Long term pharmacotherapy for obesity and overweight: updated meta-analysis

OBJECTIVE

To summarise the long term efficacy of anti-obesity drugs in reducing weight and improving health status.

DESIGN

Updated meta-analysis of randomised trials.

DATA SOURCES

Medline, Embase, the Cochrane controlled trials register, the Current Science meta-register of controlled trials, and reference lists of identified articles. All data sources were searched from December 2002 (end date of last search) to December 2006.

STUDIES REVIEWED

Double blind randomised placebo controlled trials of approved anti-obesity drugs used in adults (age over 18) for one year or longer.

RESULTS

30 trials of one to four years' duration met the inclusion criteria: 16 orlistat (n=10 631 participants), 10 sibutramine (n=2623), and four rimonabant (n=6365). Of these, 14 trials were new and 16 had previously been identified. Attrition rates averaged 30-40%. Compared with placebo, orlistat reduced weight by 2.9 kg (95% confidence interval 2.5 kg to 3.2 kg), sibutramine by 4.2 kg (3.6 kg to 4.7 kg), and rimonabant by 4.7 kg (4.1 kg to 5.3 kg). Patients receiving active drug treatment were significantly more likely to achieve 5% and 10% weight loss thresholds. Orlistat reduced the incidence of diabetes and improved concentrations of total cholesterol and low density lipoprotein cholesterol, blood pressure, and glycaemic control in patients with diabetes but increased rates of gastrointestinal side effects and slightly lowered concentrations of high density lipoprotein. Sibutramine improved [corrected] concentrations of high density lipoprotein cholesterol and triglycerides [corrected] Rimonabant improved concentrations of high density lipoprotein cholesterol and triglycerides, blood pressure, and glycaemic control in patients with diabetes but increased the risk of mood disorders.

CONCLUSIONS

Orlistat, sibutramine, and rimonabant modestly reduce weight, have differing effects on cardiovascular risk profiles, and have specific adverse effects.

Metformin improves polycystic ovary syndrome symptoms irrespective of pre-treatment insulin resistance

OBJECTIVE

Insulin resistance (IR) and obesity are common features of the polycystic ovary syndrome (PCOS). Insulin-sensitizing agents have been shown to improve both reproductive and metabolic aspects of PCOS, but it remains unclear whether it is also beneficial in lean patients without pre-treatment IR. The aim of this study was to determine the influence of metformin on the clinical and biochemical parameters of PCOS irrespective of the presence of basal obesity and IR.

DESIGN

The effect of 6 months of metformin treatment was prospectively assessed in 188 PCOS patients, divided into three groups according to body mass index (BMI; lean: BMI<25 kg/m2, overweight: BMI 25-29 kg/m2, and obese: BMI30 kg/m2). Outcome parameters, which were also assessed in 102 healthy controls, included body weight, homeostasis model assessment for IR (HOMA-IR), fasting glucose and insulin levels, area under the curve of insulin response (AUCI), hyperandrogenism, and menstrual irregularities.

RESULTS

In comparison with the respective BMI-appropriate control groups, only obese but not lean and overweight PCOS patients showed differences in fasting insulin and HOMA-IR. Metformin therapy significantly improved all outcome parameters except fasting glucose levels. Subgroup analyses revealed that in the group of lean PCOS patients without pre-treatment IR, metformin significantly improved HOMA-IR (1.7+/-1.0 vs 1.1+/-0.7 micromol/lxmmol/l2) and fasting insulin levels (7.7+/-4.2 vs 5.4+/-3.9 mU/l), in addition to testosterone levels (2.6+/-0.9 vs 1.8+/-0.7 nmol/l), anovulation rate (2.3 vs 59.5%), and acne (31.8 vs 11.6%; all P<0.017). In the overweight and obese PCOS groups, metformin also showed the expected beneficial effects.

CONCLUSION

Metformin improves parameters of IR, hyperandrogenemia, anovulation, and acne in PCOS irrespective of pre-treatment IR or obesity.

The effect of caffeine, green tea and tyrosine on thermogenesis and energy intake

OBJECTIVES

To investigate the effect of three different food ingredients tyrosine, green tea extract (GTE) and caffeine on resting metabolic rate and haemodynamics, and on ad libitum energy intake (EI) and appetite.

