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Another anti-obesity pill bites the dust

Ami Banerjee
Last edited 17th March 2010

If you search PubMed for articles relating to body-mass index, obesity, and mortality you will see an explosion in the number of articles in the last 5 years, as scientists try to characterise and explain the long-term effects of obesity. Perhaps the most impressive data came from an analysis from Oxford, which collaborated data from nearly 900 000 patients in 57 trials. It found that BMI above 25 increases the risk of death, predominantly due to vascular diseases, like coronary heart disease. A BMI of 30-35 reduced survival by 2-4 years; and a BMI of 40-45 reduced survival by 8-10 years, which the authors compared to the effects of smoking. I have written before about the huge public health cost of obesity, estimated at £3 billion per year in the NHS.

Now search PubMed for “anti-obesity” and “weight loss” and you will get 2544 and 71550 hits respectively. This tells you about the research going into finding a cure for obesity and the potential profits from such a cure. These two search terms in Google will give you literally millions of hits from dietary fads and “mandometers” to prescription pills promising to shed those pounds.

This week, two stories relating to fat have dominated the headlines. Firstly, a Royal College of Surgeons conference heard that around one million people meet NICE criteria for weight loss surgery (also known as “bariatric” surgery) with around 240,000 wanting surgery yet only 4,300 NHS weight-loss operations were carried out last year. The Medical Defence Union has also reported a rise in the number of claims against doctors whose patients have suffered complications of obesity-related surgery.

The second story relates to sibutramine (“Reductil”), the weight loss pill that the European Medicines Agency suspended, and the US Food and Drug Administration restricted from its list of licensed drugs. The reason for these decisions is that sibutramine causes a 14% increase in the risk of heart attacks and strokes, compared with placebo. The way in which these decisions have been made raises concerns about the discrepancies between judgments of different drug regulating authorities and how quickly such data should be made available to these regulating authorities. As the BMJ notes, European doctors are now left with only one anti-obesity pill, orlistat (“Xenical”), for use in the treatment of obesity.

It is high time for a dose of reality. Whilst I agree that unequal care to any treatment across the NHS is unethical, we are never going to be able to provide a quarter of a million people bariatric surgery, or to provide everybody with weight-loss pills in a tax-funded, public healthcare system. We need to have a proper debate about personal versus social responsibilities for health and for healthcare, and start talking about the simple public health measures of diet and exercise again.

After Christmas and in the run-up to Lent, people are often thinking about New Year’s resolutions and what to give up. One of the most common excesses that people want to address is food. This is the most common time of year to start new diets, exercise regimes and gym memberships, and yet obesity, particularly in childhood, is on the rise. The direct cost of overweight and obesity to the NHS has been estimated at over £3 billion. Inequalities in obesity have been identified between North and South, between men and women, and between social classes, and these inequalities seem to be worse for childhood obesity.

With the big public health problems of our age, whether smoking and high blood pressure, or diabetes and obesity, there are health inequalities, but there are also cheap, simple, population-wide interventions which can save thousands, if not millions, of lives. In the case of childhood obesity, it is not rocket science- healthier diet, less processed food, more exercise, and there are signs that the childhood obesity epidemic is levelling off. However, there is a constant push by device companies and drug companies to offer more complicated solutions which will produce big profits for them in these disease areas, because they affect so many people in the population.

This week’s BMJ includes a randomised controlled trial of a novel computerised device, the Mandometer, which provides feedback to participants during meals to slow down speed of eating and reduce total food intake. The trial ran for 12 months comparing the Mandometer with standard lifestyle modification advice and included 106 obese people aged 9 to 17 years. The Mandometer group had a BMI 0.24 units lower than the group receiving standard care. Not only does this seem a paltry difference in BMI; two of the study authors own 60% of the company which produces Mandometer, and so it is unsurprising that they found a positive effect for their device. It is hard to envisage a world where this device is going to be widely used or where it is going to make any difference to childhood obesity. If widely used, such devices will at best only increase the socioeconomic inequalities which already exist in childhood obesity. Surely the simple, population-wide policies of encouraging more exercise and better diet should be promoted instead?

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