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Belviq, Qsymia: New weight loss drugs compared

Two new prescription weight loss drugs, Belviq and Qsymia, now have the FDA's blessing. Which, if either, is for you?

Both drugs help some people lose weight. Neither drug is for everyone. Yet the two drugs are quite different.

Here's WebMD's FAQ comparing Qsymia to Belviq.

How do you pronounce Qsymia? Belviq?

Vivus Pharmaceuticals says you should pronounce Qsymia this way: kyoo-sim-EE-uh. (The company's preferred name was Qnexa, but that was nixed by FDA as sounding too much like other drugs.)

Arena Pharmaceuticals says you should pronounce Belviq this way: BEL-VEEK.

When will Belviq and Qsymia be available?

Vivus says Qsymia should be available "in the fourth quarter of 2012," which begins in September. But don't look for it in your local pharmacy. Because women taking Qsymia must use birth control (see below) the drug will be sold only through "certified pharmacies." These are likely to be major online pharmacies.

Because Belviq has a potential for abuse (see below), the U.S. Drug Enforcement Administration must rule on how to schedule the drug. That process probably began no later than last May. As this usually takes four to six months, Belviq should become available by early 2013. A quicker DEA ruling may speed the drug's arrival.

Why, after not approving any long-term weight-loss drug for 13 years, did the FDA approve two weight loss drugs in one month?

Until relatively recently, most medical researchers considered weight loss drugs to be vanity products. The benefit -- looking better -- was not considered worth very large risks. And early weight loss drugs such as fen-phen carried very large risks, indeed.

Researchers now realize that obesity itself is a disease. Obesity greatly increases all kinds of other serious medical risks, from diabetes to heart disease to depression.

Even though both Qsymia and Belviq carry risks, FDA advisory panels thought long and hard about recommending approval. But the panels were swayed by what most members saw as the much greater risk of untreated obesity.

Do Qsymia and Belviq work the same way?

No. Qsymia and Belviq are very different drugs.

Qsymia combines two currently approved drugs. One is the appetite suppressant phentermine, the safer "phen" part of the infamously unsafe fen-phen diet drug combo.

Phentermine is thought to suppress appetite by triggering release of the brain chemical norepinephrine. This suppresses the appetite by increasing blood concentrations of the appetite-regulating hormone leptin.

The other half of Qsymia is the seizure/migraine drug topiramate. Topiramate causes weight loss in several ways, including increasing feelings of fullness, making foods taste less appealing, and increasing calorie burning.

Belviq causes weight loss by turning on a specific switch that increases levels of the brain messenger serotonin. At dosages intended for weight loss, it does not significantly turn on slightly different serotonin switches responsible for the effects of hallucinogens (such as LSD) and addictive drugs of abuse. Higher doses may trigger these switches, which is why the DEA likely will schedule Belviq as a controlled substance.

Who should and shouldn't take Belviq? Who should and shouldn't take Qsymia?

Belviq and Qsymia are approved for similar problems:

Pregnant women should not take either Belviq or Qsymia.

Qsymia has particular risks for pregnancy, as it can cause birth defects if taken in the first months of pregnancy, even before a woman knows she is pregnant. Women of childbearing age must use effective birth control to keep from becoming pregnant while taking Qsymia.

Qsymia should not be taken by:

  • Pregnant women
  • People with glaucoma
  • People who have been told they have an overactive thyroid
  • People taking a type of antidepressant called a MAOI
  • People allergic to phentermine or topiramate

Belviq should not be taken by:

  • Pregnant or nursing women
  • People taking drugs linked to valvular heart disease, such as cabergoline (Dostinex)

Belviq should be taken with caution by:

  • People taking certain medicines for depression; migraine; the common cold; or mood, anxiety, psychotic, or thought disorders
  • Men with conditions that predispose them to erections lasting more than four hours. These conditions include sickle cell anemia, multiple myeloma, and leukemia
  • Men with a deformed penis

Qsymia and Belviq each come with a long list of important safety information, but this list is different for each drug.

