THE DIET TREATMENT HALL OF FAME
Across the street, at the San Antonio convention center, the warehouse-sized exhibit hall was filled with vendors selling products to the group of bariatric physicians gathered for their annual meeting. There were body fat composition chambers, high-tech scales, protein powders, juicers, psychological support booklets, weight loss herbs, very-low-calorie diet shakes and bars, and mainly, a wide array of pharmaceutical drugs. A big rainbow-colored sign lists several prescription appetite suppressants, vitamins, and minerals. Everyone seemed to be selling chromium picolinate. When I asked the vendors how these various products work, I got the same answers from each one: “They help burn fat,” or “They curb your appetite.”
Walking through the exhibit hall was like taking a stroll through the Diet Treatment Hall of Fame, with many old favorites on display. At one booth, a sign advertised thyroid. “It’s commonly used,” the exhibitor told me. “It speeds up your metabolism.” A hundred years after its use as a diet aid was pronounced dangerous by physicians, here was thyroid being sold as a diet treatment. At another table, bottles of human chorionic gonadotropin were on display, despite the fact that the AMA warned against its use three decades ago. At another booth, the tables were spread with bee pollen capsules, coenzyme Q, chelation drip lopotropic combinations, and B-vitamin injections. The exhibitor refused to talk to a journalist, turning his face and aggressively shooing me away, as if my little notebook and I were a 60 Minutes team with a TV camera and bright lights. Most of the other booths in the exhibit hall advertised pharmaceutical drugs. The American Society of Bariatric Physicians was actually formed by a drug company, Western Research Laboratories, some forty years ago. Though the group split from the company in 1969, the strong pro-pharmaceutical spirit lingers.
Since nothing works to treat obesity in most people, physicians have, over the past century, tried almost anything. In the history of dieting, it’s been physicians who have probably harmed dieters most, prescribing sometimes-lethal liquid protein fasts, damaging and addictive amphetamines, strange potions of pig’s thyroid and growth hormones, and dramatic surgeries that involve all manner of balloons, staples, and wires.
The methods doctors use to treat obesity do work in the short-term, which is what keeps them going. But almost anything — lobster salad and champagne, pumpkin pie and amphetamines, or Optifast and appetite suppressants — works in the short-term. Despite physicians’ admonishments that their patients need to follow “maintenance plans” and “lifestyle changes,” most haven’t a clue how to help their patients keep their weight off long-term. They say it’s up to their patients to keep their dramatic weight losses off at a time when their bodies are fighting to get back to normal after a period of extreme starvation. When they almost inevitably gain the weight back, their doctors say they have no willpower.
Several exhibits at the bariatricians’ conference offered different varieties of very-low-calorie diets. Some had free diet cookies and bars on display to taste (the bariatrician standing next to me discreetly spat his sample into his handkerchief), and others featured powdered shakes and liquid diets. All promised safe, rapid weight loss. These cookie and shake programs that physicians use are called very-low-calorie diets, adding up to 400 to 800 calories a day (compared with 1200 calories a day on a commercial weight loss center diet). Diet doctors aren’t the only ones prescribing these very-low-calorie diets; they are commonly prescribed in hospital-based weight loss programs and by family physicians and internists.
Very-low-calorie diets starve people. Physicians have tried several means of starvation to get people to lose weight, from total fasting to modified fasts with protein supplements to more nutritionally balanced very-low-calorie-diets. All of them eventually lead to the well-documented and unpleasant side effects of starvation — including fatigue, hair loss, cold intolerance, anemia, depression, loss of muscle tissue, dehydration, irritability, weakness, bad breath, gallstones, and cardiac arrhythmias — and all have been responsible for patient deaths. Studies show about 59 sudden unexplained deaths per 100,000 people on very low calorie diets, which is 40 times the rate of sudden death in the general population.
