Going right through you

The diet pill Xenical reduces fat absorption, but may cause unpleasant side effects.

Published June 30, 1999 4:00PM (EDT)

If you'd prefer that last night's crhme br{lei end up in the toilet
instead of on your hips, you might take orlestat. The new drug, which
came on the market less than two months ago, arranges it so that one-third
of ingested fat goes right through you, so to speak.

Orlistat, sold under the brand name Xenical, has only been FDA approved
for -- and tested in -- those who are officially obese. One of these,
Cindy Smith, could be the Xenical poster child. The new fat-blocking drug
helped her take off hated pounds she had been unable to lose any other way. At 5 feet 4 inches tall, she weighed 220 pounds when she entered clinical trials of the drug
two years ago. Now the 34-year-old bank worker in Houston is a
satisfied 150.

To qualify for the trials, you had to be, like Smith, officially fat. At 6 feet tall, for example, participants had to weigh at least 220 pounds, or no less than 200 if they had fat-related health problems. After two years of testing, it appeared that overweight people who took the drug lost an average of seven to 10 pounds more than those who didn't. Xenical also lowered levels of problem cholesterol beyond what could be explained by the weight loss.

For the desperate to reduce, such benefits may justify the fact that Xenical is chemically addressing what is essentially a social problem. In a rational world, one might suggest not eating whatever you don't want
to digest. But in our culture, at once obsessed with both food and
thinness, the blue capsules are being embraced as a way of tempering the
consequences of excess. And not just by the truly overweight.

More than 210,000 Xenical prescriptions have been sold in the drug's first seven weeks on the U.S. market. Apparently the appeal of the fat-be-gone pill trumps any memory of the recent recall of fenfluramine, another diet drug that was shown to cause heart damage after being pounced on by eager dieters. It also overshadows Xenical's own hazards, which are many and troubling.

In fact, the FDA panel considering Xenical was at first split on whether to
approve it, with nay-voters stuck on distressing medical points, such as
the fact that the drug leaches vitamins from the body and disrupts the
normal digestion process. Perhaps most alarming, one study the panel
reviewed found that drug takers had a higher rate of breast cancer than
those not on it. New data that the breast cancer cases didn't
appear to be linked to the drug eased panel members' concerns enough for
them to approve Xenical in May. But even after approval, Jules Hirsch, an
internist and nutrition expert who served on the panel, says "there is a
residual worry" over the breast cancer question.

And, since Xenical has been only tested for two years, its long-term effects add up to a big question mark. "We don't know what this drug does over long periods of time to gastrointestinal function," says Hirsch. "It's coating the intestine with a thin layer of fat. We just don't know
what this will do to intestinal function over years."

Those interested in taking the drug seem less concerned with such medically
weighty matters than with the drug's embarrassment-potential. As one dieter
encountered in the weight-loss chat room at thriveonline.com delicately put it: "I heard it makes you mess your pants." The rumor was confirmed by another chatter, whose daughter is taking Xenical.

According to the Roche product information, such "adverse events" --
including anal seepage, oily spotting, orange stool and something
disturbingly described as "fecal incontinence" -- occur in about a quarter
of drug takers, but can be minimized by scaling back fat intake. That
side effects increase according to the amount of fat a person consumes is
helpful, at least when it comes to defending Xenical against charges of
fueling an unhealthy compulsion to overeat. Like antabuse, a drug that
makes alcoholics violently ill if they drink, Xenical could theoretically
hem in behavior. But, even when eating light, the potential for oily
spotting and emergency trips to the bathroom remain.

One might be willing to withstand such symptoms in the name of extending
life or avoiding serious disease. Maybe. But would anyone risk such
humiliation for the sake of obsessive vanity? Apparently so. Ben Krentzman,
a weight loss specialist in Venice, Calif., reports that 18 of the 20
or so patients who have asked Krentzman about taking Xenical so far were
not fat enough to meet the criteria. "People who want to lose five pounds
can suffer the same torment as people trying to lose 500," Krentzman muses,
by way of explaining the generalized lust for Xenical. (At 400 pounds,
Krentzman says he is considering taking Xenical himself, but "wants to see
how it all works out.") Krentzman will only prescribe the drug to patients
who fit the official guidelines. But less scrupulous doctors can legally
approve it "off-label" for just about anyone.

