Lonny E. Horowitz M.D. - Atlanta Bariatric Medicine Diet and Wellness Centers, located in Atlanta GA specializes in personalized medical supervised weight loss and weight management programs, endocrinology and the treatment of diabetes, hormones, metabolic illnesses.


Outcomes of using a second generation AED in Recalcitrant Obesity: A Case Series

Presented by Lonny E. Horowitz, MD
Atlanta Bariatric Medicine Diet & Wellness Centers
53rd Annual Obesity Symposium
American Society of Bariatric Physicians
October 10, 2003 Chicago, Illinois.

Objective: To evaluate the clinical efficacy of topiramate as an adjunctive therapy in medically stable patients with recalcitrant obesity who have reached a plateau.

Background: Diet, pharmacologic intervention, and behavioral modification are successful strategies resulting in weight loss for many patients. Despite early success, some patients who are compliant with medical treatment will reach a plateau. A review of the literature revealed that many of the pharmacologic agents currently used to treatment obesity do not spare lean muscle mass. Weight loss with topiramate, an antiepileptic drug, has been reported as an adverse event in epilepsy with sparing of lean muscle mass. Our study was undertaken as a pilot inquiry to determine: 1) if topiramate would be an efficacious adjunctive agent in the obese patient who had reached a plateau 2) and the effect on body composition in these patients.

Design/Methods: A total of six patients were identified as appropriate candidates for a trial of adjunctive topiramate in addition to their standard bariatric medical treatment (e.g. medication, diet, exercise). Patients had been under the care of a board certified bariatrician for 1-10 years and were medically stable. All patients were assessed at initiation of treatment and monitored weekly and biweekly for a five-month period from April 2003 to September 2003. Weight, BMI and vital signs were recorded for each visit. Body composition was assessed before topiramate was added at incrementally increasing dosages for for eight weeks. Body composition was again performed at study end.

Results: Total weight gain or loss, weight loss or gain with the addition of topiramate, and effects on BMI are listed in Tables 1-3.

Table 1. Total Weight Loss or Gain (in lbs.)

Patient ID Initial Weight Weight Loss or Gain: Pre-TPM Weight at TPM  Initiation Total Weight Loss or Gain with TPM Total Weight Loss
01- SW 185.6 -7.1 179.5 - 3.5 15.0
02- CA 412.0 -74.5 337.5 -28.5 103.0
03- JD 197.5 16.5 179.0 - 4.5 4.0
04- JH 272.0 -52.0 220.0 +1.5 55.5
05- VM 364.0 -6.5 351.5 -35.5 32.0
06- DF 204.5 -20.5 181.0 -17.0 40.5

Table 2a. Weight Gain or Loss by Visit (in lbs.)

Patient ID Visit 1 Visit 2 Visit 3 Visit 4 Visit 5
01- SW -1.0 +0.5 +2.0 -0.5 -2.0
02- CA -4.0 -1.0 -5.5 -2.0 -2.0
03- JD +0.5 0.0 0.0 0.0 -0.5
04- JH 0.0 -1.0 0.0 0.0 -0.5
05- VM -2.0 0.0 -5.5 -7.0 0.0
06- DF 0.5 -5.5 -2.0 -0.5 -2.0

Table 2b. Weight Gain or Loss by Visit (in lbs.) continued

Patient ID Visit 6 Visit 7 Visit 8 Visit 9/ Study Completion Cumulative Weight Loss or Gain with TPM
01- SW -1.0 -0.5 0.0 -2.0 - 3.5
02- CA -2.0 -2.0 0.0 +0.5 -28.5
03- JD -0.5 -2.5 -1.0 -0.5 - 4.5
04- JH -2.0 +3.5 +1.5 -3.0 +1.5
05- VM -5.0 -3.0 -2.0 -3.0 -35.5
06- DF -1.5 +0.5 -1.0 -4.5 -17.0

Graph 1

Weight Gain or Loss by Visit (in lbs.)

Weight Gain or Loss by Visit (in lbs.)

