DIET PILLS

OFFICIAL NAMES: Benzphetamine (Didrex), dexfenluramine (Redux), diethylpropion (Tenuate, Tenuate dospan, Tepanil), fenfluramine (Pondimin), mazindol (Sanorex, Mazanor), methamphetamine (Desoxyn), orlistat (Xenical), phendimetrazine (Bontril, Plegine, Prelu-2, X-Trozine), phentermine (Adipex-P, Fastin, Ionamin, Oby-trim), sibutramine (Meridia)

STREET NAMES: Methamphetamine: Speed, crank

DRUG CLASSIFICATIONS: Schedule II, III, and IV, stimulant

OVERVIEW

The use of diet pills to lose weight is a twentieth-century phenomenon that carried over into the twenty-first century. During earlier centuries, society regarded plumpness as a sign of good health. Up until the late nineteenth century, a full figure indicated financial status, because a plump person could afford to eat.

An 1880s American drawing portrayed a woman asking her doctor for advice about a "fattening cure" to help her gain weight. A sign on the doctor's wall showed a list of "Flesh Forming Ingredients" that include cocoa extract and French chocolates.

The first diet pill

Attitudes about weight had changed somewhat by 1893 when the first diet pill was marketed. The pill was a thyroid extract sold under names like "Frank J. Kellogg's Safe Fat Reducer." People lost weight. However, there were dangerous side effects for people who did not have a hypothyroid condition. Hypothyroidism is a glandular condition characterized by an impaired rate of metabolism.

People who did not have the glandular condition and took the extract could experience chest pains, an increased heart rate, and higher blood pressure. Some died suddenly.

People used the thyroid hormone as a weight loss remedy until the 1950s. At the start of the twenty-first century, only hypothyroid patients received thyroid hormones as a weight-loss treatment.

Diet remedies of the 1920s

The 1920s were a time of change. During the decade known as the "Roaring '20s," women smoked cigarettes in public and shortened their hemlines to reveal their legs. While both activities were considered shocking, they reflected a new freedom for women.

Attitudes also changed about weight. People, especially women, regarded a thin body as the ideal figure. That attitude continued into the twenty-first century. Excess weight was seen as a sign of character flaws such as a lack of self-control, laziness, or poor self-image.

During the 1920s, people trying to lose weight took laxatives—medicines that relieve constipation by loosening the bowels. Through the decades, people continued to use laxatives to lose weight.

Also in the 1920s, weight loss products included La-Mar Reducing Soap. This product promised to "wash away fat and years of age," according to an advertisement from the London, England soap manufacturer.

Soap and other weight-loss gimmicks were put aside in 1933 when dinitrophenol went on the marketed as a weight loss drug. People began taking this drug after learning about the weight lost by textile factory workers exposed to dinitrophenol during the 1900s.

Thousands take dinitrophenol

Dinitrophenol was used in explosives during World War I. It was used as an insecticide and an herbicide. It was also a popular weight loss remedy; 100,000 people took dinitrophenol in 1936.

This diet pill increased a person's metabolic rate, but it had dangerous side effects. At least 12 women who took it lost their eyesight. Other people lost their sense of taste; dinitrophenol caused skin rashes. People died from hyperpyrexia, an abnormally high fever brought on by increased metabolism.

Those dangerous and sometimes fatal side effects led the United States Congress to enact the Food, Drug, and Cosmetics Act in 1938. The act gave the Food and Drug Administration (FDA) powers to regulate substances marketed as drugs.

Some people still purchased dinitrophenol through mail-order businesses during the 1940s. Use of this drug declined until the late twentieth century, when bodybuilders took dinitrophenol as a weight loss remedy. The FDA and law enforcement officials were again investigating the sales and misuse of the drug linked to the death of a New York man in September 2001.

In earlier decades, use of dinitrophenol dropped as dieters discovered amphetamine, a medication developed in 1887. Amphetamine stimulates the central nervous system, which can reduce a person's appetite. Caffeine, which is found in beverages like coffee, is a weak stimulant. During the twentieth century, dieters would drink coffee and take amphetamines to lose weight.

Medical uses of amphetamines

During the 1930s, European doctors prescribed amphetamines to treat respiratory conditions such as colds, hay fever, and asthma. The medications were also used to treat narcolepsy, a condition in which a patient experiences uncontrollable attacks of sleep. In addition, amphetamines were used to calm hyperactive children.

While the drugs soothed children with the condition now known as attention deficit hyperactivity disorder (ADHD), most people experienced a completely different reaction to amphetamines. The drugs gave them more energy and helped them to stay awake.

