Scary Mosquitoes & West Nile Virus

Bzzz....swat! The mosquitoes are particularly annoying this time of year, and now we have more to worry about than an itchy red arm- the West Nile Virus (WNV) is spiking again. In fact, the 1118 cases of human West Nile viral infection that have been reported to the CDC in 2012 mark the highest number of cases since the recognition of this disease back in 1999. Unfortunately for my neck of the woods, over 75% of the cases have occurred in Texas, Mississippi, Louisiana, Oklahoma and South Dakota, including 41 deaths. That's the bad news. The good news is that very few people who are infected ever develop serious illness- only around one in 150. In fact, about 80% of people infected will never know it, because they don't have any symptoms at all! AND, the vast majority of mosquitos are NOT infected to begin with, so most mosquito bites are not potentially serious.

What are symptoms if you get them? Picture the flu- in the wrong season. WNV occurs most often in summer and early fall. Fever, headache, body aches, nausea, vomiting, and possibly a rash make up the usual presentation. These symptoms a few days to a couple of weeks. The severe disease (remember, just one in 150 infected) starts the same way but progresses to seizures, disorientation, tremors, numbness, paralysis and potentially death.

Mosquitoes spread the West Nile Virus by feeding on infected birds and then biting humans. Symptoms show up within days to possibly two weeks of the bite. The bite itself does not look different than other mosquito bites.

Prevention is all about clothing and mosquito repellent. You already know if YOU are the "mosquito magnet" in your family or friends. I know I am! The only time my husband has been bitten by mosquitoes when I am nearby was when I was pregnant (guess the hormones that made me nauseated did the same for the mosquitoes...) I have bathed in Skin So Soft & every other "natural" repellent, but the only thing that works for me is a physical barrier (light weight hiking shirts) PLUS sprays with DEET. What else can you do? Make sure you eliminate any standing water (such as in buckets or children's wagons or other toys) in your backyard, to get rid of mosquito breeding grounds. Use mosquito repellant that contain DEET or Picardin, or oil of eucalyptus. Finally, if you find a dead bird, do NOT touch it without gloves, and call your local health department to report it.

BOTTOM LINE: If you are a mosquito magnet, take some extra precautions this time of year if you are going to be outside from dusk to dawn, so you can avoid becoming infected with West Nile virus.

Is it a New or Old Weight Loss Drug?

This month I am talking about obesity & weight loss. By our human (and American) nature, we would all like a quick fix to solve our weight issues. This summer, the FDA approved not one, but TWO new weight loss drugs.  My last blog addressed lorcaserin (Belviq), and today's focus is really something old in a new package.

Qsymia was FDA approved in July 2012, and it is a combination of two older drugs that have been used independently to help with weight loss: phentermine and topiramate. Phentermine is an appetite suppressant, and was half of the infamous fen-fen (a diet pill combo that was removed from the market once its use was associated with the development of pulmonary hypertension (a damaging condition in the lungs) and heart valve issues. Phentermine by itself is still approved for "short term" use- a few weeks- as an appetite suppressant, but there is limited efficacy and safety data available. Topiramate was originally classified as an anti-seizure medication, but indications now also include migraine prevention. Physicians and patients were generally pleased to see that a side effect of topiramate is weight loss (to the point where I have had patients without frequent migraines ask if I will prescribe this drug "just in case"!)

Qsymia combines these two drugs, and showed significant weight loss at one year- an average of 8.9%.
Both drug components are  at much lower doses than the individual drugs are typically prescribed, which hopefully will limit side effects. Indications for this new drug are for patients who have a BMI>30 (defined as obese) OR if they are overweight (BMI>27) AND have high blood pressure, diabetes, or high cholesterol.

If you meet those qualifications and are interested in trying this new drug, don't rush to your doctor quite yet! Qsymia is not yet in pharmacies, though it is anticipated to be in "certified pharmacies" next month (September 2012).

BOTTOM LINE: The newly approved weight loss medication, Qsymia, combines two older medications and may prove to be significantly effective in helping treat obesity, but it is not available quite yet. 

A New Weight Loss Drug!

Have you heard that the FDA approved not one, but TWO new weight loss drugs this summer? Hooray! Our problems are solved, right? Are there still overweight doctors out there? Well...yes, there are, so that should give you a clue that these new drugs are not miracle workers.

Today I will focus on the first drug approved. Locaserin, brand name Belviq, came out in June 2012. This drug will decrease your hunger and increase your feelings of satiety (feeling full after a meal). Locaserin works within the serotonin system (like the antidepressants such as Prozac) but targets a specific receptor that is key in the appetite game, rather than mood. Fenfluramine, an older drug with a similar mode of action, was removed from the market in 1997 due to concerns of its detrimental affect on heart valves. The selling point of locaserin is that it targets a different, very specific receptor that is not linked to these deleterious valve changes.

In the studies necessary to get approved by the FDA, patients on this drug lost an average of 12 pounds in one year. Let me remind you that good steady weight loss is a pound or two per month (not the 30 pounds in 30 days we all would like), so this is reasonable weight loss. However, from my standpoint, I'd like to see a drug produce better results before risking the side effects. In this case,  side effects of lorcaserin include headache, dizziness & nausea. So at this point, I am not impressed enough to prescribe this drug.

