Maintained intentional weight loss reduces cardiovascular outcomes: results from the Sibutramine Cardiovascular OUTcomes (SCOUT) trial

Pharmacotherapy for obesity: moving towards efficacy improvement

Obesity is a chronic, recurring, progressive disease and a major public health problem associated with several other diseases that lead to disability, morbidity, and mortality. The prevalence of obesity has increased at pandemic levels, along with increasing weight-related comorbidities and deaths worldwide. Lifestyle interventions alone provide clinically significant long-term weight loss in only a small proportion of individuals, and bariatric surgery is not suitable or desirable for all patients. Historically, anti-obesity medications achieved a mean efficacy with weight loss between 5 and 10%, which significantly impacted several comorbidities and risk factors, but the average efficacy of these medications remained lower than that expected by both patients and health care professionals and eventually curbed long-term use. Moreover, there is no direct evidence on the impact of anti-obesity medications on cardiovascular outcomes. Semaglutide is a newer anti-obesity medication that changes the overall landscape, as phase 3 studies show a mean weight loss near the 15% threshold and significant proportions of patients with a weight loss of greater than 20%. In this review, we focus on the currently available anti-obesity medications, discuss the results of semaglutide, and present perspectives on the future of obesity treatment after semaglutide.

Down the rabbit hole: reviewing the evidence for primary prevention of cardiovascular disease in people with obesity

Obesity is a prevalent chronic disorder and a well-known risk factor for cardiovascular disease. However, the evidence of treating obesity for primary prevention of major cardiovascular events is still scarce and controversial. In this review, we provided a comprehensive description of the current evidence in treating obesity regarding cardiovascular protection. Bariatric surgery appears to be the most robust method to reduce events in people without established cardiovascular disease. High compliance to lifestyle interventions can further reduce cardiovascular risk. Concerning pharmacological therapies, a post hoc analysis from SUSTAIN-6 and a meta-analysis from STEP trials suggest that semaglutide, a GLP-1 receptor agonist, could reduce cardiovascular events in people without established cardiovascular disease. The first study addressed specifically a high-risk population with diabetes and, the second, low- or intermediary-risk individuals without diabetes. Tirzepatide, a novel dual GIP/GLP-1 agonist, although not yet tested in specific cardiovascular outcomes trials, could be an alternative since it induces loss in weight similar to the achieved by bariatric surgery. Therefore, extrapolated data in distinct baseline cardiovascular risk populations suggest that these two drugs could be used in primary prevention with the aim of preventing cardiovascular events, but the grade of this evidence is still low. Specifically designed studies are needed to address this specific topic.

Recent advancements in pharmacological strategies to modulate energy balance for combating obesity

The prevalence of obesity along with its related metabolic diseases has increased globally in recent decades. Obesity originates from a heterogeneous physiological state, which is further complicated by the influence of factors such as genetic, behavioural, and environmental. Lifestyle interventions including exercise and diet have limited success, necessitating the development of pharmacological approaches. Mechanistically, strategies target either reducing energy intake or increasing consumption through metabolism boosting. Current drugs lower energy intake via inducing satiety or inhibiting substrate absorption, while targeting mitochondria or cytosolic energy sensors has shown limited success due to toxicity. Nonshivering thermogenesis (NST) has provided hope for activating these processes selectively without significant side effects. The internet-based marketing of plant-based formulations for enhancing metabolism has surged. This review compiles scientific articles, magazines, newspapers, and online resources on anti-obesity drug development. Combination therapy of metabolic boosters and established anti-obesity compounds appears to be a promising future approach that requires further research.

5-HT2C Receptor Stimulation in Obesity Treatment: Orthosteric Agonists vs. Allosteric Modulators

Obesity is a substantial health and economic issue, and serotonin (5-hydroxytryptamine, 5-HT) is an important neurotransmitter system involved in the regulation of body weight. The 5-HT2C receptors (5-HT2CRs), one of 16 of the 5-HT receptor (5-HTRs) subtypes, play a significant role in food intake and body weight control. In this review, we focused on the 5-HTR agonists, such as fenfluramines, sibutramine, and lorcaserin, which act directly or indirectly at 5-HT2CRs and have been introduced into the clinic as antiobesity medications. Due to their unwanted effects, they were withdrawn from the market. The 5-HT2CR positive allosteric modulators (PAMs) can be potentially safer active drugs than 5-HT2CR agonists. However, more in vivo validation of PAMs is required to fully determine if these drugs will be effective in obesity prevention and antiobesity pharmacology treatment. Methodology strategy: This review focuses on the role of 5-HT2CR agonism in obesity treatment, such as food intake regulation and weight gain. The literature was reviewed according to the review topic. We searched the PubMed and Scopus databases and Multidisciplinary Digital Publishing Institute open-access scientific journals using the following keyword search strategy depending on the chapter phrases: (1) “5-HT2C receptor” AND “food intake”, and (2) “5-HT2C receptor” AND “obesity” AND “respective agonists”, and (3) “5-HT2C receptor” AND “PAM”. We included preclinical studies (only present the weight loss effects) and double-blind, placebo-controlled, randomized clinical trials published since the 1975s (mostly related to antiobesity treatment), and excluded the pay-walled articles. After the search process, the authors selected, carefully screened, and reviewed appropriate papers. In total, 136 articles were included in this review.

Signaling pathways in obesity: mechanisms and therapeutic interventions

Obesity is a complex, chronic disease and global public health challenge. Characterized by excessive fat accumulation in the body, obesity sharply increases the risk of several diseases, such as type 2 diabetes, cardiovascular disease, and nonalcoholic fatty liver disease, and is linked to lower life expectancy. Although lifestyle intervention (diet and exercise) has remarkable effects on weight management, achieving long-term success at weight loss is extremely challenging, and the prevalence of obesity continues to rise worldwide. Over the past decades, the pathophysiology of obesity has been extensively investigated, and an increasing number of signal transduction pathways have been implicated in obesity, making it possible to fight obesity in a more effective and precise way. In this review, we summarize recent advances in the pathogenesis of obesity from both experimental and clinical studies, focusing on signaling pathways and their roles in the regulation of food intake, glucose homeostasis, adipogenesis, thermogenesis, and chronic inflammation. We also discuss the current anti-obesity drugs, as well as weight loss compounds in clinical trials, that target these signals. The evolving knowledge of signaling transduction may shed light on the future direction of obesity research, as we move into a new era of precision medicine.

