New pharmacological approaches for obesity management

Phentermine involvement in fatal drug overdoses in Tennessee, 2019-2022

INTRODUCTION

Phentermine, one of the most-commonly prescribed pharmaceuticals for weight-loss in the United States (US), has appeared on toxicology and listed as a cause of death in fatal drug overdoses in the state of Tennessee. This study aims to evaluate phentermine's involvement in fatal drug overdoses in the state of Tennessee.

METHODS

We used Tennessee State Unintentional Drug Overdose Reporting System (SUDORS) data and controlled substances monitoring program data (CSMD) to evaluate demographics, prescription history and co-occurring substances on toxicology in phentermine-positive cases compared with all other SUDORS cases from January 1, 2019 to June 30, 2022. A subset of these cases which listed phentermine as a cause of death was also assessed.

RESULTS

We identified 51 phentermine-positive cases, with a subset of 20 that listed phentermine as a cause of death. When compared to all SUDORS cases, a higher proportion of cases that listed phentermine as a cause of death were White race, females, and aged 35-44. Additionally, in all phentermine-positive cases, 41% (21) of decedents had not had a phentermine prescription dating back to 2012 and 20% (Lee et al., 1998) did not have one within the last 30 days. While there was a slight decline each year in the number of phentermine-positive cases, the number of cases that listed phentermine as a cause of death remained relatively consistent, with 95% (19) of cases having different prescriptions and/or illicit drugs listed as a cause of death along with phentermine.

CONCLUSION

Phentermine was listed as a cause of death in 20 fatal drug overdoses in TN. Our findings suggest there may be differences in the characteristics of these decedents when compared to all SUDORS decedents, including distribution of age, gender, and race. We also found a large presence of other prescription and illicit drugs in toxicology and cause of death along with phentermine, as well as evidence of use of the drug without a prescription. Given the lack of currently available data about non-prescribed phentermine use and its involvement in fatal drug overdoses elsewhere, a need exists to both expand surveillance capabilities and broaden research to better inform policies governing this drug in the US and internationally.

Mechanism of Action and Structure-Activity Relationships of Tetracyclic Small Molecules Acting as Universal Positive Allosteric Modulators of the Cholecystokinin Receptor

As part of an ongoing effort to develop a drug targeting the type 1 cholecystokinin receptor (CCK1R) to help prevent and/or treat obesity, we recently performed a high throughput screening effort of small molecules seeking candidates that enhanced the action of the natural agonist, CCK, thus acting as positive allosteric modulators without exhibiting intrinsic agonist action. Such probes would be expected to act in a temporally finite way to enhance CCK action to induce satiety during and after a meal and potentially even modulate activity at the CCK1R in a high cholesterol environment present in some obese patients. The current work focuses on the best scaffold, representing tetracyclic molecules identified through high throughput screening we previously reported. Extensive characterization of the two top "hits" from the previous effort demonstrated them to fulfill the desired pharmacologic profile. We undertook analog-by-catalog expansion of this scaffold using 65 commercially available analogs. In this effort, we were able to eliminate an off-target effect observed for this scaffold while retaining its activity as a positive allosteric modulator of CCK1R in both normal and high cholesterol membrane environments. These insights should be useful in the rational medicinal chemical enhancement of this scaffold and in the future development of candidates to advance to pre-clinical proof-of-concept and to clinical trials.

Anti-obesity weight loss medications: Short-term and long-term use

As obesity prevalence increases, more and more drugs that assist with weight loss have been developed. Numerous weight loss drugs had been approved, but many have also been withdrawn based on their lack of efficacy as well as safety concerns. Initial approaches in developing weight loss drugs was by increasing physiological energy expenditure and suppressing the appetite. Subsequently, as more physiological mechanisms for weight gain has been unearthed, drugs targeting newly discovered receptors and/or enzymes have been introduced with improved safety profiles and fewer psychological adverse events. Additionally, drugs targeting hunger or satiety signaling have been actively studied, and have shown increased adoption by physicians. Studies have also evaluated drugs that target metabolic tissues-such as adipose tissue or muscle-to promote weight loss, however to-date nothing has carried on into clinical practice. Starting with a brief history of early obesity treatments, this review evaluates current weight loss pharmaceutical options based on their duration of therapy status.

Exosomal miR-122 promotes adipogenesis and aggravates obesity through the VDR/SREBF1 axis

OBJECTIVE

This study examined the effects of miR-122-enriched exosomes on the expression of vitamin D3 receptor (VDR) and sterol regulatory element-binding transcription factor 1 (SREBF1) and their roles during adipogenesis.

METHODS

The roles of miR-122, SREBF1, and VDR were investigated during adipogenesis. The relationships between VDR and miR-122 or SREBF1 were assessed by dual-luciferase reporter and chromatin immunoprecipitation assays. The potential role of miR-122/VDR/SREBF1 was evaluated in high-fat diet-induced obese male mice.

