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

[Implementation of guideline-based basic therapy for obesity in Germany]

The updated German S3 guideline on the prevention and treatment of obesity strongly recommends a multimodal lifestyle intervention, consisting of nutrition, exercise, and behavior therapy. Other options such as pharmacotherapy and bariatric surgery should be used in combination with this basic treatment. Current nutritional strategies for moderate energy restriction are equivalent. Regular physical activity of 30-60 minutes per day is advised. At present, there is only rather limited access to obesity management programs in groups or individual face-to-face dietary counseling with only facultative and partial reimbursement by statutory health insurance (SHI). Recently, 2 digital health applications (DiGAs) have been approved for obesity treatment. Both DiGAs can be prescribed by medical doctors and are fully paid by SHI. Shared decision making is recommended considering patient-specific criteria and choices. The recently approved disease management program for obesity will hopefully facilitate an evidence-based obesity management.

Genetic evidence for the effects of glucokinase activation on frailty-related outcomes: A Mendelian randomisation study

AIMS

We aimed to use the Mendelian randomisation (MR) design to investigate the potential causal effects of glucokinase (GK) activation on frailty-related outcomes and to explore the potential mediating effects of metabolic and inflammatory biomarkers.

MATERIALS AND METHODS

Seventeen independent single-nucleotide polymorphisms (SNPs) located within the GCK gene and significantly correlated with the glycated haemoglobin (HbA1c) level were used as genetic proxies for the effect of GK activation. We employed two-sample MR analysis to assess the relationship between genetically proxied GK activation and multifactorial frailty-related outcomes (frailty index, grip strength, walking pace, appendicular lean mass [ALM] and telomere length) We also explored the potential mediating effects using two-step MR.

RESULTS

Genetically proxied GK activation was significantly associated with a lower frailty index (beta: -0.161 per 1% decrease in HbA1c level due to GK activation, 95% confidence interval: -0.282 to -0.040, false discovery rate-adjusted p = 0.011). Additionally, GK activation showed significant associations with increased grip strength, higher ALM, faster walking pace and longer telomere length. GK activation also demonstrated a significant indirect effect on total grip strength and telomere length by reducing C-reactive protein levels (proportion of mediation: 6.79% to 8.21%).

CONCLUSION

Our study provides genetic evidence supporting the causal effects of GK activation on lowering the risk of frailty. These findings suggest that GK activators (GKAs) may aid in the management of frailty and sarcopaenia in people with diabetes; however, future randomized controlled trials are necessary to validate these results and establish their clinical applicability.

Targeting intramyocellular lipids to improve aging muscle function

Decline of skeletal muscle function in old age is a significant contributor to reduced quality of life, risk of injury, comorbidity and disability and even mortality. While this loss of muscle function has traditionally been attributed to sarcopenia (loss of muscle mass), it is now generally appreciated that factors other than mass play a significant role in age-related muscle weakness. One such factor gaining increased attention is the ectopic accumulation of lipids in skeletal muscle, in particular, intramyocellular lipids (IMCLs). It has been appreciated for some time that metabolic flexibility of several tissues/organs declines with age and may be related to accumulation of IMCLs in a "vicious cycle" whereby blunted metabolic flexibility promotes accumulation of IMCLs, which leases to lipotoxicity, which can then further impair metabolic flexibility. The standard interventions for addressing lipid accumulation and muscle weakness remain diet (caloric restriction) and exercise. However, long-term compliance with both interventions in older adults is low, and in the case of caloric restriction, may be inappropriate for many older adults. Accordingly, it is important, from a public health standpoint, to pursue potential pharmacological strategies for improving muscle function. Because of the success of incretin-analog drugs in addressing obesity, these medications may potentially reduce IMCLs in aging muscles and thus improve metabolic flexibility and improve muscle health. A contrasting potential pharmacological strategy for addressing these issues might be to enhance energy provision to stimulate metabolism by increasing NAD + availability, which is known to decline with age and has been linked to reduced metabolic flexibility. In this narrative review, we present information related to IMCL accumulation and metabolic flexibility in old age and how the two major lifestyle interventions, caloric restriction and exercise, can affect these factors. Finally, we discuss the potential benefits and risks of select pharmacologic interventions in older adults.

Metabolic dysfunction-associated steatotic liver disease: A story of muscle and mass

