Slight Seeing

Learning from Cuba about obesity

As C. Ray Nagin wandered the streets of Havana last October checking out dictator-inspired hurricane preparedness, he would have been blind not to have noticed how trim the populace is down there. Fat Cubans in Cuba are more rare than hen’s teeth at Popeyes.

New Orleans will be hurricane-free for the remainder of His Honor’s tenure, but obesity still reigns. Too bad C. Ray didn’t study how Fidel Castro eliminated obesity, a health risk much greater than hurricanes in the long run. Twice as many Cubans could have fit into the sidewalk space needed for Nagin’s portly band of lame duck city appointees and other hangers-on.

I know: I conducted my own fat-finding mission to Cuba last February. I walked the streets of Havana, ate in the restaurants and visited tourist sights for 10 days on my dime. I did see a rare overweight Cuban, but the populace on the streets was invariably trim without excessive paunches.

As a mayor quick with quips – from keeping the city chocolate as “it’s the way God wants it to be” to how our high murder rate “keeps the New Orleans brand out there” – an anti-obesity skirmish with a Castro touch would be a natural for C. Ray. First, raise the sales tax on food. Secondly, institute immediate food rationing. Thirdly, refocus those crime cameras to capture anyone over the ideal body weight and charge them with being obese on a city street.

Fourthly, put the parking control officers in charge of the program.

An undertaking of this magnitude obviously belongs in parking control, as this is an endeavor much too important for the health department. Our municipal health department was the only one in the U.S. that “forgot” to put in a specific request for any H1N1 vaccine.

Of course, a program of this sort is easier to administer in a Communist country with a dictator. It also helps that Cuba doesn’t have enough food to begin with for multiple reasons, such as state ownership of farms and U.S.-decreed embargos. But the health benefits from their reduced caloric availability are impressive.

Weight loss accelerated when Cuba entered their so-called “Special Period,” a huge economic crisis beginning in 1990 with the collapse of the Soviet Union and the exit of Russians from the Cuban economy. A rationing program cut the country’s caloric intake across the board except for pregnant women, children and the elderly. Their average daily caloric intake fell from 2,899 to 1,863 calories, compared to an average daily New Orleans caloric intake exceeding 4,000 calories.

Along with fewer calories, Cubans increased their physical activity, according to a 2007 study published in the American Journal of Epidemiology. As fuel costs made public transportation more expensive, walking and bicycling became the norm. The number of physically active adults in Havana jumped from 30 to 70 percent.

During their Special Period, Cuban adults across the island lost an average of 10 pounds, dropping their already low obesity rate from 14 to 7 percent. This compares to an obesity rate of about 37 percent in New Orleans using a standard definition of being 20 percent or more over ideal body weight.

Their reduced food intake and increased physical activity translated into definite health benefits. Deaths from diabetes fell 51 percent, coronary heart disease 35 percent, stroke 20 percent and death from any cause fell 18 percent.

Back to December in New Orleans: Santa’s sled is not yet packed, but pharmaceutical executives promise fat Americans new Christmas gifts for 2010. Get ready to hear fat-shrinking testimonials as Madison Avenue ushers in four new drugs. But hold the reindeer. The drugs and their concepts aren’t all that novel.

In order to be approved as a treatment for obesity, a drug company must present data to the FDA showing that at least one-third of the persons taking the drug lose more than 5 percent of their weight, and that the drug is safe.

Qnexa. Qnexa is a once-a-day capsule containing fast-release phentermine combined with slow-release topiramate.

These drugs act synergistically, meaning their action together is greater than what would be expected from simply adding the appetite suppression of phentermine to sensation of being full caused by topiramate.

Phentermine is a kissing cousin to the amphetamines. The FDA first approved phentermine in 1959 as a short-term appetite suppressant. Trade names for drugs containing this ingredient over the years included Fastin, Adipex and Ionamin. It was in the infamous diet combo Fen-Phen that made hundreds of attorneys and expert witnesses rich before it was withdrawn because of heart valve abnormality concerns.

Topiramate, trade name Topamax, is an anticonvulsant drug for persons with epilepsy. Currently it’s most prescribed to help prevent recurrent migraine headaches and used off-label by psychiatrists for persons with bipolar disorder. It speeds up some neural impulses and slows others, decreasing cravings for food and alcohol.

In a preliminary study involving 200 adults at Duke University weighing mostly more than 200 pounds, patients receiving the relatively lower dosages of phentermine and topiramate for 24 weeks shed 20 pound of weight by week 24, along with improved blood pressures and lipid profiles. Expanded studies show the drug can drop weight by 9 percent over 56 weeks with “no serious drug-related adverse events to date,” yet minor adverse effects such as headaches, tingling and dry mouths were common.

Contrave and Empatic. Contrave combines the ingredients from the antidepressant Wellbutrin with naltrexone, an older drug prescribed for alcohol and opiate addictions. These drugs pinpoint two different brain centers. One helps control the balance between food intake and metabolism, while the other lessens certain food preferences and cravings. Naltrexone triggers a brain signal that blunts the craving for sweet foods. Working together, the drug combination in Contrave reduces appetite and increases metabolism by blunting hunger pains and promoting a sensation of fullness.

According to study results released during a meeting of the American Diabetes Association in New Orleans last June, persons receiving the active combination of drugs lost on average 9 percent of their pre-treatment weight. Adverse effects though included frequent nausea, constipation and increased anxiety. Two persons developed acute cholecystitis, inflammation of the gallbladder that can arise during rapid weight loss of any kind.

The same company that’s studying Contrave also has another fat-busting drug in their pipeline, with the assertive working moniker of Empatic. This combination of the antidepressant Wellbutrin and the epilepsy drug zonisamide also shows promise in early trials, but it’s less likely to be approved until after 2010.

Lorcaserin. This drug targets portions of the brain controlling appetite, feeding behavior and satiety. Unlike some other drugs with similar activity, lorcaserin increases weight loss and improves glucose and lipid control without any reported depression or suicidal behavior to date.

The bottom line – Cubans live just as long as we do and their health care costs only 20 percent of what we pay. Do we really need expensive new drugs to control weight when our neighbors to the South have shown the path to weight loss and better health is simply eating less and exercising more?
 

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