METHODS

Twelve healthy, normal weight men (age: 23.7 +/- 2.6 years, mean +/- s.d.) participated in a four-way crossover, randomized, placebo-controlled, double-blind study. Treatments were administered as tablets of 500 mg GTE, 400 mg tyrosine, 50 mg caffeine, or placebo, and were separated by >3-day washout. The acute thermogenic response was measured in a ventilated hood system for 4 h following ingestion. Blood pressure, heart rate (HR), and subjective appetite sensations were assessed hourly and ad libitum EI 4 h post-dose.

RESULTS

Caffeine induced a thermogenic response of 6% above baseline value (72 +/- 25 kJ per 4 h, mean +/- s.e.) compared to placebo (P<0.0001). The thermogenic responses to GTE and tyrosine were not significantly different from placebo. Tyrosine tended to increase 4-h respiratory quotient by 1% compared to placebo (0.01 +/- 0.005, P=0.05). Ad libitum EI was not significantly different between treatments but was reduced by 8% (-403 +/- 183 kJ), 8% (-400 +/- 335 kJ) and 3% (-151 +/- 377 kJ) compared to placebo after intake of tyrosine, GTE and caffeine, respectively. No significant difference in haemodynamics was observed between treatments.

CONCLUSIONS

Only caffeine was thermogenic in the given dose and caused no haemodynamic side effects. The sample size was probably too small to detect any appetite suppressant properties of the treatments. Further investigations are required.

Fish oil supplementation improves large arterial elasticity in overweight hypertensive patients

OBJECTIVES

To observe the effect of fish oil supplementation on arterial elasticity and blood pressure (BP) in overweight hypertensive patients.

SUBJECTS AND METHODS

This was a double-blind, randomized and placebo-controlled clinical study, in which 52 overweight hypertensive patients from a community were selected and randomly allocated to two groups (26 in the fish oil group (3 g day(-1), fish oil capsules) and 26 in the placebo group (only capsules). All the subjects were follow-up for 8 weeks. The arterial elasticity was determined by CVProfilor DO-2020 and expressed as elasticity indexes (C(1)-large artery and C(2)-small artery). During the follow-up, totally nine cases were dropped out (three cases from the fish oil group and six cases from the placebo group).

RESULTS

After 8 weeks follow-up, the large artery elasticity in the fish oil group, compared with its baseline, was significantly improved (C(1): 15.5+/-1.5 vs 12.8+/-3.7 ml mm Hg(-1) x 10), whereas no effects were found in the placebo group (C(1): 13.0+/-3.4 vs 13.4+/-3.8 ml mm Hg(-1) x 10), P=0.027, RM-ANOVA across the two groups. The small artery elasticity (C(2)), BP and pulse pressure were not found any changes, either in the fish oil group or in the placebo group. At same time, the serum soluble vascular cell adhesion molecule-1(sVCAM-1) and leptin levels, the lipid profile and insulin sensitivity index (ISI) as well, did not show significant differences between two groups.

CONCLUSIONS

Fish oil supplementation certainly would improve large arterial elasticity but no effect on BP in overweight hypertensive patients. Further study is needed to confirm the benefits of fish oil supplementation on age-related increases in arterial stiffness.

Conjugated linoleic acid supplementation alters the 6-mo change in fat oxidation during sleep

BACKGROUND

Conjugated linoleic acid (CLA) is a family of positional and geometric isomers with 2 conjugated double bonds formed from linoleic acid and linolenic acid. CLA has a wide range of biological effects, including body fat reduction.

OBJECTIVE

The aim of our study was to determine CLA's effects on energy expenditure, macronutrient utilization, and dietary fat oxidation in overweight adults after 6 mo of supplementation.

DESIGN

We recruited 23 subjects from our main CLA efficacy study who were receiving either 4 g/d of 78% active CLA isomers (3.2 g/d: 39.2% cis-9,trans-11 and 38.5% trans-10,cis-12) or 4 g/d of safflower oil. Energy expenditure and substrate utilization were measured before and after 6 mo of CLA supplementation by using whole-room indirect calorimetry. Dietary fat oxidation was measured by using stable isotope-labeled oleate and palmitate.

RESULTS

Our substudy detected a difference in the change in fat utilization between the CLA (4 +/- 8 g) and placebo (-7 +/- 11 g) groups during sleep after 6 mo of supplementation. In addition, the percentage of energy from protein was reduced during sleep in the CLA group (CLA: -3.3 +/- 2.6%; placebo: 0.3 +/- 5.7%). We also detected a difference in the change in energy expenditure during sleep (CLA: 0 +/- 38 kcal; placebo: -43 +/- 90 kcal). We did not detect a change in labeled dietary fat oxidation after 6 mo of CLA supplementation given with a breakfast meal.

