Orlistat acts by decreasing fat absorption; it is currently the only drug approved for use in obesity.

A patient with obesity (body mass index 38) is referred to your office. In the clinical history the patient refers that he/she has been obese since the age of 17 (currently 36 years old), having been on multiple diets with weight loss ranging from 5 to 10 kg but has subsequently regained weight. The patient is currently on a 1500 Kcal diet (self-administered and not restricted in fat) with a good follow-up of this diet, performing one hour of aerobic exercise 4 days a week. She has lost 3 kg but needs an additional loss of 7 kg more. Given the possibility of adding a drug against obesity, which one would you use to reduce fat absorption?

A meta-analysis of the past 25 years of weight loss research using diet, exercise or diet plus exercise intervention.

The therapeutic effectiveness of diet, exercise, and diet plus exercise for weight loss in obesity was determined. All human research reported in English, published in peer-reviewed scientific journals within the past 25 y was reviewed. Acceptance criteria (n = 493 from > 700 studies) were that a therapeutic intervention of diet, exercise or diet plus exercise was employed, specifically for weight reduction in obese adult humans and that weight change was reported numerically. Only aerobic exercise studies were included, while drug, hormone and surgical treatments were excluded. All data were extracted by the same investigator from the original research report. Except for gender and program type, all extracted data were numerical. ANOVA, with a Newman-Keuls post hoc test, was used to determine differences among programs (P < 0.05). One analysis was performed on the group mean data and one based on effect sizes. Analyses were repeated using initial body weight, initial percent body fat and program length, as covariates. Primarily, subjects aged 40 y have been studied (39.5 +/- 0.4 y, mean +/- s.e.m.) who are only moderately obese (92.7 +/- 0.9 kg, 33.2 +/- 0.5 body mass index (BMI), 33.4 +/- 0.7% body fat); for short durations (15.6 +/- 0.6 weeks). Exercise studies were of a shorter duration, used younger subjects who weighed less, had lower BMI and percentage body fat values, than diet or diet plus exercise studies. Despite these differences, weight lost through diet, exercise and diet plus exercise was 10.7 +/- 0.5, 2.9 +/- 0.4* and 11.0 +/- 0.6 kg, respectively. However, at one-year follow-up, diet plus exercise tended to be the superior program. Effect size and covariate analyses revealed similar program differences. Weight loss research over the past 25 y has been very narrowly focused on a middle age population that is only moderately obese, while the interventions lasted for only short periods of time. The data shows, however, that a 15-week diet or diet plus exercise program, produces a weight loss of about 11 kg, with a 6.6 +/- 0.5 and 8.6 +/- 0.8 kg maintained loss after one year, respectively.

Obesity and weight management in the elderly: a focus on men.

The rising rate of overweight/obesity among the ever-growing ageing population is imposing massive and rapidly changing burdens of ill health. The observation that the BMI value associated with the lowest relative mortality is slightly higher in older than in younger adults, mainly through its reduced impact on coronary heart disease, has often been misinterpreted that obesity is not as harmful in the elderly, who suffer a large range of disabling consequences of obesity. All medical consequences of obesity are multi-factorial and most alleviated by modest, achievable weight loss (5-10 kg) with an evidence-based maintenance strategy. But severe obesity, e.g. BMI >40 may demand greater weight loss e.g. >15 kg to reverse type 2 diabetes. Since relatively reduced physical activity and reduced muscle mass (sarcopenic obesity) are common in the elderly, combining exercise and modest calorie restriction optimally reduces fat mass and preserves muscle mass - age presents no obstacle and reducing polypharmacy is a valuable outcome. The currently licensed drug orlistat has no age-related hazards and is effective in a low fat diet, but the risks from bariatric surgery begin to outweigh benefits above age 60. For the growing numbers of obese elderly with diabetes, the glucagon-like peptide-1 (GLP-1) receptor analogue liraglutide appears a safe way to promote and maintain substantial weight loss. Obesity and sarcopenia should be prevented from younger age and during life-transitions including retiral to improve future health outcomes and quality of life, with a focus on those in "obese families".

My 600-lb Life

My 600-lb Life is an American reality television series that has aired on the TLC television network since 2012. Each episode follows a year in the life of morbidly obese individuals, who usually begin the episode weighing at least , and documents their attempts to reduce their weight to a healthy level. Update episodes, called "Where Are They Now?", feature one or more previous patients, picking up a year or more after their original episodes aired. Patients are placed under the care of Iranian-American Houston surgeon Younan Nowzaradan (often referred to as simply "Dr. Now"), who first has them attempt losing weight on their own by following a strict diet, and then depending on the patient's progress may offer gastric bypass surgery or sleeve gastrectomy to further assist in weight loss.

Management of obesity

A number of popular programs exist, including Weight Watchers, Overeaters Anonymous, and Jenny Craig. These appear to provide modest weight loss () over dieting on one's own () over a two-year period, similarly to non-commercial diets. Internet-based programs appear to be ineffective. The Chinese government has introduced a number of "fat farms" where obese children go for reinforced exercise, and has passed a law which requires students to exercise or play sports for an hour a day at school (see Obesity in China). In a structured setting with a trained therapist, these interventions produce an average weight loss of up to 8 kg in 6 months to 1 year, and 67% of people who lost greater than 10% of their body mass maintained or continued to lose weight one year later. There is a gradual weight regain after the first year of about 1 to 2 kg per year, but on the long-term this still results in a weight loss.

Dieting

Some studies have found that, on average, short-term dieting results in a "meaningful" long-term weight-loss, although limited because of gradual 1 to 2 kg/year weight regain. Others have suggested that dieting is ineffective as a long-term intervention. For each individual, the results will be different, with some even regaining more weight than they lost, while a few others achieve a tremendous loss, so that the "average weight loss" of a diet is not indicative of the results other dieters may achieve. A 2001 meta-analysis of 29 American studies found that participants of structured weight-loss programs maintained an average of 23% (3 kg) of their initial weight loss after five years, representing an sustained 3.2% reduction in body mass. Unfortunately, patients are generally unhappy with weight loss of <10%, and reductions even as high as 10% are insufficient for changing someone with a "obese" BMI to a "normal weight" BMI.