Effects of Ephedrine-Containing Products on Weight Loss and Lipid Profiles: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Ephedrine, the main active ingredient of mahuang, may lead to weight loss; however, it can also induce cardiovascular side effects. As ephedrine use remains controversial, this study aimed to systematically review previous studies on ephedrine-containing products and perform meta-analysis of the existing evidence on weight, blood pressure (BP), heart rate, and lipid change effects of ephedrine-containing products. We searched for placebo-controlled randomized studies in PubMed, Web of Science, and EMBASE until July 2021 using the following search terms: (ephedr* OR mahuang) AND (“weight loss” OR obes* OR overweight). Mean differences (MDs) and 95% confidence intervals (CIs) were calculated to evaluate the effects of ephedrine-containing products on weight, BP, heart rate, and lipid profiles. A total of 10 articles were included. Compared with the placebo group, the ephedrine-containing product group was associated with greater weight loss, with an MD of −1.97 kg (95% CI: −2.38, −1.57). In the ephedrine-containing product group, the mean heart rate was 5.76 beats/min higher than in the placebo group (95% CI: 3.42, 8.10), whereas intergroup differences in systolic and diastolic BP were not statistically significant. The ephedrine-containing product group had a significantly higher mean high-density lipoprotein cholesterol level (MD: 2.74 mg/dL; 95% CI: 0.94, 4.55), lower mean low-density lipoprotein cholesterol level (MD: −5.98 mg/dL; 95% CI: −10.97, −0.99), and lower mean triglyceride level (MD: −11.25 mg/dL; 95% CI: −21.83, −0.68) than the placebo group. Compared with placebo, the ephedrine-containing products showed better effects on weight loss and lipid profiles, whereas they caused increased heart rate. The ephedrine-containing products may be beneficial to obese or overweight patients; however, close monitoring is needed, especially heart rate monitoring.

Management of Obesity in Cardiovascular Practice: JACC Focus Seminar

Obesity contributes to reduced life expectancy because of its link with type 2 diabetes and cardiovascular disease. Yet, targeting this poorly diagnosed, ill-defined, and underaddressed modifiable risk factor remains a challenge. In this review, we emphasize that the tendency among health care professionals to amalgam all forms of obesity altogether as a single entity may contribute to such difficulties and discrepancies. Obesity is a heterogeneous condition both in terms of causes and health consequences. Attention should be given to 2 prevalent subgroups of individuals: 1) patients who are overweight or moderately obese with excess visceral adipose tissue; and 2) patients with severe obesity, the latter group having distinct additional health issues related to their large body fat mass. The challenge of tackling high-cardiovascular-risk forms of obesity through a combination of personalized clinical approaches and population-based solutions is compounded by the current obesogenic environment and economy.

Efficacy of dietary supplements containing isolated organic compounds for weight loss: a systematic review and meta-analysis of randomised placebo-controlled trials

BACKGROUND/OBJECTIVES

A systematic review with meta-analysis was conducted to synthesise evidence on the efficacy of dietary supplements containing isolated organic compounds for weight loss.

SUBJECTS/METHODS

Four electronic databases (Medline, Embase, Web of Science, Cinahl) were searched until December 2019. Sixty-seven randomised placebo-controlled trials of dietary supplements containing isolated organic compounds for weight loss were included. Meta-analyses were conducted for chitosan, glucomannan, conjugated linoleic acid and fructans, comparing mean weight difference post-intervention between participants receiving the dietary supplement or placebo.

RESULTS

Statistically significant weight differences compared to placebo were observed for chitosan (-1.84 kg; 95% confidence interval [CI] -2.79, -0.88; p < 0.01), glucomannan (-1.27 kg; 95%CI -2.45, -0.09; p = 0.04), and conjugated linoleic acid (-1.08 kg; 95%CI -1.61, -0.55; p < 0.01). None met our threshold for clinical significance (≥2.5 kg). There was no statistically significant effect on weight for fructans compared to placebo (p = 0.24). For dietary supplements with an inadequate number of trials for meta-analysis, a statistically and borderline clinically significant weight difference compared to placebo was found for modified cellulose, manno-oligosaccharides (in males), blood orange juice extract, and three multiple-ingredient dietary supplements. These were only reported in one trial of each. Thus, more evidence is needed before recommending them for weight loss.

CONCLUSIONS

While some dietary supplements containing isolated organic compounds warrant further investigation to determine efficacy and safety, there is currently insufficient evidence to recommend any of these dietary supplements for weight loss.

Cardiovascular safety of long-term anti-obesity drugs in subjects with overweight or obesity: a systematic review and meta-analysis

PURPOSE

Anti-obesity therapy can reduce body weight; however, it is not clear whether it can reduce major adverse cardiovascular events (MACEs). We conducted a systematic review and meta-analysis to assess the effect of long-term anti-obesity drugs on MACEs in individuals with overweight or obesity.

METHODS

The MEDLINE, Embase, and Cochrane Library databases and clinical trial registries ( https://clinicaltrials.gov ) were searched up to 3 May 2021 for randomized controlled trials (RCT) that compared anti-obesity drugs with controls and reported cardiovascular events in subjects with overweight or obesity. Heterogeneity was described by the I² value. The Mantel-Haenszel randomized effects model was adopted to calculate risk ratios (RR) and weighted mean differences (WMD). Sensitivity analysis was used to assess the stability of the effects. Publication bias was assessed by Begg's funnel plot and Egger's test. The Cochrane Collaboration risk-of-bias tool was used to evaluate the bias of each included RCT.

RESULTS

Twelve articles were included; 21,391 and 17,618 subjects were in the anti-obesity drug and placebo groups, respectively. There was no difference in MACEs between the anti-obesity drug and placebo groups (RR 0.99; 95% CI: 0.88-1.12). Compared with placebo, anti-obesity interventions reduced body weight (WMD: - 3.96 kg; 95% CI: - 4.89, - 3.03) and improved lipid and blood glucose profiles. The intervention also did not increase the incidence of depression or anxiety or the risk of suicidal ideation.

CONCLUSION

Long-term anti-obesity drugs did not show a benefit in lowering MACEs in overweight or obese subjects, although the drugs resulted in a decrease in body weight and improved cardiometabolic parameters.

Clinical Impact of Weight-Loss Pharmacotherapy in Patients with Atherosclerotic Cardiovascular Disease

Obesity is associated with the development and progression of multiple cardiovascular risk factors, such as hypertension, dyslipidemia, and type 2 diabetes mellitus, and is an important contributor to the global burden of atherosclerotic cardiovascular disease (CVD). Guidelines suggest that clinicians provide lifestyle counseling and promote lifestyle modifications before considering weight-loss surgery. However, despite lifestyle modifications and increased physical activity, most patients with obesity will not lose significant weight or will experience weight regain. Weight-loss pharmacotherapy added to lifestyle modification has long been perceived as a bridge between lifestyle modifications alone and weight-loss surgery. However, since its inception, weight-loss pharmacotherapy has been plagued by variable efficacy and concern about cardiovascular safety. Following requirements from regulatory authorities, efficacy and cardiovascular safety trials have been conducted for the currently available weight-loss pharmacotherapeutic agents. Overall, these trials have shown that weight-loss pharmacotherapy is only modestly efficient for the inducement of weight loss. Recent trials have also demonstrated the cardiovascular safety of some of these agents. We review these trials with a focus on the clinical impact of these weight-loss pharmacotherapeutic agents in patients with atherosclerotic CVD.

Cardiovascular Risk Reduction Following Metabolic and Bariatric Surgery

Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality in developed countries, with worsening pandemics of type 2 diabetes mellitus and obesity as major cardiovascular (CV) risk factors. Clinical trials of nonsurgical obesity treatments have not shown benefits in CVD, although recent diabetes trials have demonstrated major CV benefits. In many retrospective and prospective cohort studies, however, metabolic (bariatric) surgery is associated with substantial and reproducible CVD benefits. Despite a lack of prospective, randomized clinical trials, data suggest metabolic surgery may be the most effective modality for CVD risk reduction, likely through weight loss and weight loss-independent mechanisms.

