Rating the Diet Doctors

ONCE UPON A TIME, SPECIALISTS AND SURGEONS regarded die! doctors as the physicians lowest on the medical totem pole-quasi-quacks, second-cousins to snake-oil salesmen. Many still do. With scant science to back them up, die! doctors were seen as predators of those battling fat in an image-conscious society, desperate for a quick-fix. Who can forget liquid-protein diets like Optifast and Medifast? Or Dr. Stillman’s “Quick Weight-Loss Diet” in the late ’60s? Despite the estimated $3 billion Americans spend yearly on diet-related products and services, we are still fat and getting falter.

However, diet obsession has produced some benefits: increased awareness of the importance of weight loss to maintaining good health and a new way to look al obesity-as a chronic illness. Some overweight people, say researchers, are victims of heredity, with fattening lifestyle habits that might not make someone with a different set of genes obese. Some doctors who treat the obese are gaining new respect ability through their own specialty: bariatric medicine.

But this new-found legitimacy may vanish with the billboard advertising of the combination drug referred to as “phen/fen” and Redux, which in 1996 became the first new diet pill approved by the FDA in 23 years. Weight-loss clinics dispensing these drugs are cropping up around Dallas and the rest of the nation like middle-age spread, serving up pounds of promises to help you lose weight, keep it off, feel great and look fabulous-and do it all without a single hunger pang, Some bariatric specialists and other physicians not particularly trained in treating the overweight are doling out diet-pill prescriptions faster than ever.

The public’s appetite for the new pills has made significant inroads in the world of weight-loss clinics that dish out prepared foods and liquid diets. Big national chains like Jenny Craig and Nutri/System have changed their conservative, portion-control approach and now contract with physicians who dole out the new appetite suppressants to some patients. But they face intense competition from prestigious private-practice physicians who write prescriptions for the very same diet pills and manage their patients’ weight loss alongside their regular practices.

With so many choices, dieters can be confused. Who’s better- the diet clinics or bariatric specialists? Will a personal physician do the best job of monitoring weight loss? If a doctor says no to diet pills, does that mean he or she is out of touch or just cautious? Should you seek any doctor who can prescribe drugs just to get your soon-to-be-slim hands on a prescription? Are these new diet pills really the pharmacological, high-tech answer to obesity? Or are the potential side effects so harmful that any doctor who casually prescribes them or is inaccessible to his patients should be viewed with suspicion-maybe even as downright dangerous?



THE GOOD DIET DOCTORS

Amphetamines, often called “speed,” were prescribed liber-ally during the ’50s and ’60s for weight loss. Patients lost weight, but they also became addicted to the incredible stimulation and euphoria of the drugs. This association between diet doctors and speed lingers still.

Amphetamines are not recommended for weight loss today. Current diet pills are only amphetamine-like in their chemical structure. According to James F. Merker. executive director of the American Society of Bariatric Physicians in Englewood. Colo., mainstream medicine has moved to an understanding that today’s diet pills are completely different. Most physicians like the diet drugs, if used properly and if the risk of obesity outweighs the risks of the medication. And these doctors tell you right off that phen/fen and Redux are not speed or amphetamines. They are so different, in fact, that some dieters have the opposite problem: They become drowsy on Redux and D-fenflura-mine, a derivative of fenfluramine.

Fenfluramine has been around since 1973-one brand name is Pondimin. It decreases appetite by increasing the brain chemical serotonin, raises metabolism during physical activity and following meals, and delays gastric emptying, which may suppress appetite.

While fenfluramine calms, the appetite suppressant phentermine stimulates, elevating another brain chemical called noradrenaline fas caffeine does). Many doctors have been using these diet drugs separately for years.

But in the late 1980s, pharmacologist Dr. Michael Weintraub of the University of Rochester tried combining phentermine and fenfluramine. It was a successful marriage of opposites: Weintraub’s studies, which included dieting and exercise, showed the phen/fen combo to be an effective appetite suppressant, People on the two-pill combo lost more weight until they went off them than those who took a placebo.