Those effects led to another use of amphetamines during World War II. Soldiers from America, Britain, Japan, and Germany took amphetamines to combat the weariness of battle fatigue.

The immediate effects of using amphetamines are additional energy, an exhilarated feeling of happiness known as euphoria, and increases in activity and concentration levels. The drugs also reduce the sensation of being hungry.

Dieters discover amphetamines

In 1937, the amphetamine dextroamphetamine was sold as a diet pill under the trade name Dexedrine. This medication was twice as potent as other amphetamines. It was also regarded as having the least amount of side effects. However, amphetamines were highly addictive.

People called amphetamines "uppers" because the drugs gave them energy. Sometimes that side effect meant that people could not sleep at night. As a result, they took sleeping pills. Referred to as "downers," these drugs were extremely addictive barbiturates that some users called liquid alcohol.

Taking barbiturates helped people sleep, but the drugs interfered with the dream patterns that come with restful sleep. People woke up feeling tired and took an amphetamine so they would be "up" again.

The FDA in 1938 realized that amphetamines and barbiturates had a strong potential for "misuse and abuse." The federal agency used its new regulatory powers and declared that prescriptions were required for both drugs. Physicians or dentists could write those prescriptions.

Widespread drug abuse

During the 1940s and 1950s, amphetamines and barbiturates were the most widely abused drugs in the United States, according to an FDA report.

A prescription was needed for amphetamines, but people who were dependent on these drugs found ways to get them legally. They went to doctors who would continue to write refill prescriptions for amphetamine diet pills. Another option was to go to more than one doctor. People also went to diet clinics or found pharmacists who did not ask for a prescription.

For people who acted in movies, studio doctors supplied medications that helped them lose weight and work 18-hour days. Although Hollywood and celebrities had a different lifestyle than most Americans, their experiences mirrored the belief of the time that amphetamines and barbiturates were an accepted part of American life.

When actress Sheree North filmed the 1956 movie How to Be Very, Very Popular, she received methamphetamine shots, bottles of Benzedrine (another amphetamine) for daytime use and the barbiturate Nembutal to sleep at night. The actress described that situation in the book Marilyn: The Last Take. In the 1993 book written by Peter Harry Brown and Patte Barham about the late actress Marilyn Monroe, North said that people did not know the drugs were harmful. She became addicted to the drugs, as did Monroe.

Amphetamine and barbiturate abuse was so widespread that the FDA worked from the 1940s through the 1960s on that problem. The FDA prosecuted doctors and pharmacies, while other federal agencies combatted illegal sales of prescription drugs.

The government also realized that the legal sale of amphetamines was a problem. During the 1960s, youths curious about drugs could find amphetamines in their parents' medicine cabinets.

Access to amphetamines restricted

In 1970, pharmaceutical companies in the United States produced 12 million amphetamine tablets. That same year, the Senate and House of Representatives ratified the Comprehensive Drug Abuse Prevention and Control Act. The law restricted the access to highly addictive drugs like amphetamines.

During the 1970s, amphetamines accounted for 8% of prescriptions in the United States. In addition to dieters, other amphetamine users included long-distance truck drivers and college students. Both groups took the pills to stay awake.

With the nation aware of the dangers of amphetamines, pharmaceutical companies worked to produce diet pills with less potential for misuse or abuse.

Alternates to amphetamines

Pharmaceutical companies developed diet pills with amphetamine congeners, chemicals that were similar to amphetamines. Although not as potent as amphetamines, these pills had more of an appetite-reducing effect than caffeine.

The diet pills developed to replace amphetamines became known as anorectics or appetite suppressants and are central nervous system stimulants. The FDA approved phentermine in 1959, fenfluramine in 1973, and dexfenfluramine in 1996.

The FDA approved the appetite suppressants for the short-term treatment of obesity. The FDA does not place restrictions on what conditions a physician prescribes the pills for, the dosage, or the amount of time that the patient takes the pills.

Prescribing medications for times or conditions not approved by the FDA is called "off-label" use. Examples of off-label use include prescribing a short-term drug for a longer period or time and prescribing a combination of two weight loss medications.

Off-label use

Off-label use during the 1990s became an issue after doctors in the United States and other countries began prescribing fenfluramine (Pondimin) or dexfenfluramine (Redux) in combination with phentermine. The combinations known informally as "fen-phen" (sometimes also written as "phen-fen") or "fen-dex" had not been approved by the FDA, a process that involves research and hearings.

Media reports about the diet pill combinations focused on the promise of weight loss. The public embraced the message, ignoring the fact that these pills were anti-obesity drugs to be used for only several weeks.

Millions of prescriptions

People clamored for the pill combination that helped them take off the pounds. More than 18 million prescriptions were written for fen-phen in 1996, according to Time magazine.

