A Comprehensive Overview of Obesity Treatment in the United States: Medications and Bariatric Surgery

Obesity is a chronic, multifaceted disease that has seen significant growth in prevalence in the United States over the past several decades. The medical community has responded with various pharmacological and surgical interventions aimed at managing this condition. This blog post will delve into the history of obesity treatment in the United States, highlighting major medications, their approval processes, controversies, and the evolution of bariatric surgery.

The Evolution of Obesity Treatment

The treatment of obesity in the United States has evolved significantly over the past century, marked by the introduction of various medications and surgical procedures.

Early Approaches to Obesity Treatment

In the early 20th century, obesity was primarily managed through diet and exercise, with limited pharmacological options. Medications were not widely available, and those that were used, such as thyroid hormones, had significant side effects.

Introduction of Amphetamines

In the 1930s, amphetamines were introduced as appetite suppressants. These drugs, including Benzedrine (amphetamine sulfate), were initially used for their stimulant properties but were later prescribed for weight loss due to their anorectic effects. However, their potential for abuse and serious side effects, such as addiction and cardiovascular complications, led to a decline in their use by the 1970s (Bray, 1993).

Fen-Phen and Its Controversies

The 1990s saw the rise and fall of the fen-phen combination (fenfluramine and phentermine). Approved individually in 1973 and 1959 respectively, these drugs were combined off-label to enhance weight loss. Fen-phen gained popularity due to its effectiveness in suppressing appetite and promoting weight loss. However, in 1997, fenfluramine and dexfenfluramine were withdrawn from the market after being linked to valvular heart disease and primary pulmonary hypertension (Connolly et al., 1997).

Major Obesity Medications: Approvals and Controversies

Orlistat (Xenical, Alli)

• Approval: Orlistat was approved by the FDA in 1999 for prescription use under the brand name Xenical. It was later approved for over-the-counter use as Alli in 2007.

• Mechanism: Orlistat works by inhibiting pancreatic lipase, thereby reducing fat absorption in the intestines.

• Controversies: Common side effects include gastrointestinal issues such as steatorrhea. There have also been concerns about its long-term impact on liver health (Hauptman et al., 2000).

Sibutramine (Meridia)

• Approval: Approved by the FDA in 1997, sibutramine was used as an appetite suppressant.

• Mechanism: It works by inhibiting the reuptake of serotonin, norepinephrine, and dopamine, thereby promoting satiety.

• Controversies: Sibutramine was withdrawn from the market in 2010 after studies showed an increased risk of cardiovascular events, including heart attack and stroke (James et al., 2010).

Lorcaserin (Belviq)

• Approval: Lorcaserin was approved by the FDA in 2012.

• Mechanism: It acts as a selective serotonin 2C receptor agonist, reducing appetite.

• Controversies: In 2020, lorcaserin was withdrawn from the market due to an increased risk of cancer observed in clinical trials (Smith et al., 2020).

Phentermine-Topiramate (Qsymia)

• Approval: Approved by the FDA in 2012.

• Mechanism: Combines phentermine, an appetite suppressant, with topiramate, an anticonvulsant that promotes satiety.

• Controversies: Concerns have been raised about its potential teratogenic effects and cardiovascular risks. Patients are advised to avoid pregnancy while taking the medication (Garvey et al., 2012).

Naltrexone-Bupropion (Contrave)

• Approval: Approved by the FDA in 2014.

• Mechanism: Combines naltrexone, an opioid antagonist, with bupropion, an antidepressant, to reduce appetite and cravings.

• Controversies: Side effects include nausea, headache, and increased blood pressure. There have been concerns about the potential for suicidal thoughts and behaviors, particularly in younger patients (Greenway et al., 2010).

Liraglutide (Saxenda)

• Approval: Approved by the FDA in 2014 for weight management.

• Mechanism: A GLP-1 receptor agonist that enhances insulin secretion and reduces appetite.

• Controversies: Common side effects include nausea and pancreatitis. Long-term safety data are still being evaluated (Pi-Sunyer et al., 2015).

Semaglutide (Wegovy)

• Approval: Approved by the FDA in 2021.

• Mechanism: Another GLP-1 receptor agonist, it has shown significant efficacy in reducing body weight.

• Controversies: Side effects include gastrointestinal disturbances and potential risks for thyroid tumors, as seen in rodent studies. Its high cost has also been a point of discussion (Wilding et al., 2021).

History of Bariatric Surgery

Bariatric surgery has evolved considerably since its inception in the mid-20th century, becoming a critical tool in the management of severe obesity.

Jejunoileal Bypass (JIB)

• History: One of the first bariatric procedures, JIB was introduced in the 1950s. It involved bypassing a large portion of the small intestine, leading to significant weight loss.

• Controversies: The procedure was associated with severe complications, including liver disease, kidney stones, and severe nutritional deficiencies, leading to its abandonment in the 1970s (Griffith & Birch, 2008).

Gastric Bypass

• History: The Roux-en-Y gastric bypass (RYGB) was developed in the 1960s and became popular due to its efficacy in weight loss and improvement in comorbidities.

• Procedure: Involves creating a small stomach pouch and rerouting a portion of the small intestine.

• Controversies: While effective, RYGB carries risks such as dumping syndrome, nutritional deficiencies, and surgical complications (Maggard et al., 2005).

Adjustable Gastric Banding (AGB)

• History: Introduced in the 1990s, AGB gained popularity due to its minimally invasive nature.

• Procedure: Involves placing an adjustable band around the upper part of the stomach to restrict food intake.

• Controversies: Long-term complications include band slippage, erosion, and less weight loss compared to other procedures, leading to a decline in its use (O’Brien et al., 2013).

Sleeve Gastrectomy

• History: Initially performed as the first stage of a two-stage procedure for high-risk patients, it gained popularity as a standalone procedure in the 2000s.

• Procedure: Involves removing approximately 80% of the stomach, leaving a tubular pouch.

• Controversies: While effective, potential complications include leakage, GERD, and nutritional deficiencies (Schauer et al., 2017).

Biliopancreatic Diversion with Duodenal Switch (BPD/DS)

• History: Developed in the 1970s, BPD/DS is one of the most effective procedures for weight loss.

• Procedure: Combines a sleeve gastrectomy with an intestinal bypass, reducing both stomach size and nutrient absorption.

• Controversies: High risk of nutritional deficiencies and more complex surgery with a higher complication rate (Marceau et al., 1998).

Current and Emerging Treatments

Endoscopic Procedures

• History: Endoscopic treatments such as intragastric balloons and endoscopic sleeve gastroplasty have been developed as less invasive alternatives to surgery.

• Procedure: These techniques involve reducing stomach volume or inducing satiety through endoscopic means.

• Controversies: While promising, long-term efficacy and safety data are still being gathered (Kumbhari et al., 2017).

Pharmacological Advances

• Semaglutide (Wegovy): Approved in 2021, semaglutide has shown substantial promise in weight reduction.

• Setmelanotide (Imcivree): Approved in 2020 for genetic obesity disorders, it represents a new frontier in targeted obesity treatment (Clement et al., 2020).

Conclusion

The treatment of obesity in the United States has evolved significantly, from early dietary interventions to advanced pharmacological and surgical options. Each intervention, whether a medication or a surgical procedure, has its own history, benefits, and controversies. As we continue to understand obesity's complex nature, the development of safer, more effective treatments will remain a priority in the medical community.