Obesity and Orlistat


Obesity and Orlistat

44 Anti-Aging Foods



This report is dated as you will notice but the information is still credible as the particular drug called Orlistat is a current item.

Use your search engine and enter “ orlistat ” and you will find out more information and the current manufacturer.

And this report is quite long as you will find but I didn’t think it would be appropriate to edit!



with Norman Swan

Monday 29 March 1999 


Well the drug companies didn't hanging around. They smelt money in obesity and have developed a drug which, as you'll hear, might produce its own scent.

In January, a group published a large study of a drug called orlistat. It found that orlistat gave a few kilos extra weight loss over and

above a weight reducing diet.

One of the principal researchers runs the Centre for Human Nutrition at the University of California Los Angeles, which is exactly where I visited Professor David Heber.

David Heber: Orlistat is a drug that inhibits the breakdown of fat in the intestine by about 30%; it's originally a bacterial product, and it's basically something that inhibits an enzyme.

Norman Swan: How does it work in terms of weight loss?

David Heber: Well first of all, it works together with diet and lifestyle. I think for any pill that you're going to take against being fat or obese, you have to realise they work together with diet. I like to say there's no pill that jumps out of your body and closes the refrigerator door. You really have to do diet and lifestyle, cut your total calorie intake and then these pills either orlistat or other pills that affect your appetite, what they do is they help you lose weight more effectively when you stay with a diet.

Norman Swan: So tell us about this trial that's recently been reported.

David Heber: Well it was a trial done in 18 centres, and what they found was that when people took the orlistat and they did cut their fat down and so forth, that they lost some additional weight and their cholesterol levels were dropped in response to taking the orlistat, and the triglyceride levels fell as well. This is something we see with a lot of the weight loss trials, and certainly orlistat now gives another tool in the fight against obesity which at least in this country is our no.1 nutritional problem, affecting one out of every two Americans.

Norman Swan: What's often done in drug marketing is they say 'You take this drug and you lower your cholesterol by 30%, less chance of getting a heart attack.' When your heart attack chances are pretty low, a 30% reduction's not very dramatic when you look at it in absolute terms. Therefore to say orlistat gives you 65% more weight loss than just diet alone, sounds fantastic, but when it translates to 6 pounds or a couple of kilos, it doesn't sound so terrific.

David Heber: Well you know, you're right in a certain sense, and I've been one of the people who's pointed out this issue of the cholesterol that you talk about. It's a 30% difference between 90% survival in the control group, or 93% in the treated group. It's not very much on an absolute basis. Weight loss is a little different. What we do, I'd work with people every week, two, three days a week on weight loss, and there are a lot of people out there who are aggravated for one reason or another, and I try to individualise my approach to each patient depending on what types of things are most important to them. And I can think of a patient who has a very low metabolism, say a woman who's 5-foot tall, can eat hardly any fat at all, and for her the ability to take a pill that will help block the absorption of extra dietary fat, could be just the thing to help her be more successful with her diet. She'll still have to do everything else. Now that might not work for another person, it would depend on the individual.

Now we also use this drug for satiety. Sibutramine is the generic name, and what it does, it increases the sense of being full at the end of a meal. They have a little picture they show where they have some chicken breast and some vegetables and things on a plate, and then the next frame is leaving part of it behind. So it allows you to kind of leave part of the food behind. That action we find very helpful for a certain number of our patients. Now there are doctors in America who just write the prescription, hand it to the patient, and they say, 'Oh that stuff doesn't work.' Well of course it doesn't work, because they haven't done the diet with it.

So all of our effort here at the Centre for Human Nutrition is to teach doctors and their patients how to use diet and lifestyle change effectively to lose weight. And we concentrate on three principles. One is what we call trigger foods, which are foods that run you rather than you run them, things like nuts and cheese and salad dressing. The second is meal replacements and portion-controlled meals. You don't have to join an expensive weight loss program but you can get all little liquid meal replacements, things in cans that you would drink, I don't know if they have these things like Slim-Fast over in Australia or not, Healthy Choice frozen dinners, Lean Cuisine, Weight Watchers, that type of thing.

