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supporting their use, long-term clinical benefits have not been demonstrated Although these medications result in some additional weight loss at the end of 1- and 2-year clinical trials and, in some studies, improved obesity-related metabolic parameters, the impact of these medications on obesity-related clinical outcomes is unknown A new drug under investigation is rimonabant, a selective cannabinoid1 receptor antagonist In four initial studies lasting 1 year, 20 mg of rimonabant resulted in 5 kg greater weight loss than placebo Rimonabant caused more adverse affects than placebo, including nervous system, psychiatric, and gastrointestinal symptoms, and attrition rates at 1 year were approximately 40% Bariatric surgery is an increasingly prevalent treatment option for patients with severe obesity In the United States, gastric operations are considered the procedures of choice Most popular is the roux-en-Y gastric bypass (RYGB) In most centers, the operation can be done laparoscopically RYGB typically results in substantial amounts of weight loss close to 50% of initial body weight in some studies Complications occur in up to 40% of persons undergoing RYGB surgery and include peritonitis due to anastomotic leak, abdominal wall hernias, staple line disruption, gallstones, neuropathy, marginal ulcers, stomal stenosis, wound infections, thromboembolic disease, gastrointestinal symptoms, and nutritional deficiencies including iron, vitamin B12, folate, calcium, and vitamin D Operative mortality rates within 30 days are nil to 1% in low-risk populations but have been reported to be substantially higher in Medicare beneficiaries One-year mortality rates have been reported as high as 75% in men with Medicare The surgical volume (the number of cases performed by the surgeon or hospital) has been demonstrated to be an important predictor of outcome Recently, gastric banding (GB) surgeries have increased as an alternative procedure GB results in less dramatic weight loss than RYGB and fewer short-term complications Frequent follow-up is required to adjust the gastric band Longer-term follow-up suggests that both procedures are associated with significant regaining of weight NIH consensus panel recommendations are to limit obesity surgery to patients with BMIs over 40, or over 35 if obesity-related comorbidities are present Recent studies suggest that the procedure is cost-effective for patients with severe obesity and most third-party payers now cover the procedure in selected patients
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Buchwald H et al Bariatric surgery: a systematic review and meta-analysis JAMA 2004 Oct 13;292(14):1724 37 [PMID: 15479938] Curioni C Rimonabant for overweight or obesity Cochrane Database Syst Rev 2006 Oct 18;(4):CD006162 [PMID: 17054276] Dansinger ML et al Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial JAMA 2005 Jan 5;293(1): 43 53 [PMID: 15632335] DeMaria EJ Bariatric surgery for morbid obesity N Engl J Med 2007 May 24;356(21):2176-83 [PMID: 17522401] Flegal KM et al Excess deaths associated with underweight, overweight, and obesity JAMA 2005 Apr 20;293(15):1861 7 [PMID: 15840860] Flum DR et al Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures JAMA 2005 Oct 19;294(15):1903 8 [PMID: 16234496]
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Heilbronn LK et al Effect of 6-month calorie restriction on biomarkers of longevity, metabolic adaptation, and oxidative stress in overweight individuals: a randomized controlled trial JAMA 2006 Apr 5;295(13):1539 48 [PMID: 16595757] Howard BV et al Low-fat dietary pattern and weight change over 7 years: the Women s Health Initiative Dietary Modification Trial JAMA 2006 Jan 4;295(1):39 49 [PMID: 16391215] O Brien PE et al Treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program: a randomized trial Ann Intern Med 2006 May 2;144(9):625 33 [PMID: 16670131] Pi-Sunyer FX et al; RIO-North America Study Group Effect of rimonabant, a cannabinoid-1 receptor blocker, on weight and cardiometabolic risk factors in overweight or obese patients: RIO-North America: a randomized controlled trial JAMA 2006 Feb 15;295(7):761 75 [PMID: 16478899] Shah M et al Review: long-term impact of bariatric surgery on body weight, comorbidities, and nutritional status J Clin Endocrinol Metab 2006 Nov;91(11):4223 31 [PMID: 16954156] Shaw K et al Exercise for overweight or obesity Cochrane Database Syst Rev 2006 Oct 18;(4):CD003817 [PMID: 17054187] Sjostrom L et al; Swedish Obese Subjects Study Scientific Group Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery N Engl J Med 2004 Dec 23;351(26): 2683 93 [PMID: 15616203] Tsai AG et al Systematic review: an evaluation of major commercial weight loss programs in the United States Ann Intern Med 2005 Jan 4;142(1):56 66 [PMID: 15630109] Wadden RA et al Randomized trial of lifestyle modification and pharmacotherapy for obesity N Engl J Med 2005 Nov 17; 353(20):2111 20 [PMID: 16291981] Wing RR et al Long-term weight loss maintenance Am J Clin Nutr 2005 Jul;82(1 Suppl):222S 225S [PMID: 16002825]
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