CONCLUSION

Mixed isomer CLA supplementation, but not placebo, positively altered fat oxidation and energy expenditure during sleep.

Weight loss and metabolic effects of topiramate in overweight and obese type 2 diabetic patients: randomized double-blind placebo-controlled trial

OBJECTIVE

To examine the metabolic effects and body composition changes after topiramate treatment of obese type 2 diabetic patients (DM2) for 11 months.

DESIGN AND SUBJECTS

Thirty-eight DM2 on diet or sulfonylurea treatment participated in this randomized double-blind placebo-controlled trial. Thirteen placebo-treated and nine topiramate-treated patients completed the trial. Patients were randomized to treatment with topiramate 96 mg b.i.d. or placebo (6-week run-in phase, 2-months titration phase, 9-months maintenance phase).

MEASUREMENTS

Insulin sensitivity was measured with euglycaemic hyperinsulinemic clamps. Weight, HbA1c, fasting glucose, blood lipids and safety variables were measured at regular intervals. Body composition was determined with computerized tomography. Meal tests were performed to evaluate postprandial glucose and insulin levels. Three-day diet recalls were carried out to evaluate energy ingestion.

RESULTS

The mean age was 58.6+/-7.1 years, body weight 98.1+/-16.1 kg, BMI 33.0+/-4.5 kg/m(2), and glycosylated hemoglobin (HbA1c) 7.3+/-0.9%. In topiramate-treated patients, there were significant reductions in HbA1c (1.1+/-0.9%), fasting plasma glucose, body weight (-6.6+/-3.3%), as well as body fat, lean body mass, postprandial glucose and free fatty acid levels but there were no significant changes in insulin sensitivity. The daily average energy intake decreased more in the topiramate group than in the placebo group. Paresthesia and central nervous system-related side effects were the main causes for the dropout rate.

CONCLUSIONS

Topiramate treatment of overweight DM2 reduced body weight and body fat, and was associated with a marked improvement in glycaemic control whereas no significant improvement in insulin-stimulated glucose uptake was demonstrated. Further studies are required to clarify whether this effect might occur through changes in insulin sensitivity in the liver and/or pancreatic insulin secretion.

The effect of 6 months supplementation with conjugated linoleic acid on insulin resistance in overweight and obese

BACKGROUND

Contradicting results have been published regarding the effect of conjugated linoleic acid (CLA) on insulin resistance. However, only a few studies have used the euglycemic hyperinsulinemic clamp method, which is considered the standard for measuring insulin resistance.

OBJECTIVE

To evaluate if CLA as a mixture of the main isomers trans-10 cis-12 and cis-9 trans-11 affects the insulin resistance in healthy overweight and obese male and female adults.

DESIGN

The main study was a randomized, double-blind, placebo-controlled trial with change in body composition as primary end point comprising 118 subjects receiving supplementation with either placebo (olive oil) or CLA (Clarinol) for 6 months. A sub-population of 49 subjects agreed additionally to participate in an euglycemic hyperinsulinemic clamp study at baseline and after 6 months of supplementation with study drug. The primary outcome was the change in glucose uptake (M) as measured by the hyperinsulinemic euglycemic glucose clamp method. Secondary outcomes were the correlates between insulin resistance and changes in body composition or blood chemistry parameters. Forty-one subjects completed the clamp test at both time points.

RESULTS

The median M of the CLA group was 11.0 mg min(-1) lean body mass (lbm)(-1) (n=24) at baseline, 10.3 mg min(-1) lbm(-1) (n=24) after 6 months, and the median difference was +0.21 mg min(-1) lbm(-1) (n=24). The median M of placebo group was 8.4 mg min(-1) lbm(-1) at baseline and 9.3 mg min(-1) lbm(-1) after 6 months and the median difference was -0.22 mg min(-1) lbm(-1) (n=17). No significant (P<0.05) differences were found within groups or between groups. Likewise, the glucose uptake insulin concentration ratio during clamp (M/I) was independent of treatment and time. Homeostasis model assessment (HOMA) and quantitative insulin sensitivity check index derived from fasting glucose and insulin were also independent of treatment and time, and HOMA for the clamp population (n=49) corresponded well with HOMA for the per protocol population (n=83). Correlation analysis showed that changes in M were inversely correlated to changes in glucohemoglobin (P=0.002), but did not correlate with changes in either glucose, insulin, insulin c-peptide, leptin, adiponectin or percent body fat.

CONCLUSIONS

CLA does not affect glucose metabolism or insulin sensitivity in a population of overweight or obese volunteers.