Qsymia approval required Vivus to set up a strict Risk Evaluation and Mitigation Strategy (REMS). This program includes a medication guide giving patients important safety information, prescriber training, and pharmacy certification.

Which works better, Belviq or Qsymia?

There's no way to know for sure. Qsymia and Belviq have never been tested in a head-to-head clinical trial.

In the placebo-controlled clinical trials that led to approval:

  • People taking Belviq had an average weight loss that was 3% to 3.7% greater than people taking placebo.
  • After taking Belviq for one or two years, some 47% of people without diabetes lost at least 5% of their body weight. Only 23% of patients taking an inactive placebo lost this much weight.
  • People taking Qsymia for up to one year had an average weight loss of 8.9% over those taking an inactive placebo.
  • 70% of people taking Qsymia lost at least 5% of their body weight. Only 20% of patients taking an inactive placebo lost this much weight.

These numbers cannot be used to compare the two drugs, as the clinical trials had different designs.

How long would I have to keep taking Qsymia or Belviq?

People are supposed to keep taking Qsymia or Belviq for the rest of their lives, unless they develop side effects or have other reasons to stop.

If I take Belviq or Qsymia, do I still have to diet and exercise?

Absolutely. In clinical trials, the drugs were effective only when given along with a balanced diet and exercise.

SOURCES: FDA: "Medications Target Long-Term Weight Control."FDA web site, briefing information, Endocrinologic and Metabolic Drugs Advisory Committee.News release, Vivus Pharmaceuticals.News releases, Arena Pharmaceuticals/Eisai Inc.WebMD Health News: "FDA Approves Diet Pill Belviq."WebMD Health News: "FDA Approves Diet Drug Qsymia."WebMD Health News: "New Diet Drug Lorcaserin Wins Vote from FDA Panel."WebMD Health News: "FDA Panel Votes in Favor of Weight Loss Pill Qnexa."

© 2012 WebMD, LLC. All rights reserved.