[Randomized placebo-controlled trial of orlistat for weight loss and prevention of weight regain in obese patients].

We undertook a randomised controlled trial to assess the efficacy and tolerance of orlistat, a gastrointestinal lipase inhibitor, in promoting weight loss and preventing weight regain in obese patients over a 2-year period. 743 patients (body-mass index 28-47 kg/m2), recruited at 15 European centres, entered a 4-week, single-blind, placebo lead-in period on a slightly hypocaloric diet (600 kcal/day deficit). 688 patients who completed the lead-in were assigned double-blind treatment with orlistat 120 mg (three times a day) or placebo for 1 year in conjunction with the hypocaloric diet. In a second 52-week double-blind period patients were reassigned orlistat or placebo with a weight maintenance (eucaloric) diet. From the start of lead-in to the end of year 1, the orlistat group lost, on average, more bodyweight than the placebo group (10.2% [10.3 kg] vs 6.1% [6.1 kg]; LSM difference 3.9 kg [p < 0.001] from randomisation to the end of year 1). During year 2, patients who continued with orlistat regained, on average, half as much weight as those patients switched to placebo (p < 0.001). Patients switched from placebo to orlistat lost an additional 0.9 kg during year 2, compared with a mean regain of 2.5 kg in patients who continued on placebo (p < 0.001). Total cholesterol, low-density lipoprotein (LDL) cholesterol, LDL/high-density lipoprotein ratio, and concentrations of glucose and insulin decreased more in the orlistat group than in the placebo group. Gastrointestinal adverse events were more common in the orlistat group. Other adverse symptoms occurred at a similar frequency during both treatments. Orlistat taken with an appropriate diet promotes clinically significant weight loss and reduces weight regain in obese patients over a 2-year period. The use of orlistat beyond 2 years needs careful monitoring with respect to efficacy and adverse events.

Management of obesity

Comprehensive diet programs, providing counseling, targets for calorie intake and exercise, may be more efficient than dieting without guidance ("self-help"), although the evidence is very limited. Following comprehensive lifestyle modifications, the average maintained weight loss is more than or 3% of total body mass, and could be sustained for five years, and up to 20% of the individuals maintain a weight loss of at least 10% (average of 33 kg). There is some evidence that fast weight loss produce greater long-term weight loss than gradual weight loss. Moderate on-site comprehensive lifestyle changes produce a greater weight loss than usual care, of 2 to 4 kg on average in 6 to 12 months. High-intensity comprehensive programs usually yield more weight loss than moderate or low-intensity, with about 35% to 60% of overweight individuals maintaining more than 5 kg weight loss after 2 years.

Dietary Approaches to Obesity Treatment -- Function

One kilogram of fat contains 9000 kilocalories. To lose half a kilogram of fat per week, a person should achieve a 4500 kcal net deficit for a week, 642 kcal in one day. Net energy deficit is achieved by decreasing food intake (dieting) and increasing physical activity. For example, a 55-year old moderately active 136 kg woman needs 2600 kcal for her daily needs. For a person who consumes a 2600 kcal diet, creating a 642 kcal deficit will require a 25 percent reduction in daily energy intake if the individual does not increase physical activity. The patient needs to spend effort, time, and usually some extra money to reach the goal of losing 26 kg of fat in a year. The effort can be too much, and the time to achieve the target weight is too long for some individuals. Reaching ideal body weight might seem too slow for some individuals triggering giving up on lifestyle treatment. It is advisable to set realistic goals that can be achievable.

Management of obesity

Medication Several anti-obesity medications are currently approved by the FDA for long term use. Orlistat reduces intestinal fat absorption by inhibiting pancreatic lipase. Lorcaserin has been found to be effective in the treatment of obesity with a weight loss of 5.8 kg at one year as opposed to 2.2 kg with placebo and it is approved by the Food and Drug Administration for use in the treatment of obesity. Side effects may include serotonin syndrome. The combination drug phentermine/topiramate (Qsymia) is approved by the FDA as an addition to a reduced-calorie diet and exercise for chronic weight management.

[Long-term results (5-year minimum) of the diet treatment of adult obesity. Elements of weight prognosis. Apropos of 138 patients].

One hundred and thirty-eight out of 250 obese patients admitted to hospitals between 1972 and 1976 for dietetic treatment comprising 1,000 calories and 100 g carbohydrates were recontacted with a minimum follow-up of 5 years. Seventy-five patients refused to answer the questionnaire or attend an outpatient appointment. Four patients were later excluded from the study. Finally, fifty-nine patients were reassessed. The percentage of good results at 5 years (defined as greater than or equal to 5 p. 100 loss of initial body weight) was 45.5 p. 100 of those reassessed, a minimum of 20 p. 100 of the total number recontacted. The course of obesity was not linear. During the follow-up period there were 45.5 p. 100 of secondary failures (regain of initial body weight after having lost at least 5 p. 100), but also 17 p. 100 of secondary successes. The prognosis was not related to the age of onset of obesity, its duration, sex, occupation, alleged trigger factors, apparent motivation, duration of hospital admission, or treatment before or after hospitalisation. The prognosis was better in patients under 30 or over 50 years of age at the time of treatment (P less than 0.01) and when the body weight had not varied +/- 5 kg in the years preceding treatment (P less than 0.01). The following factors may also play a favourable role (but not statistically significant): the degree of obesity (better results in major obesity greater than or equal to 50 p. 100 overweight), a positive family history, the detection of a physical factor (glucose intolerance) during investigation, and the repetition of medical check-ups after initial counselling.

[Estimation of the influence of psychological support on body mass reduction in the obese patients].

