Because obesity is so prevalent in our country, we will continue to see more patients taking herbal diet remedies, over-the-counter anorectic agents, and prescribed anti-obesity medications.
Cynthia R. Biron, RDH
Americans spend more than $5 billion dollars every year on herbal remedies for weight loss. Do these remedies really help people lose weight? To date, no herb has been proven to provide long-term weight loss. Some studies have shown that certain herbs result in minor differences in weight-loss regimes, but not significant differences. Yet, many individuals claim a conglomeration of herbs have assisted them with their dieting and/or helped them maintain their new slim figures.
The products contain a combination of herbs for various effects that, in combination, may or may not cause weight loss. The effects they are supposed to produce to contribute to weight loss are:
- Provide CNS stimulation to increase energy and burn calories
- Burn fat or carbohydrates
- Act as laxatives or diuretics to increase elimination and lessen absorption of calories
- Provide calming effects to reduce stress- induced hunger and eating.
Here is a closer look at these herbs and the products that contain them.
Ephedra (ma huang) - This powerful stimulant has been likened to amphetamines, or what is commonly called speed. It has been theorized that individuals who are prone to obesity have defective regulation of thermogenesis - that is, the heating of bodily tissues as a response from catecholamines and their activation of metabolic pathways in adipose tissue. Ephedra is considered by some scientists as a thermogenic agent due to its role in weight reduction in rats. The studies in rats have shown that ephedra could reduce body lipid content and serve as a possible slimming drug. Similar studies demonstrated that ephedra did not cause thermogenesis in adipose tissue to occur in humans. Ephedra has frequently been combined with caffeine, so the synergystic effect would speed metabolism. Any herb or drug that increases blood pressure, heart rate, and respirations can surely increase caloric utilization, but at what risk?
The Food and Drug Administration has received over 800 reports about some 100 products containing ephedra that have caused adverse effects in consumers. The effects include nervousness, insomnia, tremor, headaches, high blood pressure, arrhythmias, cerebrovascular accidents, and death. In addition, more than 100 ephedrine-containing kidney stones were reported in the time period of January 1996 to June 1997. It is conceivable that kidney stones can occur without the use of ephedra-containing products, but the correlation appears to be more than coincidence.
Individuals who should not ingest ephedra-containing products include those with cardiovascular diseases, high blood pressure, hyperthyroidism, diabetes, psychiatric conditions, glaucoma, prostate enlargement, seizure disorders, kidney disorders (including a history of kidney stones), and those taking other CNS stimulant drugs (including psychotherapeutic drugs). In dentistry, retraction cords containing epinephrine and local anesthesia vasoconstrictors may be contraindicated in patients with blood levels of ephedra.
Hundreds of herbal weight-loss products contain ephedra. Here are a few: Stim & Trim, Herbal Phen-Fen, Diet-Phen, Herbal Phen Fuel, Metabolift, Diet Fuel, and Metabolife 356. The FDA has proposed a dosage limit of ephedra alkaloids: 8 mg every six hours, which is a limit of 24 mg per day.
Guarana - Guarana is a caffeine-like stimulant made from crushed seeds of a South American shrub. It is used in combination with ephedra, and this combination is more likely to cause high blood pressure, stroke, and death. By itself, guarana is no stronger than the caffeine in coffee. It can be found in products such as Diet Fuel, Metabolift, and Ultra Burn.
Citrus Aurantium (bitter orange) - Citrus Aurantium is a bitter fruit whose herb has CNS stimulant properties. It is milder than ephedra but is thought to boost metabolism. It is an ingredient in the product Herbal Phen Fuel.
Ginseng - Ginseng is an extract from the ginseng root. It is used in some herbal diet products as a stimulant to assist in increasing metabolism. Although ginseng is clearly a stimulant, there is no known proof that it causes weight loss.
Garcinia cambogia (hydroxycitric acid) - Garcinia is a herb containing citric acid that is made from dried jungle fruit. It is theorized that the citric acid in Garcinia burns calories, especially carbohydrate calories, faster. If carbohydrates are unavailable, stored fat must be broken down for fuel. This is considered unproven by researchers.
