Therapy for obesity--today and tomorrow

Obesity poses a serious health hazard and its treatment is often disappointing. Besides conservative methods, the place of pharmacotherapy, very-low-calorie diets, and even, in selected cases, mechanical means or surgery can be considered. Effective drug treatment for obesity must reduce energy intake, or increase energy expenditure, or increase energy losses in faeces. All these possibilities have potential activities but also serious limitations. Current pharmacotherapy essentially uses anorectic drugs and the other approaches, although promising, are still under investigation. Of the anorectic compounds currently available, serotoninergic agents, like dexfenfluramine and fluoxetine, appear to have the most suitable pharmacological profile. Very-low-calorie diets could help in the short-term but should be associated with other approaches to increase the rate of long-term success. They must be well-balanced as macronutrients and micronutrients are concerned, be prescribed in well-selected patients under careful medical supervision, and not be followed longer than a few weeks. Surgery can provide palliation for severe obesity when all medical approaches have failed. It may consist in decreasing food intake (gastric procedures), affecting calorie absorption (intestinal shunting, biliopancreatic bypass), or removing localized excess fat (lipectomy, liposuction). Gastric reduction operations are safe and effective provided they are performed by experienced surgeons in well-selected patients. They can be considered now as the best option for a minority of patients with morbid and refractory obesity. Finally, in very selected patients, mechanical means (such as the waist cord) may also help losing weight and/or avoiding weight regain. Even if all these therapeutic approaches can be helpful, at least in some obese individuals, they also have important limitations so that prevention remains up to now the 'treatment' of choice for obesity.