Frustrated dieters have been quietly spreading the word about a controversial use of mood meds: effortless weight loss. Elizabeth Weil investigates the questionable trend.
Everybody wants to look like the women on Justin Gelband‘s listlithe, luscious, toned, and tightand when prospective clients approach him, the New York-based trainer doesn’t just ask which shows and shoots they’re preparing for, he asks them if they’re clean. Gelband isn’t inquiring about cocaine. He’s not even asking about cigarettes or alcohol, though he cares about that, too. “It’s become a huge fad to use prescription drugs to lose weight,” he told me. “It’s even more everyday clients than it is the models.”
Some confess their pharmaceutical habits right away, telling Gelband they’re taking Adderall or Wellbutrin or any number of drugs that doctors prescribe off-label to help melt away pounds. Others are more coy. But partway through his workouts, which combine boxing, yoga, and Pilatesworkouts, incidentally, that have brought supermodels into pre-baby shape in less than three months without any medicinal edgeGelband always knows. “She fades because she’s not eating or because she’s taken something that gives her a short lift but then she can’t hold up the intensity of the workout,” he says. “It’s a big epidemic right now.”
In the Mad Men era, women chain-smoked and guzzled coffee to slide into their pencil skirts. Now they’re dipping into their medicine cabinets, maybe even the ones in their children‘s bathrooms. On the surface, this approach looks much cleaner, healthier: no ashtrays, no cancer, no stained teeth, just a discreet little pill that easily blends in with all the Yoga, Spinning (incase you need to buy a spin bike for workout at home, check out spin bike reviews here), and Gwyneth-inspired cleanses women do to maintain their figures.
For physicians, prescribing pills off-label for dieting is common and legal. Federal regulations allow doctors to prescribe almost every drug to patients for any reason at any time. (The rules are different for pharmaceutical companies; for them, promoting off-label drug use can be a felonyand a frequently prosecuted one, too.) As a result, women are heading to the pharmacy with hopes of shedding a dress size.
This gray market for thinness is hard to track, as much of the evidence for it exists in private, often coded conversations in doctors’ offices and shady Internet dealings. But culturally, the trend is predictable, perhaps even inevitable. Americans, as a group, have a convoluted and dysfunctional relationship with their weight. Our bookshelves sag with diet tomes, our gyms stay open 24 hours a day, and still the country is obese. We’re a fat country obsessed with skinnyand a quick fix.
Furthermore, the Food and Drug Administration is tied in knots over the question of whether obesity is a disease or a personal failing; thus it’s been largely unable to decide whether we should treat a weight problem with pharmaceuticals in the absence of other major health risks. The FDA has been slow to approve new weight-loss drugs in the wake of the fen-phen debacle. In 1996, fen-phen, a combination of two appetite suppressantsfenfluramine and phentermine, neither of which caused significant and lasting weight loss on its ownwas hailed as a miracle cure; doctors were writing 85,000 prescriptions a week. A year later, physicians started reporting untreatable heart-valve problems in patients who took fenfluramine. By September 1997, the fen-phen craze was over. Fenfluramine was removed from the market.
Today, FDA-approved choices for dieters remain slim. Only one diet drug is available over the counter: Alli, a compound that prevents the body from metabolizing fat and has the unfortunate side effect of causing diarrhea in some users. A handful of meds are available by prescription. The oldest and one of the most common is phentermine, but the FDA authorizes its use only for twelve weeks (because there are no data on its long-term safety). Last summer, the FDA approved two new drugs: Belviq, known generically as lorcaserin, is also an appetite suppressant and works by activating a single serotonin receptor in the brain, making a person feel full. The second drug, Qsymia, is a combination of phentermine and an anti-seizure drug called Topamax; it seems not to have the negative side effects of fenfluramine, the problem component in fen-phen. All three are sanctioned only for patients with body-mass indexes over 27 (170 pounds for a woman who is five feet six inches tall) who have weight-related health problems or those with BMIs over 30. People seeking a medical edge to drop five or ten or even fifteen pounds have no “on-label” option.
