NEW YORK (Reuters Health) May 01 - Laparoscopic adjustable gastric banding appears to be more effective in reducing weight and improving health and quality of life than behavioral modification plus pharmacotherapy among patients with mild to moderate obesity, Australian investigators report in the May 2nd issue of the Annals of Internal Medicine.

Low-calorie diets and increased physical activity combined with medication tend to have modest and transient effects on weight reduction, lead author Dr. Paul E. O'Brien and his associates note. And while observational studies have demonstrated the efficacy of bariatric surgery for obesity, there are few randomized controlled trials comparing the two strategies, and none that include patients with no more than moderate obesity.

Dr. O'Brien, of the Alfred Hospital, Melbourne, and colleagues in Australia recognize that current guidelines regarding bariatric surgery do not include patients without severe obesity. However, they note that "revision of those guidelines can only occur once data from this group are published."

They therefore recruited 80 patients with BMIs of 30 to 35 kg/m, who had comorbid conditions, severe physical limitations, or psychosocial problems related to their obesity, and who had made prior attempts to reduce weight. The metabolic syndrome was present in 37.5% of patients in each group at baseline.

Forty patients were randomized to the nonsurgical group, which included a very-low-calorie diet, advice for exercise, and treatment with orlistat over a 6-month period. Physicians saw each patient every 2 weeks during the first 6 months, then every 4 to 6 weeks, during which they continued to advise lifestyle changes.

The other 40 subjects underwent gastric banding, with the band placed along the perigastric pathway. These patients were also seen every 4 to 6 weeks. Thirty-nine patients in the surgery group and 33 in the nonsurgical group completed the 2-year study.

After 6 months, Dr. O'Brien's group reports that both groups had lost the same amount of weight (13.8%).

After 2 years, patients who underwent gastric banding had a mean loss of 21.6% of their initial weight and 87.2% of their excess weight. Metabolic syndrome remained in only one patient.

However, the nonsurgical group showed progressive weight gain after 6 months. By the end of 2 years, they maintained an average loss of 5.5% of their initial weight and 21.8% of their excess weight. Metabolic syndrome was still diagnosed in eight patients (24%).

At 2-year follow-up, those who underwent gastric banding also had significant improvements in all eight domain scores of the SF-36 questionnaire, while the behavioral therapy group had improvements in three domain scores.

The authors of an accompanying editorial have some reservations about Dr. O'Brien's study. Drs. Thomas A. Wadden and Adam Gilden Tsai, from the University of Pennsylvania in Philadelphia, point out that the researchers neglected to provide a structured weight loss maintenance program, including patient contact every 2 weeks, after the first 6 months, to the diet and exercise group.

They also consider it inappropriate to base treatment on "significant psychosocial problems associated with obesity." The physicians wonder if the patients realized that current guidelines do not recommend surgery for persons in this weight range.

Their recommendations include trials that track long-term outcomes and costs to determine which patients with mild to moderate obesity would benefit most from surgery.

Finally, they state, "We need to expend far more resources on preventing these individuals, particularly children, from becoming obese."