Fueled by changes in the health-care market as well as pharmaceutical research, the bariatric specialty has surged, says Merker. Membership in the ASBP has doubled in the past five years to 1,400 members nationally. (Board certification requires testing; membership in the ASBP requires only an application and a fee.)

“Many physicians are very dissatisfied with the managed-care environment.” Merker says. “They come into bariatrics returning to a vanishing breed-the solo practitioners who can have a relationship with their patients free from the dictums of a third-party provider or HMO.”

Whether patients want to lose five pounds or 50. bariatric doctors advise them to select a doctor who has been treating obesity long enough to be knowledgeable. “You need a complete treatment program,” says Dr. Arthur Raines of Dallas, “not just someone who’ll hand you a prescription for pills.”

Raines keeps a photograph of himself in his top desk drawer- himself plus about 50 pounds. It is a reminder, he says, that he still fights obesity and will fight it as long as he lives. Initially board-certified as a pathologist (he manages health care for Johnson County). Raines has been researching and treating bariatric patients for 14 years in Dallas, Cleburne and Fort Worth. He recently helped the Texas Slate Board of Medical Examiners update its position on bariatric medicine standards and prescription of diet pills. Raines says he will seek board certification from the ASBP when it is officially recognized as an American specialty board.

But Raines admits the new medications alone are not the answer to losing weight. “These pills are not magic bullets.” he says, Redux and phen/fen are simply aids to give the obese patient a window of time in which to get a grip on a diet and make permanent lifestyle changes such as sensible eating and regular exercise. A week or so after a patient stops taking the diet medication, the brain’s beefedup serotonin levels usually return to normal. If the patient continues to eat high-calorie, high-fat foods, he’s going to become fat again.

The Cooper Clinic in Dallas has helped thousands of patients run off fat and sweat their way to slimness for almost 27 years. But even here, at the mecca of health and aerobics, Kenneth H. Cooper. M.D.. president and chairman of the Cooper Aerobics Center. admits he has put a few patients on Redux and phen/fen. Still, he is surprised the FDA approved Redux as a diet pill. “I use diet drugs only on the morbidly obese.” says Cooper, “which is how they were intended to be used.”

At the Cooper Clinic, diet patients get an extensive work-up, starting with a comprehensive examination. 25-page medical history and stress test; body fat analysis; complete blood and lipid studies; and a nutritional analysis of their eating style. The price range: $1.200toSl.800.

St. John Medical Center ceased the weight-loss aspects of its business last year because they were too costly, patients were too difficult and other clinics were offering weight-loss programs for far less. The diet program was a bargain compared with the Aerobics Center; The $500 price included an EKG, body fat analysis, blood work, thyroid profile, urinalysis, physical and 300-ques-tion history. Only after those tests were completed would doctors consider a patient for diet pills.

“It’s easy and it’s cheaper to hand them a scrip and say ’adios,’” says Gar)’ Greer, St. John president and chief executive officer. “You attract a lot of nuts in the diet business. I don’t understand how these places can hang on for such low, low lees. It’s like they are making sure the patient’s breathing and writing him a prescription. We chose to get out of the business rather than lower our standards.”

Dr. J. Harvey Johnson, medical director of the Institute of Preventive Medicine, knows the agonies of the obese. He was told to lose weight-or die. At age 54, Johnson was a 6-foot-3, 240-pound obstetrician/gynecologist in Garland whose high-stress lifestyle was off the Richter scale. He had five coronary bypasses; two weeks after the last one, he had a heart attack.

Johnson traveled to Oakland, Calif., to attend Dr, Dean Ornish’s retreat on reversing heart disease. With dietary and lifestyle changes, including 40 minutes a day of exercise-and no diet pills-Johnson got his weight and cholesterol down and whittled his body fat to 12 percent. That’s why the 61-year-old physician decided to spend his retirement as a diet doctor. Good diet programs, he says, educate the dieter and change his lifestyle.

