Changes in fat-free mass during significant weight loss: a systematic review

Unveiling the impact of competition weight loss on gut microbiota: alterations in diversity, composition, and predicted metabolic functions

BACKGROUND

Competitive sports and sports nutrition, popular among amateur athletes aiming for a lean physique, have limited research on gut microbiota.

METHODS

We conducted a 46-week study to analyze the consequences of fat loss and diet restrictions in 23 fitness athletes who prepared for a physique competition. Body composition, dietary intakes, serum cytokines and chemokines, and fecal samples were analyzed.

RESULTS

Fat loss through caloric restriction and aerobic exercise led to an increased phylogenetic diversity of gut microbiota and changes in the composition of gut microbiota, with Faecalibacterium, Lachnospiraceae, Bacteroides, and Intestinimonas showing altered abundances. Fat loss also changed the predicted microbial functions responsible for the metabolism of carbohydrates and amino acids. Consumption of energy, carbohydrates, fiber, vitamins and minerals, and various fatty acids decreased during the preparation for the competition, which was partly associated with changes in gut microbiota. Several cytokine levels decreased (IL1a, IL1b, IL10, and TFNα), and certain chemokine levels increased (GROa and RANTES). During the 23-week regain period after the competition, gut microbiota showed signs of recovery, with increased diversity compared to pre- and post-competition measurements. Most taxonomic changes returned to their baseline levels after the regain period.

CONCLUSIONS

The study highlights the dynamic nature of gut microbiota and its response to fat loss and regain in non-obese fitness/physique competitors and provides novel insights into how competitive sports and sports nutrition can influence the gut ecosystem.

The Critical Role of Lifestyle With the Use of Contemporary Obesity Management Medications

The emergence of the latest generation of obesity management medications (OMMs) or commonly referred to as "GLP-1s," are proving to be highly efficacious for the reduction of excess body weight. A comprehensive obesity care strategy in which patients are prescribed both lifestyle and medication therapy to promote holistic health and well-being are recommended. Lifestyle modification, through changes in eating and exercise behaviors, has long been a cornerstone of obesity treatment; however, there is a lack of evidence to fully demonstrate the role that lifestyle plays with the latest generation of OMMs compared to previous obesity pharmacotherapies. While obesity continues to be a significant public health problem, medical treatments for obesity have entered a new era with a promising outlook. However, there are key aspects that warrant further consideration to treat patients with obesity in a comprehensive manner that includes medical management, lifestyle, and behavioral health. Highlighted throughout are evidence-based aspects of obesity care, areas where there are gaps in evidence and critical questions remain, and opportunities for enhancing comprehensive obesity treatment.

Metabolic dysfunction-associated steatotic liver disease (MASLD) in children with obesity: An Obesity Medicine Association (OMA) and expert joint perspective 2025

Introduction

This Obesity Medicine Association (OMA) Expert Joint Perspective examines steatotic liver disease (SLD), which is composed of metabolic dysfunction-associated steatotic liver disease (MASLD), and metabolic dysfunction-associated steatohepatitis (MASH) in children with obesity. The prevalence of obesity is increasing, rates have tripled since 1963 from 5 % to now 19 % of US children affected in 2018. MASLD, is the most common liver disease seen in children, can be a precursor to the development of Type 2 Diabetes (T2DM) and is the primary reason for liver transplant listing in young adults. We must be vigilant in prevention and treatment of MASLD in childhood to prevent further progression.

Methods

This joint clinical perspective is based upon scientific evidence, peer and clinical expertise. The medical literature was reviewed via PubMed search and appropriate articles were included in this review. This work was formulated from the collaboration of eight hepatologists/gastroenterologists with MASLD expertise and two physicians from the OMA.

Results

The authors who are experts in the field, determined sentinel questions often asked by clinicians regarding MASLD in children with obesity. They created a consensus and clinical guideline for clinicians on the screening, diagnosis, and treatment of MASLD associated with obesity in children.

Conclusions

Obesity and the comorbidity of MASLD is increasing in children, and this is a medical problem that needs to be addressed urgently. It is well known that children with metabolic associated chronic disease often continue to have these chronic diseases as adults, which leads to reduced life expectancy, quality of life, and increasing healthcare needs and financial burden. The authors of this paper recommend healthy weight reduction not only through lifestyle modification but through obesity pharmacotherapy and bariatric surgery. Therefore, this guidance reviews available therapies to achieve healthy weight reduction and reverse MASLD to prevent progressive liver fibrosis, and metabolic disease.

Exercise and dietary recommendations to preserve musculoskeletal health during weight loss in adults with obesity: A practical guide

Obesity adversely impacts musculoskeletal health, contributing to functional limitations and an increased risk for falls, fractures and disability. Weight loss can mitigate these effects, but strategies that neglect to incorporate evidence-based dietary and/or exercise approaches can exacerbate musculoskeletal and functional declines. Sustainable weight loss requires a personalised approach that prioritises adequate protein intake and essential nutrients to preserve musculoskeletal health. To enhance adherence and long-term success, dietary strategies should be practical, nutritionally balanced and cost-effective. Similarly, exercise programmes should be individually tailored and progressive, with resistance training central to any program prescribed in the context of weight loss, due to its critical role in maintaining muscle and bone mass and strength. When prescribing weight loss strategies involving lifestyle behaviour changes, clinicians must consider their patient's readiness to change. We have used the transtheoretical model of change framework as an example to identify a patient's level of readiness and provided associated motivational interviewing-based strategies to enhance adherence and engagement. This review outlines evidence-based, practical diet and exercise recommendations and behavioural strategies that can facilitate effective and sustainable weight loss, which is particularly important for at-risk populations such as older adults.

The Asia-Oceania consensus: Definitions and diagnostic criteria for sarcopenic obesity

OBJECTIVE

The aim of this study was to develop consensus definitions and diagnostic criteria for sarcopenic obesity tailored to Asia-Oceania populations, a condition characterized by reduced skeletal muscle mass and function with excess adipose tissue.

METHODS

Experts from various fields formed a working group under the Asia-Oceania Association for the Study of Obesity (AOASO) and the International Association of Gerontology and Geriatrics Asia/Oceania Region (IAGG-AOR). The group convened four meetings, employing the Delphi technique to achieve consensus on diagnostic criteria and management strategies for sarcopenic obesity.

RESULTS

The consensus defines sarcopenic obesity with a 3-step algorithm, including screening, diagnosis, and intervention. The screening criteria included BMI and waist circumference for obesity and calf circumference, the SARC-F, and the Finger Ring test for sarcopenia. The diagnostic criteria for sarcopenia include assessments of muscle mass (using dual-energy X-ray absorptiometry or bioelectrical impedance analysis), muscle strength (handgrip strength), and physical performance (gait speed, Short Physical Performance Battery, or the 5-Times Sit-to-Stand Test). Central obesity is the main concern for the diagnosis of obesity. The working group recommends a combination of dietary consultations, increased physical activity, resistance training, and the potential use of oral nutritional supplements and medications for managing sarcopenic obesity. The primary objective is to increase skeletal muscle mass and reduce adipose tissue mass.

CONCLUSIONS

The established criteria facilitate early recognition and management of sarcopenic obesity, highlighting the need for tailored interventions. Future research should focus on the long-term outcomes of these interventions and the development of pharmacological treatments.

Fasting appetite-related gut hormone responses after weight loss induced by calorie restriction, exercise, or both in people with overweight or obesity: a meta-analysis

OBJECTIVES

Altered appetite-related gut hormone concentrations may reflect a physiological adaptation facilitating weight regain after weight loss. This review investigates hormonal changes after weight loss achieved through calorie restriction (CR), exercise (EX), or both combined (CREX).

METHODS

A systematic search of PubMed (MEDLINE), EMBASE, SPORTDiscus, Cochrane Library, Web of Science, and ClinicalTrials.gov was conducted to identify randomised controlled trials (RCTs) and non-RCTs reporting in a fasting state either pre- and post-intervention appetite-related hormone concentrations or the changes therein after weight loss. The hormones examined were ghrelin, peptide tyrosine tyrosine (PYY), glucagon-like peptide -1 (GLP-1), and cholecystokinin (CCK), in their total and/or active form. Standardised mean differences (SMD) were extracted as the effect size.

RESULTS

127 studies were identified: 19 RCTs, 108 non-RCTs, 1305 and 4725 participants, respectively. In response to weight loss induced by CR, EX or CREX, the meta-analysis revealed an increase in total ghrelin from both RCTs (SMD: 0.55, 95% CI: 0.07-1.04) and non-RCTs (SMD: 0.24, 95% CI: 0.14-0.35). A decrease in acylated ghrelin was identified for RCTs (SMD: -0.58, 95% CI: -1.09 to -0.06) but an increase was observed for non-RCTs (SMD: 0.15, 95% CI: 0.03 to 0.27). Findings also revealed a decrease in PYY (total PYY: SMD: -0.17, 95%CI: -0.28 to -0.06; PYY3-36: SMD: -0.17, 95%CI: -0.32 to -0.02) and active GLP-1 (SMD: -0.16, 95% CI: -0.28 to -0.05) from non-RCTs. Changes in hormones did not differ among the three interventions when controlling for weight loss. Meta-regression indicated that greater weight loss was associated with a greater increase in total ghrelin.

CONCLUSIONS

Weight loss induced by CR, EX, or CREX elicits an increase in total ghrelin, but varied responses in other appetite-related hormones. The extent of weight loss influences changes in appetite-related gut hormone concentrations.