The diet pill combination posed a health risk. Side effects from long-term use included primary pulmonary hypertension (PPH). This is a rare condition that affects blood vessels in the lungs. The disease is potentially fatal, with death occurring within four years in 45% of its victims.

Most PPH deaths occurred to people taking fenfluramine or dexfenfluramine separately or in combination, according to a 2001 report from the National Institutes of Health (NIH). In 1996, there was also concern that long-term use of those drugs could damage brain cells.

The diet pill combination posed another risk. The Mayo Clinic announced that 24 patients who used the combination were diagnosed with valvular heart disease. In these cases, the condition caused leakiness (regurgitation) in the valves, according to an FDA report.

The federal agency issued a July 8, 1997 health advisory that stated that the FDA had received 100 reports of heart valve disease. The condition was diagnosed in people who took fen-phen as well as those who used only dexfenluramine or fenfluramine. The FDA noted that the combination treatment had not received FDA approval. In addition, FDA approval was based on short-term use for obesity treatment.

The FDA had also received requests to take the drugs off the market. The requests based on health concerns came from organizations including the National Association for the Advancement of Fat Acceptance, and Public Citizen, the advocacy group founded by consumer advocate Ralph Nader.

Available anorectics

In 1997, the manufacturers withdrew fenfluramine and dexfenfluramine from the market. Phentermine is still sold because no cases of heart valve disease were reported when that drug was taken alone, according to the FDA report.

Also on the market were anorectic diet pills including benzphetamine, diethylpropion, mazindol, and phendimetrazine. Another anorectic, methamphetamine, was sold under the trade name Desoxyn. It was also prescribed for the treatment of ADHD.

Methamphetamine is highly addictive and rarely prescribed for the short-term treatment of obesity. It is abused by addicts who may inject the drug.

Long-term diet pills

In 1997, the FDA approved sibutramine, a medication sold under the brand name Meridia. Sibutramine is an appetite suppressant prescribed for long-term treatment of severely obese patients. However, safety and effectiveness had not been determined when the sibutramine was taken for more than one year.

Another type of diet pill received FDA approval in1999. Orlistat, sold under the name of Xenical, was a lipase inhibitor. It affects the body's lipase enzyme and blocks about 30% of fat absorbed by the body.

Diet pill concerns in the twenty-first century

In March of 2002, Public Citizen filed a petition calling for the FDA to ban Meridia. Public Citizen quoted from FDA documents that showed that use of sibutramine was allegedly associated with 29 deaths and 400 adverse medical reactions. Those incidents occurred throughout the world, and Italy had banned the drug. The issue was also being studied by the United Kingdom, which banned phentermine in 2000. The ban was prompted by concern that it could cause heart disease.

A spokesman for Abbott Labs, which manufactures Meridia, said that Abbott had not seen evidence of a connection between use of sibutramine and the deaths and medical reactions. As of April of 2002, the FDA had not taken action to ban the drug.

Twenty-first century diet remedies

By the start of the twenty-first century, research was underway on at least 20 different diet pills. While some twentieth-century diet pills like Dexedrine were no longer prescribed for weight loss, people attempting to lose weight used methods tried by other generations.

People with eating disorders took laxatives. Some dieters drank coffee to suppress their hunger cravings, or they tried nonprescription remedies. Caffeine is an ingredient in many over-the-counter diet remedies.

Some dieters tried herbal remedies. These are not regulated by the FDA, and patients should check with a medical professional before taking herbal medications.

CHEMICAL/ORGANIC COMPOSITION

Amphetamine stimulates the central nervous system, which suppresses the appetite. Most diet pills are sympathomimetics. They are similar to amphetamines, but are less powerful and have less potential for addiction. The sympathomimetics are benzphetamine, diethylpropion, mazindol, methamphetamine, phendimetrazine, phentermine, and sibutramine.

Orlistat is a gastrointestinal lipase inhibitor that blocks fat absorbtion in the intestine.

INGESTION METHODS

Weight loss medications are manufactured in pill and capsule form. A doctor's prescription is required, and the medications are taken by mouth. The patient follows a dosage schedule set by the physician.

Illegal amphetamines and methamphetamine may be taken in liquid form. Addicts inject these drugs because the effect is stronger than when the drug is taken in pill form. In addition, some abusers snort (sniff) methamphetamine.

THERAPEUTIC USE

While many people think that diet pills are used to slim down and improve their appearance, weight loss medications are not a cosmetic remedy. These drugs are used to treat obesity, a medical condition characterized by excess fat stored on the body. People who are over-weight or obese weigh more than is considered healthy for their heights and ages. Obese people are at risk for conditions including non-insulin-dependent diabetes, stroke, and heart disease. Obesity contributes to the deaths of about 300,000 Americans annually, according to the FDA.

