Buying Heroin La Marsa

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Buying Heroin La Marsa

First banned in this country more than a decade ago by federal regulators, the substance--best known as a party drug used on the rave scene--remains popular with fitness buffs, insomniacs and the depressed, who buy it on the Internet and from underground sources. Now medical experts report another troubling problem: GHB is highly addictive and can be more difficult to kick than heroin. But unlike opiate addiction, most doctors are unaware of the stranglehold that GHB has on users. Consequently, medical treatment is often ineffective. GHB, which severely depresses the nervous system, has sent more people to emergency rooms than a more highly publicized club drug, Ecstasy--about 12, at last count--and has been blamed for 71 GHB-related deaths since , according to federal statistics. Stephen W. Smith, an emergency room doctor at Hennepin County Medical Center in Minneapolis who has treated about 50 patients for GHB addiction problems since No one knows exactly how many Americans are addicted to GHB, or gamma hydroxy butyrate, because the federal government did not begin monitoring GHB abuse until after the drug was declared illegal in March No statistics have yet been released. Consequently, GHB use often goes undetected. Trinka Porrata, a retired Los Angeles Police Department narcotics detective who has investigated GHB for more than five years, believes that the statistics on emergency room visits and deaths linked to GHB understate the problem. Most GHB abusers are not street junkies looking for a new high, however. Typically, they are people who have turned to the drug, which is promoted as a natural, nutritional supplement, to build buff bodies, lose weight or to fight insomnia, premenstrual pain and depression. Some professional athletes have used the substance--usually sold as a salty-tasting liquid--to improve performance. Phoenix Suns basketball player Tom Gugliotta, for instance, nearly died in after ingesting a GHB supplement to help him sleep. Some users know the drug is illegal and buy bootleg brews over the Internet or from the back rooms of health food emporiums. Others stumble across ads on the Internet and purchase what they believe is a natural remedy to beat the blues or get in shape. In higher doses, however, anecdotal reports indicate it seriously depresses the central nervous system. Even a small increase in the dosage can push the sedative effects to a lethal level, causing unconsciousness, slowed heart rate, respiratory depression and coma, doctors say. What happened to me? Tony Young, 39, of Seattle, saw an ad in a bodybuilding magazine for a product touted as an all-natural supplement that would help boost muscle mass. The supplement, whose active ingredient is a form of GHB, made him feel more relaxed and improved his sleep. He knew he was hooked. He sipped capfuls of GHB virtually around the clock. He tried drug rehabilitation twice but relapsed both times because he felt swallowed up in a depression when he stopped taking GHB. He was arrested several times for driving under the influence, and he crashed two cars, including one belonging to his employer, which cost him his job as an elevator mechanic supervisor. About a year ago, Young, a husband and a father of two young boys, was sent to jail after a DUI conviction. Despite the federal ban, GHB and its various chemical cousins, including GBL gamma butyrolactone and BD 1,4 butenediol , remain popular at gyms frequented by serious bodybuilders. It is passed around weight rooms, sold out of cars in parking lots and dispensed from behind juice-bar counters, according to those familiar with its sale and use. Promoters of the drug contend that it helps to release growth hormones, boosting muscle mass and trimming fat. GHB was first developed in the s as an anesthetic, but research was discontinued when high doses in animals caused grand mal seizures, says Dr. Wallace D. In the s, GHB was sold in health food stores as a sleep aid and nonsteroidal performance enhancer for bodybuilders. In , however, the Food and Drug Administration yanked GHB from the market after the agency received dozens of reports of adverse affects, ranging from nausea and vomiting to seizures, comas and death. Supplement manufacturers circumvented the federal ban by developing chemically similar products. When people consumed these products, which had legal uses as industrial solvents or cleaners, the body metabolized them and converted them into GHB. Thus, the products had the same effects as those of GHB. In March , federal regulators stepped in again to close a legal loophole and extended the ban to include chemical analogues of GHB. And while the manufacture and sale of GHB and similar compounds is against the law, the drug easily can be made with two legal ingredients: gamma butyl lactone, an industrial solvent used for degreasing engines and as a floor stripper, and sodium hydroxide, or lye. Recipes for making bootleg GHB are available over the Internet, and the street version is potentially hazardous because of uncertain quality control in underground labs, according to the National Institute on Drug Abuse. Alex Stalcup, an addiction specialist in Concord, Calif. Several recovering GHB addicts said in interviews that they initially felt great when they started taking the drug. They said they would take a capful at night and wake up feeling refreshed and energized after four or five hours of sleep. But these people, who asked not to be identified, said that their GHB use eventually became more frequent and that they needed more of the drug to