When we seek out an MD, we believe we're in the care of someone who has received extensive training and is ethically bound to "do no harm." But what we may not realize is that the financial realities of modern medicine are leading some physicians to tout untested, unnecessary, or potentially dangerous cures. In this three-part series, Health examines the specialties most vulnerable to these unscrupulous doctors.
Mary Lynn Adams just wanted to lose some weight while her husband was deployed in Afghanistan. "I wanted to look good by the time he got back," says Adams, a 28-year-old homemaker in Tennessee. She found a diet doctor last December after reading a flyer that came in the mail. The doctor checked her height (5 feet 7 inches), weight (238 pounds), and blood pressure, and did some basic blood work including testing her cholesterol levels. Although Adams had high blood pressure (145/95), the doctor recommended that she start the prescription appetite suppressant phenterminea drug not recommended for patients with high blood pressure because, as a stimulant, it may increase blood pressure even more. "He explained to me that the risks of my being overweight were worse than the risks of having high blood pressure," Adams says. The drug definitely curbed her appetite"I felt sick just looking at food," she saysbut she also noticed her heart was racing. A month later, her blood pressure was up to 150/100. Her doctor cut her dose in half, but Adams decided to stop taking the drug. She's now working with a personal trainer, who she says is benefiting her more than the medicine.
Many women assume that any weight-loss treatment prescribed by a doctor must be safecertainly safer than sketchy supplements or weird crash diets. But the truth is that some doctors are pushing the limits of what's medically acceptable, prescribing drugs that may put their patients' safety at risk or offering treatments that aren't proven to work. "The field is ripe for abuse because there are a lot of desperate people out there trying to lose weight and a few doctors who just want to make some fast money," says Rhonda Hamilton, MD, MPH, an instructor at Harvard Medical School and medical coordinator of Bariatric Quality at Winchester Hospital in Winchester, Massachusetts.
How dangerous doctors are made
The weight-loss field is particularly vulnerable to exploitation because there are so many people struggling to shed pounds who don't know where else to turn. An estimated 68 percent of adults in the United States are either overweight or obese, yet medicine doesn't have much to offer in the way of help; there are very few effective nonsurgical weight-loss therapies. Diet and exercise are the foundation of any successful weight-loss plan, but for many, even those don't work. "In the long run, lifestyle modifications lead to substantial, lasting weight loss in 2 or 3 percent of people with obesity," says Lee Kaplan, MD, PhD, director of the Massachusetts General Hospital Weight Center in Boston. "That's pretty frustrating for the remaining 97 percent. It's like having incurable cancerpeople will seek any new opportunity for treatment."
In the absence of better options, a new breed of diet doctor is rushing to fill the void. And many aren't even properly qualified: While they may tell patients they're board certifiedmeaning they've completed specialized training and passed a qualifying examthey often neglect to add that their training isn't in weight control but in unrelated fields, such as dermatology, obstetrics, or plastic surgery. Any doctor can join the field's two leading professional organizations, the Obesity Society and the American Society of Bariatric Physicians (ASBP)the latter of which has seen a nearly 40% surge in membership over the last five years.
"There are many good, responsible weight-loss doctors who are trained in a relevant field and who work with patients to help them make long-term changes," says Robert Kushner, MD, clinical director of the Northwestern Comprehensive Center on Obesity in Chicago. "Then there are those who offer all kinds of hocus-pocus treatments or just dispense medications to everyone who walks in their doors."
So what's driving the rush to practice in this area? "Basically, it's money," says Ken Fujioka, MD, director of the Center for Weight Management at the Scripps Clinic in La Jolla, California. "Many independent physicians are getting squeezed financially, and in weight-loss medicine they see a way to make income."
Dr. Hamilton has seen this world from both sides: She struggled with obesity for 15 years, and says she tried everything, from prescription diet pills to fad eating plans like the watermelon diet, before finally having gastric bypass surgery five years ago. "I spent thousands of dollars out of pocket during those years, and there were plenty of doctors who were happy to take my money," she says.