RESULTS

High levels of miR-122 were found only in adipose tissue-derived exosomes (Exo-AT) and Exo-AT-treated cells. Overexpression of miR-122 promoted adipogenesis, and inhibition of miR-122 prevented adipogenesis by regulating VDR, SREBF1, peroxisome proliferator-activated receptor gamma, lipoprotein lipase, and adiponectin. Knockdown of Srebf1 or overexpression of VDR could inhibit adipogenesis. However, exosomal miR-122 could reverse their inhibitory effects. The dual-luciferase reporter assay and chromatin immunoprecipitation assays confirmed that VDR was a direct target of miR-122. It could bind to the BS1 region of the SREBF1 promoter and inhibit SREBF1 expression. Moreover, miR-122 inhibition could alleviate obesity in high-fat diet-induced obese male mice, possibly through upregulating the VDR/SREBF1 axis.

CONCLUSION

MiR-122-enriched Exo-AT promoted adipogenesis by regulating the VDR/SREBF1 axis.

In vivo measurement of enhanced agouti-related peptide release in the paraventricular nucleus of the hypothalamus through Gs activation of agouti-related peptide neurons

Agouti-related peptide (AgRP) neurons of the hypothalamus play a role in hunger-triggered food intake, stability of body weight, and long-term energy balance. A recent study showed that activation of the G_s-linked G protein-coupled receptors (GCPR) expressed by hypothalamic AgRP neurons promotes a sustained increase in food intake. Enhanced AgRP release has been the postulated underlying mechanism. Here, we confirmed that activation of G_s-coupled receptors expressed by AgRP neurons in the arcuate nucleus (ARC) of the hypothalamus, which is the primary brain region for the synthesis and release of AgRP, leads to increased release of AgRP in the paraventricular nucleus of the hypothalamus (PVN). We were unable to confirm changes in AgRP expression or intracellular content using traditional histological techniques. Thus, we developed an assay to measure AgRP in the extracellular fluid in the brain using large molecular weight cut-off microdialysis probes. Our technique enables assessment of brain AgRP pharmacokinetics under physiological conditions and in response to specific pharmacological interventions designed to modulate AgRP signaling.

Obesity and the Effects of Weight Reduction: A Spotlight on Women with Hormone Receptor-Positive Breast Cancer and Heart Disease

Obesity is a common overlapping risk factor for cancer and cardiovascular disease (CVD), and the long-term consequences of these chronic, interconnected diseases are severe. The importance of CVD in breast cancer (BC) patients and survivors has been well-established, and the potential impact of some BC treatments (such as cardiotoxic effects related to chemotherapy or targeted therapy with the use of doxorubicin or trastuzumab, and radiation therapy, especially in cases of left breast tumours) on the cardiovascular condition necessitates ongoing cardiological surveillance. In addition, the possible reduction of some underlying risk factors is critical to long-term protection of BC patients and survivors. The concept of obesity dynamically interacting with both BC and CVD is important because it is a modifiable risk factor, and the modern management of obesity deserves emphasis. In particular, for many BC patients and survivors, an effective weight reduction programme integrated with standard anticancer and cardiology therapies can improve patient outcomes. This review presents the complex relationships between overweight, obesity, CVD, and BC risk and highlights outcomes in post and premenopausal women, focussing on patients with hormone receptor-positive BC. The review provides evidence from epidemiologic, observational, and weight loss intervention trials which have examined the effects of weight reduction programmes on BC outcomes. Such studies have indicated that moderate weight loss, with regular physical exercises or stress reduction, can significantly improve BC outcomes. Future lifestyle intervention trials could support the incorporation of weight loss interventions as an integral element of comprehensive management for BC patients and survivors.

Incremental cost-effectiveness of evidence-based non-surgical weight loss strategies

Recent medical advancements have led to new modes of treatment for non-surgical weight loss, including several new medications. Our aim was to conduct an incremental cost-effectiveness analysis for all commercially available, evidence-based non-surgical weight loss interventions for people with excess weight. We identified interventions through a systematic review of randomized controlled trials that reported weight loss 12 months from baseline. We then meta-analysed the results, sourced costs and performed an incremental cost-effectiveness analysis from the payer perspective. Cost-effectiveness was presented in terms of cost per kilogram lost and quality-adjusted life years (QALY) gained. We further performed sensitivity analyses on costs and duration of benefits, and a probabilistic sensitivity analysis. Ten interventions were identified for inclusion: six pharmaceutical products (Alli, Xenical, Qsymia, Contrave, Belviq and Saxenda), two lifestyle modification programmes (Weight Watchers Meetings and Online), one food replacement and lifestyle programme (Jenny Craig) and one intragastric balloon system (Orbera). At an incremental cost-effectiveness ratio of $30 071 per additional QALY gained, only Weight Watchers Meetings was cost-effective. Sensitivity analyses revealed that for the medications to become incrementally cost-effective, costs would have to decrease by as much as 91%. Results are highly dependent on duration that benefits are maintained. Despite several newly available interventions, Weight Watchers Meetings is currently the only evidence-based, commercially available, cost-effective option for non-surgical weight loss. Other interventions, specifically medications, are more effective but priced too high to be cost-effective.