This is not preventing relatively trim women from taking pills. AJ Johnson, a celebrity wellness coach in Los Angeles, sees a lot of use among her already svelte clients and blames what she calls “our multitasking lifestyle.” “We take a cocktail of medications just to get through the day,” she says. “We take something to burn fat, something else to sleep.” Just recently, Johnson herself went through a dark phase, using supplements and all sorts of pills to try to burn her already limited body fat. She wanted to look not just fitwhich, as a trainer, she already wasbut exceptional. “I live in Hollywood. It’s me on camera, not just my clients. I wanted to take my body to a whole new level.”
At first Johnson tried meeting friends for hikes instead of for drinks. But she didn’t see the results she wanted. So she started taking pills. The binge ended badly, of course. Johnson called her doctor, complaining of chest pains. He asked her to come in for an appointment and bring everything she was taking. “Here I was, thinking I’m Miss Clean, and I filled a Whole Foods shopping bag. I couldn’t believe I’d become that girl who takes six pills a day. I was so embarrassed. I’m supposed to know how this all works.” As Johnson can attest, even those focused on health and wellness can succumb to the overwhelming pressures to be thin. “You think you’re not included and then you’re sneaking your friend’s asthma inhaler because you heard it suppresses appetite.”
Jackie Keller, also a wellness coach in Los Angeles, notes a related phenomenon: high achievers overcome by their waistlines. “People who are engaged in their careers and involved in their lives are just at wit’s end when it comes to their bodies,” says Keller. “Weight loss can seem so overwhelming. People feel completely ill equipped to handle the problem.”
Enter the 10-mg. secret weapon. Off-label drug use for weight loss is not just a Los Angeles or New York practice. Trisha Danula, a 34-year-old who lives in Fairfax, Virginia, recently lost fifteen pounds the old-fashioned wayby following a strict diet and exercise planand stayed skinny for a while, then noticed the weight creeping back. A co-worker who’d recently lost and kept off more than 50 pounds suggested she see Michael Anchors, M.D., Ph.D., a bariatric physician in Gaithersburg, Maryland. At Danula’s first appointment, Anchors counseled the five-foot-four-inch firefighter about portion size and consuming minimal sugar. Then he wrote her two prescriptions: one for phentermine, the other for Prozac, even though she was neither obese nor depressed.
“Did the pills help?” I asked Danula when I phoned her one recent afternoon.
She answered with a resounding yes: “They put you in a better mood, you’re not as hungry, and they give you lots of energy.” Danula did not experience the exercise fadeout that Gelband often sees; in fact, quite the opposite. “I ended up working out twice as long as I normally would,” she said. Today she is fifteen pounds lighter and continues to take her meds.
The majority of Anchors’s patients are significantly overweight, but he believes frustrated dieters deserve pharmaceutical help to lose even a single pound. As he said, “I have 20 years’ experience with these medications. I know they’re safe. Why not?”
Paul Rivas, M.D., who runs eight weight-loss clinics in Pennsylvania and Maryland, is also enthusiastic about pharmaceutical aids. “I treat hypertension with medication. I treat high cholesterol with medication,” he told me. “I treat obesity with medication. All the same.”
In some cases, Rivas, like Anchors, pairs phentermine with a second medication, a practice known as combo-pilling. “The two big things are compulsive eating, where people eat out of stress or boredom, and cravings,” according to Rivas. Neither, he believes, can be fixed with an appetite suppressant alone. Frequently the second drug is an antidepressantone of the SSRIs (Prozac, Effexor, Celexa), which, Rivas says, are “good at curbing sweet cravings,” or Wellbutrin or another dopamine drug, which are “better for salty things like chips.” These mood drugs have the ancillary benefit of helping to lift depression and anxiety, conditions that may have been contributing to the stress or boredom eating. Still, says Rivas, drugs like Prozac and Wellbutrin “don’t do a doggone thing for weight loss by themselves. You’ve got to mix ’em and match ’em. Then you can hit.”