After she had surgery and lost 90 pounds, Dr. Hamilton began working to educate obese patients about surgical options, but she was shocked at what she witnessed at one bariatric conference she attended. "I was hoping to hear about successful diet plans that had research to back them up, but it was the first medical conference I'd ever been to where there wasn't a single randomized trial presented," she says. "Instead, it was largely a seminar on how to make it rich off of repeat customers."
Some doctors are driven to set up a diet shop not because they'll get rich, but because they just want to get by in today's managed-care world. "Sure, there are some doctors who want to drive Porsches, but there are also those who feel that the only way they can make a living is to make their offices a place to sell products," says Mitchell Roslin, MD, director of bariatric surgery at Lenox Hill Hospital and Northern Westchester Hospital in New York. "Doctors are getting killed by the increased cost of running a practice and carrying liability insurance, and they're getting less and less back from the insurance companies and government. Basically, they are looking to break even any way they can."
Many diet-doctor dangers can be hard to spot. Here are the biggest problems Health's investigation uncovered:
New pill mills Dangerous weight-loss drugs have been causing controversy for decades. The most infamous example was "fen-phen," a combination of two diet drugs, fenfluramine and phentermine, that was popular in the mid-1990s. "Doctors sometimes prescribed it indiscriminately, even to women who didn't meet the medical criteria for being overweight," says Pieter Cohen, MD, an internist at Cambridge Health Alliance in Cambridge, Massachusetts, and an assistant professor of medicine at Harvard Medical School. This blew up in 1997, after the U.S. Food and Drug Administration (FDA) received reports of serious heart-valve abnormalities in patients who took fen-phen; both fenfluramine and a related drug, dexfenfluramine, were consequently pulled off the market.
Today, diet drugs are carefully scrutinized for safety concerns before they receive FDA approval. In the last year, the FDA has declined to approve three new diet medications, Qnexa, lorcaserin, and Contrave, citing concerns ranging from potential birth defects to heart risks to cancer.
"Fen-phen was a big wake-up call for the weight-loss field," Dr. Cohen says. "Unfortunately these kinds of practices are still out there." A 2009 study found that 65% of physician members of the ASBP who responded to a survey prescribe drug combinations that are not FDA-approved for the treatment of obesity. While such "off-label" use of medications is common in all areas of medicine, the concern is that these combos, like fen-phen, may pose as-yet-unknown health risks. One sometimes-prescribed combo is phentermine plus topiramatethe formula in Qnexa, one of the drugs the FDA recently shot down over safety concerns. For more on diet-drug combos, see Are Diet-Drug Combos Safe?.
Even approved medications have potential for abuse. "The FDA only recommends phentermine for short-term useno more than 12 weeksand only in patients who don't have a history of high blood pressure or anxiety disorders," Dr. Cohen explains. "But I see many patients who have gone to a local obesity center and have been on phentermine for months, even when they have clear contraindications."
Clinics have also been sprouting up with MDs who dispense phentermineand do little else. "Many of the patients these doctors see aren't overweight enough to be taking phentermine at all," Dr. Fujioka says. But the drug can be a big source of cash for these doctors. "When I prescribe phentermine, my patient pays $15 at Walmart for a month's prescription," Dr. Fujioka explains. "But at these clinics, the doctor buys a month's worth of phentermine for, say, $5, but sells it to the patient, who doesn't know any better, for up to $100 for a week's dose. It's how they make their money."
Unproven fads Right now, everyone's talking about the HCG diet, and plenty of docs are willing to offer this controversial plan, which combines daily injections of human chorionic gonadotropin (HCG), a pregnancy hormone, with a 500-calories-a-day diet. (See The HCG Diet: Behind the Hype for more info.) Doctors charge anywhere from $600 to $1,000 for a 40-day program, which typically includes an exam, blood work, and the HCG shots.
Talk to many seasoned obesity specialists, and they will warn you that not only is there no proof that the HCG diet works, but it could even be dangerous. "There have been numerous studies of the HCG diet, all of which demonstrate that it works no better than a placebo," says George Blackburn, MD, PhD, associate director of the Division of Nutrition at Harvard Medical School. "For any physician to suggest otherwise is unethical." The hormone carries a risk of blood clots, depression, headaches, and breast tenderness. And the FDA recently received a report of a patient on the HCG diet who had a pulmonary embolism.
