…but your scientists were so preoccupied with whether or not they could, they didn't stop to think if they should(Dr Ian Malcolm in the 1993 movie Jurassic Park).  

I was at “The Obesity Society” meeting this week, and with some of the new research being presented as well as some other news in the field of obesity, I began to wonder if the above quote is now been taken to the other extreme, especially with obesity and activity. Are we again asking if we should be treating obesity medically, whether or not we can? 

On the “exercise more” side of the equation, what if there were a pill that mimicked exercise? By understanding differences in activity amounts in mice, scientists have been able to change several genes in muscles to make normal mice into “marathon mice”. And, they are in early tests of a pill that will also cause these changes. Imagine the day when you might have all the benefits of exercise while sitting on the couch watching TV. But is that a good thing, should we be even developing such a pill?

On the “eat less” side, the second example comes from the recent FDA decision to withdraw sibutramine (Meridia®) from the market. Sibutramine was a medication that primarily increased a chemical in the brain called serotonin (so it was similar to many depression medications and some migraine medications) but it did this in the appetite part of the brain not the mood or the “migraine” part of the brain. Sibutramine also increased a chemical in the brain called noradreanalin (like adrenaline but mainly increased in the brain, not all over like adrenaline, many other mood medications also increase noradrenaline). Because noadrenaline can be like adrenaline, and adrenaline can make the heart work extra hard, a study was done to see if sibutramine increased the risk of heart problems in people with obesity and heart disease and diabetes (who might benefit from weight loss but who are also at very high risk of another heart attack). In this study, called the SCOUT trial, older people with diabetes and heart disease who took sibutramine had a slightly but significantly greater risk of another heart attack or event (but no increased risk of dying) compared to people on placebo after using the medication for about 3.5 years. Because of this risk, and because the average weight loss in this study was not that high (about 5.7 lbs for the placebo and 9.5 lbs for the sibutramine group), the FDA felt the risks of this medication outweighed the benefit and decided to withdraw it from the market a few days ago. Did we again get ahead of ourselves; was this another case of seeing if we could decrease weight, and then when we were able to do this, had we forgotten if we should?

My thoughts on both supporting the effects of activity and decreasing appetite with medications is that we should be exploring these options and we need to continue to see how this can best be done. With the “exercise in a bottle”, it is possible that this could treat many other muscular dystrophies. It could also have a dramatic benefit on people who cannot be active for a variety of other reasons and are at risk for weight gain, from injuries to arthritis to even perhaps aging. Likewise with the sibutramine, I saw a dramatic effect on weight in some individuals, enough to bring diabetes under control without the need for an additional medication or to allow for a safer hip or knee surgery. In fact, in the same journal the SCOUT trial was published in, there was another study of sibutramine published five years ago that showed with intensive lifestyle intervention there was an average weight loss of over 25 lbs (N Engl J Med 2005; 353:2111).

If you look carefully at my argument, you will notice that I am saying we should continue to find “weight loss pills” because of specific cases. Cases where they support activity when it is otherwise not possible, or where they might support “will power” (see the previous blog for more on this). But the use of these medications should only be when it is really effective, and for the right person. 

Is this leading to a slippery slope? If we are able to increase those exercise centers in muscles and decrease those appetite centers in the brain in a safe and effective way, will everyone just want the pill, no one will need to eat right or be active. I still believe the benefits of these treatments will outweigh the risks (including the risk of losing all the additional benefits beyond weight loss of eating right and being more active), although we in the medical community and as a society will have to be disciplined in giving them to the right people and make sure we optimize diet and activity first and whenever possible. Do you agree, do we need more medical treatments for weight loss that support diet and exercise, or do we already have the answer and people need to just be more active and eat less?