Use of anti-obesity drugs among college students

Martins, Maria do Carmo de Carvalho e; Souza Filho, Manoel Dias de; Moura, Felipe Scipião; Carvalho, Juliana de Sousa Ribeiro de; Müller, Marina Costa; Neves, Rebeka Valença; Mousinho, Patrícia Coelho; Lima, Iúri Paz

doi:10.1590/S0104-42302011000500017

Abstracts

OBJECTIVE: To evaluate the use of anti-obesity drugs among students attending a public university. METHODS: This was a cross sectional random study of 664 college students. Drug use, socioeconomic, and anthropometric variables were observed. Body mass index (BMI) and waist circumference (WC) were classified according to World Health Organization criteria. RESULTS: Current or previous use of anti-obesity drugs was reported by 6.8% of students. Amphetamine and sympathomimetic amines (40.5%) were the most commonly used drugs. Among those who reported use of anti-obesity agents, 62.2% were female. Only 31.1% of medications were prescribed by doctors. Mean BMI and WC were higher among students reporting the use of such drugs, but 47% of them were classified as eutrophic by BMI, and 76.5% had normal WC measure. CONCLUSION: The use of anti-obesity drugs among college students is of concern, particularly due to the high proportion of drug use without indication or prescription.

Anti-obesity agents; use of drugs; students; prevalence

OBJETIVO: Avaliar o uso de drogas antiobesidade entre estudantes de uma universidade pública. MÉTODOS: Estudo transversal com amostra probabilística constituída por 664 universitários. Foram observadas variáveis socioeconômicas, antropométricas e uso das drogas. O índice de massa corpórea (IMC) e circunferência da cintura (CC) foram classificados segundo critérios da Organização Mundial de Saúde. RESULTADOS: Uso atual ou anterior de agentes antiobesidade foi referido por 6,8% dos estudantes. As anfetaminas e as aminas simpaticomiméticas (40,5%) foram as drogas mais usadas. Entre aqueles que referiram uso de agentes antiobesidade, 62,2% eram do sexo feminino. Apenas 31,1% das prescrições foram indicadas por médicos. As médias de IMC e CC foram maiores entre estudantes que referiram uso de tais drogas, mas 47% deles foram classificados como eutróficos pelo IMC, e 76,5% apresentavam medida de CC normal. CONCLUSÃO: O uso de drogas antiobesidade se mostrou preocupante, principalmente pela elevada proporção de uso sem indicação ou prescrição médica.

Agentes antiobesidade; uso de medicamentos; estudantes; prevalência

ORIGINAL ARTICLE

^IPhD in Biological Sciences; Adjunct Professor, Universidade Federal do Piauí (UFPI); Professor, Faculdade NOVAFAPI, Teresina, PI, Brazil

^IIMSc in Science and Health; Assistant Professor of Psychophysiology and Physiological Sciences, Campus Ministro Reis Veloso, UFPI, Parnaíba, PI, Brazil

^IIIMedical Student, Faculdade NOVAFAPI, Teresina, PI, Brazil

^IVMedical Students, UFPI, Teresina, PI, Brazil

Correspondence to

SUMMARY

OBJECTIVE: To evaluate the use of anti-obesity drugs among students attending a public university.

METHODS: This was a cross sectional random study of 664 college students. Drug use, socioeconomic, and anthropometric variables were observed. Body mass index (BMI) and waist circumference (WC) were classified according to World Health Organization criteria.

RESULTS: Current or previous use of anti-obesity drugs was reported by 6.8% of students. Amphetamine and sympathomimetic amines (40.5%) were the most commonly used drugs. Among those who reported use of anti-obesity agents, 62.2% were female. Only 31.1% of medications were prescribed by doctors. Mean BMI and WC were higher among students reporting the use of such drugs, but 47% of them were classified as eutrophic by BMI, and 76.5% had normal WC measure.

CONCLUSION: The use of anti-obesity drugs among college students is of concern, particularly due to the high proportion of drug use without indication or prescription.

Keywords: Anti-obesity agents; use of drugs; students; prevalence.

Introduction

Obesity is considered a global epidemic¹, which is recognized as a risk factor for many undermining and high social cost diseases, such as type 2 diabetes, hypertension, stroke, heart disease, dyslipidemia, and some types of cancer².