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  • A week ago, just six players protested. Most NFL players on Sunday locked arms with their teammates — some standing, others kneeling — in a show of solidarity. A handful of teams stayed off the field until after 'The Star-Spangled Banner' to avoid the issue altogether. As he prepared to board Air Force One to return to Washington from New Jersey, Trump said the players protesting the anthem were 'very disrespectful to our country' and called again on owners to stop what he considers unpatriotic displays in America's most popular sport. 'This has nothing to do with race,' Trump said. 'This has to do with respect for our country.' The president's attack on athletes turned the anthems — usually sung during commercials — into must-watch television shown live by the networks and Yahoo!, which streamed the game in London. In some NFL stadiums, crowds booed or yelled at players to stand. There was also some applause. The NFL and its players, often at odds, used Sunday's anthems to show unity. One of Trump's biggest supporters in the NFL, Patriots owner Robert Kraft, joined the chorus when he expressed 'deep disappointment' with Trump. 'I like Bob very much. He's my friend. He gave me a Super Bowl ring a month ago. So he's a good friend of mine and I want him to do what he wants to do,' Trump said. '... We have great people representing our country, especially our soldiers our first responders and they should be treated with respect. 'And when you get on your knee and you don't respect the American flag or the anthem.' The protests started more than a year ago when former San Francisco 49ers quarterback Colin Kaepernick refused to stand during the anthem as a protest of police treatment of minorities. This season, no team has signed him, and some supporters believe NFL owners are avoiding him because of the controversy. A handful of white players didn't stand Sunday, but the vast majority of those actively protesting were black. Defensive star Von Miller was among the large group of Denver Broncos who took a knee in Buffalo Sunday, where Bills running back LeSean McCoy stretched during the anthem. 'We felt like President Trump's speech was an assault on our most cherished right, freedom of speech,' said Miller, who normally steers clear of politics and social issues. Dozens of more players protested before the Raiders-Redskins game, the final one of the day and not far from the White House in Landover, Maryland. All but a handful of Raiders sat on their bench and seven Redskins took a knee while their teammates stood arm-in-arm along with owner Dan Snyder and president Bruce Allen. In Chicago, the Pittsburgh Steelers stayed in the tunnel except for one player, Army veteran Alejandro Villanueva, who stood outside with a hand over his heart. Both the Seahawks and Titans stayed inside until after the national anthem was over in Nashville, a throwback to the pre-2009 NFL when teams, not the league, set pre-game policy regarding players standing on the sideline for the anthem. A handful of NFL players had been continuing Kaepernick's protest this season, but that ballooned Sunday following Trump's two-day weekend rant. It began with the president calling for NFL protesters to be fired and continued Saturday when he rescinded a White House invitation for the NBA champion Golden State Warriors over star Stephen Curry's criticism. The president's delving into the NFL protests started by Kaepernick brought new attention and angered many players who took one insult as a personal attack on their mothers. 'Wouldn't you love to see one of these NFL owners, when somebody disrespects our flag, you'd say, 'Get that son of a bitch off the field right now. Out! He's fired,'' Trump said to loud applause Friday night at a rally in Huntsville, Alabama. 'I'm a son of a queen,' Falcons defensive lineman Grady Jarrett said. Super Bowl MVP Tom Brady was among the New England Patriots who locked arms in solidarity in Foxborough, Massachusetts. Aaron Rodgers did the same with his teammates in Green Bay. 'Standing with locked arms is good, kneeling is not acceptable. Bad ratings!' Trump tweeted Sunday. In Detroit, anthem singer Rico Lavelle took a knee at the word 'brave,' lowering his head and raising his right fist. In Nashville, anthem singer Meghan Linsey, took a knee as she finished singing. Jets Chairman and CEO Christopher Johnson, whose brother, Woody, is the ambassador to England and one of Trump's most ardent supporters, called it 'an honor and a privilege to stand arm-in-arm unified with our players during today's national anthem' in East Rutherford, New Jersey. The issue reverberated across the Atlantic, where about two dozen players took a knee during the playing of the U.S. anthem at Wembley Stadium. 'We stand with our brothers,' Ravens linebacker Terrell Suggs said. 'They have the right and we knelt with them today. To protest, non-violent protest, is as American as it gets, so we knelt with them today to let them know that we're a unified front.' Jaguars owner Shad Khan and players on both teams who were not kneeling remained locked arm-in-arm throughout the playing of the anthem and 'God Save The Queen.' No players knelt during the British anthem. 