WEIGHTY MATTERS
There's a new take on taking off those extra pounds. It suggests that obesity is not your fault, and that losing weight requires more than carrot sticks and self control.
by Monika Guttman
Douglas Rosen (not his real name) was not very interested in seeing yet another doctor for his weight problem. Since the age of 4, says the 45-year-old mechanical engineer, he has been more than 20 percent over his ideal weight. "I've tried every diet imaginable, all kinds of pills and fasting programs." Back in the 1970s, one diet doctor gave him amphetamines, which took the weight off but gave him a constant buzz. The minute he stopped the drugs, he regained the
weight.
Besides, doctors had seemed to reinforce what Rosen calls "the guilt and shame" of being overweight. "Fat people are viewed as people totally out of control," he says. "One doctor refused to test my thyroid, saying 'Just looking at you, I can see you don't have an overactive thyroid, you have an overactive fork.'"
Then Rosen was referred to Vikram Kamdar, M.D., USC associate professor of endocrinology and a weight loss expert. "Within five minutes of being with him, my fears and shame went out the door," says Rosen. "He understands the psychology of being overweight, he knows you hate being overweight and that it's hard for you to accept yourself that way. He reassures you that he's there to help you."
Kamdar says his attitude reflects current thinking in obesity treatment. "For many years physicians were saying it was an individual's fault, that they lacked willpower and should eat less and exercise more. It was a guilt trip," he says. "But now I think we realize obesity is a chronic disease, like diabetes, with a genetic component that requires continuous long-term management. If you stop the management, the condition comes back."*Name changed
Much of America can relate. While corporations are downsizing, the population in general is upsizing-as in gaining weight and wearing larger sizes. According to the American Diabetes Association, in 1971, 23 percent of American men were overweight. By 1989, the number had grown to 33 percent. One out of three women is overweight as well.
In some cases, wider girths are more widely accommodated. In retail, serious square footage is devoted to selling plus-size clothing, especially designer apparel for women size 14 and over. To make ourselves more comfortable with our excess poundage, a "revisionist" philosophy of obesity, as exemplified by an April 1997 Newsweek cover story and in pop culture books, suggests weight is just a number, and being fit, not slim, should be the goal.
Still, big is far from being considered beautiful, and the medical community continues to link obesity-defined by most as weighing 20 percent more than your ideal weight-with a large number of illnesses, including atherosclerosis, hypertension, heart attack, diabetes, arthritis, degenerative bone disease and endometrial cancer.
Not only does obesity cause serious medical problems, but new research has moved weight loss from the store-front diet center back to the medical arena. Scientists from Rockefeller University announced the discovery of an "obesity" gene in December 1994, confirming what many had already suspected: that obesity, which tends to run in families, was less a matter of individual will and more a matter of individual DNA.
The "ob" gene, as it is called, was found in the fat cells of rats and regulates the amount of fat stored in the body by triggering production of a hormone called leptin. Leptin signals the hypothalamus of the brain, reducing the urge to eat. If finally confirmed in humans, the theory is that the gene can be "deregulated" when the person continues to eat and gain weight, thus reducing the amount of leptin produced and obliterating the body's internal brakes on overeating.
As a result of this discovery, says Kamdar, "Weight loss has become a respected medical endeavor." This spring, when Kamdar and his colleague, Dinesh Kumar, M.D., USC associate professor of medicine, organized an obesity conference in Los Angeles to discuss the options and risks in obesity treatment, more than 200 physicians attended. The response in the medical community was "overwhelming," says Kamdar. "Looking at that, we decided there was interest in the population at large for a program that takes a serious medical approach to weight loss."
Starting this fall, Kamdar and a team of physicians will operate the new Weight Management Program at the USC Health Sciences Campus, combining experts in endocrinology, diabetes prevention and management, diet and nutrition, behavior modification, surgery, cardiology, pulmonary, gynecology and genetics. The program incorporates components like a medical evaluation, dietary evaluation and instruction along with a variety of weight loss strategies. Using a comprehensive approach to weight loss orchestrated by a team of experts, "obesity and all the complications associated with it can be evaluated and treated in a scientific, academic manner," says Kamdar.
In part, weight loss has already moved more into the medical arena, thanks to increased interest and reliance on prescription drug therapies like Phen/Fen and Redux. Prior to these drugs, the last drugs used for weight loss were amphetamines, such as Dexedrine, used in the early 1970s. "Those drugs were addictive and people had a difficult time once they started taking them," says Kamdar. "It gave diet doctors a bad name."
