Medical Therapy for Obesity

Phentermine: A Systematic Review for Plastic and Reconstructive Surgeons

PURPOSE

Phentermine is the most prescribed antiobesity drug in America, with 2.43 million prescriptions written in 2011. Case reports suggest there are anesthetic risks, such as refractory hypotension, involved with its perioperative use. Despite these risks and the frequency of phentermine use among plastic surgery patients, there are no published guidelines for the perioperative management of phentermine use in the plastic surgery literature. To address this patient safety issue, we performed a systematic review and provide management recommendations.

METHODS

A systematic review of the pharmacology of phentermine and the anesthetic risks involved with its perioperative use was undertaken using the search engines PubMed/MEDLINE, EMBASE, and Scopus.

RESULTS

A total of 251 citations were reviewed, yielding 4 articles that discussed perioperative phentermine use and complications with anesthesia. One was a review article, 2 were case reports, and 1 was a letter. Complications included hypotension, hypertension, hypoglycemia, hyperthermia, bradycardia, cardiac depression, and acute pulmonary edema.

CONCLUSIONS

The relationship between phentermine and anesthesia, if any, is unclear. Hypotension on induction of general anesthesia is the most reported complication of perioperative phentermine use. Specifically, phentermine-induced hypotension may be unresponsive to vasopressors that rely on catecholamine release, such as ephedrine. Therefore, the decision to perform surgery, especially elective surgery, in a patient taking phentermine should be made with caution. Because of the half-life of phentermine, we recommend discontinuing phentermine for at least 4 days prior to surgery. This differs from the classic 2-week discontinuation period recommended for "fen-phen." The patient should be made aware of the increased risk of surgery, and a skilled anesthesiologist should monitor intraoperative blood pressure and body temperature for signs of autonomic derailment.

Phytochemical and Biological Profile of Moricandia arvensis (L.) DC.: An Inhibitor of Pancreatic Lipase

Pancreatic lipase, a key enzyme for lipid absorption, is one of the most important targets for the treatment of obesity, while natural compounds have recently attracted much interest as potential inhibitors of this enzyme. Here, in an attempt to find new effective agents, the methanolic extract from Moricandia arvensis (L.) DC. and its sub-extracts were investigated for their potential inhibitory activity. The ability to inhibit pancreatic lipase was verified through the in vitro evaluation of the prevention of p-nitrophenyl caprylate hydrolysis. The antioxidant activity was also verified by means of DPPH and β-carotene bleaching tests. Compositional profiling revealed that flavonoid glycosides were the main specialized metabolites present in the methanolic extract from the aerial parts of the plant with kaempferol and quercetin representing the two O-glycosylated aglycones. Kaempferol-3-O-β-(2″-O-glucosyl)-rutinoside and kaempferol-3-O-a-arabinosyl-7-O-rhamnoside were the most abundant flavonols. The crude methanolic extract and the dichloromethane and ethyl acetate sub-extracts showed a strong lipase inhibitory activity, with IC50 values of 2.06 ± 0.02, 1.52 ± 0.02 and 1.31 ± 0.02 mg/mL, respectively. The best capacity to scavenge DPPH radical was detected for the ethyl acetate sub-extract (IC50 = 171.9 ± 1.0 µg/mL), which was also effective in protecting linoleic acid from peroxidation (IC50 = 35.69 ± 2.30 µg/mL). Obtained results support the hypothesis that M. arvensis can be a source of bioactive phytochemicals for the pharmacological inhibition of dietary lipids absorption.

Aqueous and ethanolic extracts of welsh onion, Allium fistulosum, attenuate high-fat diet-induced obesity

Background

Allium fistulosum (Welsh onion) is a traditional medicinal plant used for the treatment of colds, influenza, abdominal pain, headache, and heart disease. This study evaluated the effects of A. fistulosum ethanolic extract (AFE) and aqueous extract (AFW) on body weight and other obesity-related parameters.