Body composition changes during weight reduction with tirzepatide in the SURMOUNT-1 study of adults with obesity or overweight

AIMS

We assessed changes in body composition following tirzepatide treatment in a substudy of participants with obesity or overweight from the SURMOUNT-1 trial, overall and post hoc in clinically relevant subgroups.

MATERIALS AND METHODS

Substudy participants (n = 160 of the 2539 in SURMOUNT-1) underwent dual-energy X-ray absorptiometry (DXA) at baseline and Week 72. Body composition parameters were evaluated by analysis of covariance, logistic regression or Fisher's exact test. Post hoc subgroup analyses were conducted by sex (female or male), age (<50, 50 to <65, or ≥65 years) and total body weight reduction tertiles (≤15.3 kg, >15.3 to ≤25.9 kg, or >25.9 kg).

RESULTS

The 160 participants (pooled tirzepatide doses n = 124, placebo n = 36) with baseline and end of study DXA data were 73% female and had a mean weight of 102.5 kg and body mass index of 38.0 kg/m2. The change in body weight, fat mass and lean mass from baseline to Week 72 was -21.3%, -33.9% and -10.9% with tirzepatide and -5.3%, -8.2% and -2.6% with placebo, respectively (p < 0.001 for all comparisons). Of the body weight lost, approximately 75% was fat mass and 25% was lean mass for both tirzepatide and placebo. These proportions remained consistent across most subgroup analyses.

CONCLUSIONS

In participants with obesity or overweight from the SURMOUNT-1 trial, tirzepatide treatment significantly reduced body weight, fat mass and lean mass compared with placebo, while in post hoc analyses, the proportion of body weight lost as fat or lean mass was relatively consistent including in clinically relevant subgroups.

The effects of protein supplementation on body composition after bariatric surgery: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

We aimed to explore the effect of protein supplementation on anthropometric measures and body composition in patients after metabolic bariatric surgery (MBS).

METHODS

We performed a systematic search up to January 2024 including randomized controlled trials investigating the effects of protein or amino acid supplementation on the body composition of patients who underwent MBS. The overall effect was presented as the weighted mean difference (WMD) at a 95% CI.

RESULTS

Ten trials were included in this meta-analysis. Our results indicate that there was a statistically greater change in weight (WMD, -1.31 kg, 95% CI: -1.93 to -0.69, p < 0.001; Grading of Recommendations Assessment, Development, and Evaluation [GRADE] = moderate), muscle mass (WMD, 1.33 kg, 95% CI: 0.1 to 2.57, p = 0.035; GRADE = low), fat-free mass (WMD, 1.74 kg, 95% CI: 0.46 to 3.01, p = 0.01; GRADE = low), and fat mass (WMD, -3.91 kg, 95% CI: -4.10 to -0.59, p = 0.01; GRADE = low) in the protein group compared to the control group. However, protein supplementation did not significantly change BMI and lean body mass.

CONCLUSIONS

Based on moderate- to low-certainty evidence, our findings suggest that although protein supplementation may improve weight and some body composition metrics, it does not influence overall BMI and lean body mass. More research is needed to recommend protein supplementation after MBS.

Body Composition Changes and Predictor of Weight Loss in Short Term after Sleeve Gastrectomy

BACKGROUND

Metabolic bariatric surgery is the most effective treatment for achieving sustainable weight loss in patients with severe obesity. However, changes in body composition, particularly limb composition, after sleeve gastrectomy (SG) in the Asian population have not been widely reported. Additionally, few studies have focused on predicting short-term weight loss following SG.

METHODS

We evaluated 159 patients with obesity who underwent SG between May 2020 and June 2023 at our hospital. Each patient's demographic, anthropometric, laboratory, and body composition data were collected at baseline and at 1, 3, 6, and 12 months post-surgery. Logistic regression analysis was used to identify independent predictors of weight loss.

RESULTS

The mean age of the 159 patients was 30.4 ± 7.7 years, with 78.0% being female. Compared to baseline values, anthropometric parameters and metabolic profiles improved significantly after surgery. All body composition indices decreased, with fat mass (FM, in kg and percentage), visceral fat area (VFA), and obesity degree continuing to decline up to 1 year postoperatively. The percentage of excess weight loss (EWL%) reached 55.7 ± 17.6% at 3 months, meeting the standard for effective weight loss. Eleven factors were negatively correlated with EWL%, and obesity degree was identified as an independent predictor of weight loss (OR: 0.951, P = 0.001). The area under the receiver operating characteristic curve for obesity degree was 0.781 (95% CI: 0.668-0.894, P < 0.001), with sensitivity and specificity values of 0.643 and 0.857, respectively, and a cutoff value of 193.5%.

CONCLUSIONS

Sleeve gastrectomy significantly improved anthropometric and metabolic variables, achieving effective short-term weight loss. Body composition changes were observed across the whole body, limbs, and trunk. Obesity degree was closely associated with effective weight loss after surgery and may serve as a potentially useful metric for clinical practice.

The Critical Role of Body Composition Assessment in Advancing Research and Clinical Health Risk Assessment across the Lifespan

Obesity and low muscle mass are major public health concerns, especially in older adults, due to their strong links to cardiovascular disease, cancer, and mortality. Beyond body mass index, body composition metrics including skeletal muscle, fat mass, and visceral adipose tissue offer deeper insights into nutrition and disease risk. These measures are essential for both cross-sectional assessments and longitudinal tracking, providing a clearer picture of health changes over time. Selecting body composition assessment tools requires balancing cost, practicality, accuracy, and data quality. The right tools enhance research, refine clinical assessments, and inform targeted interventions. Aligning methods with specific research or clinical goals improves disease risk stratification and advances personalized treatments. This review highlights the importance of integrating body composition assessment into research and clinical practice, addressing knowledge gaps across diverse populations and emphasizing its potential in advancing precision medicine. It also highlights recent advancements in body composition assessment techniques that warrant consideration when evaluating techniques for a specific application. Future efforts should focus on refining these tools, expanding their accessibility, and developing comprehensive risk models that incorporate body composition alongside behavioral, environmental, and genetic factors to improve disease prediction and prevention strategies.

Sarcopenic obesity and weight loss-induced muscle mass loss

PURPOSE OF REVIEW

Sarcopenic obesity is a clinical condition characterized by the coexistence of excess adiposity and impaired muscle function, associated with heightened cardiometabolic risk and frailty. The emergence of new incretin-based obesity management medications (OMMs), which allow unprecedented weight loss, has raised concerns regarding weight loss-induced fat-free mass (FFM) reduction, including skeletal muscle mass (SMM). This review examines recent findings on the prevalence, diagnosis, and implications of sarcopenic obesity, explores the effects of weight-loss interventions on body composition and their impact on health, and discusses strategies to preserve muscle mass.

RECENT FINDINGS

Weight loss induced by incretin-based OMMs results in a variable but significant reduction in FFM. The extent to which this loss affects SMM and function remains uncertain. Nutritional strategies, particularly adequate protein intake, and structured exercise interventions, especially resistance training, play a key role in mitigating FFM loss. Digital health interventions and telemedicine-based exercise programs offer promising approaches for maintaining muscle health during weight loss.

SUMMARY

The clinical significance of FFM loss during weight reduction remains debated. Future research should refine sarcopenic obesity diagnostic criteria, assess the long-term impact of FFM/SMM reduction during intentional weight loss, and evaluate interventions that optimize body composition while preserving functional health.

The effect of Ramadan fasting on anthropometric and body composition of healthy adults within different time points: A systematic review and meta-analysis

To date, the effect of Ramadan fasting (RF) on anthropometric and body compositions remains inconsistent. This review aimed to investigate the impact of RF on anthropometric and body composition of healthy adults within different time points during and after RF. Qualified studies from MEDLINE, Web of Science, Embase, CINAHL Complete, ProQuest, and Scopus were included. We involved prospective observational studies with pre- and post-test design. The anthropometric and body composition parameters consist of weight, BMI, waist circumference (WC), hip circumference (HC), waist-to-hip ratio (WHR), absolute fat mass (FM), fat percentage (FP), fat-free mass (FFM), and total body water (TBW). Fifty-four studies involving 2857 subjects were identified and conducted in 21 countries between 1987 and 2024. RF exerts a significant reduction in weight and BMI, starting within the second and third week of RF, peaking in the first week after RF, and gradually returning to the pre-Ramadan value in the weeks afterward. Meanwhile, WC, HC, and WHR were significantly alleviated within the last week of RF and the first week post-RF for HC. In body composition, RF elicits a significant but small reduction of absolute FM and FP within the third and fourth week of RF, while FFM and TBW were not affected. During Ramadan, anthropometric and body composition changes are transient and elicit only a short-term effect. Such leverages need to be maintained to achieve a long-term benefit of RF on the anthropometric and body composition of healthy adults.

Effects of Long-Chain n-3 Fatty Acids Supplementation During Caloric Restriction on Body Composition in Overweight and Obese Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

This systematic review aimed to determine whether caloric restriction-induced reduction in body fat and fat-free mass can be amended by supplementation with long-chain n-3 polyunsaturated fatty acids. Databases, including PubMed, Google Scholar, Web of Science, and EMBASE, were searched for papers published from the time the databases were created until November 1, 2023. Random-effects model meta-analyses were conducted using Review Manager 5.4.1 software. Statistical heterogeneity was assessed using the I 2. A standardized mean difference with a 95% confidence interval was calculated, and pooled effects were assessed. The initial search identified 1527 articles and 11 studies met the review inclusion criteria with 637 participants included. The participants' ages ranged between 18 and 61 years with a mean body mass index ranging between 27 and 36 kg/m2. The changes in fat-free mass (standardized mean difference = 0.12, 95% CI -0.14 to 0.37, p = 0.36; I 2:35%) and fat mass (standardized mean difference = - 0.01; 95% CI -0.25 to 0.24; p = 0.96; I 2: 46%) were not different between intervention and control groups. The current review indicates that long-chain n-3 polyunsaturated fatty acids supplementation during caloric restriction neither attenuates the decline in fat-free mass nor enhances the reduction in fat mass. Considering the small number of studies and interventions included, further research is needed to investigate the effectiveness of long-chain n-3 polyunsaturated fatty acids supplementation during caloric restriction.