Current Weight Management Approaches Used by Primary Care Providers in Six Multidisciplinary Healthcare Settings in Ontario

BACKGROUND

Obesity management in primary care has been suboptimal due to lack of access to allied health professionals, time, and resources.

PURPOSE

To understand the weight management approaches used by primary care providers working in team-based settings and how they assess the most suitable approach for a patient.

METHODS

A total of 20 primary care providers (13 nurse practitioners and 7 family physicians) working in 6 multidisciplinary clinics in Ontario were interviewed. All interviews were recorded, transcribed verbatim, and coded using NVivo qualitative software. Conventional content analysis was used to inductively elucidate codes, which were then clustered into categories.

RESULTS

A referral to on-site programming was the most frequent weight management approach used. The pharmacological approach was underutilized due to adverse side effects and cost to patients. Primary care providers assessed the most suitable weight management approach based on patients': preference, level of motivation, income status and access to resources, body mass index and comorbidities, and previous weight loss attempts. Primary care providers perceived that referring to health professionals and educational resources were the approaches preferred by patients.

CONCLUSIONS

The team-based nature of these clinics allowed for referrals to various on-site professionals and/or programs. Some barriers to pursuing weight management avenues with patients were patient dependent.

Ginsenoside Rg1 inhibits dietary-induced obesity and improves obesity-related glucose metabolic disorders

Obesity and its consequent type 2 diabetes are significant threats to global health. Emerging evidence indicates that ginsenosides from ginseng (Panax ginseng) have anti-diabetic activity. We hypothesized that ginsenosides Rg1 could suppress dietary-induced obesity and improve obesity-related glucose metabolic disorders. Our results showed that ginsenoside Rg1 attenuated dietary-induced body weight gain and fat accumulation in white adipocyte tissue of mice fed a high-fat diet. Furthermore, we found that ginsenosides Rg1 not only decreased fasting glucose concentration and the 2-h postprandial glucose concentration, but also improved insulin resistance and glucose intolerance in those mice. Ginsenoside Rg1 also activated the AMPK pathway in vitro and in vivo and increased plasma membrane translocation of GLUT4 in C2C12 skeletal muscle cells. In conclusion, our observations suggested that ginsenoside Rg1 inhibited dietary-induced obesity and improved obesity-related insulin resistance and glucose intolerance by activation of the AMPK pathway.

Cholecystokinin-induced satiety, a key gut servomechanism that is affected by the membrane microenvironment of this receptor

The gastrointestinal (GI) tract has a central role in nutritional homeostasis, as location for food ingestion, digestion and absorption, with the gut endocrine system responding to and regulating these events, as well as influencing appetite. One key GI hormone with the full spectrum of these activities is cholecystokinin (CCK), a peptide released from neuroendocrine I cells scattered through the proximal intestine in response to fat and protein, with effects to stimulate gall bladder contraction and pancreatic exocrine secretion, to regulate gastric emptying and intestinal transit, and to induce satiety. There has been interest in targeting the type 1 CCK receptor (CCK1R) for drug development to provide non-caloric satiation as an aid to dieting and weight loss; however, there have been concerns about CCK1R agonists related to side effects and potential trophic impact on the pancreas. A positive allosteric modulator (PAM) of CCK action at this receptor without intrinsic agonist activity could provide a safer and more effective approach to long-term administration. In addition, CCK1R stimulus-activity coupling has been shown to be negatively affected by excess membrane cholesterol, a condition described in the metabolic syndrome, thereby potentially interfering with an important servomechanism regulating appetite. A PAM targeting this receptor could also potentially correct the negative impact of cholesterol on CCK1R function. We will review the molecular basis for binding natural peptide agonist, binding and action of small molecules within the allosteric pocket, and the impact of cholesterol. Novel strategies for taking advantage of this receptor for the prevention and management of obesity will be reviewed.

Liraglutide 3.0 mg for Weight Management: A Population Pharmacokinetic Analysis

BACKGROUND AND OBJECTIVES

This analysis used a population pharmacokinetic approach to identify covariates that influence plasma exposure of liraglutide 3.0 mg, a glucagon-like peptide-1 (GLP-1) receptor agonist approved for weight management in overweight and obese individuals.

METHODS

Samples for pharmacokinetic analysis were drawn at weeks 2, 12 and 28 of the phase IIIa SCALE Obesity and Prediabetes (N = 2339) and SCALE Diabetes (N = 584) trials. Dose proportionality of liraglutide in obese subjects was investigated using data from a phase II dose-finding study (N = 331).

RESULTS

Dose-proportional exposure of liraglutide up to and including 3.0 mg was confirmed. Body weight and sex influenced exposure of liraglutide 3.0 mg, while age ≥70 years, race, ethnicity and baseline glycaemic status did not. Compared with a reference subject weighing 100 kg, exposure of liraglutide 3.0 mg was 44 % lower for a subject weighing 234 kg (90 % CI 41-47), 41 % higher for a subject weighing 60 kg (90 % CI 37-46), and 32 % higher (90 % CI 28-35) in females than males with the same body weight. Neither injection site nor renal function significantly influenced exposure of liraglutide 3.0 mg (post hoc analysis).

