Are all metabolically healthy individuals with obesity at the same risk of diabetes onset?

Metabolically healthy obesity: Misleading phrase or healthy phenotype?

Obesity is a heterogenous condition with multiple different phenotypes. Among these a particular subtype exists named as metabolically healthy obesity (MHO). MHO has multiple definitions and its prevalence varies according to study. The potential mechanisms underlying the pathophysiology of MHO include the different types of adipose tissue and their distribution, the role of hormones, inflammation, diet, the intestinal microbiota and genetic factors. In contrast to the negative metabolic profile associated with metabolically unhealthy obesity (MUO), MHO has relatively favorable metabolic characteristics. Nevertheless, MHO is still associated with many important chronic diseases including cardiovascular disease, hypertension, type 2 diabetes, chronic kidney disease as well as certain types of cancer and has the risk of progression into the unhealthy phenotype. Therefore, it should not be considered as a benign condition. The major therapeutic alternatives include dietary modifications, exercise, bariatric surgery and certain medications including glucagon-like peptide-1 (GLP-1) analogs, sodium-glucose cotransporter-2 (SGLT-2) inhibitors and tirzepatide. In this review, we discuss the significance of MHO while comparing this phenotype with MUO.

Impaired Organokine Regulation in Non-Diabetic Obese Subjects: Halfway to the Cardiometabolic Danger Zone

Altered organokine expression contributes to increased cardiometabolic risk in obesity. Our aim was to evaluate the associations of serum afamin with glucose homeostasis, atherogenic dyslipidemia, and other adipokines in severe obesity to clarify the early metabolic alterations. 106 non-diabetic obese (NDO) subjects and 62 obese patients with type 2 diabetes matched for age, gender, and body mass index (BMI) were enrolled in this study. We compared their data with 49 healthy, lean controls. Serum afamin and retinol-binding protein 4 (RBP4), as well as plasma plasminogen activator inhibitor-1 (PAI-1), were measured with ELISA, and lipoprotein subfractions were analyzed using Lipoprint gel electrophoresis. Afamin and PAI-1 found to be significantly higher in the NDO and T2M group (p < 0.001 and p < 0.001, respectively) than in the controls. In contrast, RBP4 was unexpectedly lower in the NDO and T2DM group compared to controls (p < 0.001). Afamin showed negative correlations with mean LDL size and RBP4, but positive correlations with anthropometric, glucose/lipid parameters, and PAI-1 in both the overall patients and the in NDO + T2DM groups. BMI, glucose, intermediate HDL, and small HDL were predictors of afamin. Afamin may serve as a biomarker for the severity of cardiometabolic disturbances in obesity. The complexity of organokine patterns in NDO subjects draws attention to the diverse spectrum of obesity-related comorbidities.

Metabolically healthy obesity: Is it really healthy for type 2 diabetes mellitus?

Metabolically healthy obese (MHO) individuals are reported to have a lower risk of developing cardiovascular diseases in comparison with individuals with metabolic syndrome. However, the association between MHO and type 2 diabetes (T2DM) is still controversial. Some studies indicated that MHO is a favorable phenotype for T2DM, but more studies showed that MHO individuals have an increased risk of developing T2DM compared with metabolically healthy normal-weight individuals, especially among those who would acquire metabolically unhealthy obesity. This has been supported by finding insulin resistance and low-grade inflammatory responses in MHO individuals with a tendency for impaired beta-cell dysfunction. Studies also showed that liver fat accumulation increased the risk of incidence of T2DM in MHO. Here, we reviewed current literature on the relationship between MHO and T2DM, discussed the determinants for the development of diabetes in MHO, and summarized the measures for the prevention of T2DM in MHO.

Metabolically healthy obesity, transition to unhealthy phenotypes, and type 2 diabetes in 0.5 million Chinese adults: the China Kadoorie Biobank

OBJECTIVES

To prospectively assess the association of metabolic health status and its transition with incident diabetes risk across BMI categories.

DESIGN

Cohort study based on the China Kadoorie Biobank (CKB).

METHODS

The CKB study enrolled 512 715 adults aged 30-79 years from ten diverse areas in China during 2004-2008. After exclusion, 432 763 participants were cross-classified by BMI categories and the metabolic status was followed up for incident diabetes disease. The changes in BMI and metabolic health status were defined from baseline to the second resurvey.

