Approved/cleared anti-obesity medical devices in the USA ranked by approval date.
\r\n\t
",isbn:"978-1-80355-367-2",printIsbn:"978-1-80355-366-5",pdfIsbn:"978-1-80355-368-9",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"d3a491e5194cad4c59b900dd57a11842",bookSignature:" Vladimir V. Kalinin",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11782.jpg",keywords:"Variety of Traits, Historical Remarks, Modern Definitions and Descriptions, Personality Disorders, Comorbid Psychopathology, Depression, Anxiety, Obsessions, Delusion, Treatment of Personality Disorders, Phenomenology of Personality Traits, Delusional Symptoms",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"March 9th 2022",dateEndSecondStepPublish:"May 12th 2022",dateEndThirdStepPublish:"July 11th 2022",dateEndFourthStepPublish:"September 29th 2022",dateEndFifthStepPublish:"November 28th 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"14 days",secondStepPassed:!0,areRegistrationsClosed:!1,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:'A researcher with over 300 publications in psychopathology, psychopharmacology, neuropsychiatry, and epileptology, a member of the Russian Society of Psychiatry, and the Russian Society of Epileptology. Dr. Kalinin\'s biography is included in Marquis "Who’s Who in Medicine and Healthcare" (2006-2007); Who’s Who in Science and Engineering 2008-2009"; "Who’s Who in the World" (2010, 2011), and in the Cambridge International Biographical Centre.',coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"31572",title:null,name:"Vladimir V.",middleName:null,surname:"Kalinin",slug:"vladimir-v.-kalinin",fullName:"Vladimir V. Kalinin",profilePictureURL:"https://mts.intechopen.com/storage/users/31572/images/system/31572.png",biography:"Vladimir V. Kalinin was born in1952 into a family of physicians in Orenburg (Russian Federation). He obtained an MD from Moscow State Medical Stomatological University in 1976. In 1976-1977 he completed an internship in Psychiatry. In 1978 he became a scientific researcher at Moscow Research Institute of Psychiatry of Ministry of Health and Social Development where he is currently the department head. His scientific interests concern a broad range of psychiatry problems. The topic of his doctoral thesis in 1996 was the psychopathology and therapy of anxiety disorders with an emphasis on panic disorder. Prof. Kalinin has authored 228 publications, including research articles in professional journals (in Russian and English), three monographs in Russian, and four monographs in English.",institutionString:"Moscow Research Institute of Psychiatry – The Branch of Serbsky's National Center of Psychiatry and Narcology of Ministry of Health",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"4",totalChapterViews:"0",totalEditedBooks:"4",institution:null}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"21",title:"Psychology",slug:"psychology"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"444312",firstName:"Sara",lastName:"Tikel",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/444312/images/20015_n.jpg",email:"sara.t@intechopen.com",biography:"As an Author Service Manager, my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. Whether that be identifying an exceptional author and proposing an editorship collaboration, or contacting researchers who would like the opportunity to work with IntechOpen, I establish and help manage author and editor acquisition and contact."}},relatedBooks:[{type:"book",id:"510",title:"Anxiety Disorders",subtitle:null,isOpenForSubmission:!1,hash:"183445801a9be3bfbce31fe9752ad3db",slug:"anxiety-disorders",bookSignature:"Vladimir Kalinin",coverURL:"https://cdn.intechopen.com/books/images_new/510.jpg",editedByType:"Edited by",editors:[{id:"31572",title:null,name:"Vladimir V.",surname:"Kalinin",slug:"vladimir-v.-kalinin",fullName:"Vladimir V. Kalinin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3808",title:"Obsessive-Compulsive Disorder",subtitle:"The Old and the New Problems",isOpenForSubmission:!1,hash:"a88e0e721da6859f0d527cdf5041baf9",slug:"obsessive-compulsive-disorder-the-old-and-the-new-problems",bookSignature:"Vladimir Kalinin",coverURL:"https://cdn.intechopen.com/books/images_new/3808.jpg",editedByType:"Edited by",editors:[{id:"31572",title:null,name:"Vladimir V.",surname:"Kalinin",slug:"vladimir-v.-kalinin",fullName:"Vladimir V. Kalinin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"5152",title:"Epileptology",subtitle:"The Modern State of Science",isOpenForSubmission:!1,hash:"3cd008df10046135bfaa4f329e83af7f",slug:"epileptology-the-modern-state-of-science",bookSignature:"Vladimir V. Kalinin",coverURL:"https://cdn.intechopen.com/books/images_new/5152.jpg",editedByType:"Edited by",editors:[{id:"31572",title:null,name:"Vladimir V.",surname:"Kalinin",slug:"vladimir-v.-kalinin",fullName:"Vladimir V. Kalinin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9530",title:"Anxiety Disorders",subtitle:"The New Achievements",isOpenForSubmission:!1,hash:"702af230f376b968ca17900a9007cab9",slug:"anxiety-disorders-the-new-achievements",bookSignature:"Vladimir V. Kalinin, Cicek Hocaoglu and Shafizan Mohamed",coverURL:"https://cdn.intechopen.com/books/images_new/9530.jpg",editedByType:"Edited by",editors:[{id:"31572",title:null,name:"Vladimir V.",surname:"Kalinin",slug:"vladimir-v.-kalinin",fullName:"Vladimir V. Kalinin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6494",title:"Behavior Analysis",subtitle:null,isOpenForSubmission:!1,hash:"72a81a7163705b2765f9eb0b21dec70e",slug:"behavior-analysis",bookSignature:"Huei-Tse Hou and Carolyn S. Ryan",coverURL:"https://cdn.intechopen.com/books/images_new/6494.jpg",editedByType:"Edited by",editors:[{id:"96493",title:"Prof.",name:"Huei Tse",surname:"Hou",slug:"huei-tse-hou",fullName:"Huei Tse Hou"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9052",title:"Psychoanalysis",subtitle:"A New Overview",isOpenForSubmission:!1,hash:"69cc7a085f5417038f532cf11edee22f",slug:"psychoanalysis-a-new-overview",bookSignature:"Floriana Irtelli, Barbara Marchesi and Federico Durbano",coverURL:"https://cdn.intechopen.com/books/images_new/9052.jpg",editedByType:"Edited by",editors:[{id:"174641",title:"Dr.",name:"Floriana",surname:"Irtelli",slug:"floriana-irtelli",fullName:"Floriana Irtelli"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10981",title:"Sport Psychology in Sports, Exercise and Physical Activity",subtitle:null,isOpenForSubmission:!1,hash:"5214c44bdc42978449de0751ca364684",slug:"sport-psychology-in-sports-exercise-and-physical-activity",bookSignature:"Hilde G. Nielsen",coverURL:"https://cdn.intechopen.com/books/images_new/10981.jpg",editedByType:"Edited by",editors:[{id:"158692",title:"Ph.D.",name:"Hilde",surname:"Nielsen",slug:"hilde-nielsen",fullName:"Hilde Nielsen"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10211",title:"The Science of Emotional Intelligence",subtitle:null,isOpenForSubmission:!1,hash:"447fc7884303a10093bc189f4c82dd47",slug:"the-science-of-emotional-intelligence",bookSignature:"Simon George Taukeni",coverURL:"https://cdn.intechopen.com/books/images_new/10211.jpg",editedByType:"Edited by",editors:[{id:"202046",title:"Dr.",name:"Simon George",surname:"Taukeni",slug:"simon-george-taukeni",fullName:"Simon George Taukeni"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7811",title:"Beauty",subtitle:"Cosmetic Science, Cultural Issues and Creative Developments",isOpenForSubmission:!1,hash:"5f6fd59694706550db8dd1082a8e457b",slug:"beauty-cosmetic-science-cultural-issues-and-creative-developments",bookSignature:"Martha Peaslee Levine and Júlia Scherer Santos",coverURL:"https://cdn.intechopen.com/books/images_new/7811.jpg",editedByType:"Edited by",editors:[{id:"186919",title:"Dr.",name:"Martha",surname:"Peaslee Levine",slug:"martha-peaslee-levine",fullName:"Martha Peaslee Levine"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophile",surname:"Theophanides",slug:"theophile-theophanides",fullName:"Theophile Theophanides"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"42958",title:"Soybean and Isoflavones – From Farm to Fork",doi:"10.5772/52609",slug:"soybean-and-isoflavones-from-farm-to-fork",body:'\n\t\tSoybean (
There are many kinds of soybean cultivars with different biological composition and economic values. According to the consensus recommendations of the Organization for Economic Cooperation and Development, soybean nutrients (such as amino acids, fatty acids, isoflavones) and antinutrients (such as phytic acid, raffinose and stachyose) are important markers in assessment the nutritional quality of soybean varieties [9].
