Dr Stuart Wasser    Rockville Centre  Long Island      516 594-2514

A changing view of overeating and obesity treatment
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I used to have a level of contempt for weight loss doctors.

I saw it as a gimmicky practice where doctors gave out potentially addictive drugs which worked for only a couple of months.  Was there really a difference between these drugs and other abused stimulents like cocaine?  Additionally, they often prescribed liquid diets, sold vitamins and got involved in other endeavors that made me wonder whose interest they were looking out for.

When redux and Fen/phen were on the market I saw so many capitalistic doctors develop a "boutique" approach.  Patients were treated as long as they were able to pay for treatment privately.  This bothered me.  If obesity was similar to other health conditions, it seemed immoral to charge the patients extra (at least we should first determine if their insurance would cover such treatment).  And I chuckled to myself when these doctors went out of business after the heart consequences of the drugs were learned.

In addition, I struggle with weight as well.  How can I tell my patients to do that which I have found to be so difficult.

I have since learned a few things.

Several years ago, I attended an addiction conference; one session asked whether overeating was like other addictions.  Lets consider this.  Other drugs cause a temporary increase in neuro-transmitters like dopamine and b-endorphin.  These effects are similar to those caused by alcohol and cocaine. (see  Why we use drugs)  Not only does this cause a pleasure effect, it may also lead to imbalance in the brain which lead to depression, irritability and cravings.  These bad feelings may motivate us to eat more.

What about the types of food we eat?  Carbohydrates have recently been recognized to be very problematic in weight control.  They clearly cause a burst of dopamine and B-endorphin.  This can lead to the development of addictive tendencies.  Remember, the use of highly refined carbohydrates is a relatively new invention- we did not evolve eating this food.  Fatty foods have similar effects.

During that conference, the result of a fascinating experiment was presented.  Lab rats, all with extremely similar genetic make-ups, were given different diets.  Some were fed with naturally occurring, unprocessed food.  An unlimited food supply was left in the cages.  Nevertheless, those rats given healthy food  ate only modestly.  They maintained a normal weight; they were healthy and active.

Other rats were given  highly processed carbs and junk food.  They ate too much, gained weight and were fat and lazy.  Clearly, there was something about this diet that led them to ignore their bodies' signals.  Was there abnormal brain function causing abnormal food desires?  

What is really scary is that we give these foods to our preschoolers, many of whom want more and more.  Are we setting the stage for food addictions early?  This clearly is one reason we have such a problem with childhood obesity.

Over the years, the practice of addiction medicine has focused on reducing cravings for drugs.  We prescribe medicine to patients who are drug free in order to prevent relapse.  This is a regular part of my practice.

These patients have often lost weight.  Of course, I reasoned that the weight lost was due to the patients maintaining sobriety and being more disciplined.  But maybe, these drugs directly worked on food cravings.

Several new weight-loss drugs have been in development.  They incorporate the same medications that I have used in treating other addictive disorders.  They have clear-cut success in promoting weight loss.  In one published study, certain combinations of medication was associated with an average weight loss of 37 pounds.  Many patients lost more than that.   Of course, there are side effects and the drugs require monitoring, but they do work.

I have tried these varied medical approaches on my primary care patients who do not have drug abuse histories.  More than 50% have achieved weight loss of 10-20% of their body weight.  Often, the patient has to take several medications.  After all, we treat high blood pressure and diabetes with multiple agents; we need to take multiple agents for this as well.  There will not be major weight loss with any one medication because the body adapts to it; multiple medicines can work on several brain mechanisms at the same time and maximize weight loss.  And what is more, combination therapy prolongs the length of time that patients are losing weight.

If a patient can be disciplined and stick to a diet of their choosing, they do not need these services (although there might be a possibility that some medicines increase metabolic rate)  If they can't maintain a diet, than these approaches increase the ability to remain compliant.

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