Bariatric treatments for adult obesity - Institute of Health Economics

Table T.F.3-6: Conclusions from the systematic reviews/HTAsSRs/HTAsConclusionDietary therapy/physical exerciseGalani & Schneider, 2007 56Shaw et al., 2006 57Curioni & Lourenco,2005 58Behavioural therapyShaw et al., 2005 15PharmacotherapyJohansson et al., 2009 59Padwal et al., 2004 20Li et al., 2005 60SurgeryKlarenbach et al., 2010 38Colquitt et al., 2009 62Multiple strategiesTsai, 2009 64Life style interventions were efficacious in the mid- to long-term prevention and treatment of obesity leading to a significant reduction in body weightand cardiovascular risk factors.Exercise is an effective weight loss intervention, particularly when combined with dietary interventions. Exercise is also an effective intervention forimproving a range of secondary outcomes even when weight loss does not occur. No long-term morbidity and mortality benefits were associated withexercise. Exercise was shown to positively impact the intermediate outcomes commonly associated with cardiovascular disease.Adding exercise to diet produced greater weight loss than diet alone in overweight and obese individuals immediate after the intervention period andafter one-year follow-up, but did not produce better long-term maintenance of the lost weight.People who are overweight or obese benefit from psychological intervention, particularly behavioural and cognitive-behavioural strategies, to enhanceweight reduction. Psychological interventions are extremely useful when combined with dietary and exercise strategies. Other psychological interventionsare less rigorously useful for their efficacy as weight loss treatments.Available weight loss drugs differ markedly regarding risk of discontinuation due to adverse events, as well as differing in the underlying causes of theseevents. Given the large number of patients eligible for treatment, the low number needed for harm for rimonabant is a concern.Internal validity of studies was limited by high attrition rates. Orlistat, sibutramine, and rimonabant in trials of one year or longer are modestly effectivein reducing weight, and have differing effects on cardiovascular risk and adverse effects profiles.Sibutramine, orlistat, phentermine, diethylpropion (probably), bupropion, fluoxetine, and topiramate all promote weight loss when given along withrecommendations for diet. Sibutramine and orlistat are the two most-studied drugs. The amount of extra weight loss attributable to these medications ismodest (less than 5 kg at one year), but this amount still may be clinically significant.Although data from large, adequately powered, long-term RCTs are lacking, bariatric surgery seems to be more effective than standard care for thetreatment of severe obesity in adults.Procedures that are mainly diversionary (e.g., BPD) result in the greatest amounts of weight loss, hybrid procedures (e.g., RYGB) are of intermediateeffectiveness, and restrictive procedures (e.g., AGB) result in the least amounts of weight loss. RYGB and AGB tended to lead to trade-offs between therisk of adverse events and the need for procedure conversion or reversals. The evidence base was limited for sleeve gastrectomy.Surgery is more effective than conventional management. Certain procedures produce greater weight loss, but data are limited. The evidence on safety iseven less clear. Due to limited evidence and the poor quality of the trials, caution is required when interpreting comparative safety and effectiveness.Current evidence does not support the use of low-intensity to moderate-intensity physician counseling for obesity, by itself, to achieve clinicallymeaningful weight loss. Available data do not indicate how best to incorporate PCPs into more intensive approaches for achieving this goal. PCPcounseling, plus pharmacotherapy, or intensive counseling (from a dietitian or nurse), plus meal replacements may help patients achieve this goal.Bariatric treatments for adult obesity 149