Obesity is a chronic, multifactorial condition with significant health implications, necessitating comprehensive management strategies. Bariatric medicine has evolved to address this global epidemic through a range of medical and surgical interventions. This review examines current trends in bariatric medicine, focusing on innovative pharmacological treatments, advancements in surgical techniques, and the integration of lifestyle and behavioral therapies. Recent developments include the introduction of novel anti-obesity drugs with mechanisms targeting appetite regulation and energy expenditure, as well as refined bariatric surgical approaches such as sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), which offer varying benefits in terms of weight loss and metabolic improvement. Lifestyle interventions, including dietary modifications and increased physical activity, remain essential components of obesity management, complemented by behavioral therapies to support long-term weight loss maintenance. The review highlights emerging trends and evidence-based practices, emphasizing the need for personalized treatment plans to optimize outcomes for individuals with obesity.

Obesity, Bariatric medicine, Roux-en-Y gastric bypass, Sleeve gastrectomy, Adjustable gastric banding.

Obesity is a chronic, multifactorial disease characterized by an excessive accumulation of body fat, which poses significant risks to health. It is typically measured using the body mass index (BMI), a calculation based on an individual’s weight in kilograms divided by the square of their height in meters. A BMI of 30 or greater is classified as obese, with further subdivisions based on severity: Class I (BMI 30.0-34.9), Class II (BMI 35.0-39.9), and Class III (BMI ≥ 40.0), also known as severe or morbid obesity.[1] The development of obesity is influenced by a complex interplay of genetic, behavioral, environmental, and physiological factors.

Genetics play a crucial role in obesity, influencing factors such as appetite regulation, fat distribution, and energy metabolism. Studies have identified multiple genes associated with obesity, including those related to the regulation of appetite and energy expenditure.[2] Lifestyle choices, including poor dietary habits (e.g., high intake of calorie-dense, nutrient-poor foods) and physical inactivity, are major contributors to obesity. Behavioral patterns, such as emotional eating or sedentary behavior, also play significant roles in weight gain.[3]

The modern environment, characterized by the easy availability of high-calorie foods and a lack of physical activity opportunities, greatly contributes to the obesity epidemic. Socioeconomic factors, urbanization, and cultural influences also affect dietary and exercise behaviors.[4] Hormonal and metabolic factors, including conditions like hypothyroidism, poly cystic ovary syndrome (PCOS), and Cushing’s syndrome, can predispose individuals to obesity. Additionally, certain medications, such as anti-psychotics and corticosteroids, are associated with weight gain.[5]

Obesity significantly increases the risk of cardiovascular diseases, including hypertension, coronary artery disease, and stroke. It is also a major risk factor for heart failure.[6] Obesity is the most important risk factor for type 2 diabetes. Excess fat, particularly visceral adiposity, contributes to insulin resistance, leading to hyperglycemia and diabetes.[7] The increased mechanical load on the joints due to obesity contributes to the development of osteoarthritis, particularly in the knees and hips. Obesity also exacerbates lower back pain and other musculoskeletal conditions.[8] Obesity is a leading cause of obstructive sleep apnea and obesity hypoventilation syndrome, conditions that significantly impair respiratory function and increase cardiovascular risk.[9] Obesity increases the risk of several cancers, including breast, colon, endometrial, and pancreatic cancers. The mechanisms linking obesity to cancer include chronic inflammation, insulin resistance, and alterations in hormone levels.[10] The psychological impact of obesity includes increased risks of depression, anxiety, and other mental health disorders. Obesity is also associated with social stigma, which can exacerbate psychological distress and lead to poor self-esteem.[11]

Current Trends in Obesity Management
The management of obesity requires a comprehensive approach, including lifestyle modifications, behavioral interventions, pharmacotherapy, and in some cases, bariatric surgery. Successful management strategies are often individualized, considering the patient’s health status, comorbid conditions, and personal preferences.[12]

Effectiveness of Pharmacological Treatments for Obesity
Pharmacological treatments for obesity have gained traction as adjuncts to lifestyle modifications for weight management. Medications like orlistat, lorcaserin, phentermine-topiramate, and liraglutide have been approved by regulatory agencies like the food and drug administration (FDA) for long-term obesity management. Their effectiveness varies, with clinical trials showing weight loss ranging from 5% to 10% of baseline body weight, which can significantly improve comorbid conditions like type 2 diabetes and cardiovascular disease (CVD).