“There are lots of misconceptions about eating out there,” says Dr. Johnson. “People think it’s OK if they’re not eating fat, but if you overdo the carbohydrates and simple sugars, it turns to fat.”

No mailer how good the physician or the diet, the hardest part is not just losing weight, but keeping it off. Even with the new diet pills, doctors say most patients still regain once they stop the medication and the dieting. Some say there may even be a “rebound” effect-that when patients first go off the medication, they may actually eat more until brain serotonin levels adjust.

“Eighty percent of diet patients will put weight back on when they quit the medication,” says Dr. Johnson. “But if they stay with the program for three to six months after reaching their goal weight, we find 80 percent will be successful in keeping the weight off with lifestyle change.”

The key word here is lifestyle. But too many dieters simply want to get their hands on the quick-fix diet pills. And far loo many doctors and clinics are willing to accommodate them.



PILL MILL PHYSICIANS

OVERWEIGHT PATIENTS CAN SAFELY LOSE 50 TO 100 POUNDS TAKING Redux under close supervision by an internist who can warn them of all potential side effects, says Dr. Lynn Markle. psychiatrist and clinical director of the eating disorders program at Presbyterian Hospital of Dallas. But she says most Dallas diet clinics promise too much and are too aggressive about marketing diet pills.

“Some of these programs are basically a real commercial rip-oft”, ignoring hidden psychological issues,” says Markle. “An overweight patient’s problems cannot be fixed in a month or two with diet pills.’’

Some local diet doctors are handing out pill prescriptions like business cards. One 25-year-old Dallas woman-only 20 pounds overweight-got her phen/fen prescription at a Saturday morning group clinic in Mesquite: no tests, no physical. The “nurse” just asked her how much she wanted to weigh.

For the most part, says St. John’s Greer, patients don’t see the crème de la creme of the medical profession at diet clinics. He says many clinics hire floater doctors or retired physicians: It’s potluck whether patients get one who cares or one who could not care less. Some patients see a nurse or physician’s assistant on follow-up visits.

The Institute of Preventive Medicine is a mere toddler in the Dallas diet business. Only 2 years old, it already has three locations, in Dallas, Bedford and Piano, with eight part-time doctors on staff. Diet patients are taught how to read food labels, and patients can seek help from an exercise physiologist, a nutritionist and hypnotist.

But many don’t participate-they just want the pills. Dr. Johnson says that when his clinic has run advertisements for a pill-free weight-loss program called Apex, nobody called for information. The words “diet pills” work magic in an ad.

Johnson says he saw more than 7.000 patients last year-about 20perday. Sources say Johnson’s Forest Lane clinic alone may be clearing as much as $50,000 a month from the diet business.

Many diet clinics may be using the tactics of some segments of the health-club industry: hard sells that promise the moon but offer little personal attention. At Weight Loss Management at Preston Road and Forest Lane, a “diet counselor” told a potential client who wanted to lose 10 pounds that she really needed to lose at least 33. The counselor assured the client she could eat whatever she wanted and the weight loss would take only 10 weeks. The counselor offered the S849.98 program at a special discount of $249.98, even before the patient saw the doctor. “I’ll get this weight off you,” the counselor promised. She even suggested in a confidential manner that the client could “share” the program-insinuating the pills-with her husband.

About a year ago, when Redux was first released, Dr. Jody Wilkinson, a physician with the Cooper Institute for Aerobics Research, had his wife, who is not obese, check out several weight-loss clinics. He was alarmed at the aggressive sales pitches utilized by the young women working the front of these clinics.

“My wife told them she was trying to get pregnant and asked if the diet pills could hurt her or the baby,” Wilkinson says. “They told her how great the pills were and not to worry about pregnancy right now.”

Many of the same tactics are prevalent in other area weight-loss clinics. They offer potential patients “free” consultations. During this initial encounter, the dieter has his or her blood pressure checked and a half-page medical history taken. Then the “consultant,” who may or may not have any medical training, tells the patient because he or she is so “healthy” that-if they sign on the dotted line committing to a monthly program-the doctor will probably write a diet pill prescription.

