FIRST, DO NO HARM: DIET DOCTORS
Recently, I came across a large ad in the morning paper featuring a slim woman in tight jeans who was jumping for joy. “If you’ve tried other weight loss plans without success…” the ad teased, “Try Dr. Ralph Alperin’s weight loss plans. They mix medical care and great menu variety for safe, often lifetime weight loss. You don’t have to be overweight — call today!” In big block letters, the ad screamed: “NOW AVAILABLE FENFLURAMINE/PHENTERMINE APPETITE SUPPRESSANTS, as shown on T.V. and Reader’s Digest.” There were phone numbers for each of Dr. Alperin’s seven Bay Area offices.
Physicians in major cities across the country have been placing ads like this one, luring people into their offices with the promise of drugs and quick weight loss treatments. I called to see what I could find out about Dr. Alperin’s “Safe, rapid weight loss under a doctor’s careful eye.” I told the receptionist at one clinic that I was just fifteen or twenty pounds overweight, and she assured me that I could lose about three pounds a week on a program that included a 700-calorie-a-day liquid diet, prescription appetite suppressants, and vitamin injections. What time did I want to come in?
I was surprised: All of the medical literature on very-low-calorie diets suggest that they should only undertaken by people who are very obese, not just a few pounds over the ideal, since extremely restrictive diets can be dangerous, burning lean muscle tissue, and sometimes leading to heart failure. The literature on prescription appetite suppressants agrees, on the whole, that no one should take the drugs unless they’re at least 30 percent over a healthy weight, which is by no means just fifteen to twenty pounds for almost any woman. As for vitamin injections, they don’t even make it into the literature on weight loss.
I tried another of Alperin’s office to double-check. The receptionist there was busy; because of the ad, she told me, she was overwhelmed with phone calls. I got to the point.
“If I’m just fifteen pounds overweight, but I really want to lose the weight fast, could I still do the liquid diet?” I asked her.
“No problem, sure,” she said.
“And how about the appetite suppressants?”
“That’s part of the program, and the doctor will give you what he feels is medically safe for you.”
“But you don’t have to be a certain amount overweight to get the pills?”
“No, there’s no limit.”
It seems the line in the ad, “You don’t have to be overweight!” could be read two ways.
The most sensible advice you could give someone who wants to lose weight, it might seem, is “see your doctor.” Or better yet, see a doctor who specializes in weight loss. Dieters who have tried everything else, or who are wary of faddish weight loss schemes and diet centers where counselors are hired based on their experience as aerobics instructors, believe that their doctors, finally, know what’s best for them. We trust in our physicians, and in their motto: First, do no harm.
Most of us think of physicians as being cautious and conservative in their practices, only prescribing potentially harmful treatments when necessary, when a person has such serious medical problems that the benefits of treatment outweigh the risks. In the case of obesity, we might think treatment would be appropriate for people who are fat enough that their weight aggravates other existing medical problems, such as high blood pressure, high cholesterol, or a family history of heart disease or diabetes. Most physicians, we trust, wouldn’t prescribe treatments that involve serious risks just for cosmetic reasons.
But some doctors have a history of abusing that trust for profit, prescribing unnecessary and ineffective diet regimes to all comers. Diet doctors, who were notorious in the sixties and seventies for passing out amphetamines like handfuls of sugarless candy, and who flourished again in the eighties when Oprah Winfrey temporarily lost weight on a physician-supervised liquid diet, are making a comeback. At a time when commercial diet programs are faltering and Americans’ weight continues to rise, diet doctors are banking on the idea that more Americans will begin to view fatness as a medical condition, not an appearance problem. There are now about 17,500 private physicians in the country who specialize in weight loss, as well as 3,300 hospitals and 540 health maintenance organizations that offer diet programs. Many of these physicians don’t call themselves “diet doctors” any more, though. Now they’re “wellness specialists” or “preventive health specialists.” But while they’ve changed their image, they haven’t changed their methods. Most of them still rely on very-low-calorie diets for rapid weight loss, and are prescribing their patients new versions of old weight loss drugs.
It isn’t just diet doctors who are treating fat patients, either. Countless other family physicians, general practitioners, psychiatrists, and internists are treating their heavy patients with diets and drugs during the course of their regular practice. Some of them offer their patients sensible help in slowly changing their nutrition habits, exercising more, and learning to stop overeating. But an increasing number of them are prescribing appetite suppressants, particularly the popular combination of fenfluramine (a Prozac-like drug that increases the amount of serotonin in the brain, which promotes a feeling of wellness, calm and satiety) and phentermine (an amphetamine-like stimulant). Most physicians, despite their credentials, lab coats, and “medical” approach to weight loss, are no more successful in treating weight loss than diet counselors. They’re just more expensive, and sometimes, more dangerous.