Skeletal muscle alterations (SMA) are increasingly recognized as both contributors and consequences of metabolic dysfunction-associated steatotic liver disease (MASLD), affecting disease progression and outcomes. Sarcopenia is common in patients with MASLD, with a prevalence ranging from 20% to 40% depending on the population and diagnostic criteria used. In advanced stages, such as metabolic dysfunction-associated steatohepatitis and fibrosis, its prevalence is even higher. Sarcopenia exacerbates insulin resistance, systemic inflammation, and oxidative stress, all of which worsen MASLD. It is an independent risk factor for fibrosis progression and poor outcomes including mortality. Myosteatosis refers to the abnormal accumulation of fat within muscle tissue, leading to decreased muscle quality. Myosteatosis is prevalent (> 30%) in patients with MASLD, especially those with obesity or type 2 diabetes, although this can vary with the imaging techniques used. It reduces muscle strength and metabolic efficiency, further contributing to insulin resistance and is usually associated with advanced liver disease, cardiovascular complications, and lower levels of physical activity. Altered muscle metabolism, which includes mitochondrial dysfunction and impaired amino acid metabolism, has been reported in metabolic syndromes, including MASLD, although its actual prevalence is unknown. Altered muscle metabolism limits glucose uptake and oxidation, worsening hyperglycemia and lipotoxicity. Reduced muscle perfusion and oxygenation due to endothelial dysfunction and systemic metabolic alterations are common in MASLD associated with comorbidities, such as obesity, hypertension, and atherosclerosis. It decreases the muscle capacity for aerobic metabolism, leading to fatigue and reduced physical activity in patients with MASLD, aggravating metabolic dysfunction. Various SMA in MASLD worsen insulin resistance and hepatic fat accumulation, may accelerate progression to fibrosis and cirrhosis, and increase the risk of cardiovascular disease and mortality. Management strategies for SMA include resistance training, aerobic exercise, and nutritional support (e.g., high-protein diets, vitamin D, and omega-3 fatty acids), which are essential for mitigating skeletal muscle loss and improving outcomes. However, pharmacological agents that target the muscle and liver (such as glucagon-like peptide-1 receptor agonists) show promise but have not yet been approved for the treatment of MASLD.

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.

Animal models for development of anti-obesity drugs in the age of GLP-1 agents

INTRODUCTION

Obesity is a major health crisis globally, with prevalence escalating significantly in recent decades. Obesity is not merely excessive weight but is associated with myriad health complications. Ensuring the translational effectiveness of pre-clinical obesity models is paramount, and the success of GLP-1 therapies has highlighted important benchmarks for guiding drug development.

AREAS COVERED

The authors discuss the status of various animal models used for the development of anti-obesity drugs, with particular emphasis on rodent models and their validity of preclinical-to-clinical translation. They also highlight innovative animal model integration opportunities between obesity and other associated pathology. The article is based on literature searches using PubMed for content (up until February 2025).

EXPERT OPINION

The effectiveness of GLP-1 therapies in treating type 2 diabetes and obesity presents an opportunity to evaluate the translational relevance of animal models of obesity. Due to their compelling safety profiles, GLP-1(s) are being tested in a wide range of obesity-associated diseases. Optimization of the mechanistic qualities in this drug class requires the incorporation of new endpoints beyond body weight, including lean mass preservation, cardiovascular health, and anti-inflammatory activities. Finally, we are compelled by the intersection of non-obesity disease models into an obesogenic framework to understand the combinatorial effects of obesity on these other disease indications, including heart failure, neurodegenerative diseases, and cancer.

Sarcopenia: an Aging Perspective and Management Options

There is no doubt that sarcopenia is one of the most defining characteristics of aging that negatively impacts the people's health and quality of life. The condition is characterized by the progressive and generalized loss of muscle mass and strength, affecting physical performance. It is part of aging but can be exacerbated by pathophysiological conditions like cancer and several factors such as a sedentary lifestyle, poor nutrition, chronic diseases, falls and immobilization. Numerous cellular mechanisms have been implicated in its pathogenesis, including hormonal changes, mitochondrial dysfunctions, altered apoptotic and autophagic signaling, muscle fiber composition, and inflammatory pathways. To prevent sarcopenia, exercise is one of the most effective strategies as it has a strong influence on both anabolic and catabolic muscle pathways and helps improve skeletal muscle function. A well-rounded, multicomponent exercise program that targets muscle strength, aerobic capacity, and balance is recommended for optimal results. While nutrition is essential for muscle maintenance, relying solely on dietary interventions is unlikely to fully address sarcopenia. Therefore, a combination of adequate nutrition and regular exercise is recommended to promote muscle health and function. The purpose of this study is to review sarcopenia from an aging viewpoint and discuss the role of exercise and nutrition as prevention and management options.

Dulaglutide 1.5 mg Significantly Improves Glycemic Control and Lowers LDL-Cholesterol and Body Weight in Romanian Patients with Type 2 Diabetes

Background: Dulaglutide is a glucagon-like peptide-1 (GLP-1) receptor agonist administered subcutaneously once a week, developed through recombinant DNA technology, and prescribed as an add-on to diet and exercise for managing type 2 diabetes mellitus in adults. In several clinical trials, once-weekly dulaglutide has demonstrated reductions in cardiovascular risk associated with diabetes, as well as improvements in glycemic control and weight reduction. The scope of this study was to evaluate the effect of dulaglutide 1.5 mg on glycemic control, weight management, and LDL-cholesterol levels in patients with uncontrolled type 2 diabetes mellitus. Methods: We retrospectively reviewed the medical records of 55 patients with inadequately controlled type 2 diabetes mellitus who were on oral antidiabetic agents and insulin, and who were additionally treated with dulaglutide 1.5 mg. We monitored fasting plasma glucose and glycated hemoglobin (HbA1c) at baseline and at 6, 12, and 24 months after initiating dulaglutide treatment. Weight, body mass index, and LDL-cholesterol were assessed at baseline and after 24 months of dulaglutide therapy. Results: Treatment with dulaglutide resulted in significant improvements in fasting plasma glucose and HbA1c after 6 months (p < 0.001), 12 months (p < 0.001), and 24 months (p < 0.001). A significant weight reduction was observed after 24 months of dulaglutide therapy (-3.3 kg; p < 0.001). In addition, we observed a significant reduction in LDL-cholesterol after 24 months (p < 0.001). Conclusions: Our data demonstrate that dulaglutide 1.5 mg significantly improves glycemic control, reduces body weight, and lowers LDL-cholesterol in Romanian patients with inadequately controlled type 2 diabetes.

