The pharmacological treatment and management of obesity

Inhibitory control as a potential treatment target for obesity

OBJECTIVES

Strong reward responsiveness to food and insufficient inhibitory control are thought to be implicated in the development and maintenance of obesity. This narrative review addresses the role of inhibitory control in obesity and weight loss, and in how far inhibitory control is a promising target for weight loss interventions.

METHODS

PubMed, Web of Science, and Google Scholar were searched for papers up to May 2021. 41 papers were included.

RESULTS

Individuals with obesity have poorer food-specific inhibitory control, particularly when hungry, and less concurrent activation of inhibitory brain areas. Moreover, this was strongly predictive of future weight gain. More activation of inhibitory brain areas, on the other hand, was predictive of weight loss: individuals with successful weight loss initially show inhibitory brain activity comparable to that of normal weight individuals. When successful weight maintenance is achieved for at least 1 year, this inhibitory activity is further increased. Interventions targeting inhibitory control in obese individuals have divergent effects. Firstly, food-specific inhibitory control training is particularly effective for people with low inhibitory control and high BMI. Secondly, neuromodulation paradigms are rather heterogeneous: although rTMS to the left dorsolateral prefrontal cortex induced some weight-loss, multiple sessions of tDCS reduced food consumption (desire) and induced weight loss in two thirds of the papers. Thirdly, neurofeedback results in successful upregulation of brain activity and connectivity, but occasionally leads to increased food intake. In conclusion, inhibitory control is implicated in obesity. It can be targeted to promote weight loss although major weight losses have not been achieved.

The best drug supplement for obesity treatment: a systematic review and network meta-analysis

BACKGROUND

Obesity is a complex disease with an increasing prevalence worldwide. There are different weight-management options for obesity treatment, including dietary control, exercise, surgery, and medication. Medications are always associated with different responses from different people. More safety and efficacy of drugs with fewer side effects are valuable for any clinical condition. In this systematic review and network meta-analysis, different anti-obesity drugs are compared to identify the most effective drug.

METHODS

All relevant studies were extracted by searching national and international databases of SID, MagIran, ProQuest, PubMed, Science Direct, Scopus, Web of Science (WoS), and Google Scholar without time limit until October 2020. Finally, the meta-analysis was performed with the 11 remaining studies containing 14 different drug supplements. The standardized mean difference (SMD) was calculated at a 95% confidence interval (CI) to evaluate the effects of each treatment group compared with placebo. A random-effect model was used to evaluate the effect of individual studies on the final result. Heterogeneity and incompatibility of the network were assessed by Cochran's Q and Higgins I2, and the Net Heat chart, respectively. Data analysis was performed using R software.

RESULTS

Our results showed that there were significant mean effects in people intervened with Phentermine 15.0 mg + Topiramate 92.0 mg, Phentermine 7.5 mg + Topiramate 46.0 mg, Pramlintide, Naltrexone + Bupropion 32, and Liraglutide, with SMD effects size = - 9.1, - 7.4, - 6.5, - 5.9, - 5.35, respectively.

CONCLUSION

This study was performed to compare the effect of different drugs used for weight loss in obese patients. The most effective drugs for weight loss were phentermine and topiramate, pramlintide, naltrexone, bupropion, and liraglutide compared to placebo treatment, respectively. This study provides new insights into anti-obesity drugs and hopes to shed new light on future research to manage and treat obesity.

Natural Compounds for the Prevention and Treatment of Cardiovascular and Neurodegenerative Diseases

Secondary metabolites from plants and fungi are stimulating growing interest in consumers and, consequently, in the food and supplement industries. The beneficial effects of these natural compounds are being thoroughly studied and there are frequent updates about the biological activities of old and new molecules isolated from plants and fungi. In this article, we present a review of the most recent literature regarding the recent discovery of secondary metabolites through isolation and structural elucidation, as well as the in vitro and/or in vivo evaluation of their biological effects. In particular, the possibility of using these bioactive molecules in the prevention and/or treatment of widely spread pathologies such as cardiovascular and neurodegenerative diseases is discussed.