'Me taking a knee doesn't change the fact that I support our military, I'm a patriot and I love my country,' Bills linebacker Lorenzo Alexander said. 'But I also recognize there are some social injustices in this country and today I wanted to take a knee in support of my brothers who have been doing it.' Alexander said he'll go back to standing for the anthem next week. 'I just wanted to show them that I was with them today, especially in the backdrop of our president making the comments about our players, about their mothers,' Alexander said. 'And then you put that in conjunction with how he tried to gray-area Nazism and KKK members as being fine people, I had to take a knee.' The National Hockey League's reigning champion Pittsburgh Penguins announced Sunday they've accepted a White House invitation from Trump. The Penguins said they respect the office of the president and 'the long tradition of championship team visiting the White House.' Before Game 1 of the WNBA Finals in Minneapolis on Sunday, the Los Angeles Sparks left the floor while the Minnesota Lynx stood arm-in-arm. The Sparks returned to a chorus of boos when the song was finished. Trump also mocked the league's crackdown on illegal hits, suggesting the league had softened because of its safety initiatives. Kahn, who was among the NFL owners who chipped in $1 million to the Trump inauguration committee, said he met with his team captains before kickoff in London 'to express my support for them, all NFL players and the league following the divisive and contentious remarks made by President Trump.' Among the strongest criticisms of the president Sunday was this from Saints coach Sean Payton: 'I'm disappointed in the comments that were made. I think we need a little bit more wisdom in that office,' he said of the White House. 'I want that guy to be one of the smarter guys in the room and it seems like every time he's opening up his mouth it's something that is dividing our country and not pulling us together.' ___ For more NFL coverage: http://www.pro32.ap.org and http://www.twitter.com/AP_NFL ___ AP Sports Writers Dennis Waszak Jr., Steve Reed, Larry Lage, Teresa M. Walker, John Wawrow and Stephen Whyno and Associated Press Writer Zac Boyer contributed. ___ Follow Arnie Melendrez Stapleton on Twitter: http://twitter.com/arniestapleton
  • An early morning house fire was ruled accidental, but a husband and wife are dead, officials said.  Boyd Weese, 80, and his wife, Evelyn Weese, 79, died in their Douglas County home, spokesman for the Office of Commissioner Insurance Glenn Allen said. The home located at 64485 Ansley Blvd. in Lithia Springs was destroyed. “My fire investigator determined that the blaze started in the attic of the home,” Insurance and Safety Fire Commissioner Ralph Hudgens said. “We believe the fire was the result of an electrical malfunction.”  RELATED: Boy burned in fire started by discarded cigarette dies day after mother Investigators found no signs of a working smoke alarm found inside the home, Allen said. In July, a 6-year-old boy and his mother died after a cigarette started a fire in a trash can, Hudgens said. The Weese deaths bring the total number of Georgians who have died as a result of a fire this year to 77, according to the state office.  Know what’s really going on with crime and public safety in your metro Atlanta community, including breaking news, trial coverage, trends and the latest on unsolved cases. Sign up for the AJC’s crime and safety newsletter delivered weekly to your inbox. In other news:
  • A string of armed robberies in a northwest Atlanta neighborhood has Georgia Tech students on alert. 'That's pretty nerve-wracking because obviously you want to be safe,' one student told Channel 2's Rikki Klaus. TRENDING STORIES: Falcons, Lions link arms during national anthem Police say gunman captured after opening fire at church Man arrested in connection with infant daughter’s death Police say three robberies happened in three weeks in a popular area near Georgia Tech's campus where many students live. The latest incident happened on Mecaslin Street, the second time this area was hit. Police say the group of seven Georgia Tech students were robbed Sunday morning. Investigators say the two men holding guns got out of the car and stole the student's phones, credit cards, IDs and keys.  Some neighbors were surprised to hear of the recent trend. 'It's a little scary. I didn't know that in the past three weeks it's been up,' said neighbor Zahna Jenkins. Officers said the getaway driver stayed in the car.  Police say group of 7 Georgia Tech students robbed this a.m. in NW Atlanta complied w/ armed robbers, handing over phones, credit cards. 6pm pic.twitter.com/dRvsLHoK8D — Rikki Klaus (@RikkiKlausWSB) September 24, 2017
