The landscape of obesity treatment is rapidly evolving, presenting both patients and healthcare providers with an expanding array of options. With obesity rates on the rise, the demand for effective weight loss solutions has never been greater. This article provides a structured overview of various weight loss methods, including both pharmacological interventions and surgical procedures, to help individuals make informed decisions about their health.
The Role of Anti-Obesity Medications (AOMs) in Weight Management
Pharmacological treatments for obesity have seen significant advancements, especially since 2012, with the introduction of glucagon-like peptide-1 receptor agonists (GLP-1 receptor agonists) in the 2020s. These medications have gained considerable popularity and media attention. The arrival of dual receptor agonists like Mounjaro (indicated for type 2 diabetes) and Zepbound (approved for obesity) has further expanded the options available.
Determining Candidacy for Weight Loss Medications
To determine whether someone is a candidate for weight loss medications, healthcare providers typically start with assessing the patient's Body Mass Index (BMI). The guidelines for tirzepatide (Zepbound) and semaglutide (Wegovy) state that a patient should have a BMI of 30 or a BMI of 27 with weight-related health problems. The doctor and patient should discuss the patient’s current health issues, other medications, and family medical history.
Types of FDA-Approved Anti-Obesity Medications
Several weight loss medications have been approved by the FDA for long-term use. These include:
- Orlistat (Xenical, Alli): A lipase inhibitor that prevents the absorption of fat from the diet. Some patients may lose about 5% of their body weight. An over-the-counter formulation is available at 60 mg capsules with each fat-containing meal. Undigested fat is then passed through the body.
- Phentermine-Topiramate (Qsymia): Combines phentermine, an appetite suppressant, with topiramate, which can decrease appetite and cravings. Some patients may lose an average of 5-10% of body weight. Adults with migraines and obesity are good candidates for this weight-loss medication.
- Naltrexone-Bupropion (Contrave): Combines an opioid receptor antagonist with an antidepressant to affect the pleasure-reward areas of the brain, thereby decreasing cravings and appetite.
- Liraglutide (Saxenda): A daily injectable medication that acts on hormones to increase satiety and decrease hunger signals. Some patients may lose 5-10% of body weight, especially with higher doses.
- Semaglutide (Wegovy, Ozempic): A GLP-1 receptor agonist administered as an injection, approved for adults and children aged 12 years or more with obesity. The dose must be increased gradually to arrive at the 2.4 mg dosage.
- Tirzepatide (Zepbound, Mounjaro): A dual GIP and GLP-1 receptor agonist that suppresses appetite, improves satiety, and supports metabolic health. In the SURMOUNT-1 trial, adults with obesity or overweight (without diabetes) taking tirzepatide achieved up to 22.5% average body weight reduction at 72 weeks.
Emerging Medications and Future Trends
The pharmaceutical industry is continuously developing new medications to combat obesity. Pharmaceutical platform Ozmosi predicts one to two GLP-1 launches annually starting in 2026 specifically for obesity. Lilly is developing at least two new options, including orforglipron, an oral GLP-1 inhibitor, and retatrutide, which targets GLP-1, GIP, and glucagon. Amgen is developing MariTide, a monoclonal antibody designed to increase GLP-1 receptor activity while reducing GIP receptor activity.
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Considerations and Caveats
While AOMs can be effective, they are not without their considerations:
- Cost and Insurance Coverage: GLP-1s are notoriously costly, and insurance coverage varies.
- Side Effects: Many weight loss medications have potential side effects, including gastrointestinal symptoms, headache, dizziness, and fatigue.
- Long-Term Use: Most people regain weight if AOMs are discontinued. AOMs may counter the effects of metabolic adaptation and prevent weight regain.
- Counterfeit Medications: The FDA warns against buying medications from any source other than a state-licensed pharmacy.
Bariatric Surgery: An Overview of Surgical Weight Loss Procedures
Bariatric surgery encompasses various procedures designed to modify the digestive system for long-term weight loss and improved health. These surgeries limit food intake or decrease nutrient absorption from consumed meals.
Types of Bariatric Surgery
- Gastric Bypass (Roux-en-Y): This procedure involves creating a small pouch in the upper section of the stomach and attaching it directly to the small intestine. Gastric bypass averages 71 percent of excess weight loss at three years. The bypass changes hormones, bacteria, and other substances in the gastrointestinal tract that may affect appetite and metabolism.
- Pros: Significant weight loss, potential for reversal in severe cases, considered the gold standard treatment for morbid obesity.