produce the same feeling. Addiction experts said that withdrawal from GHB is worse than kicking cocaine. Typical symptoms include insomnia, nausea, vomiting, tremors and seizures. Some sweat profusely and ooze a waxy, oily liquid from their hands or soles of their feet. Unlike drugs or alcohol, which can be detoxified from the body within a few days, the acute phase of GHB withdrawal lasts up to two weeks, addiction specialists say. Delirium, disorientation and hallucinations can sometimes last for days. Some patients are in such a state of agitation that they are sedated with drugs or must be placed in restraints. Patti Trovato-Ragano says her son, Matthew Coda, might still be alive if he had received adequate medical care after he became addicted to GHB in the early s. Coda became addicted to GHB in after years of taking what he initially believed to be natural, herbal supplements to help him get fit. At the height of his addiction, he was rushed to the emergency room in a coma 18 times in two years. In August , Coda, then 26, entered a detoxification program. But a week later, he was back on the street, even though he was still suffering from serious withdrawal symptoms. Apparently, in his quest for relief, Coda accidentally overdosed on other drugs. On Sept. De Los. Times Everywhere. For Subscribers. All Sections. About Us. B2B Publishing. Hot Property. Times Events. Times Store. Special Supplements. Share via Close extra sharing options.

Ethical issues in the pharmaceutical industry: an analysis of US newspapers

Buying Heroin La Marsa

Official websites use. Share sensitive information only on official, secure websites. Corresponding author. Frances R. Rates of pediatric obesity have increased dramatically over the past decade. This trend is particularly alarming as obesity is associated with significant medical and psychosocial consequences. Obesity may contribute to cardiovascular, metabolic, and hepatic complications, as well as psychiatric difficulties. The development of obesity appears to be influenced by a complex array of genetic, metabolic, and neural frameworks, as well as behavior, eating habits, and physical activity. Numerous parallels exist between obesity and addictive behaviors, including genetic predisposition, personality, environmental risk factors, and common neurobiological pathways in the brain. Treatments focusing on diet and exercise have yielded mixed results, and typically have been examined in specialty clinic populations, limiting their generalizability. There are limited medication options for overweight children and adolescents, and no approved medical intervention in children younger than Bariatric surgery may be an option for some adolescents, but due to the risks of surgery it is often seen as a last resort. The parallels between addiction and obesity aid in the development of novel interventions for pediatric obesity. Motivational enhancement and cognitive-behavioral strategies used in addiction treatment may serve to be beneficial. Alarmingly, routine screening for obesity in children is very low 0. The current article will review some of the correlates of obesity, examine parallels with addictive behaviors, and review treatment recommendations. Overweight is a condition where one has excess adipose tissue 6. Low SES likewise contributes to being overweight by limiting purchase of high quality healthy foods and opportunity for exercise Finally, children born to overweight parents are at higher risk for obesity 11 , 12 perpetuating a cycle of obesity. Being overweight during childhood and adolescence is associated with a myriad of concurrent medical and psychosocial consequences, as well as placing children and teens at higher risk for medical comorbidity and mortality as adults. One of the most widely documented health consequences of overweight is a metabolic syndrome that includes insulin resistance, type 2 diabetes mellitus, polycystic ovary syndrome, dyslipidemia, and hypertension This syndrome has been documented in children and adolescents and associated with increased risk for developing cardiovascular disease CVD in adulthood 14 , In a large, nationally representative sample of American adolescents, metabolic syndrome was present in 6. Regarding insulin resistance, overweight is the most common cause of insulin resistancein children 17 and the strongest predictor of insulin resistance in young adulthood In addition to linking overweight with a metabolic syndrome, there is a literature associating overweight in children and adolescents with the unique aspects and consequences of the metabolic syndrome. For example, there is a strong association between childhood overweight and type 2 diabetes CDC 8 , 9 , CDC 20 , 21 - Being overweight is a significant risk factor for developing type 2 diabetes in childhood, perhaps through the mechanism of impaired glucose tolerance 2 , 14 , 15 , Similar to type 2 diabetes, polycystic ovarian syndrome 27 and dyslipidemia 28 have been associated with overweight in adolescents. Also, overweight in adolescence predicts the development of CVD in young adulthood 29 - In children and adolescents, overweight has been shown to increase the chances of hypertension In a large epidemiological study of 47, teens, there was an increased incidence of hypertension in obese children with a rate of once BMI exceeded 38 Another large study reviewed primary care charts for 18, children and adolescents aged years and found that increased BMI was significantly associated with increased blood pressure, regardless of age Besides the medical consequences related to metabolic syndrome, overweight in children and adolescents is associated