  • Large amounts of federal aid began moving into Puerto Rico on Saturday, welcomed by local officials who praised the Trump administration's response but called for the emergency loosening of rules long blamed for condemning the U.S. territory to second-class status. In northwest Puerto Rico, people began returning to their homes after a spillway eased pressure on a dam that cracked after more than a foot of rain fell in the wake of the hurricane. The opening of the island's main port in the capital allowed 11 ships to bring in 1.6 million gallons of water, 23,000 cots, dozens of generators and food. Dozens more shipments are expected in upcoming days. The federal aid effort is racing to stem a growing humanitarian crisis in towns left without fresh water, fuel, electricity or phone service. Officials with the Federal Emergency Management Agency, which is in charge of the relief effort, said they would take satellite phones to all of Puerto Rico's towns and cities, more than half of which were cut off following Maria's devastating crossing of Puerto Rico on Wednesday. The island's infrastructure was in sorry shape long before Maria struck. A $73 billion debt crisis has left agencies like the state power company broke. As a result the power company abandoned most basic maintenance in recent years, leaving the island subject to regular blackouts. A federal control board overseeing Puerto Rico's finances authorized up to $1 billion in local funds to be used for hurricane response, but Gov. Ricardo Rossello said he would ask for more. 'We're going to request waivers and other mechanisms so Puerto Rico can respond to this crisis,' he said. 'Puerto Rico will practically collect no taxes in the next month.' U.S. Rep. Nydia Velazquez of New York said she will request a one-year waiver from the Jones Act, a federal law blamed for driving up prices on Puerto Rico by requiring cargo shipments there to move only on U.S. vessels as a means of supporting the U.S. maritime industry. 'We will use all our resources,' Velazquez said. 'We need to make Puerto Rico whole again. These are American citizens.' A group of anxious mayors arrived in the capital to meet with Rossello to present a long list of items they urgently need. The north coastal town of Manati had run out of fuel and fresh water, Mayor Jose Sanchez Gonzalez said. 'Hysteria is starting to spread. The hospital is about to collapse. It's at capacity,' he said, crying. 'We need someone to help us immediately.' The death toll from Maria in Puerto Rico was at least 10, including two police officers who drowned in floodwaters in the western town of Aguada. That number was expected to climb as officials from remote towns continued to check in with officials in San Juan. Authorities in the town of Vega Alta on the north coast said they had been unable to reach an entire neighborhood called Fatima, and were particularly worried about residents of a nursing home. 'I need to get there today,' Mayor Oscar Santiago told The Associated Press. 'Not tomorrow, today.' Rossello said Maria would clearly cost more than the last major storm to wallop the island, Hurricane George in September 1998. 'This is without a doubt the biggest catastrophe in modern history for Puerto Rico,' he said. Rossello and other officials praised the federal government for planning its response in detail before the storm hit, a contrast with what Puerto Rico has long seen as the neglect of 3.4 million Americans living in a territory without a vote in Congress or the electoral college. 'This is the first time we get this type of federal coordination,' said Resident Commission Jenniffer Gonzalez, Puerto Rico's non-voting representative in Washington. A dam upstream of the towns of Quebradillas and Isabela in northwest Puerto Rico was cracked but had not burst by Saturday night as water continued to pour out of rain-swollen Lake Guajataca. Federal officials said Friday that 70,000 people, the number who live in the surrounding area, would have to be evacuated. But Javier Jimenez, mayor of the nearby town of San Sebastian, said he believed the number was far smaller. Secretary of Public Affairs Ramon Rosario said about 300 families were in harm's way. The governor said there is 'significant damage' to the dam and authorities believe it could give way at any moment. 'We don't know how long it's going to hold. The integrity of the structure has been compromised in a significant way,' Rossello said. Some residents nonetheless returned to their homes Saturday as the water levels in the reservoir began to sink. 'There were a lot of people worried and crying, but that's natural, because the reservoir was about to break through,' said Maria Nieves, 43. 'They couldn't open the spillway until later in the night.' The 345-yard (316-meter) dam, which was built around 1928, holds back a man-made lake covering about 2 square miles (5 square kilometers). More than 15 inches (nearly 40 centimeters) of rain from Maria fell on the surrounding mountains. Officials said 1,360 of the island's 1,600 cellphone towers were downed, and 85 percent of above-ground and underground phone and internet cables were knocked out. With roads blocked and phones dead, officials said, the situation may worsen. At least 31 lives in all have been lost around the Caribbean due to Maria, including at least 15 on hard-hit Dominica. Haiti reported three deaths; Guadeloupe, two; and the Dominican Republic, one. Across Puerto Rico, more than 15,000 people are in shelters, including some 2,000 rescued from the north coastal town of Toa Baja. Many Puerto Ricans planned to head to the mainland to temporarily escape the devastation. ____ Coto reported from San Juan.