BOTTOM LINE: Lorcaserin (Belviq) may provide obese patients help with decreasing their appetite & increasing satiety, but does not provide dramatic weight loss results.

Which Diet is Best for Weight Loss?

Now there is the million dollar question, right? Interestingly, despite billions of health care dollars being spent on "diets", there are not recent high level studies in the medical literature to support touting one weight loss diet highly above all the rest. In 2001, there was a scientific review of popular diets by Freedman, King, & Kennedy, that concluded "low fat, low calorie diets are the most successful in maintaining weight loss." Note- this is in MAINTAINING weight loss, not LOSING weight. Ultimately, as should come as little or no surprise, CALORIC BALANCE is the major determinant of weight loss, regardless of the composition.

So...which diet? HIGH protein, LOW carb diets have a very high satiety effect- you are simply not as HUNGRY when you restrict calories if there is a high protein content. Several studies have demonstrated that the less hungry (more satiated) people are, the higher their compliance rate with a calorie restricted diet. This sounds rather obvious- if you are not hungry, you won't "cheat"- BUT...remember most of us do not eat because we are hungry. We eat because we are happy, sad, mad, bored, distracted- you name it. (See related post "Break the Eat, Repent, Repeat Cycle").

Are high protein diets safe for the kidneys?  A 2012 study at the Indiana School of Medicine confirmed that low carb, high protein diets do NOT cause any harm to the kidney function in obese patients who had healthy kidneys at the start.

What about the heart? A very large study this year in Sweeden (>40,000 women) did show that women do develop an increased risk of cardiovascular disease (heart attacks & stroke) if they stay on a low carb/ high protein diet long-term.  However, in the short term (at one year), low carb/high protein diets are more effective in weight loss and reducing cardiovascular disease risk.

BOTTOM LINE: Low carb/ high protein diets may help you lose weight in the short term (~ a year), but for long-term weight maintenance or continued weight loss, go for what you know to be healthy- MORE fruits & vegetables & a lean protein source. 

You're "Obese"- Now What?

Yesterday's WAKE UP blog entry referred to the USPSTF recommendation that all patients who have a BMI >30 should be referred to an "intensive, multicomponent behavioral intervention" in order to lose weight and therefore decrease their health risk. These recommendations are evidence-based, focusing on patient outcomes (disease states, not purely lab numbers).

What is "intensive"? 

• 12-26 sessions per year (often weekly to begin, then monthly.)

What is "multicomponent"?

• Individual or group sessions with physicians, dietitians, and other trained providers
• Include physical activity
• Address issues that keep people from changing behaviors
• Encourage self-monitering of nutrition and exercise

What results can be expected? 

• Weight loss typically ranges from 8.8-15.4 pounds in the first year
• Glucose tolerance is greatly improved- in fact,  that there is a 50% decrease in new diabetes diagnoses in only 2-3 years 
• Cardiovascular risk factors are improved (lower cholesterol & lower blood pressures)

If your BMI is >30, you are more likely to develop heart disease, strokes, high blood pressure, diabetes, certain cancers (esophagus, breast, uterine, colon, kidney, thyroid,  and gall bladder). It doesn't matter if you LOOK "okay"- this is NOT a cosmetic issue! While 15 pounds may not be all you need to lose, often that is enough weight loss to make a very significant positive impact on your health

BOTTOM LINE: Talk with your doctor about your BMI at this year's annual physical, and prioritize a healthier lifestyle starting today.

WAKE UP America- Courtesy of Colorado!

This summer I had the pleasure of spending some time in the gorgeous mountains of Colorado, a state which has long been one of the "healthiest" state in the nation- especially as measured by weight. Colorado has "only" 20.7% of the population with a BMI (body mass index) that indicates obesity, compared with 35.7% of overall American adults who are obese. That's ONE in THREE American adults who are obese! But I digress...my point was going to be that as our family watched some of the Olympics on tv, we saw a Colorado health-awareness commercial that I thought was extremely well done. The commercial shows people waking up in bed, challenging the Colorado population to actually "WAKE UP" and look in the mirror and see their true reflection- not the image in their head. The point is that obesity is "not as extreme as you think", and certainly my clinical experience echoes that thought.

Most adults are so comfortable with the notion that they "will never look like/ weigh what they did in high school" to the point that as they carry around an extra 20-30 pounds, it doesn't occur to them that they are jeopardizing their health in any way. And their physicians (who are not immune to the same beliefs for both themselves AND their patients) are along for that joy ride.

In June of this year, the  United States Preventative Service Task Force issued an update to physicians regarding screening for obesity. We are called to screen EVERY adult (which means get a weight & height & determine a BMI) and then for every patient who is obese- meaning a BMI >30- we should direct them to an "intensive, multi-component behavioral intervention". What is that and why? More on this tomorrow...

BOTTOM LINE: "WAKE UP", step on a scale & check your BMI today- don't assume weight is not an issue if you don't "look" or "feel" obese. 

PS. It's the FIRST of the month- change those air filters!