Cardiovascular outcome trials in obesity: A review

Obesity is a global epidemic associated with over 200 health complications and a significant risk of developing cardiovascular disease (CVD), partly by increasing classical risk factors such as lipid and glucose levels and blood pressure. Weight loss through lifestyle interventions, pharmacotherapy and/or bariatric surgery improves CV risk factors. Cardiovascular outcome trials (CVOTs) of anti-obesity medications aim to evaluate the CV safety and benefits of pharmacotherapy. Many CVOTs in obesity have either failed to demonstrate a CV benefit or have been terminated prematurely because of safety issues, prompting regulatory agencies to define new requirements (based on those for CVOTs in type 2 diabetes [T2D]). CVOTs of glucagon-like peptide-1 receptor agonists (GLP-1RAs) in T2D have demonstrated that some GLP-1RAs reduce CV risk and may help inform future CVOTs in obesity, given the approval of liraglutide 3.0 mg for obesity. In this review, the evidence for the link between obesity and CVD is considered in the context of studies showing that weight loss improves markers of CV risk and risk of adverse CV events. The review also examines the CVOTs in obesity that have been conducted to date and those under way, such as the SELECT trial with subcutaneous semaglutide of 2.4 mg.

Novel Treatments for Transient Ischemic Attack and Acute Ischemic Stroke

The treatment of acute ischemic stroke is one of the most rapidly evolving areas in medicine. Like all ischemic vascular emergencies, the priority is reperfusion before irreversible infarction. The central nervous system is sensitive to brief periods of hypoperfusion, making stroke a golden hour diagnosis. Although the phrase "time is brain" is relevant today, emerging treatment strategies use more specific markers for consideration of reperfusion than time alone. Innovations in early stroke detection and individualized patient selection for reperfusion therapies have equipped the emergency medicine clinician with more opportunities to help stroke patients and minimize the impact of this disease.

Effects of α-Cyclodextrin on Cholesterol Control and Hydrolyzed Ginseng Extract on Glycemic Control in People With Prediabetes: A Randomized Clinical Trial

IMPORTANCE

Effective strategies for preventing type 2 diabetes are needed. Many people turn to complementary medicines, but there is little well-conducted scientific evidence to support their use.

OBJECTIVE

To assess the efficacy of α-cyclodextrin for cholesterol control and that of hydrolyzed ginseng for glycemic control in people with prediabetes and overweight or obesity.

DESIGN, SETTING, AND PARTICIPANTS

This 6-month double-blind, placebo-controlled, randomized clinical trial, with a 2 × 2 factorial design, was conducted between July 2015 and October 2018 at 2 locations in Sydney, Australia. Eligible participants were aged 18 years or older, had a body mass index (weight in kilograms divided by height in meters squared) of 25 or higher, and had prediabetes within 6 months of study entry according to the American Diabetes Association guidelines. Data analysis was performed from May to August 2019.

INTERVENTIONS

Participants were randomized to 1 of 4 groups to take active or placebo versions of each supplement (α-cyclodextrin plus hydrolyzed ginseng, α-cyclodextrin plus placebo, placebo plus hydrolyzed ginseng, or placebo plus placebo) for 6 months. All participants received dietetic advice for weight loss.

MAIN OUTCOMES AND MEASURES

The primary outcomes were the differences in total cholesterol and fasting plasma glucose between groups after 6 months. The primary analysis used the intention-to-treat principle. Multiple predetermined subsample analyses were conducted.

RESULTS

A total of 401 participants were eligible for the study (248 women [62%]; mean [SD] age, 53.5 [10.2] years; mean [SD] body mass index, 34.6 [6.2]). One hundred one patients were randomized to receive α-cyclodextrin plus hydrolyzed ginseng, 99 were randomized to receive α-cyclodextrin plus placebo, 101 were randomized to receive placebo plus hydrolyzed ginseng, and 100 were randomized to receive placebo plus placebo. For 200 participants taking α-cyclodextrin compared with 201 participants taking placebo, there was no difference in total cholesterol after 6 months (-1.5 mg/dL; 95% CI, -6.6 to 3.5 mg/dL; P = .51). For 202 participants taking hydrolyzed ginseng compared with 199 participants taking placebo, there was no difference in fasting plasma glucose after 6 months (0.0 mg/dL; 95% CI, -1.6 to 1.8 mg/dL; P = .95). Use of α-cyclodextrin was associated with constipation (16 participants vs 4 participants; P = .006) and cough (8 participants vs 1 participant; P = .02). Use of hydrolyzed ginseng was associated with rash and pruritus (13 participants vs 2 participants; P = .006). Only 37 of 401 participants (9.2%) experienced these adverse events.

CONCLUSIONS AND RELEVANCE

Although they are safe for use, there was no benefit found for either α-cyclodextrin for cholesterol control or hydrolyzed ginseng for glycemic control in people with prediabetes and overweight or obesity.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry Identifier: ACTRN12614001302640.

Association of general and abdominal obesity and their changes with stroke in Chinese adults: Results from an 11.8-year follow-up study

BACKGROUND AND AIMS

Obesity-related diseases play a significant role in the epidemiology of stroke; however, the exact effects of obesity and transitions in obesity status on stroke risk are still unclear. This study was performed to investigate the association of general and abdominal obesity and their changes with stroke in Chinese adults.

METHODS AND RESULTS

A total of 26,815 subjects (13,684 men and 13,131 women) aged ≥35 years participated in the study. The association of general and abdominal obesity and their changes with stroke was estimated by Cox proportional hazards models. During a median follow-up period of 11.8 years, 1507 people developed an incident stroke event. The multivariable-adjusted hazard ratios (HRs) (95% CIs) for stroke comparing the highest vs. lowest quartiles of these measurements were 1.276 (1.068-1.524) for BMI, 1.245 (1.035-1.499) for WC, 0.940 (0.786-1.125) for WHR, and 1.221 (1.019-1.464) for WHtR in men. For women, the corresponding values were 1.368 (1.089-1.718), 1.424 (1.119-1.813), 0.971 (0.765-1.232), and 1.341 (1.059-1.699), respectively. C- statistics showed no difference in the predictive value for stroke among various measures of adiposity. Compared with participants who maintained a normal BMI, the HRs for reversed general obesity was 1.272 (95% CI: 1.044-1.550) among men and 1.240 (95% CI: 0.948-1.623) among women.

CONCLUSION

Increasing levels of general or abdominal adiposity consistently predict increased risk of stroke, and maintenance of a normal BMI or WC may aid in stroke prevention.