Yet doctors who prescribe the HCG diet insist it worksand that they're only offering what patients are asking for. One physician, a former dermatologic surgeon who recently opened up a weight-loss clinic, told Health that she started prescribing HCG after seeing a friend successfully lose weight on the plan. She dismisses the diet's detractors: "A 1999 article in the medical journal The Lancet found that high HCG levels in pregnant women correlate with morning sickness, which decreases appetite," she argues. "It does workthe studies just need to be done a little bit better."
Shady surgeons For obese patients who have tried and failed to lose weight through diet and exercise, weight-loss surgery may be the only effective option left. One type of bariatric surgery, gastric bypass, is usually reserved only for the most seriously obese. But another procedure, known as Lap-Band surgery (in which an adjustable band is placed around the stomach to reduce the amount of food it can hold), may soon become much more widely available: In February, the FDA approved a request by the manufacturer of Lap-Band to market the procedure to patients with a body mass index (BMI) as low as 30 (for a 5-foot-4 woman, that's 175 pounds) as long as they have at least one weight-related medical condition, such as type 2 diabetes or high blood pressure.
Experts say there's less room for docs to behave badly in the field of bariatric surgery, but they acknowledge that abuses can occur. "There are doctors out there who set up outpatient clinics, perform Lap-Band surgery on tons of patients, and don't provide proper postoperative care," explains Marc Bessler, MD, director of the Center for Minimally Invasive and Metabolic Surgery at New York-Presbyterian/Columbia University Medical Center in New York City. "They do the operation, see the patient back to tighten up the band, and that's it, good luck."
Slimming down safely
There is some good news for the future: Alarmed by reports of unscrupulous doctors, 13 professional organizations, including the Obesity Society and the American Heart Association, have banded together to form a committee that will set up an independent obesity-medicine board. That means physicians who want to practice weight-loss medicine will have to undergo specific post-residency education and also pass a board exam. "We're hoping it will bring back some legitimacy to the profession," says Dr. Kushner, who is spearheading the efforts. He expects the board will begin certifying physicians within the next two to three years.
Until that time comes, make sure any diet doctor you see is board certified in a relevant field, such as endocrinology or internal medicine, Dr. Kushner says. The doctor should also have a team of other weight-loss experts, such as a registered dietitian, a psychologist, and even an exercise physiologist, working with him. If you're considering surgery, seek out a hospital or facility that is designated as an American Society for Metabolic and Bariatric Surgery (ASMBS) Bariatric Surgery Center of Excellence, and look for a surgeon who is an ASMBS member. (To join, doctors must have certain credentials and letters of recommendation.)
When you meet with the doctor, ask her if she has any studies that can document her program's success. Ideally, you want data that shows what percentage of her patients have completed her program, how much weight they lost, and how successfully they kept the weight off over a one-year period or longer, Dr. Blackburn says. If your doctor doesn't have that data, she should at least be able to provide you with published research that shows the benefits of the treatment plan she's recommending.
And ask yourself if you really need a diet doc in the first place, especially if you're not obese. "My patients come in all the time asking for weight-loss medications, and I explain to them that working with a registered dietitian is really their best bet," Dr. Cohen says. (You can find a registered dietitian through the American Dietetic Association.) "Sure, a so-called diet doctor may give them some pill or shot that they claim will help them lose weight. But even if it seems to work, it's only for the short term. Taking the time to analyze your eating habits and lifestyle and figure out what stresses trigger you to eatthat's how you'll find success in the long run."
Finally, take a good hard look at anything a diet doctor is trying to sell you. When an MD dispenses medications out of their office, that's a big red flag, experts say. (For more warning signs, see 6 Types of Diet Doctors to Watch Out For.) "A medical license should not be a license to sell something unproven for profit," Dr. Roslin says. "Maybe I'm naive, but I think that doctors have a higher responsibility."