with other serious conditions such as non-alcoholic fatty liver disease NAFLD; 35 - 38 , obstructive sleep apnea 39 , and orthopedic problems including joint pain, impaired mobility, fractures, etc. Obstructive sleep apnea also is more common among overweight children and adolescents In sum, overweight is associated with numerous health consequences in childhood and adolescence. In addition to a myriad of health problems, obesity also may negatively impact psychiatric and behavioral functioning. While the prevalence of psychiatric disorders among obese youth other than eating disorders is not well documented 44 , they have more behavioral and self-esteem problems compared to non-obese children. Longer-term complications of overweight include the development of psychosocial and psychological problems such as depression and low self-esteem in adulthood Similarly, a recent year prospective study demonstrated an association between obesity in youth and atypical depression and aggression in adulthood Although little is known about this subgroup, obese adults with BED are significantly different from those without in that they exhibit more eating disorder pathology e. Regarding comorbid substance use disorders, studies have shown that adolescents who binge eat are at increased risk for substance abuse and have more first-degree relatives with addictive disorders 53 - Obesity is a complex disorder influenced by genetics, metabolism, neural frameworks as well as behavior, food habits and physical activity. Approximately genes, gene markers and chromosomal regions are associated with obesity In addition to leptin, the neurotransmitter neuropeptide Y NPY and hormone ghrelin are involved in weight regulation. The hypothalamus contains key pathways for weight regulation and houses high concentrations of both Leptin and NPY. Higher levels of NPY activity have been found in the hypothalamus of obese rodents. Leptin, which is secreted mainly by adipose tissue, acts directly on the brain, is higher in obese than in lean individuals, and decreases during weight and fat loss Ghrelin is a recently discovered peripheral peptide hormone produced mainly by the stomach and stimulates food intake Administration of ghrelin increases food intake in animals 58 and humans Ghrelin acts primarily on the hypothalamus 60 , possibly via vagal receptors Ghrelin rises following weight loss in obese subjects The lower fasting levels in obesity and obese binge eaters 64 suggest that ghrelin is down-regulated in response to overeating or excess body weight 62 , Ghrelin, however, is elevated in Prader-Willi syndrome PWS , which is associated with severe obesity Functional neuroimaging likewise supports a neurobiological explanation for obesity In one study 68 , brain activity changes following glucose ingestion were compared in non-obese and obese individuals. In normal weight subjects, brain activity changed in approximately 9 minutes; there were significant reductions in hypothalamic activity after glucose ingestion and these reductions were correlated with increased plasma insulin levels. In obese subjects, these changes were significantly delayed and plasma insulin levels failed to correlate with decreases in hypothalamic activity This response could translate into a delayed awareness of satiety, leading to overeating and obesity 69 - Level of physical activity consistently has been demonstrated as being inversely related to weight Individuals who are inactive are at increased risk for obesity, with exercise being the single strongest predictor of long-term maintenance of weight loss Unfortunately, the popularity of sedentary activities such as TV watching and playing video games may have contributed to the increasing prevalence of childhood obesity Numerous parallels between overeating and addiction have been demonstrated 77 - Obesity and addiction share similar patterns of transmission, including genetic predisposition, environmental risk factors, and common neurobiological pathways in the brain. Understanding these parallels may be helpful in preventing and treating the growing obesity epidemic. However, genetic influence on the vulnerability to both obesity and addiction is complex, involving both environmental and cultural influences, and may be polygenetic Regarding environmental influences, both obesity and addiction have increased when food and drug have been cheap and available. The recent increase in obesity may coincide with increased prevalence of low-cost, high-fat, high-carbohydrate food and significantly larger portion sizes, similar to the recent addiction problems with crack cocaine and crystal methamphetamine as they became less costly and more available Findings from functional brain imaging studies have shown that the inability to control eating produces changes in neural activity similar to those produced by substance use 70 , The hypothalamus helps maintain energy homeostasis and alterations in hypothalamic activity could result in delayed awareness of satiety, leading to obesity. In addition, chemical neuromediators such as leptin, ghrelin, melanocortin agonists, neuropeptide Y and opioids have been implicated in alcoholism and other drug dependencies as well as in obesity Positron emission tomography PET scans have shown that there is a reduction in striatal dopamine D2 receptor availability in pathologically obese subjects similar to what has been observed in drug-addicted subjects 55 , 84 , With the anticipation and ingestion of food, there is an increase in the extracellular level of dopamine in the nucleus accumbens, as there is with other substances of abuse. In order to compensate for deficiencies