Healthy Skepticism Library item: 5876

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Publication type: news

Rogers L.
Prospect of a fat pill divides medical world : Does a new drug to treat obesity ignore the role of individual responsibility?
The Sunday Times ( UK) 2006 Aug 12
http://www.theaustralian.news.com.au/story/0,20867,20085997-23289,00.html

Full text:

Prospect of a fat pill divides medical world

http://www.theaustralian.news.com.au/story/0,20867,20085997-23289,00.html

Does a new drug to treat obesity ignore the role of individual
responsibility? Lois Rogers reports
August 12, 2006

JO Welch is like millions of modern women. “I’m overweight because I
like my food too much,” she says cheerfully. The result is that her
weight fluctuates from 83kg to more than 108, a huge burden on her 1.4m
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 19kg in the past six months but I can’t see myself losing any
more,” Welch says. “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 (chemical name rimonabant) is the first of a new generation of
slimming treatments, and contains a molecule that 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 says. “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 Britain’s struggling 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 per cent a year.

The picture in Australia is scarcely more encouraging: the most recent
figures estimate that 2.5 million Australian adults are obese, or 19 per
cent of males and 17 per cent of females aged 18 and over. A further 4.9
million Australians are overweight.

“The mechanisms that control energy intake are mostly designed to
prevent us starving to death in a famine,” says 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.”

Britain spends an estimated 7 billion pounds a year ($16.6 billion) in
treating obesity-related health problems – an alluring prospect for the
drug companies. Acomplia, which costs $132 for a month’s supply, is
expensive, but the French manufacturer, Sanofi-Aventis, argues that
although the total cost to the health service 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,” says 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.

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 and Australia are both near the top of the weight gain league.
Britain is expected to have a fatter population than America within two
decades; obesity in Australia is also increasing fast, with the
prevalence of the most severe cases rising from 11 per cent in 1995 to
15 per cent in 2001 and 16 per cent in 2004-05.

Women with waist measurements of more than 35 inches (89cm) and men
whose waists measure 40in (101cm) 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 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 on loose motions 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 6600 people in nine
countries, more than 1000 of them in Britain.

The drug trials not only promoted 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 the taxpayer
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 30. Someone is considered to be obese
if they have a BMI of 30 or higher.

But the licence will also allow it to be prescribed for patients with
slightly lower BMIs, of 27, if these patients also have other risk
factors such as diabetes and high blood pressure.

BMI is a formula based on weight-to-height ratio, and no one weighing
under at least 160kg 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 130kg.

“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 (255kg), 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 25kg off the weight of a
255kg man, provide that control? Is it really worth its pounds price?

Nick Finer, consultant in obesity medicine at Addenbrooke’s 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 150kg British dieter, believes it will. She
now runs Toast, the Obesity Awareness and Solutions Trust, which
promotes recognition of the psychological component of overeating, and
now weighs 83kg.

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

Others fear that once Acomplia becomes widely available, it will flood
onto 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 Sunday Times