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Diet Drugs Work: Why Won’t Doctors Prescribe Them? (newyorker.com)
42 points by dsr12 on Dec 5, 2013 | hide | past | favorite | 98 comments

More relevant questions:

- Why don't we stop subsidizing corn so much?

- Why don't we teach effective nutrition and cooking in school?

- Why don't we teach effective exercise, sports, and fitness in schools?

- If we can ban alcohol and tobacco sales to children, why not things like added sugar, hydrogenated oils, corn syrup, etc?

- If we can ban alcohol and tobacco advertising to children, why not products with added sugar, hydrogenated oils, corn syrup, etc?

- Why don't we limit advertising on fast and junk "food"?

- Why don't we provide healthy lunches to school children instead of using them to subsidize agricultural conglomerates for low quality food?

- Why don't we stop subsidizing fossil fuels so much so people would walk and ride bikes more?

- Why don't we align our medical system with prevention instead of expensive and risky cures?

You can come up with plenty more questions that would mostly obviate the need to wonder about obesity and wonder drugs to cure it. The overwhelming majority of people would benefit from changes in diet and exercise requiring no chemicals needing FDA approval. Fresh fruits and vegetables seasoned with fresh herbs and spices taste better than anything, at least to me, and it's hard to eat too much of them. Few feelings feel better than the exhaustion of even moderate exercise.

EDIT: reduced cynicism based on eli's welcome comment.

Obviously preventative measures should be our first resort. Obviously all farm subsidize (or at least those that are not in alignment with a healthy population) should be ended.

But I take issue with banning sugary, hydrogenated things. The problem with the modern diet isn't that a kid drinks a Coca Cola with his McDonald's fries once a month when he goes out for a treat with his mom after swim practice. The problem is that the poor lack both the skills, the time, and the money to prepare healthy and tasty food. I made homemade beef chutney last night. Mango, two different types of onions, red peppers, other peppers, etc. It was delicious. Cost about $4 or $5 per person just in food, not counting my Wustof knives or $200 non-teflon non-stick pan.

Kraft dinner would have taken 1/10th the time, at 1/5th the cost, with absolutely no knowledge or skill. If we want the poor to eat healthier we need to show them options that are cheap, easy, and fast. Tuna fish on Rye with an orange. That type of thing.

Slow cookers and mason jars are an extremely economical way in both time and money for poor people to eat well. Armed with a 6-9 quart cast iron slow cooker and maybe 2-3 evenings a week with minimal attention after mis-en-place, you can eat very well, very cheaply. Plus, the food you prepare reheats very well and stores well in mason jars in the fridge or freezer.

You can go well beyond a slow cooker in time and money with a one time purchase of a solid pressure cooker. I have a 21-qt All American that I can produce tasty brown and black bean based meals at less than the cost of the Mac-n-Cheese. I'd cook about 15 quarts of beans in one evening, freeze 12 and eat the other 3 over the next few days.

If you were to ban ready-to-eat foods high in sugar and hydrogenated fats, you'd force people to learn about these alternatives. The benefit of banning is that it eliminates the path of least resistance where people remain ignorant of alternatives.

If people still want sweet foods and other things that are bad for them, they can still have them, but they have to do some work by cooking those sweet things themselves.

I guess I'd rather have freedom than less obesity around me.

Even if you are right, and the only way for people to learn about slow cookers is by banning McDonalds / Chinese take out, I still wouldn't do it.

Although the slow cooker is a pretty good idea.

Actually, I'm not in favor of banning either. I'd much prefer starting with first eliminating any and all benefits companies that produce unhealthy food enjoy, starting with farm subsidies that greatly disadvantage healthy foods like fruits and vegetables.

Once that is done, I would take items that are known health hazards and classifying them as toxic for consumption such as HFCs and hydrogenated oils. They are basically slow acting poisons. You would still be able to buy them and use them in your own home as an individual citizen, but food companies cannot buy them and use them to make food. Instead they need to use the healthier alternatives by default. This way all the junk food we enjoy today would still exist, but we would mitigate how unhealthy they are for us, since food companies would have to use the least unhealthy recipe possible.

I see this as reasonable since it preserves individual freedom, but prevents corporations, which have a fiduciary duty to psychopathy, from producing maximally unhealthy foods in search of a profit.

If those least unhealthy options were still economically attractive to the poor after the elimination of food subsidies and classification of cheaper, less healthy substances as unfit as an ingredient in manufactured foods, I would then look into how to incent people to choosing the healthier alternatives.