in the dopaminergic system, individuals will engage in behaviors that increase brain dopamine levels, namely ingestion of more food or other substances that increase dopamine. This would then stimulate the mesocorticolimbic circuits of the brain, which are involved in behavioral reward and reinforcement Appetitive drive and drug craving are hypothesized to share overlapping and interactive pathways Several sites in the hypothalamus are involved in regulation of food intake and energy expenditure This circuitry that regulates appetite is under feedback control of hormonal signals, anorexigenic leptin from white adipose tissue and orexigenic ghrelin from the stomach. Studies in rodents have revealed that drugs of abuse share one or more components of the same hypothalamic circuits that affect appetite. Similar pathways may be involved with appetitive drive in response to decreased energy stores in the body as in drug craving during withdrawal in humans More specifically, some brain signaling proteins that mediate excessive eating and weight gain may also mediate uncontrolled alcohol drinking Both melanocortin agonists and neuropeptide Y NPY have been extensively studied and are prime targets that could link alcoholism and obesity. Melanocortin MC agonists, known to inhibit food intake and cause reduction of body weight in animal models, may also be involved in alcohol consumption Studies with melanotan-II MT II , a non-selective MC agonist that mimics the effects of melanocortins at specific cellular receptors, have shown to decrease both voluntary alcohol drinking and food intake in mice that habitually drank large amounts of alcohol 91 , Neuropeptide Y is a signaling protein that stimulates feeding, interacts with the satiety hormone leptin, and appears to be an important regulator of alcohol intake In one study, mice lacking one receptor subtype for neuropeptide Y drank significantly more alcohol than normal mice It has also been hypothesized that NPY is involved in mediating the anxiety that occurs during the alcohol withdrawal syndrome Other peptides such as corticotropin releasing factor and cholecystokinin CCK have been associated with reductions of food intake, while others such as galanin and ghrelin found to stimulate feeding Current research is directed at determining if these peptides regulate voluntary ethanol intake as well, since both food and ethanol intake are consummatory behaviors and have rewarding properties. Leptin is another well-studied peptide hormone that may be a shared physiologic substrate of alcohol and food intake Leptin, which has been implicated in the regulation of appetite and expenditure of energy, is also associated with increased craving for ethanol. Plasma levels of leptin have a positive correlation with lifetime alcohol use in male alcoholics 96 , In addition, recent research indicates that leptin may act through cross-talk with the endogenous cannabinoid system in the hypothalamus, which in turn regulates energy homeostasis, fluid balance, and stress response Endogenous cannabinoid receptors in the brain act primarily to modulate other neurotransmitter systems, including aminos acids e. Decreased levels of leptin may lead to increased endocannabinoid activity in the hypothalamus, which may lead to increased eating behavior , Further, behavioral studies indicate that endocannabinoids may increase motivation to eat see for review. Development of an endocannabinoid receptor antagonist has shown efficacy for weight loss and related cardiovascular health problems compared to placebo in several large phase III clinical trials of overweight adults but no research has examined this in children or adolescents. It has been proposed that opioid neurotransmission and stimulation of the mu opiate receptors within the nucleus accumbens and ventral stratum induce a marked increase in food intake, sucrose, salt and ethanol intake The nucleus accumbens and its circuitry are postulated to subserve motivated behaviors, such as feeding, drinking, sexual behavior, and incentive learning - This system has been frequently implicated in drug addiction - In both conditions, researchers have demonstrated elevated levels of trait impulsivity, defined as novelty and sensation seeking Studies of reward sensitivity have shown that, just as alcohol abusers demonstrate more sensitivity to the reinforcing effects of alcohol, adolescent girls who engage in binge eating shown greater sensitivity to the rewarding qualities of food when compared to girls who restrict food intake Research using this same gambling task with substance abusers shows similar impairments in judgment It is hypothesized that individuals who show poor decision-making skills will be more likely to engage in behaviors that provide immediate reward and show a disregard for future consequences of behaviors While the construct of impulsivity has been explored and established in both addiction and obesity, the distinction between compulsive versus impulsive behaviors regarding obesity and addiction has not been fully explored. Some researchers have proposed a unidimensional continuum with compulsivity and impulsivity at opposite ends as a way to help characterize psychiatric disorders , Other researchers conceptualize impulsivity and compulsivity as two separate and distinct, but often co-existing, traits - Supporting this conceptualization is the high comorbidity for obsessive-compulsive and impulse-control disorders , Eating disorders are an example of this comorbidity, as patients with BN and binge eating disorders may exhibit both obsessive-compulsive and impulsive traits , - However, findings regarding correlates of