Appetite Suppressants

Appetite suppressants are of use only as part of a program of wise eating and exercise. At best, these can make it easier for you to forget about food once you are following an appropriate diet.

Please read all our other information about weight loss before asking yourself if the information here can be helpful to you. See table at end of this article for a summary of the studies regarding degree of weight loss with various treatments.

There are two general categories of supplements - the stimulants that decrease appetite and increase the metabolism, and the non-stimulant treatments. Let's start with the stimulants as these have been more in the news.

Pharmaceutical Appetite Suppressants

What happened to Phen-fen?

Phentermine and Fenfluramine, known as Phen-fen for short, was used for obesity until 1996. A five year study had shown them to be relatively safe (certainly safer than being overweight) and they were coming into widespread use.[1] Then the fenfluramine portion was pulled from the market because it appeared to cause damage to the heart valves in some patients.

Two years later, I spoke with a cardiologist in Bremerton and asked what his experience had been treating these patients. He remarked that his cardiology group had seen very few of them and that it appeared to him that the frequency of the problem had been greatly overestimated. However, be that as it may, the product has been pulled from the market and is no longer available.

As the years passed, a number of radiology specialists were found guilty of falsifying cardiac imaging reports, showing damage from phen-fen when there was none, in order to help attorneys and scammers defraud the manufacturerer of Phen-fen.

Phentermine

Phentermine increases levels of dopamine and norepinephrine in the brain which increases alertness and level of activity. People on phentermine tend to eat less. Because it is a stimulant it is generally taken in the morning. In conjunction with diet and exercise, you can expect to lose about ten percent of your weight with phentermine alone.

Monitoring of phentermine

Phentermine is only used in conjunction with a program of diet and exercise. By itself you will not find it very helpful. We do not prescribe phentermine without a complete history and physical examination, EKG, and laboratory work. We may not need to repeat exams and testing done elsewhere if you bring your medical records. In every case, we need to evaluate you to be sure phentermine would not be an unacceptable risk to you. We need to see you weekly for the first month and monthly after that. Continuation of phentermine requires that you continue your program of diet and exercise.

Length of treatment

Phentermine is approved to be used up to 6 weeks as part of a comprehensive program of diet and exercise. I am among those who believe this not to be rational. If a blood pressure medicine is successful, do we discontinues it after six weeks? Similarly with appetite suppressants. When they are effective, we will prescribe them for longer periods of time, and again only as part of a successful nutrition and activity-based weight-loss program.

Precautions

In general the appetite suppressant drugs are well-tolerated and many people feel better taking them. However, some people may have insomnia the first few days. Headache and constipation can be initial problems as well, often relieved by increased water intake. Women may have menstrual irregularities. The most common side effect is a dry mouth. All these side effects diminish with time.

Less common side effects include agranulocytosis (loss of white blood cells leading to mouth sores and or infection), high blood pressure, palpitations or excessive stimulation.

These agents should not be taken by a woman who is pregnant or nursing or by anyone taking a MAO inhibitor (a type of antidepressant, brand names include Marplan®, Nardil® and Parnate®).

Phen-Prozac or Phen-St John's Wort

Many patients do better on phentermine when it is combined with fluoxetine(Prozac®) or St Johs wort.

Dose and cost

We generally start with a dose of 15 milligrams phentermine in the morning. We check you again in about two weeks and may adjust the dose following that. This costs about $21 per month.. (2007 prices)

Sibutramine

Meridia® or sibutramine has the appetite-suppressing effect of phentermine and the serotonin-enhancing effect of fluoxetine (Prozac®). We don't start with this as it costs from $105 to $135 per month. Though many of our patients find that phentermine reduces their appetite adequately, some do better on sibutramine.

Yohimbine

Fat cells are sensitive to adrenaline, and they respond, unfortunately, by holding on to the fat they contain, and resisting any demands made by the physiology to remove that fat.

Yohimbine is a substance found in a plant called Coryanthe johimbe. Although yohimbine is a stimulant, it blocks the receptors that protect the fat cells from destruction.

Side effects of yohimbine are stimulation, insomnia, and increased blood pressure. It should not be taken with foods containing tyramine, such as ripe cheeses. It is available by prescription. By the way, it is also used to enhance male potency.

Non-prescription Appetite Suppressants

Herbal Phen-fen and More Recent Scams

I do not count myself among the experts in herbal medicine, but those I know cringe at the term "herbal phen-fen." This term came from the fevered brain of some marketing person. The intention was and is to separate you from your funds.

While several nutrients and herbs in the various formulations of "herbal phen-fen" and more recent incarnations have some evidence of benefit, often the studies are in animals and the effect smaller than touted. My advice is to discuss these with your physician.

