Current and emerging medications for overweight or obesity in people with comorbidities

A simple yet multifaceted 90 years old, evergreen enzyme: Carbonic anhydrase, its inhibition and activation

Advances in the carbonic anhydrase (CA, EC 4.2.1.1) research over the last three decades are presented, with an emphasis on the deciphering of the activation mechanism, the development of isoform-selective inhibitors/ activators by the tail approach and their applications in the management of obesity, hypoxic tumors, neurological conditions, and as antiinfectives.

Structure-guided identification of a selective sulfonamide-based inhibitor targeting the human carbonic anhydrase VA isoform

In recent years, multistep hybrid computational protocols have attracted attention for their application in the drug discovery of enzyme inhibitors. So far, there are large collections of human carbonic anhydrase (hCA) inhibitors, but only a few of them selectively inhibit the mitochondrial isoforms hCA VA and VB as potential therapeutics in obesity treatment. Most sulfonamide-based inhibitors show poor selectivity for inhibiting isoforms of therapeutic interest over ubiquitous hCA I and hCA II. Herein, we propose a combination of ligand- and structure-based approaches to generate pharmacophore models for hCA VA inhibitors. Then, we performed a virtual screening (VS) campaign on a database of commercially available sulfonamides. Finally, the in silico screening followed by docking studies suggested several "hit compounds" that demonstrated to inhibit hCA VA at a low nanomolar concentration in a stopped-flow CO₂ hydrase assay. Notably, the best candidate, 2-(3,4-dihydro-2H-quinolin-1-yl)-N-(4-sulfamoylphenyl)acetamide (code name VAME-28) proved to be a potent hCA VA inhibitor (K_i value of 54.8 nM) and a more selective agent over hCA II when compared to the reference compound topiramate.

Anti-Obesity Medications and Investigational Agents: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

This "Anti-Obesity Medications and Investigational Agents: An Obesity Medicine Association Clinical Practice Statement 2022" is intended to provide clinicians an overview of Food and Drug Administration (FDA) approved anti-obesity medications and investigational anti-obesity agents in development.

Methods

The scientific information for this Clinical Practice Statement (CPS) is based upon published scientific citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

This CPS describes pharmacokinetic principles applicable to those with obesity, and discusses the efficacy and safety of anti-obesity medications [e.g., phentermine, semaglutide, liraglutide, phentermine/topiramate, naltrexone/bupropion, and orlistat, as well as non-systemic superabsorbent oral hydrogel particles (which is technically classified as a medical device)]. Other medications discussed include setmelanotide, metreleptin, and lisdexamfetamine dimesylate. Data regarding the use of combination anti-obesity pharmacotherapy, as well as use of anti-obesity pharmacotherapy after bariatric surgery are limited; however, published data support such approaches. Finally, this CPS discusses investigational anti-obesity medications, with an emphasis on the mechanisms of action and summary of available clinical trial data regarding tirzepatide.

Conclusion

This "Anti-Obesity Medications and Investigational Agents: An Obesity Medicine Association Clinical Practice Statement 2022" is one of a series of OMA CPSs designed to assist clinicians in the care of patients with pre-obesity/obesity.

Increases in multimorbidity with weight class in the United States

Little is known regarding how multimorbidity combinations associated with obesity change with increase in body weight. This study employed data from the national Cerner HealthFacts Data Warehouse to identify changes in multimorbidity patterns by weight class using network analysis. Networks were generated for 154 528 middle-aged patients in the following categories: normal weight, overweight, and classes 1, 2, and 3 obesity. The results show significant differences (P-value<0.05) in prevalence by weight class for all but three of 82 diseases considered. The percentage of patients with multimorbidity (excluding obesity) increases from in 55.1% in patients with normal weight, to 57.88% with overweight, 70.39% with Class 1 obesity, 73.99% with Class 2 obesity, and 71.68% in Class 3 obesity, increasing most substantially with the progression from overweight to class 1 obesity. Most prevalent disease clusters expand from only hypertension and dorsalgia in normal weight, to add joint disorders in overweight, lipidemias in class 1 obesity, diabetes in class 2 obesity, and sleep disorders and chronic kidney disease in class 3 obesity. Recognition of multimorbidity patterns associated with weight increase is essential for true precision care of obesity-associated chronic conditions and can help clinicians identify and address preclinical disease before additional complications arise.