I think the best option here would be to make it easy for a family to acquire a cheap slow cooker and recipes and subsidize a ready-made pack of food that contains spices and other bulk ingredients used in the slow cooker recipes. The latter option is already done in Brazil under the name "cesta basica". Here's an image of the foods included in the "cesta basica"


You can feed an entire very well for very cheap on it. It's also available to everyone regardless of income.

I hear this kind of argument all the time and I don't buy it at all. How do poor people have less time to cook than well off people? We all work the same hours.

Pasta costs next to nothing, as does rice, as do beans. Veg and dairy are a bit more but still cheap by any standards. Cigarettes and alcohol, on the other hand, are expensive. As is running a car, or going to McDonalds.

So maybe try subsidising your meals by smoking less, or drinking less, or eating out less, or walking more.

   How do poor people have less time to cook than well off people? We all work the same hours.
No, we don't all work the same hours. Maybe you're one of those hackers who works 80-hour weeks by choice, but even then, there's a big difference between working 80 hours because you can, and needing to work 60-80 hours at 2 or 3 different minimum-wage jobs (unlike most people) to make enough to get by.

But not all poor people are like that, so what about the ones who have jobs with regular full-time hours, or less than full-time? Well, a lot of their time might be spent looking for another job, or some other way to supplement their income, that you, with your good income, don't have to worry about. That's time they can't spend cooking or thinking about how to cook well. And if they can't afford a car? Walking to whatever job they have, which you apparently think would be an unadulterated good for them, probably takes a lot longer than driving would- less time to cook or eat well. And in bad weather it may be impossible, meaning that they have to take public transportation, because that's all they can afford right now, even though it's more expensive that owning a car in the long run- again, less money they can spend on food, and still less time than if they had their own vehicle.

And add to all of that the psychological toll of knowing that you in poverty and exercising the willpower to deal with all of the above problems and others that come with poverty, and it's freakin' hard to find both the time and mental energy to figure out how to eat both healthy and cheap.

Man, you need to adjust your privileged-lifestyle viewpoint.

Ever try to buy groceries without a car? How much time would you add to your day if you had to take the bus from work to the supermarket, and then the bus back to your house. A 15 minute 2 stop car trip becomes an hour+ with all the waiting, shuffling to and from the bus stop, etc.

Also, ever notice how those big supermarkets with the cheap prices aren't really present in poor neighbourhoods? All you can find are cheap bodegas and convenience stores in those neighbourhoods.

Finally, a lot of poor people have 2 jobs or try to get as much overtime as they can to supplement their income, so 'We all work the same hours.' is a bit of a fallacy.

Yeah, I've tried to do all those things. And no, I haven't noticed that I can't go to town and by fresh fruit and veg from the market or supermarket for less than a 4-pack.

  Finally, a lot of poor people have 2 jobs or try to get as much overtime as they can to supplement their income, so 'We all work the same hours.' is a bit of a fallacy.
Yeah, whatever. Plenty of my friends seem to manage just fine. I managed just fine back in the day.

> I hear this kind of argument all the time and I don't buy it at all. How do poor people have less time to cook than well off people? We all work the same hours.

This is almost undoubtedly false. 40 hours at the federal minimum wage doesn't come anywhere close to providing a livable income, particularly if the person is supporting a family; many low-income workers work multiple jobs.

Perhaps they should just eat cake... "We all work the same hours" I'm sure you work 2-3 jobs at minimum wage to keep things going and rent paid. The dollar menu at McDonalds looks a lot more attractive than cooking when you've barely got money for food or the time to prepare it.

Eating well is relatively Expensive. Sure you can cut out the car and carbs and obviously all poor people have their liquor and smoke money set aside... Or maybe poverty is a bit more complex than your overly simplistic and a bit dickish analysis... Just let them eat cake (Preferably gluten free)...

A better word than "time" is probably energy. Also, the GP added skills and money to the list.

To make good food on the cheap, you need a bit of equipment and you need an upfront investment in spices and staples, all of which are significantly cheaper in the long run in bulk. Besides the investment, you need to plan long term, something the poor often struggle with (being poor is rarely only a question of lacking money).

With that in mind, it's pretty naïve to expect banning marketing to achieve much improvement in poor people's diets.

We've known for a while that there's a correlation between lack of planning and poverty. It's always been assumed that the lack of planning skills causes poverty, but recent studies are starting to show that it's often the other way around: poverty causes a huge amount of stress, which significantly limits the ability of a person to plan well.