In general, people are considered obese if they weigh more than 20% over the amount that is considered healthy based on factors such as age, height, and weight.

Body mass index

A more specific standard is used for treating obesity with diet pills. These drugs are prescribed to a person with a body mass index (BMI) of at least 30 and no medical conditions related to obesity. Body mass index is a relationship between weight and height, and it is used as an indicator of health risk due to excess weight. The BMI is determined by measuring the person's height and weight, converting those measurements into metric measurements, and plugging those figures into an equation. A BMI of 30 is assigned to a 5-foot-5-inch person weighing 170 pounds, a 5-foot-7-inch person weighing 180 pounds, and a 6-foot person weighing 220 pounds.

Furthermore, diet drugs may also be prescribed for someone with a BMI of 27 or higher if that person has other health conditions such as hypertension or diabetes. A BMI of 27 is assigned to a 5-foot-5-inch person weighing 160 pounds, a 5-foot-7-inch person weighing 170 pounds, and a 6-foot person weighing 200 pounds.

Prescription diet pills are not recommended for people who are slightly overweight.

Short-term treatment

Most diet pills are prescribed for short-term use that ranges from a few weeks to several months. The goal of this treatment is for the patient to lose weight or not gain additional weight. Furthermore, diet pills are only part of the treatment that focuses on modifying the patient's behavior. These modifications generally consist of exercising more and following a low-calorie, low-fat diet.

Most appetite suppressants are prescribed for short-term use. While a physician may prescribe a different dose, the general daily dose for an adult is:

• Benzphetamine is taken from one to three times and is taken before a meal.
• Diethylpropion in 25-mg tablet form is used from one to three times. It is taken one hour before eating. The time-release, 75-mg tablet is taken in the middle of the morning.
• Mazindol is taken once, but the dose may be adjusted.
• Phendimetrazine in 35-mg tablet form is taken one hour before breakfast. Some patients may be prescribed a half-tablet (18.5-mg) that is taken twice during the day. The time-release, 105-mg tablet is taken 30 to 60 minutes before breakfast.
• Phentermine comes in tablet and capsule forms. It is used before breakfast or taken one to two hours afterward.

Methamphetamine

Methamphetamine has a high potential for abuse, and is only prescribed if the patient has not lost weight after trying other treatments. The dose is one 5-mg tablet, and it is taken a half-hour before each meal. Use of this drug should stop after several weeks.

Long-term diet pill treatment

Most prescription diet pills are prescribed for short-term use of not more than several months. Sibutramine and orlistat have been prescribed for longer use in the treatment of significantly obese people. For both medications, this treatment ranged from six months to one year. The safety and effectiveness of use for longer than one year have not been determined.

Sibutramine comes in capsule form and is used once daily. Patients can take sibutramine with food or without it. Orlistat is taken three times daily with a meal that contains fat. It may be taken an hour before the meal.

USAGE TRENDS

Diet pill usage trends must be examined both in terms of legally prescribed medications and those obtained through illegal means. Prescription diet pills are manufactured for the treatment of obesity, an increasingly common medical problem. However, not just obese or overweight people use diet pills. Some people take diet pills to lose a few pounds quickly; others have eating disorders. Furthermore, people who lose weight using methods like diet pills tend to regain it once they stop dieting. They may start taking pills again to lose the new weight.

Scope and severity

According to a 2001 report from the United States Department of Agriculture (USDA), about half of American adults are overweight or obese. That same trend was found in Australia, according to a 2001 report from Euromonitor International, a market research business.

American spending trends. Americans spend approximately $33 billion annually on weight loss remedies such as diet pills, books, and weight reduction programs, according to the USDA report.

Spending for prescription diet pills reached a record of approximately $467 million in 1996, according to the American Society of Bariatric Physicians, an association focused on weight loss. Fen-phen sales accounted for much of that record. After the withdrawal of dexfenluramine and fenfluramine from the market, diet pill sales dropped.

In 1998, prescription diet pill sales totaled $169.2 million for January through November. IMS Health Inc. charted sales trends that showed 1.1 million prescriptions filled for Meridia, 351,000 prescriptions for Ionamin, and 341,000 Adipex-P prescriptions. Prescriptions for other diet pills totaled 4.5 million.

Australian trends. Australians spend more than $500 million on dieting efforts, according to Euromonitor. However, not all dieters needed to lose weight. Underweight Australian girls used legal diet pills and amphetamines, as well as caffeine and tobacco, to lose weight, according to "Drug Use by Young Females," a 1998 University of Sydney study.