Tailoring treatment for PCOS phenotypes

Introduction: Polycystic ovary syndrome (PCOS) is one of the most common endocrinopathies in reproductive-aged women. Hyperandrogenism, polycystic ovaries, chronic anovulation, and metabolic aberrations are its common features. The treatment approach focuses on the main aberrations, which characterize the different phenotypes. Areas covered: Management strategies targeting the metabolic phenotype include lifestyle modifications for weight loss and improvement of dietary habits, as well as medication, such as insulin-sensitizers. The treatment of hyperandrogenic phenotype includes cosmetic procedures and the combined oral contraceptives with or without antiandrogens. The therapeutic approach to reproductive phenotype includes diet and lifestyle modifications, clomiphene citrate, and aromatase inhibitors. Alternative treatments include dietary supplements, herbs, resveratrol, myo-inositol, and acupuncture. Expert opinion: New studies have shown that higher anti-Müllerian hormone levels, gut microbiome composition, and plasma metabolomics are new parameters that are related to the most severe phenotypes. The clinical phenotypes can change over the lifespan with weight gain and can coexist in the same individual. Individualized treatment remains the main approach but grouping the phenotypes and following therapeutic recommendations may prove to be also clinically appropriate.

Barriers and Solutions for Prescribing Obesity Pharmacotherapy

There are many valid reasons why health care providers are reluctant to use pharmacotherapy for weight management: the negative track record of weight loss medications has led to numerous safety concerns, and there is lack of formal training in obesity medicine and a general discomfort with using these medications. New medications have improved safety profiles, and their mechanisms are based on recent discoveries of how humans regulate weight. This, combined with a change in American health coverage, has slowly increased the use weight loss medication. This article examines the barriers and changes that are increasing the use of anti-obesity medications.

Assessing the Use and Perception of Dietary Supplements Among Obese Patients with National Health and Nutrition Examination Survey

Complementary alternative medicine, especially dietary supplements (DS), has gained increasing popularity for weight loss due to its availability without prescription, price, and ease of use. Besides weight loss, there are various perceived, potential benefits linked to DS use. However, health consumers with limited health literacy may not adequately know the benefits and risk of overdose for DS. In this project, we aim to gain a better understanding of the use of DS products among obese people as well as the perceived benefits of these products. We identified obese adults after combining the National Health and Nutrition Examination Survey data collected from 2003 to 2014. We found that there is a knowledge gap between the reported benefits of major DS by obese adults and the existing DS knowledge base and label database. This gap may inform the design of patient education material on DS usage in the future.

Effects of diacylglycerol and triacylglycerol from peanut oil and coconut oil on lipid metabolism in mice

Different chain lengths diacylglycerols (DAG) (long- and medium-chain) were synthesized from peanut and coconut oils. The effects of DAG with different chain lengths on body fat, blood lipids, and lipid metabolism-related enzymes in the liver and adipose tissue of C57BL/6J mice were investigated. Compared to peanut and coconut oils containing triacylglycerol (TAG), DAG-rich oils can significantly reduce the body weight, kidney weight, serum triglyceride (TG) content, hepatic fatty acid synthase (FAS), and Acetyl-CoA carboxylase (ACC) enzyme levels (p < 0.05) in C57BL/6J mice. Therefore, the effect of coconut oil DAG on improving body fat metabolism was probably due to the impact of DAG. Meanwhile, the body weight and serum TG content in coconut oil DAG group were lower than those in peanut oil DAG group. In addition, the spleen weight, hepatic ACC, and lipoprotein lipase (LPL) enzymes in coconut oil DAG group (0.07 ± 0.01 g, 2.08 ± 0.42 ng/mg pro, and 18.44 ± 5.23 ng/mg pro, respectively) were significantly lower than those in peanut oil DAG group. Although coconut oil DAG and peanut oil DAG have different fatty acid compositions, their effects on lipid metabolism showed no significant changes. Coconut oil DAG (peanut oil DAG) showed the improved lipid metabolism than that of coconut oil (peanut oil), which was probably due to the effect of DAG. PRACTICAL APPLICATION: Peanut and coconut oils are common edible oils. The oil containing DAG synthesized decreased the body weight and lipid accumulation in mice. Coconut oil is rich in medium-chain fatty acids, while peanut oil mainly consists of long-chain fatty acids. Due to the different contents of fatty acids, the synthesized structural lipids have different effects on lipid metabolism. Medium-chain triglycerides were considered as agents to alleviate obesity.

