The pursuit of weight loss has led many individuals, particularly adolescents, to explore various methods, including the use of nonprescription weight-loss products. These products, encompassing both drugs and dietary supplements, are often used without the guidance or prescription of a physician. This article aims to provide a comprehensive overview of nonprescription weight loss products, focusing on their prevalence, potential health consequences, and the need for informed decision-making.
Prevalence of Weight-Loss Product Use Among Adolescents
A meta-analysis that included 90 studies with 604,552 participants found the prevalence of weight-loss product use in adolescents was 6% overall. The use of nonprescribed weight-loss products in adolescents is a public health concern that is associated with negative physical and psychological consequences. A concerning unhealthy weight control behavior, and the focus of this meta-analysis, is the adolescent use of weight-loss products (including drugs and dietary supplements) for weight control or reduction without a physician’s prescription. The prevalence of weight-loss product use without a physician’s prescription in adolescents ranges from past week use of 1.6% in Australia; past 30-day use of 6.1% in the US, 6.7% in Brazil, and 2.4% in South Korea; and past year use of 3.7% in New Zealand and 3.5% in Israel.
This meta-analysis found that use of weight-loss products occurs at high levels in adolescents, especially girls. When identifying use of weight-loss products in the general population, prevalence was 2.0% in the past week, 4.4% in the past month, 6.2% in the past year, and 8.9% in their lifetime. This highlights a significant trend of adolescents turning to these products for weight management.
Search Strategy and Inclusion Criteria for Meta-Analysis
To determine the prevalence of weight-loss product use among children and adolescents, a comprehensive literature search was completed in EMBASE and through the EBSCOhost platform for MEDLINE, PsycINFO, and CINAHL (Cumulative Index of Nursing and Allied Health) on December 1, 2020, and updated March 6, 2023. There were no restrictions placed on publication year (study year range of included publications was 1985-2023) or geographical region. Studies included in the meta-analysis were observational studies reporting the prevalence of weight-loss product use over a period of time (past week, past month, past year, or lifetime). Studies were included if they were published in English and included children and adolescents 18 years or younger.
For this meta-analysis, weight-loss products were defined as drugs and dietary supplements that were used for weight control without a prescription or a physician’s order. The weight-loss products included in this study were diuretics, laxatives, and diet pills. Dietary supplements also had to be used for weight loss purposes and to be used without a physician’s prescription to be included in the meta-analysis. Studies were excluded from the meta-analysis if they focused on weight controlling practices other than nonprescription use of weight-loss products, unhealthy weight control practices in general, solely qualitative aspects of use of weight-loss products, or a study population older than 18 years.
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Data Extraction and Quality Assessment
A data extraction template was developed, and the following information was extracted for each study: authors, year of publication, country, sample description, study design, sample size, study setting, type of weight-loss product that was used without a prescription, prevalence of weight-loss product use, and duration over which prevalence was calculated. Included studies were assessed for internal validity and bias risk using the critical appraisal tool, Joanna Briggs Institute (JBI) Appraisal Checklist for reporting prevalence data. The research team decided that good-quality studies were required to score 70% or greater (score of ≥7 of 9), moderate-quality studies needed to score 50% to less than 70% (score of 5 or 6 of 9), and poor-quality studies scored less than 50% (score of ≤4 of 9). Data analysis involved determining an overall pooled proportion estimate of weight-loss product use in adolescents from the 90 included studies.
The studies included general population adolescent prevalence studies and populations among whom use of weight-loss products is known to be higher, including those with substance use, the LGBTQI (lesbian, gay, bisexual, transgender, queer, and intersex) community, adolescents with type 1 diabetes, those with known eating disorders, and elite athletes. Therefore, a second analysis to determine the prevalence of weight-loss product use in the general adolescent population was completed with the exclusion of these higher-risk populations. The results of these analyses present the prevalence for different time points (past week, past month, past year, and lifetime use). Another subgroup analysis was completed at the different time points for the general adolescent population to determine the prevalence of nonprescription weight-loss product use for different types of weight-loss products. The 3 different product groups included diet pills, laxatives, and diuretics. A second subgroup analysis in the general adolescent population reviewed nonprescription weight-loss product use by sex, by continents (Africa, Asia, Europe, North America, Oceania, and South America), and by study publication years (before 2000, after 2000, and after 2010).
Statistical Analysis
The inverse variance heterogeneity (IVH) model was chosen for meta-analysis results because it is an estimator model that uses a fixed effects model assumption that has a quasi-likelihood-based variance structure, which is considered more robust than other models. Data analysis was conducted with Office Excel, version 2019 (Microsoft Corportion), using the MetaXL add-on software package. Statistical heterogeneity between the studies was evaluated using the I2 statistic and Cochran Q test.
Study Characteristics
A total of 90 studies met the inclusion criteria and were therefore included in the meta-analysis. Sixty-nine studies (77%) reported weight-loss product use in both boys and girls, while 21 studies (23%) reported use of nonprescription weight-loss products in girls only. The sample size of the included studies ranged from 80 to 65 529, with the meta-analysis base case (all use of nonprescription weight-loss products at all time periods) containing data from 604 552 participants. The study year of publication ranged from 1985 to 2023, with 73 (81%) being published after year 2000. The mean (SD) age of participants across the studies ranged from 12.8 to 18.0 years. The 90 studies were from 25 different countries and 6 different continents. Two-thirds of the studies included reported prevalence in the general population, while the remaining studies focused on higher-risk groups (eg, with diabetes, substance use, diagnosed eating disorder). Fifty of the included studies (56%) were from North America (including the US, Canada, Jamaica, and Caribbean islands), 11 (12%) were from Asia (including Korea, China, Japan, and India), 11 (12%) were from Europe (including the United Kingdom, Romania, Italy, Norway, Spain, Belgium, and Denmark), 6 (7%) were from South America (including Brazil and Colombia), 5 (6%) were from the Middle East (Saudi Arabia, Iran, and Israel), 4 (4%) were from Africa (including South Africa, Ethiopia, and Mauritius), and 3 (3%) were from Oceania (Australia and New Zealand). The JBI quality checklist determined that most of the studies were of moderate quality (46 [51%]) or good quality (41 [46%]). Three studies (3%) were of poor quality. No studies were excluded from the main meta-analysis based on the JBI score. The pooled prevalence for weight-loss product use in adolescents was 5.5% (95% CI, 5.5%-5.6%; I2 = 100%).