Risk for Recurrent Cardiovascular Events and Expected Risk Reduction With Optimal Treatment 1 Year After an Acute Coronary Syndrome

According to the latest European Society of Cardiology Guidelines for the diagnosis and management of chronic coronary syndromes, patients who suffered an acute coronary syndrome fall into a chronic stable phase after 1 year. In these patients, the estimated 10-year risk for recurrent cardiovascular events varies considerably. We applied the SMART (Second Manifestations of Arterial Disease) risk score in 281 patients 1 year after an acute coronary syndrome to estimate the 10-year risk for recurrent cardiovascular events (subsequent nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death). We assessed the distribution of the estimated risk and the potential risk reduction that might be achieved with optimal guideline-directed management of modifiable risk factors (systolic blood pressure, low-density lipoprotein cholesterol, smoking, and body mass index). In our cohort, the median SMART score was 16.1% (interquartile range [IQR] 9.7 to 27.3), particularly increased in patients with older age, diabetes, polyvascular disease or chronic kidney disease (median 28.6%, IQR 20.8 to 52.9; 23.8%, 4.8 to 41.6; 29.4%, 18.8 to 49.7; 53.8%, 26.5 to 71.6, respectively). If all modifiable risk factors met guideline-recommended targets, the median SMART risk score would be 9.6% (IQR 6.3 to 20.9), with 51% of the patients at a 10-year risk <10%, while 11% and 15% at 20% to 30% and >30% risk, respectively. In conclusion, the SMART score had a wide distribution in patients with chronic coronary syndromes. A quarter of patients remained at a >20% 10-year risk, even with optimal risk factor management, clearly underlining that residual risk is an unmet clinical challenge.

Should the Same Safety Scrutiny of Antiobesity Medications be Applied to Other Chronic Usage Drugs?

Obesity treatment is highly stigmatized, mainly because of the stigma of obesity itself. The frequent withdrawal of medications, lorcaserin being the last example, contributes to this stigma, but it is also probably a reflection of it, as data suggest that the threshold for a withdrawal is lower than with other classes of drugs. Safety should always be an absolute priority for every new medication, especially when used on a chronic basis; however, the safety scrutiny given to antiobesity medications is not given for other medications, such as postmenopausal hormone therapy and central nervous system drugs for psychiatric use. The withdrawal of medications for obesity can also impact future research in the area, so we need transparency and equality. Transparency in knowing exactly what reason led to a drug being discontinued and equality in long-term safety should be a concern with any medication prescribed for chronic diseases.

Effectiveness of herbal medicines for weight loss: A systematic review and meta-analysis of randomized controlled trials

AIM

To update the available evidence on the efficacy and safety of complementary medicines to assist in weight loss by conducting a systematic review and meta-analysis of herbal medicines for weight loss.

METHODS

Four electronic databases (Medline, Embase, CINAHL and Web of Science) were searched from inception until August 2018. A total of 54 randomized placebo-controlled trials of healthy overweight or obese adults were identified. Meta-analyses were conducted for herbal medicines with ≥4 studies available. Weight differences of ≥2.5 kg were considered clinically significant.

RESULTS

As a single agent, only Phaseolus vulgaris resulted in a statistically significant weight loss compared to placebo, although this was not considered clinically significant. No effect was seen for Camellia sinensis or Garcinia cambogia. Statistically, but not clinically, significant differences were observed for combination preparations containing C. sinensis, P. vulgaris or Ephedra sinica. Of the herbal medicines trialled in ≤3 randomized controlled trials, statistically and clinically significant weight loss compared to placebo was reported for Irvingia gabonensis, Cissus quadrangularis, and Sphaeranthus indicus combined with Garcinia mangostana, among others, but these findings should be interpreted cautiously because of the small number of studies, generally poor methodological quality, and poor reporting of the herbal medicine interventions. Most herbal medicines appeared safe for consumption over the short duration of the studies (commonly ≤12 weeks). Some warrant further investigation to determine effect size, dosage and long-term safety.

CONCLUSION

There is currently insufficient evidence to recommend any of the herbal medicines for weight loss included in the present review.

Self-Reported Body Weight Changes, Perceptions, and Weight Loss Techniques among Stroke Survivors

BACKGROUND

Little is known about the body weight goals and trends of stroke survivors, despite evidence that overweight and obesity can negatively influence poststroke rehabilitation outcomes. Thus, the purpose of this study was to identify self-reported body weight trends over time in stroke survivors and nonstroke controls (>50 years old) and describe the methods used to attempt to achieve body weight goals.

METHODS

Self-reported body weight 1) at age 25 years, 2) 10 years prior to the current assessment, 3) 1 year prior to the current assessment, 4) current weight, and 5) age of heaviest body weight were collected from adults self-reporting a stroke in the 2011-2012 and 2013-2014 National Health and Nutrition Examination Surveys (stroke: N = 387 and nonstroke: N = 5085). Questionnaires were used to assess body weight goals and weight loss techniques during the previous year.

RESULTS

Of the stroke survivors, 54% reported that their heaviest weight occurred after their stroke. Approximately 70% of stroke and nonstroke were overweight or obese. Only 24% of stroke survivors reported trying to lose weight compared with 35% of nonstroke, with only 10%-15% successful (≥5% body weight loss), during the past year. Popular weight loss methods in both groups included eating less, exercising, and eating more fruits/vegetables. The majority of stroke survivors report their heaviest weight after their stroke and a desire to weigh less; however, few report successful weight loss.

CONCLUSIONS

Future research is needed to identify optimal body weight and ways to incorporate preferred methods of lifestyle modification, including diet and exercise, to promote weight management in stroke survivors.

Maintenance of body weight is an important determinant for the risk of ischemic stroke: A nationwide population-based cohort study

Background

Overweight is known as a risk factor for ischemic stroke. However, the effect of weight change on the development of ischemic stroke remains controversial. We investigated the relationship between weight change and the risk of ischemic stroke using a nationwide population-based cohort.

Methods

Our study enrolled 11,084,683 participants (Mean age 49.7±13.5 years, range 20–114 years) in the Korean National Health Screening Program from 2009 to 2012. Weight change was calculated using the difference between the baseline weight and the weight at health screening four years prior to the baseline. The occurrence of newly-diagnosed ischemic stroke was observed until the end of 2015. We categorized the study population according to weight change and performed multivariable analysis to compare the risk.

Results

Ischemic stroke was newly diagnosed in 113,591 subjects. The crude incidence rates of ischemic stroke per 1000 person-years according to the change in body weight were 3.059, 1.906, and 1.491 in the <-5%, ±5%, and ≥+5% groups, respectively. After adjusting all variables, the hazard ratio (HR) of ischemic stroke was higher in subjects who underwent weight loss (HR 1.152) or weight gain (HR 1.087) than in those who maintained their weight. When analyzed by eight groups of 5% intervals, the risk showed a U-shaped curve with those who maintained their weight showing the lowest risk.

Conclusions

The risk of ischemic stroke was gradually increased in those who lost or gained more than 5% of their weight over four years, after adjusting for confounders. We should be aware of the increased risk of ischemic stroke in people who undergo weight change and should identify and manage the cause of weight change.

Beyond lifestyle interventions: exploring the potential of anti-obesity medications in the UK

In the UK, over one-quarter of the adult population have obesity (body mass index ≥30 kg m^-2 ). This has major implications for patients' health and the National Health Service. Despite published studies showing that significant weight loss can be achieved and maintained in primary care, and guidance from the National Institute for Health and Care Excellence, weight management services are inconsistently implemented. This may be due primarily to workload and financial constraints. There is also a lack of belief that specialist weight management services and anti-obesity medications (AOMs) are a viable alternative to bariatric surgery for long-term maintenance of weight loss. This article discusses the challenges facing obesity management and explores the reasons for the lack of investment in AOMs in the UK to date. The aim of this article is to identify whether the newer AOMs, such as naltrexone/bupropion and liraglutide 3.0 mg, are likely to perform better in a real-world setting than current or withdrawn AOMs. In addition, it considers whether the equitable provision of specialist weight management services and future clinical trial design could be improved to help identify those individuals most likely to benefit from AOMs and, thus, improve outcomes for people with obesity in the UK.