Mac-2 binding protein in non-alcoholic fatty liver disease: Is it a reliable diagnostic biomarker? A pilot study

Aim of the study

This study aimed to assess the level of serum Mac-2 binding protein (Mac-2BP) as a non-invasive biomarker for the diagnosis of non-alcoholic fatty liver disease (NAFLD).

Material and methods

Forty patients with NAFLD and 15 healthy sex- and age-matched subjects were included in this pilot study. Serum Mac-2BP level was measured using ELISA. Liver biopsy was taken from 20 patients.

Results

There was no statistically significant difference between patients and controls regarding the level of Mac-2BP (p = 0.209). Mac-2BP had a statistically significant correlation with the grade of lobular inflammation (r = 0.464, p = 0.039). The Mac-2BP cut-off value used for NASH prediction was 9.55 µg/ml, with sensitivity and specificity of 100% and 91.7%, respectively.

Conclusions

This study showed that Mac-2BP is not elevated in NAFLD patients compared to controls. It also demonstrated that the reliability of Mac-2BP as a biomarker for NAFLD diagnosis is still controversial and needs more investigation.

Calcitonin Receptor Neurons in the Mouse Nucleus Tractus Solitarius Control Energy Balance via the Non-aversive Suppression of Feeding

To understand hindbrain pathways involved in the control of food intake, we examined roles for calcitonin receptor (CALCR)-containing neurons in the NTS. Ablation of NTS Calcr abrogated the long-term suppression of food intake, but not aversive responses, by CALCR agonists. Similarly, activating Calcr^NTS neurons decreased food intake and body weight but (unlike neighboring Cck^NTS cells) failed to promote aversion, revealing that Calcr^NTS neurons mediate a non-aversive suppression of food intake. While both Calcr^NTS and Cck^NTS neurons decreased feeding via projections to the PBN, Cck^NTS cells activated aversive CGRP^PBN cells while Calcr^NTS cells activated distinct non-CGRP PBN cells. Hence, Calcr^NTS cells suppress feeding via non-aversive, non-CGRP PBN targets. Additionally, silencing Calcr^NTS cells blunted food intake suppression by gut peptides and nutrients, increasing food intake and promoting obesity. Hence, Calcr^NTS neurons define a hindbrain system that participates in physiological energy balance and suppresses food intake without activating aversive systems.

Identifying obesity-related multimorbidity combinations in the United States

Interest in understanding the effects of multimorbidity on outcomes has increased in recent years. This paper presents the most common obesity-related groupings of multimorbidity in the United States. Using Cerner HealthFacts data, we applied the frequent pattern growth algorithm to identify prevalent multimorbidity groupings of 3 or more diseases (one being obesity) by race using a dataset of 574 172 patients with obesity from all over the United States. We set the minimum prevalence to 10% and identified groupings of ICD10-CM diagnoses that occur in our dataset at or above the minimum prevalence level. We provide binomial proportion confidence interval estimates to demonstrate the validity of the proportions. We performed g-test for independence to validate differences in prevalence by race. We found 18 multimorbidity combinations with prevalence higher than or equal to 10%. Our results indicate that there are multiple common multimorbidities groupings for patients with obesity. Each multimorbidity combination is composed of diseases from the following clinical categories: endocrine, nutritional and metabolic diseases; diseases of the circulatory system; diseases of the digestive system; diseases of the nervous system; and diseases of the musculoskeletal system and connective tissue. For each multimorbidity pattern, the prevalence was found to be significantly different by race according to the g-test with P-value < .001. Most frequent patterns include essential hypertension or disorder of lipid metabolism. This study identifies common groupings of multimorbidity. We believe our data can be useful for those developing integrated care plans, particularly for those serving diverse communities.

Are There Adverse Events after the Use of Sexual Enhancement Nutrition Supplements? A Nationwide Online Survey from Japan

Dozens of safety alerts for sexual enhancement and weight loss dietary supplements have been launched from the government not only in Japan but also overseas. However, adverse events have been reported only for the use of weight loss supplements, and the prevalence of use and adverse events in sexual enhancement supplements is not known in Japan. To address this issue, we assessed the situation of sexual enhancement supplement use through a nationwide online survey. The prevalence of sexual enhancement supplement use among males was 23.0%. Use of these supplements was higher among younger people than among older people (p < 0.001). In total, 17.6% of users had experienced adverse events, but 58.3% of them did not consult about the events with anybody because of the temporality of their symptoms and their sense of shame. In addition, eight supplement products were found to be possible adulterated supplements in this survey. It is necessary to inform the public about the risk of sexual enhancement supplement use and also prepare a place for consultation on media channels that younger people are more familiar with, in order to monitor adverse events while also preserving their privacy.