Table 3. Body Mass Index

Patient ID Initial BMI BMI Pre-TPM BMI Last Visit BMI D S/P TPM
01- SW 32.83 32.64 32.18 -0.46
02- CA 70.71 57.92 53.03 -4.89
03- JD 33.89 30.63 30.55 -0.08
04- JH 37.93 30.68 30.89 +0.21
05- VM 58.74 56.72 50.99 -5.73
06- DF 36.22 36.22 29.05 -7.17

Conclusions: Preliminary evidence suggests that topiramate may be a useful adjunct treatment for severely obese patients who have stopped responding to standard medical treatment that included medication, diet, and exercise. All three patients in this sample who lost less than five pounds had beneficial effects on body composition similar to those shown in Table 4 for Patient #04-JH who gained 1.5 lb. over the study period. Furthermore, it is apparent that lean body mass is spared and is apparently augmented in some individuals. These results suggest that further analysis is warranted on patients whom we would normally consider treatment failures with non-surgical intervention for obesity.

Table 4. Patient 04 – JH: Body Composition

Baseline: Pre- TPM Last Visit: Post-TPM
Lean Body Mass 56 % 123 lb. 59 % 160 lb.
Fat Body Mass 44 % 97 lb. 41 % 112 lb.
Body Water 44 % 44 liters 44 % 54 liters
Resistance 595 --- 459 ---


Eating Disorder Test

Decisions regarding your eating disorder treatments should not be made lightly. Here are some questions designed to test your knowledge about eating disorders.

  1. Anorexia Nervosa is an eating disorder characterized by a desire to reach a target weight?
    False - Anorexia is characterized by a psychopathologic desire to be skinny. Anorexic individuals seldom associate a specific weight goal with their degree of "fatness".
  2. Binge eating and purging are always found in individuals suffering from Bulimia?
    False - Bulimic patients do not always purge. Compulsive,  excessive, eating and overeating are always present in bulimic patients.
  3. Bulimia  is a voluntary behaviour/ illness which an individual can stop any time they want?
    False - Bulimia is an addictive disorder related in some ways to alcohol and drug addiction. The biochemical as well as psychosocial problems facing bulimic individuals make it almost impossible for them to electively "cure themselves".
  4. Most anorexic patients get better with time and very few die from their disease?
    False - Anorexia has a significant mortality and morbidity. Results of various studies have found mortality rates to be upwards of 20%.
  5. The National Institutes of Health defines an individual as Obese when they are 20% above their ideal body weight?
    True- NIH policy states that an individual 10% above ideal body weight is overweight, 20% is obesity, and 100% or 100 pounds is morbidly obese. By this standard six out of ten Americans are overweight, four out of ten are obese, and one in ten is morbidly obese.
  6. An individual is Morbidly Obesity when they are 50 pounds or 50% above their ideal body weight?
    False - NIH defines morbid obesity as an individual who is 100 pounds or 100% above their ideal body weight per their standards. A new category known as "Super Morbid Obesity" has been suggested to categorize individuals who are 200% or more above ideal body weight.
  7. Fasting and Pre-packaged weight loss programs have success rates greater than 98% after 18 months of treatment?
    False - The United States Congressional Sub-Committee on small business while investigating "The Diet Industry and Fraud" found that less than 2% of individuals participating in commercial weight loss programs which required the customer to purchase Milk Shakes, Diet Foods or Products in order to loose weight maintained their  weight loss 18 months after leaving the program. A significant number of individuals weigh more than before they started on the program.
  8. Heavy exercise (eg. Isometrics, Aerobics, Running, Weight Lifting) helps you to loose weight?
    False - Although exercise does cause a slight increase in the consumption of calories, fat cannot be exercised and is not lost  by exercise. Only muscle can be exercised. Research done by the Department of Physiology of the University of Pennsylvania School of Medicine reveals that heavy exercise during weight loss can in fact be counter productive increasing lean (muscular) body mass and weight while the individual is seriously trying to loose weight. This may contribute significantly to the individuals desire to quit dieting and hence undermine significant weight loss.
  9. Most obese individuals have a positive genetic history of relatives with significant obesity?
    True- In almost 100% of Obesity Patients a family history of Obesity or other addictive disorder can be obtained.
  10. The medical association recognized by the AMA as the only physicians specializing in the treatment of Obesity and Eating Disosorders is "The American Society of Bariatric Physicians"?
    True- The American society of Bariatric Physicians is the ONLY physician run and recognized medical group accredited by the AMA for the treatment of Obesity and related eating and weight disorders. The American Board of Bariatric Medicine examines and Certifies physicians in Bariatric Medicine only after they have passed Written and Oral Examination as well as an on site office inspection and continuing medical education satisfying both AMA category 1 and ASBP criteria

Patient History

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