Low-energy diets before metabolic bariatric surgery: A systematic review of the effect on total body weight, liver volume, glycemia and side effects

There is no consensus regarding energy content or duration of hypocaloric diets used for preoperative optimization of patients before metabolic bariatric surgery. In this systematic review, we aimed to compare the effect of different hypocaloric diets on reductions in total body weight, liver volume, glucose and insulin concentrations, and side effects. Six databases were searched for articles including adults with BMI ≥35 kg/m2 treated with hypocaloric diets before metabolic bariatric surgery. Hypocaloric diets were categorized as (1) low-energy diet containing 800-1200 kcal/day for 2-4 weeks, (2) very low-energy diet containing 450-<800 kcal/day for 2-4 weeks, and (3) low-energy diet containing 800-1200 kcal/day for >4 weeks. Thirty-three articles (1868 patients) were included, and if data were sufficient, synthesis without meta-analysis was conducted. A low-energy diet and very low-energy diet for 2-4 weeks resulted in similar reductions in total body weight, but longer treatment correlated to a more pronounced weight reduction. In addition, a low-energy diet for 2-4 weeks led to decreased liver volume, which might facilitate the surgical procedure. Insulin resistance was generally reduced after a low-energy diet for 2-4 weeks. However, most studies were within-group control, and since more than 60% of the studies lacked variance measures for our outcomes, we did not perform a meta-analysis. Accordingly, our results should be interpreted carefully. The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) with registration number: CRD42022295757; available at: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=295757.

Point-Counterpoint Debate: Surgery vs Medical Treatment for the Management of Obesity

Obesity is a chronic, relapsing condition with severe health risks and a huge economic burden. Effective interventions for severe obesity include bariatric or metabolic surgery and high-intensity medical management involving lifestyle changes and pharmacotherapy. This article summarizes the debate between Drs. Schauer and Rothberg at the June 2024 Endocrine Society meeting regarding the optimal approach to managing obesity, exploring mechanisms, outcomes, safety, quality-of-life, and cost-effectiveness. Metabolic surgery results in substantial and sustained weight loss, improvements in comorbidities such as type 2 diabetes, and reduced mortality, and it is cost-effective. However, it carries risks associated with surgery and long-term complications, and its high upfront costs limit its scalability. Conversely, high-intensity medical management, which includes comprehensive lifestyle interventions and pharmacotherapy, leads to meaningful, though sometimes less substantial, weight loss and health improvements. The latter approach prioritizes behavioral changes and is cost-effective but requires patient adherence and faces challenges with medication side effects and costs. Both interventions offer substantial health benefits; the choice between them should consider individual patient needs, health status, target weight loss, and personal preferences. Metabolic surgery may be more suitable for individuals with severe obesity or when comorbidities are inadequately controlled, whereas medical management may be more suited to patients with less severe obesity and those preferring nonsurgical options. Future research should investigate the combined effects of surgery and medical management and enhance access to and affordability of these treatments. A multidisciplinary, personalized approach will likely yield the best outcomes in managing this complex health issue.

Preoperative Body Composition Analysis as a Predictor of Weight Loss Outcomes Following Bariatric Surgery: A Bioelectrical Impedance Study

BACKGROUND

Bariatric surgery (BS) is an effective intervention for severe obesity, but some patients may experience sub-optimal weight loss. This study investigates the role of preoperative body composition parameters, measured via bioelectrical impedance analysis (BIA), in predicting postoperative weight loss outcomes.

METHODS

A retrospective analysis was conducted on 102 patients who underwent sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), or one-anastomosis gastric bypass (OAGB) between January 2020 and April 2023. Preoperative body composition metrics, including fat mass (FM), fat-free mass (FFM), body cell mass (BCM), and phase angle (PhA), were correlated with percentages of excess weight loss (%EWL) and total weight loss (%TWL) at 12 months post-surgery.

RESULTS

The study found that patients with higher preoperative BCM and PhA showed significantly better weight loss outcomes. Specifically, patients with optimal weight loss had a mean BCM of 35.2 ± 3.5 kg and a PhA of 6.1 ± 0.5, whereas those with sub-optimal outcomes had a mean BCM of 29.8 ± 4.2 kg and a PhA of 4.9 ± 0.6 (p < 0.01 for both). Additionally, higher FM was associated with lower %EWL (r =  - 0.40, p < 0.01). Multivariable logistic regression analysis identified BCM (OR 2.1, 95% CI 1.3-3.4) and %FM (OR 0.7, 95% CI 0.5-0.9) as independent predictors of successful weight loss.

CONCLUSIONS

Preoperative BIA parameters, particularly BCM and %FM, are significantly associated with weight loss outcomes in BS patients. These findings suggest a potential role in guiding pre-surgical patient assessment and tailored care, while acknowledging that this relationship is correlational and not necessarily causal.

Adherence to an Early Exercise Plan Promotes Visceral Fat Loss in the First Month Following Bariatric Surgery

BACKGROUND

The evidence supporting the benefits of early exercise in post-bariatric patients is growing. This study analyzed the effects of early exercise (1-week post-bariatric surgery) on body composition in patients with overweight and obesity 1 month after surgery.

METHODS

Thirty patients (age 36.5 ± 12.3 [range, 18-65] years; body mass index [BMI], 36.2 ± 12.3 kg/m2, range, 29-48) who underwent laparoscopic sleeve gastrectomy for bariatric surgery were instructed to participate in an exercise training program initiated on day 3 post-surgery and to follow a recommended protein intake of 60 g/day. After 1-month post-surgery, patients were stratified into those who adhered to exercise recommendations and those who did not. Pre- and post-differences in total weight loss (TWL), skeletal muscle mass (SMM), fat mass (FM), and visceral fat mass (VFM) were compared.

RESULTS

TWL, SMM, and FM loss were similar between non-adherent and adherent subjects (10.2 ± 3.5 kg and 11.9 ± 3.6 kg; p = 0.2; 2.9 ± 1.0 kg and 3.2 ± 1.2; p = 0.2; 6.2 ± 2.1 kg and 7.5 ± 3.6 kg; p = 0.2, respectively), whereas VFM was markedly reduced in the adherent group (29.9 ± 18.2 cm2 vs 14.6 ± 9.4 cm2; p = 0.01) compared to the non-adherent group. When the group was divided according to adherence to exercise and protein intake or non-adherence to both conditions, there was a significant difference in TWL, FM, and VFM losses (p < 0.05). In contrast, no differences in SMM were found.

CONCLUSIONS

Early exercise training accelerated visceral fat mass loss during the initial recovery period in patients after bariatric surgery. Additionally, adherence to daily protein intake recommendations can increase total body weight and fat mass loss.

The impact of sleeve gastrectomy on pulmonary function tests and physical activity one-year after surgery

INTRODUCTION

Obesity can adversely impact respiratory function and limit physical activity (PA). Sleeve gastrectomy (SG) is an essential and uptrend treatment option for weight loss. However, the effect of SG on pulmonary function and PA in patients with obesity is still debated.

METHOD

This is an observational study of 32 cases with obesity (BMI 43.86 ± 4.39) who underwent SG in a single center. Spirometry was performed before and 12 months after SG to investigate the pulmonary function of individuals. The main variables were forced expiratory volume (1s) (FEV1), Forced vital capacity (FVC), FEV1/FVC ratio, and maximum inspiratory pressure (MIP). The correlation of weight loss variables with findings was evaluated.

RESULT

One year after surgery, patients lost an average of 23.42 kg (P <.001). The FEV1 and FVC were increased by 0.22 ml and 0.38 ml, respectively (p <.001). The absolute changes in FEV1 and FVS were significantly correlated with Total weight loss percentage (TWL). The 6-minute walking test (6MWT) results were significantly increased after surgery by 53.71 m (p <.001), and changes were correlated with TWL.

CONCLUSION

More than significant weight loss, the SG can also significantly improve the respiratory function and PA of individuals with obesity 12 months after surgery. Additionally, there was a positive correlation between weight loss and modification in lung function tests. The findings required studies with larger sample sizes and longer follow-up times to confirm and clarify.

Are strategies to increase muscle mass and strength as effective in people with type 2 diabetes?

People with type 2 diabetes (T2D) have a 2-3-time higher risk of developing sarcopenia, a musculoskeletal disease marked by a progressive loss of skeletal muscle mass and strength, compared to people without T2D. This narrative review examines the effectiveness of lifestyle interventions in enhancing muscle mass and strength in people with T2D, emphasizing their growing importance with advancements in obesity treatments. PubMed and Google Scholar were utilized to identify the most relevant published studies based on the authors' knowledge. The maintenance of skeletal muscle strength and mass in people with T2D is becoming more prominent due to the advent of weight loss therapies such as low-energy diets, bariatric surgery and pharmacotherapies. Although the weight loss is to be commended, a large proportion (20-50%) of the weight loss comes from lean mass, indicative of a loss in muscle mass. There are currently no pharmacotherapies to increase, or mitigate the loss of, lean mass, with lifestyle strategies prominent in this arena. Resistance exercise is the most effective method to increase muscle mass and strength in people with T2D, but there is some evidence of an anabolic resistance. Aerobic exercise and increased dietary protein intake may result in small increases in muscle mass and strength, with no evidence of an anabolic resistance to these stimuli. Exercise and protein supplementation can increase, or aid in the retention of, muscle strength and mass in individuals with T2D, but further research is needed to explore their benefits in patients undergoing concomitant pharmaceutical and surgical treatments.