Exploring the Discrepancies in Actual and Perceived Benefits of Dietary Supplements Among Obese Patients

Dietary supplements (DSs) have gained increased popularity for weight loss due to its availability without prescription, relatively low price, and ease of use. Consumers with limited health literacy may not adequately know the benefits and risks associated with DSs. In this project, we found a knowledge gap between reported benefits of major DSs by adults with obesity in the National Health and Nutrition Examination Survey 2003-2014 and those reported in existing DS knowledge databases.

Hepatocellular carcinoma and metabolic syndrome: The times are changing and so should we

Although hepatocellular carcinoma (HCC) is as prevalent as ever as a cancer-related mortality, and some would even argue that it is increasing, the pattern of its etiologies has been changing. Specifically, the domination of viral hepatitis C virus is being overcome, partly because of the emergence of the antiviral treatments, and partly because of the significant increase, especially in developed countries, of the combination of obesity, diabetes, metabolic syndrome, non-alcoholic fatty liver disease and non-alcoholic steatohepatitis. This editorial will explore the interconnection of this group of diseases and how they are linked to HCC. More importantly, it will argue that this shift in HCC etiology essentially means that we have to change how we approach the treatment of HCC, by changing our focus (and resources) to earlier stages of the disease development in order to prevent the appearance and progression of HCC.

Pharmacotherapy of Obesity: Limits and Perspectives

Obesity is a severe worldwide epidemic. Obesity comorbidities, such as type 2 diabetes mellitus, hypertension, and atherosclerosis, are costly for patients and governments. The treatment of obesity involves several facets, including lifestyle changes, bariatric surgery, and pharmacotherapy. As changes in lifestyle require considerable patient commitment that is sometimes unachievable, and surgery is expensive and invasive, pharmacotherapy is the primary option for most patients. This review describes the pharmacotherapy currently available in the USA, Europe, and Brazil, focusing on its limitations. We then analyze the results from clinical trials of new drug candidates. Most drugs cause weight loss of < 4 kg compared with controls, and severe adverse effects have caused a number of drugs to be withdrawn from the market in several countries. Drugs under development have not shown more significant weight loss or reduced adverse effects. We conclude that a significant portion of obese patients have few treatment options because of the adverse effects and minimal weight loss associated with current pharmacotherapy. However, drugs currently under development appear unable to change this scenario in the near future. Thus, it is essential that new compounds are developed and new molecular targets studied so obesity can be efficiently treated in all patients in the future.

Combined effects of Diospyros lotus leaf and grape stalk extract in high-fat-diet-induced obesity in mice

The aim of this study was to investigate the combined effects of Diospyros lotus leaves extracts (DLE) and Muscat Bailey A grape stalk extracts (MGSE) in obesity induced by high-fat diet (HFD) in mice. The mice were fed with HFD and orally administered daily with DLE, MGSE, a mixture of DLE and MGSE, and Garcinia cambogia extract over a period of 16 weeks. The results revealed that daily administration of DLE and MGSE mixtures markedly prevented HFD-induced weight gain, plasma lipid profile, hepatic steatosis, hepatic fibrosis, diabetic symptoms, and the risk of developing cardiovascular diseases. Also, DLE and MGSE mixtures administration greatly prevented oxidative stress and liver toxicity. The combined effects of DLE and MGSE mixtures were higher than effects of the single extracts and of G. cambogia, a plant known for its anti-obesity effects. In summary, these findings demonstrated that DLE and MGSE mixtures, exhibit anti-obesity activity in HFD-fed mice.

Muscat Bailey A grape stalk extract ameliorates high-fat diet‑induced obesity by downregulating PPARγ and C/EPBα in mice

Muscat Bailey A grape stalk is an organic waste produced in marked amounts during the vinification of grapes. Previous studies have indicated that grape stalk is rich in bioactive phenolic compounds, and exhibits antioxidant and UV‑protective activities. However, its effects on obesity and obesity‑associated disorders have not yet been investigated. The effects of grape stalk extract on improving metabolic features were examined using a high‑fat diet (HFD)‑induced obesity mouse model. Oral administration of 200 mg/kg/day grape stalk extract over 16 weeks markedly prevented HFD‑induced obesity, hepatic steatosis, diabetic symptoms and the risk of developing cardiovascular disease. Furthermore, grape stalk extract prevented oxidative stress and inflammation caused by HFD in mice. The beneficial effect may be associated with CCAAT/enhancer‑binding protein α and peroxisome‑proliferator‑activated receptor γ down-regulation in liver tissue. Collectively, the results of the present study indicated that grape stalk extract may be a potent functional food ingredient for preventing obesity, hepatic steatosis and type 2 diabetes.

