Physican (not bariatrician) Weight Loss Program

(Plan using prescription weight loss drugs: Xenical, Meridia, Phentermine)

Type of Counseling: One-to-one, by a physician

Typical Cost: 500-1,000

Type Program: medically supervised

Type of Foods Used: regular grocery store food

At-Home or Direct Mail Plan Available? Not applicable

Summary

In general, regarding treatment for overweight persons, a doctor’s recommendations usually fall into one of these categories:

• BMI under 30: Dietary instruction with behavior modification and exercise. Addition of medications may be helpful for appropriate individuals.
• BMI over 30 (or over 27 with medical complications): Medically supervised protein sparing modified fasting program combining behavior modification, dietary instruction, and exercise. Alternatively, dietary instruction with a registered dietitian with medications (Orlistat® or Sibutramine®) used (as appropriate) as an adjunct to treatment.

Many physicians, squeezed by more competition, managed care, and lower reimbursement for Medicare patients, have sought ways to augment their income, and will continue to do so in the near future. Weight loss programs are a natural for them, since (according to some estimates) as much as 20% of their patients are seriously overweight.

Some physicians have developed their own programs, based on nutritional counseling, possibly in conjunction with a local registered dietitian or nutritionist, or a local health club or fitness center. Still others have obtained training and certification to practice bariatrics, whereby they may use a VLCD (very low calorie diet) and/or prescription drugs to suppress the appetite.

Based on our ongoing research and interviews with the large pharmaceutical firms, the American Society of Bariatric Physicians, the AMA, American Hospital Association, individual hospitals, and other sources, BestDietForMe.com analysts conservatively estimate that of the roughly 668,000 active physicians in the U.S., only about 5.6% are substantially involved in offering some form of weight loss program to their patients—or about 38,000. Most family practitioners are just not involved in weight loss, and medical school training does NOT include topics such as nutrition and obesity. MDs as a group are still not focused on obesity as a sub-specialty.

According to a year 2000 survey by the Centers for Disease Control, only 11.7% of consumers surveyed reported that a doctor, nurse or other health care professional had given them advice about losing weight.

Today there are only 4-5,000 physicians estimated to be writing prescriptions for phentermine, Meridia® or Xenical® on a DAILY basisthat is those MDs initiating treatment for obesity. Most of these MDs are bariatricians. That leaves many other physicians who are using: a fasting program, meal replacements, nutritional counseling combined with exercise, or some other type of program. Many find it easier simply to refer patients to a local Weight Watchers or other commercial diet program.

The Major Prescription Weight Loss Medications Used

There are three drugs currently approved for weight loss (although all the pharmaceutical manufacturers are investing lots of research and money to find the magic pill for obesity). The approved drugs are:

Sibutramine (Meridia®)
 This medication boosts feelings of fullness and satisfaction, which may help dieters consume less calories. Meridia is one of only two drugs (Orlistat® or Xenical® being the other) that are approved for usage up to two years. This is the good part. As for the negatives, this drug can raise your blood pressure and heart rate. It should not be taken if you have a history of heart disease or poorly controlled hypertension. Other common side effects include dry mouth, constipation and headache.

Orlistat (Xenical®)
 Xenical prevents enzymes in your digestive tract from breaking down fat molecules, so fats are eliminated from the body undigested. It may be an attractive option for persons who like to eat high-fat foods. Like Meridia, it is also approved for usage for up to two years. These are the positives. The negatives include some unpleasant side effects. The elimination of excess fat can cause severe diarrhea, abdominal pain, anal leakage and oily stools. Xenical also blocks the absorption of water and some vitamins (A, E, K) that your body needs to ward off chronic disease and perform effectively.

Phentermine (Adipex-P®, Faston®, Ionamin®)
 Phentermine affects levels of the appetite controlling brain chemicals serotonin and nor-epinephrine. This weight loss drug was first approved in 1973 and its safety and effectiveness are better understood than any other major diet medication. However, on the minus side, the FDA limits its use to just 8 weeks. In addition, in some persons it may cause dependency, especially when you increase the dosage in an attempt to maintain its effectiveness. Possible side effects also may include an increased heart rate.

Phentermine also became a household name during 1996-1997 when doctors began widely prescribing it in combination with fenfluramine. But the fen-phen cocktail ultimately was linked to serious heart-valve problems and the fenfluramine half, which was implicated as the troublemaker, was pulled from the market.