Liraglutide and cardiovascular outcomes in adults with overweight or obesity: A post hoc analysis from SCALE randomized controlled trials

The cardiovascular safety of liraglutide, a glucagon-like peptide-1 receptor agonist approved for weight management at a dose of 3.0 mg, was evaluated post hoc using data from 5908 participants in 5 randomized, double-blind, placebo-controlled clinical trials. Participants were randomized to liraglutide or a comparator group (placebo or orlistat). The objective was to evaluate whether cardiovascular risk was increased with liraglutide treatment. The primary composite outcome of this time-to-event analysis was the first occurrence of cardiovascular death, nonfatal myocardial infarction or nonfatal stroke. These cardiovascular events were adjudicated prospectively for three of the trials and retrospectively for two trials by an event adjudication committee. The primary outcome was analyzed using a Cox proportional hazards model, stratified by trial. With liraglutide 3.0 mg, 8 participants had positively adjudicated cardiovascular events (1.54 events/1000 person-years) compared to 10 participants in the comparators group (3.65 events/1000 person-years). The hazard ratio for liraglutide 3.0 mg compared to comparators was 0.42 (95% confidence interval, 0.17-1.08). In this analysis, liraglutide 3.0 mg treatment was not associated with excess cardiovascular risk. However, the wide confidence intervals and retrospective adjudication of events in two of the trials are limitations of the analysis.

Current pharmacotherapy for obesity

More than one-third of adults in the USA have obesity, which causes, exacerbates or adversely impacts numerous medical comorbidities, including diabetes mellitus and cardiovascular disease. Despite intensive lifestyle modifications, the disease severity warrants further aggressive intervention, including pharmacotherapy, medical devices and bariatric surgery. Noninvasive anti-obesity drugs have thus now resurfaced as targeted adjunctive therapeutic approaches to intensive lifestyle intervention, bridging the gap between lifestyle and bariatric surgery. In this Review, we discuss FDA-approved anti-obesity drugs in terms of safety and efficacy. As most of these drugs have a mean percentage weight loss reported in clinical trials but individual variations in response rates, a future direction of obesity pharmacotherapy research might include the potential for personalized medicine to target early responders to these anti-obesity drugs.

Examining the association between depression and obesity during a weight management programme

The prevalence of depression in those with obesity is reported to be as high as double that in individuals of normal weight. There is potentially a bi-directional relationship between obesity and depression. Some research has suggested that depression results in weight gain and obesity, and other studies have suggested that those with obesity are more likely to develop depression at a later stage. The aim of this study was to investigate the association of depression symptoms with weight change over a 12-month study. Seventy participants undertook a 3-month lifestyle (diet and exercise) weight loss intervention, and were followed up as part of a 12-month study. Participants completed the Beck Depression Inventory-II (BDI-II) and had their body weight measured throughout the study. Baseline body mass index (BMI) of participants (mean ± standard deviation [SD]) was 31.1 ± 3.9 kg m^-2 , body weight was 89.4 ± 16.1 kg, and age was 45.4 ± 11.1 years; 63% of the cohort were female. The mean weight change from baseline to 3 months was -5.2% (±SD 4.3%), and from baseline to 12 months was -4.2% (±SD 6.1%). There was a significant decrease in BDI-II scores over the 12-month study, and a 1-unit decrease in BDI-II score was associated with a further decrease in body weight of -0.4%. The current study indicated that weight loss was associated with improvements in mood for non-clinically depressed individuals with obesity, and these improvements persisted during a period of 3-12 months of follow-up.

Rapid Surface Enhanced Raman Scattering (SERS) Detection of Sibutramine Hydrochloride in Pharmaceutical Capsules with a β-Cyclodextrin- Ag/Polyvivnyl Alcohol Hydrogel Substrate

Sibutramine hydrochloride (SH) is a banned weight-loss drug, but its illegal addition to health products is still rampant. This suggests a very urgent need for a fast and precise detection method for SH. Surface Enhanced Raman Scattering (SERS) is a promising candidate for this purpose, but the weak affinity between SH and bare metal limits its direct SERS detection. In the present work, β-cyclodextrin was capped in situ onto the surface of Ag nanoparticles to function as a scaffold to capture SH. The obtained Ag nanoparticles were encapsulated into polyvinyl alcohol (PVA) to fabricate a SERS active hydrogel with excellent reproducibility. A facile SERS strategy based on such substrate was proposed for trace SH quantification with a linear range of 7.0–150.0 µg·mL^–1, and a detection limit low to 3.0 µg·mL⁻¹. It was applied to analyze seven types of commercial slimming capsules with satisfactory results, showing good prospect for real applications.

What factors influence weight loss in participants of commercial weight loss programmes? Implications for health policy

BACKGROUND

Finding effective referral policies for weight management services would have important public health implications.

AIM

Here we compare percentage weight change by referral methods, BMI categories and participants who have had attended weight loss programmes multiple times.

DESIGN AND SETTINGS

A prospective cohort study of 15,621 participants referred to 12-week behavioural weight loss programmes funded by the public health service in Birmingham, UK.

METHODS

Comparisons were made between GP versus self-referrals, BMI ≥40kg/m²-<40kg/m² and multiple referrals compared to only one referral. Linear mixed modelling was used to assess percentage weight change after adjusting for covariates.

RESULTS

Participant's mean age was 48.5 years, 78.7% were of white ethnicity, 90.3% female and mean baseline BMI was 36.3kg/m². There were no significant differences in percentage weight loss, between participants that self-referred and those that were referred by their general practitioner (GP) and no significant differences between baseline BMI categories. Referral to a weight loss programme more than once was associated with less weight loss at subsequent attendances (0.92%, 95% CI 0.70-1.14, p<0.001).

CONCLUSION

Allowing self-referral to a weight loss programme widens access without compromising amount of weight lost. These programmes are beneficial for all categories of obesity, including those with a BMI ≥40kg/m². Attending weight management programmes more than once results in less weight loss and that swapping to a different program may be advisable.

Off-label drugs for weight management

The global pandemic of obesity and overweight now affects between 2.8 and 3.5 billion of the world population and shows no signs of abatement. Treatment for what is now recognized as a chronic disease includes pharmacotherapy, considered an essential component of comprehensive therapy. New drug discovery is robust, but the pace of the US Food and Drug Administration approval for obesity drugs has been glacial, and only a handful of approved drugs are available for treating obesity. In the last 20 years, the US Food and Drug Administration has approved 208 drugs for cancer, 118 for cardiovascular diseases, 168 for neurological diseases, and 223 endocrinologic drugs, but only 6 for obesity, 2 of which have been taken off market. Currently, there are only 9 drugs approved by the FDA for obesity treatment. US physicians have turned to off-label drug use in their effort to care for increasing numbers of patients with excess adiposity. Phentermine is the most commonly used drug for treating obesity. Although approved only for short-term use, US physicians have used it successfully for long-term since its initial approval in 1959. This drug, used off-label for long-term, has proven to be safe and effective, far safer than the disease it is used to treat. Phentermine and diethylpropion, an equally safe but somewhat less effective drug, are both generic and therefore inexpensive. These drugs have been maligned inappropriately because their two-dimensional structure diagrams resemble amphetamine and also because of unproven presumptions about their potential adverse effects. In the face of an increasing epidemic, worldwide obese and overweight patients deserve effective treatment that prescribing these drugs could provide, if rehabilitated and used more frequently. US physicians will likely continue to use any drug proven useful off-label for this illness until such time as more effective drugs are approved.