Spinal Cord Stimulation - Device Revision After Weight Loss in a Patient on Chronic Semaglutide - A Case Report

Background

Spinal cord stimulation (SCS) is an effective treatment option for patients suffering from chronic intractable pain of the trunk and/or limbs. One of the potential adverse effects of SCS is discomfort or pain at the site of the implantable pulse generator (IPG). It is a known phenomenon that patient weight loss may exacerbate or increase discomfort or pain at the IPG implantation site.

Objective

This case report aims to educate neuromodulation clinicians on the potential impact of glucagon-like peptide-1 receptor agonists (GLP-1RA) medications on patient weight loss and decreased subcutaneous adipose tissue stores post-SCS system implant, necessitating lead anchor or IPG pocket revision.

Study Design

Case Report.

Conclusion

The usage of GLP-1RA medications for diabetes or weight loss therapy continues to increase as does the use of implantable SCS systems for the management of chronically painful conditions. Interventional pain management or neuromodulation clinicians should be well-educated on the indications for use of GLP-1RA medications and their associated mechanisms of action, which may lead to weight loss, decreased subcutaneous adipose tissue stores, and muscle wasting, potentially impacting the comfortability of SCS devices. Pre-screening for the use of GLP-1RA medications should occur prior to SCS implant, and clinicians should plan accordingly to minimize the potential for SCS lead anchor or IPG pocket site discomfort. Further, patient's body habitus and adipose tissue stores should be taken into consideration when planning for IPG pocket site location.

The Effects of GLP-1 Agonists on Musculoskeletal Health and Orthopedic Care

PURPOSE OF REVIEW

The global rise in obesity and type 2 diabetes mellitus (T2DM) presents significant challenges in musculoskeletal care, contributing to increased perioperative complications, impaired bone health, and compromised muscle function. Glucagon-like peptide-1 receptor agonists (GLP-1RAs), initially developed for glycemic control in T2DM, have demonstrated substantial benefits in weight reduction and metabolic regulation. The purpose of this review is to understand the musculoskeletal biologic and clinical implications of GLP-1RAs.

RECENT FINDINGS

Evidence suggests that GLP-1RAs may impact musculoskeletal health through anti-inflammatory effects, bone metabolism modulation, and alterations in muscle composition. GLP-1RAs may promote osteoblastogenesis while dampening osteoclast activity to maintain bone mineral density. The result on fracture risk is unclear. Additionally, while GLP-1RAs cause lean mass loss, GLP-1RAs appear to preserve skeletal muscle, reduce fatty infiltration, and enhance fiber formation and function. Further, GLP-1Rs are present in synovial tissue and cartilage, demonstrating downregulation of inflammatory molecules and chondrocyte apoptotic pathways, though clinical studies show variable effects in the setting of osteoarthritis. Overall, the heterogeneity in findings underscores the need for further research to delineate the long-term musculoskeletal effects of GLP-1RAs. Understanding the musculoskeletal impact of GLP-1RAs is critical for optimizing their integration into orthopedic practice. This review explores the orthopedic implications of GLP-1RAs, highlighting their biologic mechanisms and clinical effects on obesity-related joint inflammation and arthropathy, bone mineral density and fracture risk, and skeletal muscle preservation.

GLP-1 Agonist Use Among Men with Localized Prostate Cancer: A Narrative Review and Rationale for Prospective Clinical Trials

GLP-1 receptor agonists are a revolutionary treatment for obesity and investigations into other uses of these agents are ongoing. Epidemiologic data suggest that prostate cancer risk may decrease following GLP-1 receptor agonist initiation. To better define the potential role of GLP-1 receptor agonist use among men with prostate cancer, we will define changes that occur in men with prostate cancer following lifestyle intervention; illuminate the current relationship between these interventions and prostate cancer risk; and explore the potential mechanism of action on tumor biology, providing rationale for evaluating its effects on prostate cancer in a planned clinical trial.

Long-term delirium and survival outcomes in patients treated with GLP-1 receptor agonists versus metformin in type 2 diabetes: A population-based cohort study

AIM

Type 2 diabetes mellitus (T2DM) is associated with an increased risk of delirium and mortality. While glucagon-like peptide-1 receptor agonists (GLP-1 RAs) provide metabolic and neuroprotective benefits, their long-term impact on delirium risk remains uncertain. This study compares GLP-1 RAs and metformin in relation to delirium and mortality in T2DM patients using real-world data.

METHODS

A retrospective cohort study was conducted using the TriNetX global federated research network, which primarily comprises U.S.-based healthcare organisations (approximately 85%), with additional sites in Europe, Asia-Pacific and the Middle East. Adults (≥18 years) with T2DM who initiated GLP-1 RAs or metformin were included. Propensity score matching (PSM) balances baseline characteristics. The primary outcome was incident delirium; the secondary outcome was all-cause mortality. Kaplan-Meier survival curves and time-dependent Cox models assessed associations.