All work the same hours? Not if you're working two part-time jobs because that's what you can get.

Not to mention the difference in commute time between owning a car versus taking a bus and walking in many areas. It takes me fifteen minutes to get to work; if I took the available buses it would be nearly three hours each way.

(We'll leave aside whether cheap pasta and rice are actually healthy eating.)

"Why don't we stop subsidizing corn so much?" Lobbyists.

"Why don't we teach effective nutrition and cooking in school?" We do. It's called home economics.

"Why don't we teach effective exercise, sports, and fitness in schools?" We do. It's called gym.

"If we can ban alcohol and tobacco sales to children, why not things like added sugar, hydrogenated oils, corn syrup, etc?" Go tell a 6 year old they can't have cake on their birthday.

"If we can ban alcohol and tobacco advertising to children, why not products with added sugar, hydrogenated oils, corn syrup, etc?" Lobbyists

"Why don't we limit advertising on fast and junk "food"?" Lobbyists

"Why don't we provide healthy lunches to school children instead of using them to subsidize agricultural conglomerates for low quality food?" We kinda do: http://www.fns.usda.gov/nslp/national-school-lunch-program

"Why don't we stop subsidizing fossil fuels so much so people would walk and ride bikes more?" How many times do I have to say this: LOBBYISTS.

"Why don't we align our medical system with prevention instead of expensive and risky cures?" That's a good question, actually.

EDIT: I like falcolas' answer: Money. Long term care is more profitable than prevention.

"Why don't we teach effective exercise, sports, and fitness in schools?" We do. It's called gym.

Um no, and that's part of the problem. In my experience, gym class was a Hunger Games like spectacle for the athletically (but not otherwise) gifted to enjoy their brief decade in the sun at the expense of those who will peak much later in life (but of course, they're more likely to be sedentary in part because of such a negative early impression of physical activity). Evidence? Do I need to mention anything else beyond Shirts vs. Skins Battle Ball? What kind of %$*!ing psychotic thought this sounded like a good idea at the time?

"Why don't we align our medical system with prevention instead of expensive and risky cures?" That's a good question, actually.

No money in it for big pharma, a segment increasingly under attack from the FDA for many of its practices and for which many critical drugs are facing patent expiration. So now they're trying to play good guy by increasingly focusing on orphan diseases ($10K to $500K/year per patient) where if someone blocks a promising therapy, its entire population of victims is doomed. And since these are the long-tail, it also creates an effective barrier to entry for smaller competitors.

I'm sorry your gym experience was so terrible. Mine wasn't great either. That said, the poor state of gym now is no reason to eliminate it all together. We need to reform it.

Absolutely, an ex-girlfriend knocked some sense into me in my early 20s and I've been in great shape ever since. There's probably a fantastic company in doing exactly what you propose and I'd love to be a part of it.

But a lot of tenured gym teachers I've met as an adult are the same people who were tormentor jocks in their childhood. So I've never moved further on it.

How do you propose reforming it with people like that blocking the way? Because I think America needs an intervention, Europe isn't far behind, and Asia is doing its level best to catch up right now.

There were a bunch of absolutely awesome ads in the subways of Hong Kong last year that showed a woman's flabby mid-section with a timebomb strapped to it. Contrast this with last week's Facebook kerfuffle between Maria Kang and Curvy Girl which demonstrated (to me) that anything but the most vanilla criticism of this situation in the US is apparently hate speech. Gag me.

> "Why don't we align our medical system with prevention instead of expensive and risky cures?" That's a good question, actually.

Money. Long term care is more profitable than prevention.

Lobbyists can't be the whole answer; tobacco hasn't had lack of lobbyists or lack of quality of lobbyists, but it got severely restricted.

In the end I think the answer is "because we, society, allow it.". It is very hard to lobby for things we really do not want.

Ultimately, this is the real answer. We can overcome anything if the political will exists.

You seem very willing to wish away the structural power of money by blaming the middleman. This is rather like blaming maggots for death.

Na, I'm with you on the money thing. Lobbyists are just a symptom of the winner-take-all economic system we've got here. That said, it's probably more realistic to control the symptoms right now than try to reform our entire economy.

You could probably answer every question with "People in power use their fortunes to preserve power" and you'd nail it 90% of the time.

I'd say instead that it was a symptom of the money-controls-resources economic system.