- Cons: Increased risk of bleeding complications, longer recovery time, higher instances of dumping syndrome, malabsorption, and inability to take NSAIDs.
- Sleeve Gastrectomy: This surgery removes about 80% of the stomach, leaving a narrow, tube-like structure. Sleeve gastrectomy averages 66 percent of excess weight loss at three years. The surgery reduces the amount of food that can fit in your stomach, making you feel full sooner.
- Pros: Less complex than gastric bypass, shorter surgery time, fewer malabsorption issues, lower risk of dumping syndrome, and effective for weight loss.
- Cons: Non-reversible, potential for stomach discomfort such as heartburn or gas, and difficulty swallowing.
- Adjustable Gastric Banding: This method involves placing an inflatable device around the stomach's upper part to create a smaller pouch for food. Adjustable gastric banding averages 55 percent of excess weight loss at three years. The inner band has a circular balloon inside that is filled with saline solution.
- Pros: No cutting into the stomach or intestine, completely reversible, fewer complications related to malabsorption and dumping syndrome.
- Cons: Lower success rate than gastric bypass and sleeve gastrectomy, potential for band slippage or erosion, complications with the stoma, and lower weight loss.
- Biliopancreatic Diversion with Duodenal Switch (BPD/DS): This complex procedure involves creating a smaller stomach pouch and rerouting the small intestine. The first step resembles gastric sleeve surgery, where about 70% of the stomach gets removed. This bariatric surgery offers substantial benefits, including impressive long-term weight loss results and improvement or even resolution in obesity-related conditions like diabetes type-2.
- Pros: Impressive long-term weight loss results and can improve obesity-related conditions like diabetes type-2.
- Cons: Higher surgical risks and may require lifelong special foods and medications for digestion changes.
- Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S): This newer option combines gastric bypass and sleeve gastrectomy aspects, creating a smaller stomach pouch and connecting it directly to the ileum. Eligibility depends on BMI and obesity-related health issues.
- Pros: Fewer complications than traditional bypass surgeries, and it results in greater weight loss and better control of diabetes.
- Cons: Nutrient deficiencies due to prolonged skipping absorption areas in the digestion tract.
Eligibility and Preparation
Eligibility for bariatric surgery depends on several factors, including BMI and associated health conditions. Qualifications you must meet before you can be a candidate for any bariatric surgery, including:
- A BMI of 40 or more
- A BMI of 35 to 39.9 with existing weight-related health problems, including hypertension, type 2 diabetes, or severe sleep apnea.
Preparation is key to ahead of any surgical procedure - especially as significant as gastric bypass. Before scheduling your bariatric surgery, your healthcare provider will want to ensure that you’re physically and mentally fit for the surgery. You’ll meet with a team of specialists who will counsel you about the risks and benefits while evaluating your physical and mental health. Psychological readiness also plays an integral role in determining success post-surgery.
Post-Operative Care and Lifestyle Changes
Adopting significant lifestyle changes post-surgery is crucial for maintaining your new, healthier body mass index (BMI). Regular exercise in your daily routine is vital to sustaining weight loss after surgery. A balanced meal plan should include lean proteins, fruits & vegetables while limiting sugar intake. Last but not least is regular follow-up appointments with your bariatric surgeon, which provide opportunities for monitoring progress and addressing any concerns promptly.
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Revisional Bariatric Surgery
Revisional bariatric surgery is a procedure to reverse or modify an earlier weight loss surgery. Studies indicate that between 5 to 8 percent of weight loss surgeries fail and require revisional procedures to correct or reverse them. Common reasons to have revisional surgery include:
- Inadequate weight loss
- Weight gain
- Anastomotic stricture
- Stomal stricture
- Difficulty swallowing
- Frequent vomiting
- Ulcers
- Reflux
- Gastric dilation or enlargement
- Esophageal dilation
- Band erosion or slippage
- Gastro-gastric fistula
- Hernia
- Bowel obstruction
Additional Weight Loss Options
Gastric Balloon
An intragastric balloon is a type of restrictive procedure in which a deflated balloon is placed in your stomach through your mouth. It’s then filled with a saline solution that provides a sense of fullness and reduces hunger. There’s no real surgery involved and no hospital stay is needed.
Vagal Blockade (vBloc)
An implanted pacemaker-like device sends regular electrical impulses to your vagus nerve, which signals your brain that your stomach is full, so you don’t feel as hungry. The vagus nerve extends from your brain to your stomach.
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