compulsivity and impulsivity in this population are mixed. For example, Engel and colleagues were able to classify their sample of females with BN into 4 groups based on high versus low scores on compulsivity and impulsivity. They found high impulsivity was related to substance abuse severity, regardless of level of compulsivity. Conversely, compulsivity was associated with more severe eating disorder behavior and depression In contrast, Favaro and colleagues reported that, in a sample of patients with eating disorders, impulsivity was associated with higher levels of eating disordered behavior and psychiatric symptoms including depression. Neurobiological studies support the notion that impulsivity and compulsivity are a uni-dimensional construct in patients with BN. For example, the link between lower serotenergic activity has been associated with impulsivity , as well as compulsivity , However, it is unlikely that serotonin is the sole neurobiological pathway through with compulsivity and impulsivity function. For example, dopamine also may play a role, as treatment with a dopamine agonist increases the risk of developing an impulse control disorder gambling, shopping, sexual behavior in patients with Parkinson disease The clarification of compulsivity versus impulsivity is not well defined in the substance abuse literature. A key diagnostic symptom of drug or alcohol addiction is compulsive drug use, including losing control of use despite negative consequences of using Volkow and Fowler outline a model of addiction that defines addiction as compulsive behavior. However, while addiction is commonly diagnosed and recognized as a problem with compulsivity, impulsivity is often the trait that is associated with addiction in humans. For example, there is a large literature establishing that impulsivity predicts current and future substance use problems of all types , - Interestingly, there is very little exploration in the literature of compulsivity versus impulsivity and how they relate to type of substance use or patterns of substance use. Regardless of this lack of exploration, there is ample evidence to demonstrate shared neurobiologic and psychosocial commonalities associated with both food and drug reward. This overlap supports the notion that over eating the behavior that leads to obesity and overweight may respond to the same type of interventions that have demonstrated effectiveness in the treatment of substance abuse. Despite these recommendations, there have been few large randomized clinical trials targeting pediatric obesity Furthermore, most of the research conducted has been in specialty obesity clinics with treatment-seekers , limiting the generalizability of findings. Less research has been conducted examining medical treatments for obesity, including medication and surgical intervention. In a recent review, Stuart et al. Initially, the authors intended to conduct a meta-analysis. However, similar to the conclusions reached by Summerbell et al. A total of studies were identified and reviewed but most did not include a comparison or control group, included participants younger or older than the inclusion criteria or were not interventions for weight loss. The studies ranged from 12 to 20 weeks. They concluded that the research showed a positive effects for multi-component, family-based programs in school-aged children years old , and a positive effect for multi-component, school-based programs for adolescents. Varying success has been found for diet regimens, such as the Stoplight Diet, the diabetic exchange system, and individual diet plans Overall, comprehensive approaches that focus on eating behaviors as well as physical activity are more effective than either waitlist or nutrition education control groups 6 , However, in a study combining nutrition education with cognitive behavioral counseling, Kirschenbaum and colleagues reported significant decreases in weight and percent body fat in year olds up to a year follow-up. Few studies have assessed the impact of dietary modifications alone and those few have reported mixed findings, making the unique contribution of diet above and beyond the other components of treatment , difficult to establish. The unique contribution of diet was examined in 2 studies by Epstein and colleagues , , but the results were inconsistent. In the first study, dietary counseling plus increased daily activity was compared to dietary counseling alone for 6 months. Both treatment groups demonstrated significant weight loss and reduction in percent body fat at discharge and 6 month follow-up, though there were no differences between the 2 conditions. In contrast, a subsequent study showed that dietary counseling plus structured exercise resulted in a significantly greater weight loss and reduction in percent body fat than dietary counseling alone Epstein et al. Exercise also may contribute to weight loss in children and adolescents 6 , - Of 24 studies reviewed by the ADA 6 , only 1 failed to demonstrate significant benefits from adding an exercise or increased activity component to the treatment. One study comparing exercise plus diet and behavior modification and exercise alone to a control group found that both treatment groups showed significant weight loss and reduction in percent body fat compared to the control group, though no differences were found between treatment groups Regarding sedentary behavior, a 4-month plus 1-year follow-up study by Epstein and colleagues , demonstrated that reducing sedentary behavior television watching was superior to increasing physical activity in helping children maintain weight loss. In addition, three primary