Basically, thought experiment: imagine a population where everyone starts with a fixed N dollars. Random-walk each dollar a few iterations and you end up with a bell curve of money distribution. Now start again and instead of random-walking them, apply a probabilistic walk, where having more dollars makes you a proportionately more likely recipient. You end up with a skewed distribution with a few rich controlling most of the resources. Now imagine being a congress-critter in that skewed world. Who are you going to have to cut deals with? And you can make the rich-get-richer rule steeper now, because the dollar-owners are cutting deals to make dollar-taking easier. And now your wealth distribution looks like the real world.

The answer is simply that money itself, the alienable control of resources, is the cause. In a society organized by money, corruption and misrule will result. Any "symptom control" amounts to pumping the distribution flatter - it's a sisyphean task, structurally opposed to the power that money creates, and hence metastable at best.

As far as nutrition goes what the government thinks is a nutritious lunch is far from it. It's way to pro carb/starch/sugar and anti fat. A typical lunch when I was in High School would be a decent sized slice of pizza, piece of bread, a scoop of corn, a sugary milk. All of those are carb sources.

The guidelines have changed. The school lunch program is putting more emphasis on fruits, vegetables, and whole grains. That said, it's still not perfect, and not every school participates, hence "we kinda do."

I know they are getting better. My school in WV participated. When inspectors came in they shut down the school store that sold chips, rice crispy treats, pop. Also a lady in the basement sold giant grease soaked pepperoni roles except when the inspectors came. All of the other soft drink machines were turned off on those days too. My wife's High School in Ohio had an ice cream sundae bar...

"Why don't we teach effective exercise, sports, and fitness in schools?" We do. It's called gym.

Maybe you had better gym classes than me, but mine were tedious and boring and turned me (along with most other "nerds" in my class) off from sport until I reached high school and discovered weight lifting. I always liked Kelly Starrett's motto of "all human beings should be able to perform basic maintenance on themselves" and I wish that point was more emphasized during physical education.

> "Why don't we teach effective nutrition and cooking in school?" We do. It's called home economics.

I don't know of many schools in my state that still have the budget to provide a home economics class/pay a teacher to teach it. The most my school went into nutrition was in the 1 semester of health class that everyone took.

In Belgium, the biggest health-insurance provider (and probably others) subsidizes sports club membership fees, gym subscriptions, ....

Their goal is to reduce the cost of treatment by encouraging prevention. I'm not sure how many people make use of it.

Most private insurers provide this option in the US as well.

Not sure why you are so cynical. It seems like there's pretty clear progressive movement on several issues. I never thought I'd see a black president in my lifetime.

I don't see him as being cynical. I think these are questions worth asking given that the OP is asking why diet pills aren't prescribed.

It's looking at a problem in a systemic way rather than isolated events, at least according to me.

Allowing the prescription of diet pills treats the symptom and not the cause.

Anecdotally I've been overweight most of my life and it is only through a change in lifestyle (cycling to work and a shift to low carb diet i.e. low sugar) that I have seen significant weight loss.

That's not to say prescription diet pills wouldn't work, but without underlying lifestyle changes I would expect the person to using the pills to be going on and off them for the rest of their life.

"it is only through a change in lifestyle"

And that's the difficult thing people aren't willing to do. Taking a pill might help for the near term (we are so short sighted these days!) but it won't address the long term. "I've been taking this pill so now I'm not overweight [so now] I don't need to take the stairs over the elevator!" A few years later, you might not be overweight but you still aren't healthy!

"it is only through a change in lifestyle"

Reminds me of a coworker that complains about his financial situation. He complains about not making enough money and thinking that if he made more then he'd be able to "pay his bills and get ahead"... that might work for the short term, but without a change in how he handles money he's going to end up as "poor" as he is now.

(Preface: He makes more than the average American, this isn't about true poverty) If you live paycheck to paycheck because you are unwilling to make the difficult change in your lifestyle by living slightly under your income level in an effort to pay off debt and save for the future, you will continue to live paycheck to paycheck after you get a raise (that you claim is what you need to "get ahead"). If you spend what you make, you'll just spend more when you make more.

Discipline. It's not easy.

Most of the measures you suggest seem to be centred around teaching children, conditioning children and banning things from children.

However, I think we need to think more about why people overeat, and then address that problem directly. It's closely related to why they smoke, why they gamble, why they take drugs, even why they swear. It's not just a health issue. Trying to coerce people into being 'virtuous' often has the opposite effect to that intended: one of the reasons why teens smoke and swear is seemingly because they know that authority figures don't like them to, for instance. Trying to live up to the expectations of other people is tiring and stressful; people look for ways to relieve that stress -- guess what they choose.