CONCLUSION

Population pharmacokinetics of liraglutide up to and including 3.0 mg daily in overweight and obese adults demonstrated dose-proportional exposure, and limited effect of covariates other than sex and body weight. These findings were similar to those previously observed with liraglutide up to 1.8 mg in subjects with type 2 diabetes mellitus. Further analysis of exposure-response relationship and its effect on dose requirements is addressed in a separate publication.

Lorcaserin Administration Decreases Activation of Brain Centers in Response to Food Cues and These Emotion- and Salience-Related Changes Correlate With Weight Loss Effects: A 4-Week-Long Randomized, Placebo-Controlled, Double-Blind Clinical Trial

Lorcaserin is a serotonin 5-hydroxytryptamine 2c receptor agonist effective in treating obesity. Studies in rodents have shown that lorcaserin acts in the brain to exert its weight-reducing effects, but this has not yet been studied in humans. We performed a randomized, placebo-controlled, double-blind trial with 48 obese participants and used functional MRI to study the effects of lorcaserin on the brain. Subjects taking lorcaserin had decreased brain activations in the attention-related parietal and visual cortices in response to highly palatable food cues at 1 week in the fasting state and in the parietal cortex in response to any food cues at 4 weeks in the fed state. Decreases in emotion- and salience-related limbic activity, including the insula and amygdala, were attenuated at 4 weeks. Decreases in caloric intake, weight, and BMI correlated with activations in the amygdala, parietal, and visual cortices at baseline. These data suggest that lorcaserin exerts its weight-reducing effects by decreasing attention-related brain activations to food cues (parietal and visual cortices) and emotional and limbic activity (insula, amygdala). Results indicating that baseline activation of the amygdala relates to increased efficacy suggest that lorcaserin would be of particular benefit to emotional eaters.

Fatty Acid Transport Proteins: Targeting FATP2 as a Gatekeeper Involved in the Transport of Exogenous Fatty Acids

The fatty acid transport proteins (FATP) are classified as members of the Solute Carrier 27 (Slc27) family of proteins based on their ability to function in the transport of exogenous fatty acids. These proteins, when localized to the plasma membrane or at intracellular membrane junctions with the endoplasmic reticulum, function as a gate in the regulated transport of fatty acids and thus represent a therapeutic target to delimit the acquisition of fatty acids that contribute to disease as in the case of fatty acid overload. To date, FATP1, FATP2, and FATP4 have been used as targets in the selection of small molecule inhibitors with the goal of treating insulin resistance and attenuating dietary absorption of fatty acids. Several studies targeting FATP1 and FATP4 were based on the intrinsic acyl CoA synthetase activity of these proteins and not on transport directly. While several classes of compounds were identified as potential inhibitors of fatty acid transport, in vivo studies using a mouse model failed to provide evidence these compounds were effective in blocking or attenuating fatty acid transport. Studies targeting FATP2 employed a naturally occurring splice variant, FATP2b, which lacks intrinsic acyl CoA synthetase due to the deletion of exon 3, yet is fully functional in fatty acid transport. These studies identified two compounds, 5'-bromo-5-phenyl-spiro[3H-1,3,4-thiadiazole-2,3'-indoline]-2'-one), now referred to as Lipofermata, and 2-benzyl-3-(4-chlorophenyl)-5-(4-nitrophenyl)pyrazolo[1,5-a]pyrimidin-7(4H)-one, now called Grassofermata, that are effective fatty acid transport inhibitors both in vitro using a series of model cell lines and in vivo using a mouse model.

Intestinal removal of free fatty acids from hosts by Lactobacilli for the treatment of obesity

Recent findings on the association of gut microbiota with various diseases, including obesity, prompted us to investigate the possibility of using a certain type of gut bacteria as a safe therapeutic for obesity. Lactobacillus mutants with enhanced capacity in absorption of free fatty acids (FFAs) were isolated to show reduced absorption of FFAs by the administered host, attributing to inhibition of body weight gain and body fat accumulation as well as amelioration of blood profiles. Consequently, high throughput screening of natural FFAs‐absorbing intestinal microbes led to the isolation of Lactobacillus reuteri JBD30 l. The administration of Lactobacillus JBD30l lowered the concentration of FFAs in the gut fluid content of small intestine, thus reducing intestinal absorption of FFAs whereas promoting fecal excretion of FFAs. Animal data also confirmed that the efficacy of Lactobacillus JBD30l on body weight similar to that of orlistat, an FDA‐approved pharmaceutical for long‐term use to treat obesity. In a subsequent random, double‐blind, placebo‐controlled clinical trial (KCT0000452 at Clinical Research Information Service of Korea), there was a statistically significant difference in the percentage change in body weight between the Lactobacillus JBD301 and the placebo group (P = 0.026) as well as in the BMI (P = 0.036) from the 0‐week assessment to the 12‐week assessment. Our results show that FFA‐absorbing Lactobacillus JBD301 effectively reduces dietary fat absorption, providing an ideal treatment for obesity with inherent safety.