The risk of cardiovascular complications with current obesity drugs

INTRODUCTION

Obesity is associated with an increased risk of cardiovascular morbidity and mortality. Four medications are approved by the US Food and Drug Administration (FDA) for chronic weight management when used as an adjunct to a reduced-calorie diet and increased physical activity in adults. These medications result in clinically significant weight losses, as well as improvements in some cardiometabolic risk factors.

AREAS COVERED

We briefly review the history of anti-obesity medications (AOMs) as related to cardiovascular safety, and summarize weight loss efficacy and cardiovascular data from clinical trials of orlistat, phentermine/topiramate, naltrexone/bupropion, and liraglutide.

EXPERT OPINION

Current AOMs approved for chronic weight management have generally favorable effects on some cardiometabolic parameters. However, the long-term safety of orlistat, phentermine/topiramate, and naltrexone/bupropion on cardiovascular morbidity and mortality have not been established. The cardiovascular safety of liraglutide, at a dose of 1.8 mg/d, was demonstrated in a large randomized outcomes trial in participants with type 2 diabetes.

Insights into the role of neuronal glucokinase

Glucokinase is a key component of the neuronal glucose-sensing mechanism and is expressed in brain regions that control a range of homeostatic processes. In this review, we detail recently identified roles for neuronal glucokinase in glucose homeostasis and counterregulatory responses to hypoglycemia and in regulating appetite. We describe clinical implications from these advances in our knowledge, especially for developing novel treatments for diabetes and obesity. Further research required to extend our knowledge and help our efforts to tackle the diabetes and obesity epidemics is suggested.

Obesity and reproduction: a committee opinion

The purpose of this ASRM Practice Committee report is to provide clinicians with principles and strategies for the evaluation and treatment of couples with infertility associated with obesity. This revised document replaces the Practice Committee document titled, "Obesity and reproduction: an educational bulletin," last published in 2008 (Fertil Steril 2008;90:S21-9).

Impact of Bariatric Surgery and Diet Modification on Periodontal Status: A Six Month Cohort Study

BACKGROUND

Nutrition is an essential component of oral health and improper nutrition is an important aetiological factor in the development of obesity as well.

AIMS AND OBJECTIVES

This study aimed to evaluate effect of diet modification and oral hygiene maintenance after bariatric surgery on the periodontal status of Class III and IV obese patients.

MATERIALS AND METHODS

Two hundred and twenty four patients between the age ranges of 18 -64 years, from both sexes, were subjected to complete periodontal examination prior to bariatric surgery and 6 months post surgery. Patients were advised diet modification which included more fibrous food intake & decreased intake of soft and sugary food along with supragingival scaling & oral health care regime after bariatric surgery with a 6 month follow up. No periodontal surgical intervention was performed.

RESULTS

The patients showed a mean differences in the bleeding score, plaque and gingival index which was found to be statistically significant (p<0.001). The improvement in clinical attachment level and probing pocket depth before and after surgery were found to be statistically insignificant (p>0.05).

CONCLUSION

Thus we conclude that fibrous diet along with good periodontal care can help to improve the oral hygiene status of patients undergoing bariatric surgery, even if periodontal surgical intervention is not performed resulting in freedom from periodontitis, thus improving quality of life of the patient.

A weight loss program in a chiropractic practice: a retrospective analysis

CONTEXT

Obesity is a global problem and places individuals at risk for developing chronic metabolic disorders. The need for investigating simple, effective and sustaining approaches to weight loss cannot be overstated.

METHODS

We performed a retrospective file analysis of patient files attending a 13-week weight loss program. Inclusion for analysis were files of adults (i.e., >18 years) completing the program consisting of chiropractic adjustments/spinal manipulative therapy augmented with diet/nutritional intervention, exercise and one-on-one counseling.

