Prescribing weight loss medications is very controversial. The term “diet pill” carries connotations of drug addiction and weak willpower. This bad image stems from at least two sources.
Prejudice Against Weight Loss Medications
First, the notion is still very much alive that overweight is simply a matter of
self-control and determination. This way of thinking says that overweight individuals are simply weak or gluttonous. Implicit in this idea is the notion that weight loss medications are a “cop out”; an attempt to gain benefit without effort—a kind of cheating, like athletes who take steroids to enhance performance.
I’ve seen this attitude among my overweight patients. They will guiltily admit that they’ve used over-the-counter weight loss pills. They feel ashamed of this, as though they’ve committed a sin. They have internalized into their own thinking society’s condemnation of weight loss medications.
The second reason for prejudice against weight loss medications stems from the fact that the first weight loss medications were amphetamines (called “speed” among drug abusers). Amphetamines were used for weight loss from the 1930s to 1960s. Amphetamines can cause depression, anxiety and paranoia. Rightfully, the medical profession decided that amphetamines were not safe for weight loss.
Modern weight loss medications are more similar chemically to antidepressant medications than they are to amphetamines. However, few people—including physicians—are aware of this. Most people still equate the term “diet pills” with amphetamines or “speed.”
The Correct Attitude about Weight Loss Medications
Using medications to control carbohydrate cravings (and, thus, excess appetite in general) is no different in principle from using medications to control cravings for cigarettes. Let’s say a three-pack-per-day smoker goes to his physician for help to quit smoking. This smoker has been smoking for many years, suffers from chronic bronchitis, and has tried to quit smoking on his own several times with no lasting success. What should his doctor do?
His doctor should prescribe medications that reduce the patient’s cigarette cravings. These medications increase the levels of certain chemicals in the patient’s brain in a manner similar to the chemical effects of a cigarette. The patient’s brain gets what it craves without the patient’s having to smoke.
As a result, the patient’s cravings for cigarettes are reduced. His chances of permanently quitting cigarettes are then dramatically increased. Both the patient and his doctor feel good about the medication treatment and the outcome. The doctor should continue the stop-smoking medications as long as they are needed—even lifelong if necessary for the patient to permanently stop smoking.
Now, let’s say that the patient is not a smoker but instead is 25 or more pounds overweight. Let’s say the patient has been overweight for many years, and suffers from low stamina and sexual insecurities related to being overweight. Let’s also say that the patient has tried various self-help diets, and has even tried Weight Watchers but with no lasting success. What should his doctor do? (Currently, what his doctor is most likely to do is to tell the patient something like, “eat less and exercise more.” This would be like the smoker’s doctor saying, “just don’t smoke” without offering any other help.)
What the overweight patient’s doctor should do is to prescribe medications that will increase the levels of certain chemicals in the patient’s brain in a manner similar to the chemical effects of eating carbohydrates. Then the patient’s brain would get what it craves without the patient’s having to eat carbohydrates. As a result, the patient’s cravings for carbohydrates would be decreased and his chances of losing weight would be dramatically increased. The doctor should continue the weight loss medications as long as they are needed to lose weight and to maintain weight loss—even lifelong if necessary.
Overweight is now the number two cause of premature death in the US, right behind smoking. Using medications to treat overweight is every bit as appropriate as is using medications to treat smoking.
The Important Appetite-Control Brain Chemicals
The brain chemistry that regulates appetite and carb cravings is extremely complex. Scientists have only uncovered the tip of this complex system. Future discoveries will lead to dozens of new medications that will fine-tune appetite and treat overweight more and more effectively. Fortunately, even at this early stage in the science of appetite regulation, we’ve learned enough to treat most overweight patients effectively.
Three brain chemicals seem to be very important in regulating carbohydrate cravings and excess appetite in general: serotonin, dopamine and norepinephrine. These three chemicals are most important in the circuits of the brain known as the limbic system. The limbic system is the part of our mid-brain that regulates our emotions and appetites. Mood, tension, sleep, sex drive, hunger,
and much more are regulated by the limbic system.
Scientists have discovered that raising the brain levels of serotonin, dopamine and norepinephrine can dramatically reduce carbohydrate cravings in most overweight individuals. This leads to the foundation of the medical treatment of overweight: medications that raise the brain’s levels of serotonin, dopamine and norepinephrine.