Obesity is an excessive accumulation of fatty tissue in the organism. Incorrect eating habits and low physical activity are the major cause of overweight and obesity. The aim of the study was to investigate the efficiency of dietetic treatment and increased physical activity in patients with excessive body mass. The study was carried out on 140 patients with overweight or simple obesity (131 women and 9 men), aged 15-65 years, the members of the support group previously instructed in dietetics. The treatment consisted of the application of diet 1000-1500 kcal/day and the participation in the programme of body-mass reducing exercises (physical exercise twice a week and exercise in water once a week for 45 min). The attendance was monitored and those who missed the classes were excluded from the group. The study was terminated after 2 years. In the group I (exercising for 0-3 months) 39 patients reduced their body mass by 7.7 kg on the average. In the group II (exercising for 3-6 months) 59 patients reduced their body mass by the average of 14.5 kg. In the group III (exercising for 6-12 months) in 38 patients the average loss of body mass was 20.9 kg. In the group IV (exercising for over 12 months) 4 patients reduced their weight by 26-70 kg (mean 50 kg), which gave the 26.5-47% loss of the initial body mass. The patients with overweight and obesity included in the present study reduced their body mass through the application of an adequately selected diet and increased physical activity. More than 40% of the patients were able to preserve up to 6 months of the programme, and about 30% up to one year.

How to help your patients lose weight: current therapy for obesity.

Obesity is epidemic and dangerous. Weight loss is difficult but worth the effort. Although new weight-loss drugs are available, there are no magic bullets: to lose weight and keep it off, people must eat less and exercise more. This article presents a practical approach on how physicians can help their patients lose weight through diet, behavior modification, and adjunctive pharmacologic therapy. An appropriate initial goal is to lose 5% to 10% of one's baseline weight over 3 to 6 months. Drug therapy should not be used in isolation, but it can be an adjunct to diet, exercise, and behavior modification if a patient is committed and able to make necessary changes in eating and activity, and if the patient has a BMI of 30 or higher or a BMI greater than 27 with weight-related comorbid conditions. Anorectic therapy is unlikely to succeed and should be stopped if the patient does not lose at least 4 lb in the first 4 weeks of therapy. Orlistat is unlikely to be of benefit if patients do not lose at least 3% of their baseline weight by 12 weeks. Because obesity is a chronic disease, drug treatment should be continued indefinitely. The physician and patient must understand the intention to treat long-term. The weight loss plan devised should improve upon previous plans: for example, implementing a regular, convenient exercise program that had not been included in the past, or offering pharmacotherapy.

Pharmacotherapy for obesity.

Pharmacotherapy for the management of obesity is primarily aimed at weight loss, weight loss maintenance and risk reduction, and has included thyroid hormone, amphetamines, phentermine, amfepramone (diethylpropion), phenylpropanolamine, mazindol, fenfluramines and, more recently, sibutramine and orlistat. These agents decrease appetite, reduce absorption of fat or increase energy expenditure. Primary endpoints used to evaluate anti-obesity drugs most frequently include mean weight loss, percentage weight loss and proportion of patients losing >or=5% and >or=10% of initial bodyweight. Secondary endpoints may include reduction in body fat, risk factors for cardiovascular disease and the incidences of diseases such as diabetes mellitus. Most pharmacotherapies have demonstrated significantly greater weight loss in patients on active treatment than those receiving placebo in short-term (<or=1 year) randomised controlled trials of pharmacological treatment in conjunction with a calorie-controlled diet or lifestyle intervention. The evidence of long-term efficacy is limited to sibutramine (2 years) and orlistat (4 years). These are the only drugs currently approved for the long-term management of obesity in adults. Sibutramine recipients randomised following 6 months' treatment to either sibutramine or placebo demonstrated significantly better weight maintenance at 2 years than those taking placebo (p<0.001), with >or=10% loss of initial bodyweight in 46% of patients. For patients taking orlistat, weight loss was 2.2 kg greater than those on placebo at 4 years (p<0.001), with significantly more patients achieving >or=10% loss of initial bodyweight (26.2% and 15.6%, respectively; p<0.001). Other drugs that have been evaluated for weight loss include ephedrine, the antidepressants fluoxetine and bupropion, and the antiepileptics topiramate and zonisamide. Two clinical trials with fluoxetine both reported no significant difference in weight loss compared with placebo at 52 weeks. Clinical trials evaluating ephedrine, bupropion, topiramate and zonisamide have demonstrated significantly greater weight loss than placebo but have been limited to 16-26 weeks' treatment. A major obstacle to the evaluation of the clinical trials is the potential bias resulting from low study completion rates. Completion rates varied from 52.8% of phentermine recipients in a 9-month study, to 40% of fenfluramine recipients in a 24-week comparative study with phentermine and 18% of amfepramone recipients in a 24-week study. One-year completion rates range from 51% to 73% for sibutramine and from 66% to 85% for orlistat. Other potential sources of bias include run-in periods and subsequent patient selection based on compliance or initial weight loss. Several potential new therapies targeting weight loss and obesity through the CNS pathways or peripheral adiposity signals are in early phase clinical trials. Over the next decade the drug treatment of obesity is likely to change significantly because of the availability of new pharmacotherapies to regulate eating behaviours, nutrient partitioning and/or energy expenditure.

Liraglutide

Liraglutide was approved for medical use in the European Union in 2009, and in the United States in 2010. In 2019, it was the 142nd most commonly prescribed medication in the United States, with more than 4million prescriptions. Medical uses Liraglutide is a medication used for the treatment of type 2 diabetes or obesity. Type 2 diabetes Liraglutide improves control of blood glucose. As of 2017 it is unclear if incretin mimetics like liraglutide affect a person's risk of death. In diabetes it is a less preferred agent. It may be used in those in who metformin and another antidiabetic medication such as a sulfonylurea are not sufficient. Obesity Liraglutide may also be used together with diet and exercise for chronic weight management in adult patients. The body mass index (BMI) needs to be greater than 30 kg/m2, or greater than 27 kg/m2 together with high blood pressure, type 2 diabetes mellitus, or dyslipidemia.

The Biggest Loser (season 13)

Winners $250,000 Winner (among the finalists) $100,000 Winner (among the eliminated contestants) Weigh-In Difference History Notes Conda's 15 pound weight loss in week 9 was displayed as a -14 due to her weight gain the previous week. Megan's 6 pound weight loss in week 11 was displayed as a -7 due to her 1 lb advantage from the challenge. Chris's 3 pound weight loss in week 12 was displayed as -4 due to her 1 lb advantage from the challenge. Mark's 0 pound weight loss in week 13 was displayed as -1 due to his 1 lb advantage from the challenge. Buddy's 9 pound weight loss in week 14 was displayed as -10 due to his 1 lb advantage from the challenge. Conda's 5 pound weight loss in week 14 was displayed as -4 due to her 1 lb disadvantage from the challenge. Weigh-In Percentages History

Weight-loss outcomes: a systematic review and meta-analysis of weight-loss clinical trials with a minimum 1-year follow-up.

