Introduction 

The age-adjusted prevalence of obesity in the

United States was 30.5 percent in 1999-2000.1

Although obtaining a precise estimate of the

change in the prevalence of obesity over time is

difficult because of changing definitions, nearly all

clinical authorities agree that obesity is reaching

epidemic proportions.1-12 In response,

pharmacological and surgical treatments for

weight loss have become both more numerous

and more commonly used. This report reviews

the evidence on such treatments in adults,

adolescents, and children.

We assess the efficacy and safety of the

following medications used for weight loss:

sibutramine, orlistat, fluoxetine, phentermine,

diethylpropion, bupropion, zonisamide,

topiramate, and sertraline. We also assess the

efficacy and safety of various types of bariatric

surgery for obesity.

Most of the medications discussed work by

suppressing the appetite. Orlistat is a lipase

inhibitor that aids weight loss by reversibly

binding to the active center of the enzyme lipase,

preventing the digestion and absorption of some

dietary fats. 

Surgical procedures result in weight loss by

restricting the size of the stomach or by bypassing

a portion of the intestines. Restricting the size of

the stomach limits the quantity of food a patient

can consume at a single meal. Malabsorptive

(bypass) procedures decrease the proportion of

nutrients that are absorbed from a meal. Gastric

banding achieves weight loss by creating gastric

restriction. The uppermost portion of the

stomach is encircled by a band to create a gastric

pouch. Vertical banded gastroplasty (VBG) and

other gastroplasty procedures use the strategy of

mechanical restriction to cause weight loss. The

upper part of the stomach is stapled to create a

narrow gastric inlet or pouch that remains

connected with the remainder of the stomach.

Roux-en-Y Gastric bypass (RYGB) achieves

weight loss through a combination of gastric

restriction and malabsorption. Reduction of the

stomach to a small gastric pouch results in

feelings of satiety following even small meals. In

addition, because this small pouch is connected to

a segment of the jejunum (which is downstream),

thus bypassing the duodenum and very proximal

small intestine, absorptive function is reduced. 

Methods

Each evidence report requested by the Agency

for Healthcare Research and Quality (AHRQ) is

guided by a Technical Expert Panel (TEP). We

invited a distinguished group of scientists and

clinicians, including individuals with expertise in

obesity, human nutrition, surgery, pediatrics, and

pharmacology, to participate in the TEP for this

report. TEP members suggested that our

assessment of pharmacological agents include

FDA-approved weight loss medications and other

medications for which reports have begun to

appear regarding their use as weight loss agents.

The FDA-approved weight loss drugs are

phentermine, sibutramine, orlistat,

diethylpropion, and mazindol; however, our TEP

advised us to ignore mazindol, because it is no

longer used. Our TEP instructed us to include

only studies with treatment durations of 6

months or longer.

Evidence Report/Technology Assessment

Number 103

Pharmacological and Surgical Treatment 

of Obesity

Summary

Agency for Healthcare Research and Quality

Advancing Excellence in Health Care • www.ahrq.gov

Agency for Healthcare Research and Quality Evidence-Based

Practice
2

We searched MEDLINE® (which encompasses information

from Index Medicus, the Index to Dental Literature, and the

Cumulative Index to Nursing and Allied Health Literature) and

the Cochrane Controlled Clinical Trials Register Database. 

To be accepted for our analysis, the study had to be a

randomized controlled trial (RCT) or controlled clinical trial

(CCT). For the analysis of surgical studies, we broadened these

inclusion criteria to encompass cohort studies and case series,

since our TEP and a brief scan of the literature suggested that

RCTs and CCTs would be few in number. While

acknowledging that inferences about efficacy could not be easily

made from case series, we did judge that such studies provided

useful information in the absence of trial data, and,

furthermore, would be useful to assess complications and

adverse events of surgery. To avoid reviewing potentially

numerous case reports, we set a threshold of 10 or more

patients for inclusion in our review.

We abstracted data from the articles onto a specialized form,

containing questions about the study design, the number of

patients and comorbidities, dosage, adverse events, the types of

outcome measures, and the time from intervention until

outcome measurement. 

