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. 

Holiday Weight Gain...Again!

Click! Step away from the Halloween candy. I repeat, step AWAY from the Halloween candy!

Okay, how many times have you walked past the leftover candy and snagged an extra treat today? It is so easy to keep it around just to "finish it off". I'll bet you're even down to the candy you don't even really like, yet you pop one in your mouth because, well, it's there. How do I know? Because I just ate a mini-Snickers, which is my least favorite candy. The Reese's cups were gone last week.

All kidding aside, please take stock of your health TODAY. We are already well into November, which is the heart of "stuff yourself silly" season. Treats and sweets abound, as well as extra adult beverages at every celebration- and those pack on the calories as much, if not more than the edible delicacies! At the office, we are already seeing the extra weight creeping up. The average American gains nearly 10 POUNDS during the holidays. And then what does everyone do? We make a New Year's Resolution to lose weight.

This year, let's be PROACTIVE! Start on that new exercise program right NOW! Take the stairs instead of the elevator. Park a little further away when you go to work or shop. Fill your party plate with healthy choices and eat them first before you head to the dessert buffet. Every bit you do now will make those New Year's Resolutions much easier.

BOTTOM LINE: Do not wait for New Year's to start thinking about improving your health!

The Perfect Diet Pill

Ready to sign up? I think we're all looking for that pill that let's us skip exercise and eat whatever we want, but still allow us to lose weight effortlessly- and oh yes, with no side effects. Sigh. I hate to disappoint you, but no such pill exists. I often think patients believe we doctors are hoarding this mysterious pill somewhere, keeping it for our own use! But seriously, if there were such a pill, there would be no overweight or obese doctors, right? And look around...doctors struggle with their weight as much as the next person.

What IS out there, and why don't we use it more? The main drug still on the market for weight loss is phentermine. The common brand names are Adipex, Fastin, Obenix, and Oby-Trim. Phentermine is a very effective appetite suppressant. It is a stimulant (similar to amphetamine) and can be addictive. It doesn't magically speed up your metabolism, it simply suppresses your appetite so you consume fewer calories. In the past, it was combined with another diet medications (fenfluramine and dexfenfluramine) but this combination turned out to potentially cause pulmonary hypertension- a very serious and possibly fatal lung disease. By itself, however, phentermine is usually well-tolerated, though it has it's own list of side effects, and it cannot be taken along with many antidepressants. Phentermine is thought to raise blood pressure, increase heart rates, and increase your risk for heart disease. A study published last month in Obesity, however, suggests that these cardiac effects may not be significant, or in fact, may not be there at all. While this was not our highest quality study, its numbers (300 patients) and methods are enough for us to take note.

So, if you don't have heart risk factors (beyond obesity) and you are not taking an antidepressant, should you rush to your doctor for a phentermine prescription? Probably not. If you need to jump start a weight loss program and you are ready to really improve your diet quality and quantity along with pursuing a solid exercise program - maybe. It's worth a discussion. However, you need to know from day one that most people REGAIN the weight when they go off the drug. Again, not magic, just they quit suppressing their appetite so they are more hungry, and they eat more.

I rarely prescribe phentermine, probably less than five patients per year. My personal standards are that the patient needs to be seeing a registered dietician and demonstrate that they are exercising daily for a least a month. I see the patient back in one month, and will not prescribe phentermine for more than two months. This is not a "cure all" drug, but in selected patients, it can be a wonderful jump start towards better health.

BOTTOM LINE: If you feel overriding hunger is truly keeping you from losing weight, open the discussion with your doctor about considering a prescription appetite suppressant.

Can't Lose Weight? Count LIQUID Calories!

Many times when people are frustrated with weight loss, they look and look again at their food records and insist that they are eating only healthy food in small portions, yet the scale wont budge. There are certainly multiple reasons for this, not the least of which is the scientifically proven human tendency to record LESS than we consume and MORE than we exercise. It's not purposeful cheating, but small things such as forgetting the handful of M&M's off a co-worker's desk, or chips at a Mexican restaurant (we didn't ORDER chips, right?) or assuming we must have walked "at least a mile" during the day (without counting steps on a pedometer.)

My focus today, however, is on the portion of calories that we all tend forget- the LIQUID calories! Yes, Virginia, the liquid calories count, too...and often way more than you'd expect. Let's review some common ones:

Soda: 1 can of Coke is 140 calories
Starbucks:Tall Cafe Latte with Nonfat milk: 126 calories (Grande: 168 )
Caramel Frappuccino Blended Coffee with whipped cream: Brace yourself- 430 calories!! (Note a McD's Quarter pounder is 410)
Wine: 4 oz- a HALF CUP- glass of Chardonnay~90 kcal. MEASURE your glass once- most of us drink at least 6-8oz- check the picture above!
Frozen Margarita: 180 kcal for 4 oz...but most Margarita glasses hold 12 oz, which is over 500 kcal!
GATORADE: 12 oz is 310 kcal.

Recognize that 3600 calories equal one POUND, which means your simple morning coffee may be adding a pound or more per month. Or your workout drink, ironically, can easily do the same.

BOTTOM LINE: Focus on WATER the most, and low or no calorie drink options if you are trying to lose weight!

How Fast Can You Lose 30 Pounds?

You only have to drive around town, flip open a magazine or your computer, and you will see an ad promising weight loss of "30 Pounds in 30 Days". And of course, all you have to do is buy this brand new miracle pill. You don't have to exercise or eat healthy foods. Ready to sign up? I hope not!

Our parents taught us that if it sounds too good to be true, it probably is. Yet, as Americans, we have become so used to instant gratification, we are convinced that somewhere out there exists a pill we can pop for easy, quick weight loss. Let me ask you this- do you think there would be any fat doctors (especially women, forgive my bias!) if such a prescription existed?