Methods

Male 8-week-old C57BL/6 J mice were fed either a standard chow diet (normal control) or a high-fat diet (HFD) either alone (HFD-control) or in combination with G. cambogia extract containing hydroxycitric acid (HCA, an herbal weight-loss supplement), conjugated linoleic acid (CLA, a weight-loss supplement), orlistat (a clinically available anti-obesity drug), AFW, or AFE (n = 6 mice per group) for 6 weeks. At the end of 6 weeks, several body weight and obesity-related parameters were examined, including: liver and adipose weight, adipocyte size, serum lipid profiles, liver expression of adenosine monophosphate-activated protein kinase (AMPK), and adipose tissue expression of uncoupling protein 2 (UCP2).

Results

High-performance liquid chromatography showed that both AFE and AFW contain ferulic acid and quercetin. Oral administration of AFW and AFE to HFD-fed mice decreased body weight as well as liver and adipose tissue weight and adipocyte size. Serum lipid profiles and adiponectin levels were improved in HFD-fed mice treated with AFE but not AFW. However, both AFW and AFE significantly attenuated HFD-induced changes in serum leptin and insulin-like growth factor 1 levels, liver expression of AMPK, and adipose tissue expression of UCP2.

Conclusions

The findings from this study suggest that A. fistulosum extracts have potential as functional food materials for weight control in obesity.

Regulation of lipid deposition in farm animals: Parallels between agriculture and human physiology

For many years, clinically oriented scientists and animal scientists have focused on lipid metabolism and fat deposition in various fat depots. While dealing with a common biology across species, the goals of biomedical and food animals lipid metabolism research differ in emphasis. In humans, mechanisms and regulation of fat synthesis, accumulation of fat in regional fat depots, lipid metabolism and dysmetabolism in adipose, liver and cardiac tissues have been investigated. Further, energy balance and weight control have also been extensively explored in humans. Finally, obesity and associated maladies including high cholesterol and atherosclerosis, cardiovascular disease, insulin resistance, hypertension, metabolic syndrome and health outcomes have been widely studied. In food animals, the emphasis has been on regulation of fatty acid synthesis and lipid deposition in fat depots and deposition of intramuscular fat. For humans, understanding the regulation of energy balance and body weight and of prevention or treatment of obesity and associated maladies have been important clinical outcomes. In production of food animals lowering fat content in muscle foods while enhancing intramuscular fat (marbling) have been major targets. In this review, we summarize how our laboratories have addressed the goal of providing lean but yet tasty and juicy muscle food products to consumers. In addition, we here describe efforts in the development of a new porcine model to study regulation of fat metabolism and obesity. Commonalities and differences in regulation of lipid metabolism between humans, rodents and food animals are emphasized throughout this review.

Gelidium amansii extract ameliorates obesity by down-regulating adipogenic transcription factors in diet-induced obese mice

BACKGROUND/OBJECTIVES

In this study, we investigated whether Gelidium amansii extract (GAE) ameliorates obesity in diet-induced obese (DIO) mice.

MATERIALS/METHODS

The mice were maintained on a high-fat diet (HD) for 5 weeks to generate the DIO mouse model. And then mice fed HD plus 0.5% (GAE1), 1% (GAE2) or 2% (GAE3) for 8 weeks.

RESULTS

After the experimental period, GAE-supplemented groups were significantly lower than the HD group in body weight gain and liver weight. GAE supplemented groups were significantly lower than the HD group in both epididymal and mesenteric adipose tissue mass. The plasma leptin level was significantly higher in the HD group than in GAE-supplemented groups. The leptin level of HD+GAE3 group was significantly lower than that of the HD+conjugated linoleic acid (CLA) group. In contrast, plasma adiponectin level of the HD group was significantly lower than those of HD+GAE2 and HD+GAE3 groups. The expression levels of adipogenic proteins such as fatty acid synthase, sterol regulatory element-binding protein-1c, peroxisome proliferator-activated receptor γ, and CCAAT/enhancer binding protein α in the GAE supplemented groups were significantly decreased than those in HD group, respectively. In addition, the expression levels of HD+GAE2 and HD+GAE3 groups are significantly decreased compared to those of HD+CLA group. On the contrary, the expression levels of hormone-sensitive lipase and phospho-AMP-activated protein kinase, proteins associated with lipolysis, were significantly increased in the GAE supplemented groups compared to those in the HD group. HD+GAE3 group showed the highest level among the GAE supplemented groups.