To assist health professionals who counsel patients with overweight and obesity, a systematic review was undertaken to determine types of weight-loss interventions that contribute to successful outcomes and to define expected weight-loss outcomes from such interventions. A search was conducted for weight-loss-focused randomized clinical trials with >or=1-year follow-up. Eighty studies were identified and are included in the evidence table. The primary outcomes were a measure of weight loss at 6, 12, 24, 36, and 48 months. Eight types of weight-loss interventions-diet alone, diet and exercise, exercise alone, meal replacements, very-low-energy diets, weight-loss medications (orlistat and sibutramine), and advice alone-were identified. By using simple pooling across studies, subjects mean amount of weight loss at each time point for each intervention was determined. Efficacy outcomes were calculated by meta-analysis and provide support for the pooled data. Hedges' gu was combined across studies to obtain an average effect size (and confidence level). A mean weight loss of 5 to 8.5 kg (5% to 9%) was observed during the first 6 months from interventions involving a reduced-energy diet and/or weight-loss medications with weight plateaus at approximately 6 months. In studies extending to 48 months, a mean 3 to 6 kg (3% to 6%) of weight loss was maintained with none of the groups experiencing weight regain to baseline. In contrast, advice-only and exercise-alone groups experienced minimal weight loss at any time point. Weight-loss interventions utilizing a reduced-energy diet and exercise are associated with moderate weight loss at 6 months. Although there is some regain of weight, weight loss can be maintained. The addition of weight-loss medications somewhat enhances weight-loss maintenance.

Tesofensine

Clinical trials Phase IIB trial (TIPO-1) results reported in The Lancet showed levels of weight loss over a 6-month period that were significantly greater than those achieved with any currently available drugs. Patients lost an average of 12.8 kg on the 1 mg dose, 11.3 kg on the 0.5 mg dose and 6.7 kg on the 0.25 mg dose, compared with a 2.2 kg loss in the placebo group. All participants were instructed to follow a diet with a 300 kcal deficit and to increase their physical activity gradually to 30–60 minutes of exercise per day. The placebo-subtracted mean weight losses were 4.5%, 9.2% and 10.6% in the 0.25 mg, 0.5 mg and 1 mg dose groups, respectively. This is approximately twice the weight loss produced by medications currently approved by the US Food and Drug Administration (FDA) for the treatment of obesity.

[Weight changes and the effect of anti-diabetes treatment in the first 5 years after diabetes diagnosis - secondary publication].

We monitored changes in patients' weight during the first 5 years after diabetes diagnosis. Data were from 711 newly diagnosed diabetic patients aged 40 or over managed in general practice. Patients whose only treatment was advice on diet generally maintained an initial weight loss of 5-7 kg over the 5 years. Patients receiving metformin or sulfonylureas maintained an average weight loss of 2-4 kg depending on age and sex, while an acceptable average glycaemic control was achieved. The results indicate that weight reduction is a practicable treatment in diabetic patients.

[Pharmacological therapy of obesity].

Obesity is reaching epidemic proportions worldwide and it is correlated with various comorbidities, among which the most relevant are diabetes mellitus, arterial hypertension, and cardiovascular diseases. Obesity management is a modern challenge because of the rapid evolution of unfavorable lifestyles and unfortunately there are no effective treatments applicable to the large majority of obese/overweight people. The current medical attitude is to treat the complications of obesity (e.g. dyslipidemia, hypertension, diabetes, and cardiovascular diseases). However, the potential of treating obesity is enormous, bearing in mind that a volitional weight loss of 10 kg is associated with important risk factor improvement: blood pressure -10 mmHg, total cholesterol -10%, LDL cholesterol -15%, triglycerides -30%, fasting glucose -50%, HDL cholesterol +8%. Drug treatment for obesity is an evolving branch of pharmacology, burdened by severe side effects and consequences of the early drugs, withdrawn from the market, and challenged by the lack of long-term data on the effect of medications on obesity-related morbidity and mortality, first of all cardiovascular diseases. In Europe three antiobesity drugs are currently licensed: sibutramine, orlistat, and rimonabant; important trials with clinical endpoints are ongoing for sibutramine and rimonabant. While waiting for their results, it is convenient to evaluate these drugs for their effects on body weight and cardiometabolic risk factors. Sibutramine is a centrally acting serotonin/noradrenaline reuptake inhibitor that mainly increases satiety. At the level of brown adipose tissue, sibutramine can also facilitate energy expenditure by increasing thermogenesis. The long-term studies (five) documented a mean differential weight reduction of 4.45 kg for sibutramine vs placebo. Considering the principal studies, attrition rate was 43%. This drug not only reduces body weight and waist circumference, but it decreases triglycerides and uric acid as well and it increases HDL cholesterol; in diabetics it improves glycated hemoglobin. Sibutramine has conflicting effects on blood pressure: in some studies there was a minimal decrease, in some others a modest increase. In all the studies this drug increased pulse rate. Sibutramine is not recommended in patients with uncontrolled hypertension, or in case of history of cardio- and cerebrovascular disease. Orlistat is a pancreatic lipase inhibitor that reduces fat absorption by partially blocking the hydrolysis of dietary triglycerides. A recent meta-analysis evaluated 22 studies lasting for at least 12 months, in obese patients with a mean body mass index of 36.7 kg/m2, where orlistat was associated with hypocaloric diet or behavioral interventions: the net average weight loss was 2.89 kg (confidence interval 2.27-3.51 kg). Considering the principal studies, attrition rate ranged from 33 to 57%. Orlistat significantly decreases waist circumference, blood pressure, total and LDL cholesterol, but has no effect on HDL and triglycerides. This drug significantly reduced the incidence of diabetes only in subjects with impaired glucose tolerance. The major adverse effects with orlistat are mainly gastrointestinal (fatty and oily stool, fecal urgency, oily spotting, fecal incontinence) and attenuate over time. Orlistat should be avoided in patients with chronic malabsorption and cholestasis. Rimonabant is a selective antagonist of cannabinoid type 1 receptor. This drug, by inhibiting the overactivation of the endocannabinoid system, produces anorectic stimuli at the central nervous level, but also has effects on the peripheral systems involved in metabolism control, such as liver, adipose tissue, skeletal muscles, endocrine pancreas, and gastrointestinal apparatus, influencing many processes partially unknown. An ample experimental program named RIO (Rimonabant In Obesity) involved about 6600 obese or overweight patients to identify the effects of rimonabant in weight loss and associated cardiometabolic abnormalities, over and beyond a caloric restriction of 600 kcal in the treatment and placebo arms. In the four double-blind RIO trials published (Rio-North America, RIO-Europe, RIO-Lipids, RIO-Diabetes), rimonabant 20 mg significantly (p <0.001) reduced weight by 6.3-6.9 kg in the non-diabetic groups vs placebo (-1.5-1.8 kg), whereas in the diabetic subjects enrolled in RIO-Diabetes, weight loss was 5.3 vs 1.4 kg in the placebo group. Attrition rate at 1 year ranged between 40 and 50%, similar to the studies with sibutramine or orlistat. Similarly to weight loss, also waist circumference was significantly reduced by rimonabant. As for cardiometabolic parameters, rimonabant induced a significant increase in HDL cholesterol and a significant decrease in triglycerides. Even if no significant LDL reduction was achieved, the RIO-Lipids study showed a significant decrease in small dense LDL particles, more atherogenic, in rimonabant-treated subjects. Non-diabetic treated patients improved basal insulin and indirect indexes of insulin resistance, while in the RIO-Diabetes study, the only one including diabetics, glycated hemoglobin improved by 0.7% in the active treatment arm vs placebo. The effects on HDL cholesterol and glycated hemoglobin seem in a large percentage unrelated to weight loss. These effects have been confirmed by another trial, named SERENADE, evaluating the treatment in naive diabetic patients. Rimonabant is not recommended in patients with a history of depressive disorders or suicidal ideation and with uncontrolled psychiatric illness, and is contraindicated in patients with ongoing major depression or ongoing antidepressive treatment. In conclusion, despite an enormous advancement in basic research to understand the pathogenetic mechanisms at the base of obesity, the pharmacological research did not reach the therapeutic opportunities available for other chronic conditions, like hypertension and dyslipidemia. However, the few molecules available for clinical practice (sibutramine, orlistat, rimonabant) have shown, when properly used, to contribute to reduce body weight and undoubtedly improve cardiometabolic risk factors. With this preamble, according to current guidelines and pharmacoeconomic studies, patients who might benefit from antiobesity treatment are those with a body mass index > or =30 or 27-29.9 kg/m2 with major obesity-related comorbidities such as hypertension, diabetes, dyslipidemia, obstructive sleep apnea, and metabolic syndrome.

