The Quick Fix
by Sally E. Smith

Weren't the 80s supposed to be the decade of immediate gratification? Aren't the 90s supposed to be more grounded in reality? When I look at the current trends in dieting and and the weight loss industry, I feel like I'm in a time warp. Fad diets are all the rage, diet drugs that I was sure had been left behind along with bell bottoms and tie dye have resurfaced in ever more menacing ways, and the public is blissfully yo-yoing its way up and down the bathroom scale. Is this just a bad case of deja vu, or what?

Dr. Atkins back? Hello!?
I remember my dad buying "Dr. Atkins' Diet Revolution" for me during adolescence, though I can't quite remember if it was the year before I was sent away to diet camp for six weeks, or the year after (I sincerely believe that semi-starvation impairs memory). Let's say that it was about 25 years ago. Following the Dr. Atkins craze, the news came out that an all-protein diet was dangerous and that the state of ketosis that the body achieves can be fatal. Several years back, Dr. Atkins even had his New York medical license revoked. So I could hardly believe my eyes when I read in the paper late this spring that "Dr. Atkins New Diet Revolution" was back on the shelves and selling like, er, hotcakes. I found myself wondering if other people had more severe memory loss than I.

Zoned out
Alongside the Atkins resurrection is the best-selling book "The Zone", by Barry Sears, which calls for small meals throughout the day, "The Five Day Miracle Diet", which mandates that different foods be eaten at different times, and "Protein Power", which looks like a variation on the Atkins Diet. Another article I read touted the latest trend in fad dieting, the cabbage soup diet. I remember when I was 16 and working alongside a woman who ate nothing but hard-boiled eggs in an attempt to drop 60 pounds in a couple of months (she lost the weight, but when I worked there again the following summer, she had of course gained all the weight back plus some). I remember contemplating trying the grapefruit diet, but coming to the realization that the only way I can stomach grapefruit is when it's juice mixed with vodka. To me, cabbage soup goes even one step further, as in, "You've got to be kidding".

Rush for the quick fix
Even "sensible" dieting advice--the line that you shouldn't lose more than one half pound a week--has gone out the window. (Of course, while losing weight more slowly may do less physiological damage, rate of weight loss doesn't seem to affect the dismal long-term success rate of any weight loss program.) Dieters are going whole hog, so to speak, for plans and programs that promise quick results. They don't seem to care how weird a diet is, just as long as it makes them lose weight quickly. When it comes to weight loss, the corollary of immediate gratification is "the magic pill". Not only do dieters want to lose weight now, many want to do so with as little effort as possible. Enter the pharmaceutical companies, which parlay that desire into a multi-billion dollar industry where both the drug companies and the pill-pushing doctors reap massive profits. Just witness the signs that abound on street corners all over the country: "Fen/phen $30/week".

Which brings me back to my feeling that I'm in a time warp. The message that diets don't work was mainstreamed by the size acceptance movement a few years ago, and many segments of the public accepted the media reports that there was no behavioral, dietary, or pharmaceutical treatment that had better than a three percent success rate over five years. Fad diets were labeled as dangerous and consumers were warned to avoid them. And unless memory loss is more severe than I estimate, folks should recall that the diet pill craze of the 60s and 70s caused drug abuse, side effects, death, and ultimately, people who were fatter than ever.

What happened?
So, what happened that caused people to throw caution to the wind and begin simmering cabbage soup and popping pills? It seems to me that it was a combination of slick maneuvering by obesity researchers and drug companies, and a public who so values thinness that they don't care about the consequences of their actions.

News reports indicate that fad dieters are very aware of the failure rates of diets, but that they simply don't care. Their attitude is, "I don't care if I gain the weight back, as long as I lose enough for _____" (fill in the blank--"my sister's wedding", "my class reunion", "swimsuit season"). As for the pill poppers, those who have just a few pounds to lose see diet drugs as a quick fix, and those who have been on the diet roller coaster for years see a magic pill that will turn their lives around, improve their self-esteem, and make them acceptable for the first time in their lives.