Then, four years ago, University of Rochester School of Medicine physician Michael Weintraub began looking at a combination of two long-available prescription drugs-phentermine, a stimulant that helps diminish appetite, and fenfluramine, a sedative that results in feelings of fullness. Phentermine, used alone, had a number of side effects, including nervousness, irritability, constipation, elevated blood pressure and rapid heartbeat. But Weintraub's research study, using the Phen/Fen combination, increased overall weight loss and decreased side effects.
Last year, Wyeth-Ayerst Laboratories released another drug geared to weight loss, dexfenfluramine hydrochloride, known as Redux. Similar to the other drugs, "It has a very good effect and has been used in Europe for three or four years with good response," notes Kamdar. "And this year several new drugs geared to weight loss, such as Merida, have been released on the market."
Kamdar cautions that many of these drugs have side effects that should be monitored by a physician. "Redux, for example, has a similar structure to antidepressants. If you take this drug away, the person goes back into depression. So you need to address this before you stop the medication."
One serious side effect of the fenfluramines has received much media attention: primary pulmonary hypertension. Although extremely rare-only one out of 17,000 who take fenfluramine for longer than three months will get it-primary pulmonary hypertension causes the lung blood vessels to constrict, leading to often irreversible damage and, within a few years, heart failure and death. "It's important that you pick it up early so you can stop the medicine and prevent further damage," says Kamdar. "That is why we've included a cardiologist on the team who is interested in this area and can investigate this possibility by using noninvasive measures."
Those with chronic diseases can also take the drugs, notes Kamdar's colleague Kumar, who was one of the first to study the use of the new diet medications in patients with diabetes. But in these cases especially, he notes, medical supervision is imperative.
One of the biggest advantages of the academic-based weight loss program, adds Kamdar, is that patients are able to participate in clinical trials of new diet drugs. With several new promising medications on the horizon, he says, "It gives us options other nonacademic programs simply can't incorporate."
Still, for all the emphasis on drug treatments for obesity, says Kumar, a comprehensive weight loss program doesn't rule out the more traditional approaches to dieting and exercise. "Patients are always more interested in taking a pill than in half an hour of exercise," he observes wryly. "It's the same for any other chronic condition. In diabetes, we give patients some pills, tell them to engage in physical activity and monitor what they eat. Which instructions do the patients follow? They take the pills."
Indeed, dietary programs, unless they incorporate additional elements like behavior modification and dietary counseling, are "doomed to failure," insists Kamdar. "Even if you incorporate behavioral therapy, if you do not have a component where you can give low calorie diets under medical supervision and simultaneously reiterate all the weight loss techniques at periodic intervals, then people get frustrated, lose interest and regain the weight."
Kamdar prefers a very low calorie diet with supplements, such as a liquid diet with vitamins. That, combined with drug therapy at the beginning, produces initial rapid weight loss, which he says is important for the overall success of the program. "The success rate with simple dieting is very slim," he notes. "With medication, the enthusiasm to stick with the diet is maintained because the initial weight loss in the first six weeks is very rapid and then tapers off. Then you add behavioral therapy and support that with ongoing meetings, monitoring and medical oversight, and the patient should have long-term success."
Eventually, he says, we may come to view diet drugs as a long-term therapy. "Right now, they are being used for a year or two," he says. "With modern medicines coming in with even fewer side effects, physicians and patients will feel more comfortable using them for longer periods of time."
At USC, the eventual goal is to link the Weight Management Program with other programs and form an overall Risk Reduction Clinic. The idea: provide one central location where anyone with a risk factor-hypertension, diabetes, obesity, high cholesterol levels, osteoporosis-could be thoroughly evaluated and appropriately guided by a team of physicians. "It's the same idea we now apply to the Weight Management Program, just expanded," explains Kamdar.
Whatever the name or organization of the program, he adds, making patients feel confident that their weight problems can be managed is the ultimate objective.
"There are so many clinics for obesity these days," says Kamdar, "waiting to just take the money and run. And patients become frustrated when the programs don't work." At the Weight Management Program, "what I do has to be useful, fruitful and beneficial to the patient. I believe in letting the work speak for me rather than promoting myself or going into gimmicks."
Even a small weight loss, Kamdar says, is worth the effort. "We've shown that just 10 percent of weight loss has a beneficial effect on diabetes, hypertension, heart attacks, artery disease, arthritis and the many conditions associated with obesity," he notes. "Not to mention increased confidence in one's appearance. Beyond a doubt, weight loss is beneficial."
For more information about the USC Weight Management Program, please call 1-800-USC-CARE (1-800-872-2273) and ask to be connected with Dr. Vikram Kamdar.