RESULTS

After 1:1 PSM (N = 63 096 per group), GLP-1 RAs showed no overall reduction in delirium risk (AHR: 0.98, 95% CI: 0.94-1.02, p = 0.3628). However, they were protective in the first 5 years (AHR: 0.89, 95% CI: 0.86-0.92, p < 0.0001) but increased delirium risk between 5 and 10 years (AHR: 1.15, 95% CI: 1.04-1.26, p = 0.0046). Subgroup analysis revealed lower delirium risk with GLP-1 RAs in middle-aged patients (40-79 years) and those with HbA1c <7.5%. Higher risk was observed in Asian and Native Hawaiian/Pacific Islander populations. However, these findings should be interpreted with caution due to the relatively small subgroup sizes and the limited representativeness of these groups within the predominantly U.S.-based database, in which Asian and Native Hawaiian/Pacific Islander patients together accounted for less than 5% of the overall cohort. Mortality risk was lower in absolute terms for GLP-1 RAs (6.28% vs. 9.95%) but higher in long-term hazard (AHR: 1.16, 95% CI: 1.12-1.21, p < 0.001).

CONCLUSIONS

GLP-1 RA use was initially associated with a lower risk of delirium, but this association reversed over time. Subgroup variations suggest individualised treatment considerations. Metformin remains a preferred option given its stable cognitive and survival benefits.

Clinical staging to guide management of metabolic disorders and their sequelae: a European Atherosclerosis Society consensus statement

Obesity rates have surged since 1990 worldwide. This rise is paralleled by increases in pathological processes affecting organs such as the heart, liver, and kidneys, here termed systemic metabolic disorders (SMDs). For clinical management of SMD, the European Atherosclerosis Society proposes a pathophysiology-based system comprising three stages: Stage 1, where metabolic abnormalities such as dysfunctional adiposity and dyslipidaemia occur without detectable organ damage; Stage 2, which involves early organ damage manifested as Type 2 diabetes, asymptomatic diastolic dysfunction, metabolic-associated steatohepatitis (MASH), and chronic kidney disease (CKD); and Stage 3, characterized by more advanced organ damage affecting multiple organs. Various forms of high-risk obesity, driven by maintained positive energy balance, are the most common cause of SMD, leading to ectopic lipid accumulation and insulin resistance. This progression affects various organs, promoting comorbidities such as hypertension and atherogenic dyslipidaemia. Genetic factors influence SMD susceptibility, and ethnic disparities in SMD are attributable to genetic and socioeconomic factors. Key SMD features include insulin resistance, inflammation, pre-diabetes, Type 2 diabetes, MASH, hypertension, CKD, atherogenic dyslipidaemia, and heart failure. Management strategies involve lifestyle changes, pharmacotherapy, and metabolic surgery in severe cases, with emerging treatments focusing on genetic approaches. The staging system provides a structured approach to understanding and addressing the multi-faceted nature of SMD, which is crucial for improving health outcomes. Categorization of SMD abnormalities by presence and progression is aimed to improve awareness of a multi-system trait and encourage a tailored and global approach to treatment, ultimately aiming to reduce the burden of obesity-related comorbidities.

Nutrition support whilst on glucagon-like peptide-1 based therapy. Is it necessary?

AIM OF THE REVIEW

Weight loss is a primary goal in the treatment of obesity, but its effect on body composition - particularly fat-free mass (FFM) and skeletal muscle mass (SM) - is of increasing concern. This review examines the effects of antiobesity medications, particularly glucagon-like peptide-1 receptor analogs (GLP-1 RA), on body composition, the risk of sarcopenia, and strategies to preserve muscle mass during pharmacological weight loss.

RECENT FINDINGS

Studies have shown that while GLP-1 RA are effective in reducing fat mass, up to 40% of the total weight loss can come from FFM. However, it is important to distinguish between FFM and SM, as FFM includes nonmuscle components. Resistance training and adequate protein intake can mitigate muscle loss, but the evidence for their efficacy in the context of GLP-1 RA therapy is mixed. If these measures are insufficient to prevent and maintain muscle mass, the use of some nutrients, such as branched chain amino acids, creatine, leucine, omega-3 fatty acids and vitamin D, may be beneficial. Newer pharmacological approaches, such as bimagrumab, a human monoclonal antibody that acts by binding to the activin type II receptor II (ActRII), and other activin or myostatin inhibitors, show promise in preserving muscle mass while promoting fat loss.

SUMMARY

GLP-1 RA therapy for obesity should include resistance training, optimal protein intake and, if needed, specific nutrients and possibly pharmacological interventions to preserve muscle mass. Further research is needed to assess the long-term effects of GLP-1 RA on muscle health and to refine strategies to prevent sarcopenia in patients undergoing pharmacological weight loss.

Semaglutide and walking capacity in people with symptomatic peripheral artery disease and type 2 diabetes (STRIDE): a phase 3b, double-blind, randomised, placebo-controlled trial

BACKGROUND

Peripheral artery disease is a highly morbid type of atherosclerotic vascular disease involving the legs and is estimated to affect over 230 million individuals globally. Few therapies improve functional capacity and health-related quality of life in people with lower limb peripheral artery disease. We aimed to evaluate whether semaglutide improves function as measured by walking ability as well as symptoms, quality of life, and outcomes in people with peripheral artery disease and type 2 diabetes.

