Pharmacotherapy for Patients with Obesity

CRISPR/Cas9 Technology: A Novel Approach to Obesity Research

Gene editing technology, particularly Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR)/CRISPR-associated protein 9 (Cas9) has transformed medical research. As a newly developed genome editing technique, CRISPR technology has strongly assisted scientists in enriching their comprehension of the roles of individual genes and their influences on a vast spectrum of human malignancies. Despite considerable progress in elucidating obesity's molecular pathways, current anti-obesity medications fall short in effectiveness. A thorough understanding of the genetic foundations underlying various neurobiological pathways related to obesity, as well as the neuro-molecular mechanisms involved, is crucial for developing effective obesity treatments. Utilizing CRISPR-based technologies enables precise determination of the roles of genes that encode transcription factors or enzymes involved in processes, such as lipogenesis, lipolysis, glucose metabolism, and lipid storage within adipose tissue. This innovative approach allows for the targeted suppression or activation of genes regulating obesity, potentially leading to effective weight management strategies. In this review, we have provided a detailed overview of obesity's molecular genetics, the fundamentals of CRISPR/Cas9 technology, and how this technology contributes to the discovery and therapeutic targeting of new genes associated with obesity.

Adipose Tissue, Non-Communicable Diseases, and Physical Exercise: An Imperfect Triangle

The study of adipose tissue has received considerable attention due to its importance not just in maintaining body energy homeostasis but also in playing a role in a number of other physiological processes. Beyond storing energy, adipose tissue is important in endocrine, immunological, and neuromodulatory functions, secreting hormones that participate in the regulation of energy homeostasis. An imbalance of these functions will generate structural and functional changes in the adipose tissue, favoring the secretion of deleterious adipocytokines that induce a pro-inflammatory state, allowing the development of metabolic and cardiovascular diseases and even some types of cancer. A common theme worldwide has been the development of professional guidelines for the control and treatment of obesity, with emphasis on hypocaloric diets and exercise. The aim of this review is to examine the pathophysiological mechanisms of obesity, considering the relationship among adipose tissue and two aspects that contribute positively or negatively to keeping a healthy body homeostasis, namely, exercise and noninfectious diseases. We conclude that the relationship of these aspects does not have homogeneous effects among individuals. Nevertheless, it is possible to establish some common mechanisms, like a decrease in pro-inflammatory markers in the case of exercise, and an increase in chronic inflammation in non-communicable diseases. An accurate diagnosis might consider the particular variables of a patient, namely their molecular profile and how it affects its metabolism, routines, and lifestyle; their underling health conditions; and probably even the constitution of their microbiome. We foresee that the development and accessibility of omics approaches and precision medicine will greatly improve the diagnosis, treatment, and successful outcomes for obese patients.

The effects of E'Jiao on body composition, bone marrow adiposity and skeletal redox status in ovariectomised rats

Background: Menopause is accompanied by increased oxidative stress, partly contributing to weight gain and bone marrow adiposity. Traditional Chinese medication, E'Jiao, has been demonstrated to reduce excessive bone remodelling during oestrogen deprivation, but its effects on body composition and bone marrow adiposity during menopause remain elusive. Objective: To determine the effects of E'Jiao on body composition, bone marrow adiposity and skeletal redox status in ovariectomised (OVX) rats. Methods: Seven groups of three-month-old female Sprague Dawley rats were established (n=6/group): baseline, sham, OVX control, OVX-treated with low, medium or high-dose E'Jiao (0.26, 0.53, 1.06 g/kg, p.o.) or calcium carbonate (1% in tap water, ad libitum). The supplementation was terminated after 8 weeks. Whole-body composition analysis was performed monthly using dual-energy X-ray absorptiometry. Analysis of bone-marrow adipocyte numbers and skeletal antioxidant activities were performed on the femur. Results: Increased total mass, lean mass, and bone marrow adipocyte number were observed in the OVX control versus the sham group. Low-dose E'Jiao supplementation counteracted these changes. Besides, E'Jiao at all doses increased skeletal catalase and superoxide dismutase activities but lowered glutathione levels in the OVX rats. Skeletal malondialdehyde level was not affected by ovariectomy but was lowered with E'Jiao supplementation. However, peroxisome proliferator-activated receptor gamma protein expression was not affected by ovariectomy or any treatment. Conclusion: E'Jiao, especially at the low dose, prevented body composition changes and bone marrow adiposity due to ovariectomy. These changes could be mediated by the antioxidant actions of E'Jiao. It has the potential to be used among postmenopausal women to avoid adiposity.

Short-term Intensive Lifestyle Therapy in a Worksite Setting Improves Cardiometabolic Health in People With Obesity

Context

The Pritikin Program, which provides intensive lifestyle therapy, has been shown to improve cardiometabolic outcomes when provided as a residential program.

Objective

The purpose of the present study was to conduct a short-term, randomized, controlled trial to evaluate the feasibility and clinical efficacy of treatment with the Pritikin Program in an outpatient worksite setting.

Methods

Cardiometabolic outcomes were evaluated in people with overweight/obesity and ≥2 metabolic abnormalities (high triglycerides, low high-density lipoprotein (HDL) cholesterol, high blood pressure, HbA1c > 5.7%), before and after they were randomized to 6 weeks of standard care (n = 26) or intensive lifestyle therapy, based on the Pritikin Program (n = 28). Participants in the lifestyle intervention group were provided all food as packed-out meals and participated in group nutrition, behavioral education, cooking classes, and exercise sessions 3 times per week at a worksite location.

Results

Compared with standard care, intensive lifestyle therapy decreased body weight (-5.0% vs -0.5%), HbA1c (-15.5% vs +2.3%), plasma total cholesterol (-9.8% vs +7.7%), low-density lipoprotein cholesterol (-10.3% vs +9.3%) and triglyceride (-21.7% vs +3.0%) concentrations, and systolic blood pressure (-7.0% vs 0%) (all P values < .02), and increased exercise tolerance (time to exhaustion walking on a treadmill by +23.7% vs +4.5%; P < .001).

Conclusion

This study demonstrates the feasibility and clinical effectiveness of short-term, intensive outpatient lifestyle therapy in people with overweight/obesity and increased risk of coronary heart disease when all food is provided and the intervention is conducted at a convenient worksite setting.