Non-Pharmaceutical Substances that Influence Weight

Caffeine and ephedrine

To understand how this works, we need to talk about why it is so difficult for overweight people to lose weight.

With a low calorie diet most people have a reduction in metabolic rate. So when they eat less, they burn less energy and don't lose weight! Ephedrine is a natural stimulant obtained from a plant called Ephedra sinensis. It has been used medicinally for years. We still use it for asthma.

A double blind study showed in that woman who took 50 milligrams of ephedrine three times a day while on a one thousand to fourteen hundred calorie a day diet lost about five pounds over two months compared to one pound in the placebo group.[2] The reason is that the ephedrine prevents the metabolism from slowing up as it usually does with dieting. Aspirin, potassium and magnesium further enhance this effect.[3][4]

The studies on ephedrine are summarized in the table at the end of this article. You will note that a dose of twenty milligrams three times a day was used. The beneficial side effect of this is the stomach empties much slower. The downside is that it is a stimulant, and can result in rapid heartbeat and a feeling of the jitters. All these stimulant aids to weight loss can cause high blood pressure in normal people; of course, those who are overweight may end up with a lower blood pressure if their weight goes down.

Ephedrine is more effective when used together with caffeine. In people eating 1000 calories per day, twenty milligrams of ephedrine and 200 milligrams of caffeine three times a day resulted in a weight loss of thirty six pounds in twenty four weeks.[5] Aspirin further enhanced the effect.[6] See the table below for details.

The mechanism here is that the metabolic rate is enhanced. These studies have shown that fat loss is promoted and lean muscle mass increased.

Diethylpropion is a pharmaceutical appetite suppressant similar to fenfluramine. Danish physicians found that caffeine and ephedrine were as effective as diethylpropion in a twelve week study of 120 patients, all of whom were on a1200 calorie diet.[7]

While on the subject of ephedrine and caffeine, don't forget that aspirin enhances the weight loss effect. Twenty four people were given ephedrine twenty-five to fifty milligrams, caffeine fifty milligrams, and aspirin one hundred milligrams before each meal, and no particular diet. In just two weeks these patients lost about four and a half pounds compared with about one pound in a placebo group. Patients who continued this routine continued to lose weight. There were no side effects at these doses.[5]

Grapefruit Juice and Caffeine

Why doesn't that morning cup of coffee keep you awake all night? Caffeine is metabolized and removed from the circulation in the liver, which takes several hours. Grapefruit juice slows this process. If you take grapefruit juice along with caffeine, the caffeine will have a stronger effect that will be slower to wear off. So, if you think you need a greater effect from caffeine, take a little grapefruit juice with it. If the caffeine is making you jittery, avoid grapefruit juice.

Ephedrine and aspirin

Ephedrine is obtained from a plant called Ephedra sinensis(in Latin) or Ma Huang (in Chinese). It is available only by prescription.

Caffeine

Here are some common sources of caffeine:

If you take part of your caffeine as green tea, you will be getting some beneficial polyphenols along with it. Polyphenols are natural antioxidants that help prevent heart disease and cancer. I'd suggest a strong cup of green tea, steeped for five minutes or more, and one over-the-counter caffeine tablet such as No-Doz.

Precautions

Sources

The dose used in these studies was 20 mg of ephedrine, 200 mg of caffeine, and 100 mg of aspirin before each meal. Not all people tolerated these doses. Please check with us to work out a dose that is best for you.

Non-stimulant appetite suppressants

Guar gum and other fiber supplements

Certain fibers such as glucomannan and guar gum absorb water in the stomach and form a gelatinous mass. This produces a sensation of fullness. People feel less hungry. In some studies people absorb between thirty and one hundred-eighty calories less a day. Over the course of a year this can result in a ten to fifteen pound weight loss.

The best results have been obtained with guar gum which comes from the Indian cluster bean Cyamopsis tetragonoloba. It slows the emptying of the stomach which causes people who take it to feel full sooner in the meal.

This fiber reduced cholesterol from an average of 277 to 193 in a two month study of a dozen people with diabetes. The dose used was 10 grams of guar and 5 grams of wheat bran twice a day. Blood sugar levels were also dramatically improved.[9]

In one study women given a three-level-teaspoon dose before lunch and dinner lost an average of nine pounds in a couple of months.[10] Another research team gave ten obese people10 grams (three level teaspoons) guar gum before lunch and dinner in 5 ounces of water, every other week for 7 to 10 weeks. The patients were given wheat bran on the intervening weeks. The people were not told what kind of fiber they were taking, and were asked to rate their hunger four times a day. Their glucose and cholesterol were also measured. The study showed that the guar gum lowered glucose and cholesterol, and significantly reduced hunger compared to the wheat bran. These people lost an average of 15 pounds over the 7 to 10 weeks even though they took the guar gum just every other week.[11]

In our experience, most people found it inconvenient to mix and swallow the powder.