Obesity and type 2 diabetes: Also linked in therapeutic options

The prevalence of obesity has increased worldwide over the past decades. Obesity is associated with multiple comorbidities, such as type 2 diabetes, that generates a great impact on health and economy. Weight loss in these patients leads to glycemic control so it is a target to achieve. Lifestyle changes are not effective enough and recently other treatments have been developed such as bariatric/metabolic surgery, as well as drugs for type 2 diabetes and antiobesity drugs. The aim of this review is to compare the results in weight reduction and glycemic control of the different kinds of drugs with bariatric / metabolic surgery's results in type 2 diabetes.

The effect of glucagon-like peptide 1 and glucagon-like peptide 1 receptor agonists on energy expenditure: A systematic review and meta-analysis

AIM

We reviewed clinical trials addressing the effect of glucacon-like peptide 1 (GLP-1) or GLP-1 receptor agonists (GLP-1RA) on energy expenditure (EE) in adults.

MATERIALS AND METHODS

PubMed, Science Direct and Web of Science were searched for clinical trials investigating the effect of GLP-1 or GLP-1RA on EE in adults.

RESULTS

Ten trials (93 participants) assessed the effect of GLP-1 administration over 1 to 48 h and found no change in resting EE (REE). Two out of three trials (62 participants) reported a significant decrease in diet-induced thermogenesis (DIT) following GLP-1 administration. Ten trials with exenatide (10 μg bid, for 10-52 weeks) or liraglutide (0.6, 1.2, 1.8 or 3 mg, for 3 days-52 weeks), with a total of 282 participants, indicated a neutral effect of these GLP-1RA on REE, DIT or physical activity-induced EE. Importantly, the longest trial with GLP-1RA reported a significant increase in REE in response to treatment with both exenatide or liraglutide and most trials reported that GLP-1RA-induced weight loss was not accompanied by decreased REE.

CONCLUSIONS

This review indicates that GLP-1 has no short-term effect on REE but may decrease DIT. The GLP-1RA exenatide and liraglutide have a neutral effect on REE, although it is not possible to rule out an increase in REE following prolonged treatment.

Coadministration of Canagliflozin and Phentermine for Weight Management in Overweight and Obese Individuals Without Diabetes: A Randomized Clinical Trial

OBJECTIVE

To assess the efficacy and safety of coadministration of canagliflozin (CANA) and phentermine (PHEN) compared with placebo (PBO) and CANA or PHEN monotherapies in individuals who were overweight and obese without type 2 diabetes.

RESEARCH DESIGN AND METHODS

This 26-week, phase 2a, randomized, double-blind, PBO-controlled, multicenter, parallel-group study enrolled individuals who were obese or overweight without type 2 diabetes (N = 335, aged 18-65 years, BMI ≥30 to <50 kg/m² or BMI ≥27 to <50 kg/m² with hypertension and/or dyslipidemia). Participants were randomized (1:1:1:1) to receive PBO, CANA 300 mg, PHEN 15 mg, or coadministration of CANA 300 mg and PHEN 15 mg (CANA/PHEN) orally once daily. The primary end point was percent change in body weight from baseline to week 26; key secondary end points were the proportion of participants achieving weight loss ≥5% and change from baseline in systolic blood pressure.

RESULTS

CANA/PHEN provided statistically superior weight loss from baseline versus PBO at week 26 (least squares mean difference -6.9% [95% CI -8.6 to -5.2]; P < 0.001). CANA/PHEN also provided statistically superior achievement of weight loss ≥5% and reduction in systolic blood pressure compared with PBO. CANA/PHEN was generally well tolerated, with a safety and tolerability profile consistent with that of the individual components.

CONCLUSIONS

CANA/PHEN produced meaningful reductions in body weight and was generally well tolerated in individuals who were overweight or obese without type 2 diabetes. Further studies are warranted to evaluate potential use of this combination for long-term weight management.