Association of body mass index with mortality and functional outcome after acute ischemic stroke

The relation between obesity and stroke outcome has been disputed. This study was aimed to determine the association of body mass index (BMI) with mortality and functional outcome in patients with acute ischemic stroke. Data were from a national, multi-centre, prospective, hospital-based register: the ChinaQUEST (Quality Evaluation of Stroke Care and Treatment) study. Of 4782 acute ischemic stroke patients, 282 were underweight (BMI < 18.5 kg/m²), 2306 were normal-weight (BMI 18.5 to < 24 kg/m²), 1677 were overweight (BMI 24 to <28 kg/m²) and 517 were obese (BMI ≥ 28 kg/m²). The risks of death at 12 months and death or high dependency at 3 and 12 months in overweight (HR: 0.97, 95% CI: 0.78–1.20; OR: 0.93, 95% CI: 0.80–1.09; OR: 0.95, 95% CI: 0.81–1.12) and obese patients (HR: 1.07, 95% CI: 0.78–1.48; OR: 0.96, 95% CI: 0.75–1.22; OR: 1.06, 95% CI: 0.83–1.35) did not differ from normal-weight patients significantly after adjusting for baseline characteristics. Underweight patients had significantly increased risks of these three outcomes. In ischemic stroke patients, being overweight or obese was not associated with decreased mortality or better functional recovery but being underweight predicted unfavourable outcomes.

Aggressive clinical approach to obesity improves metabolic and clinical outcomes and can prevent bariatric surgery: a single center experience

BACKGROUND

The number of bariatric procedures has exponentially increased in the past decade, as a result of the lack of successful clinical weight-loss interventions. The main reasons for the failure of clinical obesity management are: (1) anti-obesity medications are administered as monotherapies (or pre-combined drugs); (2) lack of combination between pharmacotherapy and non-pharmacological modalities; (3) short duration of pharmacotherapy for obesity; (4) lack of weight-loss maintenance strategies; (5) misunderstanding of the complex pathophysiology of obesity; and (6) underprescription of anti-obesity medications. We developed a protocol that can potentially overcome the drawbacks that may lead to the failure of clinical therapy for obesity. The aim of this study is therefore to report the clinical and metabolic effects of our proposed obesity-management protocol over a 2-year period, and to determine whether this more intensive approach to obesity management is feasible and a possible alternative to bariatric surgery in patients with moderate-to-severe obesity.

METHODS

This retrospective study involved 43 patients in whom bariatric surgery was indicated. Patients underwent an intensive anti-obesity protocol that included pharmacotherapy with multiple drugs; intense surveillance with monthly body analysis by air-displacement plethysmography, electrical bioimpedance, and 3D body scans; weekly psychotherapy; diet planning with a dietician every 2 months; and exercises at least 3 times a week with exercises prescribed by a personal trainer at least once a month. Body weight (BW), total weight excess (TWE), obesity class, body mass index, fat weight, muscle weight, waist circumference, and visceral fat were analyzed. Markers of lipid and glucose metabolism, liver function, and inflammation were also evaluated. Therapeutic success was defined as >20% BW loss or >50% decrease in TWE after 1 year.

RESULTS

Significant improvements were observed in all clinical and metabolic parameters. Thirty-eight (88.4%) patients achieved 10% BW loss, and 32 (74.4%) achieved 20% BW loss. TWE decreased by >50% in 35 (81.4%) patients. Forty (93.0%) patients were able to avoid bariatric surgery.

CONCLUSION

An intensive clinical approach to obesity management can be an effective alternative to bariatric surgery, although further randomized controlled studies are necessary to validate our findings.

Critical review: CPAP and weight management of obstructive sleep apnea cardiovascular co-morbidities

The cardiovascular co-morbidities of obstructive sleep apnea (OSA) are similar to those of obesity. Cardiovascular co-morbidities often are the cause of adverse outcomes in overweight/obese OSA patients. Continuous positive airway pressure (CPAP) therapy resolves the symptoms of OSA, but may, or may not lead to improvement of a given cardiovascular co-morbidity. The impact of CPAP on cardiovascular risk variables, adverse cardiovascular events in overweight/obese OSA patients has been evaluated primarily in prospective, uncontrolled cohort studies. These studies show improvement in myocardial and endothelial function, blood pressure, left ventricular performance and stroke survival. Randomized controlled studies (RCTs) examining the effect of weight management on cardiovascular risk factors and disease outcomes show that intentional weight loss leads to improvement in cardiovascular risk, hypertension, coronary artery disease, but not in stroke. Weight loss improves mortality in relatively healthy overweight/obese populations, but possibly not in all groups with cardiometabolic diseases. Clinicians caring for overweight/obese OSA patients should consider the advantages of incorporating weight management into their treatment programs for such patients.

Interventions that cause weight loss and the impact on cardiovascular risk factors: a systematic review and meta-analysis

Overweight and obesity increase the risks of diabetes and cardiovascular disease (CVD). This has been shown to be reversed with weight loss. A systematic review and meta-analysis were performed to determine the effect of weight loss in the primary prevention of CVD. PubMed, Embase and the Cochrane Library databases were searched electronically through to May 2013. Randomized controlled trials assessing weight loss and cardiovascular risk factors and outcomes were included. A random effects meta-analysis, with sub-group analyses for degree of weight loss, and age were performed. Because few studies reported clinical outcomes of CVD, analyses were limited to cardiovascular risk factors (83 studies). Interventions that caused any weight loss significantly reduced systolic blood pressure (-2.68 mmHg, 95% CI -3.37, -2.11), diastolic blood pressure (-1.34 mmHg, 95% CI -1.71, -0.97), low-density lipoprotein cholesterol (-0.20 mmol L(-1) , 95% CI -0.29, -0.10), triglycerides (-0.13 mmol L(-1) , 95% CI -0.22, -0.03), fasting plasma glucose (-0.32 mmol L(-1) , 95% CI -0.43, -0.22) and haemoglobin A1c(-0.40%, 95% CI -0.52, -0.28) over 6-12 months. Significant changes remained after 2 years for several risk factors. Similar results were seen in sub-group analyses. Interventions that cause weight loss are effective at improving cardiovascular risk factors at least for 2 years. © 2016 World Obesity.