A controlled study showed that Garcinia had produced no significant difference in weight loss than that of the placebo. Garcinia has no known dangers. It is found in products such as CitriMax, Ultra Burn, Super Diet Max, and others.
Pyruvate - Pyruvate is found in fruits, red wine, apples, and cheese. It supposedly acts like Garcinia, breaking down carbohydrates. Manufacturers claim pyruvate improves endurance and athletic performance. It has no known dangers. It is found in products such as Chroma Slim Pyruvate, ProVATEZ, and Calcium Pyruvate.
Chromium picolinate - Chromium picolinate is an ingredient that is supposed to increase metabolism and reduce body fat. While chromium itself is a necessary nutrient that occurs in mushrooms, broccoli, and potatoes, chromium picolinate is a synthetic compound. So herbal diet remedies that claim to be "all natural" are making false claims when chromium picolinate is included in the products.
Several conflicting studies on chromium picolinate have been reported, including the two below:
The first was conducted by The Naval Health Research Center in San Diego, Calif. It was a double-blind, placebo-controlled protocol that lasted for 16 weeks. Ninety-five active-duty personnel (on average, 30 years old) completed the study. They met body-fat standards of males (22 percent) and females (30 percent). Participants took 400 mg of chromium picolinate or placebo daily. Comparisons of the 95 participants, as well as the 109 dropouts, showed no difference in baseline percentage of body fat. It was concluded that chromium picolinate did not enhance body-fat reduction.
In contrast, another double-blind study conducted in Germany involved 36 obese middle-age patients who took 200 mg chromium picolinate, 200 mg chromium yeast, or placebo for 26 weeks. For the first eight weeks, they were all on very low calorie diets, and then all continued on an 18- week maintenance period. There was a loss in lean body mass in all groups after the eight-week reduction diet. In 26 weeks, only those taking the chromium picolinate supplements showed an increase in lean body mass. This study concluded that chromium picolinate is able to increase lean body mass in obese patients in the maintenance period following a very low calorie diet - without reversing the weight loss.
The naval personnel in the first study were not obese. They were younger and took twice as much chromium picolinate as the subjects in the German study (who took the chromium picolinate for 10 weeks longer). In order to determine why there were conflicting results, more research with larger numbers of participants taking the same dosages for the same periods of time must be conducted.
The risks involved with taking chromium picolinate have been determined thus far in studies with animals, which have shown chromosomal damage associated with high doses. Kidney failure in one woman was thought to be caused by chromium picolinate. Products that contain chromium picolinate include Chroma Slim Plus, Metabolift, Citrex, Super Fat Burners, and Metabolife 356.
Other various herbs thought to help burn fat are: bee pollen, burdock, alfalfa, marshmallow, uva ursi, horsetail, chick weed, bladder wrack, kelp, licorice, white willow bark, astragalus, and ginseng. Some may be toxic in large doses and interact with prescribed or over-the-counter drugs. Some or all are frequently listed as secondary ingredients in products such as Thermo Max, Super Fat Burners, Herbal Slim, Ultra Burn, and Metabolife 356.
Laxatives and diuretics
Various herbal teas and other herbs - such as borage, broom, dandelion, and juniper, to name a few - act as diuretics. Senna is an herbal laxative found in weight-loss teas, such as Laci Le Bieu Super Dieter`s Tea and Trim-Maxx. Dangers with diuretics and laxatives are dehydration and hypokalemia. A loss in electrolytes can lead to cardiac arrythmias.
Studies have shown that diets rich in fiber have improved weight loss. In one double-blind study of six months in length, subjects taking fiber supplements were compared with subjects taking placebo. Not only did the subjects taking fiber lose more weight, they were able to adhere to the diet regimen more easily, as they were not hungry. Fiber causes a feeling of fullness, preventing hunger. Supplements of 7 grams of fiber per day were taken by the group whose weight loss was significantly higher than the placebo group. Adverse events included gastrointestinal effects, which were shared equally by both groups.
Herbal diet remedies often include the ingredients that have antidepressant, calming effects. The most commonly used ingredients are St. John`s Wort and Hydroxytryptophan.