Eating no food whatsoever will obviously cause people to lose weight quickly, though no one can keep it up for long without serious physical damage. “Fasting” — the term is a euphemism for starvation, as if the body can tell whether it is receiving no food on purpose or not — has been popular as a diet aid, off and on, since William the Conqueror. (In 1087, no longer able to ride on horseback because of his tremendous bulk, William the Conqueror took to his bed to lose weight with a “liquid diet” consisting mainly of alcoholic beverages.) Fasting had a recent heyday in the 1970s, when several diet doctors wrote books claiming that long-term fasting would not only help dieters lose weight, but would rid the body of impurities and give the organs a well-needed rest. Allan Cott, a Manhattan psychiatrist who wrote Fasting as a Way of Life in 1977, for instance, advocated that fasting was the “healthiest way to lose weight” and believed that the body has at least a month’s supply of food in reserve to feed on. But in reality, fasting for more than a day or two is hardly healthy. Instead of eliminating toxins from the body, it creates them, and puts a great strain on the heart, kidneys and liver. The body not only burns up fat, but muscle and organs as well. No one can last for long on a fast, and at least five hospital patients who were put on fasts in the late 1960s died (others died during the course of treatment, or in the refeeding stage immediately afterward, but physicians claimed that the deaths were the result of obesity-related problems).
Obesity researchers, impressed by the quick weight losses achieved by fasting, but dissuaded by the deaths, attempted to improve on the fast by adding enough protein to the diet to prevent muscles, including the heart, from being consumed by the body. In the 1970s, Harvard University surgeon George Blackburn fed his fat patients four to eight ounces of protein a day, about 300 calories worth, enough to keep the body from cannibalizing itself. He developed what came to be known as the protein-sparing modified fast.
The protein-sparing modified fast was popularized in the form of liquid protein diets. Philadelphia osteopath Robert Linn, inspired by Blackburn’s research, wrote a book called The Last Chance Diet in 1976 that advocated a fast supplemented with liquid protein. Unlike Blackburn, who fed his patients plain meat or fish, Linn suggested people subsist on Prolinn, a formula he created (named for “protein” + “Linn”), which was only available through physicians. In 1976, the New York state attorney ordered Linn’s publisher to refund the purchase price of the book to buyers because it prescribed a diet that wasn’t available except through the author. Linn responded by donating the Prolinn name to a nonprofit foundation and publishing the formula. Prolinn, it turned out, consisted of ground-up animal hides, tendons, and bones, useless slaughterhouse byproducts that were now going for a premium price. It was cooked into a gooey pinkish syrup and flavored with enough artificial cherry, orange or pineapple to disguise the cowhide taste. Soon, liquid formula diets were available in drugstores throughout the United States.
By the time some four million Americans had tried the ghastly liquid protein formula, the FDA began to get reports that people were dying of heart attacks after several weeks on the diet. For them, it truly had been a “last chance” diet. Physicians argued over whether it was the formula or the absence of potassium in it that had caused the fatalities (potassium gives the heart the electrical signals to keep pumping), and many thought the liquid protein itself was wrongly blamed. “It’s the same kind of hysteria that surrounded Legionnaires’ disease,” Blackburn told Newsweek in 1978. The magazine quoted him saying that if the FDA took the liquid protein products off the market, reclassifying them as drugs that would require testing for FDA approval, it would be a “miscarriage of justice.” Blackburn, however, distanced himself from the liquid protein formulas by 1979, after the Centers for Disease Control reported that 58 people had indeed died on the diet. “It was fine as long as it was in the physicians’ hands, because they could talk people into taking vitamins and minerals,” he said, changing his tune somewhat. “But the exploiters just carried on with the connective tissue protein without the co-factors [vitamins and minerals]…A gullible public and exploiting industry added up to disaster.”