The study noted that some Australian researchers found a double standard in 1982 and 1996. Both years, it appeared acceptable for girls to take diet pills and other drugs to slim down. That was regarded as a medical condition. On the other hand, boys took stimulant drugs for the intoxicating effect.

Age, ethnic, and gender trends

Passage of the 1970 Controlled Substances Act restricted Americans' access to amphetamines. Before that, amphetamine users included dieters who were primarily women, truck drivers who were usually men, and college students of both genders.

The federal government classifies most diet pills as stimulants. Trends related to the illegal use of drugs like stimulants can be seen in the National Household Survey on Drug Abuse. The federal Substance and Mental Health Services Administration (SAMHSA) coordinates the survey.

In 2000, approximately 14 million Americans—6.3% of the population—used an illicit drug during the month before the survey. Those surveyed were 12 and older. In the survey, stimulants were included in the category of psychotherapeutic drugs that included pain relievers, sedatives, and tranquilizers.

Of the 14 million Americans surveyed in 2000, psychotherapeutic drugs were taken for a "nonmedical reason" by 1.8% of men, 1.7% of women, 3.3% of girls aged 12 to 17, and 2.7% of boys in that age group.

MENTAL EFFECTS

A person takes diet pills to slim down. As the person loses weight, she or he will feel happy about these accomplishments. Self-confidence will rise as the person works towards a weight goal. However, use of diet pills may produce other psychological effects.

Possible effects range from a feeling of well-being to psychological addiction. Furthermore, these pills may be abused by people with an eating disorder like anorexia. If anorexia is not treated, the affected person may experience mood changes and have problems remembering or concentrating. Eventually, untreated anorexia can be fatal.

Sympathomimetic drugs

Taking anorectics may cause a feeling of well-being. The drugs could also make a person feel light-headed or dizzy. Anorectics are related in composition to amphetamines and may lead to psychological abuse and addiction. Symptoms of dependence include the need to continue taking the diet pill or to increase the dosage. These drugs should not be taken by people who abused drugs in the past.

When people stop taking anorectic drugs, they may experience withdrawal symptoms. These may include depression, apathy, confusion, and irritability.

Sympathomimetic drug overdose. A person who abuses drugs is at risk of an overdose. Symptoms include irritability, personality changes, and a mental condition that resembles schizophrenia.

Furthermore, a drug overdose can cause the person to see, hear, or experience feelings that are not real. These sensations are known as hallucinations.

Long-term diet pills

Although sibutramine is prescribed for long-term use, the drug is a sympathomimetic. A patient taking it may feel more energetic. However, there is a potential for misuse.

As of 2002, orlistat produced no known psychological effects.

PHYSIOLOGICAL EFFECTS

A person who takes diet pills expects to lose weight. These drugs help with weight reduction by suppressing the appetite and increasing the sensation of feeling full. People who take diet pills and follow a weight-management plan of diet and exercise should lose weight. However, diet pills also produce other possible physiological changes that range from dizziness to an increased number of bowel movements.

Sympathomimetic diet pills. Taking anorectics can impair a person's ability to drive, operate heavy equipment, or perform other potentially hazardous activities. In addition, taking sympathomimetics late in the day can cause insomnia.

Other side effects include dizziness, dryness in the mouth, a false feeling of well-being, nausea, irritability, and nervousness. A person taking these drugs may tremble or shake. Other symptoms occur less frequently. These include blurred vision and a lessening of the sex drive or decreased ability to experience an erection. The person may sweat more and need to urinate more frequently.

Orlistat. Orlistat can cause temporary symptoms such as an increased number of bowel movements, gas with discharge, oily or fatty stools, and the inability to control bowel movement. The person taking orlistat may feel an urgent need to go to the bathroom. These symptoms are generally mild and short-term in nature. However, the symptoms can be aggravated if a person eats high-fat foods.

In addition, orlistat reduces the body's ability to absorb some vitamins. To compensate for that, person taking orlistat must take a multivitamin two hours before or after taking the drug.

Pregnancy and motherhood. Women who are pregnant or nursing their babies should consult with their physician about diet pill use. Orlistat is not recommended for use by pregnant women. Factors to consider about other diet pills are:

• The effects of methamphetamine on pregnant women are not known, so expectant mothers are advised against taking this drug unless health benefits outweigh risk factors.
• Pregnant mothers who are dependent on amphetamines risk giving birth prematurely. The baby may have a low birth weight and could experience withdrawal symptoms.
• The FDA placed benzphetamine in its pregnancy category X because the drug causes birth defects.
• The effects of phendimetrazine on an unborn baby are unknown.
• Nursing mothers should check with their doctors about use of sympathomimetics. It is not known if the mother transmits the drug to the baby through breast milk.