High-Fat Diet Feeding Alters Expression of Hepatic Drug-Metabolizing Enzymes in Mice

Medical conditions accompanying obesity often require drug therapy, but whether and how obesity alters the expression of drug-metabolizing enzymes and thus drug pharmacokinetics is poorly defined. Previous studies have shown that high-fat diet (HFD) feeding and subsequent obesity in mice lead to altered expression of transcriptional regulators for cytochrome P450 CYP2D6, including hepatocyte nuclear factor 4α (HNF4α, a transcriptional activator of CYP2D6) and small heterodimer partner (SHP, a transcriptional repressor of CYP2D6). The objective of this study was to examine whether diet-induced obesity alters CYP2D6 expression by modulating HNF4α and SHP expression. Male CYP2D6-humanized transgenic (Tg-CYP2D6) mice were fed with HFD or matching control diet for 18 weeks. Hepatic mRNA expression of CYP2D6 decreased to a small extent in the HFD group (by 31%), but the differences in CYP2D6 protein and activity levels in hepatic S9 fractions were found insignificant between the groups. Although hepatic SHP expression did not differ between the groups, HNF4α mRNA and protein levels decreased by ∼30% in the HFD group. Among major mouse endogenous cytochrome P450 genes, Cyp1a2 and Cyp2c37 showed significant decreases in the HFD group, whereas Cyp2e1 expression did not differ between groups. Cyp2b10 and Cyp3a11 expression was higher in the HFD group, with corresponding 2.9-fold increases in hepatic CYP3A activities in HFD-fed mice. Together, these results suggest that obesity has minimal effects on CYP2D6-mediated drug metabolism, although it modulates the expression of mouse endogenous P450s in a gene-specific manner.

Effects of obesity treatments on bone mineral density, bone turnover and fracture risk in adults with overweight or obesity

BACKGROUND

New evidence suggests that obesity is deleterious for bone health, and obesity treatments could potentially exacerbate this.

MATERIALS AND METHODS

This narrative review, largely based on recent systematic reviews and meta-analyses, synthesizes the effects on bone of bariatric surgery, weight loss pharmaceuticals and dietary restriction.

RESULTS AND CONCLUSIONS

All three obesity treatments result in statistically significant reductions in hip bone mineral density (BMD) and increases in bone turnover relative to pre-treatment values, with the reductions in hip BMD being strongest for bariatric surgery, notably Roux-en Y gastric bypass (RYGB, 8%-11% of pre-surgical values) and weakest for dietary restriction (1%-1.5% of pre-treatment values). Weight loss pharmaceuticals (orlistat or the glucagon-like peptide-1 receptor agonist, liraglutide) induced no greater changes from pre-treatment values than control, despite greater weight loss. There is suggestive evidence that liraglutide may increase bone mineral content (BMC) - but not BMD - and reduce fracture risk, but more research is required to clarify this. All three obesity treatments have variable effects on spine BMD, probably due to greater measurement error at this site in obesity, suggesting that future research in this field could focus on hip rather than spine BMD. Various mechanisms have been proposed for BMD loss with obesity treatments, notably reduced nutritional intake/absorption and insufficient exercise, and these are potential avenues for protection against bone loss. However, a pressing outstanding question is whether this BMD reduction contributes to increased fracture risk, as has been observed after RYGB, and whether any such increase in fracture risk outweighs the risks of staying obese (unlikely).

The Obesity-Impulsivity Axis: Potential Metabolic Interventions in Chronic Psychiatric Patients

Pathological impulsivity is encountered in a broad range of psychiatric conditions and is thought to be a risk factor for aggression directed against oneself or others. Recently, a strong association was found between impulsivity and obesity which may explain the high prevalence of metabolic disorders in individuals with mental illness even in the absence of exposure to psychotropic drugs. As the overlapping neurobiology of impulsivity and obesity is being unraveled, the question asked louder and louder is whether they should be treated concomitantly. The treatment of obesity and metabolic dysregulations in chronic psychiatric patients is currently underutilized and often initiated late, making correction more difficult to achieve. Addressing obesity and metabolic dysfunction in a preventive manner may not only lower morbidity and mortality but also the excessive impulsivity, decreasing the risk for aggression. In this review, we take a look beyond psychopharmacological interventions and discuss dietary and physical therapy approaches.

What weight loss treatment options do geriatric patients with overweight and obesity want to consider?

INTRODUCTION

Since the 1990s, a number of weight loss medications have been removed from the USA and or European market because of adverse events associated with these medications. These medications include fenfluramine (heart valve thickening), sibutramine (cardiovascular risk) and rimonabant (depression). This history may affect a patient's desire to consider weight loss medications as an option for weight management.