  • Memo to Republican senators: Many of the states President Donald Trump won last year would lose significant federal financing under the last-ditch Republican health care bill headed for a possible showdown in the Senate this week. Among states expected to lose are Arizona, Florida, Kentucky, and Ohio, where cuts could swell the number of uninsured people. That has political implications for Republicans girding for congressional midterm elections next year, as well as for the next presidential race in 2020. That year is when the biggest spending reductions from the legislation by GOP Sens. Lindsey Graham and Bill Cassidy would start taking effect. Consider the following: Of the 30 states Trump carried in his surprise victory, 16 would lose federal health care money under the bill to dismantle Barack Obama's Affordable Care Act, according to Kaiser Family Foundation estimates reviewed by The Associated Press. Among the losers are not just Democratic strongholds like California and New York, but also a sizable number of Republican-leaning states. That includes Indiana and Arkansas, as well as swing states like Florida, Pennsylvania, and Ohio, which proved critical to Trump's victory. The glow from repealing 'Obamacare' could vanish in a political backlash. With the rush to pass legislation before the expiration of special budget rules allowing a simple majority vote in the Senate, many Republicans are worried about their states. The Congressional Budget Office will only have time to produce a partial analysis before the expected vote. 'The process is such that people can't be sure if the dollars are right and if the formulas make sense,' said GOP economist Douglas Holtz-Eakin, a top adviser to Arizona Republican Sen. John McCain in his 2008 presidential campaign. 'Not understanding the implications, I think, has people really nervous.' In principle, Holtz-Eakin said he agrees with the bill's authors, Graham of South Carolina and Cassidy of Louisiana, that federal health care spending is unsustainable and that the Obama-era law gives government too much control. But he says he'd be surprised if the bill can pass. 'At some level, the Graham-Cassidy bill picks one of the biggest formula fights in history,' Holtz-Eakin said. The legislation has two major components that affect health care spending: First, it would take money currently being used to finance the coverage expansion under Obama's law, and create one big pot, pared down somewhat. The money would be redistributed to states, which could spend it to design their own insurance programs for low-income people. The pot would include money currently being spent on tax credits for subsidized private insurance, as well as financing for expanded Medicaid. The second part, seen as more far-reaching, would cap overall federal spending on the Medicaid program for low-income people, which currently covers more than 70 million Americans, including many newborns, adults in low-wage jobs, disabled people, and many elderly nursing home residents. Last week's analysis from the nonpartisan Kaiser Family Foundation found that the combined effect of the changes would lead to 35 states plus Washington, D.C., losing nearly $160 billion in federal financing from 2020-2026. Trump administration officials say the bill still offers plenty of money, and governors would find efficient ways to serve as many people, if not more. Additional tweaks are possible as the White House and Senate leaders try to corral votes. 'Governors will be given the opportunity to allocate the program the way that makes most sense for their constituents and their residents,' White House legislative director Marc Short said Sunday on NBC. Officials say studies like Kaiser's don't fully account for the bill's market stabilization features. But doctors and hospitals are worried that the cuts would reverse recent progress that has reduced the nation's uninsured rate to a historic low of about 9 percent. The finding that the Graham-Cassidy bill could inflict collateral damage on red states as well as reliably Democratic ones seems somewhat counter-intuitive. It's because the cuts affect not just states that expanded Medicaid under the Obama health law, but also some states where the ACA's private insurance markets have worked fairly well, said Kaiser's Gary Claxton, an expert on private insurance. One example is Florida, estimated by Kaiser to lose $9.7 billion from 2020-2026. The state did not expand Medicaid, but has a robust insurance market. Florida features a competitive Senate race in 2018 for the seat currently held by Democrat Bill Nelson, a supporter of the Obama health law. 'It's a very large amount of redistribution for our political system to do this quickly, when you don't even have an official estimate,' said Claxton. AP's review of the Kaiser estimates found other states with 2018 Senate races where cuts could play a role. In states with seats being defended by Democrats, the list includes Indiana, North Dakota, Ohio, Pennsylvania, and West Virginia. In seats being defended by Republicans, it includes Arizona, Nebraska and Nevada. States with 2018 Senate races that would get more money under the bill are Mississippi, Tennessee, Texas and Utah. Those seats are currently held by Republicans.