Harmful side effects

Anorectics. Taking anorectics can produce dizziness, restlessness, or blurred vision. People using these drugs may not realize they are extremely tired. Long-term use can lead to addiction.

Sympathomimetics can be physically addictive and should not be prescribed to people with a history of drug abuse. A person may develop a tolerance to the drug and attempt to increase the dosage. The person may develop intoxication symptoms such as insomnia and severe skin diseases.

Withdrawal symptoms. When people stop taking anorectics, their bodies need to adapt to the lack of drugs in their systems. The amount of withdrawal time will vary, depending on the strength of the dosage and how long the patient used it. Withdrawal symptoms could include insomnia, nightmares, nausea, vomiting, and stomach cramps. The person may also experience strong hunger pangs.

Sympathomimetic drug overdose. Some overdose symptoms are similar to those experienced during withdrawal. These include cramps, nightmares, nausea, and trembling. Vomiting will be more intense. The person may be dizzy and blood pressure may drop or rise. Respiration (breathing) is rapid, and the person may faint.

The final signs of a fatal overdose are generally convulsions and coma.

Sibutramine. Sibutramine can cause mild increases in blood pressure and pulse rates. The FDA advised people taking sibutramine to have their blood pressure evaluated regularly.

As of 2002, it was not known whether sibutramine caused primary pulmonary hypertension. However, sibutramine was not recommended for people with conditions including heart disease, irregular heartbeat, or a history of stroke.

Long-term health effects

Only two diet pills on the market in 2002 were recommended for long-term use, orlistat and sibutramine. Long-term effects of sibutramine were not known in 2000.

Use of orlistat could interfere with the body's absorption of fat-soluble vitamins and beta carotene. Long-term use could result in deficiencies of vitamins A, D, E, and K, and beta carotene. Patients are advised to take supplements. Another possible side effect is calcium deficiency.

Long-term use of sympathomimetic diet pills. A patient generally develops a tolerance to the effects of an anorectic drug within several weeks, and the pill is no longer effective as an appetite suppressant. Use of the drug should then be discontinued because of the risk of addiction.

REACTIONS WITH OTHER DRUGS OR SUBSTANCES

Before taking diet pills, patients need to discuss the medications that they take with their health care providers. Physicians may adjust the dosage or advise patients to discontinue medications.

Drug interactions

Monamine oxidase (MAO) inhibitors are antidepressants that can interact with sympathomimetic appetite depressants. Patients must discontinue using MAO inhibitors two weeks before taking these diet pills. Use of MAO inhibitors while taking anorectics will cause a sharp rise in blood pressure.

Furthermore, taking some other antidepressants and diet pills may cause high blood pressure or an irregular heartbeat.

TREATMENT AND REHABILITATION

When a person abuses diet pills, the type of treatment needed will be based on several factors. The person may need to be treated for psychological and physical dependency. If the person has an eating disorder, that condition needs to be treated. If the person is over-weight, he or she may need help learning to lose weight without pills.

Drug dependency

Treatment of drug dependency may start with detoxification, during which the person withdraws the physical effects of diet pills. In severe cases, a person may be hospitalized. Otherwise, the person will work with a doctor or other health care provider to end the physical craving for a drug.

Counseling is recommended after detoxification to help the person fight the psychological craving for drugs. A person may meet individually with a counselor or participate in group sessions.

Eating disorders

Psychological counseling is an important component of the treatment of eating disorders. The National Eating Disorders Association recommends treatment that is adapted to the individual. In that way, the person can address the causes and symptoms of the eating disorder.

Medical treatment focuses on helping the patient return to a healthy weight. In severe cases, a patient may be hospitalized.

Support groups and success

The success rate of treatment depends on factors such as the type of drug used, and the severity of the addiction or eating disorder. Since recovery is an ongoing process, support groups can help a person with post-treatment goals.

People recovering from diet pill addiction may find additional support in 12-step programs, similar to the Narcotics Anonymous or Alcoholics Anonymous programs. There are also support groups and programs for people with eating disorders, people who are compulsive eaters, and those trying to lose weight.

PERSONAL AND SOCIAL CONSEQUENCES

In a society where people are often judged by their appearance and the ideal body is thin, taking diet pills is often considered acceptable behavior. However, diet pills are a temporary solution to a long-term problem.

Maintaining a healthy weight is a ongoing process that involves eating healthy meals and exercising regularly, according to organizations ranging from the United States National Institutes of Health (NIH) to the American Medical Association. According to the NIH, treating obesity with diet pills for a few months does not work over the long term. To be effective, a person would need to take pills for years, possibly for a lifetime.