\n\t\t\t\tSoybean production has expanded to most of continents and 90% of the world’s soybean production is concentrated in tropical and semi-arid tropical regions which are characterized by high temperatures and low or erratic rainfall. In tropics, most of the crops are near their maximum temperature tolerance [10].
\n\t\t\t\tUSA is the largest soybean producer in the world, following by Brazil and Argentina. World soybean harvest production reached 264.25 million metric tons in 2010/2011. USA, Brazil and Argentina were responsible to about 92.75% of all production [11].
\n\t\t\t\tSoybeans have been appreciated by consumers as a health-promoting food [12]. Soybeans and soy products are wide consumed by Asian populations and are encouraged for western diets because of its nutritional benefits. Soy products are abundant in traditional Asian diets which daily intake is from 7–8 g/day in Hong-Kong and China, up to 20–30 g/day in Korea and Japan. Most of Europeans and North Americans, however, consume less than 1 g/day [13].
\n\t\t\t\tThe soybean consumption will depend on grains characteristics, for example large seed sizes with high sucrose content are desirable for the production of vegetable soybean, which is harvested at immature stage, also called edamame. On the other hand, cultivars with small seed size and low calcium contents are desirable for natto, a traditional fermented soy food in Japan with a firmer texture. For soymilk and tofu production, soybeans with light hilum color, large seed size, high water absorption, high protein and sucrose contents and low oligosaccharides contents are desirable [14].
\n\t\t\tSoybean´s unique chemical composition place this food products as one of the most economical and valuable agricultural commodity. Among cereal and other legume species, it has the highest protein content (around 40%) and the second highest (20%) oil content among all food legumes, after peanuts. Other valuable components found in soybeans include phospholipids, vitamins and minerals. Furthermore, soybeans contain many minor substances known to be biologically active including oligosaccharides, phytosterols, saponins and isoflavones. The actual composition of the whole soybean and its structural parts depends on many factors, including varieties, growing season, geographic location and environmental stress [12,15].
\n\t\t\t\tOn the average, oil and protein together constitute about 60% of dry soybeans. The remaining dry matter is composed of mainly carbohydrates (about 35%) and ash (5%) [15].
\n\t\t\t\t\tSoybeans store their lipids in an organelle known as oil bodies or lipid-containing vesicles. Their lipids are mainly in the form of triglycerides or triacylgycerols, with varying fatty acids as part of their structure. Triglycerides are neutral lipids, each consisting of three fatty acids and one glycerol that bound to three acids. Both saturated and unsatured can occur in the glycerides of soybean oil, however the fatty acids of soybean oil are primarily unsaturated [15,16]. The highest percentage of fatty acid in soybean oil is linoleic acid, following in decreasing order by oleic, palmitic, linolenic and stearic acid. Soybean oil contains some minor fatty acids, including arachidic, behenic, palmitoleic and myristic acid [16].
\n\t\t\t\t\tProtein content varies between 36% and 46% depending on the variety [17-19]. This component is present in the greatest amount in soybeans. Seed proteins are usually classified based on biological function in plants (metabolic proteins and storage proteins) and on solubility patterns. According to their functionality, metabolic proteins (such as enzymatic and structural) are concerned in normal cellular activities, including even the synthesis of storage proteins. Storage proteins, together with reserve of oils, are synthesized during soybean seed development and provide a source of nitrogen and carbon skeletons for the development seedling. In soybeans, most of proteins are storage type. A solubility pattern divides proteins into those soluble in water (albumins) and in salt solution (globulins). Globulins are further divided in legumins and vicilins. Under this classification system, most of soy protein is globulin. Certain soy proteins have their trivial names, as glycinin (legumins) and conglycinin (vicilins). Others, particularly those with enzymatic function, are based on the biological function of proteins themselves. Examples include hemagglutinin, trypsin inhibitors and lipoxygenases. A solubility classification can pose problems because an association with other proteins can change their solubility profile. Thus, a more precise means of identifying proteins has been based on approximate sedimentation coefficient using ultracentrifugation to separate seed proteins. Under appropriate buffer conditions, soy proteins exhibit four fractions after centrifugation. These fractions are designed as 2, 7, 11 and 15S. The major portion of the protein component is formed by storage proteins such as 7S globulin (β-conglycinin) and 11S globulin (glycinin), which represent about 80% of the total protein content [17]. Other proteins or peptides present in lower amounts include enzymes such as lipoxygenase, chalcone synthase and catalase.
\n\t\t\t\t\tOn average, moisture-free soybeans contain about 35% of carbohydrates and defatted dehulled soy grits and flour contain about 17% soluble and 21% insoluble carbohydrates. Therefore, they are the second largest component in soybeans. However, the economical value of soy carbohydrates is considered much less important than soy protein and oil. A limited use of soybeans in human diet is due the flatucence produced by soluble carbohydrates such as raffinose and stachyose. Humans lack the enzymes to hydrolyze the galactosidic linkages of raffinose and stachyose to simpler sugars, so the compounds enter the lower intestinal tract intact, where they are metabolized by bacteria to produce flatus [16]. As a result, relatively fewer efforts have been made to study soy carbohydrates and their potential utilization. The principal use of soybean carbohydrate has been in animal feeds (primarily ruminant because they can digest the compound better than monogastric animals) where it contributes calories to the diet. Food processing can alter the carbohydrates composition making them more digestible to human organism. Although the presence of these oligosaccharides is generally considered undesirable because of their flatus activity, some studies shown some beneficial effects of dietary oligosaccharides in humans, mainly due to a increasing population of indigenous bifidobacteria in colon, such as: suppressing the activity of putrefactive bacteria by antagonist effect; preventing pathogenic and autogenous diarrhea; anti-constipation due to the production of high levels of short-chain fatty acids; producing nutrients such as vitamins. Other positive effects are: toxic metabolites and detrimental enzymes reduction; protecting liver function due to reduction of toxic metabolites; blood pressure reduction; anticancer effects [15,16].
\n\t\t\t\tSoybean also contains a wide range of micronutrients and phytochemicals including minerals, vitamins, phytic acid (1.0–2.2%), sterols (0.23–0.46%) and saponins (0.17–6.16%) [20].
\n\t\t\t\t\tThe primary inorganic compounds of the soybeans are minerals. Potassium is found in the highest concentration, followed by phosphorus, magnesium, sulfur, calcium, chloride and sodium, which vary in concentration to the variety, growing location and season. Minor minerals include silicon, iron, zing, manganese, copper and other [15,16].
\n\t\t\t\t\tBoth water-soluble and oil-soluble vitamins are present in soybeans. Water-soluble vitamins in soybeans include thiamin, riboflavin, niacin, panthotenic acid and folic acid. They are not substantially lost during oil extraction and subsequently toasting of flakes. The oil-soluble vitamins present in soybeans are vitamins A and E. Vitamin E is especially unstable during soybean processing. During solvent extraction of soybeans, vitamin E goes with oil [15,16].
\n\t\t\t\t\tPhytate is the calcium-magnesium-potassium salt of inositol hexaphosphoric acid commonly known as phytic acid. As in the most seeds, phytate is the principal source of phosphorus in soybeans. His content depends on not only variety, but also growing conditions and assay methodology [15,16].
\n\t\t\t\t\tOne important group of minor compounds present in soybean that has received considerable attention is a class of phytoestrogen called the isoflavones. Phytoestrogens are non-steroidal compounds that bind to and activate estrogen receptors (ERs) α and β, due to the fact that they mimic the conformational structure of estradiol. Phytoestrogens are naturally occurring plant compounds found in numerous fruits and vegetables, and are categorized into three classes: the isoflavones, lignans and coumestans [21,22]. Isoflavone compounds have been considered as nonnutrients, because they neither yield any energy nor function as vitamins. However, they play significant roles in the prevention of several diseases, so they may considered health-promoting substances.
\n\t\t\t\t\tIsoflavones belong to a group of compounds that share a basic structure consisting of two benzyl rings joined by a three-carbon bridge, which may or may not be closed in a pyran ring. This group of compounds is known as flavonoids, which include by far the largest and most diverse range of plant phenolics [15,16].