There are two major things missing from your list.

First: the lipostat mechanism needs fixing, because evolution built what worked, not what would be ideal. Exposure to overeating should not result in a life sentence of obesity.

Second: replace capitalism. There is a reason why there are food deserts, why people have to make the choice of nutrition versus quantity, why people aren't educated on nutrition, why people don't have the time or emotional energy to work at food after they've done working at work, and it's capitalism. Or more precisely, any money-and-work economy. Capitalism just makes it run wildly out of control.

The NY Daily News demonstrated that the "food desert" concept is mostly a myth.


edit: Also NY Times, if that is a more authoritative source for some.


Mostly obviate my foot.

The number of issues that would need addressing to make it possible for everyone to eat a healthy diet (hell how do we go about making cheap, convenient, healthy food on such a scale?) vastly exceeds the number involved in coming up with post-hoc remedies.

More relevant questions are surely those which enable us to do something about the problem in the foreseeable future (such as diet pills) rather than pondering about how things could be better if we were able to solve dozens of complex issues over an unrealistically short timespan?

"how do we go about making cheap, convenient, healthy food on such a scale?"

We need people to stop worrying about "casual gaming at scale" and start worrying about "living a good life at scale".

It's just that, there's not usually as much profit in the solutions that actually work or matter.

> We need people to stop worrying about "casual gaming at scale" and start worrying about "living a good life at scale".

I'm a healthy male in my 20's, I eat well and exercise regularly. I'd be PISSED if everyone stopped working on games and tried to solve all the eating problems of my friends because they're too lazy to do it themselves, instead of catering to what people who already try to live healthily want to do.

Don't we already have cheap convenient healthy food?

I mostly eat tacos for dinner, beans, occasionaly rice, random vegetables, a little bit of hot sauce, sometimes eggs.

Its cheaper than mcdonalds and takes about 5 minutes to make.

I've been looking for a way to make vegetables like brocoli or green beans palatable. What's your secret?

Two suggestions, slightly contradictory, but either will work:

1.) Spices. there are loads of really interesting, amazing spices out there, but even a simple sautée of olive oil, lemon juice, garlic, salt, and black pepper can make almost any vegetable taste amazing.

2.) Stop eating over-flavoured foods. Doritos etc. have a ridiculous amount of flavouring; if you eat foods like this consistently then you'll desensitise your palette to the subtler but still absolutely lovely tastes of vegetables, in the same way that staring into a spotlight makes it difficult to appreciate the aesthetic qualities of twilight. You can't re-sensitise your palette by simply cutting down on hyperflavoured food; you need to eliminate it almost completely. After a while, you'll discover that brocoli and green beans are wonderful, and Doritos are absolutely brutal on the tongue.

This is great advice, and worked for me beautifully since I stopped smoking and started eating at home with my wife. +1

Roasting helps add flavor. (Maillard reaction.) So do spices/herbs.Don't overcook. (Also butter, of course, but I assume the goal here is to keep it healthy.)

Roasting definitely helps, and I don't worry too much about how much olive oil I coat vegetables with.

For example, I'll roast some cauliflower for 45 minutes, and then I can eat it like that or mash it like potatoes (tastes way better than mashed potatoes to me).

String beans I'll coat with olive oil and chipotle powder and that tastes great.

I think the real question is: how are they unpalatable now?

I ask because taste bud response varies; one common reference is the supertaster-taster-nontaster continuum, which is focused on perception of bitter component found in some vegetables.

If you're a supertaster, you might not be able to do anything to make them completely acceptable to you; they're always going to be a bit over-bitter. Hate to say it, but cheese, butter, and gentle use of honey may be your best bets.

On the other hand, if you're a taster, the suggestions here will help... and if you're a non-taster like me, you might discover that fresher -- and weirder -- produce has a more intense flavor that you enjoy, though you might need to acquire a taste for it.

Boil some water, throw the green beans in for just a couple minutes. Remove the beans and put them in a colander to dry. Mince and fry a shallot (or onion) in oil or butter. Throw in the beans, chopped walnuts, and a little bit of feta cheese. Salt to taste (salt is often the difference between bland and tasty).

If you cut out junk food they'll taste better. Don't over cook.