[The base data from Weight Watcher's groups as the parameter for long-term follow-up of weight reduction].

The available data of members of Weight Watchers groups were statistically evaluated and their efficiency is discussed with respect to the underlying therapeutic concept. As a result of the data evaluation and the discussion of the literature it can be concluded: 1. The time of active membership in the group correlates with the weight loss. 2. Dropouts can be expected at the beginning of the therapy and have usually a greater obesity than other members. An early motivation has to consider the slower success in those people with a high degree of obesity. 3. A continuous motivation and re-motivation is of greatest importance to prevent any weight gain after the end of group therapy. This re-motivation program should be established within the group; members who succeeded in losing weight should return for meetings at regular intervals.

Dietary treatment for obesity.

In patients with obesity, low-fat diets seem to result in a weight loss of 3-4 kg at 3 years, but long-term data are limited. Calorie-controlled diets seem to outperform low-fat diets with reported weight losses of 6-7 kg at 4 years, but, again, data are very limited; an initial very-low-calorie diet approach does not lead to greater weight loss than low-fat diets in the long term. Use of meal replacements can lead to an 8 kg weight loss at 4 years, but this finding has been reported only in one, uncontrolled study. High-protein, low-carbohydrate (or very-low-carbohydrate) diets have also been evaluated and seem to be superior to high-carbohydrate diets at least for up to 2 years. Very-low-carbohydrate diets can lead to elevations in LDL cholesterol levels in some individuals. Cognitive behavioral therapy added to diet therapy can facilitate approximately 5 kg additional weight loss, and exercise can facilitate an additional 1-1.5 kg weight loss. Drug treatment, particularly with sibutramine and rimonabant, can increase weight loss with a mildly hypocaloric diet by an additional 3-5 kg, but weight-loss drugs are costly and have adverse effects. If dietary and medical therapies fail, gastric banding can lead to a weight loss of approximately 14% at 10 years, with greater losses of up to 25% with gastric bypass and gastroplasty. Bariatric surgery can also lead to a reduction in mortality and comorbidities but adverse effects can occur including nutritional deficiencies and gastrointestinal symptoms.

[Obesity in adult patients: check up and treatment].

Obesity is now one of the major health problems in industrial countries as well as in developing world. Excess caloric intake and reduction of the physical activity are the main causes of obesity. This epidemic precedes a tremendous increase of type 2 diabetes, which is generally linked to weight excess. Obesity and type 2 diabetes are associated with morbidity and mortality and are very expensive for the social security. The important point is to define the risks linked to obesity taking into account the Body Mass Index and the importance of visceral obesity evaluated by waist measurement. After medical check up, a strategy will be discussed with the patient, including moderate caloric restriction and increased physical activity. Our patients and also some doctors suggest "popular diets" whose efficacy has not been demonstrated as superior. On a short time basis, low carbohydrate and high protein diets have some advantages, which can help our obese subjects but on long term, only hypocaloric and equilibrated diets are advisable. Drugs that proved their efficacy and tolerance may be prescribed in case of failure. Three drugs are presented, orlistat, sibutramine and metformine: their efficacy, secondary effects, interactions and finally their positioning. Bariatric surgery will be proposed to highly selected patients presenting morbid obesity.

Bariatric surgery: an evidence-based analysis.