The World Health Organization estimates that in 2015 approximately 2.3 billion adults will be overweight and more than 700 million will be considered obese³. In Brazil, overweight and obesity prevalence are universally growing and reached in 2002-2003 about 40% and 12.7%, respectively, according to estimates of a Brazilian survey (Pesquisa de Orçamentos Familiares [POF]⁴) of the adult population. In the city of Teresina, according to estimates of the same survey, the overweight and obesity prevalence for male and female were 41.5%-7.8% and 36.3%-9.5% (respectively).

Pharmacological treatment of obesity is indicated when the individual has body mass weight (BMI) > 30 kg/m² or disease associated with overweight, BMI > 25 kg/m² in situations where treatment with diet, physical activity, and behavioral modifications was unsuccessful⁵. Drug therapy for obesity includes the use of agents involved in the control mechanism of energy intake, or agents related to the shift of normal nutrient metabolism or that increase energy expenditure⁶. The anti-obesity agents most commonly used are sibutramine and orlistat, both available in clinical practice for nearly a decade⁷. Sibutramine blocks the reuptake of norepinephrine and serotonin reducing food intake, and also stimulates thermogenesis in brown adipose tissue in animals⁸. Orlistat is a more stable and partially hydrolyzed analog of lipstatin (tetrahidrolipstatin), which acts by inhibiting gastrointestinal lipases through irreversible binding at the active site of lipase by covalent binding⁹.

In the prevailing epidemiological context of high prevalence of overweight and the fact that today the stereotype of beauty is the kind of lean and lanky body¹⁰, a high consumption of anorexigens has been observed in Brazil since 1988, estimated at 10 daily doses statistically defined (S-DDD) per thousand inhabitants¹¹. According to the Report of the International Narcotics Control Board (INCB), there was an increase of 500% in the consumption of anorexigens in Brazil since 1998, noting also that the consumption of stimulants in Brazil, mainly as anorexigens, is one of the highest worldwide¹², reaching in 2005 the highest rates of stimulants consumption calculated per 1,000 inhabitants (per day) in the Schedule IV of the 1971 Convention (12.5 S-DDD)¹³.

The reasons for the high consumption of anorexigens reflect not only the increased prevalence of obesity and overweight in Brazil over the past 40 years, but also the irrational and wide spread use of these and other drugs in the country¹⁴.

The young adult population, especially college students, stands out particularly with the role of higher education in the adoption of preventive actions and plans to give the undergraduate an opportunity to contribute to the community they belong to¹⁵. From this perspective, a study of this population group acquires greater relevance when the goal is a true assessment of drug use in a group of young and opinion-maker individuals, which enables the provision of subsidies for future preventive measures in this population. Our aim was to evaluate the use of drugs for weight loss among students in a Brazilian federal university.

Methods

This work was part of the research project entitled "Socioeconomic, nutritional, and health profile of students at the Universidade Federal do Piauí (UFPI) - Brazil" and consisted of a descriptive cross-sectional study, with a probabilistic sample of 664 students. Sample size was calculated assuming a confidence interval of 95% and finite population of 11,152 students, according to the formula used by Martins16 for estimates of large sample proportion, and the margin of error found was 3.75%. The sample was proportional to the number of students attending the course, course period, and teaching center of UFPI (Center for Agricultural Sciences, Education Sciences Center, Center for Humanities and Arts, Natural Sciences Center, Center for Health Sciences, and Technology Center).

The instrument used for data collection was a questionnaire to attain information on socio-economic (age, sex, marital status, family income, and the mothers' level of education) and anti-obesity drug use. In addition, anthropometric measurements of body weight were taken (determined on a digital scale Plenna Acqua SIM-09190, with measuring capacity of 180 kg and variation of 0.1 kg), height (blood pressure anthropometric tape measure with a precision of 1 mm), and hip circumferences (measured with a fiberglass tape with precision of 1 mm).

Measurements of weight, height, and waist circumference were conducted with students barefoot, wearing light clothes and accessories that would not interfere with measurements, according to the recommendations in the Manual of techniques and procedures of the Brazilian Ministry of Health¹⁷. Waist circumference was measured at the midpoint between the last rib and the iliac crest, and waist and hip circumference measured at the largest circumference of the buttocks, with the tape held in a horizontal plane, without pressing soft tissues¹⁷.