GLP1Ra-based therapies and DXA-acquired musculoskeletal health outcomes: a focused meta-analysis of placebo-controlled trials

OBJECTIVE

The objective of this study was to evaluate the effect of glucagon-like peptide-1 receptor agonist (GLP1Ra)-based therapies on change in dual-energy x-ray absorptiometry (DXA)-acquired lean mass (LM) or bone mineral density (BMD).

METHODS

PubMed and Web of Science were searched from database inception through January 29, 2024, for randomized, placebo-controlled trials reporting on change in DXA-acquired LM or BMD measures associated with 12+ weeks of GLP1Ra-based treatment. Of 2618 articles, 9 trials met prespecified search criteria, with 7 reporting on change in total body LM and 2 reporting on change in BMD. For LM outcomes, a hierarchical Bayesian model was used to estimate treatment mean differences. BMD outcomes were described narratively.

RESULTS

LM was reported in a total of 659 participants (GLP1Ra-based therapies: n = 419; placebo: n = 240), with follow-up times ranging from mean (SD) 12 to 72 (33.5) weeks. At baseline, participants were aged mean (SD) 41.7 (7.6) years, and 75% were female, with BMI values ranging from 30 to 43 kg/m2. Compared with placebo, GLP1Ra-based treatment was associated with significantly reduced total body weight (-6.9 kg; 95% credible interval [CI]: -10.7 to -3.0). GLP1Ra-based treatment was also associated with significantly reduced LM (-1.9 kg; 95% CI: -3.5 to -0.2).

CONCLUSIONS

Approximately 30% of body weight lost with GLP1Ra-based therapy is LM. More data are needed assessing BMD outcomes.

Efficacy and Safety of Glucagon-Like Peptide-1 Receptor Agonists for Weight Loss Among Adults Without Diabetes : A Systematic Review of Randomized Controlled Trials

BACKGROUND

Recent randomized controlled trials (RCTs) have investigated glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and dual or triple co-agonists for weight loss among adults with overweight or obesity and without diabetes.

PURPOSE

To assess the efficacy and safety of GLP-1 RAs and co-agonists for the treatment of obesity among adults without diabetes.

DATA SOURCES

MEDLINE, Embase, and Cochrane CENTRAL from inception to 4 October 2024.

STUDY SELECTION

Placebo-controlled RCTs in otherwise healthy participants with overweight or obesity.

DATA EXTRACTION

The primary outcome was change in relative or absolute body weight from baseline to maximum on-treatment follow-up. Safety outcomes included death, serious adverse events (SAEs), any adverse events (AEs), and gastrointestinal AEs.

DATA SYNTHESIS

A total of 26 RCTs comprising 15 491 participants (72% female; mean body mass index, 30 to 41 kg/m2; mean age, 34 to 57 years) and 12 agents (3 commercially available agents [liraglutide, semaglutide, and tirzepatide] and 9 premarket agents for long-term weight management) were included. Treatment ranged from 16 to 104 weeks (median, 43 weeks). Compared with placebo, tirzepatide (15 mg once weekly) resulted in weight loss of up to 17.8% (95% CI, 16.3% to 19.3%) after 72 weeks of therapy; semaglutide (2.4 mg once weekly), up to 13.9% (CI, 11.0% to 16.7%) after 68 weeks; and liraglutide (3.0 mg once daily), up to 5.8% (CI, 3.6% to 8.0%) after 26 weeks. Retatrutide (12 mg once weekly) produced greater weight loss of up to 22.1% (CI, 19.3% to 24.9%) after 48 weeks; other novel single and combination GLP-1 agents were also efficacious to varying degrees. Although AEs were frequent (GLP-1 RA vs. placebo: 80% to 97% vs. 63% to 100%), the majority were gastrointestinal-related (47% to 84% vs. 13% to 63%, respectively), most commonly nausea, vomiting, diarrhea, and constipation. AEs requiring treatment discontinuation (0% to 26% vs. 0% to 9%, respectively) and SAEs (0% to 10% vs. 0% to 12%, respectively) were rare.

LIMITATIONS

No head-to-head RCTs were available. Heterogeneity prevented meta-analysis.

CONCLUSION

GLP-1 RAs and co-agonists are efficacious for weight loss, with reported safety concerns predominantly gastrointestinal in nature, when used among adults with overweight or obesity and without diabetes.

PRIMARY FUNDING SOURCE

None. (PROSPERO: CRD42024505558).

Strategies for minimizing muscle loss during use of incretin-mimetic drugs for treatment of obesity

The rapid and widespread clinical adoption of highly effective incretin-mimetic drugs (IMDs), particularly semaglutide and tirzepatide, for the treatment of obesity has outpaced the updating of clinical practice guidelines. Consequently, many patients may be at risk for adverse effects and uncertain long-term outcomes related to the use of these drugs. Of emerging concern is the loss of skeletal muscle mass and function that can accompany rapid substantial weight reduction; such losses can lead to reduced functional and metabolic health, weight cycling, compromised quality of life, and other adverse outcomes. Available evidence suggests that clinical trial participants receiving IMDs for the treatment of obesity lost 10% or more of their muscle mass during the 68- to 72-week interventions, approximately equivalent to 20 years of age-related muscle loss. The ability to maintain muscle mass during caloric restriction-induced weight reduction is influenced by two key factors: nutrition and physical exercise. Nutrition therapy should ensure adequate intake and absorption of high-quality protein and micronutrients, which may require the use of oral nutritional supplements. Additionally, concurrent physical activity, especially resistance training, has been shown to effectively minimize loss of muscle mass and function during weight reduction therapy. All patients receiving IMDs for obesity should participate in comprehensive treatment programs emphasizing adequate protein and micronutrient intakes, as well as resistance training, to preserve muscle mass and function, maximize the benefit of IMD therapy, and minimize potential risks.

The Presence of Food Addiction in Patients with Binge Eating Disorder Was Associated with Higher Weight, Poor Body Composition Outcomes, Lower Serum Level of Magnesium and Higher Ferritin 2 Years Post-LSG Surgery

BACKGROUND

This study examined the presence of food addiction (FA) in patients with binge eating disorder (BED) 2 years after laparoscopic sleeve gastrectomy (LSG) and explored its association with some minerals, ferritin, weight loss and, body composition outcomes.

MATERIALS AND METHODS

In this study, 120 patients with BED who had undergone LSG 2 years prior to participation were enrolled. BED was assessed using Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria and presence of FA was assessed using the Yale Food Addiction Scale (YFAS). The collected data included general characteristic, food intake, physical activity, weight loss percentage, body composition measurements such as fat mass (FM) and fat-free mass (FFM), as well as serum level of magnesium, zinc, iron, and ferritin.

RESULTS

Fifty individuals with BED met the criteria for FA disorder (41.66%). BED patients who had FA had significantly higher weight (P = 0.01) compared to those without FA. Regarding body composition changes, the finding reveals that patients with BED + FA (vs. only-BED) had a significantly lower FM loss percentage (p = 0.04) and higher FFM loss percentage (p = 0.04). The BED patients with FA had significantly lower levels of magnesium (p = 0.02) and a higher level of ferritin (p = 0.04) compared to those without FA at second year after LSG.

CONCLUSION

The presence of FA in patients with BED was associated with higher weight, poor body composition outcomes, lower serum level of magnesium, and higher ferritin two years post-LSG surgery.

Integrated Insights into Metabolic and Bariatric Surgery: Improving Life Quality and Reducing Mortality in Obesity

Metabolic and bariatric surgery (MBS) is an effective intervention for patients with severe obesity and metabolic comorbidities, particularly when non-surgical weight loss methods prove insufficient. MBS has shown significant potential for improving quality of life and metabolic health outcomes in individuals with obesity, yet it carries inherent risks. Although these procedures offer a multifaceted approach to obesity treatment and its clinical advantages are well-documented, the limited understanding of its long-term outcomes and the role of multidisciplinary care pose challenges. With an emphasis on quality-of-life enhancements and the handling of postoperative difficulties, the present narrative review seeks to compile the most recent findings on MBS while emphasizing the value of an integrated approach to maximize patient outcomes. Effective MBS and patients' management require a collaborative team approach, involving surgeons, dietitians, psychologists, pharmacists, and other healthcare providers to address not only physiological but also psychosocial patient needs. Comparative studies demonstrate the efficacy of various MBS methods, including Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy that may considerably decrease morbidity and mortality in individuals with obesity. Future studies should target long-term patient treatment, and decision making should be aided by knowledge of obesity, comorbidity recurrence rates, and permanence of benefits.