Evolution of pharmacological obesity treatments: focus on adverse side-effect profiles

Pharmacotherapy directed toward reducing body weight may provide benefits for both curbing obesity and lowering the risk of obesity-associated comorbidities; however, many weight loss medications have been withdrawn from the market because of serious adverse effects. Examples include pulmonary hypertension (aminorex), cardiovascular toxicity, e.g. flenfluramine-induced valvopathy, stroke [phenylpropanolamine (PPA)], excess non-fatal cardiovascular events (sibutramine), and neuro-psychiatric issues (rimonabant; approved in Europe, but not in the USA). This negative experience has helped mould the current drug development and approval process for new anti-obesity drugs. Differences between the US Food and Drug Administration (FDA) and the European Medicines Agency, however, in perceptions of risk-benefit considerations for individual drugs have resulted in discrepancies in approval and/or withdrawal of weight-reducing medications. Thus, two drugs recently approved by the FDA, i.e. lorcaserin and phentermine + topiramate extended release, are not available in Europe. In contrast, naltrexone sustained release (SR)/bupropion SR received FDA approval, and liraglutide 3.0 mg was recently approved in both the USA and Europe. Regulatory strategies adopted by the FDA to manage the potential for uncommon but potentially serious post-marketing toxicity include: (i) risk evaluation and mitigation strategy programmes; (ii) stipulating post-marketing safety trials; (iii) considering responder rates and limiting cumulative exposure by discontinuation if weight loss is not attained within a reasonable timeframe; and (iv) requiring large cardiovascular outcome trials before or after approval. We chronicle the adverse effects of anti-obesity pharmacotherapy and consider how the history of high-profile toxicity issues has shaped the current regulatory landscape for new and future weight-reducing drugs.

Examining mindfulness as a predictor of weight loss - Findings from the DIABEGG study

OBJECTIVE

Identifying individuals who are less likely to respond to a weight loss intervention allows better allocation or focus of resources to achieve better weight loss results. The current study investigated whether baseline levels of mindfulness would predict weight loss during a 12-month diet and exercise intervention.

METHODS

The Five Facet Mindfulness Questionnaire (FFMQ) was administered and body weight measured, at baseline, three, six and 12 months in 140 participants with pre-diabetes or type 2 diabetes mellitus and a body mass index of ≥25kg/m². 137 of 140 participants completed the FFMQ at baseline and were included in this study.

RESULTS

There was no correlation between baseline mindfulness scores and weight loss. Mean baseline total FFMQ score was 112.2 [95% confidence interval: 109.4, 115.1] which did not change over the course of the study. Mean baseline body weight was 95.1kg (standard deviation (19.1kg)). There was a significant decrease in weight at month 12 (-3.8kg (±standard deviation 5.8kg)). This is comparable to the weight loss achieved by participants in other interventions of the same duration.

CONCLUSIONS

The findings suggest that baseline dispositional mindfulness does not predict the amount of weight loss in a lifestyle (diet and exercise) intervention.

A randomized controlled trial to determine the efficacy of a high carbohydrate and high protein ready-to-eat food product for weight loss

Incorporating meal replacements has been shown to produce a significantly greater weight loss than a conventional reduced calorie diet. Ready-to-eat conventional foods may also be effective in this role and provide additional benefit because of their palatability, acceptance and enjoyment and thus increase dietary compliance. This trial investigated the efficacy of a ready-to-eat food product (Vita-Weat biscuit) that is both high in carbohydrate and high in protein as part of a diet prescription for weight loss in an overweight and obese population group. A total of 76 participants were randomized to a 6-week weight loss intervention including the ready-to-eat food product (intervention group) or advice on the 'Australian Guide to Healthy Eating' (control group). Both groups lost approximately 2 kg weight which equated to a reduction in body mass index of 0.70 kg m(-2) . There was no significant difference in percentage weight loss from screening to 6 weeks between the two groups; mean difference for the intervention vs.

CONTROL GROUP

-0.20% (95% confidence interval: -0.96, 1.36); P = 0.73. Both diets were nutritionally matched and well-accepted over the 6-week period. This study shows that the inclusion of a ready-to-eat food product can be included as part of a dietary programme to achieve a clinically significant weight loss over a short period. This may have benefit when incorporated into an individual's meal plan intermittently to assist weight control. It also provides support for current public health nutritional guidelines as the participants in this study following such advice were also successful in achieving a clinically meaningful weight loss.

Weight management in obesity - past and present

AIMS

To describe the treatment of obesity from ancient times to present day.

METHODS

Articles reporting the development of anti-obesity therapies were identified through a search for 'anti-obesity' AND 'pharmacotherapy' AND 'development' within the title or abstract on PubMed and 'obesity' in ClinicalTrials.gov. Relevant articles and related literature were selected for inclusion.

RESULTS

Stone-age miniature obese female statuettes indicate the existence and cultural significance of obesity as long as 30,000 years ago. Records from Ancient Egyptian and Biblical eras through Greco-Roman to Medieval times indicate that obesity was present throughout the major periods of history, although peoples of previous centuries would probably have experienced overweight and obesity as exceptional rather than normal. Health risks of obesity were noted by the Greek physician Hippocrates (460-377 BCE) when the earliest anti-obesity recommendations on diet, exercise, lifestyle and use of emetics and cathartics were born. These recommendations remained largely unchanged until the early 20th century, when spreading urbanisation, increasingly sedentary jobs and greater availability of processed foods produced a sharp rise in obesity. This led to the need for new, more effective, ways to lose weight, to address comorbidities associated with obesity, and to attain the current cultural ideal of slimness. Drug companies of the 1940s and 1950s produced a series of anti-obesity pharmacotherapies in short succession, based largely on amphetamines. Increased regulation of drug development in the 1960s and new efficacy requirements for weight-loss drugs led to rapid reduction in anti-obesity therapies available by the early 1990s.

CONCLUSION

In the last two decades, several new and emerging therapies have been approved or are in development to provide safe, long-term pharmacological agents for the treatment of obesity.

The effectiveness of pharmaceutical interventions for obesity: weight loss with orlistat and sibutramine in a United Kingdom population-based cohort

Aims

Drug treatments for obesity have proven efficacy from randomized trials, but their effectiveness in routine clinical practice is unknown. We assessed the effects on weight and body mass index (BMI) of orlistat and sibutramine when delivered in routine primary care.

Methods

We used United Kingdom data from the Clinical Practice Research Datalink to estimate the effects of orlistat or sibutramine on weight and BMI over 3 years following treatment initiation. For comparison, we matched each patient with up to five obese patients receiving neither drug. Mixed effects linear regression with splines was used to model change in weight and BMI. Mean change with 95% confidence intervals (CI) was estimated.

Results

We identified 100 701 patients receiving orlistat, 15 355 receiving sibutramine and 508 140 non-intervention patients, with body mass index of 37.2, 36.6 and 33.2 kg m⁻², respectively. Patients receiving orlistat lost, on average, 0.94 kg month⁻¹ (0.93 to 0.95) over the first 4 months. Weight gain then occurred, although weight remained slightly below baseline at 3 years. Patients receiving sibutramine lost, 1.28 kg month⁻¹ (1.26 to 1.30) over the first 4 months, but by 3 years had exceeded baseline weight. Non-intervention patients had slight increases in weight throughout the 3 year period, with gains ranging between 0.01 and 0.06 kg month⁻¹.

Conclusions

Orlistat and sibutramine had early effects on weight loss, not sustained over 3 years. As new treatments for obesity are approved, their effectiveness should be measured in routine clinical practice, as effectiveness may be considerably less than seen in randomized trials.

