Correspondence
Pharmacotherapy for Obesity
N Engl J Med 2002; 346:2092-2093June 27, 2002
- Article
To the Editor:
Regarding the review article by Yanovski and Yanovski on the treatment of obesity (Feb. 21 issue),1 I am concerned about the use of the body-mass index (the weight in kilograms divided by the square of the height in meters) to categorize patients. The body-mass index arose as a screening tool for determining which persons had a high risk of obesity.2 Classifying persons as “normal,” “overweight,” or “obese” according to their body-mass index elevates the measure from a screening tool to a diagnostic criterion and creates potential problems.3
Compare a National Football League star with a body-mass index of 30 but only 6 percent body fat with a middle-aged woman with a body-mass index of 26.9, hyperlipidemia, and 35 percent body fat. If the body-mass index were used as a criterion for diagnosis, the athlete would be considered obese and the woman would not.
The article discusses off-label use of drugs as acceptable medical practice but does not note that the approved labeling for anorectic agents can be problematic. If obesity is a chronic disease, the approving of drugs for only “a few weeks” of use seems irrational. Approved labeling for sibutramine includes a restriction based on the user's body-mass index but allows a one-year treatment period. The labeling for phendimetrazine includes no restriction according to body-mass index but contains the “few weeks” clause.4
Unfortunately, licensure boards promulgate rules and may prosecute physicians on the basis of approved labeling, as outlined by Bray.5 There are a number of legitimate reasons (e.g., sarcopenic obesity, or weight gain in the presence of the loss of lean tissue) for using anorectic agents in persons with a body-mass index of less than 27. The use of the body-mass index as a screening device or to compare research cohorts appears reasonable, but using it as a criterion for diagnosis may serve to increase barriers to proper treatment for obesity.
5 ReferencesMichael Steelman, M.D.
American Society of Bariatric Physicians, Oklahoma City, OK 731201
Yanovski SZ ,Yanovski JA . Obesity. N Engl J Med 2002;346:591-602
Full Text | Web of Science | Medline2
Health implications of obesity. NIH Consensus Development Conference statement. Vol. 5. No. 9. Bethesda, Md.: National Institutes of Health, 1985.
3
Steelman M . Body mass index: tool or weapon? Am J Bariatr Med 2001;16:13-144
Physicians' desk reference. 56th ed. Montvale, N.J.: Medical Economics, 2002.
5
Bray GA . Use and abuse of appetite-suppressant drugs in the treatment of obesity. Ann Intern Med 1993;119:707-713
Web of Science | Medline
To the Editor:
Dinitrophenol was introduced into clinical medicine in 1932 for weight reduction, for which it appeared to be excellently suited thanks to its mechanism of uncoupling of the processes involved in oxidative phosphorylation: it took excess energy and turned it into heat rather than into fat. The increase in the metabolic rate is proportional to the dose of dinitrophenol, and in animal experiments, the drug induced fatal hyperthermia. The drug is well absorbed by the human gut and has been effective in weight loss. Unfortunately, its reported toxic effects preclude its use, and it was therefore removed from the market.1
Medications currently approved for weight loss include appetite suppressants (who wants that?) and those that decrease nutrient absorption (with attendant undesirable gastrointestinal effects). Looking for a third category — drugs that uncouple the processes involved in oxidative phosphorylation — is like a search for manna, the food that was miraculously supplied to the Israelites during their journey through the wilderness. For the developed (and overweight) world, manna would be even more of a potential lifesaver than it was in biblical times. I impatiently await the discovery of an uncoupler without life-threatening side effects.
1 ReferencesWilliam P. Weiss, M.D.
121 Park St., Springfield, VT 05156To the Editor:
Adjustable gastric banding was approved in the United States on June 5, 2001. The adjustable gastric band is usually placed laparoscopically in less than 1 hour, with a hospital stay of 24 hours or less. Most patients return to work within two or three days. The rate of weight loss is 6 to 10 lb (2.7 to 4.5 kg) per month. If this rate drops, saline is added to the port under fluoroscopic guidance, causing return of early satiety and continued weight loss. With a multidisciplinary approach and regular follow-up, 65 to 75 percent of the excess weight is commonly lost within 18 months. Side effects are minimal (occasional reflux). The cost is one third that of the other types of operations for obesity or less, and operative mortality is close to zero. Results appear to be maintained at four and five years. Furthermore, the rate of reoperation is less than 5 percent (reoperation is required because of erosion, migration, port infection, or unhooked tubing). Other advantages over traditional types of surgery include the absence of malabsorption, vitamin deficiencies, dumping syndrome, leakage, and eventual weight regain. Adjustable gastric banding is reversible, and bands may be removed laparoscopically, with preserved natural anatomy. Clinicians treat a rapidly growing population of older, severely obese persons with concomitant medical problems who are unable to lose substantial amounts of weight with the multiple strategies outlined in the review by Yanovski and Yanovski. Perhaps some of these high-risk patients might be candidates for a more definitive strategy involving adjustable gastric banding.1-5
5 ReferencesFred Maese, M.D.
Ferris Heart Center, Ferris, TX 75125Marcel Lechin, M.D.