However, many of the people who died were under a doctors’ care, and no one ever determined just exactly what caused the heart attacks. The protein itself was found to have little biologic value, and didn’t contain all the amino acids the body needs. The CDC identified the common pattern of heart failure among those who died. “This pattern is characterized by either sudden death or death due to intractable cardiac arrhythmias in individuals with no previous history of heart disease.” At least fifteen of these deaths occurred in women aged 25 to 50, who were healthy when they started the diet. One study of 17 of the 58 deaths found that the deaths had nothing to do with the type of medical supervision received during the diet, the daily dosage of potassium supplementation, or the quality of the protein product used. The researchers concluded that based on the risk of cardiac arrest that occurred with starvation, “The use of very low calorie weight reduction regimens should be curtailed until further studies determine what modifications, if any, can insure their safety.”
Nevertheless, doctors continued to support the use of starvation diets. In the 1980s, because of the risks involved with these diets — and perhaps to corner the profits derived from the sales of the treatment — they insisted that these diets should be left in the hands of physicians. The diets were reformulated to include more vitamins, minerals, and carbohydrates. Medical versions of very-low-calorie diets became extremely popular after Oprah Winfrey dragged a wagonload of fat onto her talk show on November 15, 1988 and announced that she had lost 67 pounds in four months by consuming very-low-calorie Optifast. While such diets are less dangerous than the liquid protein diets, because they are more nutritionally balanced, they still have problems of their own. Most obviously, they cause people to regain weight just as quickly as they lost it (a la Oprah). Even physicians who support the diets say they shouldn’t be undertaken except by people who are at least 30 percent over a healthy weight. “Large losses of lean mass in dieters can have disastrous consequences, including disturbance of cardiac function and damage to the organs,” wrote one group of obesity researchers, including Blackburn, in the Journal of the American Medical Association in 1990. It isn’t clear why, given the very low success rate of the diets, the researchers justify these risks for obese patients, either.
Some obesity researchers feel that very-low-calorie diets do no one any good, except the physician, whose financial health is vastly improved by prescribing the treatments to patients. John Garrow, an obesity specialist from St. Bartholomew’s Hospital in London, says, “VLCD [the very low calorie diet] is not needed by the severely obese patient (because everyone would lose weight on a conventional diet), and still less by the mildly obese patient, but it is needed by diet manufacturers and physicians associated with commercial weight loss organizations.” He noted that the cost of these diets, in time and money, is much greater for the patient, who has to pay for clinic visits and laboratory tests. Furthermore, these diets undermine patients’ abilities to learn to develop internal control over their eating habits. “The net effect is that obese people are put to additional expense to buy a product that they do not need, and their confidence in their ability to control their own diet is unnecessarily destroyed.”
Even though the serious health problems and deaths due to very-low-calorie diets were most publicized during the late 70s, they are still with us. Aside from the risk of death on these diets, patients who undertake a very-low-calorie-diet will have a one in four chance of developing gallstones — about thirty times the risk they might expect if they didn’t go on the diet. Patients who read the fine print before signing up for the diets, would find, in the case of United Weight Control Corp, which makes a medically-supervised fasting program, that they’re agreeing to this: “Some reports have suggested that a relationship between programmed diets and sudden death, probably due to irregularities of the heart. I understand that participation in this weight reduction program may entail a minute risk of fatal heart irregularities.”
How “minute” that risk may be no one knows. Very few deaths from very-low-calorie dieting are reported in the United States. “When a fat person dies, it’s blamed on their obesity,” explains endocrinologist Wayne Callaway, who has testified in several court cases involving sudden deaths. “We don’t know how many sudden deaths occur.” Dieting deaths aren’t recorded in U.S. mortality statistics gathered by the Centers for Disease Control and Prevention, and diet programs are not required to report diet deaths. In most cases, diet deaths are simply listed as cases of cardiac arrest. In 1990, in congressional hearings on the diet industry chaired by Oregon representative Ronald Wyden, Callaway testified that even known dieting deaths are quieted in court. “When the victim or his or her survivors have raised legal issues, in general, the cases have been settled out of court and the documents sealed.,” he said. “There is no registry for providing data on a national scale. As you can well appreciate, the companies themselves do not volunteer such information to outside researchers.”
© Laura Fraser