Prevalence of Nonprescription Weight-Loss Product Use Over Various Time Periods
The pooled prevalence of nonprescription weight-loss product use in adolescents over various time periods (past week, past month, past year, and lifetime) was conducted for the general population of adolescents only. 2.0% of adolescents used any nonprescription weight-loss products (ie, diet pills, laxatives, or diuretics) in the last week. Second, 4.4% of adolescents used nonprescription weight-loss products in the past 30 days. Figure 4 reports past-year prevalence of weight-loss product use in 16 studies and shows that 6.2% of participants used nonprescription weight-loss products in the past year.
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Risks Associated with Nonprescription Weight Loss Products
The use of nonprescribed weight-loss products in adolescents is concerning because it increases the risk of unhealthful weight gain in adulthood, as well as being prospectively associated with elevated risk of being diagnosed with an eating disorder within several years of onset of use. Furthermore, longitudinal studies found that the nonprescribed use of weight-loss products was associated with low self-esteem, depression, and poor nutritional intake. Cross-sectional studies found an association between nonprescribed use of weight-loss products and substance use.
Lack of Regulation and Potential for Harmful Ingredients
Over-the-counter dietary supplements for weight loss are not reviewed or approved for safety or efficacy, nor does evidence support their clinical use. The Food and Drug Administration (FDA) doesn't need to approve dietary supplements. Companies that make supplements must make sure they're safe. However, makers of dietary supplements rarely do clinical trials, and some weight-loss supplements have been found to have ingredients that aren't listed on the label, such as prescription medicines.
The FDA banned Pai You Gou, a dietary supplement sold for weight loss, after detecting at least two banned pharmaceutical compounds, sibutramine and phenolphthalein, in this product. Dangerous stimulants are often found in widely available supplements for weight loss and muscle building. When one stimulant is banned, supplement makers often continue using the banned substances, or replace them with a related chemical. Half of supplements marketed as containing the herbal ingredient acacia rigidula were found to contain β-methylphenylethylamine (BMPEA), a stimulant that has not been assessed for safety or efficacy in humans.
Health Consequences
Diet pills may block the function of other drugs, including cancer treatments, and may also be associated with organ toxicity. Research suggests that the diet drug orlistat limits the function of a kind of protein, CES2, needed to activate a common cancer drug, PPD. Orlistat has also been associated with gastrointestinal issues, as well as liver toxicity. Diet pills may decrease users’ vitamin D levels, which is important for bone health, cell growth, and immune function.
Muscle-building supplements may lead to increased risk of testicular germ cancer in men. Many supplements whose labels say they contain “pro-hormones,” “natural steroids,” or “testosterone boosters” actually contain designer anabolic steroids-with dangerous consequences. Use of these compounds through dietary supplements is widespread and may be a common cause of liver injury, problems with bile secretion, testicular disorders, growth of breast tissue, and infertility in younger men.
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Ethical Considerations for Clinicians
Clinicians cannot ethically recommend over-the-counter weight loss supplements since the safety and efficacy of the actual ingredients are not known, as might be the entirety of the ingredients. Addressing weight loss supplement use with a patient can be tricky. On one hand, quick dismissal can be interpreted as judgmental. On the other, a patient who feels pressured by a friend to use a supplement might need a reason not to use that supplement. Finally, weight management discussions can be difficult if the health care practitioner is also overweight.
Alternatives to Nonprescription Weight Loss Products
Given the risks associated with nonprescription weight loss products, it is crucial to explore safer and more effective alternatives. The key to losing weight is a whole lifestyle approach that involves eating well and moving more.
Lifestyle Changes
There are a number of successful, evidence-based lifestyle approaches focused on diet quality, energy intake, physical activity, and behavior therapy that reduce weight and chronic disease risk factors. These programs typically include group or individual sessions for at least 6 months, are led by trained interventionists, and address diet, physical activity, and behavior modification. Lifestyle change can be difficult and requires time and support from family and friends. Research shows that social support is an important predictor of improved diet and increased physical activity. Successful weight loss maintainers report that, in addition to maintaining a healthy diet and physical activity, body weight monitoring is key to keeping off excess weight.
Clinicians should discuss the impact of excess weight on health with patients before a best weight loss approach is determined. There is no magic diet for weight loss. It is essential to provide culturally and individually appropriate support and guidance regarding weight loss.
Prescription Medications
With prescription medications, a healthcare professional can weigh all factors affecting the patient’s lifestyle and BMI and monitor progress and side effects. FDA-approved anti-obesity medications (AOMs) are safe, evidence-based therapies that target specific physiology to improve the disease and are most effective when used as part of a comprehensive treatment plan. All weight loss medications work best in the context of a healthy eating plan and exercise. Some weight management medications are designed for short-term use and others for long-term use. Those approved by the FDA for long-term use include orlistat (Xenical, Alli), phentermine-topiramate (Qsymia), naltrexone-bupropion (Contrave), liraglutide (Saxenda), semaglutide (Wegovy, Ozempic), and tirzepatide (Zepbound, Mounjaro).
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