Weight Loss for Sale

Tue, 14 June 2011 - 5:30 p.m. MT
Credit: Jeff Venables

           Like it or not, these days physicians are enthusiastically joining the ranks of commercial weight loss plan (CWLP) entrepreneurs. For the doctor looking to expand reach beyond a local practice, touting such a plan is no doubt a great way to sell books—and certainly the inverse is true. In an increasingly privatized health care universe, it is no longer taboo to seem entrepreneurial. To be sure, paying out-of-pocket for state-of-the-art treatment well suits the vanity and frivolity of a public susceptible to the fad diet market. And so the trend extends beyond diet plans and books and into retail meals, supplements, medications, consultations, and other treatments.

 The potential for conflicts of interest gives many physicians pause. Ethically speaking, an authoritative, seldom second-guessed professional charged with monitoring your health who recommends a product that s/he ultimately has a financial stake in can certainly be considered a slippery slope. Yet these plans are not all to be dismissed as frivolous fads or onerous marketing ploys. There are certainly doctor-engineered and -endorsed programs out there worth the paper they are prescribed upon. We examine here a few of the more popular ones, and also attempt to establish some guiding principles for choosing a CWLP should you decide to do so.

Dismissing for a start any plan that fails to look past the quick-fix (fit into that wedding gown in 3 weeks!) we seek to evaluate those truly aiming for long-term health. But no plan is perfect, and along the way you’ll find compromise is often necessary if you choose to lose weight via any CWLP. Still, what are some warning signs that your money is best spent elsewhere?

Immodest proposals. What’s the general tone of the diet plan’s health claims? Extraordinary claims require extraordinary evidence. Examples of the former, which never seem to be followed by the latter, include: “No exercise necessary!” and “Lose five pounds a week!” Also dismiss recently discovered wonder drugs and other miracle products. True scientific advance is a slow process. A new product or cure may seem to be an overnight success, but a little research always reveals that it was a very long night indeed.

Disclosures that protest too much. Plans that partner with supplement manufacturers and who straightforwardly disclose the relationship are laudable, but be wary of a plan that undermines any disclosure with awkward backpedaling. Take this example from the Nuviva website:

We've partnered with one of the nation's leading supplement companies - Douglas Laboratories - to develop a suite of nutritional aids to sustain you through your individualized weight loss plan…FDA audited and ISO certified and accredited, Douglas Laboratories uses cutting edge technology in conjunction with the very latest, most credible science to deliver optimal benefits for your health. Additionally, all of their supplements undergo rigorous testing monitored by on-staff PhDs.

This sounds fancy but actually isn’t promising much. In fact, this small blurb touches on a number of issues worth examining.

First off, “ISO” is not defined. After a best guess, a Google search of “International Supplements Organization” yielded zero matches. “ISO,” it turns out, stands for a body called the International Organization for Standardization, which says that it “launches the development of new standards in response to sectors and stakeholders that express a clearly established need for them.”

The point they want to make is that their supplements are safe and effective, but this not-quite assertion just opens a can of worms. Several steps away from showing any meaningful regulation of their products, it’s unclear what leads to becoming “certified and accredited.” Supplements purchased and consumed directly through a plan like Nuviva do have a good chance of being as-advertised. But, as mounting FDA warnings and consumer-led class action lawsuits attest to, the chains of manufacture and sale for thousands of readily available dietary supplements remain alarmingly sloppy, and the law policing their claims is even worse.

For example, in December the FDA sent a stern letter to several supplement manufacturers asking for better policing of undeclared ingredients. Several supplement trade associations endorsed the letter, including the Council for Responsible Nutrition, the Natural Products Association, the United Natural Products Alliance, the Consumer Healthcare Products Association, and the American Herbal Products Association. A spokesperson for the FDA declared that the FDA hopes the manufacturers “take the letter seriously.” All of this sounds pretty hollow, and in any case the good folks at Douglas Laboratories aren’t claiming that any of these trade associations have “certified and accredited” their work.

A heavy reliance on supplements. In 1994 Congress passed the Dietary Supplement Health and Education Act (DSHEA), which allowed manufacturers to sell them without first getting FDA approval. This shifted the burden of proof to the FDA to determine not that a product is safe before it is sold—as with prescription drugs—but to determine whether a product is unsafe before it can be removed from the market. Furthermore, The FDA website states that “Manufacturers must make sure that product label information is truthful and not misleading.”

Independent testing groups such as consumerlab.com do their best to test popular new supplements, but any claim that a supplement manufacturer is “FDA audited,” implying in an ongoing way, is false. It is unfair to single out the Nuviva weight loss plan, however, which we’ll look at more closely later—but generally a high level of scrutiny is deserved for all supplements-focused weight-loss claims.

