In 2000 an estimated 305 percent of...

In 2000 an estimated 305 percent of adults were obese (i.e., had a material substance mass index [BMI] greater than 30 kg for [m.sup.2]) (1) and 15.5 percent of adolescents were overweight (BMI of 25 to 30 kg by [m.sup.2]). (2) Given the medical and psychosocial impact of being overweight, as well as the difficulty in making sustained improvements in diet and physical activity, it is not surprising that patients ofttimes turn to over-the-counter (OTC) proprietary weight-loss returnss containing single or multiple dietary appendixs (e.g., herbs, vitamins, minerals, amino acids).

A multi-state overlook (3) in 1998 found that 7 percent of adults used OTC weight-loss supplys with the greatest use noted among young obese women (28 percent) Retail sales of weight-loss fill ups were estimated to be more than $13 billion in 2001 (4) Metabolife 356 an ephedra-containing combination correlative was the top-selling diet correlative with $70 million in sales, representing a 127 percent increase from sales in 2000 (4)

Possible reasons that patients use dietary addition s for weight loss are summarized in Table 1 These addition s appeal to the desire for a "magic bullet" that is les demanding than special diets and increased physical activity. They are available without a prescription and frequently advertise remarkable benefits. Patients also may be attracted to them because they are marketed as "natural," which may be interpreted at some (albeit inaccurately) as an assurance of safety and efficacy.

To help identify patients using these supplys physicians should ask their overweight and obese patients in a nonjudgmental manner questions like as, "Have you tried, or considered trying, special diets, exercise programs, diet pills, herbs, or vitamins for weight loss?" If the ingredients of a patient's weight-loss outcome are not evident, an Internet search can rapidly yield a product's Web site and its labeled components

To advice patients appropriately, physicians must be knowledgeable about the efficacy, safety, and quality of used by all weight-loss supplements. Given that correlative users also may be taking prescription medications, (3) the potential for drug/supplement interactions should be considered. Because of the Dietary continuation Health and Education Act of 1994 manufacturers are not required to provide the U nourishment and Drug Administration (FDA) with demonstration of safety and efficacy before marketing postscripts Furthermore, adoption of good manufacturing practices by dint of supplement makers is not commonly mandatory. Therefore, product quality (eg absence of contamination, accuracy of labeling) is variable and uncertain.

More than 50 individual dietary add tos and 125 proprietary products are listed in the Natural Medicines Comprehensive Database as commonly being used for weight los (5) Individual supplys found in at least five commercial returnss (Table 25,6) are discussed in this review, according to their purported mechanism of action. Of note, approximately undivided half of the most everyday individual supplements used in weight-loss outcomes listed in Table 2 have not been studied in randomized controll trials (RCTs) in humans.

addition s Purported to Increase Energy Expenditure

EPHEDRA ALKALOIDS AND CAFFEINE COMPOUNDS

Ephedra sinica (or Ma huang in Chinese) is a dwarf-tree native to China and Mongolia that contains sympathomimetic settles referred to as ephedra alkaloids. Bitter orange and geographical division mallow contain related chemicals. Ephedra alkaloids commonly are combined with caffeine or botanical sources of caffeine (eg guarana, yerba mate) for weight los (7) A latter meta-analysis (8) of RCTs showed a weight los of 09 kg (2 lb) more through month for ephedra-containing supplements compared with placebo. However, no long-term data (i.e., greater than six months) upon efficacy were available.

Using adverse circumstance data from 50 trials of ephedra, a 22- to 36-fold increase in the unevens of psychiatric, autonomic, cardiovascular, and gastrointestinal symptoms was estimated. (8) Another review (9) of adverse facts possibly associated with ephedra use included 87 reports to the FDA MedWatch program between June 1997 and March 1999 These reports included episodes of hypertension, arrhythmias, myocardial infarction, thump and seizures. Ten events l to death and 13 yielded permanent disability. Of these 23 reports, nine occurr at commited dosages of ephedra in human frames without significant preexisting cardiovascular risk factors. (9)

Ephedra yields comprised only 0.8 percent of all dietary add to sales in 2001, yet they were responsible for 64 percent of all herb-related adverse incidents reported to U.S. Poison direction Centers during the same year. (10) Although ephedra-caffeine combinations may be effective for retiring weight loss, safety issues motivated the FDA to ban their sale in April 2004 (11)

complements Purported to Modulate Carbohydrate Metabolism CHROMIUM AND GINSENG