\n\t\t\t\t\tIsoflavones are present in just a few botanical families, because of the limited distribution of the enzyme chalcone isomerase, which converts 2(R)-naringinen, a flavone precursor, into 2-hydroxydaidzein. The soybean is unique in that it contains the highest amount of isoflavones, being up to 3 mg.g-1 dry weight [15,23].
\n\t\t\t\t\tThe isoflavones in soybeans and soy products are of three types, with each type being present in four chemical forms. Therefore there are twelve isomers of isoflavones. Isoflavones in soybean are mainly found as aglycones (daidzein, genistein, glycitein) (Figure 1), β-glucosides (daidzin, genistin, glycitin), malonyl-β-glucosides (6´´-O-malonyldaidzin, 6´´-O-malonylgenistin, 6´´-O-malonylglycitin) and acetyl-β-glucosides (6´´-O-acetyldaidzin, 6´´-O-acetylgenistin, 6´´-O-acetylglycitin) (Figure 2) [24].
\n\t\t\t\t\tChemical structure of soy aglycones.
Chemical structure of β-glucosides soybeans isoflavones.
Aglycones are flavonoid molecules without any attached sugars or other modifiers. Among the different forms of isoflavones, aglycones are especially important because they are readily bioavailable to humans [24]. Flavonoid β-glucosides also may carry additional small molecular modifiers, such as malonyl and acetyl groups. Sugar-linked flavonoids are called glycosides. The term glucoside only applies to flavonoids linked to glucose [25]. The malonyl-β-glucosides are the predominant form in conventional raw soybean [24].
\n\t\t\t\t\tIsoflavones concentration and composition vary greatly with structural parts within soybean seed. The concentration of total isoflavones in soybean hypocotyl is 5.5-6 times higher than that in cotyledons. Glycitein and its three derivatives occur extensively in the hypocotyl. Isoflavones are almost absent in seed coats [15]. The isoflavone content varies among soybean varieties, but most varieties contain approximately 100–400 mg per 100 g dry basis [26].
\n\t\t\t\tIsoflavones have received much attention because of their weak estrogenic property and other beneficial functions [24]. A large number of researchers have reported the positive aspects of isoflavones on human health, such as the ability to reduce the risk of cardiovascular, atherosclerotic and haemolytic diseases; alleviation of osteoporosis, menopausal and blood-cholesterol related symptoms; inhibition of the growth of hormone-related human breast cancer and prostate cancer cell lines in culture; and increased antioxidant effect in human subjects [27-30]. Isoflavones are also known for having anticancer activity and an effect on cell cycle and growth control [31-33].
\n\t\t\t\tIsoflavones in glycosides forms are poorly absorbed in the small intestine, due to their higher molecular weight and hydrophilicity. However bacteria in the intestine wall can biologically activate by action of β-glucosidase to their corresponding bioactive aglycone forms. Once hydrolyzed, aglycone forms are absorbed in the upper small intestine by passive diffusion. Nevertheless, pharmacokinetic studies confirm that healthy adults absorb isoflavones rapidly and efficiently. The average time to ingested aglycones reach peak plasma concentrations is about 4–7 h, which is delayed to 8–11 h for the corresponding β-glycosides. Despite the fast absorption, isoflavones or their metabolites are also rapidly excreted [13].
\n\t\t\tSeveral investigations have been performed during the last years on soybeans consumption and their benefits, however the effects of seed processing and soybean processing into foods on the distribution of soy isoflavones are sparse. Processing significantly affects the retention and distribution of isoflavone isomers in soyfoods. The conversion and loss of isoflavones during processing significantly affect the nutraceutical values of soybean. Post-harvest changes in isoflavones in soybeans are influenced by processing methods however genotype has an effect on isoflavones profiles during seed development [34] and the environment has a greater effect than the genotype [26,35-37]. Distribution of isoflavones in soybean can be altered during various processing steps including fermentation, cooking, frying, roasting, drying and storage [24]. These effects in isoflavones can be even accelerated by heat, acid, alkaline and enzymes [38-40] (Figure 3). The effects of several food processing techniques on soybeans isoflavones will be reviewed and discussed in the following section.
\n\t\t\t\tFlow diagram illustrating the processing of soybeans to commercial soybeans products. Adapted from Toda
Harvesting soybean seeds after their development and maturation is a critical step in profitable soybean production. Although most soybeans are harvested at the dry mature stage, a very small portion is harvested at the immature stage in certain regions. Immature soybeans refer to soybeans harvested at 80% maturity. The immature seed is used as a vegetable or as ingredient recipes. Soybeans are considered dry mature when seed moisture reduces to less than 14% in the field [15,42]. At this stage, seeds are ready for harvesting. The exact harvesting date depends on the variety, growing regions, plating date and local weather conditions [15].
\n\t\t\t\tDrying is an important process to extend the shelf life or to prepare food, including soybean, for subsequent production [43]. After harvest, if moisture content is more than 14%, soybeans need to be dried immediately in order to the following reasons: meet the quality standard of soybean trading; retain maximum quality of the grain; reach a level of moisture that does not allow the growth of bacteria and fungi and; prevent germination of seeds. Drying could be done naturally or artificially. Sun drying, or natural drying, soybeans are spread on the threshing for 2-3 days with frequently turning between top to bottom layers. Once dried, seeds are transferred to storage facilities. Sun drying is not suitable for large quantities of soybeans or under humid and cloudy weather conditions. Artificially drying is carried out with various mechanical driers, including low temperature driers, on-the-floor driers, in-bin driers, medium temperature driers, tray driers, multiduct ventilated driers, countercurrent open-flame grain driers and solar driers. Regardless of which driers are used, caution is required so as to avoid too rapid drying; rapid drying hardens outlayers of seeds and seals moisture within the inner layer. Although the temperature of soybeans must be raised sufficiently to achieve the desired moisture content during drying process, excess heating (not exceed 76%) should be avoided to protect beans from discoloration and beans proteins from denaturation [15].
\n\t\t\t\t\tIt is well known that drying significantly affects the quality and nutrients of dried food products. Drying temperatures affect the activity and stability due to chemical and enzymatic degradation which can for example alter significantly the isomeric distribution of the 3 aglycones [44]. All forms of isoflavones are generally lost due to thermal degradation and oxidation reactions during processing [45]. Conventional thermal treatment decreases malonyl derivatives into β-glucosides via intra-conversion while aglycones have higher heat resistance. Dry heat treatment such as frying, toasting, or baking process increases the formation of acetyl derivatives of isoflavones through decarboxylation from malonyl derivatives [24,41].
\n\t\t\t\t\tA comparison between freeze-drying and drum-drying of germ flour demonstrated that the former contained higher isoflavone aglycones than the latter. However, isoflavone glucoside contents in freeze-dried germ flour were lower than those of drum-dried germ flour. The content of isoflavone glucosides was significantly lower in processed (drum- and freeze-dried) germ flours compared with that of unprocessed germ flour because of conversion of isoflavone glucosides to isoflavone aglycones. Total isoflavone contents of drum-dried and freeze-dried germ flours were comparable but more than that of unprocessed germ flour [46].
\n\t\t\t\t\tDifferent drying methods (hot-air fluidized bed drying, HAFBD; superheated-steam fluidized bed drying, SSFBD; gas-fired infrared combined with hot air vibrating drying, GFIR-HAVD) were compared at various drying temperatures (50, 70, 130 and 150 °C). Higher drying temperatures led to higher drying rates and higher levels of β-glucosides and antioxidant activity, but to lower levels of malonyl-β-glucosides, acetyl-β-glucosides and total isoflavones. Comparing different drying methods to each other, at the same drying temperature GFIR-HAVD resulted in the highest drying rates and the highest levels of β-glucosides, aglycones and total isoflavones, antioxidant activity as well as α-glucosidase inhibitory activity of dried soybean. A drying temperature of 130 °C gave the highest levels of aglycones and α-glucosidase inhibitory activity in all cases [47].
\n\t\t\t\t\tDehydration also helps to achieve longer shelf life and easier transportation and storage, enabling wider distribution of a product. Fermentation of soymilk with microorganisms with β-glucosidase activity promotes the biotransformation of isoflavone glucosides into bioactive aglycones, brings down the contents of aldehydes and alcohols responsible for the beany flavor in soy milk [48] and reduces the content of indigestible oligosaccharides. A spray-drying technology has been also applied to fermented soymilk. Daidzein and genistein retention were of about 87.6% and 85.3%, respectively. Retention was better at the lower inlet air temperatures. Coarser droplets formed at higher feed rates helped in higher retention of isoflavones because it reduced the incidence of direct exposure of isoflavones to higher temperature [49].
