Are non-prescription medications needed for weight control?

Acute liver injury following Garcinia cambogia weight-loss supplementation: case series and literature review

Herbal weight-loss supplements are sold as self-medication products, and are often used under the misconception that their natural origin guarantees their safety. Food supplements are not required to provide any benefit/risk profile evaluation before marketing; however, possible risks associated with use of herbal extracts in food supplements are becoming more and more documented in the literature. Some herbs are listed as the leading cause of herb-induced liver injury, with a severe or potentially lethal clinical course, and unpredictable herb-drug interactions. Garcinia cambogia (GC) extract and GC-containing products are some of the most popular dietary supplements currently marketed for weight loss. Here, we present four cases of acute liver failure in women taking GC extract for weight loss, and a literature review of clinical evidences about hepatic toxicity in patients taking dietary supplements containing GC extract.

Effect of a herbal extract powder (YY-312) from Imperata cylindrica Beauvois, Citrus unshiu Markovich, and Evodia officinalis Dode on body fat mass in overweight adults: a 12-week, randomized, double-blind, placebo-controlled, parallel-group clinical trial

BACKGROUND

YY-312 is a herbal extract powder from Imperata cylindrica Beauvois, Citrus unshiu Markovich, and Evodia officinalis Dode, which have health promoting effects, including body fat reduction. We aimed to evaluate the efficacy and safety of YY-312 for body fat reduction in overweight adults.

METHODS

This was a 12-week, randomized, double-blind, placebo-controlled, parallel-group clinical trial performed in overweight Korean adults aged 19-60 years with a body mass index of 25.0-29.9 kg/m². The daily dose of YY-312 was 2400 mg (containing 1800 mg of active herbal extract and 600 mg of cyclodextrin). Primary outcomes were reductions in body fat mass (BFM) and body fat percentage (BF%) after 12 weeks. Secondary outcomes included reductions in body weight and waist circumference (WC) after 12 weeks.

RESULTS

After 12 weeks, BFM (1.6 kg vs. 0.1 kg; P = 0.023) and BF% (1.5% vs. -0.2%; P = 0.018) decreased significantly more in the YY-312 group than in the placebo group, as did body weight (2.7 kg vs. 1.0 kg; P = 0.014) and WC (2.2 cm vs. 0.8 cm; P = 0.049). All safety parameters were within normal limits; no serious adverse events occurred in either group.

CONCLUSIONS

In a 12-week clinical trial in overweight adults, YY-312 resulted in significantly greater reduction in body fat vs. placebo, while being safe and well tolerated.

TRIAL REGISTRATION

cris.nih.go.kr: ( KCT0001225 ).

Successful aging: Advancing the science of physical independence in older adults

The concept of 'successful aging' has long intrigued the scientific community. Despite this long-standing interest, a consensus definition has proven to be a difficult task, due to the inherent challenge involved in defining such a complex, multi-dimensional phenomenon. The lack of a clear set of defining characteristics for the construct of successful aging has made comparison of findings across studies difficult and has limited advances in aging research. A consensus on markers of successful aging is furthest developed is the domain of physical functioning. For example, walking speed appears to be an excellent surrogate marker of overall health and predicts the maintenance of physical independence, a cornerstone of successful aging. The purpose of the present article is to provide an overview and discussion of specific health conditions, behavioral factors, and biological mechanisms that mark declining mobility and physical function and promising interventions to counter these effects. With life expectancy continuing to increase in the United States and developed countries throughout the world, there is an increasing public health focus on the maintenance of physical independence among all older adults.