Orlistat, a pancreatic lipase inhibitor, reduces dietary fat absorption by approximately 30%. Clinical trials, such as the Xenical in the prevention of diabetes in obese subjects (XENDOS) study, demonstrated that orlistat could lead to significant weight loss and a reduction in the incidence of type 2 diabetes in obese patients.[13] However, gastrointestinal side effects often limit its use. Liraglutide, a glucagon-like peptide-1 (GLP-1) receptor agonist, mimics the incretin hormone and delays gastric emptying, leading to appetite suppression. Studies, such as the Liraglutide evidence in individuals with and without diabetes (SCALE) obesity and prediabetes trial, have shown that liraglutide at a dose of 3 mg leads to greater weight loss compared to placebo.[14] Additionally, liraglutide has been associated with improvements in cardiovascular risk factors. The combination of phentermine- topiramate offers a synergistic effect by combining an appetite suppressant with an antiepileptic drug, leading to significant weight loss. The CONQUER trial demonstrated that this combination could lead to an average weight loss of 8.1% at the highest dose.[15]

Comparative studies of different bariatric surgery techniques and their long-term outcomes
Bariatric surgery is the most effective intervention for significant and sustained weight loss in patients with severe obesity. Various surgical techniques, such as RYGB, SG, and adjustable gastric banding (AGB), have been developed, each with distinct mechanisms of action and long-term outcomes.

RYGB, a combination of restrictive and malabsorptive procedures, has been considered the gold standard for bariatric surgery. Long-term studies, such as the Swedish Obese Subjects (SOS) study, have shown that RYGB leads to significant and sustained weight loss, with patients maintaining approximately 25% weight loss over 10 years.[16] Additionally, RYGB has been associated with significant improvements in comorbid conditions such as type 2 diabetes, hypertension, and dyslipidemia. SG, which involves the resection of approximately 80% of the stomach, is now one of the most performed bariatric procedures. Comparative studies suggest that SG provides similar weight loss and metabolic benefits to RYGB but with a lower risk of complications such as dumping syndrome and micronutrient deficiencies.[17] However, SG is associated with a higher risk of gastroesophageal reflux disease (GERD).

AGB, once a popular procedure, has seen a decline in use due to inferior weight loss outcomes and higher rates of reoperation compared to RYGB and SG. Long-term studies indicate that while AGB can lead to 10-15% weight loss, its effectiveness diminishes over time, with many patients requiring band removal or revision surgery.[18] Overall, RYGB and SG offer superior long-term weight loss and metabolic benefits compared to AGB. The choice of procedure should be individualized, taking into consideration patient preferences, comorbidities, and potential risks.

Impact of Lifestyle Interventions (Diet, Exercise) on Obesity Management
Lifestyle interventions, including dietary changes and increased physical activity, are foundational components of obesity management. These interventions aim to create a negative energy balance, leading to weight loss and improvement in obesity-related comorbidities. Dietary interventions range from caloric restriction to specific macronutrient modifications. The Dietary Approaches to Stop Hypertension (DASH) diet and Mediterranean diet have been widely studied for their effects on weight loss and cardiovascular health. A meta-analysis by Esposito et al found that adherence to the Mediterranean diet was associated with a significant reduction in body weight and waist circumference, as well as improvements in metabolic parameters.[19]

Exercise is another critical component of obesity management. Regular physical activity not only contributes to weight loss but also helps in maintaining weight loss and improving cardiovascular fitness. The American College of Sports Medicine recommends at least 150 minutes of moderate-intensity aerobic activity per week for weight loss, with higher amounts required for weight maintenance.[20] A combination of aerobic exercise and resistance training is particularly effective in preserving lean body mass during weight loss. While lifestyle interventions can lead to significant weight loss, their success is often limited by patient adherence. Behavioral strategies, such as self-monitoring, goal setting, and social support, are crucial for sustaining these interventions and achieving long-term weight management.

The Role of Behavioral Therapy in Weight Loss Maintenance
Behavioral therapy plays a critical role in weight loss maintenance by addressing the psychological and behavioral factors that contribute to obesity. Techniques such as cognitive-behavioral therapy (CBT), motivational interviewing, and mindfulness-based interventions have been employed to support weight loss and prevent weight regain. CBT focuses on identifying and modifying maladaptive thought patterns and behaviors related to eating and physical activity. Studies have shown that CBT, when combined with dietary and exercise interventions, can enhance weight loss outcomes and help maintain weight loss over time. For example, the Look Action for Health in Diabetes (AHEAD) trial demonstrated that participants who received intensive lifestyle intervention, including CBT, achieved greater weight loss and improvements in glycemic control compared to those who received diabetes support and education alone.[21]