CONCLUSIONS

These results suggested that GAE supplementation stimulated the expressions of lipid metabolic factors and reduced weight gain in HD-fed C57BL/6J obese mice.

Tumour necrosis factor-α inhibition with lenalidomide alleviates tissue oxidative injury and apoptosis in ob/ob obese mice

Lenalidomide (Revlimid; Selleck Chemicals, Houston, TX, USA), an analogue of thalidomide, possesses potent cytokine modulatory capacity through inhibition of cytokines such as tumour necrosis factor (TNF)-α, a cytokine pivotal for the onset and development of complications in obesity and diabetes mellitus. The present study was designed to evaluate the effect of lenalidomide on oxidative stress, protein and DNA damage in multiple organs in an ob/ob murine model of obesity. To this end, C57BL/6 lean and ob/ob obese mice were administered lenalidomide (50 mg/kg per day, p.o.) for 5 days. Oxidative stress, protein and DNA damage were assessed using the conversion of reduced glutathione (GSH) to oxidized glutathione (GSSG), carbonyl formation and Comet assay, respectively. Apoptosis was evaluated using caspase 3 activity, and levels of Bax, Bcl-2, Bip, caspase 8, caspase 9 and TNF-α were assessed using western blot analysis. Lenalidomide treatment did not affect glucose clearance in lean or ob/ob mice. Obese mice exhibited a reduced GSH/GSSG ratio in the liver, gastrocnemius skeletal muscle and small intestine, as well as enhanced protein carbonyl formation, DNA damage and caspase 3 activity in the liver, kidney, skeletal muscle and intestine; these effects were alleviated by lenalidomide, with the exception of obesity-associated DNA damage in the liver and kidney. Western blot analysis revealed elevated TNF-α, Bax, Bcl-2, Bip, caspase 8 and caspase 9 in ob/ob mice with various degrees of reversal by lenalidomide treatment. Together, these data indicate that lenalidomide protects against obesity-induced tissue injury and protein damage, possibly in association with antagonism of cytokine production and cytokine-induced apoptosis and oxidative stress.

All roads bring to Rome: a different way for predicting success in the therapy of obesity through psychological features

PURPOSE

Obesity treatment based on lifestyle modifications is characterized by a high proportion of treatment failures. The study of predictors of success could be useful for a better definition of therapeutic needs in individual patients. Few studies have attempted a comprehensive assessment of psychological factors related with treatment response. Aim of the study is the identification of psychological and psychopathological features associated with a good treatment response in patients referring for obesity.

METHODS

This prospective observational study was conducted on a consecutive series of 270 obese patients and a six-month follow-up was performed. At enrollment, a complete medical history was collected and, psychopathology and psychological features were assessed with: General psychopathology: Symptom Checklist 90-revised, Eating Disorder Examination-Questionnaire, Obesity Related well-being and Treatment, Motivation and Readiness test.

RESULTS

Among the 231 patients evaluated at follow-up, the mean weight loss was 3.2% of initial body weight and 68 patients (29.4%) reached the pre-defined therapeutic target of 5% weight loss. Higher psychopathology was associated with a worse outcome in women only; whereas motivation was higher in patients achieving therapeutic targets among men, but not in women.

CONCLUSIONS

Mean weight loss obtained with lifestyle interventions is confirmed to be rather small and a more accurate selection of patients to be enrolled in lifestyle intervention programs is needed. The present study provides some intriguing information on predictors of weight loss, which could be useful for the identification of patients with a higher chance of succeeding with lifestyle programs for the treatment of obesity.

Viola mandshurica ethanolic extract prevents high-fat-diet-induced obesity in mice by activating AMP-activated protein kinase