Specific Medications
Usually, I prescribe two medications that, combined, increase the brain’s levels of the three key chemicals: norepinephrine, dopamine, and serotonin.
The most common medication prescribed to raise norepinephrine and dopamine is phentermine. This is the half of fen-phen that didn’t cause health problems. You may remember the fen-phen controversy in the mid-1990s. Fenfluramine (brand name Redux, Pondimin), the “fen” part, was the problem in the fen-phen combination, and it was removed from the market. It raised levels of serotonin—but way too much and caused heart and lung problems.
Phentermine (the “phen” part) was not part of the fen-phen problem. Phentermine recently has been rigorously scrutinized by the FDA and other organizations, and has not been found to contribute to the heart and lung problems that fenfluramine can cause.
Phentermine has been used extensively since 1972 with no significant health problems attributed to it. While it comes with the same long list of possible side effects that practically every medication comes with, I’ve neither seen nor heard of a major medical complication due to phentermine. It also comes with a warning of possible addiction or drug abuse, left over from the days of “diet pills” that were amphetamines. I’ve never seen or heard of addiction to phentermine happening either. Usually there are no side effects; occasionally a patient will report some trouble sleeping the first night or two.
While phentermine used alone can significantly reduce appetite, much better results are achieved when a medication that raises the brain’s level of serotonin is also used. I usually prescribe Celexa to raise serotonin (but much less than fenfluramine did).
The differences between fenfluramine and Celexa are important for you to understand, because the safety of modern weight-loss medications hinges on this point. Fenfluramine raised serotonin levels very forcefully and very high. Serotonin levels were so high that damage could occur to thin tissues in the heart and lungs.
Celexa and all similar medications (Prozac, Paxil, Zoloft, Lexapro, Luvox), on the other hand, raise serotonin much more mildly than fenfluramine. The Celexa type of medications have been widely prescribed since the early 1980s with a very good safety record (they are not usually even stopped during pregnancy).
Celexa is classified as an antidepressant medication. Like most medications, its classification is based on its first type of use. It is also used to treat anxiety disorders, PMS, and chronic pain. Like all modern antidepressants, it is extremely safe, and non-addictive. Celexa also can help counter the effects of stress, and can help reduce the level of cortisol. Since elevated cortisol leads to more fat storage, reducing cortisol can help with weight loss.
The combination of phentermine and Celexa raises brain serotonin, dopamine and norepinephrine. This combination is very powerful for reducing excess appetite in general and carb cravings in particular.
The Celexa-phentermine combination described above reduces carb cravings and excess appetite down to near zero within 48 hours for 95% of my overweight patients. They have almost no difficulty adhering to the low-carb diet that I recommend. Fortunately, this combination of medications is virtually free of side effects in 98% of my patients, and it continues to work well for months and years, if needed.
I see patients back in my office four weeks after starting the phentermine-Celexa combination. At that visit the vast majority of patients report having virtually no excess appetite or carb cravings. They usually report no lasting side effects. A small percentage will say that the first week or so of taking the medications they felt a little “wired,” as if they had drunk too much coffee. These patients may have had some trouble sleeping the first few nights of taking the medications. This is usually mild and only occurs in the first couple of days.
A very small percentage of patients complain of lasting side effects. Virtually always, this is a complaint of feeling too jittery. In these cases I switch from phentermine to Tenuate SR every morning. Tenuate raises norepinephrine and dopamine, just like phentermine, but it is less likely to cause jitteriness. Switching to Tenuate almost always solves the jitteriness problem, and Tenuate works almost as well as phentermine to control appetite and carb cravings.
For elderly patients, or those individuals with serious heart problems, I’ll sometimes not prescribe phentermine or Tenuate, but will instead prescribe buproprion. This medication increases the brain level of norepinephrine, and to a certain extent dopamine, too.
Buproprion has been found to reduce cravings for carbohydrates and cigarettes. It is marketed under two brand names, Zyban and Wellbutrin (and under the generic name, buproprion). Its primary use has been as an antidepressant (although it is less effective for most individuals than other antidepressants). It is, however, one of the most widely used appetite-control medications prescribed in Europe.
