3. Drugs
There are several agents for the pharmacologic therapy of obesity leading to decreased appetite, gastric emptying, nutrient absorption, or increased satiety. Some of these have gained marketing authorization during the last six years, and some others are still under development process [94,95]. Currently, the European Medicines Agency (EMA) authorized three drugs (orlistat, naltrexone/bupropion, and liraglutide), and the US Food and Drug Administration (FDA) has approved four drugs (orlistat, phentermine/topiramate, naltrexone/bupropion, and liraglutide) for obesity treatment [96]. The purpose of using pharmacotherapy to manage obesity is to increase patient adherence to lifestyle changes and to overcome the biological adaptations that occur with weight loss [97]. Increasing evidence has shown that behaviour-based interventions with one antiobesity medication can result in greater weight loss than usual care conditions only [96]. The efficacy of available anti-obesity drugs is often limited to a reduction of 5–10% of body weight over a 1-year period and weight loss typically does not occur for more than 6–8 months [98]. In a systematic review and network meta-analysis, five weight loss medications (orlistat, lorcaserin, naltrexone-bupropion, phentermine-topiramate, or liraglutide) were compared regarding efficacy on weight loss. In total, 28 RCTs with 29,018 patients were included. Study participants in the placebo group had a statistically significant lower odds ratio for achieving 5% weight loss after one year than participants taking drugs. Excess weight loss was 8.8 kg for phentermine-topiramate, 5.3 kg for liraglutide, 5.0 kg for naltrexone-bupropion, 3.2 kg for lorcaserin, and 2.6 kg for orlistat [99].
4. Bariatric Surgery
Bariatric surgery is appropriate for persons with severe obesity. Indications of bariatric surgery vary across countries. In most countries, the access to bariatric surgery is, e.g., restricted to persons for whom other weight loss measures have failed. There are two primary mechanisms: restriction and malabsorption of ingested food. A restrictive approach is physically limiting the quantity of food that can be ingested by limiting the size and capacity of the stomach while leaving the remainder of the gastrointestinal tract intact. Malabsorption of calories and nutrients occurs when a portion is bypassed or removed. Kilocalories and nutrients are less able to be absorbed because ingested food remains in the gut to a shorter distance. The International Federation for Surgery of Obesity and Metabolic Disorders (IFSO) has published an annual report of all bariatric surgery provided to the Global Registry [100]. Data from 51 countries with documented surgery between 2014 and 2018 were evaluated. The surgery procedure carried out most frequently was sleeve gastrectomy (46.0%) followed by Roux en Y gastric bypass (38.2%), one anastomosis gastric bypass (7.6%), and gastric banding (5.0%) [100]. Within the systematic review by Puzziferry et al., 29 clinical studies with 7971 patients were evaluated. The main finding was that gastric bypass resulted in greater weight loss than the gastric band [101]. A further systematic review and meta-analysis showed that all current bariatric procedures are associated with significant weight loss, but more long-term data are needed for one-anastomosis gastric bypass and sleeve gastrectomy [102]. Particularly worthy to mention is that patients with higher adherence rates to visits and behaviour changes before surgery are more likely to Nutrients 2022, 14, 169 10 of 15 lose more weight after surgery [103]. In any case, good preparation before and after surgery is indispensable to ensure the best outcomes [104]. Several steps during the preoperative evaluation are necessary. These include the individual’s psychological fitness to undergo bariatric surgery, the professional nutritional assessment, and patient education to guide the patient towards dietary modifications that are necessary after surgery [104]. Nutritional deficiencies are a long-term clinical issue in patients through modifications to the gastrointestinal tract [105]. The Clinical Practice Guidelines of the European Association for Endoscopic Surgery (EAES) recommend postoperative nutritional and behavioural advice for patients undergoing bariatric surgery [106]. Nutritional monitoring is an essential component of weight management after bariatric surgery to increase the patients’ adherence to healthy dietary habits and to appropriate supplementation measures [105]. In addition, monitoring prevents the risk of weight regain, makes it easier to detect possible nutritional deficiencies, and contributes to the preservation of a good quality of life [105].
5. Conclusions
This scientific viewpoint is a narrative review and not comparable with a systematic review but gives an overview of various treatment approaches, which should be used and combined considering the individuals‘ needs, preferences, weight status, and cardiometabolic risk factors. All treatment approaches have to result in a negative energy balance. Independent of the weight loss concept (e.g., intermittent fasting, low carb, low fat, drugs or, bariatric surgery), weight loss failed without a negative energy balance. Many trends like gene-based or microbiome-based dietary recommendations still lack conclusive scientific evidence. In general, weight loss studies often have methodological limitations (e.g., study design or duration), leading to results not being comparable, and they therefore should be interpreted with caution. With lifestyle changes, a moderate weight loss after one year is possible. Other approaches, such as bariatric surgery, lead to greater weight loss, but are proven only for specific target groups. More research, especially by long-term intervention studies, is needed to evaluate weight loss concepts and to obtain evidencebased tailored recommendations.
Author Contributions: M.W. and C.H. wrote the manuscript. All authors have read and agreed to the published version of the manuscript.
Funding: This work was supported by the enable competence cluster, an interdisciplinary cluster of nutrition science, funded by the German Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung, BMBF). The manuscript was written by the research group “Personalized nutrition and eHealth” (grant number: 01EA1709). The enable publication number is 79.
Acknowledgments: The authors thank Teresa Hölzl for designing the figures.
Conflicts of Interest: M.W. declares no conflict of interest. C.H. is a member of the scientific advisory board of the 4sigma GmbH Oberhaching, Germany.
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