Viola mandshurica W. Becker has been used as an expectorant, diuretic, and anti-inflammatory agent. We evaluated the effects of V. mandshurica ethanol extract (VME) on high-fat-diet (HFD)-induced obesity in mice. HPLC analysis showed that the VME contained 11.95 ± 0.37 mg/g esculetin and 0.13 ± 0.01 mg/g scopoletin. Orally administered VME decreased the body weight, adipose tissue mass, adipocyte size, and triglyceride and leptin serum concentrations. In contrast, VME increased serum adiponectin concentrations and adiponectin expression levels in epididymal adipose tissues. VME also significantly reversed the HFD-induced elevation of the mRNA and protein levels of lipogenic genes such as peroxisome proliferator-activated receptor γ, sterol regulatory element-binding protein-1c, fatty-acid synthase, and adipocyte protein 2. Moreover, VME reversed the HFD-induced inhibition of AMP-activated protein kinase (AMPK) and acetyl-coA carboxylase phosphorylation in epididymal adipose tissues. Furthermore, treatment of VME and esculetin in 3T3-L1 cells inhibited adipocyte differentiation and fat accumulation. These results suggest that VME exerts anti-obesity effects in HFD-induced obese mice by activating AMPK and suppressing PPARγ expression in adipose tissues.

Obesity and the need for bariatric surgery in Pakistan

After establishing a foothold in the West, the pandemic of obesity now threatens to spin out of control in the developing nations of Asia and the Indian subcontinent. Like many of its neighbors, Pakistan has witnessed an unprecedented growth in the number of overweight and obese individuals in its population, and obesity is proving to be an issue of considerable public health concern. Conventional medical therapies for obesity and related complications have proven to be less than effective, especially in the population of the southeast, which appears to be inherently predisposed to developing obesity-related complications. Bariatric surgery is fast emerging as a definitive therapeutic alternative for obesity and has proven to be highly successful and cost-effective at producing remission of complications of the same. In this article, we expound the need for introducing and incorporating bariatric surgery as part of the therapeutic protocols for obese individuals of South Asian descent suffering from the chronic and debilitating complications of obesity.

A long journey to effective obesity treatments: is there light at the end of the tunnel?

As the obesity epidemic continues, more Americans are getting fatter, having more weight-related problems such as cardiovascular disease, and are experiencing new metabolic dysfunctions. For over 50 years, the adipose tissue (AT), commonly referred to as fat, has been of interest to academic and clinical scientists, public health officials and individuals interested in body composition and image including much of the average public, athletes, parents, etc. On one hand, efforts to alter body shape, weight and body fat percentage still include bizarre and scientifically unfounded methods. On the other hand, significant new scientific strides have been made in understanding the growth, function and regulation of anatomical and systemic AT. Markers of transition/conversion of precursor cells that mature to form lipid assimilating adipocytes have been identified. Molecular 'master' regulators such as peroxisome proliferator-activated receptor gamma and CCAAT-enhancer-binding proteins were uncovered and regulatory mechanisms behind variables of adiposity defined and refined. Interventions including pharmaceutical compounds, surgical, psychosocial interventions have also been tested. Has all of the preceding research helped alleviate the adverse physiologies of overweight and/or obese people? Does research to date point to new modalities that should be the focus of efforts to rid the world of obesity-related problems in the 21st century? This review provides a general overview of scientific efforts to date and a provocative view of the future for adiposity.

Evaluation of mutagenic effect of two antiobesity drugs on mice's genetic materials

Obesity is a complex, multifactorial disease that, similarly to high blood pressure and diabetes, frequently requires pharmacological treatment with long-term use, suggesting that pattern of use could increase the rates of genetic damage. Among antiobesity drugs, meridia and orlistat act with completely different mechanisms of action. This study aimed to evaluate the mutagenic effect of meridia and orlistat on genetic material of mice by cytogenetic analysis, which included the micronucleus test and chromosomal aberration assay at two doses comparable to propose human therapeutic and double therapeutic doses. Results revealed that the total number of structural chromosomal aberrations in bone marrow cells, with gap, was significantly increased for the two drugs at therapeutic doses. The structural chromosomal aberrations involved breaks, gaps, deletions and fragments, and centric fusion. Chromosomal deletions and fragments were the most frequently increased types of structural chromosomal aberrations. At double therapeutic doses, the treated animals showed a high significant increase of total structural chromosomal aberrations with and without gaps for the two drugs. The frequency of micronucleus in mice treated with therapeutic doses was significantly increased for both drugs. The treated animals at double therapeutic doses showed a positive response for both drugs. In conclusion, treatment with these two drugs at therapeutic doses should be taken under precaution and contraindicated at double therapeutic doses, because the cytogenetic analysis of meridia and orlistat showed an adverse effect on genetic materials at therapeutic doses and a mutagenic effect at double therapeutic doses.