Motivational interviewing is another behavioral technique that enhances intrinsic motivation for weight loss by resolving ambivalence and promoting self-efficacy. Research has shown that motivational interviewing can be particularly effective in engaging patients who are resistant to change and improving adherence to weight loss interventions.[22] Mindfulness-based interventions, which emphasize awareness and acceptance of present-moment experiences, have also been explored for obesity management. Studies suggest that mindfulness can reduce emotional eating, stress-induced eating, and binge eating, thereby supporting weight loss and maintenance.[23] Behavioral therapy is an essential component of comprehensive obesity management. It helps patients develop sustainable lifestyle changes, cope with challenges, and maintain long-term weight loss.

Evaluation of emerging anti-obesity drugs and their mechanisms of action
The development of new pharmacological agents for obesity reflects the growing understanding of the complex pathophysiology of this condition. Emerging anti-obesity drugs target various pathways involved in energy balance, appetite regulation, and metabolic processes. Semaglutide, a GLP-1 receptor agonist, is one such emerging drug that has shown promise in clinical trials. In the systematic training and education programme (STEP), semaglutide 2.4 mg once weekly led to a significant weight loss of approximately 15% to 18% of baseline body weight, making it one of the most effective pharmacological treatments for obesity to date.[24] Semaglutide works by enhancing insulin secretion, delaying gastric emptying, and reducing appetite.

Another promising drug is tirzepatide, a dual Gastric inhibitory polypeptide (GIP)/GLP-1 receptor agonist. The SURMOUNT-1 trial demonstrated that tirzepatide could achieve substantial weight loss, with participants losing up to 22.5% of their body weight at the highest dose.[25] Tirzepatide’s dual mechanism of action targets both the GLP-1 and GIP pathways, offering enhanced glycemic control and weight loss compared to GLP-1 agonists alone.

Other emerging drugs include setmelanotide, a melanocortin-4 receptor (MC4R) agonist, which is specifically indicated for rare genetic forms of obesity such as leptin receptor deficiency. Setmelanotide has shown efficacy in reducing hunger and promoting weight loss in these patient populations.[26]

Bariatric medicine represents a spectrum of approaches in obesity management. While pharmacological treatments can be effective in managing obesity, their success is often dependent on patient adherence and the management of potential side effects. The choice of medication should be tailored to the individual patient, considering their comorbidities, risk factors, and potential for drug-related adverse effects.

The development of these new drugs reflects an evolving understanding of the mechanisms underlying obesity and offers hope for more effective treatments. However, their long-term safety and efficacy require further investigation, and their use should be carefully considered within the broader context of obesity management, including lifestyle interventions and behavioral therapy.

In the evolving field of bariatric medicine, the management of obesity continues to advance with a focus on both innovative treatments and holistic approaches. Current trends emphasize a multimodal strategy that integrates pharmacological advancements, refined surgical techniques, and comprehensive lifestyle interventions.

Novel anti-obesity medications offer promising mechanisms for appetite control and weight management, while bariatric surgeries, including sleeve gastrectomy and Roux-en-Y gastric bypass, provide effective options for significant and sustained weight loss.

Lifestyle and behavioral therapies remain crucial for long-term success, addressing the root causes of obesity and supporting weight maintenance. The comparative review of these interventions underscores the importance of personalized treatment plans tailored to individual needs and health profiles.

As the field progresses, ongoing research and clinical practice will continue to refine and enhance strategies for effective obesity management, aiming to improve patient outcomes and address the global obesity epidemic.

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Corresponding Author:
Chinua Onyebuchi
Department of Public Health
Liverpool John Moores University, UK
Email: chinua7711@gmail.com

Co-Authors:
Oluchi Hope Uzochukwu-Obi, Chuba Samuel Jeremiah
Department of Medicine
Nnamdi Azikiwe University Teaching Hospital, Nigeria

All authors contributed to the conceptualization, investigation, and data curation by acquiring and critically reviewing the selected articles. They were collectively involved in the writing – original draft preparation, and writing – review & editing to refine the manuscript. Additionally, all authors participated in the supervision of the work, ensuring accuracy and completeness. The final manuscript was approved by all named authors for submission to the journal.

Not applicable

The authors declare no conflicts of interest.

None

https://doi.org/10.63096/medtigo3062250

Chinu O, Oluchi U-O, Chuba SJ. Bariatric Medicine: A Comparative Review of Current Trends in Obesity Management. medtigo J Med. 2024;2(3):e3062250. doi:10.63096/medtigo3062250 Crossref