Healthy Skepticism Library item: 5360

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Publication type: news

Rogers L.
Focus: Is a pill really the answer to the fat epidemic or could it make things worse?
The Sunday Times ( UK) 2006 Jul 2
http://www.timesonline.co.uk/article/0,,2087-2252507.html

Full text:

The Sunday Times July 02, 2006

Focus: Is a pill really the answer to the fat epidemic or could it make things worse?
Lois Rogers

Jo Welch is like millions of modern English women. “I’m overweight because I like my food too much,” she says cheerfully.

The result is that her weight fluctuates from 13 stone to more than 17, a huge burden on her 5ft 4in frame. It means she must put up with muttered remarks from bikini-clad teenagers when on holiday.

She has nearly triple the normal risk of dying prematurely from diabetes, heart disease or cancer. And she is engaged in a constant quest to find clothes that fit. But still the 31-year-old mother of three from Mitcham, south London, struggles to stop eating.

“I’ve lost three stone in the past six months but I can’t see myself losing any more,” Welch said. “Food is a big part of the life of my family. We are always having birthday parties with huge cakes or family barbecues and we eat out a lot. I would love to be thinner but I don’t suppose I ever will be.”

Last week, however, Welch, like millions of other obese people, was offered hope when a new drug was launched on prescription in Britain ahead of any other country.

Acomplia is the first of a new generation of slimming treatments, and contains a revolutionary molecule which knocks out the receptors in the brain that transmit pleasure from eating. Not only that, claims its manufacturer, it creates feelings of fullness and acts on individual fat cells throughout the body to block weight gain.

“I would definitely give it a try if I could,” Welch said last week. “I do stop eating when I feel full and if this drug made me do that sooner, it would be great.”

Potentially great, too, for the National Health Service, because obesity is no longer a private matter. One fifth of the adult population in Britain is now affected, and the number is growing by 4% a year.

“The mechanisms that control energy intake are mostly designed to prevent us starving to death in a famine,” said John Wilding, professor of medicine at Liverpool University. “They are entirely at odds with modern environmental pressures, where we are surrounded by food and have little need to take exercise.

“Being overweight is the equivalent of smoking in causing illness and premature death,” he said.

The NHS spends an estimated £7 billion a year in treating obesity-related health problems – an alluring prospect for the drug companies. Acomplia, which costs £55.20 for a month’s supply, is expensive, but the French manufacturer, Sanofi-aventis, argues that although the total cost to the NHS could run into billions, billions more would be saved in treating people for illnesses such as diabetes and cancer.

“We have to be very careful how we manage expectations, but what this drug does is to reduce body fat, and lower cholesterol and blood fat levels beyond what could be achieved by diet and exercise. That will certainly save the NHS money,” said a spokesman for Sanofi-aventis.

This approach is strongly contested by other specialists, however. They argue that turning fatness into a disease absolves individuals of responsibility for controlling their eating habits and may make things worse in the long term.

Tessa Prior, medical adviser to Slim-Fast, the meal replacement scheme, points out that dozens of independent studies have repeatedly shown that self discipline, good diet and regular exercise are the keys to losing weight.

“Meal replacements work because obese people under-estimate their calorie intakes by an average of 40%,” she said. “They blame their genes, hormones and anything else outside their control. Meal replacements are carefully balanced and give people a precise calorie value which enables them to take control, yet a lot of doctors remain convinced by obesity drugs. Maybe it is because this method is too simple for them.”

So who is right – will the new pills help or simply make matters worse, and who is really driving the agenda? Is it unbiased doctors or a pharmaceutical industry in pursuit of yet another miracle lifestyle drug?

A pill that cuts appetite and stops people eating without side effects has been a holy grail for drug companies for 30 years. The global obesity epidemic is being led by the world’s wealthiest countries, creating a market that is potentially bigger than any other in pharmaceutical history.

Britain is top of the weight gain league, and is expected to have a fatter population than America within two decades. Ten million adults or one in five of our population is obese, a proportion which has doubled since the mid-1980s. Women with waist measurements of more than 35in and men whose waists measure 40in or more are judged to be “high risk” for heart disease and diabetes.

For the drug companies, cracking such “lifestyle” markets is crucial. Not only do they contain a virtually limitless supply of potential customers but they are open ended in terms of repeat prescriptions.

Viagra, designed to boost the sexual performance of flagging middle-aged men, has become the biggest-selling drug on the internet. An anti-fat pill that works on those categorised as “morbidly obese” by hospitals could generate internet sales many times higher to mildly overweight people within as little as a few years.

There have, however, been several false starts on the path to a miracle fat-buster. In the early 1990s came a margarine that prevented absorption of fat, but promoted diarrhoea. Then there was the drug Xenical, which has a similar effect unless fat is eliminated from the diet; and Reductil, which like Acomplia is meant to create signals of fullness in the brain, but according to doctors simply does not work well.