Efficacy and safety of Obex® in overweight and obese subjects: a randomised, double-blind, placebo-controlled clinical trial

BACKGROUND

Obex® may be helpful in reducing body weight and fat. The current study was carried out to evaluate the efficacy and safety of Obex® in the treatment of overweight and obese subjects.

METHODS

A double-blind, randomised, controlled phase III clinical trial was conducted involving 160 overweight and obese subjects (BMI ≥ 25.0 and < 40 kg/m²) aged 20 to 60 years, who received Obex® (n = 80) and placebo (n = 80) plus non-pharmacological treatment (physical activity and nutritional counseling). One sachet of Obex® or placebo were administered before the two main meals each day for 6 months. In addition to anthropometric measurements and blood pressure, fasting plasma and 2 h glucose levels during the oral glucose tolerance test, lipid profile, insulin, liver enzymes, creatinine, and uric acid (UA) were determined, insulin resistance (HOMA-IR) beta-cell function (HOMA-β) were assessed and insulin sensitivity (IS) was calculated with three indirect indexes.

RESULTS

After 3 months of Obex®, 48.3% of the participants (28/58) achieved complete success in reducing both weight and waist circumference by greater than or equal to 5% from baseline, as opposed to 26.0% (13/50) of individuals receiving placebo (p = 0.022). Compared to baseline, at 6 months no differences were found between the groups concerning anthropometric and biochemical measurements, except for high-density lipoprotein cholesterol (HDL-c) levels, which were higher in subjects receiving Obex® compared to those receiving placebo (p = 0.030). After 6 months of treatment, both groups showed reduced cholesterol and triglyceride levels (p < 0.012) compared to baseline value. However, only those intake Obex® showed reduced insulin concentrations and HOMA-IR, improved IS (p < 0.05), and decreased creatinine and UA levels (p < 0.005).

CONCLUSIONS

The consumption of Obex® together with lifestyle changes increased HDL-c, contributed to a rapid reduction of weight and waist circumference, as well as improved insulin homeostasis, which did not occur in the placebo group, and appears to be safe as an adjunct at conventional obesity treatment.

TRIAL REGISTRATION

Clinical trial protocol was registered in the Cuban public registry of clinical trials under code RPCEC00000267 on 17/04/2018 and also registered in the international registry of clinical trials, ClinicalTrials.gov, under code: NCT03541005 on 30/05/2018.

The effect of Xuezhikang capsule on gene expression profile in brown adipose tissue of obese spontaneously hypertensive rats

ETHNOPHARMACOLOGICAL RELEVANCE

Obesity is a critical threat to global health, and brown adipose tissue (BAT) is a potential target for the treatment of obesity and comorbidities. Xuezhikang Capsule (XZK), an extract of red yeast rice, has remarkable clinical efficacy and is widely used for the treatment of hyperlipidemia and coronary heart disease. However, its modulatory effect on BAT remains unknown.

AIM OF THIS STUDY

The aim of this study was to investigate the protective mechanism of XZK in the obese spontaneously hypertensive rat (SHR) model by evaluating the regulatory effect of XZK on the BAT gene profile through transcriptome sequencing.

MATERIALS AND METHODS

The SHRs were randomly divided into four groups: the standard chow diet (STD) group, the STD supplemented with 126 mg/kg of XZK group, the high-fat diet (HFD) group, and the HFD supplemented with 126 mg/kg of XZK group. All SHRs were fed for 18 weeks. The metabolic phenotypes, including body weight, fat mass, oral glucose tolerance test (OGTT), and serum glucose and lipid levels, was evaluated, and hematoxylin and eosin staining (H&E) staining was performed to evaluate the adipose tissue histopathological phenotype. Transcriptome sequencing was performed to determine the mechanism by which XZK improves the metabolic phenotype and the expression of key differential expression genes was verified by real-time quantitative polymerase chain reaction (qRT-PCR).

RESULTS

XZK inhibited HFD-induced weight gain and adipose tissue remodeling in SHRs and prevented hypertrophy of epididymal adipocytes and maintained the brown fat phenotype. XZK intervention also improved glucose and lipid metabolism in SHRs, as suggested by a reduction in serum triglyceride (TG), low-density cholesterol (LDL-C), and fasting blood glucose (FBG) levels as well as increasing in serum high-density cholesterol (HDL-C) levels. Transcriptome sequencing analysis confirmed the regulatory effect of XZK on the gene expression profile of BAT, and the expression patterns of 45 genes were reversed by the XZK intervention. Additionally, the results of the transcriptome analysis of 10 genes that are important for brown fat function were in line with the results of qRT-PCR.

CONCLUSIONS

XZK protected SHRs from HFD-induced obesity, inhibited fat accumulation and improved glucolipid metabolism. Additionally, the protective effect of XZK on the overall metabolism of obese SHRs might partly be related to its regulatory effect on the BAT gene expression profile. These findings might provide novel therapeutic strategies for obesity-related metabolic diseases in traditional Chinese medicine (TCM).

Development of an Ingestible Expandable Capsule for Weight Loss

Obesity has grown to epidemic proportions with 2.1 billion people being overweight worldwide. A food-grade expandable capsule named EndoXpand for the treatment of overweight people was designed and developed in this study. EndoXpand consists of an inner expandable material (core), an embracing membrane, and a gelatin capsule shell. It is designed to occupy volume in the stomach and reduce hunger sensation. The occupied volume is changeable over time, dependent on the number of ingested capsules and their degradation time. This will avoid gastric accommodation to constant volume devices as seen in the use of intragastric balloons. Several materials were tested. Collagen casing was selected as the membrane and corn silk was used to tie the membrane. Dried black fungus (Auricularia auricula) was the biological material that expanded most. However, synthesized cellulose-based hydrogel expanded more and was chosen as the optimal expandable core material. The hydrogel-based EndoXpand expanded 72 times after soaking in an acidic environment for 80 min. The corn silk ligations weakened and broke after 3 h. This resulted in release of the expanded material that was designed to easily pass the pylorus and travel down the intestine for digestion or excretion. In conclusion, this study provides design and in vitro proof-of-technology data for a potential groundbreaking approach. Further studies are needed in animal models and human phase I studies.

Acupuncture Therapies for Individuals with Overweight or Obesity: An Overview of Systematic Reviews

Purpose

An increasing number of people are affected by overweight or obesity, and the personal and social health burden is growing rapidly. Acupuncture is gaining popularity as an alternative treatment to manage weight. This research aims to update and synthesize the evidence of acupuncture therapies from systematic reviews for treating overweight and obesity.