But all drugs have side effects, and diet pills make medical sense only if the benefits more than compensate for the risks. Among the side effects for phentermine are heart palpitations, dizziness, headaches, and difficulty sleeping; for Wellbutrin, anxiety and seizures; for Prozac, drowsiness and loss of libido. Part of the FDA’s job is to weigh a drug’s potential harms against its therapeutic value and decide in what circumstances it will do the public good. Prescribing off-label circumvents this. “By definition, if it’s off-label, there isn’t enough evidence either for a doctor or a patient to accurately analyze the benefits versus the risks,” says Sidney Wolfe, M.D., director of Public Citizen’s Health Research Group. “Every one of these drugs has adverse side effects. No one has been able to find an appetite suppressant that doesn’t touch the heart.”
Adderall is arguably the riskiest pharmaceutical regularly used to trim down. The drug is an amphetamine and highly addictive. Its weight-loss properties are well knownin the 1960s a compound nearly identical to Adderall was sold under the brand name Obetrol as an FDA-approved “anorectic.” Obetrol was phased out because there was not enough evidence of its safety and efficacy as a diet pill (but now its on-label use is to treat attention-deficit/hyperactivity disorder, or ADHD). According to wellness coach Jackie Keller, some women buy it online from foreign pharmacies; others complain to their doctors about symptoms “that are thinly veiled disguises for other issues.” Pulitzer Prize-winning journalist Katherine Ellison, author of Buzz: A Year of Paying Attention, a book that explores treatment for ADHD, including her son’s and her own, has tracked Adderall usage in recent years and found what she calls “a bulge.” “There’s a huge increase in Adderall prescriptions among women in their mid-20s,” says Ellison. “It’s the fastest-growing segment.”
Tempting as it may sound, fast-talking oneself into an Adderall prescription is not a free ride to slim. Adderall’s side effects include insomnia, depression, and severe headaches. Worse, Adderall addiction can form in just a few weeks, and those hooked may experience hallucinations, delusional thinking, abnormal heart rhythms, and numbness in the hands and feet. Withdrawal can be both unpleasant and disheartening. Along with several weeks of fatigue, panic attacks, and paranoia, users often experience appetite surges, causing them to regain the weight they lost.
“Here I was, thinking I’m Miss Clean. I couldn’t believe I’d become that girl who takes six pills a day. I was so embarrassed”
Rachel Beller, a dietitian and founder of the Beller Nutritional Institute in Beverly Hills, sees a lot of clients who are trying to wean themselves from drugs used off-label for losing weight and views the whole adventure as a big mistake. “Most of my clients are women who looked pretty good to begin with,” says Beller. “Hollywood folks, actresses. They always say they want to lose seven pounds. Not five, not ten. Seven.” Often these women arrive motivated to hone their figures the tried-and-true way, through exercise and eating right. But then what Beller calls “lazy-mind syndrome” kicks in. “At some point, they’ll flop in a chair and say, ‘It was so much easier when I was taking the drugs!’ ” There’s also a lot of fear associated with stopping the medication. Says Beller, “They all think they’re going to balloon.”
For those trying to lose a significant amount of weight, some risk might well be worth it. Extra pounds can lead to high blood pressure, heart disease, and diabetes. What’s more, when a person has too much fat tissue, her metabolism is thrown off kilter, and lifestyle changes alone often can’t set it straight. As Anchors explains, “Obesity is not the result of hunger. Hunger is the result of obesity.” For this reason, in the obese, drugs can kick-start a positive-feedback loop, decreasing appetite and with it weight, allowing “the plane to get off the ground,” Anchors says.
But for those who are already trim, dabbling with drugs is bound to backfire. “If you haven’t changed your lifestyle, when you quit taking the drug you’re going to want 10,000 calories,” says wellness coach AJ Johnson. “You either do the work now or you do the work later. Much better to slow down, let shaping up take 60, not fifteen, days, and commit to the healthier way.”