RESULTS

Sixteen of 30 people (i.e., 53.33%) completed the program. Statistically and clinically significant changes were noted in weight and BMI measures based on pre-treatment (average weight = 190.46 lbs. and BMI = 30.94 kg/m(2)) and comparative measurements (average weight = 174.94 lbs. and BMI = 28.50 kg/m(2)).

CONCLUSION

A cohort of patients under enrolled in a weight loss program was described. This provides supporting evidence on the effectiveness of a multi-modal approach to weight loss implemented in a chiropractic clinic.

Prevention of type 2 diabetes in subjects with prediabetes and metabolic syndrome treated with phentermine and topiramate extended release

OBJECTIVE To evaluate over 108 weeks the effect of phentermine and topiramate extended release (PHEN/TPM ER) treatment on progression to type 2 diabetes and/or cardiometabolic disease in subjects with prediabetes and/or metabolic syndrome (MetS) at baseline. RESEARCH DESIGN AND METHODS Subanalysis of a phase 3, randomized, placebo-controlled, double-blind study of overweight/obese subjects (BMI ≥27 to ≤45 kg/m(2)) with two or more comorbidities. Subjects were randomized to placebo, PHEN 7.5 mg/TPM ER 46 mg (7.5/46), or PHEN 15 mg/TPM ER 92 mg (15/92) plus lifestyle modifications for 108 weeks. Percent weight loss in the intent-to-treat population using multiple imputation (ITT-MI), annualized incidence rate of progression to type 2 diabetes, and changes in glycemia, lipid parameters, blood pressure, and waist circumference were evaluated. RESULTS At baseline, 475 subjects met the criteria for prediabetes and/or MetS. After 108 weeks, subjects with prediabetes and/or MetS in the placebo, 7.5/46, and 15/92 groups experienced mean percent weight loss of 2.5, 10.9, and 12.1%, respectively (ITT-MI; P < 0.0001 vs. placebo), associated with reductions of 70.5 and 78.7% in the annualized incidence rate of type 2 diabetes for those receiving 7.5/46 and 15/92, respectively (ITT, P < 0.05), versus placebo. The ability of PHEN/TPM ER to prevent diabetes was related to degree of weight lost and was accompanied by significant improvements in cardiometabolic parameters. PHEN/TPM ER was well tolerated by this subgroup over 2 years. CONCLUSIONS PHEN/TPM ER plus lifestyle modification produced significant weight loss and markedly reduced progression to type 2 diabetes in overweight/obese patients with prediabetes and/or MetS, accompanied by improvements in multiple cardiometabolic disease risk factors.

Gastric and intestinal satiation in obese and normal weight healthy people

OBJECTIVE

The gastrointestinal tract plays a key role in feelings of satiation. It is known that there is a reciprocal interaction between the stomach and intestine, but it is not known which factors are of gastric origin and which are intestinal. This three-step study therefore sought to provide illumination on satiation parameters with respect to body mass.

METHOD

In the first part, the time needed to reach maximal satiation and total caloric intake was calculated after participants (20 normal weight, 20 obese) imbibed a standardized nutrient drink. In the second part gastric emptying of solids and liquids was evaluated using the (13)C-breath test (participants: 16 normal weight, 9 obese for gastric emptying of solids; 15 normal weight, 14 obese for gastric emptying of liquids). And in the third part, fasting and post-prandial plasma glucagon-like peptide-1 (GLP-1), peptide tyrosine tyrosine (PYY) and ghrelin levels were measured after a standardized nutrient drink (participants: 20 normal weight, 20 obese).

RESULTS

Our results show that, when compared to those of normal weight, obese participants reached maximal satiation sooner (P=0.006), their total intake of calories was higher (P=0.013), and their gastric emptying rates were delayed (P<0.001). Furthermore, their post-prandial increase in plasma GLP-1 and PYY was reduced, (P<0.001 for both), as was their ghrelin suppression (P=0.001).