\n\t\t\t\tSoybeans are stored at farms, elevators and processing plants in various types of storage structures (steel tanks or concrete silos) before being channeled to next destination, and finally to processing. Loss in quality of soybeans during storage results from the biological activities of seeds themselves, microbiological activities and attacks of insects, mites and rodents. Quality loss is characterized by reduced seed viability and germination rate, coloration, reduced water absorption, compositional changes and ultimately reduced quality of protein and oil. Heat damage is a major cause of quality loss. Characterized by darkening of seed color coat, it results mainly from the improper control of temperature and moisture during storage and transportation. The excess presence of foreign matter can also cause heat buildup. Thus, cleaning soybeans before drying minimizes heat damage. Although minor losses are inevitable, major losses can be prevented by carefully control of storage temperature and humidity. Any biological activity requires a certain level of moisture present. Higher moisture content (or high moisture humidity) not only promotes bacteria and mold infection but also speeds up biological activity of seed themselves. Excessive moisture may also leed to seed germination. Generally, moisture content of 13.5% or below is considered to ensure storage stability of soybeans over reasonably long periods. However, this is true only when temperatures are kept below certain levels [15].
\n\t\t\t\t\tStorage conditions have also an important effect in the composition of soybeans, including isoflavone, anthocyanin, protein, oil and fatty acid.
\n\t\t\t\t\tVariation in isoflavone contents of different soybean cultivars were evaluated under different location and storage duration. Total isoflavone contents of soybeans stored for 1 year were only slightly higher than those of soybeans stored for 2 or 3 years. However, the concentrations of individual isoflavones, especially 6´´-O-malonyldaidzin and 6´´-O-malonylgenistin, decreased markedly in soybeans stored for 2 or 3 years, probably due to high temperatures during storage and oxidative reactions which transformed malonylated type to glycoside and aglycone groups, increasing their amounts with longer storage. They also pointed that the effect of crop year seemed to have a much greater influence on the variation in isoflavone content than did the location because of weather differences from one year to another. Differences among cultivars have been already expected [35]. Similar results were found comparing cropping year and storage for 3 years of soybeans seeds. Malonyldaidzin and malonylgenistin concentrations also decreased and the concentration of glucosides increased slightly over the 3 years [50]. Storage effect in soybeans isoflavones have been exhaustedly studied, and a markedly decreased in isoflavones content is proportional to storage periods, whereas protein, oil, and fatty acid of black soybeans showed a slight decrease over storage at room temperature [51].
\n\t\t\t\t\tA combined effect of storage temperature and water activity was evaluated on the content and profile of isoflavones of soy protein isolates and defatted soy flours. Storage for up to 1 year of soy products, at temperatures from -18 to 42 °C, had no effect on the total content of isoflavones, but the profile changed drastically at 42 °C, with a significant decrease of the percentage of malonyl glucosides with a proportional increase of β-glucosides. A similar effect was observed for soy protein isolates stored at aw = 0.87 for 1 month. For defatted soy flours, however, there was observed a great increase in aglycons (from 10 to 79%), probably due to the action of endogenous β-glucosidases [52].
\n\t\t\t\tProcessing and fermentation of soybean has been reported to influence the forms isoflavones take. Studies have shown that the fermentation process of soybean promotes changes in the phytochemical compounds, causing changes in the isoflavone forms, hydrolysing the proteins and reducing the antinutritional factors, by reducing trypsin inhibitor content [53-55]. Fermentation process of soy leads to manufacturing different soy fermented foods, such as tempeh, soy extract, miso and natto.
\n\t\t\t\t\tDifferences on isoflavones content between non-fermented and fermented soybean products have been extensively describe in literature in the last years. Isoflavone glucosides were the major components in soybean and non-fermented products, while isoflavone aglycones were abundant in sufu and partially in miso of soybean fermented products [56].
\n\t\t\t\t\tTempeh is a traditional fermented soybean food product from Indonesia. It is normally consumed fried, boiled, steamed or roasted. A way to processing soybeans into tempeh occurs by fungus mediated fermentation. Several authors have already studied the effect of fermentation on isoflavones content. It was reported an increase of aglycones amount with fermentation time of tempeh, approximately two-fold higher after 24 h fermentation [57]. Later on, similar results were found by Haron
Sufu, a fermented tofu product, showed ambiguous changes in isoflavone contents during manufacturing. Sufu manufacturing procedure promoted a significant loss of isoflavone content mainly attributed to the preparation of tofu and salting of pehtze. The isoflavone composition was altered during sufu processing. The initial fermentation corresponded to the fastest period of isoflavone conversion. Aglycones levels increased while the corresponding levels of glucosides decreased. The changes in the isoflavone composition were significantly related to the activity of β-glucosidase during sufu fermentation, which was inhibited by the NaCl content [64]. These influence of processing and NaCl supplementation on isoflavone contents was also investigated during douchi manufacturing. Douchi is a popular Chinese fermented soybean food. These results indicated that 61% of the isoflavones in raw soybeans were lost when NaCl content was 10%. Indeed, changes in isoflavone isomer distribution were found to be related to β-glucosidase activity during fermentation, which was affected by NaCl supplementation [65].
\n\t\t\t\t\tOther fermented soybean products are miso and soy sauce. Their production involves the application of pressurized steaming following to fermentation by bacteria for a lengthy period. During the fermentation of miso and soy sauce, β-glucosides are also reported to be hydrolyzed to aglycons by β-glucosidase of bacteria [41].
\n\t\t\t\t\tFermentation shows the same pattern on isoflavones transformation, no matter the fermented soybean product. The fungi-fermented black soybeans (koji) also contained a higher content of aglycone, the bioactive isoflavone, than did the unfermented black soybeans [66]. However, it was later realized that the contents of various isoflavone isomers in black soybean koji may reduce during after 120 days of storage. Although the retention of isoflavone varied with storage temperature, packaging condition enabled black soybean koji to retain the highest residual of isoflavone [67].
\n\t\t\t\tTofu is a popular nonfermented soy food. Processing of tofu involves soaking and heating procedures as well as the addition of protein coagulants such as calcium sulfate to soymilk to coagulate to make tofu. This soybean product has been also target of several studies during its manufacturing. Results of the stability of isoflavone during processing of tofu showed that the concentrations of the three aglycones increased with increasing soaking temperature and time, while a reversed trend was found for the other nine isoflavones. Tofu produced with 0.3% calcium sulfate was found to contain the highest total isoflavones yield (2272.3 µg/g) whereas a higher level (0.7%) of calcium sulfate resulted in a lower yield (1956.6 µg/g) of total isoflavones in tofu. In the same study, authors showed that during processing of soymilk, an increase of concentration for β-glucosides and acetyl genistin, whereas malonyl glucosides exhibited a decreased tendency and the aglycones did not show significant change [68]. Previous reports have already demonstrated that during soaking of soybean malonyl glucosides can be converted to acetyl glucosides, which can be further converted to glycosides or aglycones depending on soaking temperature and time [34,69].
\n\t\t\t\t\tRegarding soymilk isoflavones, a research was done on the transformation of isoflavones and the β-glucosidase activity in soymilk during fermentation. Regardless of employing a lactic acid bacteria or a bifidobacteria as starter organism, fermentation causes a major reduction in the contents of glucoside, malonyl glucoside and acetyl glucoside isoflavones along with a significant increase of aglycone isoflavones content. Indeed, the increase of aglycones and decrease of glucoside isoflavones during fermentation coincided with the increase of β-glucosidase activity observed in fermented soymilk [70].
\n\t\t\t\tDistribution of isoflavones in soybeans and soybeans products are significantly affected by the method, temperatures and duration of heating.