METHODS

STRIDE was a double-blind, randomised, placebo-controlled trial done at 112 outpatient clinical trial sites in 20 countries in North America, Asia, and Europe. Participants were aged 18 years and older, with type 2 diabetes and peripheral artery disease with intermittent claudication (Fontaine stage IIa, able to walk >200 m) and an ankle-brachial index of less than or equal to 0·90 or toe-brachial index of less than or equal to 0·70. Participants were randomly assigned (1:1) using an interactive web response system to receive subcutaneous semaglutide 1·0 mg once per week for 52 weeks or placebo. The primary endpoint was the ratio to baseline of the maximum walking distance at week 52 measured on a constant load treadmill in the full analysis set. Safety was evaluated in the safety analysis set. This trial is registered with ClinicalTrials.gov, NCT04560998 and is now completed.

FINDINGS

From Oct 1, 2020, to July 12, 2024, 1363 patients were screened for eligibility, of whom 792 were randomly assigned to semaglutide (n=396) or placebo (n=396). 195 (25%) participants were female and 597 (75%) were male. Median age was 68·0 years (IQR 61·0-73·0). The estimated median ratio to baseline in maximum walking distance at week 52 was significantly greater in the semaglutide group than the placebo group (1·21 [IQR 0·95-1·55] vs 1·08 [0·86-1·36]; estimated treatment ratio 1·13 [95% CI 1·06-1·21]; p=0·0004). Six serious adverse events in five (1%) participants in the semaglutide group and nine serious adverse events in six (2%) participants in the placebo group were possibly or probably treatment related, with the most frequent being serious gastrointestinal events (two events reports by two [1%] in the semaglutide group and five events reported by three [1%] in the placebo group). There were no treatment-related deaths.

INTERPRETATION

Semaglutide increased walking distance in patients with symptomatic peripheral artery disease and type 2 diabetes. Research implications include the need for future studies to further elucidate mechanisms of benefit and to assess the efficacy and safety in patients with peripheral artery disease who do not have type 2 diabetes.

FUNDING

Novo Nordisk.

Impact of GLP- 1 Receptor Agonist Therapy in Patients High Risk for Sarcopenia

PURPOSE OF REVIEW

Glucagon-like peptide- 1 receptor agonists (GLP- 1 RA) are a rapidly expanding class of medications used to treat many chronic diseases. This review explores factors that may contribute to accelerated muscle loss among higher-risk patient populations and describes tailored interventions to reduce the risk of accelerated sarcopenia and frailty.

RECENT FINDINGS

While GLP- 1 RA can result in total weight loss upwards of 25%, recent studies show that they can also lead to significant loss of lean body mass, reaching as high as 15-40% of total weight lost. This rapid and significant decline in muscle mass while taking GLP- 1 RA places certain patient populations already predisposed to sarcopenia at higher risk for muscle loss and adverse events. Currently, there is insufficient evidence delving into the impact of GLP- 1 RA on body composition among older adults, patients with chronic kidney disease, liver disease, and inflammatory bowel disease. However, research suggests that a high protein diet and resistance training may help prevent loss of muscle mass during GLP- 1 RA usage. A targeted and individualized nutrition and physical activity regimen should be instituted for each patient with a focus on optimizing protein intake and performing frequent resistance training in order to minimize loss of muscle mass while promoting the loss of fat mass. Future research should evaluate the impact of GLP- 1 RA on sarcopenia in high-risk patient populations.

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.

Impact of Metabolic Dysfunction-associated Steatotic Liver Disease on Cardiovascular Structure, Function, and the Risk of Heart Failure

Mounting evidence has established metabolic dysfunction-associated steatotic liver disease (MASLD) as an independent risk factor for heart failure (HF), particularly HF with preserved ejection fraction (HFpEF). In this narrative review we explore the impact of MASLD on cardiovascular structure and function. We summarize findings from multiple cohort studies demonstrating that MASLD is associated with distinct patterns of adverse cardiac remodeling, including increased left ventricular concentricity and impaired diastolic function. These subclinical changes in cardiac structure and function often precede overt HF development and appear to occur in the context of multiple interconnected pathways involving metabolic dysfunction, systemic inflammation, adipose tissue dysregulation, vascular dysfunction, and altered hepatic hemodynamics. Early identification of cardiac structural and functional abnormalities through systematic screening may enable timely intervention in this high-risk population. Lifestyle modifications remain foundational, but achieving and maintaining significant weight loss is challenging. Recent clinical trials have shown promising results with cardiometabolic agents, particularly glucagon-like protein 1 receptor agonists, which demonstrate significant weight loss and hepatic and cardiovascular benefits. Despite these advances, key knowledge gaps remain regarding optimal screening strategies, mechanisms linking MASLD to HF, and targeted therapeutic approaches. Addressing these gaps will be essential for developing effective prevention and treatment strategies in this high-risk population.