Note that in general the regulatory gray area in which supplements function gives way to alarming abuse of the system. Several criminally negligent manufacturers, mainly overseas but also stateside, have been caught making slight molecular alterations to powerful prescription drugs and remarketing them in the unregulated supplements category, therefore dangerously selling them to the public without prescriptions or any dosage restrictions.

            “Brazilian diet pills” for example, have been repeatedly found to contain a frightening array of stroke-inducing amphetamines and prescription-grade antidepressants. For a thorough, if by nature never comprehensive, warning advisory visit www.fda.gov/Food/DietarySupplements/Alerts/default.htm.

 

Doctor or doctorate? Weigh carefully whether a company is staffed, policed, or advised mainly by MDs or by PhDs. There are of course legions of well-credentialed PhDs out there researching, monitoring, and reporting at the highest level of professionalism with regard to diet, weight loss, health, and lifestyle. But there are PhD programs offered at every caliber of trustworthiness. Medical doctors have generally undergone a far more standardized and knowable process of evaluation before becoming board certified and active in a medical practice. In short, it’s easier to find a person with an obscure pseudoscientific doctorate from an unknown institute to endorse your unfounded weight loss claims than a practicing physician from an established medical school.

A lack of peer review. It’s worth a search of the PubMed database for clinical trials or other published research papers on as many specific aspects of a commercial diet plan as you can. Plans nearly always proffer cleverly packaged in-house data, some of which is passable as science and other of which is complete mumbo-jumbo—or at least P.R.-department generated and therefore highly questionable. A lack of any peer reviewed studies in medical journals is always troubling. This is a way of saying that good science means replicability, and therefore predictability. “Studies show” is a lot more reliable than “Our study showed.”

FDA conspiracy theories. Buyer beware of too much FDA bad-mouthing because it is convenient and disingenuous on a number of fronts. Contempt for all things federal is en vogue these days, making a body like the FDA an easy target. But why target? If your weight loss plan can’t prove its claims, the easiest thing to do is downplay any regulatory body’s relevance of opinion in the matter. FDA bashing is so tempting for the shadier supplement companies and weight loss plans because it capitalizes on a possibly legitimate complaint, deliberately confusing the two issues. This complaint stems from the belief that approval of prescription drugs is somewhat politicized, too slow, and often favors the pharmaceutical giants over generics that could be provided at much less cost to the consumer. As earlier noted, supplements by contrast are given freewheeling permission to enter the market, and so they remain utterly unrelated to the prescription drug-approval process.

 

Weak logic and vague language. Often you’ll find overreaching connections in the general literature of a CWLP. In a discussion of B12 injections, one website declared, “This injection is also referred to as being a lipotropic nutrient.” Note that the company stops short of saying definitely that the injection is a lipotropic nutrient.

Other hedging buzzwords and phrases include:

  • Doctor So-and-so “believes”
  • Doctor So-and-so is “renowned”—by whom?
  • The term “expert”
  • Saying something “just makes sense”

To this list we might add saying that this or that treatment or product is “exclusively available” at XYZ Clinic—although that might not make it ineffective. This statement just warrants an air of caution because it’s improbable that one clinic has access to something truly remarkable that no other clinic has, and so the statement likely means only that a specific brand is exclusively available. That may be ok too, but it certainly gives the clinic a great excuse to financially exploit its exclusivity.

Other considerations include whether the FAQs in the literature seem written with your questions truly in mind, or as a platform for the CWLP’s website to proffer selling points. Also beware of an anti-aging emphasis—there are no known anti-aging diets/creams/pills, strictly speaking. Some creams or dietary decisions can slow the process or even reduce wrinkles (at least in the short term), but anti-aging, which implies reversing the aging process, is an indefensible concept by current scientific standards.

A close look at some CWLPs. Egregious claim-making aside, just because something is aggressively marketed or very expensive doesn’t mean it doesn’t work. In May that trusty watchdog of all that we buy, Consumer Reports, surveyed people about the results of their experiences with various popular mainstream weight loss programs. They also independently evaluated the programs based on available scientific data.

Jenny Craig came out on top, having had a 332-person, two-year study of the program published in the Oct. 27, 2010, issue of JAMA. Ninety-two percent of participants stuck with the Jenny Craig program for two years, which represents a remarkable level of adherence. At the end of that time folks weighed an average of about eight percent less than when they started. The key components that contributed to such a high level of adherence appear to be personal counseling, portion control through pre-packaged meals, and the incorporation of Volumetrics’ strategy to consume high-bulk, low-calorie food.