Next generation of weight management medications: implications for diabetes and CVD risk

Since the 1980s, the prevalence of obesity has almost doubled worldwide. Treatments for obesity include lifestyle modification, medications and surgery. Newer anti-obesity medications have been shown to be effective at inducing initial weight management in addition to successful long-term weight maintenance. Historically, weight management medications have been associated with public safety concerns that have resulted in the majority being withdrawn from the market or never receiving medicinal authorization. Recently, several countries have approved some newer generation weight management medications which may be beneficial to combat obesity. These medications have varying effects on cardiometabolic parameters, both positive and potentially negative. This review will outline the mechanisms of action of these medications and their implications for both diabetes and cardiovascular risks.

Pharmacotherapy for the treatment of obesity

The recognition of the complex counter-regulatory hormonal, metabolic and neurochemical mechanisms that promote weight regain following weight loss and the conceptualisation of obesity as a chronic disease requiring long-term management has led to increasing focus on the role of adjunctive therapies for obesity, particularly pharmacotherapy. Currently available pharmacotherapy achieves a weight loss intermediate between that commonly attained by lifestyle intervention and bariatric surgery, however its accessibility, compared to bariatric surgery increases its appeal. Despite the poor history of obesity pharmacotherapy, novel agents that are in development appear to have several advantages over predecessors. They are generally more selective in their mechanism of action, thereby potentially minimising adverse sequelae and improving the risk-benefit ratio of pharmacotherapy. Another approach has been to use combined pharmacotherapy to better counteract the multiple counter-regulatory neuroendocrine mechanisms which promote weight regain, as well as allowing lower constituent doses of the combined monotherapy agents, which improves the safety and tolerability of these agents that are usually required long-term for chronic weight maintenance. This review will provide an overview of past, present and future pharmacotherapy for obesity. The efficacy and safety profile of currently available pharmacotherapy will be discussed in the setting of stringent regulatory review processes now in place given the fraught history of pharmacological interventions for obesity. Potential novel therapies that seek to better target the multiple complex counter-regulatory mechanisms promoting weight regain while improving the efficacy/safety profile, will also be examined.

Dual melanocortin-4 receptor and GLP-1 receptor agonism amplifies metabolic benefits in diet-induced obese mice

We assessed the efficacy of simultaneous agonism at the glucagon-like peptide-1 receptor (GLP-1R) and the melanocortin-4 receptor (MC4R) for the treatment of obesity and diabetes in rodents. Diet-induced obese (DIO) mice were chronically treated with either the long-acting GLP-1R agonist liraglutide, the MC4R agonist RM-493 or a combination of RM-493 and liraglutide. Co-treatment of DIO mice with RM-493 and liraglutide improves body weight loss and enhances glycemic control and cholesterol metabolism beyond what can be achieved with either mono-therapy. The superior metabolic efficacy of this combination therapy is attributed to the anorectic and glycemic actions of both drugs, along with the ability of RM-493 to increase energy expenditure. Interestingly, compared to mice treated with liraglutide alone, hypothalamic Glp-1r expression was higher in mice treated with the combination therapy after both acute and chronic treatment. Further, RM-493 enhanced hypothalamic Mc4r expression. Hence, co-dosing with MC4R and GLP-1R agonists increases expression of each receptor, indicative of minimized receptor desensitization. Together, these findings suggest potential opportunities for employing combination treatments that comprise parallel MC4R and GLP-1R agonism for the treatment of obesity and diabetes.

Obesity Education Strategies for Cancer Prevention in Women's Health

Obesity is the cause of up to one-third of all cancers affecting women today, most notably endometrial, colon and breast cancer. Women's health providers are poised to advise women on obesity's link to cancer development, but often lack resources or training to provide appropriate counseling. Here, we review obesity's role in increasing the risk of several common reproductive system conditions faced by women, including polycystic ovarian syndrome, infertility, gynecologic surgical complications, and pregnancy complications. These events can be used as teachable moments to help frame the discussion of weight management and promote cancer prevention. We also review national guidelines and existing tangible weight-loss strategies that can be employed within the outpatient women's health setting to help women achieve weight loss goals and affect cancer prevention.

Obesity medications: what does the future look like?

PURPOSE OF REVIEW

Lifestyle modification remains the mainstay of treatment for obesity despite the lack of substantial long-term efficacy. For many who do not respond to lifestyle therapy and are not candidates for weight loss surgery, pharmacotherapy is a viable treatment option. Advances in understanding mechanisms of appetite control, nutrient sensing, and energy expenditure have not only helped shape current drug development but have also changed the way in which antiobesity medications are prescribed. Current antiobesity medications and pharmacological strategies will be reviewed.