Pharmacological recapitulation of the lean phenotype induced by the lifespan-extending sulfur amino acid-restricted diet

Sulfur amino acid restriction (SAAR), lowering the dietary concentration of sulfur amino acids methionine and cysteine, induces strong anti-obesity effects in rodents. Due to difficulties in formulating the SAAR diet for human consumption, its translation is challenging. Since our previous studies suggest a mechanistic role for low glutathione (GSH) in SAAR-induced anti-obesity effects, we investigated if the pharmacological lowering of GSH recapitulates the lean phenotype in mice on a sulfur amino acid-replete diet. Male obese C57BL6/NTac mice were fed high-fat diets with 0.86% methionine (CD), 0.12% methionine (SAAR), SAAR diet supplemented with a GSH biosynthetic precursor, N-acetylcysteine in water (NAC), and CD supplemented with a GSH biosynthetic inhibitor, DL-buthionine-(S, R)-sulfoximine in water (BSO). The SAAR diet lowered hepatic GSH but increased Nrf2, Phgdh, and serine. These molecular changes culminated in lower hepatic lipid droplet frequency, epididymal fat depot weights, and body fat mass; NAC reversed all these changes. BSO mice exhibited all SAAR-induced changes, with two notable differences, i.e., a smaller effect size than that of the SAAR diet and a higher predilection for molecular changes in kidneys than in the liver. Metabolomics data indicate that BSO and the SAAR diet induce similar changes in the kidney. Unaltered plasma aspartate and alanine transaminases and cystatin-C indicate that long-term continuous administration of BSO is safe. Data demonstrate that BSO recapitulates the SAAR-induced anti-obesity effects and that GSH plays a mechanistic role. BSO dose-response studies in animals and pilot studies in humans to combat obesity are highly warranted.

Critical analysis of dual-energy x-ray absorptiometry-measured body composition changes with voluntary weight loss

OBJECTIVE

When treated with a macronutrient-balanced hypocaloric diet, do male individuals who have overweight and obesity lose relatively more dual-energy x-ray absorptiometry (DXA)-measured lean soft tissue (LST) mass than female individuals? Are there changes in bone mineral content (BMC), and if so, how do they impact relative reductions in LST compared to fat-free mass (FFM; LST plus BMC)? Are decrements in fat, LST, and FFM predictable from the magnitude of weight loss or baseline body composition?

METHODS

To answer these questions, DXA studies were conducted before and after a 9- to 12-week calorie-restriction period in 43 male and 97 female individuals who lost a mean (SD) of 10.8% (2.2%) and 10.7% (1.6%) of their baseline weight, respectively.

RESULTS

The proportion of weight loss as LST was significantly (p < 0.001) larger in male (mean [SD], 0.33 [0.11] kg) than female individuals (0.25 [0.11] kg); BMC paradoxically increased, thereby leading to a significantly smaller reduction in FFM than LST in the male (-3.87 [1.73] kg vs. -3.92 [1.74] kg; p < 0.001) and female individuals (-2.22 [1.18] kg vs. -2.24 [1.18] kg; p < 0.001), and three different analyses showed that the composition of weight loss tracked as predicted a priori from weight change and baseline body composition.

CONCLUSIONS

These observations provide insights into and future guidance for analyzing the DXA-measured body composition changes associated with newer pharmacotherapies for weight loss.

Novel pharmacotherapies for weight loss: Understanding the role of incretins to enable weight loss and improved health outcomes

Obesity and type 2 diabetes mellitus (T2D) are widespread diseases that significantly impact cardiovascular and renal morbidity and mortality. In the recent years, intensive research has been performed to assess the role of adipose tissue and body fat distribution in the development of metabolic and non-metabolic complications in individuals with obesity. In addition to lifestyle modifications, glucagon-like peptide-1 receptor agonists (GLP-1-RA) have become a meaningful treatment expansion for the management of both disorders. In addition to improving metabolic control and reducing body weight, treatment with GLP-1-RAs reduces cardiovascular and renal events in individuals with obesity with and without diabetes. These important benefits of GLP-1-RAs have triggered new interest in other enteroendocrine and enteropancreatic peptides for treating obesity and its metabolic and non-metabolic consequences. The first peptide dual-agonist targeting glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 receptors has been approved for the treatment of T2D and obesity. GIP/GLP-1 dual-agonism appear to provide better metabolic control and greater weight reduction compared with GLP-1-R mono-agonism. Other peptide and non-peptide co-agonists are in clinical development for obesity, T2D, metabolic dysfunction-associated steatotic liver disease (MASLD) and other metabolic disorders. This narrative review aims to summarize the available data on approved and emerging enteroendocrine and enteropancreatic based treatment approaches for obesity and metabolic disorders. In addition to available clinical efficacy measures, side effects, limitations and open challenges will also be addressed.