RESULTS

Type 2 diabetes risk is higher for metabolically healthy obese (MHO) subjects than metabolically healthy normal weight (MHN) individuals (HR: 3.97, 95% CI: 3.64-3.66), and it is highest for those affected by metabolically unhealthy obese (MUO) (HR: 6.47, 95% CI: 6.17-6.79). About 15.26% of participants with MHN converted to metabolically healthy overweight or obesity (MHOO), whereas 48.40% of MHOO remained unconverted throughout the follow-up. In obese or overweight people, the conversion from metabolically healthy to unhealthy might increase the chances of developing diabetes as compared to those with a stable metabolic healthy state (HR: 3.70, 95% CI: 2.99-4.59), while those with persistent metabolic disorders are most likely to have diabetes (HR: 8.32, 95% CI: 7.08-9.78).

CONCLUSIONS

Metabolic healthy is a transient state, and individuals converted from metabolically healthy status to unhealthy phenotypes across all BMI categories might raise the risk of diabetes.

Prediction of Metabolic Disorders Using NMR-Based Metabolomics: The Shanghai Changfeng Study

A metabolically healthy status, whether obese or not, is a transient stage with the potential to develop into metabolic disorders during the course of life. We investigated the incidence of metabolic disorders in 1078 metabolically healthy Chinese adults from the Shanghai Changfeng Study and looked for metabolites that discriminated the participants who would develop metabolic disorders in the future. Participants were divided into metabolically healthy overweight/obesity (MHO) and metabolically healthy normal weight (MHNW) groups according to their body mass index (BMI) and metabolic status. Their serum metabolomic profile was measured using a ¹H nuclear magnetic resonance spectrometer (¹H-NMR). The prevalence of diabetes, hypertriglyceridemia, hypercholesterolemia and metabolic syndrome was similar between the MHNW and MHO participants at baseline. After a median of 4.2 years of follow-up, more MHO participants became metabolically unhealthy than MHNW participants. However, a subgroup of MHO participants who remained metabolically healthy (MHO → MHO) had a similar prevalence of metabolic disorders as the MHNW participants at the follow-up examination, despite a significant reduction in their serum concentrations of high-density lipoprotein (HDL) and an elevation in valine, leucine, alanine and tyrosine. Further correlation analysis indicated that serum intermediate-density lipoprotein (IDL) and very low-density lipoprotein cholesterol (VLDL-CH) might be involved in the transition from metabolically healthy to unhealthy status and could be valuable to identify the MHNW and MHO with increased metabolic risks.

Short-Term Changes in Metabolically Healthy Overweight/Obesity Status Impact the Susceptibility to Type 2 Diabetes in Chinese Adults

PURPOSE

Changes in transition from metabolically healthy overweight/obesity (MHO) to metabolically unhealthy overweight/obesity (MUO) are associated with the risk for cardiometabolic complications. This study aims to investigate the effects of short-term dynamic changes in body mass index (BMI) and metabolic status on the risk of type 2 diabetes (T2D) and to identify biological predictors for the MHO-to-MUO transition.

PATIENTS AND METHODS

A total of 4604 subjects from the REACTION study were included for a 3-year follow-up. Subjects were categorized based on their BMI and metabolic syndrome status. Overweight/obesity was defined as BMI ≥ 24 kg/m². Metabolically healthy was defined as having two or fewer of the metabolic syndrome components proposed by the Chinese Diabetes Society. Thus, subjects were divided into four groups: metabolically healthy normal weight (MHNW), MHO, metabolically unhealthy normal weight (MUNW), and MUO.

RESULTS

Compared with MHNW, MHO was not predisposed to an increased risk for T2D (OR 1.08, 95% CI 0.64-1.83, P = 0.762). However, a 3-year transition probability of 20.6% was identified for subjects who shifted from MHO to MUO; this conversion increased the risk of T2D by 3-fold (OR 3.04, 95% CI 1.21-7.68, P = 0.018). The fatty liver index independently predicted the MHO-to-MUO transition with an OR 3.14 (95% CI 1.56-7.46, P = 0.002) when comparing the fourth quartile to the first quartile.