OBJECTIVE

This descriptive study was designed to observe what treatment options the geriatric patient (age 65 or higher) seeking weight loss would like to consider, as well as the reasons they felt they struggled with overweight or obesity.

METHODS

A questionnaire was given to 102 geriatric patients with overweight or obesity before starting a weight loss programme at a weight management centre. The questionnaire asked the patient why they felt they were overweight or obese and what treatment options they wished to consider. The geriatric patients were matched with younger patients in body mass index and sex.

RESULTS

The three most common perceptions that geriatric patients felt were causes of their increased weight were 'lack of exercise' (76.2%), 'poor food choices' (59.4%) and 'cravings' (47.5%). When geriatric patients were asked what treatment options they would like to discuss, the four most common options requested were 'diet and healthy eating' (67.3%), weight loss medications (57.4%), a request for a 'metabolic work up' (55.4%) and 'exercise' (53.5%). These responses were no different from their younger cohorts. When geriatric patients with a body mass index of 35 or higher were given bariatric surgery as a treatment option, 21.9% marked it as a treatment option they would like to consider.

CONCLUSIONS

Over half of geriatric patients desired to discuss weight loss medications as a treatment option. Diet and exercise were also of strong interest, which is in line with current weight management guidelines.

Effects of a meal replacement system alone or in combination with phentermine on weight loss and food cravings

OBJECTIVE

To examine the effects of phentermine combined with a meal replacement program on weight loss and food cravings and to investigate the relationship between food cravings and weight loss.

METHODS

In a 12-week randomized, double-blind, placebo-controlled clinical trial, 77 adults with obesity received either phentermine or placebo. All participants were provided Medifast^® meal replacements, were instructed to follow the Take Shape for Life^® Optimal Weight 5&1 Plan for weight loss, and received lifestyle coaching in the Habits of Health program. The Food Craving Inventory and the General Food Cravings State and Trait Questionnaires were used to measure food cravings.

RESULTS

The phentermine group lost 12.1% of baseline body weight compared with 8.8% in the placebo group. Cravings for all food groups decreased in both groups; however, there was a greater reduction in cravings for fats and sweets in the phentermine group compared with the placebo group. Percent weight loss correlated significantly with reduced total food cravings (r = 0.332, P = 0.009), cravings for sweets (r = 0.412, P < 0.000), and state food cravings (r = 0.320, P = 0.007).

CONCLUSIONS

Both phentermine combined with a meal replacement program and meal replacements alone significantly reduced body weight and food cravings; however, the addition of phentermine enhanced these effects.

Can we win the war on obesity with pharmacotherapy?

INTRODUCTION

Obesity is a major health concern for several countries. The United States (U.S.) has arguably led the world in the percentage of overweight and/or obese per capita for several decades. As a result, numerous FDA-approved pharmacotherapeutic options are available for the long-term treatment of obesity. Although most of these medications have been on the U.S. market for a few years and have demonstrated efficacy for long-term weight loss in clinical trials, the impact of these medications on obesity in the U.S. has yet to be realized. Areas covered: We will review and evaluate why pharmacotherapy for obesity has not produced a meaningful reduction in the number of overweight and obese adults in the U.S. Expert commentary: Several obstacles, such as adverse drug effects, poor insurance coverage, not treating obesity as a chronic disease, and availability of other weight loss alternatives, has resulted in poor performance of pharmacotherapy for obesity in the U.S. market.

Update on bariatric surgical procedures and an introduction to the implantable weight loss device: the Maestro Rechargeable System

There are many different methods of treating obesity, ranging from various medical options to several surgical therapies. This paper briefly summarizes current surgical options for weight loss with a focus on one of the newest US Food and Drug Administration-approved devices for surgical weight loss therapy, the Maestro Rechargeable System. Also known as the vagal blocking for obesity control implantable device, this tool blocks vagal nerve activity to induce weight loss.