Use of glucagon-like peptide-1 receptor agonists and incretin mimetics for type 2 diabetes and obesity: A narrative review

Incretin mimetics, including glucagon-like peptide-1 and glucose-dependent insulinotropic polypeptide agonists, have become first-line treatment options for the treatment of type 2 diabetes and obesity. Their therapeutic status is attributed to their high level of efficacy as well as positive impact on related comorbidities, such as sleep apnea and heart failure. Multiple incretin mimetics are currently available with different durations of drug action, dosing frequencies, and delivery devices. Patients may benefit from education on the proper drug administration, anticipated adverse effects, and nutrition considerations with treatment. Practitioners must monitor progress and support the patient to achieve maintenance doses for optimal weight reduction and diabetes-related outcomes. This review aims to present the current literature supporting US Food and Drug Administration-approved indications of incretin mimetics, equip healthcare professionals to optimize care for patients who are prescribed these agents, and provide insights into potential future applications, which may include dual- or triple-mechanism agents that are injected or administered orally. Additional studies are anticipated with existing and future incretin mimetics for the treatment of type 2 diabetes, obesity, and related comorbidities in a rapidly developing therapeutic pipeline.

How 'miracle' weight-loss semaglutide promises to change medicine but can we afford the expense?

Obesity is a complex and growing global concern, affecting one in eight individuals and compromising health, quality of life and life expectancy. It carries significant metabolic, cardiovascular, oncological, hepatorenal, skeletal and psychiatric risks, imposing substantial costs on health-care systems. Traditional treatments have often been ineffective or have led to relapse after lifestyle changes. Whereas bariatric surgery is effective, it also involves risks such as mortality and hospitalisation. Semaglutide, licensed in 2018, is a synthetic analogue of glucagon-like peptide 1 which regulates glucose metabolism and gastrointestinal (GI) motility. Studies show that semaglutide, administered either weekly and subcutaneously, or daily orally, induces an average weight loss of -11.62 kg compared to placebo and reduces waist circumference by up to -9.4 cm. It also improves blood pressure, fasting glucose levels, C-reactive protein levels and lipid profiles. The most common adverse events are mild-to-moderate GI complaints occurring more frequently with daily administration than weekly doses; hypoglycaemia is more common without lifestyle intervention. Weight regain often follows semaglutide withdrawal. Furthermore, semaglutide offers cardiovascular benefits for patients with established atherosclerotic cardiovascular disease (CVD), lowers the risk of kidney outcomes and cardiovascular-related death, resolves nonalcoholic steatohepatitis in many cases, and positively impacts mental health and quality of life. In conclusion, semaglutide therapy could significantly benefit many adults regarding CVD and mortality if made widely accessible. Ethical and financial considerations must be addressed for personalised obesity treatment approaches.

Effects of Dulaglutide on Ectopic Fat Deposition in Chronic Kidney Disease (CKD): A Pilot and Feasibility Study (GLIMP)

Introduction

Patients with chronic kidney disease (CKD) often exhibit ectopic fat accumulation, including intermuscular adipose tissue (IMAT), which is associated with metabolic and muscular dysfunctions. This study aimed to evaluate the effects of dulaglutide, a glucagon-like peptide-1 receptor agonist (GLP-1RA), on reducing IMAT and improving metabolic and physical functions in patients with CKD stage 3-4.

Methods

Seven patients were recruited between April 2022 and November 2023. A 12-week dulaglutide (1.5 mg/wk) intervention was conducted with pre-and post-treatment assessments, including magnetic resonance imaging (MRI) for the IMAT evaluation and systemic physical performance battery test (SPPB) for physical performance evaluation. Their body mass indexes (BMI) were calculated and blood samples were analyzed for inflammatory and metabolic markers, including high sensitive C-reactive protein (Hs-CRP), tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), glucose, insulin resistance (IR), total cholesterol, triglyceride, adiponectin, leptin, and leptin-adiponectin ratio (LAR) before and after treatment. Paired t-tests and Mann-Whitney U tests were used for statistical analysis, with significance set at p < 0.05.

Results

Out of 58 assessed patients with CKD stage 3-4, 7 were enrolled, with 5 completing the full 12-week dulaglutide treatment. The total 7 people had a mean age of 59 years, mean BMI of 31.4 kg/m2, and baseline eGFR of 31.7 mL/min/1.73m2. IMAT decreased in 4 patients and increased in 3 patients, with no statistically significant changes overall (p = 0.69). The quadriceps muscle cross-sectional area (CSA) also showed no significant difference (p = 0.73). BMI and serum leptin levels significantly decreased after treatment (p < 0.05), while other inflammatory and metabolic markers, and physical performance scores showed no significant changes. No serious adverse events were reported.

Conclusions

This study examined the effects of a 12-week dulaglutide treatment on IMAT accumulation in patients with CKD stage 3-4. While BMI significantly decreased, changes in IMAT were modest and not statistically significant, with potential but unproven clinical and metabolic benefits. Many metabolic and inflammatory markers improved, though not statistically significantly, and physical performance remained unchanged. Muscle CSA and function were maintained, which may alleviate concerns about potential GLP-1RA-induced muscle loss. Dulaglutide was well-tolerated, with minimal side effects. The small sample size and short duration highlight the need for further research.