prevention studies targeting decreased television watching resulted in decreases in BMI - The extent of parental involvement in treatment has varied across studies and findings have been mixed. Family-based interventions are those that target the behavior of multiple family members usually parents and children; Kitman and Beech reviewed 31 family-based interventions and concluded that family-based interventions were effective at reducing weight and percent body fat in children and adolescents, relative to controls. In addition, parental weight loss was related to child weight loss in two studies , Kitzman and Beech also caution that most families that are able to engage in family-based interventions are likely to be more motivated to change and have the resources to attend regularly scheduled appointments for a lengthy period of time. Indeed, higher family support have been associated with greater child weight loss, while higher levels of family conflict have been associated with decreased retention in treatment In addition, Kitman and Beech point out that family-based interventions may need to be tailored for ethnic or racial minority families, as well. They cite differential effects for similar family-based treatments in a sample of White adolescent females , compared with African American adolescent females of comparable SES; in White families, treatment groups in which mother and daughter remained separate lost significant more weight than those where they were together , whereas the reverse was true in African American families Support for long-term weight loss is less clear, with some family-based interventions demonstrating weight loss maintenance as far out as 5 and 10 year follow-ups , , - , and other studies not ; DISC Writing Group, ; In addition, a meta-analysis of 41 family-based interventions showed that parental participation in treatment did not increase the effectiveness of multi-component interventions in overweight children and adolescents Not surprisingly, most of the interventions that have been assessed in a controlled fashion were delivered in specialty clinics, thus limiting treatment the generalizability for teen minorities of low SES, who are disproportionately affected by obesity. Several studies have addressed this issue by delivering treatment in settings that teens frequent. For example, several studies have shown that teen weight loss interventions can be feasibly delivered within school settings, though the impact of these programs on weight loss for children and teens is mixed , , - In addition, it may not be feasible for many schools to continue offer these interventions due to the high cost of hiring specialized instructors from the community or training current physical education instructors in these interventions. Additionally, many of these interventions take place at least partly within designated physical education periods. Given the significant decreases in time and funding allocated to physical education in public schools, it is unlikely that these limited resources will be used to support a specialized program for a relatively small portion of students. It also is important to note that there exists potential for stigmatization of overweight youth who participate in school-based interventions, as they are singled-out for special treatment due to their weight 6. Results for incorporating problem-solving strategies into treatment are promising, but few. One study demonstrated that the addition of problem-solving to a family-based, multi-component intervention for year olds significantly enhanced weight loss and maintenance at 3 and 6 month follow-up These findings suggest that problem-solving may have long-term benefits, but have only shown efficacy when parents are included in the intervention. Initially developed for treatment with alcohol abusers, MI has been shown to be effective in addressing drug abuse, smoking, HIV risk, eating disorders, Type II Diabetes, and obesity in adults , However, few studies using MI have focused specifically on weight loss, and none have done so for youth. Motivational interventions have been shown to be effective in reducing cigarette smoking , alcohol use , and cannabis use in teens Given that teens are difficult to retain in treatment, MI may be effective at engaging them and reducing drop out. In addition, using an MI platform may allow us to increase the potency of the traditional CBT techniques. Such results highlight the ability of MI to deliver therapeutic effects in a time limited and cost efficient manner, as this treatment is equally powerful to other longer, traditional treatment approaches. Computer-delivered interventions have been shown to be as effective as therapist-delivered interventions - These interventions can be used repeatedly, with the majority of costs going towards a one-time purchase of hardware or software; in contrast, clinician-delivered interventions have a fixed cost per use, with additional costs associated with therapist training, etc. Such programs may be less threatening to teens and also may be viewed as providing greater anonymity, particularly important among teens when sensitive issues are addressed. Furthermore, computer-based interventions can be modified to accommodate new information as it becomes available. Finally, computer-based interventions may allow patients to engage in educational activities and interventions for a greater period of time than would be possible with an educator or counselor alone In sum, a computer driven intervention is sparing of both money and staff time, and is an individual intervention on a platform with a natural appeal to teenagers. Despite these