The impact of weight loss on fat-free mass, muscle, bone and hematopoiesis health: Implications for emerging pharmacotherapies aiming at fat reduction and lean mass preservation

Similar to bariatric surgery, incretin receptor agonists have revolutionized the treatment of obesity, achieving up to 15-25 % weight loss in many patients, i.e., at a rate approaching that achieved with bariatric surgery. However, over 25 % of total weight lost from both surgery and pharmacotherapy typically comes from fat-free mass, including skeletal muscle mass, which is often overlooked and can impair metabolic health and increase the risk of subsequent sarcopenic obesity. Loss of muscle and bone as well as anemia can compromise physical function, metabolic rate, and overall health, especially in older adults. The myostatin-activin-follistatin-inhibin system, originally implicated in reproductive function and subsequently muscle regulation, appears to be crucial for muscle and bone maintenance during weight loss. Activins and myostatin promote muscle degradation, while follistatins inhibit their activity in states of negative energy balance, thereby preserving lean mass. Novel compounds in the pipeline, such as Bimagrumab, Trevogrumab, and Garetosmab-which inhibit activin and myostatin signaling-have demonstrated promise in preventing muscle loss while promoting fat loss. Either alone or combined with incretin receptor agonists, these medications may enhance fat loss while preserving or even increasing muscle and bone mass, offering a potential solution for improving body composition and metabolic health during significant weight loss. Since this dual therapeutic approach could help address the challenges of muscle and bone loss during weight loss, well-designed studies are needed to optimize these strategies and assess long-term benefits. For the time being, considerations like advanced age and prefrailty may affect the choice of suitable candidates in clinical practice for current and emerging anti-obesity medications due to the associated risk of sarcopenia.

Impact of daily fasting duration on body composition and cardiometabolic risk factors during a time-restricted eating protocol: a randomized controlled trial

BACKGROUND

Time-restricted eating (TRE) is a dietary regimen that limits food intake for at least 12 h daily. Unlike other fasting protocols, TRE does not dictate what or how much to eat but rather focuses on the timing of meals. This approach has been previously demonstrated to improve body composition in individuals with obesity or metabolic impairments. However, its impact on body composition and cardiometabolic factors in healthy individuals remains unclear. Furthermore, the optimal fasting duration is still debated. Thus, we aimed to compare the effects of 8 weeks of different fasting durations on body composition and biochemical parameters in metabolically healthy, non-trained individuals using a parallel randomized controlled trial.

METHODS

Forty-one volunteers were randomly assigned to one of the four experimental groups: TRE 16:8 (16 h of fasting,8 h of eating), TRE 14:10 (14 h of fasting,10 h of eating), TRE 12:12 (12 h of fasting,12 h of eating) or a normal diet group (ND; no dietary restriction). Participants underwent body composition measurements and blood tests for lipid profiles (i.e., total cholesterol, LDL, HDL, and triglycerides), fasting glucose, leptin, and anabolic hormones (i.e., insulin and testosterone) levels. Data were analyzed using both intention-to-treat (ITT) and per-protocol (PP) analysis to account for compliance. A two-way ANOVA for repeated measures was employed to assess interactions between time and group.

RESULTS

In the ITT analysis, TRE 16:8 reduced body mass (-2.46%, p = 0.003) and absolute fat mass (-8.65%, p = 0.001) with no changes in lean soft tissue and in calorie intake. These results were consistent with the PP analysis which included 8 participants in TRE 16:8, 5 in TRE 14:10, 9 in TRE 12:12, and the entire ND group. Participants in the TRE 16:8 group spontaneously reduced their total caloric intake, although this reduction was not statistically significant. None of the other measurements significantly changed after 8 weeks.

CONCLUSIONS

Our results suggest that a 16-hour fasting window, even without caloric restriction, may be a viable strategy for improving body composition in healthy and non-trained individuals, whereas a shorter fasting period may be insufficient to produce significant changes in a healthy population.

TRIAL REGISTRATION

NCT, NCT04503005. Registered 4 August 2020, https://clinicaltrials.gov/study/NCT04503005 .

The effect of a low-carbohydrate diet on subcutaneous adipose tissue in females with lipedema

Introduction

Lipedema is a common, yet underdiagnosed, subcutaneous adipose tissue (SAT) disorder. The main characteristics are SAT expansion in the lower extremities and arms, pain, and tenderness to palpation. It remains unknown if a low-carbohydrate diet (LCD) influences SAT in females with lipedema.

Objectives

To evaluate the effect of a LCD low-energy diet, compared to a low-fat isoenergetic control diet, on calf subcutaneous adipose tissue area, muscle area, SAT/muscle ratio, calf circumference and body composition in females with lipedema.

Subjects/methods

Adult females with obesity and lipedema were randomized to 1,200 kcal/day diets, either LCD or control (75 and 180 g/day of carbohydrates, respectively) for 8 weeks. Body composition was measured with bioelectrical impedance analysis, calf SAT area, muscle area, and circumference with magnetic resonance imaging and pain with brief pain inventory, before and after the intervention.

Results

Thirteen participants were included (five in the LCD group), with a mean age of 46 ± 12 years and a BMI of 37 ± 6 kg/m2. A significant reduction in calf SAT area, calf circumference, and pain was observed in the LCD group only. Both LCD and control groups experienced a significant reduction body weight, fat mass, fat free mass, and muscle area, with no differences between groups. No significant changes over time were found for SAT/muscle ratio.

Conclusion

A LCD has the potential to reduce SAT and pain in females with lipedema, despite a reduction in muscle mass in lipedema affected areas in both diet groups. Further studies are needed to confirm these findings and explore potential mechanisms.

Clinical trial registration

NCT04632810: Effect of ketosis on pain and quality of life in patients with lipedema (Lipodiet). https://clinicaltrials.gov/study/NCT04632810.

Effects of caloric restriction with different doses of exercise on fat loss in people living with type 2 diabetes: A secondary analysis of the DOSE-EX randomized clinical trial

BACKGROUND

Fat loss mainly conveys the benefits of caloric restriction for people living with type 2 diabetes. The literature is equivocal regarding whether exercise facilitates fat loss during caloric restriction. This analysis aimed to assess the dose-response effects of exercise in combination with a caloric restriction on fat mass (FM) and FM percentage (FM%) in persons with diagnosed type 2 diabetes.

METHODS

In this secondary analysis of a 4-armed randomized trial, 82 persons living with type 2 diabetes were randomly allocated to the control group (CON) (n = 21), diet control (DCON) (25% caloric restriction; n = 20), diet control and exercise 3 times per week (MED) (n = 20), or diet control and exercise 6 times per week (HED) (n = 21) for 16 weeks. The primary analysis was the change in FM% points. Secondary analyses included fat-free mass and visceral adipose tissue (VAT) volume (cm3).

RESULTS

FM% decreased compared to CON by a mean difference of -3.5% (95% confidence interval (95%CI): -5.6% to -1.4%), -6.3% (95%CI: -8.4% to -4.1%), and -8.0% (95%CI: -10.2% to -5.8%) for DCON, MED, and HED, respectively. Compared to DCON, MED, and HED decreased FM% by -2.8% (95%CI: -4.9% to -0.7%) and -4.5% (95%CI: -6.6% to -2.4%), respectively. The difference in FM% between HED and MED was -1.8% (95%CI: -3.9% to 0.4%). DCON and MED decreased fat-free mass compared to CON, whereas HED preserved fat-free mass (-0.2%; 95%CI: -2.0% to 1.7%). Compared to CON, VAT volume decreased by -666.0 cm3 (95%CI: -912.8 cm3 to -385.1 cm3), -1264.0 cm3 (95%CI: -1679.6 cm3 to -655.9 cm3), and -1786.4 cm3 (95%CI: -2264.6 cm3 to -1321.2 cm3) more for DCON, MED, and HED, respectively. HED decreased VAT volume more than DCON (-1120.4 cm3; 95%CI: -1746.6 cm3 to -639.4 cm3) while the remaining comparisons did not reveal any differences.

CONCLUSION

All interventions were superior in reducing FM% compared to standard care. Adding exercise to a caloric restriction was superior in reducing FM% compared to a caloric restriction alone.

Plant-Based Dietary Protein Is Associated with Lower Metabolic Syndrome Risk in Division III Female Athletes: A Pilot Study

BACKGROUND

College athletes are often overlooked for metabolic syndrome (MetS), as their increased physical activity is assumed to reduce their disease risk. However, energy or macronutrient imbalance has been shown to increase risk independent of activity. The purpose of this investigation was to assess the current dietary habits of Division III female athletes and determine their associations with body composition and MetS. Secondly, we sought to determine whether dietary intake and dietary protein source (i.e., animal- and plant-based, ABP and PBP) and quality were associated with MetS, as estimated by the Simple Method for Quantifying Metabolic Syndrome (siMS) score and the siMS risk score, and whether protein pacing was associated with body composition in Division III female athletes.

METHODS

Stepwise linear regression determined whether age (years), body mass (kg), body mass index (BMI; kg/m2), ABP (g/d), PBP (g/d), ABP:PBP, ratio of high-quality to low-quality ABP (ABP QR), relative energy intake (kcal/kg/d), and relative protein, carbohydrate, and fat intake (g/kg/d) were predictors of siMS score and siMS risk score.

RESULTS

Twenty-five athletes (19.6 ± 1.3 years; 65.9 ± 7.0 kg; 23.5 ± 2.0 kg/m2; ABP 71.7 ± 28.2 g/d; PBP 30.0 ± 12.2 g/d) were included in the analyses. An inverse relationship was observed between PBP and the siMS score (F1, 22 = 5.498, p = 0.028) and siMS risk score (F1, 22 = 7.614, p = 0.011). The models explained 20% and 26% of the variance in siMS score and siMS risk score, respectively.

CONCLUSIONS

PBP was associated with lower MetS risk in Division III female athletes, while ABP, regardless of quality, was unrelated. These associations were independent of physical activity in this cohort of Division III female athletes.

Protein supplementation preserves muscle mass in persons against sleeve gastrectomy

Introduction

Sleeve gastrectomy surgery can lead to deficiencies in both macro and micronutrients, with protein being particularly crucial due to its role in muscle mass, physiological, and metabolic functions. Inadequate protein intake due to physiological, psychological, or financial reasons may prevent achieving the recommended intake levels. The significance of this issue is often underappreciated.