Greed and the diet industry
For their part, obesity researchers and the drug industry have laid the groundwork for these attitudes. While their greed understands that people's motivation for losing weight has little to do with health and everything to do with appearance, their professional personas have always used the smokescreen of health issues to promote weight loss. In 1985, a National Institutes of Health consensus conference claimed that obesity is a "killer disease", and that the health of anyone 20% or more over "ideal" weight was in serious jeopardy. Terming fatness a disease kept the floodgates of research money open in search of treatments for obesity, and over the years many dietary, behavioral, and surgical treatments were promoted. For years, the emphasis was on reaching and maintaining one's "ideal" body weight; only when this occurred (according to researchers) could the drastic health consequences of fatness be mitigated.

Over time, the dismal success rates of weight loss methods and the genetic components of fatness were mainstreamed, and even the researchers had to admit that the "ideal" weight goals were unrealistic. Meanwhile, pharmaceutical companies were reexamining the old diet drugs and coming up with new combinations that could produce a 10% weight loss sustainable (they thought) for as long as the patient remained on the drugs. Lo and behold, researchers began doing studies which found that a 10% weight loss was enough to improve the health status of fat people. As it turns out, even glossing over short term side effects such as memory loss, diet drugs can have severe (and sometimes fatal) consequences with long term use. And there is evidence that even with long term use of the drugs, people began to regain lost weight over time.

Phony Task Force
Contrary to what every fat person who has ever yo-yo dieted knows, a couple of years ago the National Task Force for the Prevention and Treatment of Obesity (some members of which are paid consultants to diet and/or drug companies) reviewed (selective) research and reported that weight cycling produced no ill effects. Today, some researchers are going one step further and claiming (without the benefit of studies) that any weight loss, even if it's temporary, provides health benefits. At a recent conference a leading researcher stated that it's not only acceptable but beneficial in the long run for a person to lose weight and regain it every two years. This flies in the face of many studies which have found a higher incidence of disease and increased mortality with as little as a ten pound fluctuation in weight.

Waffling Fed guidelines
Federal guidelines for weight have also changed, though in different ways than those espoused by the mainstream obesity research community. The Feds began by advising that a person's goal should be to "maintain ideal weight" as defined by the Metropolitan Life Insurance Company's height-weight charts. Then their advice was modified (along with the weight tables, which became more "lenient") to "maintain desirable weight". By 1990, with more revisions to the tables, the Feds were telling folks to "maintain healthy weight", and by 1995, to stay at a stable weight or "improve your weight".

Let's give them drugs
But cutting edge obesity researchers (and pharmaceutical companies) don't want anything to do with weight stabilization; they are betting the farm on diet drugs. Drugs for weight loss have a long and sordid history, beginning with thyroid drugs in 1893 and moving to dinitrophenol (1933), amphetamines (1973) and HcG (1954).

Today researchers are working on several classes of drugs, each of which acts upon the body in a different way. One avenue that is being explored by Amgen Pharmaceuticals, leptin, comes out of genetic research into satiety signals from the brain. Hoffmann-LaRoche is working on an ob-receptor, which would make the leptin receptors in the brain work more effectively. Fatness is being positioned next to diabetes, and just as diabetics who do not have an insulin deficiency are given high doses of injected insulin, fat people with no leptin deficiencies may be given high doses of leptin to regulate satiety and, therefore, weight.

In another arena, researchers are trying to find neuro-peptide Y (a powerful endorphin) analogues in order to fool the brain and block npY receptors which regulate satiety signals. Others, including American Home Products, the parent company of the makers of Redux, are searching for beta-3 agonists which would speed up a person's metabolism.

Another class of drugs block the absorption of fat in the intestinal tract. Hoffmann LaRoche is working on orlistat, which will be marketed under the trade name Xenical. Orlistat will come up for approval before the Food and Drug Administration in 1997, and will most likely be used to complement other diet drugs.

