Obesity is known to increase the risk of many chronic diseases, including coronary artery disease, diabetes, hypertension, high cholesterol, osteoarthritis, and some cancers. In the United States, obesity contributes to about 400,000 deaths annually, making it the second greatest cause of preventable death next to smoking, and costing us approximately $100 billion in healthcare costs each year. The number of adults trying to lose weight and the amount of money spent on weight loss interventions of little or unproven efficacy adds to the national cost of excess weight. Therefore, obesity demands new treatments, including lifestyle, surgical and new pharmacological options.

While there are marked benefits from intensive lifestyle intervention alone, these benefits are typically limited to the short-term. In other words, it’s keeping weight off that is the challenge. In most studies, 1/3 to 2/3 of weight loss is regained within 1 year and all of the weight loss is regained by 5 years.

It is neither volitional nor due to an inherent moral weakness that obese individuals remain obese or regain weight after weight reduction. Obesity is not a lifestyle choice. Genetic predisposition and environmental influences underlie differences in our food consumption and physical activity patterns. Denying an obese individual a safe therapeutic option is discriminatory. Health care providers who deny medications to patients with diabetes or hypertension would be considered negligent. There must be a paradigm shift with regards to how aggressively we treat those with obesity. Obesity not only contributes to other comorbid conditions, but it also leads to a poor quality-of-life, reduced longevity, and increased health care expenditures.

More recently, we have gained a better understanding of weight regulation and the complex interplay of the overlapping systems that contribute to obesity. The neuroendocrine axis, gut satiety signals, peripheral adiposity indicators, and a host of genetic, environmental, cultural, and hedonic factors influence obesity. Obesity is complicated, but this new understanding has provided additional insight into effective treatments. Unfortunately, targeting one pathway alone is unlikely to result in sustained weight loss for all individuals. Combination therapies are needed that may include medications along with behavioral modification including diet and exercise.

Historically, medications for the treatment of obesity were classified according to their mechanism of action: to reduce food intake, to alter metabolism, or to increase energy expenditure. Appetite suppressing drugs have been used in the past for weight loss. These included the combination medication Fen-Phen, which was withdrawn and discredited because of increased risk of heart valve problems.

But in June and July of 2012, the US Food and Drug Administration (FDA) approved two new medications for weight management. One was Belviq, a medication that treats obesity by suppressing appetite. A two-year phase III clinical trial with 4,000 obese adults showed a 5 percent weight loss in 47 percent of participants who were randomized to receive the medication twice daily. Among patients who lost 5 percent or more of their baseline weight at one year, the loss was maintained in more patients who continued to receive Belviq during year two (68 percent) than in patients who received placebo during year two (50 percent). At both year one and two, the study found no increase in heart valve problems. Side effects included headaches, fatigue, dizziness and nausea, but occurred in fewer than 5 percent of participants.

The second medication, Qsymia, is a combination of two FDA approved medications, phentermine and topiramate, in an extended release formulation. Phentermine is indicated for short-term weight loss in patients who are eating a low calorie diet and exercising. Topiramate is used to treat seizure disorders and migraine headaches. A 56-week randomized, controlled clinical trial of this combination medication showed that a significantly greater percentage of obese individuals lost 5-10 percent of their body weight compared to placebo. Only 21 percent in the placebo group compared to 62 percent and 70 percent in the low dose and high dose combination groups, respectively, lost greater than or equal to 5 percent of their initial weight. The percentage achieving greater than or equal to 10 percent weight loss was 7 percent in the placebo group, 37 percent in the low dose, and 48 percent for the high dose combination groups. Common side effects include tingling sensations in the fingers and toes, altered taste sensation, dry mouth, constipation and insomnia. Women will be required to use birth control, as topiramate is known to cause birth defects.

These approved drugs do have side effects, but few, if any medications of proven efficacy are free of risk. The risks must be weighed against the potential benefits. While lifestyle interventions remain the optimal treatment for the prevention and treatment of obesity, they may not result in enduring effects or necessarily be sufficient as a single therapy for all patients. Obesity is a global pandemic and it is important to recognize its associated comorbidities. It is imperative that physicians and patients have all effective and safe therapeutic options at their disposal. The risks and benefits of weight loss medications, like any medication, must be understood by the patient and health care provider, but the ultimate decision as to the best therapeutic approach must be an individual decision. To deny physicians and patients appropriate therapeutic options simply does not make sense.

You must be logged in to leave a comment.