Aim

This study evaluates the impact of protein supplementation on muscle mass in individuals undergoing sleeve gastrectomy and emphasizes the need for more comprehensive dietary training by expert dietitians.

Method

Data were collected from 60 participants (15 male, 45 female, aged 20-54) who visited the surgery clinic. Participants were divided into two groups: those receiving the recommended protein supplement (15 g/day) with post-bariatric surgery diet training (BSD + PS), and those receiving only the post-bariatric surgery diet (BSD). A pre-surgery questionnaire gathered health and general information. Daily energy and nutrient intakes were recorded using 24-h food consumption logs on the day before surgery and at 7 days, 1 month, and 3 months postoperatively. Anthropometric measurements, including muscle and fat mass, and International Physical Activity Questionnaire (IPAQ) data were also collected.

Findings

The characteristics of participants in both groups were similar, although there were more females in the BSD + PS group (86.7%) compared to the BSD group (63.3%). Despite an increase in energy and nutrient intake over time, levels remained below the recommended amounts in both groups. A significant difference was found in protein supplement consumption between the groups (p = 0.000). Repeated measures showed significant differences in body muscle mass percentage over time (F = 202.784; p = 0.000).

Conclusion

In individuals who underwent sleeve gastrectomy surgery, deficiencies in macro and micronutrient intake were observed below reference levels. For this reason, the first approach in the treatment of obesity should always be medical nutrition therapy accompanied by a dietician. When designing post-bariatric surgery nutrition programs, it should be taken into consideration that nutrition protocols and trainings should be followed more closely and given in more detail under the supervision of a specialist before supplements are considered.

Physical Activity and Excess Body Weight and Adiposity for Adults. American College of Sports Medicine Consensus Statement

ABSTRACT

Excessive body weight and adiposity contribute to many adverse health concerns. The American College of Sports Medicine (ACSM) recognizes that the condition of excess body weight and adiposity is complex, with numerous factors warranting consideration. The ACSM published a position stand on this topic in 2001 with an update in 2009, and a consensus paper on the role of physical activity in the prevention of weight gain in 2019. This current consensus paper serves as an additional update to those prior ACSM position and consensus papers. The ACSM supports the inclusion of physical activity in medical treatments (pharmacotherapy, metabolic and bariatric surgery) of excess weight and adiposity, as deemed to be medically appropriate, and provides perspectives on physical activity within these therapies. For weight loss and prevention of weight gain, the effects may be most prevalent when physical activity is progressed in an appropriate manner to at least 150 min·wk-1 of moderate-intensity physical activity, and these benefits occur in a dose-response manner. High-intensity interval training does not appear to be superior to moderate-to-vigorous physical activity for body weight regulation, and light-intensity physical activity may also be an alternative approach provided it is of sufficient energy expenditure. Evidence does not support that any one single mode of physical activity is superior to other modes for the prevention of weight gain or weight loss, and to elicit holistic health benefits beyond the effects on body weight and adiposity, multimodal physical activity should be recommended. The interaction between energy expenditure and energy intake is complex, and the effects of exercise on the control of appetite are variable between individuals. Physical activity interventions should be inclusive and tailored for sex, self-identified gender, race, ethnicity, socioeconomic status, age, and developmental level. Intervention approaches can also include different forms, channels, and methods to support physical activity.

A Systematic Review and Meta-Analysis of the Effect of Caloric Restriction on Skeletal Muscle Mass in Individuals with, and without, Type 2 Diabetes

BACKGROUND

Severe caloric restriction interventions (such as very-low-calorie diets) are effective for inducing significant weight loss and remission of type 2 diabetes (T2DM). However, suggestions of associated significant muscle mass (MM) loss create apprehension regarding their widespread use. We conducted a systematic review and meta-analysis to provide a quantitative assessment of their effect on measures of MM in individuals with, or without, T2DM.

METHODS

EMBASE, Medline, Pubmed, CINAHL, CENTRAL and Google Scholar were systematically searched for studies involving caloric restriction interventions up to 900 kilocalories per day reporting any measure of MM, in addition to fat mass (FM) or body weight (BW).

RESULTS

Forty-nine studies were eligible for inclusion, involving 4785 participants. Individuals with T2DM experienced significant reductions in MM (WMD -2.88 kg, 95% CI: -3.54, -2.22; p < 0.0001), although this was significantly less than the reduction in FM (WMD -7.62 kg, 95% CI: -10.87, -4.37; p < 0.0001). A similar pattern was observed across studies involving individuals without T2DM. MM constituted approximately 25.5% of overall weight loss in individuals with T2DM, and 27.5% in individuals without T2DM. Subgroup analysis paradoxically revealed greater BW and FM reductions with less restrictive interventions.

CONCLUSIONS

Our review suggests that caloric restriction interventions up to 900 kilocalories per day are associated with a significant reduction in MM, albeit in the context of a significantly greater reduction in FM. Furthermore, MM constituted approximately a quarter of the total weight loss. Finally, our data support the use of less restrictive interventions, which appear to be more beneficial for BW and FM loss.

Fundamental Body Composition Principles Provide Context for Fat-Free and Skeletal Muscle Loss With GLP-1 RA Treatments

During weight loss, reductions in body mass are commonly described using molecular body components (eg, fat mass and fat-free mass [FFM]) or tissues and organs (eg, adipose tissue and skeletal muscle). While often conflated, distinctions between body components established by different levels of the 5-level model of body composition-which partitions body mass according to the atomic, molecular, cellular, tissue/organ, or whole-body level-are essential to recall when interpreting the composition of weight loss. A contemporary area of clinical and research interest that demonstrates the importance of these concepts is the discussion surrounding body composition changes with glucagon-like peptide-1 receptor agonists (GLP-1RA), particularly in regard to changes in FFM and skeletal muscle mass. The present article emphasizes the importance of fundamental principles when interpreting body composition changes experienced during weight loss, with a particular focus on GLP-1RA drug trials. The potential for obligatory loss of FFM due to reductions in adipose tissue mass and distribution of FFM loss from distinct body tissues are also discussed. Finally, selected countermeasures to combat loss of FFM and skeletal muscle, namely resistance exercise training and increased protein intake, are presented. Collectively, these considerations may allow for enhanced clarity when conceptualizing, discussing, and seeking to influence body composition changes experienced during weight loss.

Dietary intake by patients taking GLP-1 and dual GIP/GLP-1 receptor agonists: A narrative review and discussion of research needs

Background

Obesity and type 2 diabetes mellitus (T2DM) are increasingly common in the United States and worldwide. Because both conditions are associated with serious health consequences, weight reduction is recommended by professional medical and nutrition societies to improve outcomes. Due to the striking efficacy of glucagon-like peptide receptor agonists (GLP-1RAs) and dual mechanism glucose-dependent insulinotropic polypeptide/glucagon-like peptide receptor agonists (GIP/GLP-1RAs) for weight reduction and glycemic control, there is increased utilization for patients with obesity and/or T2DM. Yet, the impact of these medications on dietary intake is less understood.

Methods

This narrative literature review summarizes clinical studies quantifying and characterizing dietary intake in people with obesity and/or T2DM using GLP-1 or GIP/GLP-1 RAs.

Results

Though data from these studies reveal that total caloric intake was reduced by 16-39 %, few studies evaluated the actual composition of the diet.

Conclusions

Further research is needed to understand the unique nutritional needs of adults on GLP-1 or dual GIP/GLP-1RAs and to support the development of nutritional guidelines for these individuals.

Changes in lean body mass with glucagon-like peptide-1-based therapies and mitigation strategies

Weight loss induced by glucagon-like peptide-1 receptor agonists (GLP-1RAs) and dual glucagon-like peptide-1 receptor (GLP-1R)/glucose-dependent insulinotropic polypeptide receptor agonists is coming closer to the magnitudes achieved with surgery. However, with greater weight loss there is concern about potential side effects on muscle quantity (mass), health and function. There is heterogeneity in the reported effects of GLP-1-based therapies on lean mass changes in clinical trials: in some studies, reductions in lean mass range between 40% and 60% as a proportion of total weight lost, while other studies show lean mass reductions of approximately 15% or less of total weight lost. There are several potential reasons underlying this heterogeneity, including population, drug-specific/molecular, and comorbidity effects. Furthermore, changes in lean mass may not always reflect changes in muscle mass as the former measure includes not only muscle but also organs, bone, fluids, and water in fat tissue. Based on contemporary evidence with the addition of magnetic resonance imaging-based studies, skeletal muscle changes with GLP-1RA treatments appear to be adaptive: reductions in muscle volume seem to be commensurate with what is expected given ageing, disease status, and weight loss achieved, and the improvement in insulin sensitivity and muscle fat infiltration likely contributes to an adaptive process with improved muscle quality, lowering the probability for loss in strength and function. Nevertheless, factors such as older age and severity of disease may influence the selection of appropriate candidates for these therapies due to risk of sarcopenia. To further improve muscle health during weight loss, several pharmacological treatments to maintain or improve muscle mass designed in combination with GLP-1-based therapies are under development. Future research on GLP-1-based and other therapies designed for weight loss should focus on more accurate and meaningful assessments of muscle mass, composition, as well as function, mobility or strength, to better define their impact on muscle health for the substantial number of patients who will likely be taking these medications well into the future.

