By Alexandra Garvey and W. Timothy Garvey, MD
The American Medical Association’s (AMA) House of Delegates recently approved a resolution sponsored by the American Association of Clinical Endocrinologists (AACE) officially recognizing obesity as a disease. What does that mean to you and your doctors? What it means to members of AACE – which has been advocating the position for several years – is that obesity is a chronic disease just like diabetes, hypertension or asthma, with its own genetic, behavioral and environmental causes and medical treatment needs that require a range of prevention and treatment interventions.
Scientific research has given us a much better understanding of what regulates how much food we eat, how much energy we burn and the things that go wrong that result in accumulation of too much body fat. Genes make a big difference and explain, in part, why obesity can run in families and why obesity is more prevalent in some ethnic populations. However, just because we inherit these genes does not mean we will be overweight! These genes interact with behavior and environment. We can modify our behavior (e.g., lifestyle factors like daily activity, diet, exercise) to minimize the effects of these genes. However, on average, the people who carry genes for obesity will be the people that gain the most weight. For this reason, designating obesity as a disease does not absolve patients from the responsibility of adopting healthy lifestyles in combating the disease. Nor does it mean that obesity is a lifestyle choice – because it is not. It is a disease that should be treated by endocrinologists and other healthcare professionals using all the tools we have available in ways that are best suited for the treatment of individual patients.
Let’s consider those tools. In many ways, the treatment options are like a three-legged stool. The legs of the stool are the three major ways that obesity can be treated: behavior changes such as diet and exercise, bariatric surgery (surgery for weight loss) and medicines. Effective behavior or lifestyle modification programs have been developed, and the surgery procedures have been improved as well. Still, doctors have lacked effective medications for weight loss. However, recently approved medicines are now giving this stool a better leg to stand on.
In the summer of 2012, the Food and Drug Administration (FDA) approved two new weight loss medicines that have more recently become available for prescription. These medications are called Belviq® [BEL-VEEK] (lorcaserin) and Qsymia® [kyoo-sim- EE-uh] (phentermine/topiramate extended). These medications have changed the weight loss landscape by giving doctors and their patients a wider range of treatment possibilities.
This, of course, sounds great, but you’re probably wondering how these medicines actually work. Qsymia is a combination of two generic drugs that are known to suppress appetite: phentermine and topiramate — which is already available for
migraine headaches and seizures — cause you to feel full or satiated. Qsymia combines these two medicines in lower doses to reduce side effects and takes advantage of the fact that they work together to produce greater weight loss. Belviq, on the other hand, acts on certain receptors (places on or inside cells where hormones and other chemicals attach) in the brain (serotonin receptors) and causes you to feel full. Both Belviq and Qsymia work within the body to improve the results of your weight loss efforts due to diet and exercise. They are meant to be taken in conjunction with making lifestyle changes because patients who combine one of these medicines with a lower calorie diet and regular exercise can expect to see more weight loss than patients who treat their obesity with diet and exercise alone. In this way, these new medicines are game changers, but should not be considered a magic weight loss pill.
And what about the side effects, you may ask? Some of the side effects of Belviq include headache, nausea, constipation, dry mouth and serotonin syndrome (high temperatures, rapid heart rate, muscle twitches, confusion). Qsymia can cause dry mouth, constipation, insomnia, tingling in the fingertips, and a tinny taste to carbonated beverages and should not be taken by people with glaucoma or an overactive thyroid. Pregnant or nursing women should not take either of these medicines. The topiramate in Qsymia can increase risk of cleft lip and palate (abnormalities in the development of the lips and mouth) if taken by women during pregnancy. Therefore, women of child-bearing potential must be on birth control while taking Qsymia and check a home pregnancy test every month so they can stop the drug immediately if the pregnancy test turns positive.
How much weight can you expect to lose on these new medications? When used together with lifestyle modifications in clinical trials, the average weight loss in patients taking Belviq was about 8 percent of their body weight (16 lbs. for someone weighing 200 lbs.), and for Qsymia was around 12 percent of their weight (24 lbs. for someone weighing 200 lbs.). These are the average responses. Some lose more. Some lose less. You may be disappointed that these drugs don’t cause more weight loss on average; for example most patients will not achieve ideal body weight or a size 4 dress size in women, or a 34-inch belt size in men. This gets down to the reason why physicians treat obesity as a medical disease and why it is important for patients and doctors to agree on the goals of therapy at the beginning of treatment.
Although these new medicines may not get you down to a size 4, the weight loss that can be achieved will make a huge difference in the quality of your health. In clinical trials, treatment with either Qsymia or Belviq plus lifestyle change was shown to have impressive benefits by improving many of the complications of obesity. If you are one of the millions of Americans living with the disease, you more than likely know all know too well what some of these complications might be. The first category of obesity complications is metabolic, which includes diabetes, pre-diabetes, metabolic syndrome (a combination of medical disorders that, when occurring together, increase the risk of developing cardiovascular disease and diabetes), high blood lipids, hypertension, fatty liver disease and higher risk for heart disease. The second type of obesity complication encompasses mechanical problems due to excess body weight and includes obstructive sleep apnea, osteoarthritis, mobility problems and stress incontinence. Weight loss can be used to improve all of these conditions.
So, are you a patient with diabetes? Hypertension? Dyslipidemia? Sleep apnea? Osteoarthritis? Nonalcoholic fatty liver disease? Stress (urine) incontinence? Well, guess what? These are all things that can be treated effectively by losing 10 percent of your body weight. This will go a long way to prevent the development of future diabetes in high-risk patients with a family history or with prediabetes. And, if diabetes is already present, this amount of weight loss will lower blood sugar and the need for diabetes medicines. It will decrease your risk for heart disease, lower your blood pressure, improve your lipids by increasing good cholesterol while decreasing harmful triglycerides, remove fat from the liver, help with mobility and improve sleep apnea. Patients may not be able to expect to reach their ideal body weight, but they can expect to lose weight to a degree that will improve complications that are the source of suffering and poor health.
This is a medical approach to fighting obesity as a disease. In a society that often treats obesity as a lifestyle failure, these new developments in medicine are altering the way in which patients can approach their health. Attitudes in our society are moving away from the incorrect notion that obesity is merely a lifestyle choice and towards the scientifically correct idea that it is a disease requiring medical therapy, particularly when patients have complications that can be treated with weight loss.
With the help of these recent obesity medicines and a solid lifestyle effort, people with obesity now have new tools and new options to achieve real weight loss results and improve their long-term health. If you are seeking treatment, it is important to determine the goals of therapy up front with your doctor; in other words, how much weight you can realistically be expected to lose, what your role is as a patient in optimizing the success of treatment, and what the goals of treatment are that will improve your health. Armed with these new medicines and new options for challenging obesity and its complications, doctors and patients working together can result in a longer, healthier life for the patient.
Alexandra Garvey is a writer and journalist from Birmingham, AL. She is a recent graduate of Hamilton College in Clinton, NY, where she majored in English. She carries a lifelong passion for advocacy work with a newfound focus on patient education.
Dr. W. Timothy Garvey is Chair of the University of Alabama at Birmingham’s (UAB) Department of Nutrition Sciences and Director and Principal Investigator of the UAB Diabetes Research and Training Center (DRTC). Since 1987, Dr. Garvey has directed an independent laboratory supported by the National Institutes of Health (National Institute of Diabetes and Digestive and Kidney Diseases/National Heart, Lung, and Blood Institute), the Department of Veterans Affairs, the American Heart Association, the Juvenile Diabetes Foundation International, the American Diabetes Association and other agencies.