\n\t\t\t\t\tToasted soy flour and isolated soy protein had moderate amounts of each of the isoflavone conjugates. Pananum
Roasting has been used to deactivate anti-nutritional components in soybeans and to give characteristic flavour and brown color to final products [43]. Kinako is a soybean product produced by roasting raw soybeans around 200 °C for 10-20 min, following by grinding. Roasting also promotes changes in isoflavones contents. Soybeans roasted upon at 200 °C without prior soaking in water showed a change in isoflavones profile. It was found that at the first 10 min of roasting caused an increase in 6´´-O-acetyl-β-glucosides while 6´´-O-malonyl-β-glucosides decreased drastically. Continued roasting showed a slightly decreased proportion of the 6´´-O-acetyl-β-glucosides. These authors proposed that most 6´´-O-malonyl-β-glucosides were decarboxylated and changed to 6´´-O-acetyl-β-glucosides when roasted at a high temperature. Besides, β-glucosides and aglycons also increased gradually over time [41]. A similar trend was found roasting soybeans at 200 °C for 7, 14 and 21 min. Malonyl derivatives decreased drastically and acetyl-β-glucosides and β-glucosides increased significantly [24].
\n\t\t\t\t\tSimilar to the roasting process, explosive puffing caused a significant decrease in malonyl derivatives and significant increase in acetyl derivatives and β-glucosides through 686 kPa explosive puffing treatment. Otherwise, aglycones did not increase during the explosive puffing process. This fact was suggested due that temperature of explosive puffing may not be high enough to cleave glycosidic linkage between β-glucopyranose and aglycones [24].
\n\t\t\t\t\tSome soy products are prepared by frying process. Abura-age is one of them being produced by frying tofu in oil. As pointed by Toda
Simonne
An approach on the stability of isoflavones in soy milk stored at temperatures ranging from 15 to 90 °C showed that genistin in soy milk is labile to degradation during storage. Although the loss rate was low at ambient temperatures, authors highlighted the potential loss of genistin when estimating shelf life of soy milk products [73].
\n\t\t\t\t\tInfluence of thermal processing such as boiling, regular steaming and pressure steaming were also investigated in yellow and black soybeans. Again, all thermal processing caused significant increases in aglycones and β-glucosides of isoflavones, but caused significant decreases in malonyl glucosides of isoflavones for both kinds of soybeans. The malonyl glucosides decreased dramatically with an increase in β-glucosides and aglycones after thermal processing [74].
\n\t\t\t\tFood irradiation is a process in which food is exposed to ionizing radiations such as high energy electrons and X-rays produced by machine sources or gamma rays emitted from the radioisotopes 60Co and 137Cs. Depending on the absorbed radiation dose, various effects can be achieved resulting in reduced storage losses, extended shelf life and/or improved microbiological and parasitological safety of foods [75,76]. Food irradiation is one of the most effective means to disinfect dry food ingredients. Disisfestation is aimed at preventing losses caused by insects in stored grains, pulses, flour, cereals, coffee beans, dried fruits, dried nuts, and other food products. The dosage required for insect control is fairly low, of the order of 1 kGy or less [77,78].
\n\t\t\t\t\tSoybeans have been processed by ionizing radiation in order to improve their properties. An important improvement in microbiological properties, such as insect disinfestation and microbial contamination, can be achieved by radiation treatment. Physical properties are also enhanced, such as reduction of soaking and cooking time. Indeed, higher radiation doses may break glycosidic linkages in soybean oligosaccharides to produce more sucrose and decrease the content of flatulence causing oligosaccharides [79].
\n\t\t\t\t\tGamma irradiation at 2.5-10.0 kGy caused the reduction of soaking time in soybeans by 2-5 hours and the reduction of cooking time by 30-60% compared to non-irradiated control samples. The irradiation efficacy on physical quality improvement was also recognized in stored soybeans for one year at room temperature [80,81].
\n\t\t\t\t\tInfluence of radiation processing on isoflavones content has been also studied in the last years. Gamma-radiated (0.5-5.0 kGy) soybeans showed a radiation-induced enhancement of antioxidant contents. Interestingly, a decrease in content of glycosidic conjugates and an increase in aglycons were noted with increasing radiation doses. These results suggested a radiation-induced breakdown of glycosides resulting in release of free isoflavones. Whereas the content of genistein increased with radiation dose, that of daidzein showed an initial increase at a dose of 0.5 kGy and then decreased at higher doses. Degradation of daidzein beyond 0.5 kGy could thus be assumed. Glycitein appears to be the least stable among the three aglycons as its content decreased at all of the doses studied [82]. Gamma irradiation also induced an enhancement in isoflavones content of varying seed coat colored soybean up to a radiation dose of 0.5 kGy. However, the genotypes showed decrease in total isoflavone content at a higher radiation dose of 2.0 and 5.0 kGy [83].
\n\t\t\t\t\tSuch as gamma-irradiation, an enhanced effect on soy germ isoflavones was found after electron beam processing. Interestingly, this study showed that applied radiation doses ranging from 1.0 to 20.0 kGy showed an increase in the amount of both glucosides and aglycones simultaneously [84].
\n\t\t\t\tWe thank CAPES, IPEN and CNPq.
\n\t\tObesity is excess body weight for a given height, defined by a body mass index (BMI) ≥ 30 kg/m2. In some Asian countries (e.g., Japan), the threshold to define obesity is lower (25 kg/m2). Obesity is a major health problem worldwide associated with increased morbidity/mortality and high cost for the society. The prevalence of obesity has doubled in more than 70 countries since 1980. The number of adult subjects with obesity is around 700 million worldwide. Nearly 4 million subjects die each year from the consequences of obesity. The annual cost of obesity is more than $2 trillion [1, 2, 3].
Management of obesity requires multidisciplinary approaches including diet, food supplement, exercise, behavior change, drug, medical device, gut microbiome manipulation, and surgery [1, 4, 5, 6, 7, 8, 9]. The annual obesity treatment market is around $6 billion. In the USA, among subjects with obesity, only 2% receive drug therapy and less than 1% who are eligible for bariatric surgery benefits from it. The reasons for these undertreatment rates are mainly related to adverse effects/complications and cost of drugs and bariatric surgery.
Medical devices available 100 years ago were limited to stethoscope, original medical X-ray imaging device, and electrocardiograph [10]. Over the past several decades, the number of medical devices has increased exponentially. Anti-obesity medical devices are positioned to bridge the gap between more conservative treatments (e.g., lifestyle) and more aggressive interventions (e.g., bariatric surgery). Compared to bariatric surgery, they have the advantage of being less invasive, easier to perform, and reversible. Anti-obesity medical devices are available upon prescription or as over-the-counter products.
Anti-obesity medical devices represent a heterogeneous family of devices in terms of presentation, usage/administration, mechanism of action, effectiveness, safety, regulation, availability, and cost [8, 11, 12, 13, 14]. The devices can be as different as an intragastric balloon, a stomach aspiration system, or particles administered orally in capsule.
Unlike anti-obesity drugs that act chemically through specific receptors, anti-obesity medical devices act rather mechanically. They do not have systemic absorption, specific metabolism, or receptors. Their research and development pattern follow specific models. The terminology used for medical devices differs slightly from that used for drugs (e.g., sham instead of placebo, effectiveness instead of efficacy). With some medical devices, it is not possible to use a sham for ethical and/or technical reasons. Compared to drugs, medical devices have different effectiveness dynamics. Unlike drugs, for some anti-obesity medical devices, there is no compliance issue with the device use since the device is placed in the body for several months and there is no need for repeated administration that might be affected by the subject’s discipline. Because there is no systemic absorption, there are no side effects related to the impact of medical devices on different organs through the bloodstream. The regulatory systems ruling anti-obesity medical devices are based on short product life cycles. The marketing and sales of anti-obesity medical devices are based on different models as compared to drugs.
Anti-obesity medical devices can cause weight loss through different mechanisms by acting at different levels.
Although the primary impact of the anti-obesity medical devices is mechanical, the final effect may be achieved through changes in several factors controlling appetite and food intake, especially the gastrointestinal hormones (e.g., decrease in ghrelin, increase in glucagon-like peptide-1).
An anti-obesity medical device can decrease the food intake by limiting the bite size in the oral cavity.
An anti-obesity medical device can decrease the food intake by reducing the available stomach volume.
Other levels of impact to achieve food intake reduction are possible and have been or will be investigated.
An anti-obesity medical device can decrease the amount of available nutrient by removing part of the gastric contents.
An anti-obesity medical device can decrease the absorbed nutrient by bypassing part of the intestine.
The main challenges in the development of anti-obesity medical devices are due to lack of unique regulatory guidance and disparities in time and cost of approval processes in different countries.
The regulation of anti-obesity medical devices varies by countries or group of countries. There are important differences in the regulatory processes, cost, and time to approval between the USA and Europe [15].