RECENT FINDINGS

Two new antiobesity drugs - naltrexone/bupropion (Contrave) and liraglutide (Saxenda) - were approved by the US Food and Drug Administration in 2014 and join four other approved obesity medications, including phentermine/topiramate XR (Qsymia) and lorcaserin (Belviq), to form the largest number of medications available for the treatment of obesity. In addition, investigational drugs, like belnoranib, show promise in early clinical trials, brightening the outlook on drug development.

SUMMARY

To combat the complex physiological system of energy regulation and the known variation of treatment response, combinatory therapies for obesity, including pharmacotherapy, are needed. Now six US Food and Drug Administration-approved antiobesity medications, including two combination medications, will allow providers to tailor obesity treatment in combination with lifestyle modification for a great number of individuals with obesity.

The long-term effect of energy restricted diets for treating obesity

OBJECTIVE

To quantify the effectiveness of diet interventions by systematic review of the long-term effects of energy restricted diets in individuals with overweight and obesity.

METHODS

A systematic literature search was conducted for all clinical trials studying the effect of energy restricted diets on body weight in individuals with a BMI>25 kg/m(2) with a follow-up of at least 3 years and a minimum of 50 participants. Weight change from baseline and rates of loss to follow-up at the longest follow-up were extracted and analyzed using random-effects models.

RESULTS

Weighted mean weight loss after 3 years follow-up was 3.5% (95% CI 0.2-6.8%) (n = 6,163) and after 4 years follow-up 4.5% (95% CI 4.3-4.8%) (n = 5,696). Energy restricted diets (n = 1,433) resulted in an average 2.9% (95% CI -3.8 to -2.1%) greater weight loss compared to untreated control groups (n = 1,361). Weight regain was observed in the majority of individuals in all studies. Interpretation of the data is limited by high rates of loss to follow-up and lack of truly untreated control groups.

CONCLUSIONS

On average, the long-term effect of diets on body weight in individuals with obesity is modest, and the response is highly heterogeneous.

Gremlin 2 inhibits adipocyte differentiation through activation of Wnt/β-catenin signaling

The primary function of white adipose tissues is to store excess energy. The current study aimed to investigate the roles of Gremlin 2 (Grem2), a glycoprotein in adipogenesis. Using polymerase chain reaction‑based microarrays, it was determined that Grem2 was markedly downregulated in adipose tissues from obese animals and humans. In addition, 3T3‑L1 cells were used to investigate the details of the mechanisms underlying the anti‑adipogenic effects of Grem2. Grem2 expression was markedly decreased upon the induction of adipocyte differentiation, as demonstrated by reverse transcription‑quantitative polymerase chain reaction and western blot analysis. Notably, Grem2 overexpression inhibited adipogenesis, while knockdown of Grem2 led to an increase in adipogenesis. At the molecular level, Grem2 promotes nuclear translocation of β‑catenin, an integral Wnt signaling component. Consistently, inhibition of Wnt/β‑catenin signaling using a retrovirus targeting the β‑catenin coding region attenuated the anti‑adipogenic effects of Grem2. Therefore, to the best of our knowledge, the current study shows for the first time that Grem2 may be an important regulator of adipocyte differentiation.

Weight management in type 2 diabetes: current and emerging approaches to treatment

Diabetes is a growing global health concern, as is obesity. Diabetes and obesity are intrinsically linked: obesity increases the risk of diabetes and also contributes to disease progression and cardiovascular disease. Although the benefits of weight loss in the prevention of diabetes and as a critical component of managing the condition are well established, weight reduction remains challenging for individuals with type 2 diabetes due to a host of metabolic and psychological factors. For many patients, lifestyle intervention is not enough to achieve weight loss, and alternative options, such as pharmacotherapy, need to be considered. However, many traditional glucose-lowering medications may lead to weight gain. This article focuses on the potential of currently available pharmacological strategies and on emerging approaches in development to support the glycemic and weight-loss goals of individuals with type 2 diabetes. Two pharmacotherapy types are considered: those developed primarily for blood glucose control that have a favorable effect on body weight and those developed primarily to induce weight loss that have a favorable effect on blood glucose control. Finally, the potential of combination therapies for the management of obese patients with type 2 diabetes is discussed.

Current and Emerging Treatment Options in Diabetes Care

Diabetes constitutes an increasing threat to human health, particularly in newly industrialized and densely populated countries. Type 1 and type 2 diabetes arise from different etiologies but lead to similar metabolic derangements constituted by an absolute or relative lack of insulin that results in elevated plasma glucose. In the last three decades, a set of new medicines built upon a deeper understanding of physiology and diabetic pathology have emerged to enhance the clinical management of the disease and related disorders. Recent insights into insulin-dependent and insulin-independent molecular events have accelerated the generation of a series of novel medicinal agents, which hold the promise for further advances in the management of diabetes. In this chapter, we provide a historical context for what has been accomplished to provide perspective for future research and novel emerging treatment options.

