STYLETHREAD -- LET'S TALK SHOP!

Good morning. I have been enjoying the debate these articles cause so I am going to try to start posting them every weekday. Hope you all don't mind. I find discussions very interesting.

September 22, 2005

Selling Dreams and Drugs By STEPHANIE SAUL

THE waiting room at the office of Dr. Stanley Title on West 57th Street in Manhattan is full of women, all of them seeking a cure for fat.

It is a man's job in life to make money, but "a woman has to look good," said Dr. Title, explaining why the women flock to his office, where the walls are decorated with framed articles from newspapers and magazines that quote him as a leading weight-loss expert.

In The Daily Star, the British tabloid, he warned that Mel Gibson's diet of raw beef could contain parasites. He told The Courier-Mail of Brisbane, Australia, in 1998 that a super-thin Courteney Cox appeared to have taken her dieting too far.

Yet, for all the sane advice Dr. Title dispenses to others, he was censured last year by the State of New York for ordering too many tests and treatments for his own patients.

Dr. Title, 69, who calls the sanction the only blemish on a 45-year career, is one of an estimated 2,500 doctors practicing medical weight loss in the United States. As obesity becomes an increasingly intractable national problem and more people seek medical solutions, diet doctors represent a growing segment of the country's $46 billion diet market, according to Marketdata Enterprises, a market research firm in Tampa, Fla.

Virtually ignored by medical schools and residency programs, medical weight loss has no specific entry requirements and no recognized certification board. But the field, which recently gained a delegate seat at American Medical Association meetings, does seem to have more than its share of complaints leveled at doctors who sell products to their patients, whether special food, liquid diets, unproven therapies or potentially dangerous and habit-forming weight-loss drugs.

Like many diet specialists, Dr. Title supplies drugs directly to his patients rather than giving them prescriptions to be filled at the pharmacy.

Erika Coble of Brooklyn, who is 5 feet 6 inches tall, weighed 170 pounds when she started seeing Dr. Title in June. She had lost 14 pounds by her August weigh-in. And she says she is continuing to lose weight on a regimen of diet, exercise and the pills - one yellow, the other purple - that Dr. Title provides her for $110 a month, an amount that includes his fee. Ms. Coble says she has no idea what the pills contain; she has never asked.

Dr. Title, in an interview, said the purple pills were vitamins and yellow ones were phendimetrazine. Sold elsewhere under brand names that include Adipost and Bontril, it is an amphetaminelike drug that suppresses the appetite but has been found to raise blood pressure in some cases. The Food and Drug Administration, which considers it potentially habit forming, has approved phendimetrazine for only short-term use. Dr. Title says the medications, despite the stigma, generally are safe.

Because insurance plans typically do not cover nonsurgical treatments, patients generally pay cash to their diet doctors.

"The problem is that some of them are in the entrepreneurial, cash-up-front storefront obesity clinic, as opposed to practicing real evidence-based medicine," said Dr. Neal Kohatsu, an epidemiologist at the University of Iowa who has studied physician disciplinary records.

A recurring complaint about diet doctors is that they are too liberal in dispensing drugs. In Tennessee last month a diet doctor was ordered to perform community service after state regulators said he had signed blank prescriptions and sold drugs without a pharmacy license. Authorities in Washington State cited inappropriate use of amphetaminelike drugs when they took away the prescribing rights of an obstetrician-turned-diet doctor in Seattle last March.

No doubt there are many dedicated and qualified doctors specializing in weight loss. And those doctors fill a void left by internists who are frequently ill at ease discussing obesity with patients and who have little idea how to treat it, said Morgan Downey, who runs the American Obesity Association, a national patient advocacy organization.

The largest national organization of diet doctors, with 900 physician members, calls itself the American Society of Bariatric Physicians. (Bariatrics, the study of obesity and its treatment, is not to be confused with bariatric or gastric bypass surgery.)

The group runs a "Locate a Physician" Web page (www.asbp.org/locate.htm) as a national reference for patients seeking obesity treatment. The association says the site, which generates about 100,000 doctor referrals a year, is an important vehicle for weight-loss doctors, who often rely on advertising to draw patients. But patients should probably use the site with care.

In a recent check, nearly 10 percent of the doctors on the reference list had faced some sort of professional reprimand or disciplinary action in their careers, according to a reporter's check of medical boards around the country. A review of medical literature by Dr. Kohatsu suggests that this level of censuring is double the disciplinary rate of doctors, generally.