At the start of the twenty-first century, there were no lifelong diet pill remedies. People who use diet pills often gain weight when they stop taking weight-loss drugs. They put on the weight they lost and sometimes gain more weight. This process is called the "yo-yo syndrome" because a person's weight goes up and down like a yo-yo.

With repeated dieting, a person may lose muscle and gain back fat. The person who regains weight may also feel like a failure. While the yo-yo syndrome is not limited to people who take diet pills, a 1996 NIH report showed that nearly 100% of people who took fen-phen gained weight after they stopped taking the diet pill combination.

Misuse of diet pills can cause medical problems. In addition, there is a potential for addiction to some diet pills. Overuse of pills can affect concentration so that a person's grades or work performance suffers. Mental and physical health are also affected by eating disorders.

Diet pills and eating disorders

Although excessive weight and obesity are problems in the United States and other countries, there is also a concern about people who diet to an unhealthy low weight. These people have an unrealistic image of themselves, so they continuously try to lose weight. They look in the mirror and see a heavy person. In reality, they may be extremely underweight.

These people have eating disorders. The condition primarily affects young women of high school and college ages. However, men were increasingly diagnosed with eating disorders by the end of the twentieth century.

People with anorexia nervosa starve themselves. People with bulimia eat and purge their food by vomiting or by some other means. People with both conditions may take diet pills, as well as laxatives, diuretics, and caffeine beverages.

Causes of eating disorders are varied. People may be perfectionists. They may feel they will gain control of their lives if they lose weight. Some male anorexics said they felt the pressure to be in shape for activities like sports. For teenage girls, their role models were the thin women in television programs, movies, and advertisements.

While people with these disorders think they gained control of their lives, they instead can become seriously ill. Anorexics can experience shortness of breath, chest pains, and stomachaches or nausea. Bulimics can experience dehydration and hormonal imbalances. Their esophagus and other internal organs may be damaged.

If not treated, eating disorders can be fatal. For someone with an eating disorder, taking diet pills can aggravate an unhealthy condition.

LEGAL CONSEQUENCES

The federal government regulates prescription diet pills in several ways. Some drugs are classified as controlled substances; all drugs are regulated by the Food and Drug Administration (FDA). The FDA determines whether a new drug can be manufactured or if production should be halted on a drug currently on the market.

Legal history

The federal Food, Drug, and Cosmetics Act of 1938 gave regulatory powers to the FDA. Pharmaceutical companies apply to the FDA for approval to manufacture a new drug. The approval process includes research, testing, and hearings. Once a drug is approved, the FDA determines whether a prescription is required.

FDA regulations about prescription drugs also apply to how the manufacturer promotes or advertises the medications. Unless specified by other regulations such as the Controlled Substances Act (CSA), there are no restrictions on what condition the doctor prescribes the pill for, the dosage, or the amount of time that the patient will take the pill.

Controlled substances. The Controlled Substances Act (CSA) portion of the 1970 Comprehensive Drug Abuse Prevention and Control Act classified drugs in five categories based on the effect of the drug, its medical use, and potential for abuse. Schedule I contains drugs like heroin, which have no medical use but may be used in research. It is the most tightly controlled category.

Federal guidelines, regulations, and penalties

The CSA classifies the methamphetamine Desoxyn as a stimulant. Anorectic drugs, the diet pills developed to replace amphetamines, are regarded by the government as controlled substances. While these drugs are not as powerful as amphetamines, their effects are similar.

Schedule II drugs. Schedule II drugs have a high potential for abuse. They are accepted for medical use with restrictions. These drugs may lead to severe psychological or physical dependence, according to the CSA. Desoxyn is a Schedule II drug. Dexedrine, the popular diet pill of the 1950s, is also in this category. It is no longer prescribed for weight loss. A prescription is required for these drugs, and it cannot be refilled.

Schedule III drugs. Schedule III drugs have less of a potential for abuse than drugs in Schedules I and II. The drugs have a medical use. Abuse of these drugs may lead to "moderate or low psychological dependence or high psychological dependence," according to the CSA. Anorectics in this category are benzphetamine (Didrex) and phendimetrazine (Bontril, Plegine, and Prelu-2). A prescription may be filled up to five times during the six months after the first prescription was written.

Schedule IV drugs. Schedule IV drugs have a low abuse potential as compared to Schedule III drugs. These substances have an accepted medical use. They could lead to limited psychological or physical dependence, according to the CSA.

The anorectic drugs in this category are phentermine (Ionamin, ApidexP), diethylpropion (Tenuate, Tepanil), and mazindol (Mazanor, Sanorex). Sibutramine (Meridia) is also in this category. The withdrawn drugs dexfenluramine (Redux) and fenfluramine (Pondimin) were also in this category.