Texas A&M University, College Station, TX 778451
O'Brien P ,Dixon J ,Brown W . Lap-band placement -- a prospective study of outcomes for 632 patients with up to 5 year follow-up. Obes Surg 2000;10:144-144 abstract.
CrossRef | Web of Science2
Doldi SB ,Micheletto G ,Lattuada E ,Zappa MA ,Bona D ,Sonvico U . Adjustable gastric banding: 5-year experience. Obes Surg 2000;10:171-173
CrossRef | Web of Science | Medline3
Suter M ,Bettschart V ,Giusti V ,Heraief E ,Jayet A . A 3-year experience with laparoscopic gastric banding for obesity. Surg Endosc 2000;14:532-536
CrossRef | Web of Science | Medline4
Cadiere GB ,Himpens J ,Vertruyen M ,Germany O ,Favretti F ,Segato G . Laparoscopic gastroplasty (adjustable silicone gastric banding). Semin Laparosc Surg 2000;7:55-65
Medline5
Salinas A ,Santiago E ,Luciano A ,Ferro Q ,Trejo M . Gastric banding: five to ten years follow-up. Obes Surg 2000;10:324-324 abstract.
Author/Editor Response
The authors reply:
To the Editor: Dr. Steelman raises some interesting research issues regarding the use of pharmacotherapy for obesity. Body-mass index is currently used to define obesity because it is easy to use in clinical settings and correlates well with the percentage of body fat.1 It is true that some persons, such as athletes, can meet body-mass index criteria for obesity without having a high percentage of body fat. Similarly, one can have a body-mass index in the normal range but have elevated levels of body fat. We are unaware of long-term studies evaluating the safety, efficacy, or health effects of weight-loss medications in persons with a body-mass index of less than 27 who have excessive body fat either with or without obesity-related coexisting conditions. Such studies would be valuable in determining whether the measurement of body fat (in addition to, or instead of, the body-mass index) would improve the selection of appropriate patients for treatment.
The current labeling of older weight-loss medications as approved for “a few weeks” of treatment reflects the fact that they were approved at a time when the sustained use of such medications was deemed to be inappropriate. Unfortunately, these medications have not been systematically evaluated for long-term safety and efficacy, although they are frequently prescribed off-label for longer periods. We encourage both clinicians and researchers to publish systematic documentation of their experiences with off-label use and to enroll patients in clinical trials whenever possible, which should lead to a better understanding of the risks and benefits of these medications as they are used in clinical practice.
Drs. Maese and Lechin describe adjustable gastric banding, one option for the treatment of extremely obese patients. Bariatric surgical procedures, such as gastric bypass or banding, may be appropriate for obese patients with a body-mass index of 40 or higher or for those with a body-mass index of 35 or higher along with coexisting conditions, although such procedures carry their own risks of procedure-related complications.1 Such patients represent a small but increasing proportion of the obese population.
Dr. Weiss reminds us that the history of weight-loss treatments is a long and often painful one, with numerous promising but failed efforts.2 We still await the “manna” he describes in the form of safe, effective, and easily tolerated medications that are shown to improve the health and quality of life of our obese patients.
2 ReferencesSusan Z. Yanovski, M.D.
Jack A. Yanovski, M.D., Ph.D.
National Institutes of Health, Bethesda, MD 20892-5450
sy29f@nih.gov 1
Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults -- the evidence report. Obes Res 1998;6:Suppl 2:51S-209S[Erratum, Obes Res 1998;6:464.]
Medline2
Bray GA ,Greenway FL . Current and potential drugs for treatment of obesity. Endocr Rev 1999;20:805-875
CrossRef | Web of Science | Medline
- Citing Articles (2)
Citing Articles
1
Hanna Grol-Prokopczyk. 2010. Who says obesity is an epidemic? How excess weight became an American health crisis. , 343-358.
CrossRef2
L D Voss, B S Metcalf, A N Jeffery, T J Wilkin. (2006) IOTF thresholds for overweight and obesity and their relation to metabolic risk in children (EarlyBird 20). International Journal of Obesity 30:4, 606-609
CrossRef