The idea that not all food calories are created equal has gained quite a bit of traction since Consumer Reports issued the same survey four years ago, when the Volumetrics plan in fact beat out the others. As we all know, regardless of your plan, to lose weight you must burn more calories than you consume. “The first law of thermodynamics still applies," says Dean Ornish, MD, whose nearly vegan plan was also rated high by Consumer Reports.

But some forms of calories are more filling than others. Protein is the most satiating nutrient, followed by high-fiber grains, fruits, and vegetables. The Atkins diet once used this idea to great effect—at least in its marketing—but the diet has largely been discredited since. The far better option is to go for high fiber, which is extremely filling but passes through your system (providing myriad other health benefits). In addition to a low-fat diet, Dr. Ornish’s program includes exercise, stress management, and group support, and has proven so effective that Medicare now covers it for cardiac patients. Weight Watchers also came around to this idea in 2010, unveiling PointsPlus, which still deploys calorie-counting but now specifically steers hungry dieters to the most filling foods.

The 2010 edition of the U.S. Dietary Guidelines for Americans frowns on eating 10 percent or more of calories from saturated fat and more than 35 percent from fats overall. So the Atkins diet, which is 64 percent fat calories overall and 18 percent saturated fat, ends up with only a Fair nutrition score. The idea behind Atkins is that insulin tells your body to make and store fat. When you restrict carbs, your insulin level goes down and you can burn body fat. Replacing refined carbs with high-fiber fruits and vegetables—and even unsaturated fats, as from fish and avocado—is a far better way to restrict insulin production than consuming huge quantities of saturated fat. Any CWLP you seriously consider should understand this powerful relationship between fiber, fullness, and healthy weight loss.

Nuviva Medical Weight Loss Clinics. Florida-headquartered Nuviva runs a series of independently franchised national weight loss clinics. Overall, the centers do seem to have a knowledgeable, practicing cardiologist on board in addition to a reasonable, multifaceted, and long-term—if costly—individualized plan to offer consumers. Medical director Brian K. Arcement, MD, is keen on combining diet and exercise, and wisely sites “poor lifestyle choices” as a leading cause of overweight.

Apart from individualized diet and exercise planning, this CWLP combines some older, well tested short-term appetite suppressing drugs with more suspect cleanses and supplements. Their emphasis on something called Human Chorionic Gonadotropin (hCG) is slightly disconcerting. Administered by (expensive) subcutaneous injection, hCG, Nuviva reports, is a “natural hormone, produced by the human placenta, [and] has been shown to mobilize abnormal stored fat into the circulation where it becomes available for use as energy and for appetite control.” hCG is not FDA approved for use in weight loss, and it hasn’t really “been shown” in a way that satisfies even Dr. Oz, who recently withdrew his endorsement of the hormone, removing his association with it from the web. Nothing raises drug efficacy issues quite like a broken video link and a legal notice from Dr. Oz’s LLC.

In a May 23, 2011 press release entitled Is hCG Safe For Dieters? Nuviva representatives stated, “While we lack the empirical data, new anecdotal data comes in every day, and now it's being examined closely in the media as well as some new studies.” New data every day? This statement has the dubious honor of being simultaneously vague and hard to believe. Nuviva offers far better nutrition coaching. They say that physicians will “work with each client to educate them about the proper way to exercise, the smartest foods to eat, the best ways to cook and the healthiest supplements to take.”

Nuviva seems to cater to wealthy folks: “Our commitment to your individualized weight loss plan begins with a comprehensive intake consultation that includes a blood test, EKG, body measurements, weigh-in and a physical examination.” Next a doctor examines you. All of this seems extravagant, but it does combine the several known components of good weight loss plans: counseling, individualization, exercise, a low-fat diet, and, as needed, short-term pharmacology.

Nuviva does seem to overreach at times:

Herbal cleansing programs provide nutritional support…Our bodies were designed with 7 channels of elimination (Lungs, Liver, Skin, Kidneys, Colon, Lymph, and Blood). Providing nutritional formulas that support our cleansing channels just makes sense.

They can also seem hucksterish, as in this recent press release:

 - What Does a Pregnant Woman Have that Can Make You Thin?
- Is hCG a Diet Maker or Breaker?
- Is hCG Safe for Dieters?
- Does the FDA Want to Keep America Fat?

In addition to the “click here to find out” quality of the pregnant woman teaser question, the above raises several red flags, including an extraordinary claim (the FDA conspiracy), betting a lot of chips on a wonder drug few people have heard of (hCG), and use of a FAQ that the company really wants to ask and answer (“Is hCG a Diet Maker or Breaker?”). Perhaps the best item Nuviva offers on their website is the piece simply entitled Seven Specific Ways Exercise Can Improve Your Life. This plan will likely continue to flourish, and hopefully they will move further away from the more unfounded supplements claims and increasingly proclaim the benefits of exercise, the true magic bullet.