Current status of intragastric balloon for obesity treatment

Endoscopic bariatric therapy may be a useful alternative to pharmacological treatment for obesity, and it provides greater efficacy with lower risks than do conventional surgical procedures. Among the various endoscopic treatments for obesity, the intragastric balloon is associated with significant efficacy in body weight reduction and relief of comorbid disease symptoms. Anatomically, this treatment is based on gastric space-occupying effects that increase the feeling of satiety and may also affect gut neuroendocrine signaling. The simplicity of the intragastric balloon procedure may account for its widespread role in obesity treatment and its applicability to various degrees of obesity. However, advances in device properties and procedural techniques are still needed in order to improve its safety and cost-effectiveness. Furthermore, verification of the physiological outcomes of intragastric balloon treatment and the clinical predictive factors for treatment responses should be considered. In this article, we discuss the types, efficacy, safety, and future directions of intragastric balloon treatment.

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.

Topiramate monotherapy for weight reduction in patients with type 2 diabetes mellitus: A systematic review and meta-analysis

AIMS

To conduct a systematic review with meta-analysis to determine the efficacy and safety of topiramate as monotherapy for weight reduction in patients with type 2 diabetes mellitus.

METHODS

We searched MEDLINE, Embase, and International Pharmaceutical Abstracts from inception to June 2015. We included randomized controlled trials that evaluated topiramate monotherapy versus control agents or placebo for weight loss in obese type 2 diabetes patients.

RESULTS

Of the 284 studies identified, 5 studies fulfilled the inclusion criteria. Topiramate decreased weight by a mean difference of 3.4kg (95% CI, -3.79 to -3.04) compared to placebo. Mean HbA1c reduction of -0.4% (95% CI, -0.58 to -0.32) and mean BMI reduction of -1.43kg/m(2) (95% CI, -1.83 to -1.03) were both significantly observed with topiramate (p<0.00001). Serious and total adverse events occurred more commonly among topiramate users, with a risk ratio for serious adverse events of 1.69 (95% CI, 1.00-2.87). All but one study had high risk of bias.

CONCLUSIONS

Topiramate monotherapy reduced weight in obese type 2 diabetes patients, but increased adverse events including serious adverse events. Given these safety concerns and the absence of data on clinically meaningful efficacy endpoints, clinicians should generally avoid use of topiramate alone for this indication.

GLP-1 and weight loss: unraveling the diverse neural circuitry

Glucagon-like peptide-1 (GLP-1) is currently one of the most promising biological systems for the development of effective obesity pharmacotherapies. Long-acting GLP-1 analogs potently reduce food intake and body weight, and recent discoveries reveal that peripheral administration of these drugs reduces food intake largely through humoral pathways involving direct action on brain GLP-1 receptors (GLP-1R). Thus, it is of critical importance to understand the neural systems through which GLP-1 and long-acting GLP-1 analogs reduce food intake and body weight. In this review, we discuss several neural, physiological, cellular and molecular, as well as behavioral mechanisms through which peripheral and central GLP-1R signaling reduces feeding. Particular attention is devoted to discussion regarding the numerous neural substrates through which GLP-1 and GLP-1 analogs act to reduce food intake and body weight, including various hypothalamic nuclei (arcuate nucleus of the hypothalamus, periventricular hypothalamus, lateral hypothalamic area), hindbrain nuclei (parabrachial nucleus, medial nucleus tractus solitarius), hippocampus (ventral subregion; vHP), and nuclei embedded within the mesolimbic reward circuitry [ventral tegmental area (VTA) and nucleus accumbens (NAc)]. In some of these nuclei [VTA, NAc, and vHP], GLP-1R activation reduces food intake and body weight without concomitant nausea responses, suggesting that targeting these specific pathways may be of particular interest for future obesity pharmacotherapy. The widely distributed neural systems through which GLP-1 and GLP-1 analogs act to reduce body weight highlight the complexity of the neural systems regulating energy balance, as well as the challenges for developing effective obesity pharmacotherapies that reduce feeding without producing parallel negative side effects.

Naltrexone/bupropion for the treatment of obesity and obesity with Type 2 diabetes

Contrave® is a combination of naltrexone hydrochloride extended release and bupropion hydrochloride extended release for the treatment of obesity, and is used with lifestyle modification. Its safety and efficacy were assessed in four randomized, double-blind, placebo-controlled, 56-week Phase III clinical trials in 4536 adult subjects: COR-1, COR-II, COR-BMOD and COR-DM. All four studies demonstrated statistically significant and clinically meaningful weight loss following up to 52 weeks of treatment with naltrexone/bupropion compared with placebo. The average weight loss from baseline across the four studies was approximately 11–22 lbs (5–9 kg). Results show the efficacy of Contrave for weight loss, as well as significant improvements in cardiometabolic markers. This review focuses on the four studies, their outcomes and the mechanism of action of Contrave.