Buproprion is less stimulating than phentermine. It should not be used in patients who have ever had a seizure or those who have ever suffered from anorexia nervosa. Otherwise, it is very safe.
Occasionally, an overweight patient comes to me already taking a medication within the Celexa class of medications. These medications include Paxil, Prozac, Zoloft, Luvox, and Lexapro. Usually, the patient is taking one of these medications for treatment of depression or anxiety.
Prozac and Paxil have been associated with weight gain when used long term (especially Paxil, in my experience). I’ll usually try to switch from Prozac or Paxil to Celexa in these patients. Luvox and Zoloft are less strongly implicated in weight gain, so I’ll often keep these patients on their Luvox or Zoloft, if the patient is doing well on them, and simply add phentermine as above. Usually this works just fine. But if weight loss is too slow I’ll change to Celexa, later.
Some patients come for treatment already taking Cymbalta or Effexor for treatment of depression. These are the most powerful antidepressants on the market today. These two medications have an increased risk of weight gain as a side-effect. However, I usually do not switch patients off these medications right away because I don’t want to risk a worsening of depression.
Most patients on Cymbalta or Effexor are able to lose weight just fine by following the program described in this book. The few who are not able to lose weight well are usually able to switch to a different antidepressant without a worsening of their depression.
Medications for Mildly Overweight Patients
Overweight patients with a BMI of less than 27 are prohibited by most state medical boards from being prescribed phentermine, Tenuate, or Bontril (the most powerful appetite-control medications). These patients need to lose less than 25 pounds. For these patients, I’ll often prescribe buproprion (Wellbutrin) instead of phentermine. I combine buproprion with Celexa and usually see good results. Independent research reports have also found good long-term weight loss with buproprion.
Buproprion should not be taken by anyone who has ever had a seizure or who has suffered from anorexia nervosa (extreme self-inflicted thinness).
Medication to Lower Excess Insulin
Glucophage is another medication I commonly prescribe to help with weight loss. Unlike the other medications I’ve mentioned so far, its effect is not primarily to reduce appetite and carb-cravings. Glucophage improves your body’s sensitivity to your own insulin.
Most overweight individuals have insulin resistance. This loss of sensitivity to insulin seems to be due to long-term elevation of blood insulin levels, and perhaps due to briefer elevations of blood sugar as well. As a result, insulin has a harder time bringing excess blood sugar into cells. So the pancreas must secrete more insulin to force sugar into cells.
This means that overweight individuals must keep an even higher blood level of insulin to control their blood sugar (a condition called hyperinsulinemia). This continues the vicious cycle of higher insulin leading to more insulin resistance, which then causes even higher insulin. All the while, the higher level of insulin is activating the enzyme lipoprotein lipase, which pulls ever more fat into fat cells. The higher insulin level also increases the number of mature fat cells. For these reasons, it is beneficial to lower an excessively high insulin level.
The medication Glucophage (metformin) improves the power of insulin to bring sugar into cells. Therefore, less insulin is needed to control blood sugar and less activation of lipoprotein lipase occurs, leading to less fat storage. High insulin also increases carb cravings, so lower insulin helps to reduce appetite, too.
Glucophage has been used extensively since the mid-1950s, mostly with diabetics. It is also used to treat Polycystic Ovarian Syndrome, and it is used to treat pre-diabetes. It is a safe medication with minimal side effects. It cannot adversely affect insulin or blood sugar levels. Glucophage speeds weight loss in most of my patients, and I’ve seen no significant medical problems due to its use.
Persistent Evening Carb Cravings
Most of the time, when a patient returns for her second visit her carb cravings and appetite are in good control with the phentermine-Celexa-Glucophage combination. Occasionally, though, a patient still has excess carb cravings.
Usually, these carb cravings occur in the evenings, so we have her take the entire phentermine dose sometime between noon and 3 p.m. She can self-adjust the timing of this dose so that her carb cravings are well controlled until bedtime, but also so that she has little or no trouble going to sleep (too much phentermine in the system at bedtime can interfere with sleep). Usually this change from one-half phentermine morning and afternoon to one whole phentermine, early afternoons only, works well to eliminate evening carb cravings.
Persistent Stress-Related Carb Cravings
Some of my patients find that during times of increased stress they have increased carb cravings. Increasing the Celexa dose will usually reduce their carb cravings within a week or so. We continue on this higher dose for at least 4 months; longer if the stress level remains elevated.