Over-the-counter anti-obesity medical devices may or may not need regulation and approval/clearance depending on the devices and countries.
In the USA, the regulation of medical devices is centralized since 1976 through the FDA. This centralized process allows a better coordination and enforcement of rules. The CDRH is in charge of approval/clearance of anti-obesity medical devices. There are three regulatory classes of medical devices: Class I (low risk), Class II (moderate risk), and Class III (high risk). Based on the expected weight loss, two categories of anti-obesity medical devices have been defined: weight-loss devices (“more” weight loss) and weight-management devices (“less” weight loss). The approval/clearance is through premarket notification process [510(k)] or premarket approval (PMA) process and is based on safety and effectiveness.
A new guidance using benefit-risk approaches is in preparation by the CDRH taking into account the weight loss (extent and duration), the rate of responders (≥ 5% weight loss), the reduction of comorbidities (e.g., hypertension, dyslipidemia, type 2 diabetes), and the safety [rate and severity of adverse events (AEs)].
Since its formation in 1993, the European Union (EU), currently a group of 27 countries (after the recent removal of the United Kingdom), has established rules for the approval of medical devices. Anti-obesity medical devices are regulated under directive 93/42/EC. There are four regulatory classes of medical devices: Class I (low risk), Class IIa (low-moderate risk), Class IIb (moderate-high risk), and Class III (high risk). Each member country has a regulatory entity called Competent Authority (CA). The CA certifies/notifies entities called Notified Bodies (NBs) in each country. The NBs are private, for-profit companies responsible for conformity assessment and CE (Conformité Européenne) mark. There are over 50 NBs in the EU. The NBs contract with the manufacturers to supply the CE mark and the approval is based on safety and performance. Clinical effectiveness is not a requirement. An anti-obesity medical device with a CE mark can be marketed in any EU member country.
In the EU, the approval process is more flexible, faster, and less expensive in comparison to the USA.
Other countries have different regulatory procedures. The approval process has varying degrees of sophistication and challenges. In Japan for example, the application is processed by the Pharmaceutical and Medical Device Agency (PMDA). Although the Japanese market is very attractive for foreign manufacturers, the approval process is complicated, long, and expensive due to multiple factors (e.g., lack of translated documents from Japanese, need to perform specific and costly studies in the Japanese population).
Several countries accept the FDA approval/clearance or the CE mark.
Several anti-obesity medical devices have been approved/cleared in the USA, in the EU, and in other countries. Some devices have been approved first in the EU before being approved several years later in the USA. This section focuses on anti-obesity medical devices regulated in the USA.
Below are the anti-obesity medical devices approved/cleared in the USA (Table 1). Their use should always be in conjunction with lifestyle recommendations on diet and exercise.
Lap-Band® (BioEnterics Corporation) is an adjustable silicone band placed laparoscopically around the proximal stomach immediately below the gastro-esophageal junction and attached to a subcutaneous reservoir (Figure 1). The level of pressure is adjusted by varying the amount of fluid that is inserted into the band. The technique is reversible, has low procedural risk, and can be performed in an outpatient setting. Lap-Band® can be revised and/or replaced as needed. The pressure imposed to the proximal stomach causes early satiety and a decrease in food intake with subsequent weight loss [8].
Lap-Band® (BioEnterics Corporation—Picture downloaded from the internet).
In the pivotal study, 292 subjects (247 females, 45 males, mean BMI = 47.4 kg/m2) were implanted with Lap-Band® and had follow-up evaluations for 36 months. The primary effectiveness endpoint, assessed in the per protocol population at Month 36, was the excess weight loss. Safety analysis also included an additional seven subjects who previously received a similar device. At Month 36, the excess weight loss was 36.2%, relatively stable over the previous 18 months (the weight loss was 18.0%). AEs were observed in 266 subjects (89.0%). Most AEs were of gastrointestinal origin (mainly nausea/vomiting, gastroesophageal reflux, and abdominal pain, mild in the majority of cases). Serious AEs (SAEs) were observed in 16 subjects (5.4%), mainly port leakage and 2 deaths (unrelated to device).
Overall, Lap-Band® is relatively safe and has a strong effectiveness. The device was approved by the FDA in June 2001. It is indicated for weight loss in severe obesity with BMI ≥ 40 kg/m2 or obesity with BMI ≥ 35 kg/m2 in the presence of one or more severe comorbidities, in conjunction with lifestyle recommendations, in subjects who failed to respond to diet, exercise, and behavior change. It is contraindicated in several conditions including pregnancy, non-adult subjects, inflammatory diseases of the gastrointestinal tract, upper gastrointestinal bleeding conditions, portal hypertension, and severe cardiopulmonary diseases (non-exhaustive list). Complications include proximal gastric enlargement, erosion or migration of the band, and leaks of the band system (non-exhaustive list).
Orbera™ Intragastric Balloon System (Apollo Endosurgery, Inc.) is a balloon made of silicone placed endoscopically in the stomach (Figure 2). The balloon is filled with saline mixed with methylene blue (450–700 mL). The methylene blue is a marker for balloon dysfunction. In case of balloon rupture, the methylene blue will be systematically absorbed and change the color of urine to blue. The procedure is minimally invasive and can be performed in an outpatient setting. The balloon is removed endoscopically after 6 months. By occupying gastric volume, Orbera™ Intragastric Balloon System causes early satiety and a decrease in food intake with subsequent weight loss [8, 11, 13, 14].
Orbera™ Intragastric Balloon System (Apollo Endosurgery, Inc.—Picture downloaded from the internet).
In the pivotal study, 255 subjects (229 females, 26 males, mean BMI = 35.3 kg/m2) were randomized into Orbera™ Intragastric Balloon System (n = 125) or control (no intragastric intervention, n = 130) arms for 6 months and 6 months follow-up after Orbera™ Intragastric Balloon System removal. Safety analysis also included an additional 35 run-in, non-randomized subjects who received Orbera™ Intragastric Balloon System. All subjects were given lifestyle recommendations. The co-primary effectiveness endpoints, assessed in the modified intention-to-treat (mITT) population at Month 9, were the excess weight loss in Orbera™ Intragastric Balloon System arm and a significantly greater weight loss in Orbera™ Intragastric Balloon System arm compared to control arm. At Month 9, the excess weight loss was 26.5% in Orbera™ Intragastric Balloon System arm, and the weight losses were 9.1 and 3.4% in Orbera™ Intragastric Balloon System and control arms, respectively. The study did not meet the first co-primary effectiveness endpoint but met the second co-primary effectiveness endpoint. At Month 6, the weight losses were 10.2 and 3.3% in Orbera™ Intragastric Balloon System and control arms, respectively. A total of 810 device-related AEs was observed (mainly nausea/vomiting, gastroesophageal reflux, and abdominal pain, mild or moderate in the majority of cases). Fourteen device- or procedure-related SAEs were observed, mainly device intolerance but no death.
Overall, Orbera™ Intragastric Balloon System is relatively safe and has a strong effectiveness. The device was approved by the FDA in August 2015. It is indicated for weight loss in obesity with BMI between 30 and 40 kg/m2, in conjunction with lifestyle recommendations, in subjects who failed to respond to diet, exercise, and behavior change. It is contraindicated in several conditions including pregnancy, non-adult subjects, prior bariatric surgery, inflammatory diseases of the gastrointestinal tract, upper gastrointestinal bleeding conditions, and liver deficiency (non-exhaustive list). Complications include balloon migration, intestinal obstruction, gastric ulcer, and gastric perforation (non-exhaustive list).
Obalon Balloon System (Obalon Therapeutics, Inc.) is a swallowable balloon made of nylon and polyethylene contained within a gelatin capsule (attached to a thin inflation catheter) that is taken orally. The correct position of the capsule is confirmed with fluoroscopy. The capsule disintegrates in the stomach and releases the balloon. The balloon is filled with air (250 cc of nitrogen and sulfur hexafluoride gas mixture). Up to three balloons can be placed in the same session or sequentially over a 6-month period (Figure 3). The procedure is minimally invasive and can be performed in an outpatient setting without endoscopy. The balloon is removed endoscopically after 6 months. By occupying gastric volume, Obalon Balloon System causes early satiety and a decrease in food intake with subsequent weight loss [8, 13, 14].
Obalon Balloon System (Obalon Therapeutics, Inc.—Picture downloaded from the internet).