“What scared me,” says a Dallas nurse who consulted one North Dallas clinic, “was that they wanted to give me thyroid pills even before I had a blood test to see if I had thyroid problems.” (Thyroid disorders should be diagnosed through medical tests.)

Some responsibility belongs to the diet clients. Weight-loss patients are fickle and will scan ads to see what other clinics in town offer and for how much, says bariatric medicine consultant Sharon Cooper. Another problem, say consultants, is that the diet business attracts many patients who carry as much psychological baggage as they do extra pounds. And that’s where the serious problems can begin.

Although the Drug Enforcement Agency considers the new diet medications low on the potential abuse scale (far more emergency rooms across the state report problems with aspirin than with phen/fen or Redux), that doesn’t mean mat they are always safe. The national enthusiasm for phen/fen and Redux has obscured the fact that some people can suffer serious side effects from the drugs, even death.

THE DOWNRIGHT DANGEROUS

THE LIST OF SIDE EFFECTS FROM THESE DIET PILLS IS EXTENSIVE: complaints range from sleepiness to chest pains to irritability. These conditions are mild, though, compared with national répons that cite deaths of diet patients from primary pulmonary hypertension, or PPH, a rare, irreversible disease that constricts blood vessels in the heart and lungs. Studies have shown rates of PPH among patients on fenfluramine for more than three months are about 20 times the rates that occur annually in the general population, according to the ASBP.

PPH isn’t the only problem these medicated dieters face. Half adozen hospitals in Southern California have reported that surgery patients on phen/fen suffered life-threatening adverse reactions while under anesthesia. Close calls at one Piano hospital provoked one group of anesthesiologists recently to ask patients to cease all diet medications at least two weeks before surgery.

The problem could get bigger. This month, the FDA may approve Hoffman-Laroche’s Xenical, a new class of diet drug that blocks an enzyme in the intestine needed to absorb fat, preventing 30 percent of an obese patient’s ingested fat from getting beyond the intestine. Data presented to the FDA in May showed that three times as many dieting patients on Xenical lost 10 percent or more of body weight when compared with patients on a placebo. Side effects, however, can include nasty gastrointestinal problems-oily, loose stools or even bariatric leaks. Xenical also can block absorption of vitamins D and E and beta carotene. And the Drug Enforcement Agency will likely de-schedule fenfluramine and D-fenfluramine, making them easier to prescribe and refill. (Prescriptions of scheduled drugs require a doctor’s DEA number and have refill limits.)

Common sense dictates the importance of having quality medical care and adequate attention from a diet doctor. But some diet doctors play hard-to-get. They often do not carry beepers, though, if patients are lucky, they may have answering machines. They accept cash only and will give patients diet pills without even weighing them. (One Dallas diet doctor has been known to listen to a patient’s heart without putting his stethoscope in his ears.)

Dr. L.G. Thompson has been treating obese patients since 1980 at the Bariatric Medicine Clinic on North Central Expressway. He has a staff of nurses and medical assistants that patients can call if they have problems. And several physicians who have worked there say the clinic has a good diet program. But these physicians also say Thompson is seldom in the office; some patients refer to him as the “phantom doctor.”

Over the years, thousands of obese patients have lost weight at Thompson’s clinic. His waiting room prominently displays heart-wrenching testimonials from happy, formerly fat patients.

The treatment is comprehensive-but it’s also expensive and controversial: Patients receive a doctor’s exam, medications, mineral supplements and a diet limiting them to a miserly 400 to 800 calories a day. To gel the pills, they must attend weekly group therapy led by a competent clinical psychologist.

“I always felt like I was in a herd being processed,” says Sherylen Cobb, who spent more than $400 in less than four months at Thompson’s clinic. “There was very little individualized attention when 1 was going. And I felt he was downright insulting.”

Thompson’s methods do lead to weight loss. His staff does teach good skills, such as learning to gauge portions and how to eat low-calorie in restaurants. Some patients, though, complain they learned to avoid eating rather than how to eat properly. Thompson’s regimen is time-consuming-taking liquid potassium, testing urine for ketones, counting calories scrupulously-and requires drinking so much water that patients say they need to tote a toilet. “I wore a path to my bathroom looking for ketones,” says Cobb, who recently lost 64 pounds on her own.