Last, but certainly not least, are the drugs that reduce appetite by increasing the level of serotonin in the brain. According to researchers, the combination of fenfluramine and phentermine (fen/phen) constitutes the first generation of such drugs (though fenfluramine was approved for three month use 20 years ago). Fen/phen is still all the rage among those who want to drop a few pounds. According to Time magazine, the California Weight Loss Medical Associates have 19 centers and a toll free number: 1-888-4FEN-FEN.

The second generation of serotonin-related drugs is dexfenfluramine (marketed under the trade name Redux), which is actually one molecule of fenfluramine. Next year, Knoll is expected to put sibutramine on the market under the trade name Meridia. Sibutramine prevents the uptake of serotonin and noradrenaline which may increase metabolism and decrease appetite.

Redux indeed
Of all the diet drugs, Redux has generated the most media attention. Redux made the cover of Time magazine, and is the subject of the book "The Redux Revolution", by Sheldon Levine, a New Jersey diet doctor. Beginning in October the manufacturers of Redux, Wyeth-Ayerst, will begin an aggressive marketing campaign. According to Time, doctors are currently writing 85,000 prescriptions a week, and Jenny Craig and Nutri/Systems weight loss centers are scrambling to find a way to include Redux in their diet plans.

The FDA caves in
Yes, there's big money to be made from Redux, which was all too apparent during the Food and Drug Administration approval process. At the initial FDA hearing, dexfenfluramine's opponents were quite vocal, and the FDA advisory committee voted 5-3 against the drug's approval. But an FDA official called the vote invalid because there wasn't a quorum, and rescheduled another hearing for two months later. The meeting coincided with a conflicting conference, so most of the Redux opponents were absent, and the committee voted 6-5 in favor of the drug.

Deadly side effects
There are a myriad of side effects of this "miracle drug". There are the annoying side effects of dry mouth, fatigue, and diarrhea. Then there are the deadly side effects of neurotoxicity and primary pulmonary hypertension. Neurotoxicity is the killing of brain cells, and can occur with an overdose as little as twice the prescribed amount. Given the rampant abuse and overuse of diet drugs a decade or two ago, I can only shudder when I think of the potential for neurotoxicity with Redux.

Primary pulmonary hypertension destroys blood vessels in the heart and lungs, which is fatal. While this side effect was glossed over in the FDA hearings as insignificant, a recent study published in the New England Journal of Medicine found the rate to be 46 per 1 million patients who took dexfenfluramine for longer than three months, as opposed to 1 to 2 per million patients for those taking it three months or less. The pro-Redux forces rationalize the fatality rate of Redux by saying that "obesity" kills 300,000 people per year, so any treatment that kills fewer fat people actually saves lives. Say what?

Full assault on fat people
So are we in a time warp with this round of fad diets, yo-yo dieting, and diet drugs? Overall, it seems like deja vu, but there are some not-so-subtle differences between the 90s and the 70s. The folks who stand to profit the most from these weight loss methods are more sophisticated than they were 25 years ago, and are adopting a "take no prisoners" mentality. They're aware of both the size acceptance and non-dieting movements, and they're more sophisticated with their rhetoric. They know their opposition, and they're prepared for battle. In fact, some of the obesity treatment proponents have usurped the movements political theory and bastardized it, developing a political agenda that calls for federal law mandating that insurance companies pay for weight loss treatments, and suing insurance companies who do not pay for Redux on the grounds that not paying for the diet drug constitutes weight discrimination.

Movement must act
It's clear that the size acceptance and non-dieting movements must act swiftly to counteract the enormous financial resources of the pharmaceutical companies and the legitimacy and credibility of the drug companies' mouthpiece, the mainstream obesity research community. It's been a quarter of a century since my mom threw away the prescription for diet drugs that my pediatrician gave her (telling me many years later, "It just didn't seem like a good idea"), but I fear that this generation of adults will be so eager for the quick fix that they will disregard the dangers of fad dieting, yo-yo dieting, and most of all, diet drugs. ß



Musings