Methods

Nine databases were searched from their inception to March 2022. Overweight or obesity was classified using standard diagnostic criteria. Published systematic reviews that included randomized controlled trials and quasi-randomized studies were eligible. Quality was assessed via the AMSTAR-2 scale and risk of bias using the ROBIS tool.

Results

Thirty-eight systematic reviews were identified. Acupuncture therapies and auricular acupoint stimulation showed benefits in terms of reducing body weight and body mass index. Catgut embedding therapy and abdominal acupuncture are currently not in widespread use with insufficient evidence. Acupuncture therapies appear to be safe. Most of the reviews were assessed as having high risk of bias and low confidence in the findings.

Conclusion

There is a need for larger and more methodologically sound randomized controlled trials to evaluate the effectiveness of acupuncture therapies for individuals who are affected by overweight or obesity.

Proanthocyanidins as the main pancreatic lipase inhibitors in chokeberry fruits

Pancreatic lipase inhibitors are recognized as important in strategies for the management of overweight and obesity. The phytocompounds in chokeberry fruit show multidirectional pro-health effects, including anti-obesity activity. The aims of this study were to fractionate and identify the phenolic compounds of chokeberry fruit phenolic-rich extract that are active as pancreatic lipase inhibitors. Phenolic compounds were fractionated using Sephadex LH-20 resin, followed by polyphenol profile analysis using chromatographic and spectrophotometric methods, while pancreatic inhibitory activity was determined using 4-methylumbelliferyl oleate and emulsified triolein as enzyme substrates. Among the six fractions isolated from extract, two fractions rich in highly polymerized proanthocyanidins showed the greatest ability to inhibit pancreatic lipase activity. In comparison, fractions containing mainly low-molecular-weight phenolic compounds, such as phenolic acids, flavonols and anthocyanins, were 11-64 times less active. The most active fraction showed a mixed mode of pancreatic lipase inhibition, as determined by Lineweaver-Burk plot analysis, and exhibited a cumulative effect with orlistat. This study shows that black chokeberry polyphenols, particularly highly polymerized procyanidins, can effectively inhibit pancreatic lipase activity determined by in vitro methods.

Efficacy and safety of efpeglenatide in key patient subgroups from the BALANCE randomized trial, stratified by pre-diabetes status, BMI, and age at baseline

INTRODUCTION

Efpeglenatide is a long-acting glucagon-like peptide-1 receptor agonist being developed to improve glycemic control in type 2 diabetes (T2D). In the BALANCE 205 study (NCT02075281), efpeglenatide significantly reduced body weight versus placebo in patients with obesity, or overweight with comorbidities, and without T2D. These subanalyses explore the efficacy and safety of efpeglenatide in subgroups of patients with pre-diabetes and stratified by body mass index (BMI) or age from the BALANCE study.

RESEARCH DESIGN AND METHODS

The 20-week BALANCE study randomized patients with BMI ≥30 kg/m² or ≥27 kg/m² with comorbidities, and without diabetes, to efpeglenatide 4 mg or 6 mg once weekly, 6 mg or 8 mg once every 2 weeks, or placebo. For these subanalyses, patients were stratified by pre-diabetes status (glycated hemoglobin (HbA_1c) 5.7%-6.4% (39-46 mmol/mol) or fasting plasma glucose (FPG) 100-125 mg/dL) and by BMI or age < or ≥ median values (34.9 kg/m² and 44 years, respectively) at baseline.

RESULTS

In patients with pre-diabetes at baseline, all efpeglenatide doses led to greater proportions of patients reverting to normoglycemia (40.6%-64.3%) versus placebo (10.0%), and greater reductions in HbA_1c (0.30%-0.38%), FPG (7.7-14.1 mg/dL), and weight (5.6-7.3 kg) versus placebo (nominal p<0.05 for all). In patients with BMI or age < or ≥ median, greater reductions in weight were observed with all efpeglenatide doses versus placebo (nominal p<0.01 for all). The most common adverse events in patients receiving efpeglenatide across patient subgroups were gastrointestinal adverse events.

CONCLUSIONS

These results are consistent with the overall BALANCE population and suggest beneficial effects of efpeglenatide on glycemic control and body weight regardless of pre-diabetes status, age, or BMI at baseline. The effects of efpeglenatide on glycemic control in patients with pre-diabetes suggest it might help reduce the likelihood of at-risk patients developing diabetes.

Weight Loss at First Month and Development of Tolerance as Possible Predictors of 30 mg Phentermine Efficacy at 6 Months

The efficacy of anti-obesity drugs usually does not consider the high degree of interindividual variability in responses to the drug which could affect the decision to withdraw the drug early due to ineffectiveness or to continue therapy according to specific expectations of success. The aim of this study was to analyze body weight loss in kilograms during the first month (1 mo-BWL_kg) of treatment with 30 mg phentermine and development of tolerance to phentermine, on its 6-month efficacy. One hundred sixty-six subjects with obesity were individually or jointly analyzed in the study. Subjects with 1 mo-BWL_kg of <1 kg, 1–3 kg, 3–5 kg, and ≥5 kg reached 6-month mean percentage body weight reductions (BWR%) of approximately 3%, 5%, 10%, and 15%, respectively. Development of late tolerance (4–6 months) to phentermine had a lower impact than early tolerance (2–3 months). Subjects with 1 mo-BWL_kg < 3 kg who developed early tolerance did not achieve relevant BWR% (≥5%) at month 6, while the rest of the subgroups achieved increasing and progressive BWR%, according to their 1 mo-BWL_kg range and time of onset of tolerance. The 1 mo-BWL_kg and development of tolerance to phentermine could be useful to predict the expected 6-month efficacy trends in obese patients treated with 30 mg phentermine.

The Anti-Obesity Effect of Traditional Chinese Medicine on Lipid Metabolism

With the improvement of living conditions and the popularity of unhealthy eating and living habits, obesity is becoming a global epidemic. Obesity is now recognized as a disease that not only increases the risk of metabolic diseases such as type 2 diabetes (T2D), non-alcoholic fatty liver disease (NAFLD), cardiovascular disease (CVD), and cancer but also negatively affects longevity and the quality of life. The traditional Chinese medicines (TCMs) are highly enriched in bioactive compounds and have been used for the treatment of obesity and obesity-related metabolic diseases over a long period of time. In this review, we selected the most commonly used anti-obesity or anti-hyperlipidemia TCMs and, where known, their major bioactive compounds. We then summarized their multi-target molecular mechanisms, specifically focusing on lipid metabolism, including the modulation of lipid absorption, reduction of lipid synthesis, and increase of lipid decomposition and lipid transportation, as well as the regulation of appetite. This review produces a current and comprehensive understanding of integrative and systematic mechanisms for the use of TCMs for anti-obesity. We also advocate taking advantage of TCMs as another therapy for interventions on obesity-related diseases, as well as stressing the fact that more is needed to be done, scientifically, to determine the active compounds and modes of action of the TCMs.

