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Weight Management and Gallstones

In Health, Healthcare, Medicine on October 26, 2012 at 6:44 am

It is estimated that digestive diseases affect 60 to 70 million people in the United States. Gallbladder disease is one of the more common of these diseases. Experts estimate that as many as 20 million Americans have gallstones.

Most people with gallstones do not know that they have them and experience no symptoms. These people may have painless gallstones, or silent gallstones. Sometimes gallstones cause abdominal or back pain. These are called symptomatic gallstones. In rare cases, gallstones can cause serious health problems. Hundreds of thousands of hospitalizations and operations occur annually as a result of gallstones.

What are gallstones?

Gallstones are clusters of solid material that form in the gallbladder. The most common type is made mostly of cholesterol. Gallstones may occur as one large stone or as many small ones. They vary in size and may be as large as a golf ball or as small as a grain of sand.

Gallstones develop in the gallbladder, a small pear-shaped organ located beneath the liver on the right side of the abdomen. The gallbladder is about 3 inches long and 1 inch wide at its thickest part. It stores and releases bile into the intestine to help digestion.

Bile is a liquid made by the liver. It contains water, cholesterol, bile salts, fats, proteins, and bilirubin (a bile pigment). During digestion, the gallbladder contracts to release bile into the intestine, where the bile salts help to break down fat. Bile also dissolves excess cholesterol.

What causes gallstones to develop?

Illustration of the gallbladder and adjoining organs, the liver, pancreas, and duodenum.

According to researchers, cholesterol gallstones may form in several ways, such as:

When bile contains more cholesterol than it can dissolve.

When there is too much bilirubin or other substance in the bile that causes cholesterol to form hard crystals.
When there are not enough bile salts to break down fat and when the gallbladder does not contract and empty its bile regularly.

 

What are the symptoms of gallstones?

Some common symptoms of gallstones or gallstone attack include:

Severe pain in the upper abdomen that starts suddenly and lasts from 30 minutes to many hours.
Pain under the right shoulder or in the right shoulder blade.
Nausea or vomiting.
Indigestion after eating high-fat foods, such as fried foods or desserts.

Is obesity a risk factor for gallstones?

Obesity is a strong risk factor for gallstones, especially among women. People who are obese are more likely to have gallstones than people who are at a healthy weight. Obesity in adults can be defined using the body mass index (BMI), a tool that measures weight in relation to height. The table below shows how the BMI calculation works. A BMI of 18.5 to 24.9 refers to a healthy weight, a BMI of 25 to 29.9 refers to overweight, and a BMI of 30 or higher refers to obesity.

As BMI increases, the risk for developing gallstones also rises. Studies have shown that risk may triple in women who have a BMI greater than 32 compared to those with a BMI of 24 to 25. The risk may be seven times higher in women with a BMI above 45 than in those with a BMI below 24.

Researchers have found that people who are obese may produce high levels of cholesterol. This leads to the production of bile containing more cholesterol than it can dissolve. When this happens, gallstones can form. People who are obese may also have large gallbladders that do not empty normally or completely. Some studies have shown that men and women who carry fat around their midsections may be at a greater risk for developing gallstones than those who carry fat around their hips and thighs.

Is weight-loss dieting a risk factor for gallstones?

Weight-loss dieting increases the risk of developing gallstones. People who lose a large amount of weight quickly are at greater risk than those who lose weight at a slower pace. Rapid weight loss may also cause silent gallstones (painless gallstones) to become symptomatic. Studies have shown that people who lose more than 3 pounds per week may have a greater risk of developing gallstones than those who lose weight at slower rates.

A very low-calorie diet (VLCD) allows a person who is obese to quickly lose a large amount of weight. VLCDs usually provide about 800 calories per day in food or liquid form, and are followed for 12 to 16 weeks under the supervision of a health care professional. Studies have shown that 10 to 25 percent of people on a VLCD developed gallstones. These gallstones were usually silent—they did not produce any symptoms. About one-third of the dieters who developed gallstones, however, did have symptoms and some of these required gallbladder surgery.

Experts believe weight-loss dieting may cause a shift in the balance of bile salts and cholesterol in the gallbladder. The cholesterol level is increased and the amount of bile salts is decreased. Following a diet too low in fat or going for long periods without eating (skipping breakfast, for example), a common practice among dieters, may also decrease gallbladder contractions. If the gallbladder does not contract often enough to empty out the bile, gallstones may form.