The Challenges and Opportunities Associated with Reimbursement for Obesity Pharmacotherapy in the USA

Obesity has become a serious public health problem that has stimulated primordial and primary prevention efforts, and a triad of management options (lifestyle, pharmacotherapy, and surgical interventions). A growing body of evidence supports the need for a multi-pronged, clinic-based approach that leverages the synergy between pharmaceutical and lifestyle modification. Recent US policy changes-namely, the passage of the Patient Protection and Affordable Care Act coupled with recognition of obesity as a disease by the American Medical Association-suggest that financial incentives and attitudes towards obesity management are changing. This paradigm shift has implications for current and future obesity pharmacotherapy. However, barriers to pharmacotherapy utilization include patient and physician perceptions of modest efficacy, historical safety issues, regulatory obstacles, and lack of reimbursement. The shifting attitudes and challenges associated not only with a multi-payer system, but also the lack of clearly defined cross-payer reimbursement strategies, prompted a survey to determine coverage for obesity treatment. Participants indicated that federal/state mandates and growth of quality-driven healthcare initiatives will eventually drive wider pharmacotherapy reimbursement within 1-5 years. There are signs that federal/state programs are already moving towards reimbursement by improving quality measures to track obesity outcomes and reduce costs. Future research on clinical and economic outcomes of combination weight-management programs coupled with innovative approaches (e.g., eHealth) in the real-world setting that demonstrate value to patients, healthcare providers, payers, and employers will help reshape obesity management by reducing barriers and broadening reimbursement coverage for anti-obesity pharmacotherapy.

Pharmacological Management of the Obese Patient

Being obese goes beyond moral failure or a character flaw. Obesity has the defining characteristics of a chronic disease for which there is no cure. Treatment may require lifelong treatment which may include pharmacotherapy. Experience with long term use of obesity drugs is limited but evidence suggests that pharmacotherapy can improve patient outcomes and patient outlook. With current obesity drugs, weight loss is usually modest but clinically significant satisfying the FDA threshold for drug effectiveness. This weight loss is associated with clinically significant improvements in many obesity co morbidities and risk factors and could eliminate some risk factors with continued use. When used in conjunction with a comprehensive program for weight management, obesity drugs can reduce appetite or hunger, increase satiety, provide improved control over aberrant eating behaviors and modify food seeking behaviors. Pharmacotherapy can enhance weight loss and compliance during the periods of weight loss and in maintaining that weight loss, increasing physical activity and may enhance a focus on making life long changes.

This article will discuss mechanisms of action of obesity drugs, theories of altered body defense of body weight, Food and Drug Administration (FDA) approved obesity drugs, and off-label use of FDA approved drugs. The value of over-the counter (OTC) medications and diet supplements, as well as fat substitutes in the treatment of obesity drugs will be explored. Obesity drugs awaiting FDA approval and compounds under development will be reviewed. The section on approaches to drug management will include clinical considerations for; who should receive pharmacotherapy and when, length of treatment and drug discontinuation, weight regain and the role of pharmacotherapy.

Low doses of grape seed procyanidins reduce adiposity and improve the plasma lipid profile in hamsters

OBJECTIVE

Procyanidins are polyphenolic compounds with beneficial effects on health in relation to cardiovascular disease and metabolic syndrome. In this study, we evaluated the potential beneficial effects of low doses of a grape seed procyanidin extract (GSPE) on body weight and fat deposition.

DESIGN

Four groups of hamsters were fed either a standard diet (STD) or a high-fat diet (HFD) for 30 days and supplemented with either GSPE at 25 mg per kg of body weight per day (STD-GSPE and HFD-GSPE groups) or vehicle (STD and HFD groups) during the last 15 days of the study.

RESULTS

A significant decrease in body weight gain was observed in both GSPE-treated animals at the end of the experiment. GSPE treatment significantly reduced the adiposity index and the weight of all the white adipose tissue depots studied (retroperitoneal (RWAT), mesenteric (MWAT), epididymal (EWAT) and inguinal (IWAT)) in both GSPE-treated groups. GSPE administration reversed the increase in plasma phospholipids induced by the HFD feeding. In the RWAT, GSPE treatment increased the mRNA expression of genes related to β-oxidation and the glycerolipid/free fatty acid (GL/FFA) cycle, mainly in HFD-GSPE animals. In the MWAT, the effects of GSPE at the transcriptional level were not as evident as in the RWAT. Moreover, GSPE treatment induced heparin-releasable lipoprotein lipase activity in the RWAT and MWAT depots. The alterations in the lipid metabolic pathways induced by GSPE were accompanied by lower FFA levels in the plasma and decreased lipid and triglyceride accumulation in the MWAT.