Evaluation of Eating Habits and Quality of Life in Postbariatric Surgery Patients and Their Family Members: A Case-Control Study

Background

Obesity is a major health problem worldwide. Today, bariatric surgery is considered as the last option and most effective treatment for severe obesity (BMI ≥40 kg/m² or BMI ≥35 kg/m² with metabolic conditions).

Aims

We aimed to evaluate the medium-term effect (>36 months) of bariatric surgery and assess postbariatric nutritional and lifestyle management among Lebanese patients who underwent bariatric surgeries in Jbeil and Keserwan hospitals.

Methods

This study is a quantitative case-control study. The case group includes a couple of patients who have undergone sleeve or bypass surgery 6 months ago and above, along with the main family caregivers. The control group constitutes a couple of obese patients with BMI ≥30 kg/m² who did not proceed to any surgical intervention with their main caregivers. The final samples consisted of 53 cases and caregivers and 50 controls and caregivers. The assessment was made by an online questionnaire.

Results

Compared to obese patients, bariatric patients were less likely to have high energy intake (54% versus 34%, P value 0.012). Moreover, 35.8% of the caregivers of bariatric patients had a low physical activity level compared to those of the control group who had a lower level (70%). In addition, cases' main caregivers (75.5%) had much higher quality of life compared to the cases (56.6%), and also, higher quality of life was seen among the case's main caregivers (75%) compared to the controls (72%).

Conclusion

In Jbeil and Keserwan regions of Lebanon, there is a lack of postbariatric nutritional and lifestyle management leading to less desirable outcomes in the medium to long term. A set of recommendations are developed based on this study.

Patterns of Weight Loss Medication Utilization and Outcomes Following Bariatric Surgery

BACKGROUND

Bariatric surgery is the most effective treatment for obesity; however, some patients experience significant weight regain. Weight loss medications (WLM) are being increasingly used in surgery patients with limited evidence. We examine weight loss outcomes in patients using WLM after bariatric surgery.

METHODS

In a retrospective study, 197 bariatric surgery patients who started WLM between 2016 and 2019 at a single center were analyzed. Patients were categorized into 3 groups based on outcomes of the initial surgery: (1) Weight regainers (WR) = achieved goal weight loss after surgery (15% total body weight loss (TBWL) for sleeve gastrectomy (SG) and 25% TBWL for Roux-en-Y gastric bypass (RYGB)) with subsequent regain of > 20% of weight lost; (2) Adequate weight loss (AWL) = achieved goal weight loss without > 20% weight regain; (3) Non-responders (NR) = never achieved goal weight loss. Weight loss and medication use patterns were analyzed.

RESULTS

Among the three categories, there was no significant difference in duration of medical therapy or %TBWL with medications. RYGB patients lost more weight than SG patients using WLM (p = 0.03). Of the medications used, patients treated with phentermine + topiramate had the highest likelihood of achieving 5%, 10%, and 15% weight loss. Compared to other 2 groups, AWL group initiated WLM earlier and experienced more weight loss when compared to their pre-operative weight or post-operative nadir.

CONCLUSIONS

RYGB patients respond better to WLM than SG patients. Those who had started WLM before regaining weight (AWL) experienced greater overall weight loss, suggesting that proactive medical therapy at the time of weight plateau can help with greater total weight loss. Phentermine + topiramate is the most effective WLM in post-bariatric surgery patients.

Chinese Herbal Medicine for Weight Management: A Systematic Review and Meta-Analyses of Randomised Controlled Trials

OBJECTIVE

This review investigated the effects and safety of Chinese herbal medicine (CHM) formulas on weight management.

METHODS

Eighteen databases in English, Chinese, Korean, and Japanese were searched from their inceptions to September 2019. The treatment groups included CHM formulations, and the control included placebo, Western medication (WM), and lifestyle intervention (LI), with or without cointerventions (WM and/or LI). Quality of studies was assessed using Cochrane Collaboration's risk of bias assessment tool. Body weight and body mass index (BMI) were analysed in RevMan v5.4.1 and expressed as mean differences with 95% confidence intervals (CI), while adverse events were expressed as risk ratio with 95% CI.

RESULTS

Thirty-nine RCTs were eligible for qualitative analysis, 34 of which were included in the meta-analyses. The majority of studies had a high or unclear risk of selection, performance, and detection bias. Twenty-five CHM studies involving cointerventions revealed that CHM had significant adjunct effects on body weight and BMI at the end of treatment compared to control. No serious adverse events were reported in the CHM groups.

CONCLUSION

CHM indicates a promising adjunct to facilitate WM or lifestyle change for weight management. However, methodological barriers such as lack of allocation concealment and double-blinding may have led to challenges in data synthesis. More rigorously designed RCTs involving cointerventions are warranted.

Energy imbalance: obesity, associated comorbidities, prevention, management and public health implications

The prevalence of obesity has been continually increasing, as have its associated comorbidities and health care costs. Effective management of obesity and early intervention measures are necessary to overcome this global issue. The responsibility for preventing and managing this global epidemic does not lie solely on an individual, but also on the entire health care system. Policy makers-nationally and globally-must play their roles to solve the issue. In this review article, we examine methods of controlling and managing obesity through interventions, such as a low caloric diet, physical exercise, pharmacological guidance, and bariatric surgical procedures. While health care professionals should educate patients about all available treatment options for severe obesity, bariatric surgical procedures have increased in popularity and are considered very beneficial with outcomes fruitful in managing severe obesity.

The limits and challenges of antiobesity pharmacotherapy

INTRODUCTION

Pharmacotherapy is a useful adjunct when patients with obesity are unable to achieve adequate benefit from lifestyle interventions.

AREAS COVERED

This review covers the history of antiobesity drugs, efficacy, and risks of currently approved drugs, limits of their usefulness in clinical practice, gaps in knowledge, methodological limitations of clinical trials, and reasons for underutilization.