  • Struggling with an embarrassing series of misconduct and behavior problems among senior officers, the Army is putting together new mental health, counseling and career management programs to shape stronger, more ethical leaders. The programs stem from a broader worry across the military about the need to bolster professionalism within the officer corps while holding accountable those who abuse their power. The Army plan appears to focus more on building character than berating bad conduct. In recent years, general officers from the one-star to four-star level have violated the military code of conduct they've lived under and enforced — often for decades. Some infractions involved extramarital affairs, inappropriate relationships with subordinates or improper use of government funds. 'The idea that we'll be perfect, I think, is unrealistic, but we can be better and we strive to be better,' said Lt. Gen. Ed Cardon, tasked by the Army's top officer to review the problem and devise ways to strengthen the senior officer corps. 'Competence is no longer enough. Character is as or even more important.' Among the incidents leading up to the order was the suicide of Maj. Gen. John Rossi shortly before he was to become lieutenant general and assume control of Space and Missile Defense Command. Army leaders worry they missed opportunities to deal with the high levels of stress and self-doubt that reportedly led Rossi to hang himself. In the past nine months, the Army found two senior officers guilty of misconduct, forcing them out of their jobs and demoting them as they retired. One lost two stars; the other lost three. 'We recognized senior executive leaders, with varying amounts of stress, lacked a holistic program that focuses on comprehensive health,' said Gen. Mark Milley, the Army's chief of staff. The military has strived to combat stress disorders, suicide and other problems, he said, but the focus often has been on enlisted troops or lower-ranking officers. A new emphasis on senior leaders is needed, he said. In an interview with The Associated Press, Cardon said several pilot programs have started and others are under discussion. The Army, he said, needs to better help officers manage stress, organize calendars, make time for physical fitness, take time off and reach out to mentors or coaches for support. Cardon said a key effort is finding ways to build self-control and self-awareness, ensuring officers and their families can quickly recognize and deal with problems that arise. Ethical behavior should be reinforced. 'Most generals are very good at morphing themselves,' Cardon said. 'They can be with the troops and they present this persona. They can be with the secretary and they present that persona. They're very good at it and they get even better. The challenge is how do you uncover all that, and I think this is where that self-awareness, self-control, self-mastery has to help us out.' Accurate numbers of senior Army leaders who have been disciplined or fired from a job for bad behavior are limited and unreliable. Some officers quietly retire or move to a different post, sometimes with an official reprimand in the file. Or sometimes without. In response to a request for data, the Army said there have been nine general officers 'relieved of duty' among active duty, the National Guard and Army Reserves since 2012. Two high-profile cases in which senior officers were forced out and demoted weren't included in those statistics due to complicated legal or administrative reasons, making it clear the numbers underestimate the problem. One pilot program, said Cardon, creates a one-stop health care facility replacing the military's often far-flung, disjointed, multistep system. It's modeled after executive clinics that take a more in-depth, holistic approach to medical care. Other ideas focus on time management, encouraging high-level officers to take longer vacations. He said every general should take 10 to 14 uninterrupted days off each year to unplug, breaking with a military culture making them believe they're too important to disconnect. On schedules, officers would be urged not to overbook themselves. Packing their calendars with events all day and every evening can increase stress and make it difficult to prioritize. The role that chaplains, mentors, executive coaches and colleagues can play is being studied, and how individual or group discussions might help. Too often, three-star and four-star generals working as base commanders are posted in remote locations around the world and have few or no equals in rank to socialize with or ask for advice. They can become isolated, ego-driven or surrounded by subordinates afraid to challenge them on inappropriate behavior. A possibility, said Cardon, are programs strengthening officers' relationships with spouses, who often notice problems first. Ninety percent of the approximately 330 active duty generals are married, he said. Army officials stress only a minority of general officers are problems. 'We have tolerated people doing things they shouldn't be doing because we say all of them are extremely competent and really good at what they do. And that's not good enough now because you're not only damaging yourself, you're damaging the institution,' Cardon said. 'We have great trust with the American people, every time one of these things happens, you're putting a nick in that.