In Schedule IV, five prescription refills are allowed during the six months after the patient received the first prescription.

Other diet pills. Other diet pills are classified in various ways. Orlistat (Xenical) is not classified as a controlled substance. A prescription is required.

Over-the-counter diet pills are classified as Schedule V drugs. Medications in this category have the lowest potential for abuse, have an accepted medical use, and a limited potential for physical or psychological dependence.

Penalties. Federal law prohibits the possession, use, and distribution of illegal drugs. This law applies to diet pills obtained without a prescription. The Controlled Substances Act established tighter controls on the manufacture and distribution of drugs like diet pills. Limits were set on the amounts of Schedule II pills that could be manufactured.

Procedure for the legal distribution of pills includes the requirement of a written prescription for Schedule II drugs. An exception is made in emergencies.

For Schedule III and IV drugs, the prescription may be written or called into the pharmacy. Both the health care practitioner and pharmacist are required to keep records when prescriptions are filled for controlled drugs.

Trafficking. Trafficking is the illegal distribution of controlled drugs. Federal penalties for this crime can include fines and imprisonment. Sentencing is based on factors such as whether the trafficker is a first-time offender. Penalties are higher for a second offense. In addition, if the illegal distribution of a Schedule II drug results in death or serious injury, the convicted offender faces a prison term of from 20 years to life.

In cases where there is no serious injury or death, the penalties for a first-time offense are:

• Schedule II: Trafficking 100 grams or more of methamphetamine carries a prison term of from 10 years to life and a fine of up to $4 million.
• Schedule III drugs: Trafficking any quantity of these drugs is punishable by up to five years in prison and a maximum fine of $250,000.
• Schedule IV drugs: Illegally distributing any quantity of these drugs carries a prison term of up to three years and a fine of up to $250,000.

Penalties for drug abusers. The federal penalty for the first-time offense of illegally possessing a controlled substance is up to one year in prison and a fine of from $1,000 to $100,000. Penalties are generally doubled for a second offense.

In some cases, a person may not receive a prison sentence. The Anti-Drug Abuse Act of 1988 imposes a civil penalty on the minor drug offender, the person possessing a small quantity of an illegal controlled substance. Possession of this quantity known as a "personal use amount" carries a fine of up to $10,000.

See also Amphetamines; Antidepressants; Barbiturates; Caffeine; Herbal drugs; Methamphetamine

RESOURCES

Books

Brown, Peter H., and Patte B. Barham. Marilyn: The Last Take. New York: Signet Books, 1993.

Clayton, Lawrence. Diet Pill Dangers. Springfield, NJ: Enslow Publishers, Inc., 1999.

Dorsman, Jerry. How to Quit Drugs for Good. Rocklin, CA: Prima Publishing, 1998.

Seaman, Barbara. Lovely Me. New York: William and Morrow and Company, 1987.

Yancy, Diane. Eating Disorders. Brookfield, CT: Twenty-First Century Medical Library, 1999.

Periodicals

Gorman, Christine. "Danger in the diet pills?" Time 150 (July 21,1997): 58.

Organizations

Compulsive Eaters Anonymous, 5500 E. Atherton Street, Suite 22715, Long Beach, CA, USA, 90815-4017, (562) 342-9344.

Food Addicts Anonymous World Service Office, 4623 Forest Hill Blvd, Suite 109-4, West Palm Beach, FL, USA, 33415-9120,(561) 967-3871, info@foodaddictsanonymous.org, <http://www.foodaddictsanonymous.org>.

National Association to Advance Fat Acceptance, P.O. Box 188620, Sacramento, CA, USA, 95818, (916) 558-6880, (916) 558-6881, <http://www.naafa.org>.

National Eating Disorders Association, 603 Stewart St., Suite 803, Seattle, WA, USA, 98101, (206) 382-3587, info@NationalEatingDisorders.org, <http://www.nationaleatingdisorders.org>.

National Institute on Drug Abuse (NIDA), National Institutes of Health, 6001 Executive Blvd., Room 5213, Bethesda, MD, USA, 20892-9561, (301) 443-1124, (888) 644-6432, <http://www.nida.nih.gov>.

U.S. Drug Enforcement Administration, 2401 Jefferson Davis Highway, Alexandria, VA, USA, 22201, (800) 882-9539, <http://www.dea.gov>.

U.S. Food and Drug Administration (FDA), 560 Fishers Lane, Rockville, MD, USA, 20857-0001, (888) 463-6332, <http://www.fda.gov>.

Liz Swain