A drug called ursodiol that helps dissolve cholesterol in the bile may help prevent gallstones from developing during rapid weight loss. While ursodiol is not approved by the U.S. Food and Drug Administration (FDA) to prevent gallstones, its “off-label” use (the practice of prescribing medications for periods of time or for conditions not FDA-approved) has been shown to be effective and safe. If rapid weight loss is highly likely, you should consider talking with your health care provider about using ursodiol.

Is weight cycling a risk factor for gallstones?

Weight cycling, or losing and regaining weight repeatedly, may increase the risk of developing gallstones. People who weight cycle—especially with losses and gains of more than 10 pounds—have a higher risk for gallstones than people who lose weight and maintain their weight loss. Additionally, the more weight a person loses and regains during a cycle, the greater the risk of developing gallstones.

Why weight cycling is a risk factor for gallstones is unclear. The rise in cholesterol levels during the weight-loss phase of a weight cycle may be responsible. It is also thought that each cycle increases one’s risk for gallstones. However, further research is required to determine the exact link between weight loss and the risk for gallstones.

Is surgery to treat obesity a risk factor for gallstones?

Gallstones are common among people who undergo bariatric surgery to lose weight. Bariatric surgery to reduce the size of the stomach or bypass parts of the digestive system is a weight-loss method for people who have a BMI above 40. This procedure is also an option for people who have a BMI above 35 with comorbid conditions such as diabetes and high blood pressure. Experts estimate that about one-third of patients who have bariatric surgery develop gallstones. The gallstones usually develop in the first few months after surgery and are symptomatic.

How can I safely lose weight and decrease the risk of gallstones?

You can take several measures to decrease the risk of developing gallstones during weight loss. Losing weight gradually, instead of losing a large amount of weight quickly, lowers your risk. Depending on your starting weight, experts recommend losing weight at the rate of 1/2 to 2 pounds per week. Losing weight at this rate commonly occurs for up to 6 months. After 6 months, weight loss usually declines and weight stabilizes because individuals in lower weight groups use fewer calories (energy). You can also decrease the risk of gallstones associated with weight cycling by aiming for a modest weight loss that you can maintain. Even a loss of 5 to 10 percent of body weight over a period of 6 months or more can improve the health of an adult who is overweight or obese.

Your food choices can also affect your gallstone risk. Experts recommend including some fat in your diet to stimulate gallbladder contracting and emptying. Current recommendations indicate that 20 to 35 percent of your total calories should come from fat. Studies have also shown that diets high in fiber and calcium may reduce the risk of gallstone development.

Finally, regular physical activity is related to a lower risk for gallstones. Aim for approximately 60 minutes of moderate- to vigorous-intensity activity on most days of the week to manage your body weight and prevent unhealthy weight gain. To sustain weight loss, engage in at least 60 to 90 minutes of daily moderate-intensity physical activity.

What is the treatment for gallstones?

Silent gallstones are usually left alone and sometimes disappear on their own. Symptomatic gallstones are usually treated. The most common treatment is surgery to remove the gallbladder. This operation is called a cholecystectomy. In other cases, nonsurgical approaches—drugs—are used to dissolve the gallstones. Your health care professional can help determine which option is best for you.

Are the benefits of weight loss greater than the risk of getting gallstones?

Although weight loss increases the risk of developing gallstones, obesity poses an even greater risk. In addition to gallstones, obesity is linked to many serious health problems, including:

type 2 diabetes
high blood pressure
heart disease
stroke
certain types of cancer
sleep apnea (when breathing stops for short periods during sleep)
osteoarthritis (wearing away of the joints)
fatty liver disease
For people who are obese, weight loss can lower the risk of developing some of these illnesses. Even a small weight loss of 10 percent of body weight over a period of 6 months can improve health and lower disease risk. In addition, weight loss may bring other benefits such as better mood, increased energy, and positive self-image.

If you are thinking about starting an eating and physical activity plan to lose weight, talk with your health care professional first. Together, you can discuss various eating and physical activity programs, your medical history, and the benefits and risks of losing weight, including the risk of developing gallstones.

 

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Medications for the Treatment of Obesity

In Health, Healthcare, Medicine on September 5, 2012 at 11:43 am

 

Weight-loss medications should always be combined with a program of healthy eating and regular physical activity.

Obesity is a chronic disease that affects many people. To lose weight and maintain weight loss over the long term, it is necessary to modify one’s diet and engage in regular physical activity. Some people, however, may require additional treatment. As with other chronic conditions, such as diabetes or high blood pressure, the use of prescription medications may be appropriate for some people who are overweight or obese.

Prescription weight-loss medications should be used only by patients who are at increased medical risk because of their weight. They should not be used for “cosmetic” weight loss. In addition, patients should have previously tried to lose weight through diet and physical activity.