And then the third part is a new way of eating. Rebalancing the American plate, it's something we call the California Cuisine Pyramid, it's a modified plant-based diet where fruits and vegetables are on the bottom of the pyramid, instead of cereals and grains; and then we have high fibre cereals and grains above that, and then lean meats, fish, chicken, scallops, shrimp, lobster, things you'd like to eat over there in Australia. And then on the top we have all kinds of spices: garlic, olives, avocadoes, chilli peppers, rather than simply using sugar and fat to flavour our food. In India for instance, they have some of the lowest rates of cancer in the world, and we think in part it's due to the use of curry and spices and things of that sort. So we want to introduce more spice, less of a red meat-based diet, and something where the diet is based on fruits and vegetables, and cereals and grains, with some meat added to enhance the taste. I'm not a total vegetarian.

Norman Swan: Now coming back to orlistat, some people are saying that it's not so much the fact that it reduces your absorption of fat, it's the fact that it's so unpleasant when you eat fat that you actually train people to hate fat over a period of time, because they get abdominal distension and they get diarrhoea and it's really unpleasant.

David Heber: Well actually, some people do have that side effect. If you have a situation where somebody's going to binge eat a lot of fat, they will get that negative aversive therapy. That has been raised, I don't know of a scientific study that's actually been done to prove that. I've raised that as a potential study that ought to be done. In practice, many of our patients, especially the women, got quite used to the side effects. They would wear a little pad and they'd have a little bit of leakage once in a while, and it didn't bother them. Some men found it very problematic, especially if they ate a large quantity of food and it sort of exploded.

Norman Swan: So anal leakage is a problem in what sort of percentage of people?

David Heber: Well many people will get small amounts of anal leakage, and whenever they eat a large amount of high fat food. So you're absolutely right, this is not something that you want to have in someone who's not going to be able to change their diet. They really have to change their diet and use this together, or they're just going to reap the benefits of the side effects which could mean a lot of new clothing and new furniture around the house.

Norman Swan: And fat-soluble vitamins, like vitamin A and D?

David Heber: That's not much of an issue. There were some changes in the fat-soluble vitamins and we've monitored that in our study, but my view is that if everyone takes a multi-vitamin, multi-mineral every day, eats five servings a day of fruits and vegetables, you're not going to run into any trouble. I personally recommend that people do take multi-vitamins, vitamin E, 400 units every day, vitamin C 500 milligrams, and women ought to be taking calcium either 500 to 1000. I call it my four basic vitamins, it's a sort of counter to the four basic food groups that they taught us in medical school, that you could get all your nutrition from the basic four food groups, and of course that's not true, so I've countered with my four basic vitamin supplements.

Norman Swan: And you've just published a study on Chinese Red Yeast. Tell me about this substance.

David Heber: Well this is a very interesting study. It turns out, I've got woodcuts going back to the year 1300 of Chinese actually fermenting red yeast on rice. And they make a red rice wine out of this in Asia and it's a staple of the Asian diet throughout Asia. They eat it on top of tofu in the morning as a little spice, and it's related to the red spice on Peking Duck and pork spareribs, and it naturally contains in it mevacor-like substances, or HMG Co-A reductase inhibitors.

Norman Swan: Also called the statins. So these are the highest selling drugs in the United States and Australia, and they're in their natural form in this yeast.

David Heber: Yes. They're actually called monacolins, and actually where the statins originally came from was they were isolated from another species, a fungus actually. And one of these monacolin K, is the one that's most closely related structurally to mevacor. But mevacor is really a crystalline drug in a purified form. This isn't the natural form, there's a family of eight different compounds that are related, and they lower cholesterol. We did a study here in 80 individuals, 40 got placebo and 40 got this red yeast, and the cholesterol went from 250 to 210.

Norman Swan: What does that translate in mmol/L?

David Heber: Went from 6.57 down to 5.38. The importance to me was this stuff costs $20 to $30 a month and statins are anywhere from $180 to $300 a month. So if we look at the United States, there's 56-million people with cholesterol over 200. Only 3-million can afford to take prescription drugs. So that leaves us with a huge number who are not taking anything at all. So I think it's important for us to do this type of research, with natural substance, we're always being attacked that 'Oh, herbs don't work, dietary supplements don't work', here's one we understand how it works, we did the study by the most rigorous western methods and it passed with flying colours. And now everyone's saying, 'Well that's because it's not a herb, it's a drug', but we don't agree.

Norman Swan: But that's a fairly big reduction. I mean that's a reduction that would be fairly respectable in the statins. What percentage reduction is it?

David Heber: It's about a 15% reduction in the LDL cholesterol itself, which is quite substantial.

Norman Swan: So that puts it in realm of simvastatin, doesn't it?