St. John`s Wort - The yellow-flowered weed known as St. John`s Wort contains an extract that is thought to increase production of the brain chemical, serotonin. Its action is similar to the antidepressant drugs known as the selective serotonin reuptake inhibitors (SSRI`s), such as Prozac and Zoloft. When levels of serotonin are increased, the mood is elevated and emotional eating is decreased. Side effects of St. John`s Wort include photosensitivity, gastrointestinal effects, fatigue, dizziness, and rash. St. John`s Wort should not be taken by individuals who are taking antidepressants.
Hydroxytryptophan - Hydroxytryptophan contains vitamins, minerals, and amino acids and also causes an increase in brain levels of serotonin. It should not be used in combination with other antidepressants. It has been known to cause blood disorders and cardiovascular problems.
Cellasene - The latest herbal remedy is said to be a cure for cellulite. Cellulite is not a medical term. Scientists and physicians maintain that it is merely adipose tissue or fat-like fat anywhere on the body. The bumpy appearance of the skin occurs when strands of fibrous tissue connect the skin to subdermal tissue layers and create nooks that contain fat cells. When fat cells increase in size, these nooks bulge and create the pebbled appearance of the skin. To get the complete facts on Cellasene, one need only get on the Internet. Go to the website www.quackwatch.com and type in Cellasene.
The doctor on call is Stephen Barrett, MD. If you, your patients, or anyone you know plans to invest in Cellasene, read Dr. Barrett`s research first:
"An herbal product called Cellasene is being vigorously promoted as a cellulite remedy. The product was developed by an Italian chemist named Gianfranco Merizzi. Its ingredients are evening primrose oil, dried fucus vesiculosis extract, gelatine, fish oil, glycerol, soya oil, grape seed, bioflavonoids, soya lecithin, fatty acids, dried sweet clover extract, dried ginkgo biloba extract, and iron oxide. The product, to be taken twice daily (or three times per day for an `intensive` program) for two months and then once daily for maintenance, costs $1.50 to $2 per capsule. Here`s what one Internet marketer says [followed by my comments in brackets]:
"Dried ginkgo biloba extract assists in blood circulation and stimulates the metabolism of fats. [Although ginkgo can increase circulation, it does not stimulate fat metabolism. Even if it did, there is no reason why it would exert a localized effect.]
"Dried sweet clover extract can increase blood circulation and assist in removing fluid build-up. [This ingredient may have mild diuretic action, but "fluid build-up" is not a factor in the appearance or composition of fatty tissue.]
"Grape seed bioflavanoids are powerful antioxidants that protect cells and blood vessels from damage. [Whether antioxidant supplements help protect tissues is not scientifically settled. Regardless, any such mechanism has nothing to do with the quantity or appearance of fatty tissues.]
"Dried fucus vesiculosus extract stimulates metabolism and can help reduce localized fats. [This herb contains significant amounts of iodine and could adversely affect the thyroid gland. The U.S. Recommended Daily Allowance (USRDA) for iodine is 150 micrograms. The average American woman ingests 170 micrograms per day from food (not including iodized salt). Each capsule of Cellasene contains 240 micrograms of iodine. If enough were taken to increase thyroid function, the result would be unhealthy.]
OEvening primrose oil and fish oil are rich in polyunsaturated fatty acids, a source of energy that increases metabolic levels and helps in diminishing saturated fatty acids. [The OenergyO is simply the caloric value. Neither oil increases metabolism or reduces the amount of other fats one eats.]
OSoya lecithin helps to break down fats. [The body makes all the lecithin it needs. Lecithin supplements do not cause the body to shed fat.]O
If we can?t turn to herbs for weight loss, what else can we do? Other weight-loss pills that have been proven effective are the over-the-counter appetite suppressants such as Dexatrim and a host of others with similar names. The active ingredient in these pills is phenylpropanolamine HCL (PPA). Two large double-blind clinical studies demonstrated that subjects taking 75 mg per day of PPA lost significantly more weight than those taking a placebo. Side effects were limited to xerostomia and mild nausea.
Because obesity is so prevalent in our country, we will continue to see more patients taking herbal diet remedies, over-the-counter anorectic agents, and prescribed anti-obesity medications. While the risk factors of these agents are of concern, the risk factors of obesity are often of greater concern. Obese patients are trapped in a body doomed for psychological and physiological illness. If nothing else, these remedies give them hope and an incentive to persevere in their struggle with obesity.