CONCLUSION

This study reveals that metabolic changes affect the short-term susceptibility to T2D in the overweight/obese Chinese population, and the fatty liver index is an efficient clinical parameter for identifying those with a metabolic deterioration risk.

Risk of type 2 diabetes according to the cumulative exposure to metabolic syndrome or obesity: A nationwide population-based study

Aims/Introduction

We investigated the risk of incident type 2 diabetes according to the cumulative exposure to obesity or metabolic syndrome (MetS) during annual or biennial health examinations.

Materials and Methods

The Korean National Health Insurance Service datasets from 2002 to 2017 were used for this retrospective longitudinal study. The risk for type 2 diabetes was analyzed according to the cumulative exposure to obesity and MetS among individuals who underwent four health examinations from 2009 to 2012 or 2013 (n = 2,851,745).

Results

During examinations, 28.56 and 17.86% of the total participants showed fluctuations in metabolic health state and obesity, respectively. During a mean 5.01 years of follow up, 98,950 new type 2 diabetes cases developed. The risk for type 2 diabetes increased with the increase in exposure to MetS (hazard ratio [HR] 2.92, 95% confidence interval [CI] 2.86–2.99; HR 4.96, 95% CI 4.85–5.08; HR 7.46, 95% CI 7.30–7.63; HR 12.24, 95% CI 12.00–12.49 in groups with number of exposures one to four, respectively) and obesity (HR 1.60, 95% CI 1.56–1.65; HR 1.87, 95% CI 1.81–1.92; HR 2.25, 95% CI 2.19–2.31; HR 3.46, 95% CI 3.41–3.51 in groups with number of exposures one to four, respectively), showing a more detrimental effect of cumulative exposure to MetS, when compared with the exposure to obesity.

Conclusions

Metabolic health and obesity fluctuated within a relatively short period of 4–5 years. Although the impact was much greater for MetS than for obesity, the cumulative duration of both obesity and MetS was associated with an increased risk of type 2 diabetes in a dose‐response manner. Therefore, continuously maintaining metabolic health and normal weight is crucial to prevent incident type 2 diabetes.

Impact of Transition in Metabolic Health and Obesity on the Incident Chronic Kidney Disease: A Nationwide Cohort Study

CONTEXT

Metabolically healthy obesity (MHO) is a dynamic condition.

OBJECTIVE

To evaluate the risk of chronic kidney disease (CKD) among people with MHO according to its longitudinal change.

DESIGN

Observational study.

SETTING

A nationwide population-based cohort.

PARTICIPANTS

A total of 514 866 people from the Korean National Health Insurance Service-National Sample Cohort.

INTERVENTION

The initial presence and changes of obesity (using body mass index [BMI] and waist circumference [WC]) and metabolic health status.

MAIN OUTCOME MEASURE

Incident CKD from 2011 to 2015.

RESULTS

Of the people classified as MHO at baseline (BMI criteria), 47.6% remained as MHO in 2011 and 2012, whereas 12.1%, 5.5%, and 34.8% were classified as metabolically healthy, non-obese (MHNO), metabolically unhealthy, non-obese, and metabolically unhealthy, obese, respectively. The risk of incident CKD in the baseline MHO group was higher than that in the MHNO group (hazard ratio, 1.23; 95% confidence interval, 1.12-1.36). However, when transition was taken into account, people who converted to MHNO were not at increased risk (hazard ratio, 0.98; 95% confidence interval, 0.72-1.32), whereas the stable MHO group and the groups that evolved to metabolically unhealthy status had a higher risk of incident CKD than the stable MHNO group. When the risk was analyzed using WC criteria, it showed a similar pattern to BMI criteria except for the stable MHO group.

CONCLUSIONS

MHO was a dynamic condition, and people with MHO constituted a heterogeneous group. Although the MHO phenotype was generally associated with incident CKD, maintenance of metabolic health and weight reduction might alleviate the risk of CKD.

Obesity and cardio-metabolic health

Obesity is a major and growing global health problem. It is associated with increased mortality as a result of an increasing number of complications, including type 2 diabetes, dyslipidaemia, hypertension, non-alcoholic hepatic steatosis, cardiovascular disease, sleep apnoea, gallbladder disease, obesity-related renal disease, increased risk of falls and injuries, and mental health problems as well as increased risk of certain malignancies. This article discusses the metabolic derangements associated with obesity. These include insulin resistance, dysglycaemia, low and dysfunctional high-density lipoprotein, formation of small dense and oxidised low-density lipoprotein, and high circulating levels of free fatty acids. This article reviews the aetiology of these derangements and their relationship to cardiovascular disease, and discusses the concept of metabolic health.