DISCUSSION

We conclude that, in obese subjects gastric emptying can be impaired with delayed interaction of nutrients with the intestine resulting in decreased GLP-1 and PYY secretion. This could imply that obese participants would require more calories before their maximal satiation is reached and they stop eating.

[Intraluminal/endoscopic procedures in the treatment of obesity]

Few effective therapeutic tools are currently available to fight the increasing prevalence of obesity and its associated comorbidities. Bariatric surgery is the only treatment with proven long-term effectiveness, but is associated to a high surgical risk and significant economic costs because of its technical complexity and the characteristics of patients. This is leading to development of new endoscopic procedures with less clinical risks and economic costs, while maintaining the benefits in terms of morbidity and mortality, which could even serve as a bridging element before surgery in cases where this is unavoidable, allowing for preoperative weight loss and control of comorbidities in order to improve anesthetic risks and possible complications. The purpose of this review was to analyze the most relevant and promising endoscopic techniques currently available.

Consumption of buckwheat modulates the post-prandial response of selected gastrointestinal satiety hormones in individuals with type 2 diabetes mellitus

PURPOSE

In healthy participants and those with diet-controlled type 2 diabetes (T2DM), to (1) compare the acute 3-hour post-prandial response of glucose, insulin and other gastrointestinal hormones known to influence food intake and glucose metabolism after consumption of a food product made from whole grain buckwheat flour versus rice flour; (2) determine the effect of daily consumption of a food product made from whole grain buckwheat flour on fasting glucose, lipids and apolipoproteins.

METHODS

Healthy participants or those with T2DM consumed either buckwheat or rice crackers. Blood samples were collected at baseline and 15, 30, 45, 60, 120 and 180minutes after consumption. In a second phase of the study, participants consumed one serving of buckwheat crackers daily for 1week; fasting blood samples from day 1 and day 7 were analyzed.

RESULTS

Post-prandial plasma glucagon-like peptide-1, glucose-dependent insulinotropic peptide and pancreatic polypeptide were altered after consuming buckwheat versus rice crackers. Interestingly, changes in these hormones did not lead to changes in post-prandial glucose, insulin or C-peptide concentrations. Significant correlations were observed between both fasting concentrations and post-prandial responses of several of the hormones examined. Interestingly, certain correlations were present only in the healthy participant group or the T2DM group. There was no effect of consuming buckwheat for one week on fasting glucose, lipids or apolipoproteins in either the healthy participants or those with T2DM.

CONCLUSIONS

Although the buckwheat cracker did not modify acute glycemia or insulinemia, it was sufficient to modulate gastrointestinal satiety hormones.

Changes in cardiovascular risk associated with phentermine and topiramate extended-release in participants with comorbidities and a body mass index ≥27 kg/m(2)

The aim of this analysis was to evaluate changes in cardiovascular risk factors in obese patients with dyslipidemia and/or hypertension receiving phentermine (PHEN) and topiramate extended-release (TPM ER). In the 56-week, randomized, double-blind, placebo-controlled, multicenter CONQUER trial, PHEN/TPM ER demonstrated significant weight loss compared with placebo in overweight or obese participants with ≥2 weight-related co-morbidities. Participants with body mass indexes of 27 to 45 kg/m(2) were randomized to placebo, PHEN 7.5 mg/TPM ER 46 mg, or PHEN 15 mg/TPM ER 92 mg; participants also received lifestyle modification counseling. Primary end points were percentage weight loss and the proportion of participants achieving ≥5% weight loss. Additional end points were changes in lipid variables in the dyslipidemia population and blood pressure in the hypertensive population, stratified by treatment and magnitude of weight loss. PHEN/TPM ER produced significantly greater dose-related mean percentage weight loss compared with placebo in the subgroups of participants with dyslipidemia and those with hypertension. Regardless of treatment group assignment, participants with dyslipidemia who lost ≥5% of their baseline weight experienced significantly greater reductions in triglycerides (-14.5% to -39.8%), and in non-high-density lipoprotein cholesterol (-9.4% to -14.8%) than those losing <5% of their weight (p <0.05). Similarly, participants with hypertension at baseline showed reduced systolic blood pressure by -7.5 to -11.8 mm Hg (p <0.001 vs those with <5% weight loss). In conclusion, the dose-related weight loss induced by PHEN/TPM ER treatment was accompanied by significant improvements in cardiovascular disease risk factors in participants who had dyslipidemia or hypertension at baseline, suggesting that facilitating weight loss by augmenting lifestyle changes with pharmacotherapies may decrease the risk for cardiovascular disease in obese and overweight patients with co-morbidities.