Overall nutritional status was classified using the BMI based on the cutoff points proposed by WHO¹⁸, with normal weight defined as BMI > 18.5 and < 25 kg/m²; overweight as BMI > 25 and < 30 kg/m²; and obesity as BMI > 30 kg/m². The term overweight was used for grouping overweight or obese individuals (i.e. individuals with BMI > 25 kg/m²).

Waist circumference (WC) was used in order to identify the distribution pattern of body fat using the cut-offs defined by Lean et al.¹⁹ and currently recommended by WHO¹⁸, considering adequate or normal WC < 80 cm for women and < 94 cm for men, and with cut-off points described in action levels, both in clinical use and in health promotion programs, as follow: action level 1 or increased risk for morbidities associated with obesity (WC between 80 and 88 cm for women and between 94 and 102 cm for men), in which the individual should be advised to stop gaining weight and adopt a healthy lifestyle; and level 2 or very increased risk (> 88 for women and > 102 for men), in which the individual should seek help from health care professional for weight loss and investigation of other risk factors. The waist-hip ratio (dimensionless) considered values higher than 0.8 in women and 0.9 in men¹⁸.

The study protocol was approved by the Ethics Committee of the Universidade Federal do Piauí. After elucidation about the study objectives and possible benefit and risks tied to his execution, all study participants signed an informed consent.

Data were processed in 5.0²⁰EpiInfo and BioEstat 6.04b²¹ programs. Statistical analysis for associations between variables was performed by chi-square test of association, and the unpaired t-test was used for mean comparisons. The level of significance was set at 5% (p < 0.05).

Results

A total of 664 students were enrolled in the study, and 6.8% of them were using or have used anti-obesity drugs, with no statistically significant differences between sexes (Table 1). Only one third of these drugs was prescribed by doctors, especially among females (p = 0.02). The drugs most used were amfepramone, fenproporex hydrochloride, and sibutramine, which together accounted for 40.5% of the drugs used. Moreover, in the twelve months preceding the study, 17.8% of university students were using drugs for obesity treatment without prescription (Table 1).

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The family income of 2.6% of the students was less than or equal to one minimum wage, however, more than half (55.1%) of respondents had a family income above five minimum wages. Investigation of marital status showed that 88.7% of students were single, and the largest proportion of non-drug users for weight loss (p = 0.01) was among those who had mothers with higher education (Table 2).

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The students' mean age was 23.2 years and no difference was observed between the ages of individuals who reported use of anti-obesity drugs and those who have never used (p = 0.07). There was no association between waist-hip ratio (WHR) and systolic or diastolic blood pressure between these groups. Although the mean BMI (23.5 kg/m²), waist circumference (79.5 cm), and hip circumference (98.9 cm) were significantly higher (p < 0.05) in college students who were using or have used anti-obesity drugs (Table 3), the proportion of students reporting use of anti-obesity drugs classified as normal by BMI was 47%, and the classification for both WC and WHR was 76.47%. Classification of overweight and obesity by BMI were 29.42% and 11.76%, respectively. The prevalence of abdominal obesity classified by waist circumference was 5.88%. Based on the anthropometric assessment, among those who reported medical indication, the use of anti-obesity medication was justified in 66.67%.

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Restlessness, irritability or nervousness, insomnia, malaise or dizziness were the most common side effects among participants who reported using anti-obesity drugs (21.4%).

Discussion

A report released by the International Narcotics Control Board (INCB), an organ reporting to the Organization of United Nations (ONU), showed that there was a 500% increase in consumption of anorexigens in Brazil since 1998²².

In this study, 6.8% of students were using or have used drugs for weight loss. These results are similar to those (6.5%) found in an institution for rehabilitation of children and juvenile delinquents in Porto Alegre, RS²³, and are superior to data from the 2005 Household Survey on the Use of Psychotropic Drugs in Brazil, involving the 108 largest Brazilian cities, which showed that 4.1% of respondents have already used appetite suppressants²⁴. On the other hand, larger proportions were found in a study by Sichieri et al.²⁵ of women aged 35 and older, living in permanent private households in the municipality of Rio de Janeiro in which the use of some formulas at least once was reported by 34% of women, with greater frequency among younger and obese women with higher socioeconomic level. The high consumption of these substances by the college students of Piauí supports the panorama of concern about the Brazilian position in the world ranking of these drugs consumption¹².