CONCLUSION

The use of GSPE at low doses protects against fat accumulation and improves the plasma lipid profile in hamsters. We suggest that GSPE exerts these effects in part through the activation of both β-oxidation and the GL/FFA cycle, mainly in the RWAT.

Current management and recommendations for access to antiviral therapy of herpes labialis

Herpes labialis is a common skin infective condition, worldwide, which is primarily caused by HSV-1. Recurrent episodes of herpes labialis, also known as cold sores, can be frequent, painful, long-lasting and disfiguring for infected patients. At present, there are two types of antivirals for the treatment of herpes labialis, topical and oral, which are available over the counter or as prescription-only. The aim of antiviral therapy is to block viral replication to enable shortening the duration of symptoms and to accelerate healing of the lesions associated with herpes labialis. This review examines the evidence for the effectiveness of current topical and oral antivirals in the management of recurrent episodes of herpes labialis. In most countries, oral antivirals for herpes labialis are available as prescription-only. However, in early 2010, the oral antiviral famciclovir was reclassified from prescription-only medicine to pharmacist-controlled status in New Zealand. The benefits and risks associated with moving an antiviral therapy for herpes labialis from prescription-only to pharmacist-controlled status are reviewed here, and the implications for patients, general physicians and pharmacists are considered.

Is it time to regulate over-the-counter weight-loss formulations?

Many products claiming to promote weight loss are freely available to purchase over the counter and are used by a substantial proportion of the population in many countries, who are often seeking rapid weight loss without long-term lifestyle changes. While there are multiple outlets for these products, surveys in England and Australia have found that at least 70% of community pharmacies stock these products and they are also available through internet pharmacies. Since the products are formulated as tablets and capsules, consumers may regard them as medicines, particularly when sold from a pharmacy. Manufacturers often make extravagant claims for their products, suggesting they suppress appetite, increase metabolism, block absorption of fat or carbohydrates and/or bring about diuresis, but there is little robust evidence of efficacy. Most products contain a variety of herbal ingredients and are not without adverse effects. Since very few of the hundreds of products sold in pharmacies are licensed medicines, they are not subject to the controls required for over-the-counter medicines, in terms of efficacy, safety, quality or provision of a standardised patient information leaflet. Pharmacists themselves perceive these products to be unsafe, but have little knowledge about them, other than that supplied by manufacturers. The role of community pharmacy in supporting effective weight management is increasingly important, given the rise in obesity. We question the widespread supply through pharmacies of ineffective products with extravagant claims and suggest that tighter regulation of their promotion and supply may be required.