In the pivotal study, 387 subjects (341 females, 46 males, mean BMI = 35.2 kg/m2) were randomized into Obalon Balloon System (n = 198) or control (sham capsule, n = 189) arms for 6 months. At Month 6, the eligible control arm subjects were permitted to crossover and receive Obalon Balloon System for 6 months. All subjects were given lifestyle recommendations. The co-primary effectiveness endpoints, assessed in the mITT population at Month 6, were a significantly greater weight loss in Obalon Balloon System arm compared to control arm (super-superiority) and the responder rate at 5% weight loss in Obalon Balloon System arm. Device-related safety analysis also included 138 subjects who switched at Month 6 from control to Obalon Balloon System. At Month 6, the weight losses were 6.6 and 3.4% in Obalon Balloon System and control arms, respectively, and the responder rate at 5% weight loss in Obalon Balloon System arm was 62.1%. The study met both co-primary effectiveness endpoints. Most device-related AEs were of gastrointestinal origin (mainly abdominal pain and nausea/vomiting, mild in the majority of cases), observed in 300 subjects (89.3%). Device- or procedure-related SAEs were observed in one subject (0.3%), a case of peptic ulcer disease.
Overall, Obalon Balloon System is relatively safe and has a modest effectiveness. The device was approved by the FDA in September 2016. It is indicated for weight loss in obesity with BMI between 30 and 40 kg/m2, in conjunction with lifestyle recommendations, in subjects who failed to respond to diet, exercise, and behavior change. It is contraindicated in several conditions including pregnancy, non-adult subjects, prior bariatric surgery, inflammatory diseases of the gastrointestinal tract, gastric diseases, and eating disorders (non-exhaustive list). Complications include balloon migration, intestinal obstruction, gastric ulcer, and gastric perforation (non-exhaustive list).
TransPyloric Shuttle (BAROnova, Inc.) is a device placed endoscopically in the stomach (Figure 4). It is not strictly a balloon but functions like a balloon. It has two asymmetrical bulbs made of silicone connected by a flexible catheter. The procedure is minimally invasive and can be performed in an outpatient setting. The shuttle is removed endoscopically after 12 months. By creating intermittent obstruction to gastric outflow that delays gastric emptying, TransPyloric Shuttle causes early satiety and a decrease in food intake with subsequent weight loss [8, 13].
TransPyloric Shuttle (BAROnova, Inc.—Picture downloaded from the internet).
In the pivotal study, 270 subjects (252 females, 18 males, mean BMI = 36.6 kg/m2) were randomized into TransPyloric Shuttle (n = 181) or control (sham endoscopic procedure, n = 89) arms for 12 months. The TransPyloric Shuttle was successfully placed in 171 subjects. The study also included an additional 32 open-label subjects who received TransPyloric Shuttle. All subjects were given lifestyle recommendations. The co-primary effectiveness endpoints, assessed in the per protocol population at Month 12, were a significantly greater weight loss in TransPyloric Shuttle arm compared to control arm and the responder rate at 5% weight loss in TransPyloric Shuttle arm. At Month 12, the weight losses were 9.5 and 2.8% in TransPyloric Shuttle and control arms, respectively, and the responder rate at 5% weight loss in TransPyloric Shuttle arm was 66.8%. The study met both co-primary effectiveness endpoints. Most device-related AEs were of gastrointestinal origin (mainly nausea/vomiting, abdominal pain, and dyspepsia, mild or moderate in the majority of cases), observed in 200 subjects (98.5%). Device- or procedure-related SAEs were observed in six subjects (3.0%), mainly device impaction but no death.
Overall, TransPyloric Shuttle is relatively safe and has a strong effectiveness. The device was approved by the FDA in April 2019. It is indicated for weight loss in obesity with BMI between 35 and 40 kg/m2 or obesity with BMI between 30 and < 35 kg/m2 in the presence of one or more comorbidities, in conjunction with lifestyle recommendations, in subjects who failed to respond to diet, exercise, and behavior change. It is contraindicated in several conditions including pregnancy, non-adult subjects, prior bariatric surgery, inflammatory diseases of the gastrointestinal tract, gastric diseases, and eating disorders (non-exhaustive list). Complications include device impaction and gastric ulcer (non-exhaustive list).
AspireAssist® (Aspire Bariatrics, Inc.) is a device attached to a percutaneous endoscopic gastrostomy tube implanted endoscopically (Figure 5). It allows the aspiration of gastric contents 20–30 minutes after each major meal (a meal containing more than 200 calories). Thorough chewing of food is required to facilitate aspiration with the 6-mm-diameter tube. The procedure is minimally invasive and can be performed in an outpatient setting. The device is removed when the desired body weight is reached. By allowing the removal of approximately 30% of ingested calories over 5–10 minutes, AspireAssist® causes decreased absorption of gastrointestinal nutrients with subsequent weight loss [8, 11, 12, 13, 14].
AspireAssist® (Aspire Bariatrics, Inc.—Picture downloaded from the internet).
In the pivotal study, 171 subjects (149 females, 22 males, mean BMI = 41.6 kg/m2) were randomized into AspireAssist® (n = 111) or control (no intragastric intervention, n = 60) arms for 12 months. All subjects were given lifestyle recommendations. The co-primary effectiveness endpoints, assessed in the mITT population at Month 12, were a significantly greater excess weight loss in AspireAssist® arm compared to control arm (super-superiority) and the responder rate at 25% excess weight loss in AspireAssist® arm. At Month 12, the excess weight losses were 31.5 and 9.8% in AspireAssist® and control arms, respectively, and the responder rate at 25% excess weight loss in AspireAssist® arm was 56.8%. The study met the first co-primary effectiveness endpoint but not the second co-primary effectiveness endpoint. At Month 12, the weight losses were 12.1 and 3.6% in AspireAssist® and control arms, respectively. Device- or procedure-related AEs were observed in 93 subjects (83.8%, mainly peristomal granulation tissue, abdominal pain, and nausea/vomiting, mild in the majority of cases). Device- or procedure-related SAEs were observed in four subjects (3.6%), including peritonitis but no death.
Overall, AspireAssist® is relatively safe and has a strong effectiveness. The device was approved by the FDA in June 2016. It is indicated for weight loss in obesity with BMI between 35 and 55 kg/m2, in conjunction with lifestyle recommendations, in subjects who failed to respond to non-surgical weight-loss therapy. It is contraindicated in several conditions including pregnancy, non-adult subjects, upper gastrointestinal bleeding conditions, chronic abdominal pain, severe cardiopulmonary diseases, and eating disorders (non-exhaustive list). Complications include skin irritation, infection, and electrolyte abnormalities (non-exhaustive list).
SmartByte Device (Scientific Intake) is an oral device occupying space on the upper palate. It includes a temperature-recording sensor to monitor usage (Figure 6). It is worn in mouth during meal consumption. The device is renewed every 12 months. By creating limited bite size and slower eating, SmartByte Device causes a decrease in food intake with subsequent weight loss [16].
SmartByte Device (Scientific Intake—Picture downloaded from the internet).
In the pivotal study, 173 subjects (BMI between 26 and 36 kg/m2) were randomized into SmartByte Device (n = 102) or control (no oral intervention, n = 71) arms for 4 months. All subjects were given lifestyle recommendations. The primary effectiveness endpoint, assessed in the ITT population at Month 4, was a greater responder rate at 5% weight loss in SmartByte Device arm compared to control arm. At Month 4, the responder rates at 5% weight loss were 20.6 and 5.6% in SmartByte Device and control arms, respectively. The study did not meet the primary effectiveness endpoint. At Month 4, the weight losses were 1.7 and 0.4% in SmartByte Device and control arms, respectively. Device-related AEs were observed in five subjects (4.9%, including two episodes of transient choking on food). No device-related SAEs were observed.
Overall, SmartByte Device is safe and has a weak effectiveness. The device was cleared by the FDA in May 2017. It is indicated to aid in weight management in overweight and obesity with BMI between 27 and 35 kg/m2, in conjunction with lifestyle recommendations. It is contraindicated in pregnancy and eating disorders. Complications include choking on food and mouth soreness (non-exhaustive list).
