Departments of Psychiatry & Internal Medicine Grand Rounds
Pharmacological Treatment and Combinations for Overeating and Obesity
Q: How did you become interested in obesity?
A: I became interested in obesity as a fellow while working in a medical clinic. I thought that if I could get patients to lose weight, they would get better and their high blood pressure, coronary disease and arthritis would be easier to manage. When I joined the faculty at Cornell in 1986, I was asked to start a clinical program and I chose obesity. During this time, I was able to watch the development of one of the major breakthroughs in the field of obesity; the discovery of leptin. As an Internist, watching a whole new area of medicine was really fascinating.
Q: What are the most significant changes in the field of obesity over the last 20 years?
A: I think that some of the most interesting changes have been simply the fact that obesity is now recognized as a serious health problem. Initially, people felt that obesity was a disorder of willpower and it was purely that people didn’t want to lost weight. It is clear that something very physical takes hold of people, whether it is they are eating too much or they may not be exercising enough but this is what makes it so difficult to lose weight. Focusing on prevention and more aggressive forms of treatments is a major concept that is going to transform obesity.
Q: How is patient compliance with weight loss drugs?
A: There are two key factors to get patients to comply with weight loss drugs; one the insurance company needs to cover the treatment and two, the drugs need to be effective. If these two things are satisfied, the patients are generally happier to take the medication. Even if the medications have side effects, patients are willing to take these medications, as long as they are covered by their insurance company and they are effective.
Q: What are your thoughts on the various bariatric procedures for weight loss?
A: I think the bariatric procedures are the most effective option. We prefer the gastric bypass and sleeve. We feel the Lap-Band procedure is less effective for most patients that we see, although we will do it in patients. We feel the lower BMI patients will do well with the Lap-Band but most patients we refer for surgery. One of the problems we are seeing in the community now is that patients are not being managed for their weight and thus we are seeing them re-gaining their weight after surgery, compounded with a number of nutritional problems. What we have to recognize is that after a bariatric procedure, patients still have obesity. Surgery doesn’t cure obesity and patients still need to diet, exercise and they may even need medication to help them maintain their weight loss.
Q: What can we expect of obesity treatments in the future?
A: I think we can expect more obesity treatments in hypertension. There are over 120 treatments for hypertension in 9 different categories. If we look at the blood pressure regulating mechanisms, they are very, very simple compared to the weight regulating mechanism. That is why it has been so hard to develop new treatments for obesity. So I think we are going to need many different treatments if we are going to be able to manage patients’ obesity effectively.
Q: What about plain old diet and exercise? Is that enough?
A: For some people, diet and exercise is just fine. A key point is that people don’t have to get to their ideal body weight to improve their health. When you lose weight, your fat cells shrink which improves your health a lot sooner than reaching ideal body weight. Clearly diet and exercise is not enough for the majority of the population, otherwise we wouldn’t have the obesity problem that exists. I think we need new treatments if we are going to make any progress.
Q: Is there a trend of treating hypertension early before it becomes severe? Why not use the same idea and treat people who are overweight before obesity has a chance to develop?
A: I think this is a trend that as time goes on will evolve. If you go back to the history of hypertension back in the 50’s and early 60’s blood pressures of 250/150 were treated. So once people got to what we now call, malignant hypertension, that is when treatment was initiated and it wasn’t very effective. The reason was that end organ damage had already occurred. As time went on, it became clearer that if you treated people earlier and earlier, you get a better result. I envision the day when a BMI threshold may be invoked; a BMI of say 25 where the risk is lowest. We will draw a line there and say the goal of obesity treatment will be that your BMI will never go above 25 and that will be the way to treat obesity since it is so hard to bring people back. I think an approach like that would make more sense than the way we are approaching obesity right now.