Along with malnutrition and climate change, obesity is one of the 3 evils of the XXIst century. Indeed, according to the World Health Organization, 39% of adults aged 18 years and above were overweight in 2016, and 13% were obese. Among children, 39 million children under the age of 5 were overweight or obese in 2020[1].
Obesity is not only a cosmetic problem, it is rather a complex disease, defined by excessive overweight. The Body Mass Index (BMI), is a measure of body fat based on a person’s height and weight[2]. An adult is considered obese for a BMI > 30.
Obesity is a major risk factor for the poor quality of life and early death caused by cardiovascular disease (CVD), cancer and diabetes. Even though obesity is still a major public health issue without solution, treatments today include lifestyle modification, pharmacotherapy, and bariatric procedures[3]. This article will briefly review different treatments available today.
Lifestyle modification
It includes dietary change, physical activity and behavior modification (goal setting and self-monitoring), which has been shown to lead to weight loss and reduction of CVD risk factors[4],[5]. However, for optimal results, physical activity must be combined with the dietary change to increase the benefit.
Anti-obesity drugs
Those are only prescribed for patients with a BMI > 30. Among those who are FDA/EMA-approved and have an impact on weight loss and metabolic risk factors, we cite Phentermine (an appetite suppressant) alone or combined with Topiramate (appetite suppression is a side effect of this anti-epileptic medication). They both show an effective weight loss which leads to an improvement of cardiometabolic outcomes. There is also Liraglutide (prescribed for type 2 diabetes), which also shows a dose-dependent effect on weight loss[6] and improvement in CVD risk factors. We can also cite Naltrexone-bupropion, which proved its efficiency in weight loss[7]. Finally, Orlistat (impairs intestinal fat absorption), with the best safety records among cited drugs. Even though these medications have a positive effect on weight loss, the multiple side effects, lack of long-term efficacy data and their high cost can hinder the sustained use needed for weight loss and maintenance[8]. Indeed, pharmacological interventions targeting obesity have failed over the years.
Endoscopic bariatric and metabolic therapies
Here we present the surgical approaches that can lead to weight loss. Among those, we cite:
Gastric restriction (with space-occupying devices e.g., balloons or sutures). This technique shows a significant weight loss and thus a BMI decrease.
Another performed technique is malabsorption either by aspiration therapy or duodenal-jejunal bypass liner (DJBL)).
o Aspiration therapy, it consists of removing food from the stomach with a percutaneous device, leading to calories assimilation decrease and hence weight loss[9].
o The DJBL is placed inside the duodenum, thus creating a physical barrier between food and enzymes, which inhibits digestion. Studies show, that this technique shows efficient weight loss at 12 months compared to the “life modification” only group, however, no difference was observed at 24 months[10].
Although most of these endoscopic procedures show clinically significant mean differences in per cent weight loss compared to control[11], these invasive therapies present a high risk of complications during and post-surgery. Some of them also lead to malabsorption of micronutrients that are critical for metabolic health and well-being.
Bariatric surgery
Bariatric surgery has proven to be the most effective for weight loss[12], sleeve gastrectomy (which consists in ablating 80% of the stomach, and the remaining forms a small bag) and Roux-en-Y gastric bypass (which consists in linking the distal part of the intestine’s first section to the stomach pouch) being the most common procedures performed. Both of these surgeries have an impact on the quantity of food ingested and change gut hormones, inducing satiety. Typical post-surgical weight loss varies by 25.5% for bypass and 18.8% for sleeve gastrectomy (with observational data from a 5-year mean total weight loss).[13]
Even if all these treatments show an efficient variable weight loss, however, they remain high-cost therapies, long and/or invasive procedures and unsustainable. To address the obesity problem, a multidisciplinary effort bringing together health professionals and clinical, epidemiological and big data scientists are needed to establish a comprehensive framework acting on nutritional strategies towards health promotion. Indeed, from nutrigenomics to phenotyping, many factors need to be addressed in designing personalized and minimally biased nutritional interventions to prevent obesity incidence and obesity-related non-communicable diseases.
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