Impact of the Dynamic Change of Metabolic Health Status on the Incident Type 2 Diabetes: A Nationwide Population-Based Cohort Study

BACKGROUND

Metabolically healthy obese (MHO) is regarded as a transient concept. We examined the effect of the dynamic change of metabolic health status on the incidence of type 2 diabetes mellitus (T2DM) both in obese and normal weight individuals.

METHODS

We analyzed 3,479,514 metabolically healthy subjects aged over 20 years from the Korean National Health Screening Program, who underwent health examination between 2009 and 2010, with a follow-up after 4 years. The relative risk for T2DM incidence until the December 2017 was compared among the four groups: stable metabolically healthy normal weight (MHNW), unstable MHNW, stable MHO, and unstable MHO.

RESULTS

During the 4 years, 11.1% of subjects in the MHNW group, and 31.5% in the MHO group converted to a metabolically unhealthy phenotype. In the multivariate adjusted model, the unstable MHO group showed the highest risk of T2DM (hazard ratio [HR], 4.67; 95% confidence interval [CI], 4.58 to 4.77). The unstable MHNW group had a higher risk of T2DM than stable MHO group ([HR, 3.23; 95% CI, 3.16 to 3.30] vs. [HR, 1.81; 95% CI, 1.76 to 1.85]). The stable MHO group showed a higher risk of T2DM than the stable MHNW group. The influence of the transition into a metabolically unhealthy phenotype on T2DM incidence was greater in subjects with aged <65 years, women, and those with weight gain.

CONCLUSION

Metabolically healthy phenotype was transient both in normal weight and obese individuals. Maintaining metabolic health was critical for the prevention of T2DM, irrespective of their baseline body mass index.

Implications of the dynamic nature of metabolic health status and obesity on risk of incident cardiovascular events and mortality: a nationwide population-based cohort study

AIMS

We hypothesized that transitions in metabolic health status and obesity affect the cardiovascular (CV) risk and mortality in population with metabolically healthy obesity (MHO).

METHODS

This study enrolled 514,866 participants from the Korean National Health Insurance Service-National Sample Cohort. Changes in metabolic health status and obesity from the baseline examination in 2009-2010 to the next biannual health examination in 2011-2012 were determined. Study participants were categorized into four groups: (1) metabolically healthy, non-obese (MHNO), defined as BMI < 25 kg/m² and no or one metabolic risk factor; (2) metabolically unhealthy, non-obese (MUNO), defined as BMI < 25 kg/m² and ≥2 metabolic risk factors; (3) MHO, defined as BMI ≥ 25 kg/m² and no or one metabolic risk factor; and (4) metabolically unhealthy, obese (MUO), defined as BMI ≥ 25 kg/m² and ≥2 metabolic risk factors. The study subjects were followed-up from 2011 to 2015 for cardiovascular events, CV mortality and all-cause mortality.

RESULTS

Among the subjects classified as MHO in 2009-2010, 45.6% were classified as MHO in 2011-2012, whereas 11.6%, 6.0%, and 36.8% were classified as MHNO, MUNO, and MUO, respectively. The risk of CV events was higher in baseline MHO group than MHNO group (HR, 1.14; 95% CI, 1.05-1.24). However, in baseline MHO group, CV mortality was not increased (HR, 0.85; 95% CI, 0.69-1.06) and all-cause mortality was even lower than that of MHNO group (HR, 0.86; 95% CI, 0.79-0.93). Compared to the stable MHO subjects, the risk of CV events was significantly higher in the subjects who transitioned from MHO to MUO with multivariate-adjusted HRs of 1.24 (95% CI: 1.00-1.54). When weight loss and progression to metabolic unhealthy phenotype occur simultaneously in the MHO population, the all-cause mortality was increased compared to the stable MHO group (HR, 1.96; 95% CI, 1.45-2.65).

CONCLUSIONS

Subjects with MHO constitute a heterogeneous group. Our finding supports that evolving to a metabolically unhealthy status and losing weight simultaneously is associated with the adverse outcome in the MHO population.