Acomplia, however, appears to be more effective because of its wider effect through the body. It has been tested on 6,600 people in nine countries, more than 1,000 of them in Britain.

The drug trials not only gave an average 10% weight loss in at least a quarter of those taking it, but also produced lowering of cholesterol and blood fat levels far greater than would be achieved by diet alone. It is these benefits that are supporting hopes that the drug could cut our bill for treating obesity.

ACOMPLIA’S initial UK licence will limit its use to people who have a body mass index (BMI) of at least 27 with other risk factors such as diabetes and high blood pressure, or BMI of 30 with no other risk factors. BMI is a formula based on weight to height ratio, and no one weighing under at least 25 stone will initially be eligible.

Mike Brown, a GP in the Staffordshire town of Cheadle, says he sees plenty of patients who cannot accurately be weighed by his standard-issue NHS scales, which go up to 20 stone.

“We have plenty of two-chair patients in the waiting room, with BMIs of 50,” he said. “Surgery to cut the capacity of their digestive tract is one option, but anaesthetising them can be fatal.

“Nevertheless, if someone weighs 40 stone, we have to do something. The fact remains, you do not get fat people in places where food is limited, and people have to control their intake.”

So will Acomplia, with its promise of taking four stone off the weight of a 40-stone man, provide that control? Is it really worth its £55 a month price tag?

Nick Finer, consultant in obesity medicine at Addenbrookes hospital in Cambridge, says it could be. “People vary in their ability to understand the toxic environment we live in. It is essential we offer them treatment.

“It always strikes me as strange that we see obesity as lifestyle related, but not heart disease which is linked to poor diet, or osteoporosis, which is always linked to inactivity.”

It remains to be seen whether Acomplia will be endorsed by the National Institute for Clinical Excellence (Nice), the body that pronounces on the value for money of new drugs. Guidelines on treatment of obesity are due in September, and will focus on the need for greater support and advice for obese people. A spokesman said Acomplia would not be assessed until Nice was asked to do so by the health department.

The underlying question remains: will the availability of a successful anti-fat pill merely encourage obesity in the longer term?

Louise Diss, 44, a former 24-stone dieter, believes it will. She now runs Toast, the Obesity Awareness and Solutions Trust, which promotes recognition of the psychological component of over-eating, and now weighs 13 stone.

“It has taken me 20 years to feel comfortable about who I am,” she said. “Understanding how your thoughts and feelings affect your behaviour is by far the most important way of controlling weight. Losing 10% of your weight by taking a pill is nothing.”

Others fear that once Acomplia becomes widely available, it will flood on to the internet as Viagra did and end up being pitched at image-conscious twentysomethings by unscrupulous retailers. For every legal prescription of Viagra, at least 20 times more are said to be sold from websites.

Such a development with a drug like Acomplia could have grave consequences, say experts, given growth in eating disorders such as anorexia and bulimia.

Doctors say there is already ample evidence of teenage girls scouring the internet for drugs that will help them achieve the anorexic looks of Victoria Beckham or Kate Moss.

For Welch, however, Acomplia holds great promise. “A pill which makes you feel full might well work. I can’t wait to give it a go.”

THE HEALTHIER ALTERNATIVE

Build more exercise into your daily routine. Make the journey to and from work take a little longer by building in a walk. The latest research shows that regular walking is much more effective than two or three short weekly bursts in a gym

Keep clear of ready meals and other processed foods. They contain higher levels of fat than home-made equivalents, and are less psychologically satisfying than a meal made from fresh ingredients

Stop eating crisps or peanuts with drinks before meals. Doctors point out that snack food are so energy dense it is possible to consume 300 calories – the equivalent of a light meal – without even realising it

Review habits like taking sugar in tea or coffee. Such things are a matter of routine that can be altered to great effect. A month after giving up sugar in coffee you will wonder why you ever liked it

Swap that packet of biscuits for a bowl of fruit. Grazing on junk food throughout the day is one of the quickest ways to destroy your health. Go for fresh fruit, raw vegetables or sugar-free gum instead

If you are overweight, keep a diary of everything you eat during the day. Studies have shown that the fatter people are, the more they delude themselves about what they have eaten

Limit yourself to one full meal a day, and try to make that event a sociable family occasion. Steer clear of fried and fatty foods and don’t go mad on red meat

Take active holidays. Instead of lying on a beach reading for two weeks, try walking or cycling. Alternatively learn to surf or ski. The days will seem fuller and you will go home with raised energy levels

Watch the booze. Many people ignore the calorie values of beer, wine and spirits – all of which are fattening