In contrast to Nuviva, which generally has most of the correct caveats in place alongside realistic expectations, D.C.-area My Weight Doctor has several red flags visible right on their homepage, which states:

Welcome to My Weight Doctor®

Unlike typical diet centers, we help you lose weight and feel younger by using customized therapies that are only available through licensed medical doctors . Whether you have 10 or 300 pounds to lose, our guaranteed process is unique because our doctors will customize your treatment so that you lose weight rapidly and safely.

How does it work? FDA Approved Medications Physician Counseling Customized Treatment Affordable Plans State-of-the-Art Clinics Nutritional Planning & Support Permanent Results

These bold claims don’t quite strain credulity but the hyperbolic tone encourages great scrutiny. One troubling fact is, despite many enticing links made garishly visible on the page, few offer real data about the plan—e.g., when you click on “FDA Approved Medications,” there isn’t actually a list of medications published that My Weight Doctor uses. Rather, a lot of legalese accompanies each subpage. The terms and conditions under “guaranteed process” are enough to send you looking elsewhere. My Weight Doctor does provide a list of its MDs (perhaps relying on that built-in trustworthiness of real doctors). Still, reading the Terms of Service feels like you’re entering into a compact to be prescribed an astonishing array of mandatory therapies, paid a la carte by you and without which you’ve no hope of claiming a refund for the expensive, disappointing weight loss results you’ve sunk cost into ahead of time.

Medifast, which works much like Jenny Craig (and the also sensible Nutrisystem plan), essentially offers someone to make your dietary decisions for you. Here the peer-reviewed research is thin; the in-house clinical data a little better. They have somewhat stood the test of time, and do deploy the winning combo of portion control, exercise, and personal counseling. But up and running since 1980, Medifast announced just three years ago the creation of its “scientific advisory board.” That is worrisome. The professionals on the board are thankfully from hospitals and medical colleges, though only two of the seven are MDs.

Medifast claims that it has been “recommended by over 20,000 doctors,” which would be about one in 35 U.S. physicians. More likely, they disingenuously include PhDs in this statistic or their claim, which cannot be disproved, is wrong. Still, “Medifast Meals are individually portioned, calorie- and carbohydrate-controlled, low-fat meal replacements,” they write. “Every Medifast Meal is based on a similar nutritional ‘footprint’ that provides just the right balance of protein, carbohydrates, and fiber. Medifast Meals are fortified with at least 24 vitamins and minerals for optimal nutrition.” They structure your diet around six meals a day, once every two to three hours. This idea is widespread among dieticians as a sensible approach. Those six meals include five Medifast Meals and one called a “Lean & Green Meal” daily.

Medifast claims that you will lose “up to 2 to 5 lbs per week, on average,” which is so full of hedging language that it almost contains no information. Perhaps the silver lining is they seem wise enough to realize that a plan outright offering a weight-loss rate of five pounds per week is unlikely to be healthy or long-term. In the hyperbolic climate of online CWLPs, Medifast can hardly be blamed for overstepping here and there in their marketing. The plan overall is based on sound nutritional principles, does have the support of many in the medical community, and has been honing its strategies for over 30 years.

A four-week meal package, with 143 servings, costs $315 for both men and women, though the meals differ. These meals are comparable in price to other, similar plans, which can vary by gender, gourmet menu options, and whether you decide to auto-renew each month (at significant savings) or pay as you go. For example, the Nutrisystem men’s 28-day meal plan, purchased one month at a time, is $385 including shipping. By auto-renewing monthly, that basic meal plan costs $184 per month. Women save about $30 as you go and $20 on the monthly renewal—perhaps because the men’s diet costs Nutrisystem more to produce.

In June the USDA Food Pyramid was replaced by the USDA Food Plate. The new design emphasizes portion control, 50 percent fruits and vegetables, half or more of grains from whole grains, and being mindful of sodium. This reflects what many successful CWLP promote: smaller portions, low-fat substitutes, and an increased role of filling, high-fiber foods.

And not surprisingly, in the Consumer Reports survey, the most successful dieters combined restraint at the table with increased physical activity. Finally, do look for moral support in a plan. Mandatory checking in with a counselor works better for some people; others prefer a weekly support group. Ultimately, it is the small changes in the right direction that are sustainable—and therefore sustain us—in our fitness goals in the long run.

 

Jeff Venables is the editor of Running & FitNews, the publication of the American Running Association.



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