Cautions

An absorbent fiber encapsulated in a tablet may expand in the esophagus and obstruct it. This is a problem for people with esophageal disorders. For this reason I recommend against fiber in tablet form as these can swell excessively quickly. A powder is safest.

Another down side is that a fiber supplement can sometimes result in gas and abdominal discomfort. It is best to start with a low dose and gradually increase.

Fiber supplements are not going to work well if you get as little as 18% refined carbohydrates in your daily diet!

Beneficial side effects

Fiber supplements can reduce elevated cholesterol and triglycerides.

Studies of weight loss - doses, methods, and results

Study # # of people Overweight by what percent? Double blind? Length of study Calories in diet, per day Average weight loss
Medication - Placebo 		Medications used
13 19 25 to 90% yes 5 weeks Unlimited 3 lbs 1 lb 8 mg per kg 5-hydroxytryptophan
14 20 25 to 90% Yes 6 weeks Unlimited 3.7 lbs none 300 mg 5-hydroxytryptophan before each of three meals daily
14 20 25 to 90% yes 6 weeks 5040 kJ 8 lbs 2.3 lbs Continuation of above study with calorie restriction
11 12 27 to 95% No 7 to 10 weeks Unlimited 15.6 lbs none Guar gum 10 grams before lunch and dinner
2 121 30 to 80% Yes 34 wks Reduced 15.9% 4.9% 15 mg phentermine>br> 60 mg fenfluramine
6 141 Not known Yes 22 wks 1000 37 lbs 29 lbs 20 mg ephedrine and 200 mg caffeine three times daily
8 103 20 to 80% Yes 18 wks 1200 18 lbs 16 lbs with dexfenfluramin meds as in study #2, but dexfenfluramine 15 mg twice a day was used instead of placebo
7 24 60% Yes 8 wks No limit 5 lbs 1.5 lbs caffeine 150 mg, ephedrine 75 to 150 mg, aspirin 330 mg, before meals
7 5 No 7 to 26 months 5 lbs none continuation of above study
9 70 20 to 80% Yes 12 wks 1200 18 lbs 9 lbs diethethylpropion
9 69 20 to 80% Yes 12 wks 1200 18 lbs 9 lbs caffeine and ephedrine
3 10 17% or more Yes 3 mos 1000 to 1400 5 lbs 1 lb diet only for first month, then added ephedrine 50 mg before meals
10 9 Not known No 9 wks 650 30 lbs 13 lbs 100 mg coenzyme Q10 -see text- placebo group received coQ10 but was not deficient in it

[1]Weintraub M,Sundaresan PR,Madan M,Schuster B,Balder A,Lasagna L,others. "Long-term weight control study. I (weeks 0 to34). The enhancement of behavior modification, caloric restriction, and exercise by fenfluramine plus phentermine versus placebo." Clinical Pharmacology and Therapeutics.1992 May;51:586-94. Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, NY

[2]Pasquali R,Cesari MP,Melchionda N,Stefanini C,RaitanoA,Labo G. "Does ephedrine promote weight loss inlow-energy-adapted obese women?" Int J Obes. 1987;11:163-8.

[3]American Journal of Clinical Nutrition (1987;45:564).

[4]International Journal of Obesity (1991;15:429).

[5]AstrupA,Breum L,Toubro S,Hein P,Quaade F. "The effect and safety of an ephedrine/caffeine compound compared to ephedrine, caffeine and placebo in obese subjects on an energy restricted diet. A double blind trial." Int J Obes Relat Metab Disord. 1992 Apr;16:269-77.Research Department of Human Nutrition, Royal Veterinary and Agricultural University, Frederiksberg, Copenhagen, Denmark

[6]Daly PA,Krieger DR,Dulloo AG,YoungJB,Landsberg L. "Ephedrine, caffeine and aspirin:safety and efficacy for treatment of human obesity." Int J Obes Relat Metab Disord. 1993 Feb;17 Suppl1:S73-8.

[7]Malchow-Moller A,Larsen S,Hey H,Stokholm KH,Juhl E,Quaade F. "Ephedrine as ananorectic: the story of the 'Elsinore pill'." Int J Obes. 1981;5:183-7.

[9]Ray TK et alLong term effects of dietary fibre on glucose tolerance and gastric emptying in non-insulin dependent diabetic patients Am J Clin Nutr1983 Mar;37:376.

[10]Krotkiewski M. Effect of guar on bodyweight, hunger ratings and metabolism in obese subjects Clinical Science 1984;66:329.

[11]Krotkiewski M. Effect of guar gum on body weight, hunger ratings and metabolism in obese subjects Br J Nutr 1984;52:97.

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