I was consulted recently by a national television program (no need to say which one, but we may note that there are doctors involved) regarding a segment on the weight-loss drug, Qsymia, which was recently approved by the U.S. Food and Drug Administration. The producer basically wanted to know my opinion of the drug: good or bad.
We can return to the particulars of Qsymia before we wrap up here, but first, let's consider the utility of drugs for weight loss in general.
I have prescribed them over the years, including back in the now rightly notorious days of "Fen-Phen." I generally did so rather begrudgingly, and in response to my patients' pleading. The idea in each case was to jump-start weight loss, and then wean off the drug. I've never thought much of drugs for weight loss, because I've never thought of weight gain as much like a disease. I tend to think it is much more like drowning.
[Read: Our Titanic Obesity Problem.]
So, imagine relying on pharmacotherapy for drowning. What would it take for that approach to do any good? Basically, drugs would have to turn people into fish.
The Harry Potter fans in the group may recall the fourth book (and movie), "The Goblet of Fire." In one scene, there is an underwater competition and various potions are used. One of the competitors acquires the head of a shark; another has an air-filled bubble encase her head; and Harry himself sprouts gills. These would be the very drugs we need!
Human beings are terrestrial creatures. The case can be made, as it is in the book "Your Inner Fish," that we are all cousins at some remove to our maritime predecessors, but our current incarnation has left the briny deep entirely behind. Having fully adapted to life up here, we are only fish out of water when tossed back beneath the waves.
In the context of our adaptations, drowning is not any kind of failure of human physiology but merely a reminder of its nature and limits. A human body that drowns by staying under water too long is working just as it should.
A relevant adage with murky origins was a fixture in my medical training: If it ain't broke, don't fix it. With drowning, there need be nothing wrong with the body involved. And when nothing is broken, there is nothing to fix.
I trust we agree that drugs would be a poor and unpromising approach to the peril of drowning. The approaches we do take are far more sensible. We recognize drowning as an environmental problem or, at least, a problem concerning the interactions of our bodies with its environment and so, we direct our corrective efforts at that interface. We put fences around pools, post lifeguards at beaches and provide one another swimming lessons.
Weight gain is rather like drowning – only in calories rather than water. Just as human beings are adapted to breathe air, so are we adapted to convert a surplus of calories into an energy reserve we can call upon in the advent of a rainy day or famine. This is so familiar that we forget it is an adaptation in the service of survival. We need not have this ability. To my knowledge, for example, corals and sea sponges do not.
Turning today's excess calories into a secure and accessible energy reserve we take with us wherever we go in the form of body fat is not merely normal, it is downright human. Of course, it is not exclusively human; it's an adaptation far too important to survival to pertain to us alone. Most animals alive today are the descendants of creatures who confronted the threat of starvation and lived long enough to procreate in spite of it all. The capacity to get fat is merely a byproduct of this survival mechanism, just as the capacity to drown is merely a byproduct of the adaptation to breathing air.
There is no single enzyme or gene that accounts for our capacity to breathe air and therefore drown. Rather, all the genes and enzymes and metabolic pathways that make us human are complicit in it. And for that reason, no drug will ever be devised to prevent drowning. And if ever a drug powerful enough to do so were devised, its unintended consequences would challenge imagination. What I imagine is that our inner fish would have to be set free.
I am extremely dubious that a genuinely safe and effective drug for weight control will ever be found for exactly the same reason. We are endowed with multiple, powerful, intricate defenses against starvation. If these were easily undone, our ancestors – living in a world where calories were hard to get and exertion was unavoidable – would have failed to survive long enough to procreate. Creatures who don't procreate make very poor ancestors. We are only here because those defenses were as robust and reliable as the bellows-like action of our lungs.
Weight gain in the context of surplus calories is perfectly normal. The constancy of surplus calories is the part that isn't normal – and the part that needs fixing. The dangers of drugs for weight control follow logically. Most obvious is the danger of failure, which is just what all weight-loss drugs to date have delivered most of the time. Second is the danger of unintended consequences, which have ruined the careers of even the most promising of candidates.
But third, and most important, is the danger of distraction. Imagine that while waiting for drugs to fix drowning, we didn't bother learning how to swim – and sent the lifeguards home. The more we focus on fixing what isn't broken, the less attention we are apt to direct at what is.
[Read: The Myth of Healthy Processed Food.]
Qsymia, a combination of two drugs, phentermine and topiramate, is best judged in just such context. It's not a very good anti-obesity drug, but there may be no such thing.
Phentermine is an amphetamine-like stimulant and very unlikely to be safe or suitable for long-term use. Among its common side effects is an elevation of blood pressure – one of the complications of obesity itself. We gain little if a treatment causes the complications of the condition that we are treating in the hope of avoiding such complications. Cocaine – another stimulant drug – produces weight loss, too. That doesn't make it a good idea.
Topiramate is an anti-seizure drug. It can, and often does, cause fatigue, brain fog and nausea. It can be difficult getting even patients with epilepsy to keep taking such a drug, even though they have the powerful incentive of avoiding a grand mal seizure. It's hard to imagine anyone remaining on such a drug to keep weight off, even if willing to tough it out in the short term to lose the weight in the first place. If and when the drug goes away, the lost weight is apt to come back.
The other allegedly new weight-loss drug, Contrave, has thus far failed to garner FDA approval. Frankly, I'm not convinced it's really any worse than Qsymia – but I don't think it's any better.
Despite all this, I am not truly opposed to weight-loss drugs. After all, some people need bariatric surgery. Once in the realm of relatively desperate choices, options can be a long way from perfect and still be far better than no options at all. I support both drugs and surgery as choices that should be available. But we can, and should, as a society, choose to help far fewer people ever need such options in the first place. We can, and should, direct our attention primarily to the problem at its true origins, all around us, and devise solutions accordingly.
In my opinion, drugs don't hold much promise for drowning, either in water or calories. But we can learn to swim. Similarly, feet and forks can do for epidemic obesity what pharmacotherapy cannot. Like swimming, their better use is also a matter of skills we can acquire – as opposed to gills, which in the absence of magic, we cannot.
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David L. Katz, MD, MPH, FACPM, FACP, is a specialist in internal medicine and preventive medicine, with particular expertise in nutrition, weight management, and chronic-disease prevention. He is the founding director of Yale University's Prevention Research Center, and principal inventor of the NuVal nutrition guidance system. Katz was named editor-in-chief of Childhood Obesity in 2011, and is president-elect of the American College of Lifestyle Medicine. His latest book, "Disease Proof: The Remarkable Truth About What Makes Us Well," is being released this month.