To conduct an evidence-based analysis of the effectiveness and cost-effectiveness of bariatric surgery. Obesity is defined as a body mass index (BMI) of at last 30 kg/m(2).() Morbid obesity is defined as a BMI of at least 40 kg/m(2) or at least 35 kg/m(2) with comorbid conditions. Comorbid conditions associated with obesity include diabetes, hypertension, dyslipidemias, obstructive sleep apnea, weight-related arthropathies, and stress urinary incontinence. It is also associated with depression, and cancers of the breast, uterus, prostate, and colon, and is an independent risk factor for cardiovascular disease. Obesity is also associated with higher all-cause mortality at any age, even after adjusting for potential confounding factors like smoking. A person with a BMI of 30 kg/m(2) has about a 50% higher risk of dying than does someone with a healthy BMI. The risk more than doubles at a BMI of 35 kg/m(2). An expert estimated that about 160,000 people are morbidly obese in Ontario. In the United States, the prevalence of morbid obesity is 4.7% (1999-2000). In Ontario, the 2004 Chief Medical Officer of Health Report said that in 2003, almost one-half of Ontario adults were overweight (BMI 25-29.9 kg/m(2)) or obese (BMI ≥ 30 kg/m(2)). About 57% of Ontario men and 42% of Ontario women were overweight or obese. The proportion of the population that was overweight or obese increased gradually from 44% in 1990 to 49% in 2000, and it appears to have stabilized at 49% in 2003. The report also noted that the tendency to be overweight and obese increases with age up to 64 years. BMI should be used cautiously for people aged 65 years and older, because the "normal" range may begin at slightly above 18.5 kg/m(2) and extend into the "overweight" range. The Chief Medical Officer of Health cautioned that these data may underestimate the true extent of the problem, because they were based on self reports, and people tend to over-report their height and under-report their weight. The actual number of Ontario adults who are overweight or obese may be higher. Diet, exercise, and behavioural therapy are used to help people lose weight. The goals of behavioural therapy are to identify, monitor, and alter behaviour that does not help weight loss. Techniques include self-monitoring of eating habits and physical activity, stress management, stimulus control, problem solving, cognitive restructuring, contingency management, and identifying and using social support. Relapse, when people resume old, unhealthy behaviour and then regain the weight, can be problematic. Drugs (including gastrointestinal lipase inhibitors, serotonin norepinephrine reuptake inhibitors, and appetite suppressants) may be used if behavioural interventions fail. However, estimates of efficacy may be confounded by high rates of noncompliance, in part owing to the side effects of the drugs. In addition, the drugs have not been approved for indefinite use, despite the chronic nature of obesity. Morbidly obese people may be eligible for bariatric surgery. Bariatric surgery for morbid obesity is considered an intervention of last resort for patients who have attempted first-line forms of medical management, such as diet, increased physical activity, behavioural modification, and drugs. There are various bariatric surgical procedures and several different variations for each of these procedures. The surgical interventions can be divided into 2 general types: malabsorptive (bypassing parts of the gastrointestinal tract to limit the absorption of food), and restrictive (decreasing the size of the stomach so that the patient is satiated with less food). All of these may be performed as either open surgery or laparoscopically. An example of a malabsorptive technique is Roux-en-Y gastric bypass (RYGB). Examples of restrictive techniques are vertical banded gastroplasty (VBG) and adjustable gastric banding (AGB). The Ontario Health Insurance Plan (OHIP) Schedule of Benefits for Physician Services includes fee code "S120 gastric bypass or partition, for morbid obesity" as an insured service. The term gastric bypass is a general term that encompasses a variety of surgical methods, all of which involve reconfiguring the digestive system. The term gastric bypass does not include AGB. The number of gastric bypass procedures funded and done in Ontario, and funded as actual out-of-country approvals,() is shown below. Number of Gastric Bypass Procedures by Fiscal Year: Ontario and Actual Out-of-Country (OOC) ApprovalsData from Provider Services, MOHLTCCourtesy of Provider Services, Ministry of Health and Long Term Care The Medical Advisory Secretariat reviewed the literature to assess the effectiveness, safety, and cost-effectiveness of bariatric surgery to treat morbid obesity. It used its standard search strategy to retrieve international health technology assessments and English-language journal articles from selected databases. The interventions of interest were bariatric surgery and, for the controls, either optimal conventional management or another type of bariatric procedure. The outcomes of interest were improvement in comorbid conditions (e.g., diabetes, hypertension); short- and long-term weight loss; quality of life; adverse effects; and economic analysis data. The databases yielded 15 international health technology assessments or systematic reviews on bariatric surgery. Subsequently, the Medical Advisory Secretariat searched MEDLINE and EMBASE from April 2004 to December 2004, after the search cut-off date of April, 2004, for the most recent systematic reviews on bariatric surgery. Ten studies met the inclusion criteria. One of those 10 was the Swedish Obese Subjects study, which started as a registry and intervention study, and then published findings on people who had been enrolled for at least 2 years or at least 10 years. In addition to the literature review of economic analysis data, the Medical Advisory Secretariat also did an Ontario-based economic analysis. Bariatric surgery generally is effective for sustained weight loss of about 16% for people with BMIs of at least 40 kg/m(2) or at least 35 kg/m(2) with comorbid conditions (including diabetes, high lipid levels, and hypertension). It also is effective at resolving the associated comorbid conditions. This conclusion is largely based on level 3a evidence from the prospectively designed Swedish Obese Subjects study, which recently published 10-year outcomes for patients who had bariatric surgery compared with patients who received nonsurgical treatment. (1)Regarding specific procedures, there is evidence that malabsorptive techniques are better than other banding techniques for weight loss and resolution of comorbid illnesses. However, there are no published prospective, long-term, direct comparisons of these techniques available.Surgery for morbid obesity is considered an intervention of last resort for patients who have attempted first-line forms of medical management, such as diet, increased physical activity, behavioural modification, and drugs. In the absence of direct comparisons of active nonsurgical intervention via caloric restriction with bariatric techniques, the following observations are made:A recent systematic review examining the efficacy of major commercial and organized self-help weight loss programs in the United States concluded that the evidence to support the use of such programs was suboptimal, except for one trial on Weight Watchers. Furthermore, the programs were associated with high costs, attrition rates, and probability of regaining at least 50% of the lost weight in 1 to 2 years. (2)A recent randomized controlled trial reported 1-year outcomes comparing weight loss and metabolic changes in severely obese patients assigned to either a low-carbohydrate diet or a conventional weight loss diet. At 1 year, weight loss was similar for patients in each group (mean, 2-5 kg). There was a favourable effect on triglyceride levels and glycemic control in the low-carbohydrate diet group. (3)A decision-analysis model showed bariatric surgery results in increased life expectancy in morbidly obese patients when compared to diet and exercise. (4)A cost-effectiveness model showed bariatric surgery is cost-effective relative to nonsurgical management. (5)Extrapolating from 2003 data from the United States, Ontario would likely need to do 3,500 bariatric surgeries per year. It currently does 508 per year, including out-of-country surgeries.