And those who can't get Xenical from a real doctor can get it from someone who plays one over the Internet. At least a dozen sites, most of which also
sell Viagra, offer the diet drug "without a prescription," "in six easy
steps," or "with complete privacy and confidentiality!" In lieu of a
prescription, the buyer is usually asked to have an online consult, which
involves answering questions about height and weight.

There is no way of verifying the information, of course, which means that
the drug is available to pretty much anyone who has the roughly $120 it
costs per month. (Insurance pays in only a minority of instances.) That
worries some eating disorder specialists. "Bulimics quite consciously
engage in the consumption of large amounts of calories followed by a
behavior to avoid the consequences," says Tim Walsh, director of the eating
disorders research unit at the New York Psychiatric Institute. As Walsh
sees it, Xenical has the potential to be yet another consequence-avoiding
tool, along with self-induced vomiting

No one makes any money off vomiting, however. So while marketing rights to the finger remain, for the moment, unclaimed, analysts project that
Hoffman-La Roche will make some $3 billion from the drug. Roche, a
pharmaceutical giant known for selling Valium, can't be held responsible
for the abuse of its product, which it warns bulimics against using.
(Bulimia, remember, is a medical condition, Xenical is a treatment.) But
even while drug materials clearly state that Xenical is for the obese, the
launch campaign seems to extend a extremely friendly hello to most everyone concerned about weight. The promotional information announces: "First and only in a new class for weight loss, weight maintenance, and reduced risk of regain."

And, to muddy matters more, Roche is promoting something called the "taste
of healthy living campaign" in conjunction with Xenical. The PR
extravaganza -- which extends to 18 cities and has employed everyone from
high-end chefs to former New York mayor Ed Koch -- doesn't directly
plug Xenical. But it does use the same shiny, blue folders and lettering as
the Xenical materials to reach out to the population at large. That
includes "Laura," a woman the promotional brochure describes as wanting "to maintain her weight of 128 pounds." "You'll see that you don't have to
deprive yourself of foods you love to eat," assures the "healthy living"
dieting guide, which, at the bottom of every page, says "Brought to you by
Hoffman-La Roch Inc., maker of Xenical."

There is nothing wrong with the eat-light message of the campaign, in which
high-end restaurants are paid to put "healthy living" icons near low-fat
menu options. (So far, no chefs have accepted Roche's offer to directly
promote the drug itself.) And there was nothing wrong with the
"healthy-living" fare at Sonora, a New York Latin-fusion restaurant
participating in the promotion. The lobster mango ceviche was tasty and the
baked red snapper -- which comes in at a startlingly lean 117 calories --
were perfectly good. But what of the fact that the little healthy living icon on the menu will be associated with Xenical?

And, perhaps more to the point, what of the Dulce de Leche cheesecake
listed on the menu just inches from the sensible fish dish? Surrounded by
the constant celebration of richness, how could anyone not consider that
Xenical would help them repel calories from cheesecake as well as from
lighter fare? By reducing their calorie intake, wouldn't Xenical make people already partial to heavy foods more likely to indulge?

Desperation may dwarf such questions. Obesity contributes to some 300,000
deaths per year. It's hard to fault the ideal of making any dent in that
number. And there's also the emotional relief to consider. Smith, the bank
worker who participated in the clinical trials, for instance, says she was
profoundly changed by her weight loss. "I enjoy life a lot more now,"
gushes Smith. "I feel so much better about myself."

Who wouldn't want that for our entire nation? Yet, given our ever-mounting desire for consequence-free excess, Xenical seems more likely to nudge us in the direction of even greater consumption, stretching our stomachs to
accommodate bigger sundaes and whetting our appetites for the next big
nutrient-blocking pharmaceutical. Something to think about as we pass a
little oily wind and run like hell to the bathroom.

By Sharon Lerner

Sharon Lerner is a journalist and a senior fellow at the Center for New York City Affairs at Milano Graduate School, New School University.

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Drugs Obesity