyle choices than heart disease.  And these same lifestyle choices work on obesity as well.  Call it being on "the program."  Not a diet, the program is a simple concept: finding the groove of enough exercise, wise food choices and adequate rest.

I own only one belt.  It is thick leather.  At times, as I am human, the white-chocolate-chip brownies in the doctor's lounge get the best of me.  If this behavior persists with any regularity the belt feels tighter.  Thick leather belts do not stretch. The tighter belt says, pedal a little longer and cut smaller pieces of brownie. Doing so restores equilibrium.  But if I deny too much the result is grumpiness. The pattern is repetitive.

This simple formula is the problem.

However, the notion that obesity is simply an imbalance of the equation, calories-in, calories-burned, is not in vogue.  It seems, by saying to the patient, eat less (really, it is sadly amazing how few calories a sedentary middle-aged human needs) and move more, you are at risk of being perceived as judgmental, incurious and even aloof.

If on the other hand you talk about enhanced receptor sensitivities in hunger centers that may be inhibited by sophisticated chemicals, you are smart, and a sensitive doctor.  The obese patient may conclude that poor lifestyle choices are not their fault, rather a chemical imbalance in the brain.  (And maybe this will be proven so.)

I don't think we should persecute the obese. Malfeasance is bad for the heart.  Nor am I against novel pharmaceuticals or innovative surgery.  But taking a pill or having surgery (that someone else pays for) will always be easier than saying no to white-chocolate-chip brownies.

As we advance in medical technology, the simplicity of making a series of good choices should not be overshadowed by the science of receptor inhibition in the brain.

Surely, doctors should emphasize the program more.

John Mandrola is a cardiologist who blogs at Dr John M.