Self-medication with nutritional supplements and herbal over-thecounter products

In recent years, the popularity increased for nutritional supplements and herbal products. Prescription drugs, but not herbal therapies are paid by health insurances. They are sold over-the-counter (OTC) on the patients’ own expense. However, there are potential risks of self-medication, e.g. incorrect self-diagnosis, severe adverse reactions, dangerous drug interactions, risk of addiction etc. They are often used by patients at their own discretion without knowledge of and control by their physicians. Certain users are at risk of intoxication. Multiple medications taken by older patients increase the risk for adverse drug reactions, drug-drug interactions, and compliance problems for this age group (polypharmacy). Herbals should be discontinued prior to operations to avoid interactions with anesthetics or anticoagulants. Herbal preparations may also be carcinogenic or interfere with cancer treatments. Pregnant women use various OTC preparations. However, in many cases, it is unclear whether their use is safe for mother or baby. Self-medication with herbals is also largely distributed among anxious and depressive patients, and patients with other conditions and symptoms. The popularity of herbal products has also brought concerns on quality, efficacy and safety. Cases of botanical misidentification, contaminations with heavy metals, pesticides, radioactivity, organic solvents, microbials as well as adulteration with chemical drugs necessitate the establishment of international quality control standards. Hepatotoxic effects have been reported for more than 300 plant species, and some commonly used herbs have been demonstrated to interact with Western medication. Health care professionals have a critical responsibility assessing the self-care ability of their patients. Databases are available for pharmacists with information on action, side effects and toxicities as well as herb-drug interactions. There is a need for established guidelines regarding the correct use of nutritional supplements and herbal OTC preparations (phytovigilance). Physicians, pharmacists, and other health care professionals have to counsel patients and the general public on the benefits and risks associated with herbal drugs. Information centers for consumers and general practitioners are needed, and convincing evidence on safety and efficacy of herbal products has to be demonstrated in placebo-controlled, double blind and randomized clinical trials.

Pharmacology in health foods:merits and demerits of food with health claims for the prevention of metabolic syndrome

The merits and demerits of food with health claims for the prevention of metabolic syndrome (MS) are reviewed. One major underlying cause of MS is obesity. Diet and lifestyle changes remain the cornerstones of therapy for obesity, but resulting weight loss is often small and long-term success is extremely uncommon and disappointing. Many anti-obesity drugs have been associated with unintended therapeutic outcomes. Currently, only one drug (mazindol) is approved in Japan for short-term treatment of individuals with a BMI over 35 kg/m(2). Treatment with orlistat with dietary modification, caffeine, or protein supplementation; consuming a low-fat diet; adherence to physical activity routines; prolonged contact with participants; problem-solving therapy; and the alternative treatment of acupressure are efficacious in reducing weight regain after weight loss treatment. Because obesity is highly stigmatized, any effective treatment should be made available to improve quality of life and self-image. Therefore, it is necessary to provide information to consumers through the media concerning 1) basic knowledge about health foods and laws concerning them, 2) scientifically based information on safety/effectiveness of health foods and food elements, and 3) reports on health disturbances associated with health foods around the world.

Suspected adverse reactions associated with herbal products used for weight loss: a case series reported to the Italian National Institute of Health

PURPOSE

The aim of this study was to describe suspected adverse reactions (ARs) associated with herbal products used for weight control in Italy.

METHODS

Spontaneous reports of suspected ARs associated with herbal products used for weight control were collected by the Italian National Institute of Health (April 2002 to June 2010), and the causality assessment was performed.

RESULTS

Forty-six of the suspected ARs were associated with herbal products used for weight control. Women were involved in 85% of the reports. The reactions affected mainly the cardiovascular system, the skin, the digestive system, the central nervous system, and the liver. A large proportion of ARs were serious. In more than half of the suspected ARs, the use of other therapies (herbs and/or drugs) was reported, while concomitant conditions were present in 22% of the reports.

CONCLUSIONS

The use of herbal dietary supplements for weight loss is associated with several ARs. Considering the risk/benefit ratio, consumers should pay attention when using these products.

Canadian Physicians' Use of Antiobesity Drugs and Their Referral Patterns to Weight Management Programs or Providers: The SOCCER Study

Antiobesity pharmacotherapy and programs/providers that possess weight management expertise are not commonly used by physicians. The underlying reasons for this are not known. We performed a cross-sectional study in 33 Canadian medical practices (36 physicians) examining 1788 overweight/obese adult patients. The frequency of pharmacotherapy use and referral for further diet, exercise, behavioral management and/or bariatric surgery was documented. If drug treatment or referral was not made, reasons were documented by choosing amongst preselected categories. Logistic regression models were used to identify predictors of antiobesity drug use. No single antiobesity management strategy was recommended by physicians in more than 50% of patients. Referral was most common for exercise (49% of cases) followed by dietary advice (46%), and only 5% of eligible patients were referred for bariatric surgery. Significant predictors of initiating/continuing pharmacotherapy were male sex (OR 0.70; 95% CI 0.52-0.94), increasing BMI (1.02; 95% CI 1.01-1.03), and private drug coverage (1.78; 95% CI 1.39-2.29). "Not considered" and "patient refusal" were the main reasons for not initiating further weight management. We conclude that both physician and patient factors act as barriers to the use of weight management strategies and both need to be addressed to increase uptake of these interventions.

