gain, but decrease central obesity. Diabetics also achieve modest weight loss with fluoxetine and orlistat over 12–57 weeks. Rimonabant (Acomplia), another drug, had been withdrawn from the market. It worked via a specific blockade of the endocannabinoid system. It has been developed from the knowledge that cannabis smokers often experience hunger, which is often referred to as "the munchies". It had been approved in Europe for the treatment of obesity but has not received approval in the United States or Canada due to safety concerns. European Medicines Agency in October 2008 recommended the suspension of the sale of rimonabant as the risk seem to be greater than the benefits. Sibutramine (Meridia), which acts in the brain to inhibit deactivation of the neurotransmitters, thereby decreasing appetite was withdrawn from the UK market in January 2010 and United States and Canadian markets in October 2010 due to cardiovascular concerns. In 2010 it was found that sibutramine increases the risk of heart attacks and strokes in people with a history of cardiovascular disease. Fenfluramine and dexfenfluramine were withdrawn from the market in 1997, while ephedrine (found in the traditional Chinese herbal medicine má huáng made from the Ephedra sinica) was removed from the market in 2004. Lorcaserin used to be approved by the Food and Drug Administration for use in the treatment of obesity before being withdrawn due to cancer risk. Recombinant human leptin is very effective in those with obesity due to congenital complete leptin deficiency via decreasing energy intake and possibly increases energy expenditure. This condition is, however, rare and this treatment is not effective for inducing weight loss in the majority of people with obesity. It is being investigated to determine whether or not it helps with weight loss maintenance. Though hypothesized that supplementation of vitamin D may be an effective treatment for obesity, studies do not support this. There is also no strong evidence to recommend herbal medicines for weight loss. Surgery Bariatric surgery ("weight loss surgery") is the use of surgical intervention in the treatment of obesity. As every operation may have complications, surgery is only recommended for severely obese people (BMI > 40) who have failed to lose weight following dietary modification and pharmacological treatment. Weight loss surgery relies on various principles: the two most common approaches are reducing the volume of the stomach (e.g. by adjustable gastric banding and vertical banded gastroplasty), which produces an earlier