Metabolic Health in Severely Obese Subjects: A Descriptive Study

BACKGROUND

The prevalence of metabolically healthy obese (MHO) subjects among morbidly obese subjects is poorly described.

AIM

To describe the prevalence of metabolically healthy subjects in a group of morbidly obese referred for bariatric surgery.

METHODS

Descriptive cross-sectional study, 1209 subjects (825 women/384 men) mean body mass index (BMI) of 45.6 (range: 35-72.6) kg/m² and mean age of 42.9 (range: 18-72) years were included. Metabolically unhealthy obese subjects had at least two metabolic risk factors: systolic blood pressure >130 mmHg or diastolic blood pressure >85 mmHg or use of antihypertensive medication, diagnosed diabetes with a HbA1c >6.5% (>48 mmol/mol) or use of antidiabetic medication, high plasma triglycerides or low plasma high-density lipoprotein, or use of lipid-lowering medication. MHO subjects had one or no metabolic risk factors.

RESULTS

Thirty-four percent (413/1209) were characterized as MHO subjects. The MHO stage was characterized by female sex, younger age, and lower neck and waist circumferences. The odds ratio of metabolic unhealthy was 1.12 (1.07-1.17, P < 0.001) and 1.02 (1.01-1.04, P < 0002) for every 1 cm increase in neck and waist circumferences, respectively, and 0.94 (0.91-0.97, P < 0.001) for every 1 U increase in BMI and 1.04 (1.03-1.05, P < 0.001) for every 1 year increase in age.

CONCLUSIONS

Among severely obese subjects, 34% were classified as having a metabolically healthy state, which was more likely to occur in females, younger individuals and was associated with a lower neck and waist circumferences, younger age, and higher BMI. Whether a group of MHO subjects will remain healthy lifelong is unknown.

Obesity and incidence of diabetes: Effect of absence of metabolic syndrome, insulin resistance, inflammation and fatty liver

BACKGROUND AND AIMS

Obesity is frequently associated with non-alcoholic fatty liver disease (NAFLD), insulin resistance (IR), inflammation and metabolic syndrome (MetS), all of which increase the risk of type 2 diabetes (T2DM). However, the role of these risk factors in mediating the effect of obesity remains unclear. We investigated the association between obesity and T2DM in the absence and presence of NAFLD, IR, inflammation and MetS components.

METHODS

29,836 obese subjects without diabetes were studied in a Korean health screening program. Obesity was defined by the appropriate ethnic-specific body mass index (BMI) threshold ≥25 kg/m². Hazard ratios (HRs and 95% confidence intervals, CIs) for incident T2DM were estimated for the group with no hypertension, dyslipidemia, impaired fasting glucose, fatty liver, IR, or inflammation (n = 1717), compared to the reference group, with one or more of these factors (n = 19,757).

RESULTS

Mean (SD) age at baseline was 37 (7) years and 1200 incident cases of diabetes occurred. Crude T2D incidence was 12.6/10,000 person-years in the group without metabolic abnormality and 143/10,000 person-years in the reference group. HR (95% CIs) for incident diabetes was 0.13 (0.06, 0.33) in the group without metabolic abnormality.

CONCLUSIONS

Obese subjects without components of the metabolic syndrome, IR, fatty liver and inflammation have an approximately 11-fold lower risk of incident type 2 diabetes than obese subjects who have these risk factors. These simple factors could be used to target limited resources in high risk obese subjects in the prevention of diabetes.

Relationship Between Adiponectin and apoB in Individuals With Diabetes in the Atlantic PATH Cohort

Context

The increasing prevalence of obesity and diabetes greatly influences the risk for cardiovascular (CV) comorbidities and affects the quality of life of many people. However, the relationship among diabetes, obesity, and cardiovascular risk is complex and requires further investigation to understand the biological milieu connecting these conditions.

Objective

The aim of the current study was to explore the relationship between biological markers of adipose tissue function (adiponectin) and CV risk (apolipoprotein B) in body mass index (BMI)-matched participants with and without diabetes.

Design

Nested case-control study.

Setting

The Atlantic Partnership for Tomorrow's Health (PATH) cohort represents four Atlantic Canadian provinces: Newfoundland and Labrador, New Brunswick; Nova Scotia; and Prince Edward Island.