Phentermine continues to be used as an appetite suppressant. The drug accounts for about half of all weight –loss prescriptions, in part because it’s significantly cheaper than the other major FDA approved diet drugs, Meridia and Xenical. Insurance companies typically don’t cover diet pills.

Now, a handful of doctors have begun combining phentermine with other drugs, notably popular antidepressants such as Prozac®, Effexor®, and Celexa®. Side effects can include dry mouth, insomnia, headaches, and constipation. The drug combinations are considered an off label use and aren’t sanctioned by the FDA.

Among the most popular alternatives to prescription phen-fen is so-called herbal fen-phen, a mixture that combines St. John’s Wort, a flowering plant, and ephedra, an ancient Chinese herb. St John’s Wort mimics fenfluramine by acting on serotonin levels in the brain. Ephedra, a stimulant, mimics phentermine.

Drugs NOT approved for weight loss, but with weight loss as a byproduct of their use, include the following:

Glucophage (Metformin®)
 normally used to treat Type 2 diabetes.

Bupropion (Wellbutrin®)
 normally used as an antidepressant. Topiramate (Topamax®) and Zonisamide (Zonegran®)
 normally used to prevent epileptic seizures.

The Cost

There are basically two kinds of physicians when it comes to weight loss: dispensing MDs and non-dispensing MDs. The first group, such as bariatricians, can dispense obesity medications from their office. The second group of MDs will write a prescription for the drug and you get this filled at your pharmacy. The wholesale price of Meridia® (sibutramine) ranges from 3 to 90 per pill, taken once per day. Xenical® (Orlistat) costs about 1 per pill, taken 3 times a day. Phentermine is another commonly prescribed obesity drug. However, it is available in a variety generic forms at a much less expensive price, usually .26 to .45 per pill, taken one to two times per day. Consequently, you will spend an average of about 27 per month for Phentermine and 90 to 100 per month for Xenical and Meridia.

Of course, when you begin treatment with your doctor, you’ll need a complete physical and assessment that will usually cost about 250. You’ll also need monthly lab tests at about 50 each. You’ll also need at least one follow up visit per month, usually 50 per visit. Adding all of this up, for a 3-4 month weight loss plan involving drugs prescribed by your physician you can expect to pay about 850.

Comment

Traditionally, doctors have not had the time to counsel their patients in depth about smoking cessation or losing weight. And, the psychological/emotional issues related to obesity, which are crucial, are not usually handled by busy MDs. Will doctors, increasingly squeezed by managed care and growing caseloads under HMOs, have the time to motivate, cajole, counsel and offer the peer support that commercial weight loss organizations such as Weight Watchers, Jenny Craig, or eDiets.com offer? BestDietForMe.com analysts are doubtful.

This is where physicians fall short. With commercial weight loss centers and diet websites, you can speak with a counselor often and in a variety of ways (phone, email, chat rooms, etc.) Many such programs encourage you to contact them at least 1-3 times a week. Most dieters need this frequent, ongoing support. However, most doctors’ practices are not set up to provide this frequent communication and feedback to you, with the exception of bariatricians.

Physicians today, not surprisingly, have dozens of appointments per day and are squeezed for time. Therefore, don’t expect to get any nutritional counseling or motivational support involving things like how to avoid overeating triggers, strategies for dining out, stress management, emotional eating, portion control, etc. Rather, your doctor will most likely refer you to another specialist such as a dietitian, a nutritionist, or a psychologist. Of course, you won’t get an exercise program from your doctor either. This is left up to you. In this respect, in our opinion, using your doctor just to get a prescription for weight loss drugs is a very incomplete weight loss program.

Prescribing diet drugs can become a cash cow for many doctors whose incomes have been squeezed by managed care. The diet industry sometimes also attracts doctors with troubled pasts. Penalties for dispensing bad weight loss counseling are rare and minor. They may keep physicians out of insurance plans, but that doesn’t matter much in the weight loss and other optional medical services, since insurers sometimes do not cover diet plans and patients pay their doctors out-of-pocket.

If you have a doctor you can trust, that you feel comfortable with, and you meet the criteria for safe use of weight loss medications, then this type of regimen may be for you. However, one should be extremely wary of physicians who perform a superficial exam and act as little more than diet drug prescription mills. Obviously, BestDietForMe.com analysts do not recommend purchasing black market diet drugs over the Internet, without any medical supervision or personal exams or consultations. This is asking for major trouble.

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