Starting with broccolini instead of broccoli and haricots verts instead of green beans goes a long way. They cost more though.

he / she covers them in cheese

Why don't we live on soylent hooked up to our computers in nice safe plastic bubbles?

> Why don't we stop subsidizing corn so much?

Because corn has at least some value, and letting the land lay fallow would cost the tax payer even more (though that is sometimes subsidized too) in order to maintain the stabilization?

Or are you suggesting that farms don't need the stabilization program at all? As a farmer who farms in a country without subsidies, I would agree with that, but I understand the reasons why Americans value the program when you look at it from a threat of war point of view.

It's as much about the unhealthy lifestyles which are promoted as it is about the "internet" society we live in. People simply want something right now. They don't want to go to the gym and do the hard work and lose those 10lbs over say six to eight months. They want to take a pill so they can lose 10-20lbs over two months.

It's like anything in life. You have to put in the hard work to get the results you want. I feel like giving people a pill is taking the easy way out.

One should avoid falling into the trap of thoughtlessly shunning quick, easy solutions.

>They don't want to go to the gym and do the hard work and lose those 10lbs over say six to eight months.

I wouldn't want to do that, either. That's miserably slow. A pound per week (which is a fairly slow weight loss, equivalent to a roughly 500 Calorie/day deficit) loses you about 24 pounds in 6 months. Two pounds per week is still well within the healthy range and gets you nearly 50 pounds lost in 6 months.

10lbs over say six to eight months.

That's a long time. Go keto and drop 5 pounds a week.

When you're addicted to sugar, fresh fruit and vegetables won't taste as good - so it's a catch 22 - people will have to go through a shift, however I think it would help for them to hear or know that is what's going on.

It's worth pointing out that "losing weight" isn't a panacea for health. Yes, it would almost certainly be a very good thing for significantly overweight and obese individuals to shed pounds, period, but the article doesn't address the fact that in and of itself this is unlikely to make them "healthy."

There are lots of people who are not overweight who have many of the same cardiovascular issues commonly associated with obesity (high cholesterol and blood pressure, insulin resistance, etc.).

If the goal is overall health and well-being, the title of this article is arguably misleading. Diet drugs might "work" when it comes to weight reduction, but it would be unrealistic to ignore the fact that without real lifestyle changes (diet, exercise), many of those who use them will likely be plagued by the same serious health issues.

Finally a well thought out comment. One of the big issues I see with obesity is that the problem is oversimplified, as are the solutions. I know of several people on whom counter-obesity problems have had a significantly detrimental effect.

I've seen ineffective gastric bypass surgery which led to a friend gaining even more weight and watched helplessly as he slipped into a very depressed and negative state. As the article points out, if someone said there's a drug that just cures cancer it would be laughable. It is indeed so with weight loss. Phentermine will have minor side effects with impulse control, addiction, paranoia etc.

Interestingly enough, obesity is typically not associated with the "poor" in the rest of the world. I have often heard it mentioned as an anecdote to how "wealthy" Americans really are. But therein lies a very interesting problem to which I simply haven't seen a very good answer. Unfortunately the sigtma associated with obesity and the well entrenched and highly profitable "weight-loss" industry gets in the way of significant advances being made in this arena. Again, as is mentioned in the article, there is even a stigma associated with "diet doctors", which surely has dissuaded more than a few brilliant minds to explore the field more.

Ofcourse, as a programmer who is very familiar with a sedentary lifestyle and the pizza culture, obesity is a serious issues that does affect more than just the poor. And for crying out loud, I hope someone figures out more about it than pseudo science of obesity we have now. It's not as simple as it looks at first glance.

Thank you, I couldn't believe there wasn't a quoted doctor somewhere in the article bringing up this point.

I'm not overweight, but I know I don't get quite enough exercise right now either. My blood pressure and cholesterol levels are a bit higher than normal. Nothing concerning yet, but if I let it go on like this for another decade it won't matter if I'm not technically overweight. I'll still be unhealthy and facing similar cardiovascular/metabolic problems. These things can't be solved by a diet pill.

This is an interesting issue. If you're morbidly obese, a 5-10% reduction in weight could add up to significant LBs/KGs lost. So it would seem to me like this would be a great way to jumpstart and re-enforce the other aspects of weight loss. Many people give up because they don't see results fast enough.

So much of weight loss is mis-understood, but a lot of it boils down to convenience, will power (choosing to resist going through McDonalds drive thru), food choices (i.e. I don't know how to cook, and no healthy options are affordable and quick).