Combating the dual burden: therapeutic targeting of common pathways in obesity and type 2 diabetes

The increasing prevalence of obesity is contributing substantially to the ongoing epidemic of type 2 diabetes. Abdominal adiposity, a feature of ectopic fat syndrome, is associated with silent inflammation, abnormal hormone secretion, and various metabolic disturbances that contribute to insulin resistance and insulin secretory defects, resulting in type 2 diabetes, and induce a toxic pattern that leads to cardiovascular disease, liver pathologies, and cancer. Despite the importance of weight control strategies in the prevention and management of type 2 diabetes, long-term results from lifestyle or drug interventions are generally disappointing. Furthermore, most of the classic glucose-lowering drugs have a side-effect of weight gain, which renders the management of most overweight or obese people with type 2 diabetes even more challenging. Many anti-obesity pharmacological drugs targeting central control of appetite were withdrawn from the market because of safety concerns. The gastrointestinal lipase inhibitor orlistat was the only anti-obesity drug available until the recent US, but not European, launch of phentermine-controlled-release topiramate and lorcaserin. Improved knowledge about bodyweight regulation opens new prospects for the potential use of peptides derived from the gut or the adipose tissue. Combination therapy will probably be necessary to avoid compensatory mechanisms and potentiate initial weight loss while avoiding weight regain. New glucose-lowering treatments, especially glucagon-like peptide-1 receptor agonists and sodium glucose cotransporter-2 inhibitors, offer advantages over traditional antidiabetic drugs by promoting weight loss while improving glucose control. In this Review, we explore the overlapping pathophysiology and also how various treatments can, alone or in combination, combat the dual burden of obesity and type 2 diabetes.

Naltrexone sustained-release/bupropion sustained-release for the management of obesity: review of the data to date

Obesity is an emerging disease worldwide. Changes in living habits, especially with increased consumption of high-calorie foods and decreased levels of physical activity, lead to an energy imbalance that brings weight gain. Overweight and obesity are major risk factors for several chronic diseases (including cardiovascular diseases, diabetes, and cancer), reduce quality of life, and are associated with higher mortality. For all these reasons, it is of the utmost importance that the trend be reversed and obese people enabled to lose weight. It is known that eating a healthy diet and exercising regularly can help prevent obesity, but data show that in many cases these steps are not enough. This is the reason why, over the last few decades, several antiobesity drugs have been developed. However, the disappointing results demonstrated for the vast majority of them have not discouraged the pharmaceutical industry from continuing to look for an effective drug or combination of drugs. The systematic review presented here focuses on naltrexone sustained-release/bupropion sustained-release combination (Contrave^®). We conclude from the current published reports that its effectiveness in the treatment of obesity can be estimated as a placebo-subtracted weight loss of around 4.5%. This weight reduction is moderate but similar to other antiobesity drugs. The safety profile of this combination is acceptable, despite additional data regarding cardiovascular disease being needed.

Regulation of obesity and insulin resistance by nitric oxide

Obesity is a risk factor for developing type 2 diabetes and cardiovascular disease and has quickly become a worldwide pandemic with few tangible and safe treatment options. Although it is generally accepted that the primary cause of obesity is energy imbalance, i.e., the calories consumed are greater than are utilized, understanding how caloric balance is regulated has proven a challenge. Many "distal" causes of obesity, such as the structural environment, occupation, and social influences, are exceedingly difficult to change or manipulate. Hence, molecular processes and pathways more proximal to the origins of obesity-those that directly regulate energy metabolism or caloric intake-seem to be more feasible targets for therapy. In particular, nitric oxide (NO) is emerging as a central regulator of energy metabolism and body composition. NO bioavailability is decreased in animal models of diet-induced obesity and in obese and insulin-resistant patients, and increasing NO output has remarkable effects on obesity and insulin resistance. This review discusses the role of NO in regulating adiposity and insulin sensitivity and places its modes of action into context with the known causes and consequences of metabolic disease.

Obesity and outpatient rehabilitation using mobile technologies: the potential mHealth approach

Obesity is currently an important public health problem of epidemic proportions (globesity). Inpatient rehabilitation interventions that aim at improving weight-loss, reducing obesity-related complications and changing dysfunctional behaviors, should ideally be carried out in a multidisciplinary context with a clinical team composed of psychologists, dieticians, psychiatrists, endocrinologists, nutritionists, physiotherapists, etc. Long-term outpatient multidisciplinary treatments are likely to constitute an essential aspect of rehabilitation. Internet-based technologies can improve long-term obesity rehabilitation within a collaborative approach by enhancing the steps specified by psychological and medical treatment protocols. These outcomes may be augmented further by the mHealth approach, through creating new treatment delivery methods to increase compliance and engagement. mHealth (m-health, mobile health) can be defined as the practice of medicine and public health, supported by mobile communication devices for health services and information. mHealth applications which can be implemented in weight loss protocols and obesity rehabilitation are discussed, taking into account future research directions in this promising area.