EXPERT OPINION

In randomized controlled trials, currently approved antiobesity drugs have yielded an average weight loss ranging from approximately 3% to 9% relative to placebo at 1 year. Inadequate inclusion of racial and ethnic minorities and men, and high dropout rates in clinical trials limit generalizability of these findings to clinical practice. Weight loss achieved with antiobesity drugs is generally associated with lowered glycemia, but improvements in blood pressure and lipid measures tend to be marginal. There is limited evidence for sustained weight loss beyond 1 year and for safety and efficacy of antiobesity drugs in children and adolescents, and in post-bariatric surgery patients. None have demonstrated reduction in major adverse cardiovascular events or other significant disease outcomes. Limited health insurance coverage and negative perceptions of physicians have hindered the utilization of antiobesity drugs.

Exercise and High-Fat Diet in Obesity: Functional Genomics Perspectives of Two Energy Homeostasis Pillars

The heavy impact of obesity on both the population general health and the economy makes clarifying the underlying mechanisms, identifying pharmacological targets, and developing efficient therapies for obesity of high importance. The main struggle facing obesity research is that the underlying mechanistic pathways are yet to be fully revealed. This limits both our understanding of pathogenesis and therapeutic progress toward treating the obesity epidemic. The current anti-obesity approaches are mainly a controlled diet and exercise which could have limitations. For instance, the “classical” anti-obesity approach of exercise might not be practical for patients suffering from disabilities that prevent them from routine exercise. Therefore, therapeutic alternatives are urgently required. Within this context, pharmacological agents could be relatively efficient in association to an adequate diet that remains the most efficient approach in such situation. Herein, we put a spotlight on potential therapeutic targets for obesity identified following differential genes expression-based studies aiming to find genes that are differentially expressed under diverse conditions depending on physical activity and diet (mainly high-fat), two key factors influencing obesity development and prognosis. Such functional genomics approaches contribute to elucidate the molecular mechanisms that both control obesity development and switch the genetic, biochemical, and metabolic pathways toward a specific energy balance phenotype. It is important to clarify that by “gene-related pathways”, we refer to genes, the corresponding proteins and their potential receptors, the enzymes and molecules within both the cells in the intercellular space, that are related to the activation, the regulation, or the inactivation of the gene or its corresponding protein or pathways. We believe that this emerging area of functional genomics-related exploration will not only lead to novel mechanisms but also new applications and implications along with a new generation of treatments for obesity and the related metabolic disorders especially with the modern advances in pharmacological drug targeting and functional genomics techniques.

BAM15-mediated mitochondrial uncoupling protects against obesity and improves glycemic control

Obesity is a leading cause of preventable death worldwide. Despite this, current strategies for the treatment of obesity remain ineffective at achieving long-term weight control. This is due, in part, to difficulties in identifying tolerable and efficacious small molecules or biologics capable of regulating systemic nutrient homeostasis. Here, we demonstrate that BAM15, a mitochondrially targeted small molecule protonophore, stimulates energy expenditure and glucose and lipid metabolism to protect against diet-induced obesity. Exposure to BAM15 in vitro enhanced mitochondrial respiratory kinetics, improved insulin action, and stimulated nutrient uptake by sustained activation of AMPK. C57BL/6J mice treated with BAM15 were resistant to weight gain. Furthermore, BAM15-treated mice exhibited improved body composition and glycemic control independent of weight loss, effects attributable to drug targeting of lipid-rich tissues. We provide the first phenotypic characterization and demonstration of pre-clinical efficacy for BAM15 as a pharmacological approach for the treatment of obesity and related diseases.

Effects of a novel combination of orlistat and acarbose on tolerability, appetite, and glucose metabolism in persons with obesity

OBJECTIVE

There is an unmet medical need for a safe and effective weight loss product with minimal systemic side-effects. In this study, the effect of a novel modified-release fixed-dose combination of orlistat and acarbose (MR-OA) was compared with conventional orlistat (CO) regarding tolerability, appetite and glucose metabolism.

METHODS

Sixty-seven men with obesity, aged 24 to 60 years with body mass indexes (BMIs) 33 to 40 kg m-2 or BMIs 30 to 32 kg m-2 and waist circumference above 102 cm were included. They were randomized to either three different doses of the test formulation MR-OA (60 mg orlistat/20 mg acarbose, 90/30 and 120/40) or CO (Xenical, 120 mg orlistat) for a 2-week study of daily treatment. The participants spent days 1 and 14 at the clinical research centre where they received standardized meals, had blood sampling and filled in questionnaires regarding tolerability and appetite after meals. In days 2 to 13, the participants were at home and continued to fill in the questionnaires daily.

RESULTS

In the MR-OA groups, reports of liquid and oily stools as well as faecal incontinence were fewer, whereas reports of gastric distension and flatulence were higher, compared with the CO group. More participants reported decreased hunger in the 90/30 and 120/40 MR-OA, and postprandial plasma glucose concentration was reduced in all MR-OA groups compared with CO.

CONCLUSIONS

This study shows that by using a modified-release dosage form, orlistat and acarbose can be combined without compromising tolerability. Furthermore, MR-OA shows promising effects regarding reduction of appetite and reduces postprandial glucose. Tolerability is coupled to compliance and thereby efficacy of a treatment; therefore, this novel combination MR-OA could be an effective approach for weight loss treatment. A follow-up study in a more diverse population and for a longer duration with weight loss as primary outcome variable is planned.

The obesity epidemic in the face of homeostatic body weight regulation: What went wrong and how can it be fixed?

Ever since the pioneering discoveries in the mid nineteen hundreds, the hypothalamus was recognized as a crucial component of the neural system controlling appetite and energy balance. The new wave of neuron-specific research tools has confirmed this key role of the hypothalamus and has delineated many other brain areas to be part of an expanded neural system sub serving these crucial functions. However, despite significant progress in defining this complex neural circuitry, many questions remain. One of the key questions is why the sophisticated body weight regulatory system is unable to prevent the rampant obesity epidemic we are experiencing. Why are pathologically obese body weight levels defended, and what can we do about it? Here we try to find answers to these questions by 1) reminding the reader that the neural controls of ingestive behavior have evolved in a demanding, restrictive environment and encompass much of the brain's major functions, far beyond the hypothalamus and brainstem, 2) hypothesizing that the current obesogenic environment impinges mainly on a critical pathway linking hypothalamic areas with the motivational and reward systems to produce uncompensated hyperphagia, and 3) proposing adequate strategies for prevention and treatment.