David Heber: Yes, it would be about the same as a 20-milligram dose of lovastatin. And the argument I make is that there are only 6-milligrams in this daily dose of the one monacolin that's most closely related to mevacor. So I think the other monacolin members of the family are also having an effect. Because we got a very nice effect with this dose of two capsules a day of the Chinese red rice yeast.

Norman Swan: Now they're calling this a food supplement. If you're getting that sort of reduction with a food supplement, obviously you need a much larger study to be sure that you're getting that sort of reduction, why hasn't somebody picked up on that and evolved it further, because if you actually worked on it more you presumably would get far greater reductions.

David Heber: Well there have been other studies done at other centres, reproducing pretty much what we found. And there were 17 studies in China showing the same thing. I originally did this because the Chinese studies were difficult to translate into western terms because they have a different traditional Chinese medicine system, as you know. But we did a double-blind study and it really works. I think this is great for people who, say, have done everything with diet and lifestyle, they go to see their doctor, and the cholesterol is still 229. What do they do? Do they go on a prescription drug? Well, you shouldn't use a prescription drug below 240 so the doctor's left with a dilemma. And many doctors are prescribing these expensive drugs when really what would suffice would be this type of natural product as a different alternative, less costly, perfectly safe.

Norman Swan: What side effects were there?

David Heber: The only side effect that's been reported in the world's literature is a little bit of heartburn. Other than that, we saw no problems with liver function, we monitored all of that, and there were no other serious side effects.

Norman Swan: So nothing with the muscles or anything?

David Heber: No, not at all, we didn't see that.

Norman Swan: Let's just go back then to these trigger foods that you were talking about, in talking about general lifestyle issues. Because you talk about things like nuts, pizza, other types of foods. There is a theory around that in fact when you eat high fat foods, the high fat itself triggers your appetite and gives you more. The sweet tooth in fact is the fat tooth because of the association between the two. Is that what you're talking about here when you talk about trigger foods?

David Heber: Yes, absolutely. It turns out that after a period of time on a low-fat diet, you can no longer stand high fat foods, you absolutely become ill when you try to eat a high fat food. Orlistat aside, just on the diet alone, because as you eat lower fat foods, you lose the enzymes in your GI tract to digest those high fat foods. We are all adapted to a low-fat diet, sort of like the Aborigines in Australia, when they come into civilisation, they have a rise in their blood pressure, rise in diabetes, and on a low-fat diet they do just fine. Now man is pliable, because Eskimos for instance, can live on a whale blubber diet, and they're able to, over a period of time, induce the enzymes to digest fat. So on a western diet, people tolerate high fat foods, sort of the way we tolerate cigarette smoke when we're inhaling it into our lungs. And once you go on a low-fat diet, you really adapt. So I really stress re-educating the palate, staying away from artificial sweeteners, staying away from high fat foods, and what you'll notice is that your taste for unhealthy foods absolutely disappears and what's more, you'll get the feeling of being morally superior to all those around you who are still stuck on those trigger foods.

Norman Swan: But you talk about taste enhancers, using herbs freely, some people put people on almost an elimination diet for weight loss because they reckon that a bland diet helps you to reduce your interest in food and just going on a bland diet reduces your volume of food. Aren't you risking increasing the appetite a bit by using flavour enhancers?

David Heber: Well actually many of the flavour enhancers like chilli peppers have actually been shown to cause weight loss. It turns out that chilli peppers, by raising body temperature a little bit, they also raise endorphins in the central nervous system, can actually reduce appetite and spicier foods tend to replace sweet and fat. So our emphasis is to use garlic and spices and peppers, and so forth, to give the food a great taste, and use the taste to replace the fat. One of the problems with diet actually is its blandness, and boring nature and it's much better to have the spices there. We're not in favour of deprivation, we want people to enjoy their food intake. But to really replace the fat and sweet with spices.

Norman Swan: Now let's go back to your California Cuisine food pyramid because it would be very similar to an Australian cuisine food pyramid, because we eat very similar foods. What's the significance of having vegetables, just talk me through it again more slowly, what is the significance of having fruit and vegetables down at the bottom rather than the grains?

David Heber: Well you know, ancient man used to eat over 3,000 varieties of seeds, nuts, bark, leaves. We are adapted to taking in a large number of what we call Phyto nutrients, which are the red colour and yellow colour that's found in fruits and vegetables. These things help prevent cancer, they help prevent heart disease.

Norman Swan: Lycopenes and so on?