New centrally acting agents for appetite control: from biological mechanisms to clinical efficacy

BACKGROUND

Obesity is one of the major problems of health policy in different countries. Pharmacological attempts have been made to help affected people without a definitive solution. Some agents--either with peripheral or central effect--are available in the market. On July 2012, the FDA approved two novel preparations for obese patients: (1) topiramate-phentermine--the first one an anticonvulsant and the second one a sympathomimetic amine--and (2) lorcaserin, a 5-HT2CR agonist. Both preparations emerged as new options for weight management.

SCOPE

Based on the complex biology of eating behavior, in this review we discuss the features, mechanisms of action, pharmacokinetics, advantages and possible disadvantages of these new agents.

CONCLUSION

With differences in efficacy (higher for the topiramate-phentermine combination), both preparations are active in reducing appetite and body weight, as well as in improving comorbidities. Additional information will be collected from Phase IV surveillance. Focus on cardiovascular, neuropsychiatric (for both introductions) and embrio-fetal safety (especially for topiramate) is expected.

Peripheral targets in obesity treatment: a comprehensive update

Obesity is a major epidemic of our time and is associated with diseases such as metabolic syndrome, type 2 diabetes mellitus and atherosclerotic cardiovascular disease. Although weight loss drugs, when accompanied by diet and exercise, could be a very helpful medical tool in treating obese or overweight patients, their usefulness has been questioned due to the complexity of this type of medication, which regards a plethora of issues such as efficacy and safety of the drug and also risks and benefits among different patients. In general, obesity drugs that target peripheral pathophysiological mechanisms can be divided into two main categories. The first category includes anti-obesity agents able to reduce or limit energy absorption, such as pancreatic lipase and microsomal triglyceride transfer protein inhibitors. The second category consists of a heterogeneous group of compounds aiming to decrease fat mass by increasing energy expenditure or by redistributing adipose tissue. Angiogenesis inhibitors, beta-3 receptor agonists, sirtuin-I activators, diazoxide and other molecules belong to this group. The glucagon-like peptide-1 receptor agonists consist the third category of peripheral anti-obesity agents discussed therein. This review aims to provide a general overview of the molecules and substances that are already or could potentially be used as peripheral anti-obesity drugs, the molecular mechanisms by which they act, as well as their current stage of development, production and/or availability.

Management of obesity and cardiometabolic risk - role of phentermine/extended release topiramate

The US Food and Drug Administration (FDA) recently approved lorcaserin and the combination of phentermine and extended release topiramate (phentermine/topiramate ER) for the treatment of obesity in conjunction with a lifestyle intervention, expanding the therapeutic options for long-term obesity pharmacotherapy, which was previously limited to orlistat. Combination phentermine/topiramate ER is associated with greater weight loss compared to its constituent monotherapy, with a more favorable adverse effect profile. Phentermine/topiramate ER also appears to have beneficial effects on cardiometabolic risk, although longer-term cardiovascular safety data are required. While there are no head-to-head studies among the currently available obesity pharmacotherapy agents, phentermine/topiramate ER appears to have a superior weight loss profile. This review will discuss the epidemiology, natural history, and cardiometabolic risk associated with obesity, provide an overview on current obesity pharmacotherapy, and summarize the recent clinical efficacy and safety data underpinning the FDA's approval of both phentermine/topiramate ER and lorcaserin as pharmacotherapy for a long-term obesity intervention.

Anti-obesity activity of hen egg anti-lipase immunoglobulin yolk, a novel pancreatic lipase inhibitor

BACKGROUND

There is completely no report about both hen egg anti-lipase immunoglobulin yolk (IgY) and its anti-obesity action. Thus, we tried to isolate and characterize a novel anti-lipase immunoglobulin from hen egg yolk. Moreover, we investigated whether hen egg yolk anti-lipase IgY inhibits pancreatic lipase activity in vitro, and examined its ability to prevent obesity in a murine high fat diet-induced obesity model.

METHODS

We determined the inhibitory action of Anti-lipase IgY on lipase activity in vitro. We also focused our evaluation on the anti-obesity properties of Anti-lipase IgY in a murine high fat diet-induced obesity model.

RESULTS

Anti-lipase IgY blocked porcine lipase activity with an IC50 of 0.49 μM. Supplementing the high fat diet with only 0.2% (w/w) of Anti-lipase IgY for 35 days significantly decreased the weights of intraperitoneal adipose tissues, epididymal, mesenteric, retroperitoneal and perirenal adipose tissues, and the amounts of hepatic total lipid, triglyceride, and cholesterol. This was accompanied by a significant increase in the fecal excretion of triglyceride in the absence of diarrhea. Furthermore, Anti-lipase IgY treatment restored body weight gain to levels similar to mice fed with Control IgY.

CONCLUSIONS

This study provides the first report of the development of anti-lipase IgY and the direct evidence that inhibition of pancreatic lipase using Anti-lipase IgY is an effective anti-obesity treatment due to the associated increase in fecal excretion of triglyceride.