Increased weight loading reduces body weight and body fat in obese subjects - A proof of concept randomized clinical trial

BACKGROUND

Recently we provided evidence for a leptin-independent homeostatic regulation, the gravitostat, of body weight in rodents. The aim of the present translational proof of concept study was to test the gravitostat hypothesis in humans.

METHODS

We conducted a randomized controlled single center trial (ClinicalTrial.gov number, NCT03672903), to evaluate the efficacy of artificially increased weight loading on body weight in subjects with mild obesity (BMI 30-35 kg/m²). Subjects were either treated with a heavy (=high load; 11% of body weight) or light (=low load; 1% of body weight) weight vest for eight hours per day for three weeks. The primary outcome was change in body weight. Secondary outcomes included change in body fat mass and fat-free mass as measured using bioelectrical impedance analysis.

FINDINGS

In total 72 participants underwent randomization and 69 (36 high load and 33 low load) completed the study for the primary outcome. High load treatment resulted in a more pronounced relative body weight loss compared to low load treatment (mean difference -1.37%, 95% confidence interval (CI), -1.96 to -0.79; p = 1.5 × 10^-5). High load treatment reduced fat mass (-4.04%, 95% CI, -6,53 to -1.55; p = 1.9 × 10^-3) but not fat free mass (0.43%, 95% CI, -1.47 to 2.34; p = 0.65) compared to low load treatment.

INTERPRETATION

Increased weight loading reduces body weight and fat mass in obese subjects in a similar way as previously shown in obese rodents. These findings demonstrate that there is weight loading dependent homeostatic regulation of body weight, the gravitostat, also in humans.

FUNDING

Funded by Jane and Dan Olsson (JADO) Foundation, the Torsten Söderberg Foundation, The Knut and Alice Wallenberg's Foundation and the Novo Nordisk Foundation.

Modern pharmacological treatment of obese patients

There are many angles to consider in drug treatment of obese patients. On the one hand, some specific weight loss drugs are available, on the other, several drugs are associated with unintentional weight changes. When treating an obese patient for any given disease, several physiological changes may influence the pharmacokinetic properties of the drugs required. Thus, increased body weight may influence the efficacy and safety of some drug treatments. Even more complicated is the situation after weight reduction surgery. Due to the various changes to the gastrointestinal tract induced by the different surgical techniques used, and the dynamic changes in body composition thereafter, drug dosing has to be constantly reconsidered. Whereas all of these issues are of clinical importance, none of them have been investigated in the necessary depth and broadness to ensure safe and efficacious drug treatment of the massively obese patient. Individual considerations have to be based on comorbidities, concomitant medication, and on specific drug properties, for example, lipophilicity, volume of distribution, and metabolism. In this article we summarize the data available on different aspects of drug treatment in the obese patient with the hope of improving patient care.

Effectiveness and Characterization of Severely Energy-Restricted Diets in People with Class III Obesity: Systematic Review and Meta-Analysis

Severely energy-restricted diets are used in obesity management, but their efficacy in people with class III obesity (body mass index ≥40 kg/m2) is uncertain. The aims of this systematic review and meta-analysis were to determine the effectiveness and characteristics of severely energy-restricted diets in people with class III obesity. As there was a lack of publications reporting long-term dietary interventions and randomised controlled trial designs, our original publication inclusion criteria were broadened to include uncontrolled study designs and a higher upper limit of energy intake. Eligible publications reported studies including adults with class III obesity and that assessed a diet with daily energy intake ≤5000 kJ for ≥4 weeks. Among 572 unique publications from 4 databases, 11 were eligible and 10 were suitable for meta-analysis. Our original intention was to classify comparison arms into short-term (<6 months) and long-term (>1 year) interventions. Due to the lack of long-term data found, comparison arms were classified according to the commonalities in dietary intervention length among the included publications, namely dietary interventions of 4 weeks' duration and those of ≥6 weeks' duration. After a 4-week severely energy-restricted diet intervention, the pooled average weight loss was 9.81 (95% confidence interval 10.80, 8.83) kg, with a 95% prediction interval of 6.38 to 13.25 kg, representing a loss of approximately 4.1 to 8.6% of initial body weight. Diets ≥6 weeks' duration produced 25.78 (29.42, 22.15) kg pooled average weight loss, with a 95% prediction interval of 13.77 to 37.80 kg, representing approximately 10.2 to 28.0% weight loss. Daily dietary prescriptions ranged from 330 to 5000 kJ (mean ± standard deviation 2260 ± 1400 kJ), and had wide variations in macronutrient composition. The diets were administered mostly via liquid meal replacement products. While the included publications had a moderate risk of bias score, which may inflate reported weight loss outcomes, the published data to date suggest that severely energy-restricted diets, delivered via diets of varying composition, effectively produce clinically relevant weight loss (≥10% of initial body weight) when used for 6 weeks or more in people with class III obesity.

Characterizing Obesity Interventions and Treatment for Children and Youths During 1991-2018

Overweight and obesity have become a serious health problem globally due to its significant role in increased morbidity and mortality. The treatments for this health issue are various such as lifestyle modifications, pharmacological therapies, and surgery. However, little is known about the productivity, workflow, topics, and landscape research of all the papers mentioning the intervention and treatment for children with obesity. A total of 20,925 publications from the Web of Science database mentioning interventions and treatment in reducing the burden of childhood overweight and obesity on physical health, mental health, and society published in the period from 1991 to 2018 were in the analysis. We used Latent Dirichlet Allocation (LDA) for identifying the topics and a dendrogram for research disciplines. We found that the number of papers related to multilevel interventions such as family-based, school-based, and community-based is increasing. The number of papers mentioning interventions aimed at children and adolescents with overweight or obesity is not high in poor-resource settings or countries compared to the growth in the prevalence of overweight and obesity among youth due to cultural concepts or nutrition transition. Therefore, there is a need for support from developed countries to control the rising rates of overweight and obesity.

Combination of GLP-1 receptor agonists and behavioural treatment in type 2 diabetes elicits synergistic effects on body weight: A retrospective cohort study

AIMS

Intensification of type 2 diabetes (T2DM) treatment with GLP-1 receptor agonists (GLP-1RAs) promotes weight loss. We aimed to determine the synergistic effect of behavioural programmes on body weight on top of GLP-1RA treatment.