LEADER 5: prevalence and cardiometabolic impact of obesity in cardiovascular high-risk patients with type 2 diabetes mellitus: baseline global data from the LEADER trial

BACKGROUND

Epidemiological data on obesity are needed, particularly in patients with type 2 diabetes mellitus (T2DM) and high cardiovascular (CV) risk. We used the baseline data of liraglutide effect and action in diabetes: evaluation of CV outcome results-A long term Evaluation (LEADER) (a clinical trial to assess the CV safety of liraglutide) to investigate: (i) prevalence of overweight and obesity; (ii) relationship of the major cardiometabolic risk factors with anthropometric measures of adiposity [body mass index (BMI) and waist circumference (WC)]; and (iii) cardiometabolic treatment intensity in relation to BMI and WC.

METHODS

LEADER enrolled two distinct populations of high-risk patients with T2DM in 32 countries: (1) aged ≥50 years with prior CV disease; (2) aged ≥60 years with one or more CV risk factors. Associations of metabolic variables, demographic variables and treatment intensity with anthropometric measurements (BMI and WC) were explored using regression models (ClinicalTrials.gov identifier: NCT01179048).

RESULTS

Mean BMI was 32.5 ± 6.3 kg/m(2) and only 9.1 % had BMI <25 kg/m(2). The prevalence of healthy WC was also extremely low (6.4 % according to International Joint Interim Statement for the Harmonization of the Metabolic Syndrome criteria). Obesity was associated with being younger, female, previous smoker, Caucasian, American, with shorter diabetes duration, uncontrolled blood pressure (BP), antihypertensive agents, insulin plus oral antihyperglycaemic treatment, higher levels of triglycerides and lower levels of high-density lipoprotein cholesterol.

CONCLUSIONS

Overweight and obesity are prevalent in high CV risk patients with T2DM. BMI and WC are related to the major cardiometabolic risk factors. Furthermore, treatment intensity, such as insulin, statins or oral antihypertensive drugs, is higher in those who are overweight or obese; while BP and lipid control in these patients are remarkably suboptimal. LEADER confers a unique opportunity to explore the longitudinal effect of weight on CV risk factors and hard endpoints.

The effect of sibutramine prescribing in routine clinical practice on cardiovascular outcomes: a cohort study in the United Kingdom

BACKGROUND/OBJECTIVES

The marketing authorization for the weight loss drug sibutramine was suspended in 2010 following a major trial that showed increased rates of non-fatal myocardial infarction and cerebrovascular events in patients with pre-existing cardiovascular disease. In routine clinical practice, sibutramine was already contraindicated in patients with cardiovascular disease and so the relevance of these influential clinical trial findings to the 'real World' population of patients receiving or eligible for the drug is questionable. We assessed rates of myocardial infarction and cerebrovascular events in a cohort of patients prescribed sibutramine or orlistat in the United Kingdom.

SUBJECTS/METHODS

A cohort of patients prescribed weight loss medication was identified within the Clinical Practice Research Datalink. Rates of myocardial infarction or cerebrovascular event, and all-cause mortality were compared between patients prescribed sibutramine and similar patients prescribed orlistat, using both a multivariable Cox proportional hazard model, and propensity score-adjusted model. Possible effect modification by pre-existing cardiovascular disease and cardiovascular risk factors was assessed.

RESULTS

Patients prescribed sibutramine (N=23,927) appeared to have an elevated rate of myocardial infarction or cerebrovascular events compared with those taking orlistat (N=77,047; hazard ratio 1.69, 95% confidence interval 1.12-2.56). However, subgroup analysis showed the elevated rate was larger in those with pre-existing cardiovascular disease (hazard ratio 4.37, 95% confidence interval 2.21-8.64), compared with those with no cardiovascular disease (hazard ratio 1.52, 95% confidence interval 0.92-2.48, P-interaction=0.0076). All-cause mortality was not increased in those prescribed sibutramine (hazard ratio 0.67, 95% confidence interval 0.34-1.32).

CONCLUSIONS

Sibutramine was associated with increased rates of acute cardiovascular events in people with pre-existing cardiovascular disease, but there was a low absolute risk in those without. Sibutramine's marketing authorization may have, therefore, been inappropriately withdrawn for people without cardiovascular disease.

Short-term effects of intragastric balloon in association with conservative therapy on weight loss: a meta-analysis

Obesity is an epidemic chronic disease which is a risk factor for a number of serious medical conditions. Intragastric balloon, as an alternative, non-surgical treatment approach for the management of obesity, was rejected in previous evidence-based reviews. The object of this review is updating the data and confirming the safety and efficacy of the procedure. In this review, systematic literature retrieve of MEDLINE, EMBASE, CENTRAL and other information sources was performed from inception to December 2014. The quality of selected studies was assessed and meta-analyses of weighted mean differences were made using the inverse variance method. Meta-analyses presented significant effect sizes of -8.9 kg, -3.1 kg/m(2) and -21.0% for SMG as well as of -1.5 kg and -1.2 kg/m(2) for LSG, favoring the intervention group. Safety analysis showed that minor complications occurred at a high rate in intervention group, however, no serious or fatal complication was reported in these studies. In conclusion, the current review presents that short-term efficacy for 6 months treatment of intragastric balloon in association with conservative therapy is clinically significant.

Participation in a Structured Weight Loss Program and All-Cause Mortality and Cardiovascular Morbidity in Obese Patients With Chronic Kidney Disease

OBJECTIVE

To determine if participation in a weight loss program impacted upon a composite end point of all-cause mortality and cardiovascular morbidity in obese patients with chronic kidney disease (CKD).

DESIGN

Retrospective cohort study.

SUBJECTS

All patients with a body mass index (BMI) >30 kg/m(2) or >28 kg/m(2) with at least 1 comorbidity (hypertension, diabetes, or dyslipidemia) referred to an established weight management program (WMP) from 2005 to 2009 at a metropolitan tertiary teaching hospital were eligible for inclusion in the study cohort.

INTERVENTION

Twelve-month structured weight loss program.

MAIN OUTCOME MEASURES

Combined outcome of all-cause mortality, myocardial infarction, stroke, and hospitalization for congestive heart failure; kidney transplantation waitlisting.

RESULTS

A total of 169 obese patients with CKD commenced the WMP and 169 did not-becoming the observational control group (CON). There were no significant differences between groups for age, BMI, sex, ethnicity, smoking, hypertension, or kidney function at baseline, although CON included more patients with diabetes than WMP (49% vs. 38%, P = .03). Kaplan-Meier survival analysis with log-rank test differed between groups for the combined outcome (P = .03). Cox regression analysis with adjustment for age, sex, ethnicity, hypertension, diabetes, kidney function, baseline BMI, and smoking status, indicated that patients in WMP had a significantly longer event-free period for the combined outcome, than those in CON (adjusted hazard ratio 0.53; 95% confidence interval [CI] 0.29-0.97; P = .04). Participation in the WMP did not increase the likelihood of kidney transplantation waitlisting (odds ratio [OR] 1.06; 95% CI 0.39-2.87; P = .9). Lower baseline BMI and greater weight loss over 12 months were the only factors related to kidney transplantation waitlisting (adjusted R(2) = 0.426).

CONCLUSIONS

Participation in a structured weight loss program may be associated with improved outcomes in obese patients with CKD.