Many non-surgical avenues have been explored to develop effective treatments for obesity. Unfortunately, in people with morbid obesity, all of these strategies have been unsuccessful so far.

Diet and Exercise

The primary approach to treating obese patients is lifestyle modification: a decrease in calories consumed and an increase in energy expended. This well-known approach is generally safe and beneficial for all patients. However, among obese patients, there’s been no demonstrated long-term maintenance of weight loss.

The cornerstone of dietary management is the low calorie diet (LCD), which usually restricts the diet to 800 to 1,500 kcal per day. Average intake includes 250 gm or more of carbohydrates, 68 gm protein, and 60 gm or less from fat.

Many commercial diet programs are available, including Weight Watchers, NutriSystem, Optifast, and Jenny Craig.

Under special circumstances, a very-low-calorie diet (VLCD) is used providing 250 to 800 kcal/day, but special medical monitoring is required. VLCD may be useful in special circumstances for rapid improvement of symptoms of sleep apnea, hypertension, or hyperglycemia, however clinical studies show that LCDs are just as effective as VLCDs in producing weight loss after one year.

A review by VanItallie of the reported results from low-calorie diets concluded they could produce a weight reduction of 8 to 10 percent over a six-month period. Long-term maintenance of weight loss in obese patients has not been documented in any study.

Many other popular diet programs such as Atkins and the Zone diets have attempted to reduce weight by changing the types of foods consumed.

Exercise Programs

An increase in physical activity is recommended for any weight reduction program, including surgery. Exercise increases energy expenditure, improves comorbid conditions, combats depression, and helps maintain weight loss. Generally, up to 30 minutes of moderate-intensity physical activity is recommended five to six days a week.

In a study of women who had regained lost weight compared to those who maintained their weight loss, 90 percent of maintainers engaged in vigorous exercise at least three times per week for at least 30 minutes, whereas only 34 percent of the regainers reported this level of activity.

Past Therapies

Multiple attempts were made in past decades to manage morbid obesity using various drug regimens. The amphetamine-like drugs did induce weight loss better than placebo in clinical trials.

However, all studies were short-term and weight gain occurred after withdrawal of the drugs. Because the risk of drug abuse was relatively high, long-term utilization was not recommended.

Minimally invasive mechanical methods to limit dietary intake, including acupuncture, jaw wiring, and gastric bubbles, were likewise met with little success.

Current Drug Therapies

Today, drug therapies are usually reserved for patients with a BMI greater than 30, or greater than 27 in those individuals with at least one comorbidity related to obesity.

Several appetite suppressants continue to find use in weight reductions programs. They are usually used only for short-term results (up to 3 months): phentermine, mazindol, and diethylpropion. The most commonly prescribed of these is phentermine, a component of the now-banned phen/fen. When used alone, phentermine has not been associated with cardiac valvular abnormalities or primary pulmonary hypertension.

Two new pharmacologic approaches, have had some limited success in the treatment of obesity: sibutramine and orlistat. However, in morbidly obese patients, no successful studies have been reported.

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