Among the anti-obesity agents commonly used by respondents were amfepramone, fenproporex hydrochloride, and sibutramine. A sobering fact concerning the use of these drugs is that only one third of students reported the use of prescription drugs and medical guidance, which refers to the great problem of self-medication and the risks associated with it. Among the causes of the indiscriminate use of drugs by the population, especially in self-medication, are the multitude of pharmaceutical products in the market and its massive advertising, the shy awareness campaigns about the possible health problems resulting from this practice, as well as drug information transmitted by "word of mouth", the internet or other media²⁶, and the psychosocial problems caused by the "dictatorship of thinness"¹⁰.

In addition to the problem of self-medication, the irrational use of appetite suppressants and a series of improper practices regarding its prescription in Brazil¹⁴ - and possible medical malpractice in prescribing psychotropic medication²⁷ - point out the need for a comprehensive review of the government's control system of these substances¹⁴. In this sense, Carneiro et al.²², analyzing 168,237 prescriptions and notifications of prescriptions dispensed, evidenced the poor quality of notifications and highlighted the indiscriminate and irrational use of anorexigens, revealing how crucial it is the improvement of market regulation.

This whole scenario should alert the regulatory agencies regarding the high frequency of side effects caused by appetite suppressants usage, as this was one of the reasons (for a long time) why the pharmacological treatment of obesity was seen as a controversial treatment option, subject to considerable criticism⁹.

Feelings of restlessness, irritability, nervousness, insomnia, malaise, dizziness, and anxiety have been described as the side effects most reported by the students interviewed in this study. Massuia et al. ¹⁰, investigating the use of weight-loss schemes associated with the use of drugs with or without prescription among 230 college students of São João da Boa Vista, SP, found that the side effect of such medications was the main reason leading to discontinuation of its use.

The socioeconomic profile of study participants was similar to that found in other studies with regard to family income and marital status^28,29, and the anorexigen drugs used were also similar^14,22,30. Furthermore, there was a higher proportion of non-users among those who had mothers with higher education degree.

Another fact worth mentioning is the difference in consumption pattern of anorexigen drugs between men and women³¹. In absolute numbers, the highest proportion of female users (62.2%) found in this study agrees with the national trend¹⁴ and also with other studies conducted with students^10,22,29.

The difference in consumption of anorexigens between the sexes is probably based on female and male differences regarding body dissatisfaction³², quantitatively greater in female³³, and the difference in usage purpose between the sexes, as demonstrated by Barcellos et al.³⁴ In this sense, Nappo et al.³⁵ concluded that the use of drugs such as amphetamines in Brazil is particularly prevalent among women, and its use is strongly related to the culture of thinness as a symbol of beauty. In addition, the knowledge that 90% of the individuals who develop serious eating disorders are adolescents and young women may have relevance to the explanation of this fact³⁶.

It is also important to note that the mean BMI, WC, and HC were significantly higher in students who were using or have used drugs for weight loss. This finding is probably justified by the fact that many people start consumption because they are overweight. In addition, this observation corroborates the fact that body image³³ has relevance in the use of such medications, but may also reveal the ineffectiveness of such drugs when used recklessly and irrationally.

Drugs such as sibutramine, for example, reduce body weight by only 4-6%³⁷, a mean similar to that obtained by interventions involving only low-energy diets³⁸. In addition, the pharmacological treatment of obesity when discontinued or interrupted results in body weight regain^9,39.40. Note also that prolonged therapy with sibutramine for more than two years is associated with a mean weight recovery of approximately half of the initial weight loss⁴¹.

The results presented here showed high prevalence of appetite suppressant users or former users, and the most commonly used drugs were amphetamines and sympathomimetic amines. We also found a considerable proportion of these non-prescription drugs been used by college students of Piauí, particularly among the female group of this population and those with overweight.

Conclusions

The proportion of anti-obesity drugs used among college students is worrisome, particularly considering the high proportion used without indication or prescription. Thus, it is clear the need for reassessment of control policies and regulations so far adopted for these products in the country, a fact now being discussed by the Brazilian National Agency of Sanitary Vigilance, along with the medical professionals and various governmental and non-governmental organizations regarding the use of psychoactive drugs

This study demonstrates the importance of implementing health education programs targeted at college students, aiming to clarify the risks and complications caused by the indiscriminate use of anorexigens and other drugs.

