Your Doctor, Your Diet Coach
There's nothing revolutionary about the appetite suppressants—stimulants like phentermine (Adipex-P) and phendimetrazine (Bontril) have been on the market for decades. The drugs are potentially habit forming and may cause nervousness and sleeplessness; that's why the pills are generally meant only for obese patients (those with a body mass index [BMI] of 30 and above—a 5'5" woman would have to weigh at least 180 pounds to qualify), who should take them no longer than three months. Hospital-based obesity clinics, which are subject to institutional oversight, usually abide by these limitations. At neighborhood weight loss centers, docs may be more likely to bend the rules, though only, they say, with diligent patient monitoring.
Even when accompanied by careful supervision, appetite-suppressant drugs are controversial. "I personally don't think there's a huge role for medication approved for short-term use," says Christina Wee, MD, director of the health services and behavioral research program in obesity at Beth Israel Deaconess Medical Center in Boston. "Why use something for three months and stop it only to watch your patients gain back the weight they lost? In some ways, it's almost cruel."
Kaplan sees the drugs in a different light—more as a way to help break bad habits, the way Antabuse gets an alcoholic to stop drinking. They are the first step on the difficult road to permanent lifestyle change, and that, he says, is his true mission. He counsels patients on self-esteem, emotional eating, and food addiction. He cajoles them to take walks and go to the gym. "If we're not working on changing behaviors," Kaplan says of his staff, "we're wasting our time."
The patient testimonials can be glowing. "I've been on every diet known to mankind," says Dina Marks, 48, an elementary school music and literacy teacher who lives in Wantagh, New York. Nothing worked for her until she signed up with the Center for Medical Weight Loss. Kaplan's colleague Giannakopoulos put her on Optifast and, two weeks later, an appetite suppressant. Over three months, she spent about $2,200 and lost 35 pounds. Marks feels as if she's learned enough from the doctor to keep it off going forward. "I like dealing one-on-one with a medical person," she says. "I'm talking with someone who knows not only how to lose weight but how to be healthy. I feel better than I ever have in my life." All the centers can point to people like Marks who have lost a lot of weight. But as yet there's insufficient research demonstrating that the clinics offer a better chance at keeping the weight off—the true measure of success—than Weight Watchers or other diet programs.
Some clinics offer drugs that patients can take for a longer period of time: Orlistat (Xenical), which decreases fat absorption, and the appetite suppressant sibutramine (Meridia) are both FDA-approved for long-term use. But patients don't lose much more weight than they would from diet and exercise alone. (The drugs typically help people lose an additional 4 to 12 pounds in six months to a year.) Unpleasant side effects such as cramping and gas can make Xenical and its over-the-counter cousin, Alli, hard to tolerate. Anyone with high blood pressure or heart problems—which includes many obese people—should steer clear of Meridia. Common side effects include headache, constipation, and insomnia.