The outcome of interest specified by our sponsor was weight

loss. However, excess weight is associated with other health

outcomes, such as diabetes mellitus, hypertension, sleep apnea,

osteoarthrititis, and so on. Because weight loss achieves its

health benefits primarily by reducing the incidence or severity

of weight-related comorbidities like diabetes, we also

endeavored to assess treatments by comparing their efficacy on

these outcomes. Very few of the pharmaceutical studies

reported these outcomes, making it not feasible to make acrossstudy comparisons addressing the control of comorbidities. We

did find surgical studies that made within-study comparisons of

the control of comorbidities, and summarize their findings in

this report. We also assessed the case series reports of obesity

surgery for the control of selected comorbidities and compared

these results to those reported in studies containing withingroup comparisons. 

Of the medications we assessed, three had up-to-date

existing meta-analyses (sibutramine, phentermine, and

diethylpropion), and others had a sufficient number of new

studies to justify a new meta-analysis (orlistat, topiramate,

fluoxetine, and bupropion). In order for a trial to be included

in analysis, the associated publication(s) had to report on

weight loss, one control or placebo group, provide data prior to

the crossover point if the trial was a crossover design, and

contain sufficient statistical information for the calculation of a

mean difference at 6 months and/or 1 year followup as defined

below. 

We extracted the followup mean weight loss for the control

group, the followup mean weight loss for the medication

group, and the standard deviation for each group. For studies

that included measures for both a 6-month and 1-year

followup, we collected those measures separately. If a study did

not report a followup mean, or a followup mean could not be

calculated from the given data, the study was excluded from

analysis. We extracted weight loss as a positive, i.e., greater than

zero, quantity. For studies that did not report a standard

deviation or for which a standard deviation could not be

calculated from the given data, we imputed the standard

deviation by using those studies and groups that did report a

standard deviation and weighting all groups equally.

We converted all means and standard deviations to

kilograms. We then calculated a mean difference for each study,

which was the difference between the control group followup

mean weight loss and the medication group followup mean

weight loss. A negative mean difference indicates that the

medication group experienced more weight loss at followup

than did the control group. The mean difference is readily

interpretable, as it is measured in kilograms.

For the 6-month and 1-year analyses respectively, we

conducted a meta-analysis, estimating a pooled random-effects

estimate13 of the overall mean difference and its associated 

95 percent confidence interval. The individual trial mean

differences are weighted by both within-study variation and

between-study variation in this synthesis. We constructed a

forest plot and reported the chi-squared test of heterogeneity 

p-value based on Cochran’s Q.14 We conducted sensitivity

analyses on four study dimensions: Jadad quality score, year of

publication, completion rate, and dosage. We assessed the

possibility of publication bias by evaluating a funnel plot of the

trial mean differences for asymmetry, which can result from the

nonpublication of small trials with negative results. Because

graphical evaluation can be subjective, we also conducted an

adjusted rank correlation test15 and a regression asymmetry test16

as formal statistical tests for publication bias. 

Each trial included in the weight loss analysis was examined

to determine whether it reported data on adverse events. We

abstracted either the number of events or the number of

people, depending on how the trial chose to report events. The

majority of trials recorded the number of events, rather than

the number of unique people who experienced the event. Each

event was counted as if it represented a unique individual.

Because a single individual might have experienced more than

one event, this assumption may have overestimated the number

of people having an adverse event. After abstracting the data,

we identified mutually exclusive subgroups of similar events,

based on clinical expertise. For example, one subgroup was

“gallbladder problems,” consisting of all adverse events
concerning this body system. When we subgrouped events, we

again treated all observed events as having occurred in unique

individuals. For each adverse event subgroup, we report the

number of trials that provided data for any event in the

subgroup. We also report the total number of individuals in the

medication groups in the relevant trials who were observed to

have experienced the event and the total number of patients in

the medication groups in those trials. We then report the

analogous counts for the control groups in the relevant trials. 

For subgroups of events that had two or more trials, at least

one event in the medication group, and at least one event in

the control group, we performed a meta-analysis to estimate the

pooled odds ratio and its associated 95 percent confidence

interval. For interpretability, for any significant pooled odds

ratio greater than one, which indicates the odds of the adverse

event associated with medication is larger than the odds

associated with being in the control group, we calculated the

relative risk and number needed to harm (NNH). We also

conducted a power calculation to determine the lowest adverseevent rate that the medication trials we identified had at least

80 percent power to detect. 

