Your Doctor, Your Diet Coach

Love handles. Rose Katz, 43, an attorney, wanted to lose hers. Even though she worked out five times a week and watched what she ate, she just couldn't smooth those bulges. Katz had read that injections of something called Lipodissolve might help. An Internet search led her to the Center for Medical Weight Loss near her home on Long Island, New York—a place founded and staffed by doctors. She figured she'd be in good hands and that she could get some quick shots and be done.

At the center, Andre Giannakopoulos, MD, gave the 147-pound, 5'5" mother of three a physical, an EKG, and blood tests. He found that the dose of medication she was taking for her underactive thyroid was dangerously high and wrote her a new prescription. When she told him she wanted to get rid of her flabby pooches along with 20 pounds before her son's bar mitzvah, just a few weeks away, he scheduled the injections and also recommended an 800-calorie diet based on meal-replacement shakes and bars. Five weeks later, when Katz found herself struggling to stick to the plan, Giannakopoulos wrote a prescription for the appetite suppressant phentermine. The 800-calorie diet isn't recommended for minor weight problems, and phentermine isn't indicated for cases like hers—but then, the so-called fat-dissolving shots that brought her to the center aren't even FDA approved. Katz had no qualms, though. She trimmed 2.5 inches from her waistline, dropped 9 pounds in six weeks, and wore a size 6 dress to the bar mitzvah. After two months, Katz was holding steady at her new weight; if she starts to regain, she can go back to the clinic for more help.

Katz's experience encapsulates the promise and potential pitfalls of physician-run weight loss clinics, which are sprouting up in medical office buildings and strip malls coast-to-coast. Yes, many customers lose weight fast. And they typically get a thorough exam, something too many people ordinarily neglect. "I don't normally go to doctors. I should be seeing an endocrinologist for my thyroid every six months, but I haven't gone in years," Katz says. But the clinics offer a bewildering assortment of treatments that range from sensible to highly questionable, and the doctor in charge may have little experience in dealing with weight loss—many physicians open up shop after attending a brief seminar, if they get any special training at all. "Practitioners are seeing a business opportunity," says David L. Katz (no relation), MD, director of the Yale-Griffin Prevention Research Center and O's nutrition columnist. "Frankly, many clinics are making up their approaches as they go."

Most physicians were not taught to do that, however. "I learned more in medical school about malaria than about obesity," says Michael Kaplan, a board-certified internist and bariatric specialist who also has a degree in osteopathy. That's changing: Awareness that obesity is a complex metabolic issue, not a simple matter of willpower, is growing in the medical community. "Obesity is a chronic disease," says Kaplan, founder and president of the Center for Medical Weight Loss. "The only person who should be managing this disease is a physician."

Kaplan used to practice general medicine but switched to weight loss five years ago because he grew tired of treating obesity-related ailments. "I knew that if most of my patients just lost weight, they would be able to stop taking pills for diabetes and hypertension,'' he says. His new specialty proved so financially successful that in September 2006 he began marketing his program to other primary care physicians. In two-day seminars in hotel convention rooms, Kaplan teaches doctors how to prescribe a low-calorie diet and weight loss drugs and how to predict the number of pounds patients will lose. He also brings the doctors up-to-date on obesity research and provides patient education materials and a six-hour DVD on counseling techniques. Kaplan charges $17,000 a head and grants each participant the right to use the Center for Medical Weight Loss name. As of August 2007, 75 doctors had signed up to open 91 centers.

Some experts argue that two days of training can't begin to cover what a doctor should know to handle weight problems. "You can't jump into it," Dr. Katz says. "You should spend years studying it." But others say they welcome any move to expand treatment in a nation where two-thirds of adults are overweight. "Two days is not ideal, but the country is in a desperate state," says Michael Dansinger, MD, an obesity researcher at Tufts–New England Medical Center in Boston and consultant to NBC's reality show The Biggest Loser.

Kaplan's centers typically offer patients prescription appetite suppressants and high-protein, low-calorie shakes and bars—although only, he says, as part of a broader program aimed at long-term diet and lifestyle changes. It's a common approach: The Medical Weight Loss Clinic in Michigan—which has 28 centers that treat 400 to 600 patients a week—hands out prescription drugs to nearly half the clientele, says Alberta Lipinski, a nursing supervisor there. At Dr. Smith's Get Thin Program, with four offices in metropolitan Atlanta, about 93 percent of patients "opt for" appetite suppressants, says founder Walter Smith, DO.

For those on an 800-calorie diet, the shakes and bars are designed to preserve muscle and avoid the chemical imbalances associated with what is essentially supervised starvation. Patients must be checked weekly for nutritional deficits and shouldn't remain on the diet beyond four months. Studies show patients lose three to six pounds a week while they're on the diet, but most of them gain the weight back when they stop. "Those 800-calorie diets are very effective for short-term weight loss but notorious for long-term failure," says Dansinger.

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.
 

Doctors at clinics as well as those in private practice sometimes prescribe drugs off-label: In other words, they give a medication that's FDA approved to treat another disease—diabetes or epilepsy, for example—to overweight patients because the drug can cause weight loss. The approach is a gamble since these medications may have severe, even life-threatening side effects. According to the National Institutes of Health, off-label prescribing is an option only when patients face significant health risks because of their weight.

The clinics enter a gray area when they treat people who are basically healthy but would like to drop a few pounds. No prescription pill is approved for cosmetic weight loss, and meal-replacement diet plans are indicated only for people who are dangerously overweight. And some doctors, such as Kaplan, also offer nonsurgical cosmetic body sculpting, the kind Rose Katz had. Referred to as Lipodissolve, injection lipolysis, or mesotherapy, the treatment involves a series of shots into pockets of fat beneath the skin, using various agents including plant extracts, vitamins, enzymes, and a substance—phosphatidylcholine—that seems to kill fat cells.

The technique, developed decades ago and popular in Europe and South America, has only recently gained a big following in this country. Because doctors often use their own recipes, patients don't always know what they're getting, and some people experience considerable swelling and pain. While research suggests that the shots are relatively safe, there is still not enough data on long-term effects or on whether the shots actually work.

If you want to go down only a dress size or two, the research is resoundingly clear: The safest and most effective method is to cut calories and exercise more. A doctor-run clinic can provide guidance and regular check-ins—two other techniques that research has proven can help. But before any consumer signs up with a clinic, Dansinger advises her to visit more than one and ask the doctors these questions: What is your training? How long have you managed weight loss? What evidence do you have of your long-term success? What will I learn that will stick with me when I'm no longer a patient at your clinic? "Be wary of programs that have been around less than a year or two and don't have a track record," Dansinger says.

For those who qualify for drug treatment, ask all the above questions and then carefully consider the benefits and risks of any treatment the doctor proposes. If the doctor balks at answering your questions, doles out pills, shots, or shakes without a thorough checkup and regular follow-up, or pushes you to buy expensive vitamins and supplements the office happens to be selling, walk away. With the growth in medical weight loss, you're likely to find a more responsible doctor just up the road.

Fran Smith is a writer and editor living in Dobbs Ferry, New York.