So, what is realistic? Well, obviously, it depends on your starting weight. If you are only 20 or 30 pounds overweight, though, a good rule of thumb is a half to one pound per week. It takes a 3600 calorie deficit to lose a pound. Period. If you can burn an extra 250 calories a day (walk 2 -3 miles, for example) AND delete another 250 calories from your usual diet (give up two sodas or one loaded latte per day), then you can expect to lose a pound per week.

Try to look at the big picture. There are 52 weeks in a year. If you make healthy changes such as eating MORE fruits and vegetable servings and moving MORE, you can easily take off those extra 20 to 50 pounds in a year...and KEEP THEM OFF because you did it through small, permanent changes!

BOTTOM LINE: Fast does NOT equal good, nor permanent, weight loss. Realistic, EXCELLENT weight loss is ONE POUND per week, so it will take 6 months to lose 30 pounds.

What Works for Weight Loss? MORE!

MORE, MORE, MORE! That is chant I want you to hear in your head as you focus on FITNESS. Yesterday I talked about MORE fruit and vegetable servings- 5-10 per day. Today let's shift to MORE MOVEMENT.

Many of my patients started 2011 with the resolution to go to the gym EVERY DAY after work. Guess what percentage are still doing that? Hmm...not too many. Why is that? It is a setup for failure. While exercising EVERY DAY is absolutely possible, and indeed, what I do and what I encourage everyone to make a life habit, exercising in a specific place outside your home- like the gym- is very difficult. Say today you wake up and your child has a fever, so you can't leave the house. Tomorrow you have a business meeting in the evening (no time to workout, shower and clean up between work and that meeting) and boom, then it snows/rains/floods...you get the picture!

I think planning a day or two per week at the gym (or the track, or walking the mall) is wonderful, but please, set yourself up for success by having backup plans AT HOME. I am a big fan of exercise bikes and DVDs for this reason. Grab your tunes and/or your dog and head out the front door. Set a timer for 30 minutes, turn on some music, and dance! OR- I got this idea from another woman physician last October- set the timer for 30 minutes, turn on music, and CLEAN YOUR HOUSE- actively! Vigorously scrub the counters, alternate hands, squat up and down unloading the dishes, mop quickly, whatever it takes to keep your heart rate up. Which exercise is best? The one you will DO.
The main idea is to MOVE MORE. Check out my blog on PEDOMETERS- they work great, too!

BOTTOM LINE: Switch your focus to MORE: MORE movement, MORE fruits & veggies!

Gluten-Free for Weight Loss?

Many people think going gluten-free is a great way to diet in order to lose weight. Not surprisingly, it can be a pleasant side effect if you are overweight and diagnosed with celiac disease. It makes complete sense that if you simply ELIMINATE breads, cakes, pastries, pastas, cookies and breaded or coated foods (think chicken nuggets, french fries, meatballs) your calories will shrink dramatically!

I would likely approve any diet that reduces processed foods and complex carbohydrates, but I am MORE excited about diets that not only decrease those items, but INCREASE fruits and vegetables. Here is the trick with not only a gluten-free diet, but a vegan or vegetarian diet. Keep it HEALTHY by upping the produce (veggies and fruit) and NOT merely replacing everything you are "giving up" with a manufactured version that is GF (or CF, or Veggie-free).

For example, there are many gluten-free breads, crackers, cookies and treats out there. Very few of them happen to be low calorie and/or "good" for you- BUT- saying gluten-free somehow implies healthy and nutritious, doesn't it? It's that health-food store seal of approval when we see labels proclaiming a food item is "free" of something "BAD".

Ultimately, however, in the battle of the bulge, it still comes down to calories IN vs. calories OUT, regardless of the quality of those calories. So, enjoy those GF pancakes and breads in moderation, but don't pursue the search for the GF Twinkie, okay? Push up the produce and reap the rewards.

BOTTOM LINE: Eating gluten-free CAN be an incredibly healthy diet, rich in nutrients from fresh vegetables and fruit plus a protein source and GF carbs in moderation, but gluten-free does NOT equal low calorie!

MORE* Reasons to BIKE and WALK

I love it when new studies come out that reinforce what I already have been telling patients! Today, in the Archives of Internal Medicine, a study from the Harvard School of Public Health was published with the illustrious title: Bicycle riding, walking, and weight gain in premenopausal women. Basically, they found that YOUNG women-less than age 50, give or take- (yes, at 44, I still count as "young") who either walked briskly or bicycled had less weight gain than those who did not.

On the one hand, this seems like a no-brainer. Those who exercised more gained less weight. Where's the shock?
However, there is more to it, and I think this is is an interesting study. It derives from a large study (over 100,000 participants) of female nurses aged 25-42 in 1989, and follows them over 16 years. Sadly, despite their medical knowledge, they ALL gained weight in this timeframe, with an average gain of close to 20 pounds. Remember, that's barely over a pound per year, so it wasn't dramatic as it happened, but this is why we've got to look at the big picture!

The good news is that this study does document that small increases in activity- specifically adding even 5 minutes per day of bicycling (stationary or outdoor) or 30 minutes of brisk walking- will decrease weight gain. Obviously, if you are going for weight LOSS or weight maintenance, you've got to up the amount or intensity (and ultimately, calories OUT must be greater than calories IN.)

The best take home point of this study is that if you can make a lifestyle change such as BIKING TO WORK instead of driving (or biking with the kids to school instead of driving) then "bicycling could then be an unconscious form of exercise because the trip's destination, and not the exercise, could be the goal."

BOTTOM LINE: Find ways to get moving MORE in your daily life, and avoid that annual 1-2 pound weight gain!
(*See "MORE" strategies for weight loss in the January 2010 posts)