MATERIALS AND METHODS

We retrospectively analysed the time course of 328 individuals with T2DM starting GLP-1RA treatment because of insufficient metabolic control. In 29, a structured programme of elementary nutritional counselling was also implemented (elementary nutritional education [ENE]-5 group sessions), whereas 53 entered a programme of cognitive-behavioural treatment (CBT-12 group sessions). Both programmes were completed within 6 months of switching to GLP-1RAs. Data of body weight and metabolic control were followed up to 2 years as part of regular follow-up. Weight loss targets (≥10% and ≥5%) and metabolic target (HbA1c < 7%) were analysed by Cox regression model in comparison with standard care (SC, N = 244).

RESULTS

Body weight remarkably decreased following both behavioural programmes, with significant differences compared with SC at 2 years (CBT, 8.5 ± 5.9% vs 6.3 ± 6.9 in ENE and only 3.1 ± 5.7 in SC; P < 0.001 and P = 0.045 vs CBT and ENE, respectively). The 10% weight loss was achieved and maintained in approximately 30% of cases during follow-up, and an additional 35% of cases lost between 5% and 10%. Data were consistent between behavioural programmes, after adjustment for confounders, including initial body weight (logreg Mantel-Cox: ENE vs SC, P < 0.01; CBT vs SC, P < 0.001). No differences in metabolic control were detected between groups.

CONCLUSIONS

Initiation of GLP-1RA treatment provides an opportunity for addressing patients' needs of weight control. By producing initial weight loss, patients' motivation and self-efficacy are expected to increase and adherence to long-term lifestyle changes might be more easily attained.

Pharmacophore Directed Screening of Agonistic Natural Molecules Showing Affinity to 5HT2C Receptor

Obesity prevalence continues to be a foremost health concern across the globe leading to the development of major health risk conditions like type II diabetes, hyperlipidemia, hypertension and even cancers. Because of the deprived drug-based management system, there is an urgent need for the development of new drugs aiming at satiety and appetite control targets. Among the reported satiety signaling targets, 5HT_2C receptor plays a crucial role in decreasing appetite and has become a promising target for the development of anti-obesity drugs. Lorcaserin, a 5HT_2C receptor agonist and the only drug available in the market, was designed based on the receptor mechanism of action. Due to limited drug options available and considering the adverse drug effects of Lorcaserin, the development of new drugs which are highly specific toward the 5HT_2C target and with lesser side effects is essential. The present study is majorly focused on developing new 5HT_2C agonists through computational approaches like screening, docking, and simulation using Phase, QikProp, Glide and Desmond applications of the Schrodinger suite. Screening protocols resulted in eight best hit molecules with affinity for the receptor and among them, five hits displayed binding affinity toward the conserved residue Asp 134 of the receptor. The stability of the five molecules in complex with the 5HT_2C receptor was studied through molecular dynamic simulations. Three molecules, ZINC32123870, ZINC40312983 and ZINC32124535, maintained stable interactions with the Asp 134 residue throughout the 50 ns simulation run time. Further, due to the high sequence similarity seen among the receptors of 5HT2 family, the three potential hits were cross validated against other subtypes 5HT_2A and 5HT_2B of the 5HT2 family to determine the specificity of the molecules against the target. Among the three hits, ZINC32124535 was identified as the best potential hit based on the hydrogen bond interaction percentage with Asp residue [5HT_2A (Asp 155:60%); 5HT_2B (Asp155: No interaction); 5HT_2C (Asp 134:86%)]. The ZINC32124535 molecule produced one salt bridge and hydrogen bond interactions with Asp 134, alike the known drug Lorcaserin. Based on the results, ZINC32124535 was identified as the best potential hit against the 5HT_2C receptor.

Suspected adverse reactions associated with herbal products used for weight loss: spontaneous reports from the Italian Phytovigilance System

PURPOSE

Overweight and obesity represent worldwide a rising health problem. In this context, dietary supplements and herbal preparations are often used as self-medication for weight loss. The aim of this study was to describe the safety profile of dietary supplements for weight control by analyzing spontaneous reports of suspected adverse reactions (ARs) received by the Italian Phytovigilance System, from July 2010 to October 2017.

METHODS

The suspected ARs were collected using an ad hoc reporting form, registered in a database at the National Institute of Health and evaluated by a multidisciplinary group of experts. The causality assessment was performed using the WHO-UMC system or the CIOMS/RUCAM score. In case of serious adverse reactions, a feedback is provided to the reporter by e-mail.

RESULTS

Sixty-six spontaneous reports were collected. ARs involved cardiovascular system (26%), liver (14%), central nervous system (12%), skin (9%), gastrointestinal system (17%), thyroid (8%), kidney (4%), and other organs/systems (10%). In 64% of cases, the reaction was serious. Dechallenge was positive in 46 cases; three cases of positive rechallenge were reported. After the causality assessment, the association between the product intake and the adverse reaction was judged as possible in the majority of the cases (n = 43; 65%).

CONCLUSIONS

The data collected confirmed the existence of safety concerns on herbal dietary supplements used for body weight control, mainly related to quality of products and their use as self-medication. In this scenario, spontaneous reports represent the only tools available to monitor safety of these products.

Long-Term Weight Loss With Metformin or Lifestyle Intervention in the Diabetes Prevention Program Outcomes Study

BACKGROUND

Identifying reliable predictors of long-term weight loss (LTWL) could lead to improved weight management.

OBJECTIVE

To identify some predictors of LTWL.

DESIGN

The DPP (Diabetes Prevention Program) was a randomized controlled trial that compared weight loss with metformin, intensive lifestyle intervention (ILS), or placebo. Its Outcomes Study (DPPOS) observed patients after the masked treatment phase ended. (ClinicalTrials.gov: NCT00004992 and NCT00038727).

SETTING

27 DPP and DPPOS clinics.

PARTICIPANTS

Of the 3234 randomly assigned participants, 1066 lost at least 5% of baseline weight in the first year and were followed for 15 years.

MEASUREMENTS

Treatment assignment, personal characteristics, and weight.