Prescription weight-loss drugs are approved only for those with:

  • A body mass index (BMI) of 30 and above.
  • A BMI of 27 and above with an obesity-related condition, such as high blood pressure, type 2 diabetes, or dyslipidemia (abnormal amounts of fat in the blood).

BMI is a measure of weight in relation to height that helps determine if your weight places your health at risk. A BMI of 18.5 to 24.9 is considered healthy. A BMI of 25 to 30 is considered overweight, and a BMI over 30 is considered obese. (See WIN’s brochure Weight and Waist Measurement: Tools for Adults for more information.)

Although most side effects of prescription medications for obesity are mild, serious complications have been reported. Also, few studies have evaluated the long-term safety or effectiveness of weight-loss medications. Weight-loss medications should always be combined with a program of healthy eating and regular physical activity.

The information in this fact sheet may help you decide if and what kind of weight-loss medication may help you in your efforts to reach and stay at a healthy weight. It does not replace medical advice from your doctor.

Table 1 provides an overview of medications that may be prescribed for weight loss.

Table 1
Generic Name Food and Drug Administration Approval for Weight Loss Drug Type Common Side Effects
Phentermine Yes; short term (up to 12 weeks) for adults Appetite Suppressant Increased blood pressure and heart rate, sleeplessness, nervousness
Diethylpropion Yes; short term (up to 12 weeks) for adults Appetite Suppressant Dizziness, headache, sleeplessness, nervousness
Phendimetrazine Yes; short term (up to 12 weeks) for adults Appetite Suppressant Sleeplessness, nervousness
Orlistat Yes; long term (up to 1 year) for adults and children age 12 and older Lipase Inhibitor Gastrointestinal issues (cramping, diarrhea, oily spotting), rare cases of severe liver injury reported
Bupropion No Depression Treatment Dry mouth, insomnia
Topiramate No Seizure Treatment Numbness of skin, change in taste
Zonisamide No Seizure Treatment Drowsiness, dry mouth, dizziness, headache, nausea
Metformin No Diabetes Treatment Weakness, dizziness, metallic taste, nausea

Because weight-loss medications are used to treat a condition that affects millions of people, the possibility that side effects may outweigh benefits is of great concern.

Most of the Food and Drug Administration (FDA)-approved weight-loss medications are approved for short-term use, meaning a few weeks, but doctors may prescribe them for longer periods of time—a practice called “off-label” use. (See the below for more information about off-label use.) Orlistat is the only weight-loss medication approved for longer-term use in patients who are significantly obese. Its safety and effectiveness have not been established for use beyond 2 years, however.

Appetite Suppressants. Most available weight-loss medications approved by the FDA are appetite-suppressant medications. These include phentermine, phendimetrazine, and diethylpropion. Appetite-suppressant medications promote weight loss by decreasing appetite or increasing the feeling of being full. These medications make you feel less hungry by increasing one or more brain chemicals that affect mood and appetite. Phentermine is the most commonly prescribed appetite-suppressant in the United States.

NOTE: Amphetamines are a type of appetite suppressant. However, amphetamines are not recommended for use in the treatment of obesity due to their strong potential for abuse and dependence.

Lipase Inhibitors. In 1999, the FDA approved the drug Xenical (orlistat) as a prescription weight loss drug. Orlistat reduces the body’s ability to absorb dietary fat by about one-third. It does this by blocking the enzyme lipase, which is responsible for breaking down dietary fat. When fat is not broken down, the body cannot absorb it, so it is eliminated and fewer calories are taken in.

In early 2007, orlistat was approved for over-the-counter (OTC) sale for adults age 18 and over. This means that the drug may be purchased without a prescription. The OTC version of orlistat is sold under the brand name alli. Alli is meant to be taken with a reduced-calorie, low-fat diet, exercise, and a daily multivitamin. Its side effects are similar to those for prescription orlistat. Anyone considering taking alli should read information about side effects, drug interactions, and usage recommendations on the drug’s packaging or website, http://www.myalli.com

The following types of medication(s) are not FDA-approved for the treatment of obesity. However, they have been shown to promote short-term weight loss in clinical studies and may be prescribed off-label.

Drugs to treat depression. Some antidepressant medications have been studied as appetite-suppressant medications. While these medications are FDA-approved for the treatment of depression, their use in weight loss is an off-label use . Studies of these medications have generally found that patients lose modest amounts of weight for up to 6 months, but that patients tend to regain weight while they are still on the drug. One exception is bupropion. In one study, patients taking bupropion maintained weight loss for up to 1 year.