Some of my patients find that the medications control their carb cravings well except for the week or so before their menstrual periods. (Carb cravings are a common symptom of PMS.) These patients can double their Celexa dose for the 10 days before their period each month. As soon as menses starts, they drop back down to their “regular” Celexa dose. This technique usually eliminates PMS carb cravings.
Elevated Blood Pressure
Rarely, patients who already have high blood pressure experience a rise in blood pressure on phentermine or Tenuate. If their blood pressure has been well controlled with medications this is usually not a problem. If their blood pressure has not been well controlled then, sometimes, the blood pressure can rise too much when phentermine or Tenuate are started.
If blood pressure increases more than about 10 mmHg when the patient takes phentermine or Tenuate, I add a blood pressure medication.
As the patient loses weight, blood pressure usually falls and the blood pressure medication can be stopped. I have never seen buproprion raise blood pressure, so using it with Celexa to reduce carb-cravings is an option with severely uncontrolled hypertension.
Medication Continuation
How long to continue appetite-control medications has been a point of great controversy. Most physicians still believe that these medications should be used (if at all) for only a couple of months, “until the patient has learned new eating habits.” Research has shown that this virtually never works.
I continue appetite-control medications at least until the patient reaches her goal weight (or has stopped losing weight). If the patient has a strong history of rapid weight regain in the past, I may recommend continuing the medications lifelong. Otherwise, after she reaches her goal weight we may try to taper off the medications over a few months and watch for weight regain carefully. If the patient regains 5 pounds she can’t get off in a month, we restart the medications for a month or two.
Some patients will experience severe rapid regain as soon as the medications are stopped, so they’ll need daily medications the rest of their lives—and that’s OK. There are no known problems due to taking these medications lifelong. Of course, some patients never need medications again. Most will need the medications only one or two months per year.
If long-term appetite-control medications are needed for weight loss maintenance, we try switching from phentermine to buproprion. We start the buproprion morning and afternoon, and adjust up if needed to control appetite. We continue the Celexa long-term in combination with the buproprion and Glucophage.
The more completely patients adopt a “low-carb lifestyle” (discussed in a later chapter), the less likely is the need for long-term medications.
The regimen of medications I’ve described in this chapter will eliminate excess carb cravings and excess appetite in nearly 100% of overweight patients. Patients are free from irresistible urges that sabotage their weight loss efforts. They can follow a reasonable eating plan to lose excess weight and to lead a happier, healthier life.
I would be remiss not to mention the currently most famous weight-loss medications, Meridia and Alli (formerly named Xenical). Meridia increases serotonin, similarly to Celexa. I know of no advantages that Meridia has over Celexa, and it is more expensive so I don’t recommend it.
Alli blocks the absorption of fat from the intestinal tract. It works via a “punishment” technique. That is, if you eat much fat, you get severe diarrhea. Therefore, you reduce fat (calorie) intake when taking Alli. Since the most current research indicates that a low-carb diet, not a low-fat diet, is best for weight loss, there is no rationale for using Alli. In fact, it is impossible to follow the diet I recommend and take Alli at the same time—you’d have constant diarrhea. So, I recommend avoiding both Meridia and Alli.
Key Points
- The widespread prejudice against weight loss medications is unjustified
- Medication treatment of overweight is as well justified as is medication treatment of smoking, clinical depression, or anxiety disorders
- Appetite-control medications reduce mid-brain carb cravings by increasing the brain’s levels of serotonin, norepinephrine, and dopamine
- Phentermine has a track record of safety and good results since 1972; it is usually without significant side-effects
- Celexa raises serotonin, is non-addictive and is very safe; combined with phentermine, it will further reduce carb cravings
- Buproprion may be substituted for phentermine if the patient has severe heart problems, or needs to lose less than 20 pounds
- Tenuate SR may be substituted for phentermine if jitteriness or insomnia are a problem with phentermine
- Glucophage reduces insulin levels and can speed weight loss
- Medications should be adjusted as needed and continued at least until goal weight is attained
- Medications are used for weight loss maintenance, either continually or whenever the patient regains five pounds that she can’t lose within one month
Now let’s go on to discuss the particular eating plan that I recommend.