References

1. World Health Organization. Physical status: the use and interpretation of anthropometry. Report of a WHO expert committee. Geneva, Switzerland: World Health Organization;1995. [Technical report series n. 854]
2. Field AE, Coakley EH, Must A, Spadano JL, Laird N, Dietz WH et al. Impact of overweight on the risk of developing common chronic disease during a 10-year period. Arch Intern Med 2001;161:1581-6.
³
World Health Organization. Global strategy on diet, physical activity and health. Documents related to overweight and obesity. Fact sheet on Obesity and overweight. [citado: 25 fev 2011]. Disponível em: http://www.who.int/mediacentre/factsheets/fs311/en/index.html
⁴
Brasil. Ministério do Planejamento, Orçamento e Gestão. Instituto Brasileiro de Geografia e Estatística. Pesquisa de orçamento familiar 2002-2003. Análise da disponibilidade domiciliar de alimentos e do estado nutricional no Brasil. Rio de Janeiro: IBGE; 2004. pp. 40-76.
⁵
WHO. Consultation on obesity. Preventing and managing the global epidemic. Geneva: World Health Organization; 1998.
6. Mancini MC, Halpern A. Pharmacological treatment of obesity. Arq Bras Endocrinol Metab 2006;50:377-89.
7. Coutinho W. The first decade of sibutramine and orlistat: a reappraisal of their expanding roles in the treatment of obesity and associated conditions. Arq Bras Endocrinol Metab 2009;53:262-70.
8. Stock MJ. Sibutramine: a review of the pharmacology of a novel antiobesity agent. Int J Obes Relat Metab Disord 1997;21:S25-9.
9. Mancini C, Halpern A. Tratamento farmacológico da obesidade. Arq Bras Endocrinol Metab 2002;46:497-513.
10. Massuia GA, Bruno TIB, Silva LS. Regime de emagrecimento x utilização de drogas. Rev Científ UNIFAE 2008;2:1-9.
11. Brasil. Ministério da Saúde. Secretaria de Vigilância Sanitária. Parecer e recomendações do grupo de estudos assessor da SVS-MS sobre medicamentos anorexígenos. São Paulo: Ministério da Saúde; 1993.
12. JIFE. Relatório anual 2007 da junta internacional de fiscalização de entorpecentes. Brasília (DF): Escritório das Nações Unidas contra Drogas e Crime; 2008. [citado 18 mar 2011]. Disponível em: http://www.unodc.org/pdf/brazil/JIFE/OBrasilnoRelatorioJIFE.pdf
13. JIFE. Relatório anual 2006 da junta internacional de fiscalização de entorpecentes. Brasília (DF): Escritório das Nações Unidas contra Drogas e Crime; 2007. [citado 18 mar 2011]. Disponível em: http://www.unodc.org/brazil/pt/pressrelease_20070103.html
14. Noto AR, Carlini EA, Mastroianni PC, Alves VC, Galduróz JCF, Kuroiwa W et al . Analysis of prescription and dispensation of psychotropic medications in two cities in the State of São Paulo, Brazil. Rev Bras Psiquiatr 2002;24:68-73.
15. Rodrigues ESR, Cheik NC, Mayer AF. Nível de atividade física e tabagismo em universitários. Rev Saúde Pública 2008;42:672-8.
16. Martins GA. Estatística geral e aplicada. 2Ş ed. São Paulo: Atlas; 2002. p.180.
¹⁷
Brasil. Ministério da Saúde. Universidade Federal de Goiás. Centro Colaborador em Alimentação e Nutrição da Região Centro-Oeste. Antropometria. Manual de técnicas e procedimentos. Vigilância Nutricional. 2ª ed. Goiânia; 2003.
18. World Health Organization. Obesity: preventing and managing the global epidemic. Geneva: WHO; 2000. [Techinical Report Series]
19. Lean ME, Han TS, Morrison CE. Waist circumference as a measure for indicating need for weight management. Br Med J 1996;311:158-61.
