Line Up and Weight

Spring is the awakening of Mother Nature’s treasures. It is also the time for me to “de-layer” the clothing I need to keep warm when going out for a flight. 

I would estimate it is about five to eight pounds of clothing. I also am not pushing on my student with my oversized puffy winter jacket. We are coming out of hibernation and do not need any extra body fat to keep us warm. Losing the additional layers of clothes is easy. Losing some of that excess body weight is not so easy.

The first option for weight loss is diet and exercise. The most important criterion to determine if weight loss is needed is BMI. A healthy person has a BMI between 18.5 and less than 25. The overweight standards are a BMI over 25 to less than 29. Obesity is a BMI greater than 30. There is a mindset that is needed to start the process of weight loss.

The U.S. Department of Health and Human Services recommends at least 150 minutes of moderate aerobic activity or 75 minutes of vigorous aerobic exercise a week, or a combination of both. The diet component is a little more complex. Since the 1960s we have had multiple diet programs for weight loss. In 2005, a study compared four diet plans with some thought-provoking results. The four weight loss programs included Weight Watchers (restriction of portion sizes and calories), Atkins (minimized carbohydrate intake without fat limitation), Zone (modulate macronutrient balance and glycemic load), and Ornish (fat restriction). The trial included 60 overweight or obese participants from the ages of 22-72 years with known hypertension, high cholesterol, or high blood glucose levels. All four groups had moderate weight loss. Approximately 25 percent of the patients had a sustained weight loss of 5 percent of their initial body weight. Ten percent of the participants had, at one year, lost 10% of their initial body weight. The most significant weight loss was with the Ornish diet at 7.3 pounds. The adherence rates over the one year ranged from 50% (Ornish diet) to 65% (Weight Watchers and Zone diets) (JAMA 2005;293(1):43-53). Adherence rates being only 5-6 out of 10 participants is to me not acceptable for the health of the general patient population.

Weight loss has become a hot topic over the past year, and I will continue my educational journey. My first foray into anti-obesity drugs was an article on February 1, 2022, called “The Ramifications of Obesity on the Pathophysiology and Medication Utilization.” At that time, semaglutide (Rybelsusâ) and Orlistat (Xenicalâ) were discussed. Liraglutide (Saxendaâ) is another medication that is FAA approved for weight loss.

Orlistat (Xenicalâ-Rx and Alliâ-OTC) is a gastric and pancreatic lipase inhibitor. Gastric and pancreatic lipases break down triglycerides into monoglycerides and fatty acids. The monoglycerides and fatty acids are used for energy and deposited into adipose tissue. Orlistat blocks the absorption of fats. Orlistat blocks the lipases, and fat does not accumulate in the adipose tissue. Orlistat is administered three times daily with a fat-containing meal. The criteria for Orlistat use are calorie-restricted meals and exercise. The side effects include flatulence, fatty, oily stools, increased defecation, fecal incontinence, and decreased absorption of fat-soluble vitamins and beta carotene, and use may cause hepatic necrosis. The user must take a multivitamin with vitamins A, D, E, and K. A metanalysis of 33 randomized controlled trials studied 5,522 patients taking Orlistat and 4,210 patients taking a placebo and showed a statistically significant decrease in body weight and triglyceride and LDL levels (Pharmacological Research, Vol 122, August 2017, pages 53-65). Be aware that the doses are less for the OTC brand of Orlistat (60 mg vs. 120 mg for the prescription version). The cost of prescription Orlistat is $555 per month without insurance.

Liraglutide is a glucagon-like peptide 1 (GLP-1) agonist. Liraglutide is an injectable medication. Two liraglutide medications are on the market, each with a different indication. Victozaâ is indicated in patients with type 2 diabetes, and Saxendaâ is indicated for weight loss. Saxendaâ attaches to the GLP-1 receptor in the body to increase insulin production to push glucose into the cells for energy. Saxendaâ’s indication for weight loss can be explained by a decrease in leptin levels. Leptin is a hormone that senses weight loss. If you rapidly lose weight, leptin levels increase, and appetite increases. Liraglutide attenuates the rise in leptin levels (leptin resistance) to lower the patient’s appetite. Based on a randomized controlled trial, Liraglutide showed a decrease of 10% in a person’s body weight. The trial length was 56 weeks, which included diet management. The clinical endpoint of the trial was a change in body weight, evaluating how many study participants lost > 5% or > 10% of initial body weight. The liraglutide group had a 63% loss of at least 5% of initial body weight and 33% of the liraglutide group lost greater than 10% weight versus placebo (N Engl J Med 2015;373:11-22). Nausea and diarrhea were the most common side effects. That may not seem like a lot. If you weigh 250 pounds, that would be 25 pounds over one year. Studies have shown that in addition to a healthy diet plan and exercise, weight loss increased to a 50-pound loss. The cost of Liraglutide is $1,600 per month without insurance coverage.

Semaglutide is a GLP-1 agonist in the same category of medications as Liraglutide. Semaglutide is available as an injection, and its trade name is Wygoviâ. Semaglutide is also available in oral form, and its trade name is Rybelsusâ. An oral tablet of Semaglutide is especially advantageous to patients who fear needles and injecting themselves with medication. The PIONEER 4 trial studied 950 type 2 diabetic patients on metformin. Metformin increases the uptake of glucose into the liver and decreases the absorption of glucose in the stomach. The study groups were metformin versus placebo, metformin and oral semaglutide, and metformin and liraglutide. The study was for 52 weeks. The semaglutide group lost on average 10 pounds, the liraglutide group lost approximately 7 pounds, and the placebo group lost on average 1 pound. The semaglutide group had a 44% weight loss greater than 5% of the initial study weight (The Lancet, Volume 394, Issue 10192, pages 39-50, July 06, 2019). The cost of oral semaglutide, without insurance, is $1,000 per month.

Obesity is not a healthy state. The risk of cardiovascular disease, renal dysfunction, peripheral vascular and diabetes is very high, and in many cases, if not treated early could lead to an increased risk of mortality. Due to the high non-compliance rate of long-term diets and exercise regimens, adding a medication to the weight loss program for a patient may be indicated. If that is necessary, insurance coverage and compliance are required to have success in losing weight. Weight and balance are must-do tasks for all pilots. Let’s keep ourselves and the airplane in the envelope. Be well and fly safely.

Larry M. Diamond, PharmD, CFII
Larry Diamond has a Doctor of Pharmacy Degree and has been a pharmacist for 37 years. Larry’s pharmacy practice has been as a Clinical Pharmacy Specialist in Cardiology, Orthopedic Surgery Specialist and most recently Clinical Pharmacy Coordinator. He is a CFII, a pilot for 33 years and has been an AOPA member since 1984.

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