For the surgery studies, we conducted several analyses. First,

we note that some studies (controlled trials) had control

groups, whereas others did not (case series [CS]). Depending

on the analysis, these two general study types may have been

handled differently. For all surgical studies, we extracted the

mean weight loss and its standard deviation for each study

group, generally defined by surgery procedure, at 12 months

post-operative and at the maximum followup time greater than

or equal to 36 months as available. For randomized controlled

trials that reported a within-study comparison of two

procedures of interest, a mean difference was calculated (mean

weight loss in procedure “1” group minus mean weight loss in

procedure “2” group). A positive mean difference indicates that

patients in the procedure 1 group lost more weight on average

than patients in the procedure 2 group. A negative mean

difference indicates that patients in the procedure 1 group lost

less weight on average than patients in the procedure 2 group.

These mean differences were pooled using a random effects

model and a 95 percent confidence interval was estimated. For

all studies, randomized or not, a pooled mean weight loss for

each procedure group was estimated using a random effects

model and an associated 95 percent confidence interval was

constructed. 

Data for diabetes, hypertension, sleep apnea, and lipids were

also extracted. A crude proportion across studies was calculated

for those who resolved or improved (e.g., the number of people

who resolved or improved divided by the number of people

with the condition at baseline).

For each group in each study, we recorded the number of

deaths observed and the total number of patients in the group.

If the study self-identified the deaths as “early” or

“postoperative” or if it identified the deaths as within 30 days of

the surgery, we termed these “early deaths.” If the deaths were

self-identified as “late” or if they were identified as after 30

days, we termed these “late deaths.” If the study was unclear as

to the timing of the recorded deaths, we termed these “unclear

deaths.” If a study did not report data on death for a group, we

recorded zero unclear deaths for that group. That is, we

imputed zero for missing data, under the assumption that had

there been a death, the authors would have reported it. We

calculated the crude death rate. That is, we divided the total

number of deaths observed by the total number of patients in

the relevant study groups. This calculation treats all patients

from all studies equally and does not take into account any

variation across studies in mortality rates, but given the small

number of observed deaths, this statistic is simple and easily

interpretable. 

Each surgery study (RCT/CCT or CS) was examined to

determine whether it reported data on adverse events other

than death. The extraction of data for the surgery adverse event

analysis was the same as that described above for the

medication trials. After abstracting the data, we identified

mutually exclusive subgroups of similar events based on clinical

expertise. For selected surgery comparisons (one type of surgery

versus another type of surgery) for which there were RCT/CCT

data available, we estimated a pooled odds ratio and its

associated 95 percent confidence interval using exact methods

as described above for the medication adverse events metaanalysis. We also report the crude adverse event rate for each

RCT/CCT surgery group (total number of affected patients

divided by total number of patients at risk). In addition, we

report the crude adverse event rate for each surgery group

across all studies (RCT/CCT/CS) combined. 

Results

A recent meta-analysis on sibutramine efficacy reported a

mean difference in weight loss (compared to placebo) of 3.43

kg at 6 months. At 12 months, the difference was 4.45 kg.

Treatment with sibutramine was associated with modest

increases in heart rate and blood pressure, very small

improvements in glycemic control among diabetics, and (based

on the longest duration and best quality studies) small

improvements in HDL cholesterol and triglycerides.

In our own meta-analysis on orlistat, mean weight loss for

orlistat-treated patients, compared to placebo-treated patients,

was 2.51 kg at 6 months; at 12 months, it was 2.75 kg. We

found an increase in diarrhea, flatulence, and bloating/

3
4

abdominal pain/dyspepsia in orlistat-treated patients, compared

to placebo, with relative risks of 3.4, 3.1, and 1.5, respectively.

We identified a published review on phentermine and

diethylpropion for weight loss. (Our literature review identified

no new RCTs of these drugs since publication.) Compared to

placebo, subjects treated with phentermine lost on average 3.6

additional kg of weight at 6 months compared to placebo,

while subjects treated with diethylpropion lost on average 3.01

kg of weight, but this difference had only borderline statistical

significance. This review did not report side effects or adverse

event data.

Our own meta-analysis of fluoxetine studies showed a mean

weight loss, compared to placebo-treated patients, of 4.74 kg at

6 months and 3.05 kg at 12 months. There was an increase in

nervousness/sweating/tremors, nausea/vomiting,

fatigue/asthenia/ hypersomnia/somnolence, insomnia, and

diarrhea in fluoxetine-treated patients compared to placebo,

with relative risks of 6.4, 2.7, 2.4, 2.0, and 1.7, respectively.