obvious advantages, few technology interventions have addressed behavioral health problems in youth, including overeating and sedentary behavior. In addition, three clinical trials have examined technology to promote weight loss in teens. The first employed the internet to teach CBT techniques and provide education to overweight African-American adolescent females and their parents. Investigators found that teens in the CBT group accessed the website more frequently and lost more weight than teens randomized to an education only condition However, each teen was provided with a personal computer and internet access for the duration of the study, greatly limiting the feasibility of the treatment in real world settings. The intervention was primarily video-based, with personalized feedback provided via e-mail and on on-line workbook. Sessions were completed during a computer class at school. For teens who completed at least 4 of 8 sessions, the intervention was effective in increasing activity, decreasing dietary fat intake, and enhancing motivation to change Unfortunately, no measures of weight or percent body fat were completed on these teens, so it is unclear whether these changes translate to decreased obesity in the sample. While the evidence for technology interventions to promote weight loss in teens is promising, the few existing studies have significant limitations including lack of real-world feasibility and lack of assessment of obesity. Aside from behavioral treatments, options for youth are limited. Currently, no weight loss medications have been approved by the Food and Drug Administration for use in children under the age of 16 , although several studies have employed medications previously shown to be efficacious in overweight adults. In addition, although no studies of gastric bypass surgery have been conducted in adolescents, reviews of the database of bariatric surgeries performed on adolescents over the past 20 years suggest outcomes similar to those found for adults , To date, few drugs have been approved by the Food and Drug Administration to treat obesity in adults and the 2 most widely used in clinical practice are sibutramine and orlistat In addition, a recent Cochran review noted that the only two medications with adequately controlled trials to support their efficacy thus far were sibutramine and orlistat. While no weight loss medications have been approved by the FDA for use in children under the age of 16 , several studies employing medications efficacious in overweight adults have also shown promise for use in adolescents. The research examining the impact of medication on weight loss in overweight children is minimal Sibutramine is an appetite suppressant that functions by inhibiting the reuptake of noradrenaline and serotonin , Sibutramine contribute to significant weight loss within the first 6 months and effects have been documented as far out as 2 years , Sibutramine also shows promise for decreasing related cardiovascular risk factors and improving glucose control in adults with Type II diabetes , Unfortunately, because sibutramine may increase heart rate and blood pressure, its use is contraindicated for patients with some medical co-morbidities of obesity — uncontrolled hypertension, cardiac dysrhythmias, congestive heart failure, and stroke Orlistat reduces the amount of fat absorbed during digestiion by inhibiting gastric and pancreatic carboxylester lipases, reducing the hydrolysis of the digested triglycerides Orlistat has been shown to contribute to significant weight loss and decreases weight regain at 2-year follow-up In addition, like sibutramine, it has been shown to help decrease high cholesterol and blood pressure , The most common side effects of Orlistat are related to fat malabsorption and include loose stools, fecal urgency, and fat soluble vitamin deficiencies Two well-controlled placebo-controlled double-blind studies have shown promise for sibutramine in overweight adolescents. The first study of 82 adolescents receiving behavior therapy plus sibutramine versus placebo showed a significantly greater reduction in percent weight loss for the sibutramine group In addition, the adolescent participants in the study did not demonstrate the other medical gains found in adults; no differences were found between the groups on cholesterol, triglycerides, serum insulin, glucose, or insulin sensitivity A more recent study of 60 adolescents demonstrated significantly greater weight loss in the sibutramine group versus placebo, with no adverse effects reported Reisler and colleagues examined sibutramine as an adjuvant to diet and exercise in a sample of 20 adolescent females with morbid obesity. Most patients showed early weight loss at 3 and 6 months , but stopped losing weight in the following 6 months. During the follow-up period, 17 patients discontinued treatment, primarily due to the slow in weight loss in the second 6 months of treatment. A recent, large, multicenter trial examined sibutramine versus placebo in obese adolescents, years old, enrolled in a behavior therapy program Adolescents treated with sibutramine showed significant decreases in BMI at month 12, compared to those treated with placebo. Unfortunately, all of the trials conducted thus far have been of limited duration that has not allowed for the examination of long-term weight maintenance or health effects. In addition, three of four trials demonstrated poor feasibility for maintaining adolescents on the medication long-term. Finally, the few extant medication trials have examined only adolescents; none have looked at safety or efficacy in overweight children. Several studies support