But many patients never come into contact with Thompson. They see another doctor the first time for the physical, then are monitored by medical assistants and seen by the staff physicians at intervals. The 63-year-old Thompson is seldom at the clinic.

Thompson’s inaccessibility and allegedly rude behavior to patients have resulted in problems with the Texas State Board of Medical Examiners. Some complaints resulted in disciplinary actions by the board in 1992. For example. Thompson was accused of intentionally misleading the public with newspaper advertisements saying that Fluoxetine (Prozac) could safely induce weight-loss. He later discontinued the ads. He also was accused of addressing (wo patients, identified only as “J.S.” and “F.H.,” in a demeaning manner in front of other weight-loss patients and publicly, loudly terminating their doctor-patient relationship.

Thompson also was accused of signing blank prescription forms, tucking them in patient files, then letting his nursing staff fill in the anorec-tics (appetite suppressants) and doses, as well as misdiagnosing five patients as having diabetes when their glucose levels were normal and subsequently billing them and their insurance carriers for treatment of diabetes. To settle the disputes, Thompson signed an agreed order on June 19,1992. in Travis County. He maintained that he had done nothing improper but agreed to abide by the Medical Practice Act of Texas. (He declined to comment for this story, other than to say he is now retired.)

The board action wasn’t all of Thompson’s legal problems. According to Dallas County records, two criminal-assault charges have been filed against him. In October 1991. Thompson was arrested by Richardson police during a deposition after he was accused of assaulting an opponent in a lawsuit. According to records, Thompson was convicted and spent a day in jail. Later, in October 1994, Thompson was arrested by Balch Spring police when Marietta Cate, Thompson’s 29-year-old girlfriend, complained he had assaulted her. The case was dismissed because Cate did not appear in court.

But the doctor’s legal troubles don’t bothersome dieters, whose desperation to be thin at all costs is as much a part of the problem as the doctors who prey on them. “It wouldn’t matter to me what he does outside of the clinic.” says one current Thompson patient who has spent $3,300 to get rid of 50 pounds, “All I know is I lost that weight and I lost it fast.”

THE MOST PRESCRIBED DIET PILLS

The most popular weight-loss drugs in Dallas are Adipex, Pondimin and Redux, Phen/fen is a combo of the first two. lonamin is a form of phentermine.

ADIPEX-P: Phentermine (HSL and resin); S46.05 for 30. Daily dosage: 15 to 30 mg. Suppresses appetite by increasing brain chemicals noradrenaline and dopamine. Possible side effects: increased alertness, insomnia, nervousness, headache, palpitations, elevated blood pressure, tremors, dry mouth, diarrhea, constipation, impotence.

PONDIMIN: DLFenfluramine; $38.65 for 60 (month supply). Daily dosage: 60 to 120 mg. Decreases appetite by increasing serotonin, increases metabolism, decreases time food passes through stomach. Possible side effects: nausea, diarrhea, drowsiness, dizziness, memory loss, headache, insomnia, moodiness, confusion, constipation, sweating, chills, blurred vision, blood pressure changes, palpitations, rash, libido changes, primary pulmonary hypertension.

REDUX: D-fenfluramine; $78.75 for 60 (month supply). Daily dosage: 15 to 30 mg. Reduces caloric intake by 13-25 percent by increasing serotonin and raising metabolism. Possible side effects: fatigue, diarrhea, dry mouth, in* creased urinary frequency, drowsiness.

IONAMIN: Phentermine (HSL and resin); $47.35 for 30; generic, $12.35. Daily dosage: 15 to 30 mg. Suppresses appetite by increasing brain chemicals noradrenaline and dopamine. Possible side effects: insomnia, nervousness, headache, palpitations, elevated blood pressure, dry mouth, tremors, diarrhea, constipation, hives, impotence.