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Weight Matters: When Willpower Isn't Enough

When you're significantly overweight, nobody has to tell you that you'd probably be happier and healthier without the extra pounds. But what if the weight won't come off, no matter how hard you try?

Willpower alone might not be enough for people who are significantly overweight. If you've honestly tried to lose weight and failed, medications or surgery may be helpful under certain conditions.

Most medical weight-loss programs first try to help you make the long-term behavioral changes necessary to lose weight, and then maintain a healthy weight. This includes exercising regularly and eating healthy food.

If you still remain seriously overweight, you may want to discuss these other options with your health care provider.

Medications

Prescription medications can be helpful, but they're not for everyone. According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), weight-loss drugs are generally recommended only if you have a body mass index (BMI) of 30 or higher, or if your BMI is 27 or more and you have conditions caused or made worse by obesity, such as high blood pressure; dyslipidemia, which means abnormal amounts of fat in the blood; or type 2 diabetes. (According to NIDDK, a BMI of 18.5 to 24.9 is considered healthy.)

People with certain chronic health conditions or who are taking certain medications may not be able to take weight-loss medications. Be sure your health care provider knows if you have any of these conditions: high blood pressure, hyperthyroidism, anorexia, bulimia, depression, migraine headaches, glaucoma, diabetes, or heart disease, or you have abused drugs or alcohol. Medications to help weight loss must be used in combination with regular physical activity and a healthy eating program.

Weight-loss drugs lead to an average loss of about 10 pounds more than a person could lose using nondrug treatments. The greatest amount of weight loss usually occurs within the first six months after starting a medication. After six months, weight tends to level off or increase. Maintaining weight after stopping weight-loss medications can be difficult.

These are the types of medications available for weight loss:

Appetite suppressants

These drugs decrease appetite or increase the feeling of being full, the NIDDK says. They do this by increasing one or more chemicals in the brain that affect mood and appetite. Phentermine (Fastin, Adipex-P, Pro-Fast, and other brand names) is the most commonly prescribed appetite-suppressant. Other appetite suppressants are diethylpropion (Tenuate) and phendimetrazine (Bontril, Plegine, and other brand names).

Side effects of phentermine, phendimetrazine, and diethylpropion can include sleeplessness, nervousness, and euphoria. These drugs may lead to heart problems, high blood pressure, an overactive thyroid gland, or glaucoma. People with these conditions should not take these medications.

Sibutramine (sold as Meridia) was voluntarily pulled from the market in October, 2010, after the FDA found that the drug was associated with an increased risk of heart attack and stroke.

(Amphetamines also suppress appetite, but because of the potential for abuse and dependence, they are NOT recommended as weight-loss drugs.)

Lipase inhibitors

There is only one drug in this class approved by the FDA: orlistat (Xenical). It is approved for teens ages 12 and older. (All other weight-loss drugs are approved for teens older than 16 and adults). Orlistat works by decreasing the body’s ability to absorb some fat from food, the NIDDK says. If less fat is absorbed, there are fewer calories for the body to use or store. Side effects of orlistat include cramping, intestinal discomfort, gas, diarrhea, and leakage of oily stool. Eating foods that are high in fat can make the side effects worse. Orlistat reduces the absorption of fat-soluble vitamins, so your doctor may advise taking a multivitamin at least two hours before or after taking orlistat.

In 2007, orlistat was approved for over-the-counter sale, for adults age 18 and over, under the brand name Alli. Its side effects are similar to the prescription orlistat. Both orlistat and Alli are meant to be taken in association with a low-fat diet, exercise, and a daily multivitamin.

Surgery

Obesity surgery, also called bariatric surgery, may be appropriate for people who have tried other methods to lose weight but remain severely obese, or for people who have a serious disease caused or made worse by obesity. Gastric bypass surgery, the most common bariatric operation, is a major procedure. It changes the way your body digests food. It may be appropriate for people with a BMI of 40 or greater, or about 100 pounds overweight for men and 80 pounds for women, or for people with a BMI of 35 or greater if they have serious medical conditions.

These are four types of surgical options: adjustable gastric band (LAGB), Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with a duodenal switch (BPD-DS), and vertical sleeve gastrectomy (VSG). Each has its own benefits and risks: 

  • LAGB is known as a restriction operation because it reduces food intake by limiting the amount of food the stomach can hold. Permanent weight loss after this surgery requires changes in diet and exercise. The NIDDK says that after 10 years, only 20 percent of people who had this type of surgery kept the weight off. As yet, the adjustable gastric band has not been approved for use in the United States for people younger than age 18.

  • RYGB and DS/BD operations also create a small volume stomach pouch or a "gastric sleeve," rerouting food directly into a lower portion of the intestine so fewer nutrients are absorbed. These procedures produce more weight loss, but also involve higher risks for complications, especially after DS/BD. These include nutritional deficiencies, such as anemia and osteoporosis.

  • VSG is a newer procedure that uses staples to remove about 80 percent of the stomach. The remaining stomach, which is shaped like a shirt sleeve, will hold about a quarter of a cup of liquid. Over time, the stomach can expand to hold one cup of food. Like LAGB, this operation does not reroute the passage of food or prevent absorption. However, VSG is still a fairly new procedure, so long-term results, such as maintaing weight loss over time, are still not known. Because VSG doesn't include a "malabsorption" of vitamins and minerals, this may be a good operation for teens. Risks specific to VSG include breakdown of the line of staples or bleeding from the staple line. 

Because of the potential for nutritional deficiencies, the need to take vitamin and mineral supplements for life and other side effects, these surgeries are not usually recommended for teens. They may be considered for a teen who has a BMI of 40 or more, has reached his or her adult height (usually age 13 or older for girls and 15 or older for boys), and has a serious weight-related health problem, such as type 2 diabetes or heart disease. Both the teen and his or her parents must be prepared to make the lifestyle and emotional changes required to make the surgery successful.

Although drugs and surgery can promote weight loss, they are not magic. They all require your active participation. If you continue with the same old habits, you can easily override anything a doctor can do for you.

FYH

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