The latest evidence and clinical guidelines for use of meal replacements in very-low-calorie diets or low-calorie diets for the treatment of obesity

Obesity is a complex chronic disease with increasing prevalence across the globe. Medical nutrition therapy (MNT) is an important component of obesity treatment, and low-calorie diets (LCDs) and very-low-calorie diets (VLCDs) are part of the MNT toolbox. This narrative review focuses on the latest evidence and clinical guidelines regarding the use and impact of meal replacements (MRs) as part of LCDs/VLCDs for the treatment of obesity and some associated complications. MRs can be used in conjunction with food as partial diet replacement (PDR) or can be used exclusively to serve as the sole source of dietary energy (total diet replacement [TDR]). Use of MR may be associated with better control of cravings and hunger typically observed during reduced calorie intake through effects of ketosis or stimuli narrowing, although the exact mechanisms for these effects remain unclear. Several clinical guidelines have endorsed the use of MRs as a part of MNT for obesity, primarily based on evidence that shows an average weight reduction of ~10 kg or more with TDR over at least 12 months in large, randomized controlled trials. When compared to usual care controls, these effects are 6-8 kg greater, and when compared to food-based diets, the effects are nearly twice the effect of a food-based diet. MR-based diets have been found to be safe and associated with improvements in quality of life. These diets are also effective for improving key cardiometabolic health outcomes, including dysglycaemia, blood pressure, lipids, and metabolic associated fatty liver. The effectiveness, safety, and associated health improvement makes MRs use a valuable strategy for several higher risk clinical scenarios where weight reduction is indicated.

Enhanced Efficacy of Gastric Cancer Treatment through Targeted Exosome Delivery of 17-DMAG Anticancer Agent

In this study, we explored the potential of genetically engineered exosomes as vehicles for precise drug delivery in gastric cancer therapy. A novel antitumor strategy using biocompatible exosomes (Ex) was devised by genetically engineering adipose-derived stem cells to express an MKN45-binding peptide (DE532) on their surfaces. 17-(Dimethylaminoethylamino)-17-demethoxygeldanamycin (17-DMAG) was encapsulated in engineered exosomes, resulting in 17-DMAG-loaded DE532 exosomes. In both in vitro and in vivo experiments using mouse gastric cancer xenograft models, we demonstrated that 17-DMAG-loaded DE532 Ex exhibited superior targetability over DE532 Ex, 17-DMAG-loaded Ex, and Ex. Administration of the 17-DMAG-loaded DE532 Ex yielded remarkable antitumor effects, as evidenced by the smallest tumor size, lowest tumor growth rate, and lowest excised tumor weight. Further mechanistic examinations revealed that the 17-DMAG-loaded DE532 Ex induced the highest upregulation of the pro-apoptotic marker B-cell lymphoma-2-like protein 11 and the lowest downregulation of the anti-apoptotic marker B-cell lymphoma-extra large. Concurrently, the 17-DMAG-loaded DE532 Ex demonstrated the lowest suppression of antioxidant enzymes, such as superoxide dismutase 2 and catalase, within tumor tissues. These findings underscore the potential of 17-DMAG-loaded DE532 exosomes as a potent therapeutic strategy for gastric cancer, characterized by precise targetability and the potential to minimize adverse effects.

Nutritional Mechanisms of Cancer Cachexia

Cancer cachexia is a complex systemic wasting syndrome. Nutritional mechanisms that span energy intake, nutrient metabolism, body composition, and energy balance may be impacted by, and may contribute to, the development of cachexia. To date, clinical management of cachexia remains elusive. Leaning on discoveries and novel methodologies from other fields of research may bolster new breakthroughs that improve nutritional management and clinical outcomes. Characteristics that compare and contrast cachexia and obesity may reveal opportunities for cachexia research to adopt methodology from the well-established field of obesity research. This review outlines the known nutritional mechanisms and gaps in the knowledge surrounding cancer cachexia. In parallel, we present how obesity may be a different side of the same coin and how obesity research has tackled similar research questions. We present insights into how cachexia research may utilize nutritional methodology to expand our understanding of cachexia to improve definitions and clinical care in future directions for the field.

Adding Branched-Chain Amino Acids and Vitamin D to Whey Protein Is More Effective than Protein Alone in Preserving Fat Free Mass and Muscle Strength in the First Month after Sleeve Gastrectomy

OBJECTIVES

Sleeve gastrectomy (SG) is one of the most commonly performed weight loss (WL) bariatric procedures. The main goal of WL is reducing total body weight (TBW) and fat mass (FM). However, TBW loss is systematically accompanied by a decline in fat-free mass (FFM), predominantly in the first post-surgical month, despite protein supplementation. Branched-chain amino acids (BCAAs) and vitamin D seem to attenuate loss of FFM and, thus, reduce the decline in muscle strength (MS). However, data on the role of an integrated supplementation with whey protein plus BCAAs plus vitamin D (P+BCAAs+Vit.D) vs. protein alone on total weight loss (TWL), fat mass (FM), fat-free mass (FFM), and (MS) in the first month after SG are lacking. Therefore, the present study aims to evaluate the impact of P+BCAAs+Vit.D vs. protein alone supplementation on TWL, FM, FFM, and MS in the first month after SG.

MATERIALS AND METHODS

Before SG and at 1 month afterward, we prospectively measured and compared TBW, FM, FFM, and MS in 57 patients who received either a supplementation with P+BCAAs+Vit.D (n = 31) or protein alone (n = 26). The impact of P+BCAAs+Vit.D and protein alone supplementation on clinical status was also evaluated.

RESULTS

Despite non-significant variation in TBW, FM decreased more significantly (18.5% vs. 13.2%, p = 0.023) with the P+BCAA+Vit.D supplementation compared to protein alone. Furthermore, the P+BCAA+Vit.D group showed a significantly lower decrease in FFM (4.1% vs. 11.4%, p < 0.001) and MS (3.8% vs. 18.5%, p < 0.001) compared to the protein alone group. No significant alterations in clinical status were seen in either group.

CONCLUSION

P+BCAA+Vit.D supplementation is more effective than protein alone in determining FM loss and is associated with a lower decrease in FFM and MS, without interfering with clinical status in patients 1 month after SG.

Unexpectedly Rapid Onset of Severe Sarcopenia in an Elderly Diabetic Man following SGLT2i Administration: A Case Report

Sarcopenia is characterized by the progressive loss of muscle mass, strength, and function and poses a significant health challenge among people with diabetes. Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are the backbone of type 2 diabetes treatment. The interplay between SGLT2is and sarcopenia is an area of active research with inconclusive results. This article presents an unexpectedly rapid weight reduction, along with physical performance deterioration, in an elderly patient with type 2 diabetes, which led to treatment discontinuation. A bioelectrical impedance analysis confirmed severe sarcopenia development. Until more data are available, sarcopenia and body composition screening and monitoring may be warranted whenever SGLT2is are prescribed.

Preoperative dietitian-led Very Low Calorie Diet (VLCD) Clinic for adults living with obesity undergoing gynaecology, laparoscopic cholecystectomy and hernia repair procedures: a pilot parallel randomised controlled trial

Obesity can increase the risk of postoperative complications. Despite increased demand for patients living with obesity to lose weight prior to common surgical procedures, the impact of intentional weight loss on surgical outcomes is largely unknown. We aimed to conduct a pilot study to assess the feasibility of a full-scale randomised controlled trial (RCT) to examine the effect of preoperative dietitian-led Very Low Calorie Diet (VLCD) Clinic on surgical outcomes in gynaecology and general surgeries. Between August 2021 and January 2023, a convenience sample of adults living with obesity (BMI ≥ 30 kg/m2) awaiting gynaecology, laparoscopic cholecystectomy and ventral hernia repair procedures were randomised to dietitian-led VLCD (800-1000 kcal using meal replacements and allowed foods), or control (no dietary intervention), 2-12 weeks preoperatively. Primary outcome was feasibility (recruitment, adherence, safety, attendance, acceptability and quality of life (QoL)). Secondary outcomes were anthropometry and 30-d postoperative outcomes. Outcomes were analysed as intention-to-treat. Fifty-one participants were recruited (n 23 VLCD, n 28 control), mean 48 (sd 13) years, 86 % female, and mean BMI 35·8 (sd 4·6) kg/m2. Recruitment was disrupted by COVID-19, but other thresholds for feasibility were met for VLCD group: high adherence without unfavourable body composition change, high acceptability, improved pre/post QoL (22·1 ± 15 points, < 0·001), with greater reductions in weight (-5·5 kg VLCD v. -0·9 kg control, P < 0·05) waist circumference (-6·6 cm VLCD v. +0·6 control, P < 0·05) and fewer 30-d complications (n 4/21) than controls (n 8/22) (P > 0·05). The RCT study design was deemed feasible in a public hospital setting. The dietitian-led VLCD resulted in significant weight loss and waist circumference reduction compared with a control group, without unfavourable body composition change and improved QoL.

Body Composition Changes in Adolescents Who Underwent Bariatric Surgery: A Systematic Review and Meta-analysis

PURPOSE OF REVIEW

The purpose of this review and meta-analysis is to characterize the changes in body composition of children and adolescents who underwent bariatric surgery and identify possible negative effects of performing this procedure during pediatric ages.

RECENT FINDINGS

Bariatric surgery in children and adolescents is an emerging strategy to promote higher and faster body weight and fat mass losses. However, possible negative effects usually observed in surgical patients' muscle-skeletal system raise a major concern perform this intervention during growth. Despite these possible issues, most experimental studies and reviews analyze bariatric surgery's effectiveness only by assessing anthropometric outcomes such as body weight and BMI, disregarding the short- and long-term impact of bariatric surgery on all body composition outcomes. Bariatric surgery is effective to reduce fat mass in adolescents, as well as body weight, waist circumference, and BMI. Significant reduction in lean mass and fat-free mass is also observed. Bone mass seems not to be impaired. All outcomes reduction were observed only in the first 12 months after surgery. Sensitivity analysis suggests possible sex and type of surgery-related differences, favoring a higher fat mass, body weight, and BMI losses in boys and in patients who underwent RYGB.