I am a firm believer that weight loss is 75+% diet, and the rest exercise (disclaimer: I lost 30lbs [17% bodyweight] doing the 4 hour body diet).

A major point of the article is that obesity is not a single disease, it is many different diseases. It might be one of various neurological, psychological, endocrinological or digestive problems, or a combination of several. Not surprisingly, cure or mitigation will differ from individual to individual based on the underlying problem.

IOW, what works for you may or may not work for others.

I have the opposite problem - can't gain weight. Doesn't matter if I eat more or less, what kind of food, how many times a day and if I am training or not - it just stays the same no matter what. Recently it's been even worse - a simple 2 hour exercise would leave me with -1 kg and I had to wait like 4 days to gain back that 1 kg lost in one exercise. I think the hormones almost singlehandedly decides what you look like. I knew people that were obese and gained weight simply by drinking water and not eating anything. I thought maybe "survival instinct" would help me gain at least fat, where it supposedly activates when you are eating very little, and that is supposed to be the reason why not eating does not help fat people lose weight, but my weight even then just stays the same. I occasionally go for a whole day without eating (not intentionally) and never start to gain fat. It's really frustrating. Sometimes I just wish I could be fat and just go to gym.

Honestly most people I know who say they have this problem aren't eating as much as they believe. We call these people "hard gainers". If you have that much trouble gaining weight then try eating 6000 calories a day and tell me you don't put on any weight.

Honestly the problem is I don't have time to eat that much. I'd have to devote all the time to this single one activity - eating, making food and thinking what to eat next. Others just live eating same as me and gain weight no problem. Besides, if there's not enough growth hormones in the blood, you can eat as much as you want, nothing will stay in your body.

I'm curious what you're eating and when. Even my skinniest friends I've seen them gain weight when they started changing their diets. Lot of it is they may eat ice cream and other fatty foods, but not very much. Look into why we get fat by gary taube. Talks about the science of weight a lot. Insulin response being a key factor.

Currently I barely eat at all tbh. Because I found out it doesn't seem to matter anyway. Only difference is when I eat much I shit unproportionally more often.

Weight loss is all diet. Exercise just helps the process.

Because they "cause side effects and yield undramatic results."

Doctors are protected from the consequences of prescribing statins and SSRIs because everybody else does it too. If you could get a critical mass of them to start prescribing diet pills by directly generating consumer demand, the floodgates would open. We're one good advertising campaign from everybody 5% overweight having a bottle in the bathroom - of a 'new' formulation of course, because I'm sure a lot of these are going out of patent.

Then we'll find out that they really don't work any better than placebo and cause nerve damage, but the lawsuits will drag until all patents expire.

>The drugs work by suppressing appetite, by increasing metabolism, and by other mechanisms that are not yet fully understood.

Why would FDA approve something which it we don't fully understand?

I think you'd be shocked by how little we understand about the mechanism of action of a lot of the drugs out there.

The FDA's job is to ensure that approved drugs are (1) safe and (2) efficacious. Knowing the mechanism of action (MOA) of a drug can help further define the safety/efficacy parameters for a drug, but in it's absence you can still get a very good sense of the risk benefit analysis.

The best example of a lack of understanding of drug MOAs is Lyrica (epilepsy drug from Pfizer). The drug was designed to target the GABAase enzyme. It got approved and then several years later it was realized that the main MAO is the drug's impact on the glutamate neurotransmitter, an entirely different MOA.

There are many drugs where this is true. Antidepressants, especially.


I was going to say this. Most antidepressants are not really understood. Also I have central sleep apnea (brain forgets to breath when sleeping). They give me a machine but they don't know exactly why the machine helps but it does. It's approved for use.

Because you don't need to understand the mechanism of a drug to have a strong understanding of the effects of a drug. Numerous widely proscribed psychiatric drugs have at best conjectured mechanisms of action.

We also don't understand the mechanisms of a very large number of the drugs we use (e.g. anesthetics).

So, what do you think would be the costs and benefits of waiting to approve a drug until we fully understood how produced it's intended effects? Clearly waiting until we understood every possible interaction for a drug would prevent any sort of mistake, but I'm not aware that we understand any drug in that detail. I hope you wouldn't suggest we abandon antibiotics because theres a chance that any given person taking one for the first time might have a unique allergic reaction.

My best guess on the numbers is that waiting to understand all drugs mechanisms beyond existing testing would, over the course of the FDA's history, have saved dozens of lives at the cost of failing to save millions.