Economic costs of overweight and obesity

Obesity has substantially increased in recent decades and is now one of the major global health problems. The large obesity-related health burden negatively impacts many relevant health outcomes (e.g. quality of life, disability, mortality) and leads to increased healthcare utilization. This excess service use is the main driver behind high healthcare costs of obese individuals. Findings indicate that costs rise curvilinearly with increasing body mass index, especially among the obese. As more individuals of a country's population become obese, a larger share of total annual national healthcare expenditure is spent on obesity and obesity-related health problems. In addition to escalating healthcare costs, obesity goes along with indirect costs through decreases in workforce productivity. The empirical evidence has shown beyond doubt that obesity negatively impacts individuals, healthcare systems, employers, and the economy as a whole. This article provides a brief overview of selected economic consequences associated with excess-weight.

Differential effects of grape powder and its extract on glucose tolerance and chronic inflammation in high-fat-fed obese mice

The objective of this study was to determine the anti-inflammatory properties of grape powder (GP) or GP extract (GE) and examine (1) which polyphenol metabolites in GE were bioavailable, (2) the impact of GP and GE on glucose tolerance and inflammation in obese mice, and (3) if bioavailable polyphenols in GE decrease markers of inflammation in primary adipocytes. In experiment 1, C57BL/6J mice were gavaged with GE and serum polyphenols were measured. In experiment 2, mice were fed high-fat diets supplemented with 3% GP or 0.02% GE for 18 weeks and markers of inflammation were measured. In experiment 3, human adipocytes were treated with the bioavailable polyphenols quercetin 3-O-glucoside (Q3G) or quercetin 3-O-glucuronide (Q3GN) and markers of inflammation were measured. Serum Q3G and Q3GN increased at 1 h post-GE gavage and decreased thereafter. GP supplementation improved glucose tolerance at 5 weeks and decreased markers of inflammation ∼20-50% in serum and adipose tissue at 18 weeks. Q3G, but not Q3GN, attenuated TNFα-mediated inflammatory gene expression ∼30-40% in human adipocytes, possibly by suppressing c-Jun-NH(2) terminal kinase and c-Jun activation. In summary, (1) Q3G and Q3GN are bioavailable polyphenols in GE, (2) GP acutely improves glucose tolerance and chronically reduces markers of inflammation in obese mice, and (3) Q3G reduces several markers of inflammation in human adipocytes.

The regulation of food intake by the gut-brain axis: implications for obesity

Our understanding of the regulation of appetite has improved considerably over the last few decades. Recent work, stimulated by efforts aimed at curbing the current obesity epidemic, has unravelled some of the complex pathways regulating energy homeostasis. Key factors to this progress have been the discovery of leptin and the neuronal circuitry involved in mediating its effects, as well as the identification of gut hormones that have important physiological roles relating to energy homeostasis. Despite these advances in research, there are currently no effective treatments for the growing problem of obesity. In this article, we summarise the regulatory pathways controlling appetite with a special focus on gut hormones. We detail how recent findings have contributed to our knowledge regarding the pathogenesis and treatment of common obesity. A number of barriers still need to be overcome to develop safe and effective anti-obesity treatments. We outline problems highlighted by historical failures and discuss the potential of augmenting natural satiety signals, such as gut hormones, to treat obesity.