The Biggest Loser (season 15)

Winners $250,000 Winner (among the finalists) $100,000 Winner (among the eliminated contestants) Weigh-In Difference History Notes Rachel's 4 pound weight loss in week 10 was displayed as -5 due to her 1-pound advantage from the challenge. Tanya's 3 pound weight loss in week 11 was displayed as -2 due to her 1-pound disadvantage from the challenge. Rachel's 6 pound weight loss in week 12 was displayed as -7 due to her 1-pound advantage from the challenge. Bobby's 8 pound weight loss in week 13 was displayed as -6 due to the weight he gained last week. Weigh-In Percentage History

Impact of carbohydrate and fat intake on weight-reducing efficacy of orlistat.

Orlistat treatment of obesity results in a poor long-term weight loss (< 5%) in about 30% of patients. Total energy and macronutrient intake were examined to assess the effect of a change in eating habits on weight loss. Sixty-two patients consumed a hypocaloric diet, together with orlistat (3 x 120 mg/day), for 72 weeks, with a maximal fat allowance of 30% of the energy intake. At regular intervals, food diaries were recorded. Fifty-six patients completed the study and lost 8.5 +/- 0.88 kg (P < 0.001). Energy intake was approximately 1500 kcal/day during the entire study period. In three sub-groups established according to weight loss (1, < 5%; 2, > 5% and < 10%; 3, > 10%), fat intake was within the recommended range in all groups during the first 6 months, but thereafter only in group 3. All groups increased their carbohydrate consumption, with the greatest increase in group 1, which could account for the rapid regain of initially lost body weight in this group. At the beginning of a weight management programme in conjunction with orlistat, a low fat intake is advised for an efficient reduction in body weight. Subsequently, in patients with poor long-term weight loss, dietary recommendations must also consider carbohydrate restriction to ensure an adequate hypocaloric diet.

The Biggest Loser (season 13)

Weigh-In Percentages History Notes Conda's 6.10% weight loss in week 9 was displayed as 5.71% due to her weight gain the previous week. Megan's 2.94% weight loss in week 11 was displayed as 3.43% due to her 1 lb advantage from the challenge. Chris's 1.69% weight loss in week 12 was displayed as 2.26% due to her 1 lb advantage from the challenge. Mark's 0.00% weight loss in week 13 was displayed as 0.50% due to his 1 lb advantage from the challenge. Buddy's 3.35% weight loss in week 14 was displayed as 3.72% due to his 1 lb advantage from the challenge. Conda's 2.38% weight loss in week 14 was displayed as 1.90% due to her 1 lb disadvantage from the challenge. Elimination Voting History

Comparison of efficacy of sibutramine or orlistat versus their combination in obese women.

Sibutramine and orlistat are currently used for weight loss. We aimed to investigate the effect of orlistat and sibutramine combination therapy in treatment of obese women. Study population consisted of 89 obese women who had a body mass index > or = 30 kg/m2, were normotensive, and had normal glucose tolerance. All patients were placed on a diet which contained fat approximately 30% of total calorie intake and the diet was designed to cause an energy deficit of approximately 2.51-3.56 megajoule/day. At the first month of diet (baseline), all patients were randomly divided into three therapy groups: Diet + Orlistat (group 1; n = 30 patients), Diet + Sibutramine (group 2; n = 29 patients), Diet + Orlistat + Sibutramine (group 3; n = 30 patients). Body weight, body fat distribution and serum lipid levels were evaluated baseline and after six months in all subjects. Mean weight loss was 5.5 +/- 4.9 kg (p = 0.024) in group 1, 10.1 +/- 3.6 kg (p < 0.001) in group 2, 10.8 +/- 6.6 kg (p < 0.001) in group 3 after the six months. Weight loss was significantly greater in group 2 (p = 0.003) and group 3 (p = 0.002) when compared with group 1. Percentage of mean weight loss was 5.5 +/- 3.1% in group 1, 10.2 +/- 4.8% in group 2, 10.6 +/- 5.7% in group 3. Percentage of weight loss was higher in group 2 (p = 0.01) and group 3 (p = 0.009) when compared with group 1. Weight loss and percentage of weight loss were not different between group 2 and group 3. These three regimens had different results on weight loss in obese women. Combination drug therapy and sibutramine therapy were both more effective than orlistat therapy alone. However, no significant difference was noted between combination drug therapy and sibutramine treatment groups.

Great expectations: "I'm losing 25% of my weight no matter what you say".

This study investigated whether informing obese individuals that they would lose only modest amounts of weight would lead them to adopt more realistic weight loss expectations. At a screening interview, 53 obese women reported that they expected to lose the equivalent of 28% of their initial weight during 1 year of treatment with the medication sibutramine. Prior to beginning treatment, participants were informed, both verbally and in writing, that they could expect to lose 5% to 15% of initial weight, the loss typically induced by current behavioral and pharmacologic approaches. This information, however, had little impact on their weight loss expectations when assessed on subsequent occasions. Results are discussed in terms of the origins, clinical significance, and potential malleability of obese individuals' weight loss expectations.

The Biggest Loser (season 7)

At the weigh-in, teams are shown to have lost a total 382 pounds, including a 30-pound weight loss by Daniel (Orange) who started out as the heaviest contestant in Biggest Loser history, and a 32-pound weight loss by Ron, which Alison says puts him in the Biggest Loser record books for most weight loss in the first week. As Jerry was not present at the first weigh-in to determine the contestants' starting weights due to his fainting spell, they weighed him in at the hospital, and his starting weight was announced as 369 lbs.