* Barrett, Stephen M.D. www.quackwatch.com
* Bahadori B, Wallner S, Schneider H, Wascher TC, Toplak H. Ambulanz fur Diabetes und Stoffwechsel der Medizinischen Universitatsklinik, Graz, Osterreich [Effect of chromium yeast and chromium picolinate on body composition of obese, nondiabetic patients during and after a formula diet]. Acta Med Austriaca 1997;24(5):185-7.
* Davidson MH, Hauptman J, DiGirolamo M, Foreyt JP, Halsted CH, Heber D, Heimburger DC, Lucas CP, Robbins DC, Chung J, Heymsfield SB. Control and risk factor reduction in obese subjects treated for two years with orlistat: a randomized, controlled trial. JAMA 1999 Jan 20;281(3):235-42.
* Greenway F. A double-blind clinical evaluation of the anorectic activity of phenylpropanolamine versus placebo. Clin Ther 1989 Sep-Oct;11(5):584-9.
* Mingrone G, Greco AV. Endocrinology: fat busters fail. Lancet 1997;350 Suppl 3:SIII4.
* Pasquali R, Baraldi G, Cesari MP, Melchionda N, Zamboni M, Stefanini C, Raitano A. A controlled trial using ephedrine in the treatment of obesity. Int J Obes 1985;9(2):93-8.
* Rigaud D, Ryttig KR, Angel LA, Apfelbaum M. Overweight treated with energy restriction and a dietary fibre supplement: a six-month randomized, double-blind, placebo-controlled trial. Int J Obes 1990 Sep;14(9):763-9.
* Schteingart DE. Effectiveness of phenylpropanolamine in the management of moderate obesity. Int J Obes Relat Metab Disord 1992 Jul;16(7):487-93.
* Sj?str?m L, Rissanen A, Andersen T, Boldrin M, Golay A, Koppeschaar HP, Krempf M. Randomized placebo-controlled trial of orlistat for weight loss and prevention of weight regain in obese patients. Lancet, 1998 Jul, 352:9123, 167-72.
* Toubro S, Astrup AV, Breum L, Quaade F, Safety and efficacy of long-term treatment with ephedrine, caffeine, and an ephedrine/caffeine mixture. Int J Obes Relat Metab Disord 1993 Feb; 17 Suppl 1:S69-72.
* Trent LK, Thieding-Cancel. Effects of chromium picolinate on body composition. Naval Health Research Center, San Diego, CA 92186-5122, USA. J Sports Med Phys Fitness 1995 Dec;35(4):273-80.
* Website for FDA www.cfscan.fda.gov/-dms/ supplmnt.html
Cynthia R. Biron, RDH, is chair of the dental hygiene program at the Tallahassee Community College. She is also a certified emergency medical technician.
Orlistat joins the fat fighters
In April 1999, the Food and Drug Administration approved orlistat, a new drug manufactured by Roche Laboratories Inc. under the trade name Xenical, for the treatment of obesity. Obtained by prescription only, orlistat is the first drug of its kind, because it works as a lipase inhibitor. It prevents enzymes in the gastrointestinal tract from breaking down dietary fats for absorption by the body. Fat absorption is decreased by about 30 percent.
Seven long-term, multicenter, clinical trials included 2,800 patients taking orlistat and 1,400 patients taking a placebo. All participants were placed on a well-balanced, low-calorie diet. At the end of the one-year study, 57 percent of the patients taking orlistat lost 5 percent of their baseline body weight. Only 31 percent of those taking the placebo lost 5 percent of their baseline body weight.
The recommended dose of orlistat is 120 mg (three pills a day) with meals that contain fat. Orlistat decreases the absorption of some fat-soluble vitamins and beta carotene. Patients must be placed on a vitamin supplement that contains fat soluble (A, D, E, and K) vitamins, as well as beta carotene. Adverse effects of orlistat are gastrointestinal disturbances such as frequent bowel movements, oily spotting, gas with discharge, fecal urgency, and fatty/oily stools.