Aminopeptidase O Protein mediates the association between Lachnospiraceae and appendicular lean mass

Objective

Investigating the causal relationship between Lachnospiraceae and Appendicular lean mass (ALM) and identifying and quantifying the role of Aminopeptidase O Protein (AOPEP) as a potential mediator.

Methods

The summary statistics data of gut microbiota composition from the largest available genome-wide association study (GWAS) meta-analysis conducted by the MiBioGen Consortium (n = 13,266). Appendicular lean mass data were obtained from the UK-Biobank (n = 450,243). We conducted bidirectional two-sample Mendelian randomization (MR) analysis using summary-level data from GWAS to investigate the causal relationship between Lachnospiraceae and ALM. Additionally, we employed a drug-targeted MR approach to assess the causal relationship between AOPEP and ALM. Finally, a two-step MR was employed to quantitatively estimate the proportion of the effect of Lachnospiraceae on ALM that is mediated by AOPEP. Cochran's Q statistic was used to quantify heterogeneity among instrumental variable estimates.

Results

In the MR analysis, it was found that an increase in genetically predicted Lachnospiraceae [OR = 1.031, 95% CI (1.011-1.051), P = 0.002] is associated with an increase in ALM. There is no strong evidence to suggest that genetically predicted ALM has an impact on Lachnospiraceae genus [OR = 1.437, 95% CI (0.785-2.269), P = 0.239]. The proportion of genetically predicted Lachnospiraceae mediated by AOPEP was 34.2% [95% CI (1.3%-67.1%)].

Conclusion

Our research reveals that increasing Lachnospiraceae abundance in the gut can directly enhance limb muscle mass and concurrently suppress AOPEP, consequently mitigating limb muscle loss. This supports the potential therapeutic modulation of gut microbiota for sarcopenia. Interventions such as drug treatments or microbiota transplantation, aimed at elevating Lachnospiraceae abundance and AOPEP inhibition, synergistically improve sarcopenia in the elderly, thereby enhancing the overall quality of life for older individuals.

The impact of leucine supplementation on body composition and glucose tolerance following energy restriction: an 8-week RCT in adults at risk of the metabolic syndrome

BACKGROUND

L-Leucine (Leu) supplementation may benefit fat-free mass (FFM) per se and glucose metabolism.

OBJECTIVES

To determine whether Leu supplementation during energy restriction blunted the loss of FFM, enhanced the loss of fat mass (FM) and improved glucose tolerance.

DESIGN

Thirty-seven adults, aged 20-65 years, with increased waist circumference and at least one other metabolic syndrome (MetS) component, were selected. We employed a two-arm parallel, double blind, randomized control trial (RCT) design. Participants were randomly assigned to an intervention group (leucine - 3 g/d) or placebo (lactose - 2.67 g/d), while following an individualised energy restricted diet for an 8-week period. Detailed body composition (DEXA), oral glucose tolerance test (OGTT), insulin and components of MetS were measured before and after the trial. Analysis of covariance (ANCOVA) assessed the effect of Leu on an intention-to-treat (ITT) principle. Bootstrapping method with 1000 bootstrap samples was used to derive parameter estimates, standard errors, p-values, and 95% confidence intervals for all outcomes.

RESULTS

Adjusted for baseline values and other covariates, FFM (p = 0.045) and lean tissue mass (LTM) (p = 0.050) were significantly higher following Leu. These outcomes were modified by a significant treatment x sex interaction that indicated Leu had the greater effect in men. However, on adjustment for body composition changes, there was no difference in insulin sensitivity, oral glucose tolerance, or change in MetS components following Leu.

CONCLUSION

Short-term leucine supplementation during energy restriction resulted in a greater preservation of FFM and LTM particularly in men, but did not impact glucose metabolism.

The Yucatan minipig model: A new preclinical model of malnutrition in obese patients with acute or chronic diseases

BACKGROUND & AIMS

Malnutrition can develop in patients with obesity suffering from acute or chronic illness or after obesity surgery, promoting sarcopenic obesity. A better understanding of this pathophysiology and the development of new therapeutics for chronic diseases, that are often complicated with malnutrition and obesity, justify the development of new animal experimental models close to the human physiology. This study aims to characterize the effects of obesity and underfeeding on Yucatan obese minipigs, assessing its validity as a preclinical model for obesity-related malnutrition.

METHODS

Sixteen 30-month-old Yucatan minipigs were divided into two groups for 8 weeks: a standard diet group (ST, n = 5) and an obesogenic diet group (OB, n = 11). After 8 weeks, the OB group was further divided into two sub-groups: a standard diet group (OB-ST, n = 5) and a low-calorie/low-protein diet group (OB-LC/LP, n = 6) for 8 weeks. Body composition by CT-Scan and blood parameters were monitored, and trapezius muscle biopsies were collected to analyse signaling pathways involved in protein turnover and energy metabolism.

RESULTS

At W8, OB-ST animals exhibited significantly higher body weight (+37.7%, p = 0.03), muscle mass (+24.9%, p = 0.02), and visceral fat (+192.0%, p = 0.03) compared to ST. Trapezius cross sectional area (CSA) normalized to body weight was lower in OB-ST animals (-15.02%, p = 0.017). At W16, no significant changes were observed in protein turnover markers, although REDD1 increased in OB-ST (96.4%, p = 0.02). After 8 weeks of low-caloric/low protein diet, OB-LC/LP showed decreased body weight (-9.8%, p = 0.03), muscle mass (-6.5%, p = 0.03), and visceral fat (-41.5%, p = 0.03) compared to OB-ST animals. Trapezius fiber CSA significantly decreased in OB-LC/LP (-36.1%, p < 0.0001) and normalized to body weight (-25.4%, p < 0.0001), combined to higher ubiquitinated protein content (+38.3%, p = 0.02).

CONCLUSION

Our data support that the Yucatan minipig model mimics nutritional and skeletal muscle phenotypes observed in obese patients, with or without protein-energy malnutrition. It also reproduces muscle atrophy observed in chronic diseases or post-obesity surgery, making it a promising preclinical model for obesity-related malnutrition.

Proportion of caloric restriction-induced weight loss as skeletal muscle

OBJECTIVE

This study's objective was to develop models predicting the relative reduction in skeletal muscle (SM) mass during periods of voluntary calorie restriction (CR) and to validate model predictions in longitudinally monitored samples.

METHODS

The model development group included healthy nonexercising adults (n = 897) who had whole-body SM mass measured with magnetic resonance imaging. Model predictions of relative SM changes with CR were evaluated in two longitudinal studies, one 12 to 14 weeks in duration (n = 74) and the other 12 months in duration (n = 26).

RESULTS

A series of SM prediction models were developed in a sample of 415 males and 482 females. Model-predicted changes in SM mass relative to changes in body weight (i.e., ΔSM/Δbody weight) with a representative model were (mean ± SE) 0.26 ± 0.013 in males and 0.14 ± 0.007 in females (sex difference, p < 0.001). The actual mean proportions of weight loss as SM in the longitudinal studies were 0.23 ± 0.02/0.20 ± 0.06 in males and 0.10 ± 0.02/0.17 ± 0.03 in females, similar to model-predicted values.

CONCLUSIONS

Nonelderly males and females with overweight and obesity experience respective reductions in SM mass with voluntary CR in the absence of a structured exercise program of about 2 to 2.5 kg and 1 to 1.5 kg per 10-kg weight loss, respectively. These estimates are predicted to be influenced by interactions between age and body mass index in males, a hypothesis that needs future testing.

The Role of Lifestyle Modification with Second-Generation Anti-obesity Medications: Comparisons, Questions, and Clinical Opportunities

PURPOSE OF REVIEW

This review examines lifestyle modification for obesity management with the goal of identifying treatment components that could support the use of a new generation of anti-obesity medications (AOMs).

RECENT FINDINGS

Semaglutide reliably reduces baseline body weight by approximately 15% at 68 weeks, in contrast to 5-10% for lifestyle modification. Tirzepatide induces mean losses as great as 20.9%. Both medications reduce energy intake by markedly enhancing satiation and decreasing hunger, and they appear to lessen the need for traditional cognitive and behavioral strategies (e.g., monitoring food intake) to achieve calorie restriction. Little, however, is known about whether patients who lose weight with these AOMs adopt healthy diet and activity patterns needed to optimize body composition, cardiometabolic health, and quality of life. When used with the new AOMs, the focus of lifestyle modification is likely to change from inducing weight loss (through calorie restriction) to facilitating patients' adoption of dietary and activity patterns that will promote optimal changes in body composition and overall health.

The Effects of Sodium-Glucose Cotransporter 2 Inhibitors on Body Composition in Type 2 Diabetes Mellitus: A Narrative Review

Body composition is related to cardiometabolic disorders and is a major driver of the growing incidence of type 2 diabetes mellitus (T2DM). Altered fat distribution and decreased muscle mass are related to dysglycemia and impose adverse health-related outcomes in people with T2DM. Hence, improving body composition and maintaining muscle mass is crucial in T2DM. Sodium-glucose cotransporter 2 (SGLT2) inhibitors are novel glucose-lowering medications gaining popularity because of their cardiorenal-protective effects and weight-lowering characteristics. However, reports on myopathy secondary to SGLT2 inhibitor treatment raised a safety concern. The importance of maintaining muscle mass in people with T2DM necessitates further investigation to explore the impact of novel medications on body composition. In this review, we discussed current evidence on the impact of SGLT2 inhibitors on body composition in people with T2DM.