Drugs to treat seizures. Two medications used to treat seizures, topiramate and zonisamide, have been shown to cause weight loss. Whether these drugs will be useful in treating obesity is being studied.

Drugs to treat diabetes. The diabetes medication metformin may promote small amounts of weight loss in people with obesity and type 2 diabetes. How this medication promotes weight loss is not clear, although research has shown reduced hunger and food intake in people taking the drug.

Drug combinations. The combined drug treatment using fenfluramine and phentermine (known as “fen/phen”) is no longer available due to the withdrawal of fenfluramine from the market after some patients experienced serious heart and lung disorders. (See the “Potential Risks and Concerns” section.) Little information is available about the safety or effectiveness of other drug combinations for weight loss, including fluoxetine/phentermine, phendimetrazine/phentermine, herbal combinations, or others. Until more information on their safety or effectiveness is available, using combinations of medications for weight loss is not recommended, except as part of a research study.

What is “off-label” use?

Although the FDA regulates how a medication can be advertised or promoted by the manufacturer, these regulations do not restrict a doctor’s ability to prescribe the medication for different conditions, in different doses, or for different lengths of time. The practice of prescribing medication for periods of time or for conditions not FDA-approved is known as off-label use. While such use often occurs in the treatment of many conditions, you should feel comfortable about asking your doctor if he or she is using a medication or combination of medications in a manner that is not approved by the FDA. The use of more than one weight-loss medication at a time (combined drug treatment) is an example of an off-label use. Using weight-loss medications other than orlistat for more than a short period of time (i.e., more than “a few weeks”) is also considered off-label use.

People respond differently to weight-loss medications, and some people experience more weight loss than others. Weight-loss medications lead to an average weight loss of about 10 pounds more than what you might lose with nondrug obesity treatments. Maximum weight loss usually occurs within 6 months of starting the medicine. Weight then tends to level off or increase during the remainder of treatment.

Over the short term, weight loss in individuals who are obese may reduce a number of health risks. Studies have found that weight loss with some medications improves blood pressure, blood cholesterol, triglycerides (fats), and insulin resistance (the body’s inability to use blood sugar). New research suggests that long-term use of weight-loss drugs may help individuals keep off the weight they have lost. However, more studies are needed to determine the long-term effects of weight-loss drugs on weight and health.

Potential Risks and Concerns

Research has yet to determine the long-term health effects of weight-loss drugs. To date, the longest study is a 4-year investigation of orlistat. Most other studies have lasted 6 to 12 months or less. In addition, research has not examined rare side effects (those occurring in less than 1 per 1,000 patients), and the optimal duration of treatment is unknown.

When considering long-term weight-loss drugs to treat obesity, you should consider the following areas of concern and potential risks.

Potential for abuse or dependence. Currently, all prescription medications to treat obesity except orlistat are controlled substances, meaning doctors need to follow certain restrictions when prescribing them. Although abuse and dependence are not common with nonamphetamine appetite-suppressant medications, doctors should be cautious when they prescribe these medications for patients with a history of alcohol or other drug abuse.

Development of tolerance and weight regain. Most studies of weight-loss drugs show that a patient’s weight tends to level off after 6 months while still on the drug. Although some patients and doctors may be concerned that this shows tolerance to the medications, the leveling off may mean that the maximum amount of weight loss that the drug can produce has been achieved.

Studies examining the effects of weight loss drugs showed that after one year, patients receiving a weight loss drug lost more weight than patients in the placebo group. Findings also indicated that patients who continued treatment regained less weight compared with those who stopped treatment.

Reluctance to make behavioral changes while using prescription medications. Patients who are overweight or obese should be able to seek medical treatment to prevent health risks that can cause serious illness and death. Weight-loss drugs, however, are not “magic bullets” or a one-shot fix for this chronic disease. They should always be combined with a healthy eating plan and increased physical activity.

Side effects. Because weight-loss drugs are used to treat a condition that affects millions of people, many of whom are basically healthy, the possibility that side effects may outweigh benefits is of great concern. Most side effects of these drugs are mild and usually improve with continued use. Rarely, serious and even fatal outcomes have been reported. Some of the common side effects of the drugs are explained in this section.