RESULTS

After 1 year, 289 (28.5%) participants in the metformin group, 640 (62.6%) in the ILS group, and 137 (13.4%) in the placebo group had lost at least 5% of their weight. After the masked treatment phase ended, the mean weight loss relative to baseline that was maintained between years 6 and 15 was 6.2% (95% CI, 5.2% to 7.2%) in the metformin group, 3.7% (CI, 3.1% to 4.4%) in the ILS group, and 2.8% (CI, 1.3% to 4.4%) in the placebo group. Independent predictors of LTWL included greater weight loss in the first year in all groups, older age and continued metformin use in the metformin group, older age and absence of either diabetes or a family history of diabetes in the ILS group, and higher fasting plasma glucose levels at baseline in the placebo group.

LIMITATION

Post hoc analysis; examination of nonrandomized subsets of randomized groups after year 1.

CONCLUSION

Among persons with weight loss of at least 5% after 1 year, those originally randomly assigned to metformin had the greatest loss during years 6 to 15. Older age and the amount of weight initially lost were the most consistent predictors of LTWL maintenance.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Cognitive Training Therapy Improves the Effect of Hypocaloric Treatment on Subjects with Overweight/Obesity: A Randomised Clinical Trial

Obesity has been associated with impaired cognitive performance. This study aimed to determine whether improvements in cognitive function may contribute to higher weight loss in patients with obesity. In this randomised, 12-week trial, participants with overweight/obesity were randomised into a cognitive training intervention (Cognitive) group or a cognitive-behavioural (Control) group. In addition, both groups followed a hypocaloric dietary treatment. Cognitive functioning measurements and anthropometrical parameters were evaluated. All cognitive measures improved in the intervention group (p < 0.005 in all contrasts). In controls, significant improvements in attention, flexibility and task planning were also observed. Regarding anthropometrical parameters, the effect of the intervention in the cognitive group was higher for the total percentage of weight loss, body mass index (BMI), body fat and waist circumference. Biochemical parameters improved in both groups. Attending to our data, cognitive training was more effective that the hypocaloric intervention alone, partly related to an improvement in the working memory. Despite the shortage of training interventions for executive functions in the context of weight control, this type of combined intervention could establish the first steps towards a more appropriate intervention for patients with obesity.

Chronic abdominal vagus stimulation increased brain metabolic connectivity, reduced striatal dopamine transporter and increased mid-brain serotonin transporter in obese miniature pigs

Background/objective

Changes in brain metabolism has been investigated thoroughly during unilateral cervical chronic vagal stimulation in epileptic or depressive patients. Bilateral stimulation of the abdominal vagus (_aVNS) has received less attention despite the reduction in body weight and an altered feeding behavior in obese animals that could be clinically relevant in obese individuals. Our study aims to examine the changes in brain glucose metabolism (CMR_glu) induced by _aVNS in obese adult miniature pigs. Dopamine (DAT) and serotonin transporters (SERT) were also quantified to further understand the molecular origins of the alterations in brain metabolism.

Subjects/methods

Pairs of stimulating electrodes were implanted during laparoscopy on both abdominal vagal trunks in 20 obese adult’s miniature pigs. Half of the animals were permanently stimulated while the remaining were sham stimulated. Two months after the onset of stimulation, dynamic ₁₈FDG PET and ¹²³I-ioflupane SPECT were performed. Food intake, resting energy expenditure and fat deposition were also assessed longitudinally.

Results

Food intake was halved and resting energy expenditure was increased by 60% in _aVNS group compared to sham. The gain in body weight was also 38% less in _aVNS group compared to sham. Brain metabolic connectivity increased between numerous structures including striatum, mid-brain, amygdala and hippocampus. On the contrary, increased CMR_glu were restricted to the thalamus, the periaqueducal grey and the amygdala. DAT binding potential was decreased by about one third in the striatum while SERT was about doubled in the midbrain.

Conclusions

Our findings demonstrated that _aVNS reduced weight gain as a consequence of diminished daily food intake and increased resting energy expenditure. These changes were associated with enhanced connectivity between several brain areas. A lower striatal DAT together with a doubled mid-brain SERT were likely causative for these changes.

Electronic supplementary material

The online version of this article (10.1186/s12967-019-1831-5) contains supplementary material, which is available to authorized users.

Weight Loss Medications in the Treatment of Obesity and Hypertension

PURPOSE OF REVIEW

Weight loss is strongly associated with improvement in blood pressure; however, the mechanism of weight loss can impact the magnitude and sustainability of blood pressure reduction.

RECENT FINDINGS

Five drugs-orlistat, lorcaserin, liraglutide, phentermine/topiramate, and naltrexone/bupropion-are currently approved for weight loss therapy in the USA. Naltrexone/bupropion results in an increase in in-office and ambulatory blood pressure compared to placebo. Other therapies are associated with modest lowering of blood pressure, and are generally well-tolerated; nonetheless, evidence is limited regarding their effect on blood pressure, particularly longitudinally, in individuals with hypertension. Although weight loss medications can be an effective adjunct to lifestyle modifications in individuals with obesity, there is limited evidence regarding their benefit with regard to blood pressure. Future studies evaluating the effectiveness of weight loss medications should include careful assessment of their short- and long-term impact on blood pressure in individuals with hypertension.

Cyanidin and cyanidin-3-glucoside derived from Vigna unguiculata act as noncompetitive inhibitors of pancreatic lipase

The consumption of legumes positively correlated with the reduction of body weight. In the present study, we identified and evaluated pancreatic lipase inhibitors from Vigna unguiculata and unraveled their mode of inhibition. The highly sensitive fluorometric method was adopted to access the pancreatic lipase activity and the ethanolic extract of Vigna unguiculata showed the maximum inhibition (IC₅₀ of 15.2 µg/ml). Cyanidin and cyanidin-3-glucoside are the major anthocyanins observed in Vigna unguiculata. The IC₅₀ value of cyanidin was 28.29 µM which was 6.5-fold higher than the cyanidin-3-glucoside (188.28 µM). We determined an apparent K_i of 27.28 µM for cyanidin and cyanidin-3-glucoside (88.97 µM) with noncompetitive inhibition. Collectively, these results suggest that the glycosylation of the anthocyanidins significantly reduces lipase inhibition. The noncompetitive inhibition of pancreatic lipase by Vigna unguiculata anthocyanins may exert significant pharmacological activities toward obesity complications by calorie restriction. PRACTICAL APPLICATIONS: The results of this study emphasize the importance of legumes in our diet to combat obesity-related complications. Consumption of legumes minimizes fat absorption by inhibiting the action of the fat-digesting enzyme.