I decided to visit a couple of diet docs in person. No reasonable physician, I thought, could observe up close how strong and healthy I am and then prescribe me pills or put me on a liquid diet that is designed for the morbidly obese. To avoid the occasional quacks and shameless entrepreneurs that exist every branch of medicine, I chose physicians who are members of the American Society of Bariatric Physicians (ASBP) — the Greek word, barros, means heavy — an organization of doctors who treat obesity. To most consumers, the ASBP sounds like a legitimate medical specialty, and the group says it’s trying to change the pill-pushing image problem diet doctors have had in the past. “Bariatrics” is not recognized as a bona fide specialty by the American Medical Association, though, and no one needs to pass board exams or undergo a residency to be “certified” as a bariatrician, as one needs to do in order to become, say, a board-certified psychiatrist or pediatrician. The society issues physician guidelines for prescribing diet drugs, holds training sessions and conferences, and publishes standards of practice, which suggest that physicians should perform complete physicals on patients, weigh the benefits and risks of treatments, and keep up-to-date on the relevant medical literature. I randomly picked a couple of physicians to visit from the Bay Area section of the ASBP directory.
When I walked into the office of Robert Roth, in San Jose, California, I didn’t walk in thin, but we’re not talking obese here. At my last complete physical, at the well-respected Cooper Clinic in Dallas, the doctor congratulated me for exercising every day, eating a healthy diet, and having extremely good cholesterol numbers; on a treadmill test, I scored in the top fitness category for women my age. While I am overweight by America’s cosmetic standards, there’s no medical reason for me to lose weight.
Roth’s nurse — like the counselor at Jenny Craig — weighed me with my heavy boots and jacket on, then led me to the examining room. “Who referred you?” she asked me. “If they refer five people they get a free month.” I blinked. For a second I thought I was in the sales office at a 24-hour Nautilus gym. No: there’s the examining table, the blood pressure cuff; it’s a doctor’s office. The nurse took my measurements, and, I noticed, added a generous two and a half inches to my relatively small waist; whatever my progress on the diet, it would seem like I’d lost some inches when she measured me again on my next visit.
Roth came in and greeted me by staring at my hips. “You have a sit-down job, honey?” He reviewed my medical history, noticed I had allergies, asked me a few questions about them, and gave me — “at no extra charge” — a bottle of allergy pills. “These’ll help you sleep,” he said. Then it was on to weight loss.
“We have an injection program here,” he said. “Is that what you had in mind?” This was a little odd: I’m used to having a physician evaluate my condition, discuss the options, and suggest a course of treatment. Roth apparently took my blank-eyed look as an assent. He explained that in addition to appetite suppressants and a 600-calorie-a-day diet, he gives his patients injections of vitamins and minerals three times a week. “My patients say, ‘Doc, I feel wonderful.’” He promised me I’d lose fifteen pounds in the first month. “A lot of docs charge twice what I charge,” he said. “I give you a good deal.”
He spent half an hour describing the evils of fats and heart disease, his yellow hi-liter flying through the pages of a booklet he’d given me. Halfway through he stopped for a moment and looked at me. “You know, you don’t look like you have much to lose. You don’t look like you weigh that much.”
“The scales don’t lie,” I said.
He nodded and continued apace, lecturing me about how I should drink no alcohol and eat no fat. He named a chapter in the Bible that exhorts us not to eat fat, and told me to go home and read the Good Book myself. Even though I’d told him I eat no meat and few sweets, he spent quite a bit of time lecturing me not to do those things, running his usual tape. He studied me. “You have nice teeth, so you must not be pigging out too much on sugar.”
He did a routine exam, listening to me breathe and tapping on my chest. He pinched my calf, which is large and solid from bicycling. Again, common sense raised its head — “You exercise a lot?” — but not for long. He launched back into advice on how to stick to my diet — “It’s mind over platter!” — and said he’d give me, free, a big bottle of appetite suppressants. Then he gave me a pitch for buying the protein powder soups the office had on sale, showed me charts of people who had lost 12 to 15 pounds in the first month, and dismissed me. “I want you to lose 15 pounds for me, Laura,” he said. “You have to be faithful to me. There’s too much infidelity in the world.”
At the front desk, when the nurse asked me whether I wanted to buy the B-vitamin injection program — at $150 — or just the appetite suppressants, at $65, I wavered. I don’t like injections, I told her. Roth shot me a stern look from across the hall. “Injections,” I said, compliantly.
As I left, rubbing the needle wound in my arm, I thought about all the women who squeeze three doctors’ visits a week into their hectic lives, enduring needle pricks, just for vitamins. Then I drove across town, ate a nice sushi lunch, and went to the office of James Andrews, M.D. The sign in the waiting room read, “DO YOU KNOW THAT YOU CAN LOSE WEIGHT BY EATING CHOCOLATE CHIP COOKIES?” On his scale — after lunch — I weighed three-and-a-half pounds less than at Roth’s office.