We identified three studies of bupropion for weight loss that

were suitable for meta-analysis; two studies reported results at 6

months, the other at 12. The pooled result, compared to

placebo treated patients, was 2.8 kg. Bupropion causes dry

mouth (RR = 2.99) and insomnia.

We identified six studies (all but one available only as

abstracts) of topiramate for weight loss that were suitable for

meta-analysis. The pooled result at 6 months, compared to

placebo-treated patients, was an additional 6.5 percent of pretreatment weight lost. Parasthesias (RR = 4.9) and taste

perversion (RR = 9.2) were the most commonly reported side

effects attributable to topiramate. 

Our literature search identified one eligible study that

assessed the efficacy of the drug zonisamide for weight loss.17

Patients were followed for 16 weeks in the double-blind

portion of the study, with an additional 16-week single blind

extension available. The researchers reported that patients in the

zonisamide group lost an average of 6.0 percent of baseline

body weight, compared to 1.0 percent for placebo patients (p <

.001). 

We identified no direct comparisons of weight loss

medications. Our summary of the results for each drug

(compared to placebo) does not support a hypothesis that any

one drug is more effective than the others.

We identified numerous reports on obesity surgery. Two

RCTs of surgery compared to nonsurgical treatment were

considered to be of limited relevance because they used surgical

procedures that are considered obsolete. An observational study,

the Swedish Obese Subjects (SOS) study,18-25 matched subjects

on 18 variables, including gender, age, height, and weight. At 8

years of followup, among 251 surgically treated patients, the

average weight loss was 20 kg (or 16 percent of body weight),

whereas among 232 medically treated patients, the average

weight did not change. We consider this study as providing

conclusive evidence of the superiority of surgical treatment for

the patients that were enrolled (middle-aged adults with a BMI

of about 41 kg/m2). The strength of this study is the extended

duration of followup, documenting sustained weight loss and

improved health up to 10 years following treatment. A series of

reports from the SOS study support the superiority of obesity

surgery compared to medical therapy in ameliorating or

preventing the morbidities due to obesity such as hypertension,

diabetes, and lipid abnormalities. At 24 months after surgery,

among 845 surgically treated patients and 845 matched

controls (two-thirds women, average age of 48, average BMI

about 41), the incidence of hypertension, diabetes, and lipid

abnormalities was markedly lower in the surgically treated

patients (adjusted odds ratios of 0.02 to 0.38, depending on

condition).25 At 8 years of followup, the effect of surgery on

the reduction in diabetes risk was still dramatic (odds ratio =

0.16), whereas the effect on reduction in risk for hypertension

did not persist (odds ratio = 1.01).19 However, significant

decreases in both systolic (8.3 mm Hg) and diastolic (6.7 mm

Hg) blood pressure persisted in the small (6 percent) subset of

patients who underwent a gastric bypass and lost significantly

more weight than the 94 percent of patients who underwent a

vertical banded gastroplasty or gastric banding.18 Additional

reports from the SOS study support a substantial benefit of

surgery in reducing sleep apnea,20 symptoms of dyspnea and

chest pain,20 and improving quality of life.23 The SOS study is

the only one we identified that compares the effect on

comorbidities between surgically treated patients and a

concurrent control group receiving non-surgical treatment.

Weight loss outcomes were reported in a large number of

RCTs comparing various surgical procedures and case series of

specific surgical procedures. For patients with a BMI between

35-40 kg/m2, the data strongly support the superiority of

surgical therapy, but cannot be considered conclusive yet, in the

absence of a study with a concurrent comparison group. These

studies support the conclusion that gastric bypass produces

superior weight loss compared to gastroplasty procedures. The

weight loss reported in surgical studies is an order of magnitude

greater than weight loss reported in pharmaceutical or diet

studies of obesity (weight losses of 20 to 40 kg at 1 or 2 years

in surgical studies versus 2 to 5 kg in pharmaceutical studies),

although direct comparisons cannot be made across studies.