Plenity™ (Gelesis, Inc.) is a superabsorbent hydrogel (cellulose and citric acid, forming a three-dimensional matrix) administered orally in capsules with 500 mL of water (three capsules, 20–30 minutes before lunch and dinner). The hydrogel particles hydrate up to 100 times their initial weight in the stomach and intestine (Figure 7). The particles mix with ingested food and create a larger volume with higher elasticity and viscosity. The particles degrade in the colon and are eliminated in the feces. By creating a larger volume with higher elasticity in the stomach and intestine, Plenity™ causes early satiety and a decrease in food intake with subsequent weight loss [17].
Plenity™ (Gelesis, Inc.—Picture downloaded from the internet).
In the pivotal study, 436 subjects (245 females, 191 males, mean BMI = 33.8 kg/m2) were randomized into Plenity™ (n = 223) or control (sham capsule, n = 213) arms for 6 months. All subjects were given lifestyle recommendations. The co-primary effectiveness endpoints, assessed in the ITT population (multiple imputation) at Month 6, were a significantly greater weight loss in Plenity™ arm compared to control arm (super-superiority) and the responder rate at 5% weight loss in Plenity™ arm. At Month 6, the weight losses were 6.4 and 4.4% in Plenity™ and control arms, respectively, and the responder rate at 5% weight loss in Plenity™ arm was 58.6%. The study did not meet the first co-primary effectiveness endpoint but met the second co-primary effectiveness endpoint. Most device-related AEs were of gastrointestinal origin (mainly abdominal distension, diarrhea, infrequent bowel movements, and flatulence, mild in the majority of cases), observed in 84 subjects (37.7%). No device-related SAEs were observed.
Overall, Plenity™ is safe and has a modest effectiveness. The device was cleared by the FDA in April 2019. It is indicated to aid in weight management in overweight and obesity with BMI between 25 and 40 kg/m2, in conjunction with lifestyle recommendations. It is contraindicated in pregnancy, non-adult subjects, and history of allergic reaction to the components of Plenity™ capsule. No relevant complications have been reported.
Comparative effectiveness of the above anti-obesity medical devices is reported in Table 2.
Medical device | Approval date | Indication |
---|---|---|
Lap-Band® | June 5, 2001 | Weight-loss device (BMI ≥ 35 kg/m2) |
Orbera™ Intragastric Balloon System | August 5, 2015 | Weight-loss device (BMI 30–40 kg/m2) |
AspireAssist® | June 14, 2016 | Weight-loss device (BMI 35–55 kg/m2) |
Obalon Balloon System | September 8, 2016 | Weight-loss device (BMI 30–40 kg/m2) |
SmartByte Device | May 18, 2017 | Weight-management device (BMI 27–35 kg/m2) |
Plenity™ | April 12, 2019 | Weight-management device (BMI 25–40 kg/m2) |
TransPyloric Shuttle | April 16, 2019 | Weight-loss device (BMI 30–40 kg/m2) |
Approved/cleared anti-obesity medical devices in the USA ranked by approval date.
Medical device | Treatment duration | Total body weight loss |
---|---|---|
Lap-Band® | 36 months | 18.0% |
AspireAssist® | 12 months | 12.1% |
Orbera™ Intragastric Balloon System | 6 months | 10.2% |
TransPyloric Shuttle | 12 months | 9.5% |
Obalon Balloon System | 6 months | 6.6% |
Plenity™ | 6 months | 6.4% |
SmartByte Device | 4 months | 1.7% |
Approved/cleared anti-obesity medical devices in the USA ranked by extent of total body weight loss in pivotal studies.
Relevant complications (non-exhaustive list), some being very rare, of the above anti-obesity medical devices are reported in Table 3.
Medical device | Treatment duration | Relevant complication |
---|---|---|
Lap-Band® | 36 months | Proximal gastric enlargement, band erosion or migration, system leaks |
AspireAssist® | 12 months | Skin irritation, infection, electrolyte abnormalities |
Orbera™ Intragastric Balloon System | 6 months | Balloon migration, intestinal obstruction, gastric ulcer, gastric perforation |
TransPyloric Shuttle | 12 months | Device impaction, gastric ulcer |
Obalon Balloon System | 6 months | Balloon migration, intestinal obstruction, gastric ulcer, gastric perforation |
Plenity™ | 6 months | None |
SmartByte Device | 4 months | Choking on food, mouth soreness |
Relevant complications of the approved/cleared anti-obesity medical devices in the USA in pivotal studies.
Cost of the above anti-obesity medical devices is reported in Table 4.
Medical device | Average cost (Range) |
---|---|
Lap-Band® | $15,000 ($10,000–$30,000) |
AspireAssist® | $10,000 ($7,000–$13,000) |
Orbera™ Intragastric Balloon System | $6,000 ($3,000–$9,000) |
TransPyloric Shuttle | To be determined |
Obalon Balloon System | $8,000 ($6,000–$9,000) |
Plenity™ | $100/month |
SmartByte Device | $500 |
Cost of the approved/cleared anti-obesity medical devices in the USA.
Several anti-obesity medical devices have been withdrawn by the manufacturers from the market in the USA after approval by the FDA (e.g., Maestro Rechargeable System, Realize Adjustable Gastric Band, ReShape Integrated Dual Balloon System, Garren Gastric Bubble).
Several anti-obesity medical devices are currently in development in different countries (e.g., Epitomee Device [18]).
EndoBarrier® has obtained a CE mark in the EU but its approval in the USA has been challenged for safety reasons [8, 11, 12, 13, 14].
A variety of anti-obesity medical devices are available as over-the-counter products (e.g., NozNoz, slow control fork, slipper genie).
Anti-obesity medical devices represent a heterogenous family of devices in terms of presentation, usage/administration, mechanism of action, effectiveness, safety, regulation, availability, and cost. They offer an attractive approach in managing obesity. Anti-obesity medical devices are positioned to bridge the gap between more conservative treatments (e.g., lifestyle) and more aggressive interventions (e.g., bariatric surgery). Their use should always be combined with lifestyle changes.
Considering the large market size of obesity treatment and the small percentage of subjects treated with drugs or bariatric surgery, anti-obesity medical devices can play a major role in the management of obesity.
The author received honorarium for consultancy from Gelesis, Inc.
If your research is financed through any of the below-mentioned funders, please consult their Open Access policies or grant ‘terms and conditions’ to explore ways to cover your publication costs (also accessible by clicking on the link in their title).
\n\nIMPORTANT: You must be a member or grantee of the listed funders in order to apply for their Open Access publication funds. Do not attempt to contact the funders if this is not the case.
",metaTitle:"List of Funders by Country",metaDescription:"If your research is financed through any of the below-mentioned funders, please consult their Open Access policies or grant ‘terms and conditions’ to explore ways to cover your publication costs (also accessible by clicking on the link in their title).",metaKeywords:null,canonicalURL:"/page/open-access-funding-funders-list",contentRaw:'[{"type":"htmlEditorComponent","content":"Book Chapters and Monographs
\\n\\nMonographs Only
\\n\\nBook Chapters and Monographs
\\n\\n\\n\\nBook Chapters and Monographs
\\n\\nBook Chapters and Monographs
\\n\\nBook Chapters and Monographs
\\n\\nBook Chapters and Monographs
\\n\\nBook Chapters and Monographs
\\n\\nBook Chapters and Monographs
\\n\\nBook Chapters and Monographs
\\n\\nMonographs Only
\\n\\nLITHUANIA
\\n\\nBook Chapters and Monographs
\\n\\n\\n\\nBook Chapters and Monographs
\\n\\n\\n\\nBook Chapters and Monographs
\\n\\n\\n\\nSWITZERLAND
\\n\\nBook Chapters and Monographs
\\n\\nBook Chapters and Monographs
\\n\\n\\n\\nBook Chapters and Monographs
\\n\\nBook Chapters and Monographs
\n\nMonographs Only
\n\nBook Chapters and Monographs
\n\n\n\nBook Chapters and Monographs
\n\n\n\nBook Chapters and Monographs
\n\nBook Chapters and Monographs
\n\nBook Chapters and Monographs
\n\nBook Chapters and Monographs
\n\n\n\nBook Chapters and Monographs
\n\nBook Chapters and Monographs
\n\n\n\nMonographs Only
\n\n\n\nLITHUANIA
\n\nBook Chapters and Monographs
\n\n\n\nBook Chapters and Monographs
\n\n\n\nBook Chapters and Monographs
\n\n\n\nSWITZERLAND
\n\nBook Chapters and Monographs
\n\n\n\nBook Chapters and Monographs
\n\n\n\nBook Chapters and Monographs
\n\n