20. Ayres M, Ayres JRM, Ayres DL, Santos AAS. Bioestat 5.0. Pará: Sociedade Civil Mamirauá; 2007.
21. Dean AG, Dean JA, Coulombier D, Brendel KA, Smith DC, Burton HA et al. Epi Info, version 6.04: a word processing database and statistics program for a epidemiology on microcomputers. Atlanta: Centers for Disease Control and Prevention; 1996.
22. Carneiro MFG, Guerra Junior AA, Acurcio FA. Prescrição, dispensação e regulação do consumo de psicotrópicos anorexígenos em Belo Horizonte, Minas Gerais, Brasil. Cad Saúde Pública 2008;24:1763-72.
23. Ferigolo M, Barbosa FS, Arbo E, Malysz AS, Stein AT, Barros HMT. Prevalência do consumo de drogas na FEBEM, Porto Alegre. Rev Bras Psiquiatr 2004;26:10-6 .
24. Carlini EA, Galduróz, JC, Noto AR, Carlini CM, Oliveira LG, Nappo SA et al. II levantamento domiciliar sobre o uso de drogas psicotrópicas no Brasil: estudo envolvendo as 108 maiores cidades do país - 2005. São Paulo: Páginas & Letras; 2007.
25. Sichieri R, Andrade R, Baima J, Henriques J, Vaisman M. TSH Levels Associated with Slimming Pill Use in a Population-Based Study of Brazilian Women. Arq Bras Endocrinol Metab 2007;51:1448-51.
26. Souza JFR, Marinho CLC, Guilam MCR. Consumo de medicamentos e internet: análise crítica de uma comunidade virtual. Rev Assoc Med Bras 2008;54:225-31.
27. Nappo AS, Oliveira EM, Morosini S. Inappropriate prescribing of compounded antiobesity formulas in Brazil. Pharmacoepidemiol Drug Safety 1998;7:207-12.
28. Soldera M, Dalgalarrondo P, Corrêa-Filho HRC, Silva CAM. Use of psychotropics drugs among students: prevalence and associated social factors. Rev Saúde Pública 2004;38:277-83.
29. Lucas ACS, Parente RCP, Picanço NS, Conceição DA, Costa KRC, Magalhães IRS et al. Uso de psicotrópicos entre universitários da área da saúde da Universidade Federal do Amazonas, Brasil. Cad Saúde Pública 2006; 22:663-71.
30. Feltrin AC, Zordan G, Wagner F, Schmitt GC, Boligon AA, Delamolle N et al. Medicamentos anorexígenos - panorama da dispensação em farmácias comerciais de Santa Maria (RS). Rev Saúde 2009;35:46-51.
31. Galrduróz, JCF. Uso e abuso de drogas psicotrópicas no Brasil. Rev IMESC 2001;3:37-42.
32. Russo R. Imagem corporal: constrição através da cultura do belo. Mov Percepção 2005;5:80-90.
33. Gonçalves TD, Barbosa MP, Rosa LCL, Rodrigues AM. Comportamento anoréxico e percepção corporal em universitários. J Bras Psiquiatr 2008;57:166-70.
34. Barcellos AP, Paggi AP, Silva DB, Campagnolo MI, Dieterich MDD, Santos RLR et al. Padrão de consumo de anfetaminas entre universitários de Porto Alegre. Rev Psiquiatr Rio Gd Sul 1997;19:161-9.
35. Nappo SA, Tabach R, Noto AR, Galduróz JCF, Carlini EA. Use of anorectic amphetamine-like drugs by Brazilian women. Eat Behav 2002;3:153-65.
36. Faria P, Shinohara H. Transtornos alimentares. Rev Interação 1998;2:51-73.
37. Padwal R, Li SK, Lau DCW. Long-term pharmacotherapy for overweight and obesity. Int J Obes Relat Metab Disord 2003;27:1437-46.
38. Franz MJ, Vanwormer JJ, Crain L, Boucher JL, Histon T, Caplan W et al. Weight-loss outcomes: a systematic review and meta-analasys of weight-loss clinical trials with a minimum 1-year follow-up. J Am Diet Assoc 2007;107:1755-67.
39. Ryan DH. Use of sibutramine to treat obesity. Prim Care Clin Office Pract 2003;30:405-26.
40. Bray GA, Ryan DH. Drug treatment of the overweight patient. Gastroenterology 2007;132:2239-52.
41. Kaplan LM. Pharmacological therapies for obesity. Gastroenterol Clin North Am 2005;34:91-104.