The nurse took my blood pressure, and Andrews came in. “Which diet do you want?” he asked, without really looking at me. “The liquid protein or the cookie diet?” I told him I wasn’t sure, and he pushed the liquid protein. Because of the risks involved — gallstones, hair loss, anxiety, stress, rapid weight regain, depression — most physicians won’t prescribe liquid protein for anyone who doesn’t weigh about forty pounds more than I do. Andrews, however, told me he’d prescribe the expensive liquid-protein diet to anyone who was at least 25 pounds overweight. Only a modeling agent would say I’m 25 pounds overweight. He asked to see my wrist, which is medium-size. Since I’m not big-boned, he thought I could handle getting down to about 130 pounds, which would make me 25 pounds “overweight” now. “You could get down that low,” he said. “Sure.”
The advantage of the liquid protein diet, Andrews told me, is that it is “drastic,” so I would lose at least three pounds a week. “It’s the one Oprah Winfrey went on,” he said, as if that were a recommendation.
I told him that since I’m an active person, I was concerned the 500-calorie-a-day liquid protein diet wouldn’t be enough to sustain me. That weekend, for instance, I said, I was going on a six-hour mountain bike ride on some pretty steep terrain. “That’s great,” he said. “That’ll help you lose weight.” When I demurred — no one can ride hard all day on the equivalent of two Power Bars without “bonking,” as bicyclists call it, hitting a wall of exhaustion — he said I could add an extra diet shake that day, bringing the day’s total to only 750 calories or so. That many calories might get me to the top of the mountain, all right, but not all the way home. Then Andrews launched into a pitch for a whole line of protein products I could buy, though I was under no obligation. “I’m not Jenny Craig,” he said. “These are just here for your convenience.” I finally insisted that I wanted the higher-calorie cookie diet (four fiber cookies and one frozen dinner a day still amount to 400 calories a day less than a 1200-calorie-a-day semi-starvation diet). The cookie diet costs less, since no lab work is needed, as it is required under ASBP regulations for the extremely low-calorie diets.
Andrews gave me a quick physical. He didn’t ask me for details about my eating and exercise habits, nor did he inquire whether I’d ever had an eating disorder. He gave me a package of prescription appetite suppressants, which he said had no real side effects. “These aren’t like the ones in the past,” he said. “They aren’t addictive or anything.” I told him that I’d read about the negative effects of crash dieting, and was concerned. “Well, it lowers your metabolism a bit, but if you exercise, you’ll be fine.” Finally, I asked him how successful his program was. He told me they didn’t keep track, since most of his patients didn’t stay with him after the two to six-week maintenance period. “We can help you lose weight,” he said. “But there’s nothing we can do if you go back to your bad habits.”
The visit cost $110; the nurse gave me a large bag of fiber cookies and told me to come back next week, for a $50 weigh-in, more cookies, and my next batch of pills. My take for the day, from both offices, were two appetite suppressants: a large bottle of tablets of diethylproprion and seven tablets of phentermine; two bottles of multi-vitamins, a bottle of chromium, another of potassium, some over-the-counter allergy pills, a prescription for other allergy pills, and several cellophane bags of high-protein fiber cookies.
The next day, I tried a fiber cookie, which tasted like wood shavings and could be called a cookie only by someone starving. I took a diethylproprion tablet, and spent the morning antsy and nervous. I rapidly rang up Paul Ernsberger, a pharmacologist at Case Western Reserve Medical School, and asked him about the drug. “It’s a stimulant, an amphetamine mimic,” he told me. “It’ll cause psychomotor stimulation, keep you awake, make you feel nervous, and raise your blood pressure. At high doses it can promote heart arrhythmia. It’s serious stuff.” There have even been several cases in the literature of psychosis induced by taking diethylproprion. No wonder Roth had given me something to help me sleep. Ernsberger said he was astonished I’d been given a B-vitamin injection. “That’s what they did in the early ‘60s,” he said. “It was shown to do absolutely nothing about thirty years ago.”
Interrupting him — this drug did nothing for my politeness or attention span — I asked several questions about his studies putting rats on very-low-calorie diets. The rats’ metabolisms slow down when they’re on the diet, he told me; when they’re off the diet, they get fatter eating the same amount of food that maintained their weight before. They also produce more of the stress hormones that can lead to heart problems when they’re dieting. Rockefeller University researchers recently demonstrated that humans have similar reactions to diets; their metabolism slows to help them regain weight back to the original “set-point.” “Put people on crash diets and they’ll gain back more weight than they lost,” Ernsberger said.
The next day I took a dose of phentermine, which was even speedier than the diethylproprion. I was so wired I had to drink a pint of beer with lunch in order to be able to sit still to work. I had a headache and was incredibly grouchy. In my agitated state, I became enraged thinking about all the people who trust their doctors to help them with a problem, pay them a lot of money, dutifully starve themselves, then blame themselves when the program doesn’t work and they’ve gained the weight back. I imagined how frustrated many good physicians must be, too, to find so many of their colleagues motivated by greed.
As I threw away my bag of medical diet products, I considered the Hippocratic oath: First, do no harm. I was sure, at the very least, that diet docs had done thousands of women like me no good.
© Laura Fraser