the use of orlistat to significant reduce weight in overweight children Norgren et al. Unfortunately, these studies only examined outcomes as far out as 6 months. It is important to note that orlistat reduces the absorption of fat-soluble vitamins e. Metformin may be another medication that holds promise for teens. Metformin is a hypoglycemic agent used commonly in the treatment of type 2 diabetes in adults. Metformin has demonstrated effectiveness in treating many of the medical problems associated with obesity in pediatric populations, including diabetes and insulin resistance , , polycystic ovary disease - , and fatty liver disease Four randomized, controlled trials in overweight adolescents indicate that metformin contributed to signficiant reductions in BMI and improvement in related medical problems, including serum glucose, insulin and lipid profile up to 6 months , - Unfortunately, poor adherence was reported in several of the trials. Bariatric surgery may be a treatment option for some adolescents with morbid obesity or overweight adolescents with weight-related medical problems , , AAP In addition, gastric bypass is often performed using minimally invasive laparoscopic techniques Although few controlled trials of gastric bypass surgery have been conducted in adolescents, reviews of the literature on overweight adolescents suggest outcomes similar to those found for adults , , However, the disadvantages of gastric bypass surgery include potential deficiencies of iron, calcium, and B vitamins as well as a 0. Given the post-surgical risks, bariatric surgery for overweight adolescents should be considered carefully. Inge recommends that adolescents should be evaluated by an experienced, multidisciplinary bariatric team who are able to provide long-term follow-up. He recommends that teams include specialists in pediatric psychology, nutrition, exercise, and bariatric surgery, as well as adolescent medicine, endocrinology, pulmonology, and gastroenterology. Over the past several decades, pediatric overweight has emerged as a major public health concern Being overweight is associated with a host of medical, behavioral health, and psychological problems and is more prevalent among economically disadvantaged and minority children and adolescents. While these demographics suggest the need for community outreach in settings frequented by low SES and minority youth, most treatment occurs within the confines of specialty clinics that are inaccessible to those who need them most. Given the need to reach a larger portion of overweight children and adolescents, we recommend that services be provided in more accessible settings. Current reviews of the literature show that multi-component treatments are effective for overweight children and adolescents. Effective components of treatment generally include dietary counseling, increasing physical activity, decreasing sedentary behavior. Unfortunately, multi-component interventions are lengthy, expensive, and require extensive physician time and expertise making implementation in many settings impractical. Providing concrete, realistic strategies to parents and their children may be beneficial. For example, Kirk and colleagues suggest helping children and teens modify their diet by limiting the availability, frequency, and amount of high-fat or high-sugar foods and drinks consumed; helping children and teens to eat smaller portions at regularly scheduled times, limiting seconds to fresh fruits and non starchy vegetables, drinking more water and sugar-free beverages, and choosing food that has been baked, broiled, grilled or boiled instead of fried. They also recommend between minutes of physical activity, which may be more easily achieved if the activity is fun, noncompetitive, and part of their daily routine. In addition, decreasing sedentary activities, like TV watching or video game playing may be helpful. In addition, there is strong evidence to suggest that parental involvement is important in helping overweight children and teens lose weight. Because of this, it may be important to engage parents and provide education and support about using these strategies to change the dietary and activity habits of the entire family. The parallels between obesity and addiction also may provide guidance in effective treatments. For example, employing motivational strategies to engage children and families in treatment may be helpful. Similarly, cognitive-behavioral therapy techniques that teach children and families to identify the triggers to their bad eating habits may help them to problem-solve ways to eat healthier or exercise. In addition to behavioral intervention, there is evidence that medication may serve as a helpful adjuvant to treatment for overweight children and adolescents. If medication is used, it is important to inform parents and children about potential side effects and monitor children and adolescents closely. Gastric bypass surgery also may be an option for morbidly obese adolescents or for adolescents with weight-related medical problems. When considering surgical intervention, it is important to consider the risks and adolescents should be carefully screened and evaluated by an experienced, multi-disciplinary team before proceeding. As a library, NLM provides access to scientific literature. Harv Rev Psychiatry. Published in final edited form as: Harv Rev Psychiatry. Find articles by Michelle C Acosta. Find articles by Jeanne Manubay. Find articles by Frances R Levin. PMC Copyright notice. The publisher's version of this article is available at Harv Rev Psychiatry. Similar articles. 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