Because they're ultimately beholden to big business? I mean, we have no idea how many drugs work yet the FDA goes after 23andme and other organizations (selling stevia as a sweetner before they allowed it recently, etc), etc with questionable motives. I think there's an obvious double standard when it comes to big pharma.

I'm not attacking the FDA per se, but the entire USG. It seems like the buck stops with congress and congress is simply beholden to their financial backers. It doesn't help that SCOTUS is largely conservative (money is speech, citizens united, etc) and the POTUS's direction of the FDA is mystifying as well.

Ultimately beholden to big business? Tell that to all the drug companies who have either had their drug denied by the FDA or pulled after approval [1].


They played the game wrong. There are counter examples of drugs that should never have been approved rushed to approval.

I think my example is pretty good evidence that the FDA isn't "beholden to big business".

Really? The FDA just removed safety warnings from Avandia based on new safety data.


I'm not arguing that drugs get approved that shouldn't. My argument is that the FDA is not beholden to the pharma industry. Do the pharma industry lie sometimes and drug get approved? Sure, but that's not "beholden".

Another reason that's not touched upon in the article is that many of these drugs are Schedule IV drugs. While prescribing a Schedule IV isn't theoretically more onerous than prescribing antibiotics, often pharmacy chains, insurances, and the government can combine to make busy primary care doctors less likely to prescribe them.

I know many a PCP that rage at the fact that Phentermine is schedule IV, which adds extra complexity to prescribing it.

If you want to see a biotech start-up working on a very interesting obesity drug, check out http://zafgen.com/

They just release the results from their Phase 2a trial and results are amazing. After 12 weeks on the highest dose, patients lost an average of 24 lbs, which is competitive with bariatric surgery.

If the drug makes it to approval, it could be a real game changer for the healthcare system.

Couldn't another part of the problem simply be lack of marketing for these drugs?

Everyone is aware there are goto drugs to toenail fungus and restless leg syndrome from all of the commercials. Shouldn't drugs like these that apply to even more people be all over the airwaves?

I suppose it is potentially, but I have to assume that the people in the pharmaceutical industry understand which drugs they should market (and how, and when) to make the most money. To me it seems that "diet drugs" would basically print money from them, but my point is I believe there is a reason for them doing what they are doing, and that if they calculated they would make that much money, you better believe that they would pour truckloads of money into advertising.

Still, it just seems so odd, given the rather... large potential market.

This is actually a relevant point. Both Qnexa and Belviq were only recently approved. The companies who got them approved are pretty small and don't have the backing of a massive pharma company to help them with marketing.

In fact, the maker of Qnexa, Vivus, has had 3 CEOs over the past year and they are getting a lot of flack from shareholders over not putting in enough effort to market the drug.

The answer is simple. A doctor won't be sued for not giving an obese person diet pills. These drugs aren't very effective, and they have side effects such as raising blood pressure. A typical doctor will just tell you to be more active and eat less.

Because there's nothing wrong. The ability to store energy as fat is a natural survival mechanism. Your body doesn't care about looking good on the beach, it knows that Winter Is Coming and it's tooling up to deal with it.

Because the markets have been flooded with either snake oil products or unproven chemicals like ephedra. Nothing is a replacement for diet and exercise. Diet drugs should be used in tandem with proper diet and exercise.

>Nothing is a replacement for diet and exercise.

I don't know why people say this. The benefits of exercise are simply initiating biochemical processes that cause your body to grow and become more efficient (drugs that target the SIRT1 gene are an example). There's absolutely no reason why we can't develop drugs that initiate that same process. Same goes for preventing fat accumulation. Claiming that there's no substitute is a cop-out and its an unfounded assumption.

For some people its simply an over indulgence problem. You could easily counter by saying why don't people just throw up after eating problem solved. Yet in my experience quick fixes often have other consequences that may not be immediately known. I don't believe you can simulate complex bio mechanical processes like muscle tearing but you may be able to allow you body to be more efficient when you do these things.

Would anyone be able to give or link to a summary of the four drugs it mentions? How would a person evaluate which would be the best one to try?

Here is what Dr. Joel Fuhrman, M.D. has to say about weight loss: http://www.drfuhrman.com/weightloss/

Articles like these are so sad to see. They're on the same level of reporting how large the shit was of some celebrity's dog when a national crisis occurred the day before. If journalism isn't dead it's certainly being slowly strangled.

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