Participants

The study population (n = 480) was aged 35 to 69 years, 240 with diabetes and 240 without diabetes.

Main Outcome Measures

Groups with and without diabetes were matched for sex and BMI. Both measured and self-reported data were used to examine disease status, adiposity, and lifestyle factors. Immunoassays were used to measure plasma markers.

Results

In these participants, plasma adiponectin levels were lower among those with diabetes than those without diabetes; these results were sex-specific, with a strong relationship seen in women. In contrast, in participants matched for sex and adiposity, plasma apoB levels were similar between participants with and those without diabetes.

Conclusion

Measures of adiposity were higher in participants with diabetes. However, when matched for adiposity, the adipokine adiponectin exhibited a strong inverse association with diabetes.

"Metabolically Healthy" Obesity and Hyperuricemia Increase Risk for Hypertension and Diabetes: 5-year Japanese Cohort Study

OBJECTIVE

Whether obesity without metabolic syndrome (i.e., "metabolically healthy" obesity) confers similar or less metabolic risk remains controversial.

METHODS

A retrospective 5-year cohort study of 9,721 Japanese subjects (48.5 ± 10.5 years, 4,160 men) was conducted in 2004 and reevaluated 5 years later. Subjects were excluded if they were hypertensive or diabetic or were receiving medications for dyslipidemia and/or gout or hyperuricemia in 2004. Study subjects were categorized according to baseline BMI  ≥ 25 kg/m² (overweight/obesity) and < 25 kg/m² (lean/normal weight) and also whether they had metabolic syndrome. The cumulative incidence of hypertension and diabetes over 5 years between groups was assessed. A second analysis evaluated whether baseline hyperuricemia provided additional risk.

RESULTS

Subjects with overweight/obesity but without metabolic syndrome carried increased cumulative incidence of hypertension (14.6% vs. 7.2%, P < 0.001) and diabetes (2.6% vs. 1.1%, P = 0.004) over 5 years compared to lean/normal subjects without metabolic syndrome. Overweight/obesity conferred an increased risk for diabetes even in individuals with normal fasting blood glucose. Hyperuricemia became an independent risk factor for developing hypertension over 5 years in lean/normal subjects without metabolic syndrome. A 1 mg/dL increase in serum uric acid carried increased risk for hypertension (19%) and diabetes (27%).

CONCLUSIONS

Metabolically healthy obesity and hyperuricemia confer increased risk for hypertension and diabetes.

Incidence of components of metabolic syndrome in the metabolically healthy obese over 9 years follow-up: the Atherosclerosis Risk In Communities study

Background

Some obese adults are not afflicted by the metabolic abnormalities often associated with obesity [the “metabolically healthy obese” (MHO)], however, they may be at increased risk of developing cardiometabolic abnormalities in the future. Little is known about the relative incidence of individual components of metabolic syndrome (MetSyn).

Methods

We used data from a multi-center, community-based cohort aged 45–64 years at recruitment [the Atherosclerosis Risk in Communities (ARIC) study] to examine the first appearance of any MetSyn component, excluding waist circumference. Body mass index (BMI, kg/m²) and cardiometabolic data were collected at four triennial visits. Our analysis included 3,969 adults who were not underweight and free of the components of MetSyn at the initial visit. Participants were classified as metabolically healthy normal weight (MHNW), over weight (MHOW) and MHO at each visit. Adjusted hazard ratios (HR) and 95% confidence intervals were estimated with proportional hazards regression models.

Results

The relative rate of developing each risk factor was higher among MHO than MHNW with the strongest association noted for elevated fasting glucose [MHO vs. MHNW, HR: 2.33 (1.77, 3.06)]. MHO was also positively associated with elevated triglycerides [HR: 1.63 (1.27, 2.09)], low HDL-C [HR: 1.68 (1.32, 2.13)] and elevated blood pressure [HR: 1.54 (1.26, 1.88)]. A similar, but less pronounced pattern was noted among the MHOW vs. MHNW.

Conclusions

We conclude that even among apparently healthy individuals, obesity and overweight are related to more rapid development of at least 1 cardiometabolic risk factor, and that elevations in blood glucose develop most rapidly.

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.