Facilitating Access to Evidence-Based Weight Management in Canada: A Consensus

Obesity is a chronic disease that has reached epidemic status in Canada and around the world. In April 2009, 7 Canadian obesity experts convened to discuss the challenges of raising public awareness of the health issues associated with obesity and the limited access to evidence-based obesity treatment. The panel identified several important challenges to effective management of obesity, including education, access to evidence-based therapies and behavioural support. The public, as well as health care professionals and health care policy makers, must understand that obesity is not a lifestyle issue, but rather a chronic disease that requires ongoing sustainable intervention. The panel agreed that there is a need for safe, proven pharmacotherapies, as well as a need to dispel the myths around non-evidence-based treatments. The panel concluded that pharmacists and other health care professionals are well placed and should be encouraged to provide ongoing behavioural support as well as education about the disease and the role of evidence-based treatments in obesity management.

Pharmacologic therapies for obesity

This article examines the transitions in pharmacological therapy for obesity. It reviews the current options approved by the Food and Drug Administration and several drugs approved for other indications that can be used to treat obesity as well. Because weight regulation is complex and redundant systems protect against perceived starvation, optimal treatment of obesity in individual patients will likely require different combinations of behavioral, nutritional, pharmacologic, endoscopic, and surgical therapies.

Cannabinoid receptor antagonists: pharmacological opportunities, clinical experience, and translational prognosis

The endogenous cannabinoid (CB) (endocannabinoid) signaling system is involved in a variety of (patho)physiological processes, primarily by virtue of natural, arachidonic acid-derived lipids (endocannabinoids) that activate G protein-coupled CB1 and CB2 receptors. A hyperactive endocannabinoid system appears to contribute to the etiology of several disease states that constitute significant global threats to human health. Consequently, mounting interest surrounds the design and profiling of receptor-targeted CB antagonists as pharmacotherapeutics that attenuate endocannabinoid transmission for salutary gain. Experimental and clinical evidence supports the therapeutic potential of CB1 receptor antagonists to treat overweight/obesity, obesity-related cardiometabolic disorders, and substance abuse. Laboratory data suggest that CB2 receptor antagonists might be effective immunomodulatory and, perhaps, anti-inflammatory drugs. One CB1 receptor antagonist/inverse agonist, rimonabant, has emerged as the first-in-class drug approved outside the United States for weight control. Select follow-on agents (taranabant, otenabant, surinabant, rosonabant, SLV-319, AVE1625, V24343) have also been studied in the clinic. However, rimonabant's market withdrawal in the European Union and suspension of rimonabant's, taranabant's, and otenabant's ongoing development programs have highlighted some adverse clinical side effects (especially nausea and psychiatric disturbances) of CB1 receptor antagonists/inverse agonists. Novel CB1 receptor ligands that are peripherally directed and/or exhibit neutral antagonism (the latter not affecting constitutive CB1 receptor signaling) may optimize the benefits of CB1 receptor antagonists while minimizing any risk. Indeed, CB1 receptor-neutral antagonists appear from preclinical data to offer efficacy comparable to or better than that of prototype CB1 receptor antagonists/inverse agonists, with less propensity to induce nausea. Continued pharmacological profiling, as the prelude to first-in-man testing of CB1 receptor antagonists with unique modes of targeting/pharmacological action, represents an exciting translational frontier in the critical path to CB receptor blockers as medicines.