Among the diet doctors who as of yesterday was still listed is Dr. Augustus F. Marsella of Cranston, R.I.

In July the Rhode Island Department of Health advised 669 patients of Dr. Marsella to undergo AIDS and hepatitis testing after the department discovered that he reused disposable syringes to give injections of Vitamin B-12, an unproven weight loss treatment. The health department said it fears that some patients may have contracted infectious illnesses through the syringes, even though Dr. Marsella said he used a sterilization method.

Following the state's allegations, Dr. Marsella retired. Reached by telephone, he said his malpractice lawyer had advised him not to discuss the matter.

Among doctors in New York, the "Locate a Physician" list includes Dr. Jonathan Schwartz, a weight-loss doctor in Bayside, Queens. Dr. Schwartz gave up his surgical practice eight years ago, after more than 20 patients complained that a penile-enlargement procedure left them scarred or disfigured. After state regulators barred him from performing the operation, Dr. Schwartz set up Big Apple Medical Weight Loss in a small office in a professional suite above the Bay Terrace Shopping Center.

Dr. Schwartz said that this specialty was less high powered and was lower in stress.

"Patients are delighted" Dr. Schwartz, said of his prescribed regimen: a combination of diet, exercise and phendimetrazine. The drug is part of his standard $145-a-month plan, which also includes exams.

One patient, Ralph Venuti, of Whitestone, Queens, says he has lost 140 pounds since last October with Dr. Schwartz's help. He was urged to visit Dr. Schwartz by his mother, Maria Venuti, who found him through an advertisement and who lost 20 pounds under the doctor's direction.

Medical ethics do not preclude doctors from selling drugs or other products from their offices, as long as they are for the patient's benefit, but the sale of products can create conflicts of interest, if doctors pressure patients to buy them.

Corinne Keene, a longtime dieter in Naples, Fla., says the weight-loss doctors in her hometown pitch everything from diet cookies sold by one doctor to a line of food marketed by another, Dr. Caroline Cederquist.

Dr. Cederquist, whose office is tucked between a tanning salon and a workout center in an upscale shopping center, has developed what many in her field consider a model weight-loss practice. It includes a dietician and a psychologist, along with medical monitoring and, sometimes, the use of weight-loss drugs.

Dr. Cederquist has also sells her own line of frozen diet food, both to her own patients and through a Web site (www.diettoyourdoor.com).

An industrial-size freezer occupies a large space in Dr. Cederquist's office, where the décor evokes a Tuscan villa.

"What we found is that people were busy, and sometimes it's just not convenient to cook," she said, pulling a frozen packet of chicken tropicale, a 300-calorie entree, from her freezer. The full weekly plan - including 20 meals and 14 snacks - is $149.95. Dr. Cederquist said that she never pushed her food program on patients, who can buy the ingredients themselves at the supermarket. She has also published a book, "Helping Your Overweight Child," which contains low-calorie recipes for patients to follow.

Dr. Cederquist is a trustee of the American Society of Bariatric Physicians. The organization's affiliated certification board has been calling for official recognition from the American Board of Medical Specialties. Dr. Mary Vernon, a weight-loss specialist in Lawrence, Kan., who serves as the president-elect of the bariatric society, said that licensing boards across the country have not been sympathetic to weight-loss practices because of misconceptions about the use of drugs.

"The licensing boards have not necessarily applied the current science about weight-loss medicine in their decision-making process," Dr. Vernon said, suggesting that could be a reason for disciplinary actions against weight-loss doctors. But some obesity specialists who practice within the academic obesity field are dubious.

Dr. Louis Aronne, a weight specialist at Weill Medical College of Cornell University, recalls attending a meeting of the bariatic society that included a presentation on mesotherapy, which he said was an unproven treatment using injections that purport to smooth fat.

"There are no references in the medical literature of its efficacy, only reports of various complications," he said. "Obesity needs to move into the mainstream of medicine, where physicians know what they're talking about."

Dr. Aronne is among a group of doctors who have set up a competing group in conjunction with the American Diabetes Association. It has adopted a name - Shaping America's Health: Association for Weight Management and Obesity Prevention - that is anything but sleek.

Dr. Schwartz, the Queens diet doctor, accuses the academic obesity experts of trying to horn in on a booming industry. And he has his own criticism of his field's critics. While his patients lose weight, Dr. Schwartz says, the doctors at large academic centers have found no cure for obesity. "I don't see any great results from them," he said.