The long-term cost-effectiveness of obesity prevention interventions: systematic literature review

Obesity prevention provides a major opportunity to improve population health. As health improvements usually require additional and scarce resources, novel health technologies (interventions) should be economically evaluated. In the prevention of obesity, health benefits may slowly accumulate over time and it can take many years before an intervention has reached full effectiveness. Decision-analytic simulation models (DAMs), which combine evidence from diverse sources, can be utilized to evaluate the long-term cost-effectiveness of such interventions. This literature review summarizes long-term economic findings (defined as ≥ 40 years) for 41 obesity prevention interventions, which had been evaluated in 18 cost-utility analyses, using nine different DAMs. Interventions were grouped according to their method of delivery, setting and risk factors targeted into behavioural (n=21), community (n=12) and environmental interventions (n=8). The majority of interventions offered good value for money, while seven were cost-saving. Ten interventions were not cost-effective (defined as >50,000 US dollar), however. Interventions that modified a target population's environment, i.e. fiscal and regulatory measures, reported the most favourable cost-effectiveness. Economic findings were accompanied by a large uncertainty though, which complicates judgments about the comparative cost-effectiveness of interventions.

Two-year sustained weight loss and metabolic benefits with controlled-release phentermine/topiramate in obese and overweight adults (SEQUEL): a randomized, placebo-controlled, phase 3 extension study

BACKGROUND

Obesity is a serious chronic disease. Controlled-release phentermine/topiramate (PHEN/TPM CR), as an adjunct to lifestyle modification, has previously shown significant weight loss compared with placebo in a 56-wk study in overweight and obese subjects with ≥2 weight-related comorbidities.

OBJECTIVE

This study evaluated the long-term efficacy and safety of PHEN/TPM CR in overweight and obese subjects with cardiometabolic disease.

DESIGN

This was a placebo-controlled, double-blind, 52-wk extension study; volunteers at selected sites continued with original randomly assigned treatment [placebo, 7.5 mg phentermine/46 mg controlled-release topiramate (7.5/46), or 15 mg phentermine/92 mg controlled-release topiramate (15/92)] to complete a total of 108 wk. All subjects participated in a lifestyle-modification program.

RESULTS

Of 866 eligible subjects, 676 (78%) elected to continue in the extension. Overall, 84.0% of subjects completed the study, with similar completion rates between treatment groups. At week 108, PHEN/TPM CR was associated with significant, sustained weight loss (intent-to-treat with last observation carried forward; P < 0.0001 compared with placebo); least-squares mean percentage changes from baseline in body weight were -1.8%, -9.3%, and -10.5% for placebo, 7.5/46, and 15/92, respectively. Significantly more PHEN/TPM CR-treated subjects at each dose achieved ≥5%, ≥10%, ≥15%, and ≥20% weight loss compared with placebo (P < 0.001). PHEN/TPM CR improved cardiovascular and metabolic variables and decreased rates of incident diabetes in comparison with placebo. PHEN/TPM CR was well tolerated over 108 wk, with reduced rates of adverse events occurring between weeks 56 and 108 compared with rates between weeks 0 and 56.

CONCLUSION

PHEN/TPM CR in conjunction with lifestyle modification may provide a well-tolerated and effective option for the sustained treatment of obesity complicated by cardiometabolic disease. This trial was registered at clinicaltrials.gov as NCT00796367.

Potential use of exenatide for the treatment of obesity

INTRODUCTION

Obesity is a major health threat in the Western world because of its high incidence and prevalence, and its association with metabolic and cardiovascular disease as well as cancer. The reduction of food intake in obese patients can be achieved only transiently (generally for no longer than 6 months), in the absence of concomitant pharmacological therapy. Only bariatric surgery provides a means to increase satiety and/or decrease nutrient absorption in obese patients, in the long term.

AREAS COVERED

This article reviews the available pharmacological treatments for obesity as well as the pharmacology and mechanism of action of exenatide in obese type 2 diabetic patients.

EXPERT OPINION

Exenatide is a potential new candidate treatment for obesity, possibly in combination with other hormones that increase satiety (leptin) and slow gastric emptying (amylin).