One-year treatment of obesity: a randomized, double-blind, placebo-controlled, multicentre study of orlistat, a gastrointestinal lipase inhibitor.

To assess the efficacy and tolerability of orlistat (Xenical) in producing and maintaining weight loss over a 12-month period. Patients were randomized to double-blind treatment with either orlistat 120 mg or placebo three times daily, in conjunction with a low-energy diet, for 12 months. Five centres in the UK. 228 obese adult patients with body mass index between 30 and 43 kg/m2 and mean weight 97 kg (range 74-144 kg). All patients were prescribed a low-energy diet, providing 30% of energy from fat, designed to produce an individually tailored energy deficit of approximately 600 kcal/day, for a run-in period of 4 weeks and then 12 months, plus orlistat 120 mg or placebo three times daily. Change in body weight (the primary efficacy parameter), waist circumference and adverse events were reviewed regularly, together with serum lipids, insulin, glucose and plasma levels of fat-soluble vitamins and beta carotene. Based on an intent-to-treat analysis, after 1 y of treatment patients receiving orlistat had lost an average of 8.5% of their initial body weight compared with 5.4% for placebo-treated patients; 35% of the orlistat group lost at least 5% of body weight compared with 21% of the placebo group (P < 0.05), and 28% and 17%, respectively (P = 0.04) lost at least 10% of body weight. Orlistat-treated patients showed significant decreases (P < 0.05) in serum levels of total cholesterol, low density lipoprotein cholesterol, and in the low density lipoprotein: high density lipoprotein ratio in comparison with placebo. Both groups had similar adverse-event profiles, except for gastrointestinal events, which were 26% more frequent in the orlistat group but were mostly mild and transient. To maintain normal plasma levels of fat-soluble vitamins, supplements of vitamins A, D and E were given to 1.8%, 8.0% and 3.6%, respectively, of orlistat-treated patients, compared with 0.9% of placebo-treated patients for each vitamin type. After 1 y, the decrease in vitamin E and beta carotene was significantly greater in orlistat-treated patients compared with those receiving placebo (P < 0.001). No significant change was found in the mean vitamin E:total cholesterol ratio in either group after 52 weeks. Orlistat, in conjunction with a low-energy diet, produced greater and more frequent significant weight loss than placebo during 1 y of treatment. One-third of orlistat-treated patients achieved clinically relevant weight loss (> or = 5% initial body weight). There was also an improvement in relevant serum lipid parameters. Fat-soluble vitamin supplements may be required during chronic therapy. Orlistat was well tolerated and offers a promising new approach to the long-term management of obesity.

Weight loss and long-term follow-up of severely obese individuals treated with an intense behavioral program.

To review weight loss and maintenance for severely obese individuals enrolled in intensive behavioral weight loss program using very-low or low-energy diets. Chart review of consecutively treated patients between 1995 and 2002 seen at three weight loss centers. One thousand five hundred and thirty one patients with severe obesity (>or=40 kg/m(2)) treated in three cities ('Study Group'). Of these, 1100 completed the 12-week core curriculum ('Completer Group'). Weight loss >or=100 lbs (>45 kg) was seen in 268 patients ('100-Pound Group'). Charts were reviewed for baseline characteristics, weekly weights, follow-up weights and side effects. In the Study Group, average weight loss+/-s.e. for 998 women was 23.9+/-0.6 kg (18.5% of initial body weight (IBW)) and for 533 men was 36.0+/-1.0 kg (22.5%) over 30 weeks. For Completers, average weight loss for women was 30.8+/-0.6 kg (23.9%) and for men was 42.6+/-1.1 kg (26.7%) over 39 weeks. In the 100-Pound Group, average weight loss for women was 58.2+/-1.2 kg (41.5%) in 65 weeks and for men was 65.7+/-1.5 kg (37.5%) in 51 weeks. Side effects, assessed in 100 patients losing >45 kg, were mild to moderate in severity. Severe adverse events unrelated to the diet were noted in 5% of patients and during weight loss 1% had elective cholecystectomies. Follow-up weights were available for 86% of Completers at an average of 72 weeks with average maintenance of 23 kg or 59% of weight loss; follow-up weights were available for 94% of the 100-Pound Group at an average of 95 weeks with average maintenance of 41 kg or 65% of weight loss maintained. Intensive behavioral treatment with meal replacements is a safe and effective weight-loss strategy for selected severely obese individuals.

Obesity treatment with a progressive clinical tri-therapy combining sibutramine and a supervised diet--exercise intervention.

: Sibutramine favors a negative energy balance and also has the potential to increase heart rate and blood pressure. We investigated if a progressive supervised sibutramine--diet--exercise clinical intervention could increase the body weight loss previously reported while minimizing the potential cardiostimulatory effects of this drug. : The tri-therapy intervention was divided into two phases of 6 weeks each in which sibutramine (10 mg) was taken once daily by eight obese men (body mass index (BMI) between 30 and 40 kg/m(2)). Part A consisted of a dietary follow-up with an energy restriction, whereas in part B an aerobic exercise program combined with a low-fat diet was introduced. Systolic (SBP) and diastolic (DBP) blood pressure, resting heart rate (RHR) and body weight were measured every 2 weeks while body density, resting metabolic rate (RMR) and respiratory quotient (RQ) were determined before and after the intervention. : This clinical intervention produced a substantial body weight loss (-10.7 kg, P<0.01) which was about twice as much as other 12-week studies. In part A, both RHR (+4 beats/min) and DBP (+5 mmHg, P<0.01) were increased. However, after part B, RHR (-8 beats/min, P=0.02) and DBP (-3 mmHg, P<0.01) were significantly decreased. RMR was decreased at the end of the program but this effect did not persist after adjustments for fat-free mass. RQ was also reduced (-0.05, P<0.01) following the clinical tri-therapy. : In conclusion, these observations suggest that this clinical tri-therapy favored a satisfactory benefit--risk profile since it enhanced weight loss without inducing increases in heart rate and blood pressure or detrimental changes in RMR and substrate oxidation.