I have a 16 year old adolescent son. He has struggled to lose weight for the past seven years. Despite our best efforts to change his lifestyle, it seems we are constantly failing. Should we be thinking about medications?
At a recent conference, organized by the Centers for Obesity Research and Education (CORE), a number of papers were presented suggesting that in some instances pharmaceutical management of obese adolescents may be an option. Overall in North America, only 4% of obese people get prescribed medication to treat their obesity; this may be lower than 4% for adolescents, and even lower for children overall.
Considering the poor outcomes in helping adolescents to not only lose weight, but to subsequently maintain a stable and ideal weight, it is no wonder that some clinicians are considering the use of medications. Successful weight management apart from medications is possible though for at least 5-25% of the general population. In fact, research by the National Weight Control Registry (NWCR) confirms this.
The NWCR reviewed patients who lost at least 10% of their body weight, but were also able to keep off subsequent regained weight for at least one year. Although the data pertains mainly to adults, it may hold important lessons for most families who struggle with overweight.
Some highlights of the Registry data reveal that successful patients have the following behaviors in common:
- They exercise regularly, and at a level which varies from moderate to vigorous in intensity. Only 9% of patients reported doing no physical activity at all. (Note: Heart rate monitors or total energy expended are scientific, but not practical ways to define the intensity of physical activity. Thus, moderate physical activity can be likened to walking at a pace where one is late and rushing to get to a meeting, or to being in a hurry and not wanting to miss a bus or train).
- They never miss breakfast.
- They have a meal plan, but they do not have a specific diet per se. Most radical diets cannot be maintained over the long term. In fact, only 1% of the successful patients registered with the NWCR adhered to a strict low carbohydrate diet.
- They weighed themselves at least once every weak. Research shows that self-monitoring makes a major, positive difference in being consistent.
- They recognized the important difference between weight loss and weight loss maintenance, and were able to plan well when they noticed relapses in maintaining their weight loss plan.
- They limited their TV watching habits to much less than the national average of 28 hours of viewing per week.
Given the above methods for successful weight loss and subsequent maintenance, one can understand why adolescents – who are not known for their high degree of self-discipline - may be less prone to be successful, especially over the long-term. This may help to explain the trend among some clinicians to consider medications.
Medications which have been available in the past for treating obesity include phentermine, fenfluramine and amphetamines. Some of these medications had serious side-effects. The majority of current clinicians, who will consider medications for treating overweight, will prescribe relatively newer products such as Sibutramine (Meridia) or Orlistat (Xenical).
Sibutramine (Meridia), a combination of Norepinephrine/serotonin re-uptake inhibitor, inhibits one's appetite and increases satiety (feeling full). The medication has to be used for life. However, research has shown that combining Sibutramine with lifestyle changes works better than either lifestyle changes or Sibutramine alone (NEJM, 353:2111-2120, 2005).
Use of sibutramine results in a loss of 5% body weight in 50-60% of patients, and a 10% loss of body weight in 30% of patients. Not only does it lower body weight, but it also lowers total triglycerides and raises the good cholesterol (HDL). The side effects of this medication include: dry mouth (17%), constipation (11%), insomnia (10%), dizziness (7%) and high blood pressure (2.1%).
Another product which may be considered for an older obese adolescent is Orlistat (Xenical). It works by reducing fat absorption by 30% via mechanisms which inhibit the pancreatic enzyme lipase. Orlistat has been approved for long-term use, and has been shown to lead to an average weight loss of 5-8%. It also plays a role in reducing the risk of Type 2 Diabetes.
The side effects of Orlistat include oily stools, an urgency to defecate, flatulence (passing gas), and fecal incontinence. Given the latter is a nasty and embarrassing side-effect, teens often stop treatment when this oily side-effect repeats itself. Orlistat users should also take a multivitamin supplement because the medication interferes with the absorption of fat-soluble vitamins such as Vitamins A, D, E and K.
In the USA, Orlistat will become available over the counter in June 2007 under the name Alli. There is an intentional marketing effort here, where the name is a play on the word "ally" - one's friend, supporter and helper during a battle. The dose strength of Alli will be 50% of Orlistat. The future of this product in Canada remains uncertain as the current intentions of Ottawa's Health Protection Branch are unknown at this point.
Rimonabant is a new product on the horizon. It was originally intended for helping with marijuana dependence, yet the side-effect of weight loss was unintentionally discovered. Specifically, rimonabant is a cannabinoid antagonist which has been shown to lead to a 5-8% weight loss. The use of this medication in adolescents may be another example of future off-label use as is the current case with a number of other psychotropic medications (e.g., antidepressants).
At the moment, the typical timeline for obesity drug development takes 8.5 years. It is a long and expensive process. The main “carrot” to the companies may be the fact that these medications have to be used for life in order to deliver successful outcomes.
The bottom line is still the same: lifestyle changes such as the ones described by the NWCR still remain the most reliable and perhaps safest way to lose weight and maintain that loss. The average primary care physician in Canada will probably not be comfortable to prescribe these medications for adolescents, especially when patients have not been given the benefit of a custom-made multidisciplinary obesity clinic staffed by a nutritionist, physician, psychologist and a physical activity trainer.
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