Physician considers obesity a genetic disease



July 07, 1996|By Patricia Meisol

Physician considers obesity a genetic disease; Weight: Paul Rivas, a Lutherville internist, fights fat with drugs in low doses.

Slow is better when it comes to weight loss. And low is better when it comes to doses of drugs to help obese patients. So says diet doctor Paul Rivas, a Lutherville internist.

He is a different kind of diet doctor. He has written a book on his belief that being fat is determined by genetics rather than behavior.

That is a controversial position. Most doctors don't agree. There are no definitive studies on the issue. Rivas drew his conclusions based on interviews with his patients -- nearly all of whom have fat parents or relatives. Rather than a lack of self-discipline, he says, they have an illness akin to depression or alcoholism that requires lifelong treatment.

To him, obesity is the most common illness of all and the most serious, because it leads to other illnesses.

There's something else that makes him controversial -- he prescribes drugs before diet and exercise regimens. If obesity is genetic and involves a biochemical imbalance, he says, then it can be helped with drugs.

He prescribes two appetite suppressants, the controversial phentermine and fenfluramine, also known as phen-fen, like others in the new generation of diet doctor. These drugs regulate serotonin, the chemical in the brain that controls appetite. Some other doctors refuse to prescribe these drugs because of their potential side effects. In rare cases they have been linked to a fatal lung disease called primary pulmonary hypertension.

Rivas gives them out only in tiny doses. Instead of the standard dose of phentermine, he recommends half. Standard fenfluramine is between 60 and 120 milligrams. He starts with between 10 and 20 milligrams.

He tells patients about the potential side effects as well as the risks they face because of their weight -- hypertension, heart attacks, colon cancer, premature death, birth defects, etc. -- and asks them what they want to do. Not everyone goes forward.

And he doesn't push a restrictive diet, although, he says, "I have them eat a certain way. And I don't prescribe vigorous exercise."

The reason for the low doses and minimal change in lifestyle: "I'm not looking for short-term success. We are looking for long-term success. You have to be able to live with your diet. It has to be easy to do." Most people, he adds, can't live with restricted diet.

He has treated 5,000 people in the past four years and now has about 1,000 patients. A paper he published last year reported success for 2,000 patients; these drugs haven't been around long enough to know their effect over time. His fee is about $1,230, including drugs, the first year, and the price drops to $40 a month for those on long-term treatment.

Rivas, who finished his training in internal medicine at the University of Maryland in 1980, was medical director of a nursing home before he turned to obesity. He decided to specialize in weight loss, he said, because it seemed to be the biggest factor after smoking in many of the diseases he treated. It is summer, and the presidential election is fast approaching. The man in the White House is worrying about a woman with a big mouth. "Do I need to change your diapers?" he snaps at an underling. "I don't care what spin you put on this."

Perhaps some clarification is needed. The year is 1999, and the White House you have just entered exists only in the imagination of local artist Harvey Mercadoocasio, who is about to bring out his first creator-owned series, "Europa and the Pirate Twins."

The series follows the twins, Harry and Mississippi, through fTC treacherous Washington, where the president has been impeached and the vice president assassinated. The power-mad speaker of the House has seized the Oval Office, but he is threatened by Europa, a madam who knows many secrets. Careful readers may think they recognize such inside-the-Beltway archetypes as Ted Kennedy, Bob Dole and Newt Gingrich.

"The names have been changed to protect the guilty," says Mercadoocasio, from the Bolton Hill apartment that does triple duty for him and his publisher, Wendy Kowalski: home, studio and headquarters for their business, Powder Monkey Press.

The two, who met at a comic book convention, moved to Baltimore in 1995. Kowalski had worked on the business side of the comic book industry; Mercadoocasio, a former Marine, had illustrated various comics over the past 15 years. Involved in covert activities during his five-year stint, he plans to incorporate his continuing fascination with the CIA and NSA into the series.

But perhaps the most notable thing about "Europa and the Pirate Twins" is that Mercadoocasio's full name is visible on the cover. That's more than one can say for his discharge from the Marines, or his driver's license.

Powder Monkey Press was born when Mercadoocasio and Kowalski were snowbound during last January's blizzard; the name was inspired by the children who used to run gunpowder from the magazine to the guns on men-of-war. "Gunga Din was a powder monkey," explains Mercadoocasio, 33.

"Powder Monkey will put the spark back into comics," says Kowalski, 26.

But will Harry and Mississippi save the world? Will readers recognize figures inspired by Ted Kennedy, Bob Dole and Newt Gingrich? We'll have to wait until October, when the series debuts in local comic book stores.

Pub Date: 7/07/96

Laura Lippman

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