Orlistat. Some side effects of orlistat include cramping, intestinal discomfort, passing gas, diarrhea, and leakage of oily stool. These side effects are generally mild and temporary, but may be worsened by eating high-fat foods. Rare cases of severe liver injury have been reported in patients using either Xenical or alli. Both drugs contain different strengths of orlistat. Xenical contains 120 mg, while alli contains 60 mg. Also, because orlistat reduces the absorption of some vitamins, patients should take a multivitamin at least 2 hours before or after taking orlistat. More information about orlistat (marketed as Xenical or alli) and liver injury is available at http://www.fda.gov/Drugs/DrugSafety/ PostmarketDrugSafetyInformationforPatientsandProviders/ucm213038.htm

Other appetite suppressants. Phentermine, phendimetrazine, and diethylpropion may cause symptoms of sleeplessness, nervousness, and euphoria (feeling of well-being). People with heart disease, high blood pressure, an overactive thyroid gland, or glaucoma should not use these drugs.

Two appetite-suppressant medications, fenfluramine and dexfenfluramine, were withdrawn from the market in 1997. These drugs, used alone and in combination with phentermine (fen/phen), were linked to the development of valvular heart disease and primary pulmonary hypertension (PPH), a rare but potentially fatal disorder that affects the blood vessels in the lungs. There have been only a few case reports of PPH in patients taking phentermine alone, but the possibility that phentermine use is associated with PPH cannot be ruled out.

NOTE: In 2010, the FDA asked Abbott Laboratories to voluntarily remove Meridia (sibutramine) from the U.S. market. Abbott Laboratories agreed to remove the drug from the market. Sibutramine is a weight-loss drug that works to reduce one’s appetite. Data from clinical trials showed an increased risk of heart attacks and strokes among patients using the drug. More information about sibutramine is available athttp://www.fda.gov.

Commonly Asked Questions About Weight-Loss Drugs

Q: Can drugs replace physical activity or changes in eating habits as a way to lose weight?

A: No. Studies show that weight-loss medications work best when combined with a weight-control program that helps you improve your eating and physical activity habits. Ask your doctor about ways you can improve your eating plan and become more physically active.

Q: How do I decide which drug is right for me?

A: Choosing a weight-loss drug is a decision between you and your health care provider. You will consider the drug’s side effects, your family’s medical history, and your current medical conditions and medicines.

Q: What medical history, conditions, or medications might influence my decision to take a weight-loss drug?

A: Let your doctor know if any of the following applies to you, as these factors may affect which weight-loss drugs you can take, if any:

  • History of drug or alcohol abuse.
  • History of eating disorders.
  • History of depression or manic depressive disorder.
  • Pregnancy or breast-feeding.
  • Migraine headaches requiring medication.
  • Glaucoma.
  • Diabetes.
  • Heart disease or heart condition, such as an irregular heart beat.
  • High blood pressure.
  • Use of blood-thinning medication.
  • Use of monoamine oxidase (or “MAO”) inhibitors or antidepressant medications.
  • Plan to have surgery that requires general anesthesia.

Q: How long will I need to take weight-loss medications to treat obesity?

A: The answer depends upon whether the medication helps you to lose and maintain weight and whether you have any side effects. Because obesity is a chronic disease, nondrug treatment including diet changes and regular physical activity may need to be continued for years, and perhaps a lifetime, to improve health and maintain a healthy weight. However, like many other types of drugs, there is still little information on how safe and effective weight-loss medications are for many years of use. At least one study has shown that intermittent use (1 month on medication and 1 month off medication) may help some people lose and maintain weight, but more research is needed.

Q: Will I regain some weight after I stop taking weight-loss medications?

A: Probably. Most studies show that the majority of patients who stop taking weight-loss medications regain the weight they lost. Maintaining healthy eating and physical activity habits may help you regain less weight or keep it off.

Q: Can children or teens use weight-loss medications?

A: Prescription orlistat is currently approved for use in teens age 12 or above. Other weight-loss drugs are not approved for use in children under age 16, although studies in children and teens are ongoing. Metformin is a drug being studied in clinical trials. Early reports show it to be safe and effective, but more research is needed and it has not been FDA-approved for children or adolescents.

Q: Will insurance cover the cost of weight-loss medication?

A: Currently, many insurance companies will not pay for weight-loss drugs, but this is changing as insurers begin to recognize obesity as a chronic disease. Contact your insurance company to find out if prescription weight-loss medication is covered under your plan. A 1-month prescription can cost from 60 dollars to more than twice this amount. Ask a staff member at your pharmacy what a 1-month supply of the medication you are considering taking will cost.

Most patients should not expect to reach an “ideal” body weight using currently available medications. However, even a modest weight loss of 5 to 10 percent of your starting body weight can improve your health. Together, you and your doctor can make an informed choice as to whether medication can be a useful part of your weight-control program.

 

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