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Prescription Appetite Suppressants

The National Health and Nutrition Examination Survey (NHANES
III) of 1988-1991 indicated that over one-third of the United States
population aged 20 years or older was overweight. Moreover, the
prevalence of overweight has increased over the past three decades.
Nearly 40% of American women and 24% of men are currently trying to reduce
their weight. The human and economic costs of obesity and its treatment
are also considerable. Over 280,000 deaths a year are attributable to
obesity, making it the second leading cause of death after smoking.[4]
Those attempting to lose weight spend approximately billion a year on
diet aids, foods, treatments, and exercise programs. These statistics
highlight the pressing need for better ways to prevent obesity and for
effective weight control therapies.

Obesity: Definition. The most commonly used definition of obesity is a
body mass index (BMI) of 27, which corresponds to 120% of desirable weight
for height. Significant weight loss is 5% or more of body weight and/or
a reduction of the BMI by one or more units. Successful long-term
weight maintenance is defined as maintaining either a goal weight or
weight lost during treatment for at least a year.

Risks of Obesity. Even when overweight is only slightly excessive (eg, BMI
25-27), biological malfunction and some chronic disease risks are
apparent. These include high blood pressure; hyperglycemia; dyslipidemia;
insulin resistance; gallstones; cholecystitis; osteoarthritis; gout; and
cancers of the endometrium, cervix, uterus, breast, and colon. Above
a BMI of 27 (or 120% of desirable weight), the presence of
obesity-associated chronic degenerative disease risks increases still
more, and the negative effects on body image, self-worth, social
interactions, and quality of life become even more apparent. Mortality
risks increase progressively as obesity rises above a BMI of 27. Above a
BMI of 30, most of the risks of chronic degenerative disease, orthopedic
problems, morbidity, and mortality caused or worsened by excess weight
increase sharply.
The massively obese (BMI [is greater than] 40) usually exhibit elevated
risks not only for mortality and several chronic degenerative diseases,
but for broken bones and bruises from falls. They may also frequently
experience pain on weight-bearing joints, sleep apnea, other respiratory
dysfunction, and greatly increased surgical risks.

Current Treatment for Obesity. Shape Up America! and the American Obesity
Association recently issued an algorithm summarizing the process of
assessment and choice of treatments for obese persons. Obesity
treatments should include both a weight loss and weight maintenance phase.
The most common methods used to treat obesity include hypocaloric diets to
decrease energy intake (de, nutrition counseling coupled with balanced
deficit diets or very low-calorie diets of [is less than] 800 kcal/d),
physical activity to increase energy output, and behavior modification to
modify lifestyles and manage eating. Drugs are used as adjuncts to
decrease hunger and / or increase satiety and thereby to assist in
achieving dietary compliance. Treatment of obesity is most effective when
it involves a combination of therapies; long-term results using any one of
these methods alone are poor. Because the root causes of obesity
usually involve a combination of socioeconomic, situational, b!
ehavioral, and cultural factors, these must also be addressed in its
therapy. If weight loss is sustained, it can improve both overall
health and decrease risk factors. When medical treatments for obesity
fail, surgical procedures, such as gastric bypass and gastric stapling,
are sometimes employed, especially when the obesity is severe enough to
damage health. One recent innovation for the treatment of obesity is the
advent of the newly approved prescription drugs to control weight. Weight
control drugs work by various mechanisms that include reducing hunger and
energy intake, enhancing satiety, altering metabolism, or preventing
absorption. This article focuses on one class of such medications, the
"second generation" of prescription drugs that operate on the central
nervous system (CNS) to reduce appetite and / or increase satiety. The
rationale for their use is that by reducing hunger and appetite or
increasing satiety, it becomes easier for the individual to control!
food intake and adhere to a reducing diet. As a consequence of better
adherence to hypocaloric diets, it is assumed that energy intake will fall
and weight will be lost. The modes of action, risks, and benefits, as well
as how and when these drugs should be used in obesity therapy, will be
discussed. For those drugs that have effects on risk factors for other
diseases, these aspects will also be examined.

PRESCRIPTION APPETITE SUPPRESSANTS

History of Appetite Suppressants. The amphetamines and other
first-generation anorectic agents became popular several decades ago.
Although weight losses were greater with than without drugs, they had
striking effects on mood, prescription and use were widespread and
indiscriminate, and the potential for abuse was soon evident. They
were classified as drugs with a potential for abuse that require state and
federal regulatory agencies to monitor prescribing patterns of physicians
and to investigate "overprescribers." By the mid-1970s, because of these
disadvantages, the drugs fell into disfavor as adjuncts to obesity
treatment. In the late 1980s, Weintraub et al., showed that
combinations of two existing anorectic drugs were far more efficacious in
bringing about weight loss, that losses were greater than with single
drugs, and that these drugs also had some efficacy during the phase of
weight maintenance.

During the early 1990s, several new second-generation anorectic drugs or
combinations of older drugs with less potential for abuse also became
available, and anorectic drugs again became popular. They are discussed in
this article.

Physiology: Appetite suppressants may be helpful both in accelerating the
rate of loss during the initial weight loss phase on a comprehensive
weight control program and in preventing weight regain once a healthier
weight has been reached.

Weight loss phase: Several short-term studies, most less than a year long,
show positive correlations between the use of many anorectic drugs and
weight loss, even after taking into account the effects of placebos and
other active therapies. All of the appetite suppressant drugs
available to date require continuous administration. This regimen is not
only costly, but it also increases the potential for polypharmacy and
drug-related side effects. For these reasons, monitoring is essential.
Weight losses appear to plateau after a period of approximately 4-6 months
on the drug, just as they do when conventional hypocaloric diets, physical
activity, exercise programs, or behavior modification are employed.
Efficacy of drug treatment in clinical use varies and is likely to be less
than that in experimental studies. In the experimental studies of drug
efficacy, weight losses were reported for all persons who were actively
taking the drugs, who had relatively high levels of adherence not only during the weight loss phase, but also during the
weight maintenance phase. In experimental studies, treatment was usually
provided free; in clinical practice, because obesity treatment is often
not covered by third-party insurance and must be paid for out-of-pocket,
adherence may be lower. In actual practice, efficacy may be less on
average, owing to a patient's lesser degree of adherence to drug therapy,
failure to adopt a hypo caloric diet, or failure to increase physical
activity. However, in individual instances, some persons will be more
successful because they experience greater than "average" effects of
weight loss.


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