There is no clear pattern of differential mortality between

the various procedures, and there is no clear pattern in terms of

higher or lower early death rates in randomized trials compared

with case series. In these reports early mortality following

bariatric surgery is less than 1 percent. Existing reports of post-
operative mortality in unselected populations are twice this

value (about 2 percent). Adverse events other than mortality are

reported with great variability between the studies. None of the

comparisons of complications between various surgical

procedures show statistically significant differences. The

absolute rates of some complications are substantial, although

many may be minor in their degree of severity. For example,

the proportion of subjects receiving vertical banded gastroplasty

who have gastrointestinal complications is 15.2 percent in the

RCT/CCT data and 17.8 percent in the case series data, the

proportion of subjects receiving RYGB who experience

nutritional deficiencies is 26.8 percent in the case series data

(many of these nutritional deficiencies were mild); and the

proportion of subjects receiving a banding procedure who

require re-operation is 7.3 percent in the case series data. The

proportion of patients with adverse events or complications

may be on the order of 10 percent to 20 percent, although the

majority of these may be mild and respond to conservative

treatment. The data also support a reduced occurrence of

wound and incisional hernia complications in patients treated

laparoscopically compared to open procedures; data are

insufficient to reach conclusions about differences in other

complications.

As part of our literature search and appraisal process, we

attempted to identify studies that reported data specific to

adolescent and pediatric populations. Too few studies were

identified to permit quantitative analysis. We identified three

controlled trials of medication that reported data specific to

adolescents. One study (in two reports) assessed mazindol,

which was not an included drug for this review.26,27 A second

study assessed the use of a caffeine/ephedrine mixture, which

was also not an included drug for this review.

28 The other trial

studied sibutramine. At six months, subjects treated with the

drug lost a mean of 7.8 kg, which was equal to an 8.5 percent

reduction in initial BMI, whereas placebo-treated patients had a

significantly smaller 3.2 kg weight loss, which was equal to a

5.4 percent reduction in BMI.

There have been a handful of case reports of bariatric surgery

in adolescents, which in total report on 172 subjects. These

reports document both benefits in terms of weight loss and

resolution of complications and harms in terms of

complications. There are no studies comparing these benefits

and harms to similar patients receiving alternative therapies,

such as diet or medication. 

Conclusions

Sibutramine, orlistat, phentermine, diethylpropion

(probably), bupropion, fluoxetine, and topiramate all promote

weight loss when given along with recommendations for diet.

Sibutramine and orlistat are the two most studied drugs. The

amount of extra weight loss attributable to these medications is

modest (less than 5 kg at 1 year), but this amount still may be

clinically significant. No evidence indicates that any particular

drug promotes more weight loss than another drug. All of these

drugs have side effects. The choice of drug may be made on an

individual basis, based on tolerance to the expected side effects. 

Surgical treatment is more effective than nonsurgical

treatment for weight loss and the control of some comorbidities

in patients with a body mass index of 40 kg/m2 or greater.

More data are needed to confirm or refute the relative efficacy

of surgery for less severely obese persons. Perioperative

mortality rates of less than 1 percent have been achieved by

some surgeons and surgical centers. The perioperative mortality

rates in other settings may be higher. Surgical treatment is

associated with a substantial number of complications and

adverse events, although most of these are minor.

The existing literature is almost bereft of data regarding

either pharmaceutical or surgical treatment of adolescent and

pediatric patients. To the extent that existing data on adults are

judged to be inapplicable to adolescents or children, new

studies will need to be performed.

Availability of the Full Report

The full evidence report from which this summary was taken

was prepared for the Agency for Healthcare Research and

Quality (AHRQ) by the Southern California–RAND

Evidence-based Practice Center, under Contract No. 290-02-

0003. It is expected to be available in July 2004. At that time,

printed copies may be obtained free of charge from the AHRQ

Publications Clearinghouse by calling 800-358-9295.

Requesters should ask for Evidence Report/Technology

Assessment No. 103, Pharmacological and Surgical Treatment of

Obesity. In addition, Internet users will be able to access the

report and this summary online through AHRQ’s Web site at

www.ahrq.gov.

Suggested Citation

Shekelle PG, Morton SC, Maglione M, Suttorp M, Tu W, Li

Z, Maggard M, Mojica WA, Shugarman L, Solomon V.

Pharmacological and Surgical Treatment of Obesity. Summary,

Evidence Report/Technology Assessment No. 103. (Prepared by

the Southern California–RAND Evidence-based Practice

Center, under Contract No. 290-02-0003.) AHRQ Publication

No. 04-E028-1. Rockville, MD: Agency for Healthcare

Research and Quality. July 2004.

5
6

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July 2004

ISSN 1530-440X