David Heber: Yes. Lycopenes, carotenoids all these kinds of substances. And so these are the things that we believe the diet needs to be based on. Above that, we put high fibre cereals and grains, because fibre itself has been found to be very, very important.

Norman Swan: And that's secondary to vegetables?

David Heber: Right. What used to be on the bottom of the pyramid was that same bread product, but with all the fibre beaten out of it, all the nutrition taken out of it. That's not what we believe in, we believe that should be on the next tier. And I believe that biodiversity is going to be the answer to nutrition and cancer, to the dilemma of nutrition and cancer in the future.

Norman Swan: By that meaning as diversified as possible and as unrefined as possible?

David Heber: That's correct. Going as much as we can back to raw ingredients, combinations of foods, cooked as little as possible with a broad variety of spices to make them more tasty. One of the problems of getting vegetables in, is they do taste relatively bland and we need to use spices to be able to make them flavourful. You know, we don't really have a national spice here in the US, I don't know about in Australia, but here the two most common vegetables are potatoes and tomatoes, and it's French fries and ketchup.

Norman Swan: Absolutely. And when you talk about cancer here, you're talking more about cancer prevention and the fact that these vegetables contain what believe are co-factors, probably many of which are yet to be discovered, which are cancer preventive agents.

David Heber: Yes, that's correct, although we're also doing research on the progression of cancer. And it turns out that many of the substances in fruits and vegetables can affect the growth progression in blood vessel formation in tumours once they've been treated. And you know, the most common thing now is people being treated with an early prostate or early breast cancer, and then going a long period waiting for recurrence. And our current research is to try to prevent that recurrence from occurring. In particular we're doing a lot of research on prostate cancer here in the United States, looking at prostate cancer and nutrition.

Norman Swan: Is this the idea of fat and prostate cancer?

David Heber: Yes, this is actually the same type of diet we've been talking about: low fat, high fibre, and we also use soy protein which we think is very important as well. It's a protein throughout Asia, not eaten very much in the United States at all, and substances in the soy protein actually inhibit tumour growth.

Norman Swan: Of course it's a fraught area, cancer diets, because a lot of the alternative cancer diets that are on the market are actually weight loss diets, and one thing you don't particularly want I would have thought when you've got cancer, is to lose weight.

David Heber: Well actually it's interesting. I agree with you about the alternative issue, and we're trying to make everything as scientific as we can here. However the impression that cancer patients should never lose weight is actually wrong. It turns out that women who are obese at the time of diagnosis of breast cancer have a shorter median survival than women who are lean, and the same type of data for colon cancer and prostate cancer. In fact it turns out that obesity is a major risk factor for many common forms of cancer, breast, prostate, colon, kidney, gall bladder, uterus, ovarian and so forth, and this was based on a large study from the American Cancer Society in over 750,000 people. So often when people talk about cancer nutrition, they leave out obesity and yet it's a very important part of the overall picture.

Norman Swan: That's cancer causation, has anybody shown that intervening, reducing obesity, makes a difference?

David Heber: Well those are the toughest studies to do. Though one that comes the closest is actually a non-melanoma skin cancer, of which there's an epidemic in the south-west US due to the all the sun exposure, and I'm sure you have the same problem in Australia. A fellow named Homer Black in Texas did a two-year intervention with low fat diet and found that people on a low-fat diet had fewer new skin cancers than the people on the high fat diet. Now obviously skin cancer is not serious, 90% of them are curable, you just lop them off with a scissors or whatever, but nonetheless it's a proof of principle, because in animal studies the same thing had been shown 80 years earlier by painting a carcinogen on the skin and giving animals a low fat or high fat diet. Now breast and prostate cancer, ovarian cancer, these are much harder to study, they're fraught with all kinds of intervening therapy, different stages, it will be a long time before we prove this, but I think the principle is there, and of course in 1964 we told people to stop smoking long before we knew the molecular basis of how tobacco caused lung cancer. So I think it's time for us to make healthy recommendations to cancer patients even after they've been treated.

Norman Swan: Now we've been phoning around and it seems that Chinese red yeast is available in Australia. It's from the east, called Monascus purpureus and the Chinese know it as Hong Qu (pronounced Hong 'Chew')

And Professor David Heber is Director of the Centre for Human Nutrition at the University of California Los Angeles.

Two of his books are called 'The Resolution Diet' and 'Natural Remedies for a Healthy Heart' and are published in the United States by Avery Books.


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