Fen-phen is history — now what? ew diet drugs are in the pipeline

Providers brace for next round while tackling weight myths

Two months ago, women’s health providers were turning away prescription requests for popular diet drugs. Today, with the sudden withdrawal of fen-phen from the market, they’re counseling ex-diet pill users about the cardiac and pulmonary damage they already might have developed. And even as they counsel women on these potential problems, most women’s health professionals know that new potions, with their promises of magical weight loss, aren’t far away.

"We’re taking the risk of killing ourselves over 20 pounds!" says Barb Silver, NP, clinical coordinator of the Women’s Health Resource Center at California Pacific Medical Center in San Francisco. She insists women’s health programs must become self-appointed dispensers of realism in the clash between good health and market-driven beauty standards.

When medicine and profit-making merge, health and common sense sometimes lose rank, women’s health providers warn. "Weight loss has become a huge business in this country because people want to be thin," argues Nancy Carteron, MD, FACR, chair of the advisory council of the women’s program at the California Pacific Medical Center in San Francisco. She predicts that we haven’t yet seen the last of weight loss drugs. Currently in the pipeline is a new generation of medications that operate at the hormonal level. Carteron explains that they’re in a different family of drugs than Pondimin and Redux. (When Redux hit the market, Women’s Health Center Management briefed you on the mixed reactions of women’s health providers, including the concerns about primary pulmonary hypertension risks. See the cover story in our October 1996 issue.)

The obsession with thinness drives the diet drug demand. The table on p. 139 offers a glimpse at the obvious differences between women’s perceptions of themselves and their normal body size. Most telling is the perception among women of normal weight: 43% think they’re overweight.

Unfortunately, Carteron says, the normal weight for most women is "probably greater than what we think is the ideal. But it’s a time-consuming, intensive process to talk through these issues. Sadly enough, there’s more economic gain in prescribing drugs, and that’s what made a big industry out of medical weight loss clinics."

Regarding diet pills as beauty aids is dangerous. However, Carteron notes that 99% of the requests she received for diet drug prescriptions come from women seeking a quick fix for a few unwanted pounds. She refused, yet, she laments, "I could walk around my neighborhood and see the weight loss clinics where they could get them.

"These drugs [fenfluramine and phentermine] have been around for a long time, but their resurgence came about because huge numbers of people went to weight loss clinics to get them." When bad side effects surface — such as heart valve damage from diet pills — our first move is to ask, ‘Who can we blame?’ However, Carteron points out, such side effects are among the post-market release findings that providers can discover only after a drug has been in use for a time.

"Companies have to jump through huge hoops to get these drugs through the [Food and Drug Administration]," Carteron notes. It’s similar to the tragedy of thalidomide, she says. Thalido-mide is the drug that caused birth defects when taken for morning sickness by women in their first trimester of pregnancy. Prescribed in the 1950s and early 1960s, it left the market in the early 1960s.

"It is not until drugs like these are used in large numbers that significant abnormalities show up," Carteron says. "Nobody can protect us 100%." And drug companies don’t deserve all the blame, she cautions. "They are businesses, and they develop drugs that people want."

Silver counters: "I would like to think the drug manufacturers had the best motivations, but there are not that many morbidly obese women who weigh 300 pounds to make a profitable market for these pills. I believe they have jumped on the vulnerability of women who think they need to shed a few pounds to fit today’s standard of beauty."

Juliet Rogers, MPH, administrative manager of the women’s health program at the Women’s Health Resource Center, University of Michigan Health System in Ann Arbor, perceives a growing distrust of drugs among women. With each new warning about fen-phen, "We braced ourselves with press releases. We thought it would bring a flood of calls, but we were surprised. I think women are getting leery of drugs in general."

In the quiet between fen-phen and the next generation of diet drugs, Silver says women’s health providers need to counsel women to come to grips with the difference between healthy weight and the illusion that a state of svelte is within every woman’s reach.

"We see the actress who wants to lose five pounds to look good in front of the camera or the woman who needs to fit into a wedding gown next month," Silver says ticking off the reasons women gave for popping pills from the medical weight loss clinics. She believes women’s health programs are the logical sources of sound body image counseling. "We have a little more time to talk with clients than physicians do,"she says.

And Silver makes the best of that extra talk time. If a woman is 20 pounds — or even 25 or 30 pounds — over ideal weight, and has a blood pressure of 120 over 80 and normal cholesterol, "I start talking with her about how she’s going to accept her weight," she explains.

It’s a tough sell, though. As long as women fixate on the popular images of beauty, Silver continues, "We will not be allowed to feel good about how we look." Let’s say a client comes from an obese family. "She’s got the gene, and she has to figure out how she’s going to live with it."

Women can be 20 pounds over ideal weight and be fit, Silver contends. "Most of the women on diet drugs were taking them for ridiculous reasons," she asserts, adding, "They’ve bought the American ideal of the 110-pound woman."

Even in the cases of morbid obesity in which diet medications are indicated, they’re a little piece of a long-term therapeutic regimen. Joel Posner, MD, professor of medicine and director of the Meta-H weight management program at Allegheny University of the Health Sciences in Philadelphia, reports that the 20% percent of patients in Meta-H who used the medications were on them for only three to five months.

"But they need four or five years to rethink their relationship to food and learn to exercise regularly and to retrain their tastebuds to enjoy more than fat-rich foods," Posner explains. (For consumer teaching handouts on healthy eating choices, see inserts, "10 Food Secrets You Should Know!" and "Food Guide Pyramid.")

For women’s health providers, the moral of the fen-phen tale is to support women in making smart choices among marketplace options. Take a cue from the warning Posner extends to his weight loss patients: Chemicals potent enough to manipulate a primal instinct like hunger will have side effects. Count on it. ß