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Obesity is a disease that affects millions of American adults, adolescents, and children, posing serious health risks. Medical professionals generally consider obesity to be a chronic illness requiring life-long treatment and management. It is often grouped with other chronic conditions, such as high blood pressure and diabetes, as a condition that can be controlled but not cured. One is considered obese if 20% over ideal body weight, according to standard height-weight charts, or if one's Body

Mass Index, or BMI, (a ratio of height to weight, indi-caating the amount of fat tissue in the body) exceeds 30%.

The most important strategies for managing obesity are not medications but rather, a healthy diet coupled with moderate exercise. As in other chronic conditions, the use of prescription medications may assist in managing the condition for some individuals but it is never the sole treatment for obesity, nor is it ever considered a cure.

The class of medications used most often for weight loss are commonly referred to as "appetite suppressants."

■g These medications promote weight loss by helping to

£ diminish appetite, and/or by increasing the subjective

£ feeling of fullness. They work by increasing serotonin or

S catecholamines, two neurotransmitters (chemicals) in su the brain that affect both mood and appetite. te

£ Several prescription medications are currently approved for treatment of obesity. In general, the effects ^ of these medications are modest, leading to an average initial weight loss of between 5 and 22 pounds; though studies show that weight returns after cessation of the drugs. There is considerable individual difference in response to these medications; some people experience greater weight loss than others. The goal of prescribing weight loss medication is to help the medically at-risk obese patient "jump-start" their weight loss effort and lose 10% or more of their starting body weight. When this can be accomplished, it usually leads to a reduction in risk for obesity-related illnesses, such as high blood pressure, heart disease and diabetes. Weight loss tends to be greatest during the first few weeks or months of treatment, leveling off after about six months. Research suggests that if a patient does not lose at least four pounds during the first four weeks on a particular medication, that medication is unlikely to be effective over the long run. Few studies have addressed safety or effectiveness of medications taken for more than a few months at a time. Little data exists on the long-term effectiveness of the drugs.

All but two of the prescription appetite suppressants in the United States have been approved by the U.S. Food and Drug Administration (FDA), for short-term use only. Short-term use generally means a few weeks or months at the longest. One appetite suppressant medication was approved for longer-term use within the past decade, but that drug, dexfenfluramine (Redux) was withdrawn from the market because of unacceptable risks associated with its use.

Another medication was approved within the past few years for longer-term use, up to a year and possibly longer, in significantly obese patients. This drug, an appetite suppressant, is called sibutramine (Meridia). Individuals with a history of heart disease, irregular heartbeat, high blood pressure, or history of stroke should not take sibutramine. All patients taking this medication should have their blood pressure monitored regularly.

A relatively new drug, orlistat (Xenical), was approved in 1999 by the FDA for at least a year or longer, as well. Orlistat is not an appetite suppressant, but rather, a member of a new class of anti-obesity drugs known as "lipase inhibitors." These medications work by preventing enzymes in the gastrointestinal tract from breaking down dietary fats into smaller molecules that can be absorbed by the body. The result is that fat absorbed from food is decreased by about 30%. This effectively reduces the calories absorbed by the body by 30%, aiding in weight loss.

While the FDA regulates how a medication can be advertised or promoted by the manufacturer, these regulations do not constrain physicians from prescribing them as they believe appropriate. This practice of prescribing medications for conditions other than those for which they were approved, or at different dosages, or for different lengths of time, is known as "off-label" use. Many of the prescription medications available for weight management are used in an "off-label" manner.

Most of the side effects of prescription medications for weight loss are mild; but some very serious complications have been reported in recent years. They were so serious that two medications were voluntarily removed from the market by the manufacturers in 1997.These two medications, fenfluramine (Pondimin), and dexfenflu-ramine (Redux), were shown to be associated with a rare but very serious and potentially fatal disorder known as primary pulmonary hypertension (PPH), a disease of the lungs. Forty-five percent of patients with PPH die within four years of diagnosis.

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