Weight Reduction with GLP-1 Agonists and Paths for Discontinuation While Maintaining Weight Loss

Worldwide, nearly 40% of adults are overweight and 13% are obese. Health consequences of excess weight include cardiovascular diseases, type 2 diabetes, dyslipidemia, and increased mortality. Treating obesity is challenging and calorie restriction often leads to rebound weight gain. Treatments such as bariatric surgery create hesitancy among patients due to their invasiveness. GLP-1 medications have revolutionized weight loss and can reduce body weight in obese patients by between 15% and 25% on average after about 1 year. Their mode of action is to mimic the endogenous GLP-1, an intestinal hormone that regulates glucose metabolism and satiety. However, GLP-1 drugs carry known risks and, since their use for weight loss is recent, may carry unforeseen risks as well. They carry a boxed warning for people with a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2. Gastrointestinal adverse events (nausea, vomiting, diarrhea) are fairly common while pancreatitis and intestinal obstruction are rarer. There may be a loss of lean body mass as well as premature facial aging. A significant disadvantage of using these medications is the high rate of weight regain when they are discontinued. Achieving success with pharmacologic treatment and then weaning to avoid future negative effects would be ideal.

GLP-1 Agonists for Weight Loss: Do They Increase Complications in Non-diabetic Patients Undergoing Primary Total Hip Arthroplasty?

BACKGROUND

Glucagon-like peptide 1 (GLP-1) agonists are an effective medication for glycemic control and weight loss. These effects may reduce complications in diabetic patients undergoing total hip arthroplasty (THA). However, there remains a paucity of data on the impact of GLP-1 medications in nondiabetic patients using the medication solely for weight reduction. There is concern that rapid weight loss associated with GLP-1 agonists may lead to malnutrition and increase the risk of postoperative complications in patients undergoing THA.

METHODS

A retrospective query was performed from January 1, 2010, to January 1, 2022, using an insurance claims database to identify patients undergoing primary THA on GLP-1 agonists (n = 839,715). Patients on GLP-1 therapy (n = 5,345) at the time of surgery were propensity score-matched 1:1 to controls who were not on GLP-1 agonists (n = 5,345) based on age, sex, the Elixhauser Comorbidity Index, and its components. Patients who had diabetes mellitus were excluded. The 90-day outcomes were evaluated, including medical complications, readmission, and reoperation rates. We also examined the incidence of all-cause revision and implant-related complications at a 2-year follow-up. Odds ratios (ORs) were generated using logistic regression analyses.

RESULTS

Patients who were on GLP-1 agonist medications were less likely to develop acute blood loss anemia (OR: 0.57; 95% confidence interval [CI]: 0.34 to 0.96) and require postoperative transfusion (OR: 0.53; 95% CI: 0.36 to 0.78) or visit the emergency department within 90 days of surgery (OR: 0.81; 95% CI: 0.69 to 0.92) when compared to patients who did not have GLP-1 therapy. Patients were at comparable risk of deep venous thrombosis, pulmonary embolism, mortality, stroke, myocardial infarction, acute kidney injury, and sepsis regardless of GLP-1 status (P > 0.05). Notably, the rate of aspiration pneumonia was similar between groups (OR: 1.17; 95% CI: 0.62 to 2.19). Also, GLP-1 therapy did not put patients at higher risk of surgical complications, including periprosthetic joint infection, instability, fracture, loosening, or all-cause revision, at 90 days and two years (P > 0.05).

CONCLUSIONS

Use of a GLP-1 agonist does not appear to increase the odds of postoperative medical and surgical complications after THA in nondiabetic patients taking GLP-1 medications for weight loss alone.

The impact of lifestyle-based weight loss in older adults with obesity on muscle and bone health: a balancing act

Despite adverse metabolic and functional consequences of obesity (BMI ≥30 kg/m2), clinical recommendations for weight loss (WL) in older adults (65+ years) with obesity remain controversial. Reluctance stems partly from epidemiologic data demonstrating musculoskeletal tissue loss with WL and increased risk of disability and osteoporotic fracture. Randomized controlled trials in older adults complement and extend knowledge in this area showing: (1) lifestyle-based WL interventions often yield clinically meaningful (~8%-10%) WL in older adults; (2) lean mass loss is significant, although fat mass loss is preferential and physical performance is often improved, particularly when combined with aerobic and resistance training (RT); (3) bone loss is also significant, with some evidence that RT can attenuate WL-associated bone loss; and (4) fat mass regain after intervention cessation is common, yet physical performance gains appear to be maintained. Best practices for treating older adults with obesity include comprehensive assessment of baseline musculoskeletal health; patient-centered goal setting; moderate (i.e., -500 kcal/day) caloric restriction ensuring protein (1-1.2 g/kg/day), calcium (1000-1200 mg/day), and vitamin D (800-1000 IU/day) needs are met; incorporation of RT (≥2 days/week) and moderate-intensity weight-bearing aerobic training (≥150 min/week); and delivery of care by a multidisciplinary team.

An exploratory analysis of glucagon-like peptide-1 (GLP-1) agonists and biosimilars: A literature review

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are at the forefront of treating the global health crisis of diabetes mellitus (DM) and obesity. However, the demand for GLP-1 RAs has far outstripped its supply and comes with a high monthly cost. Thus, the development of GLP-1 RA biosimilars can potentially address these barriers by providing greater access to medications that provide clinical outcomes similar to those of the reference products. A narrative review was conducted to examine the current and future developments for GLP-1 RA biosimilars. Liraglutide and semaglutide are the predominant GLP-1 RAs being investigated for the development of biosimilars. Preliminary liraglutide biosimilar comparisons to reference liraglutide have demonstrated similar clinical efficacy and safety profiles. Semaglutide and beinaglutide biosimilars are currently under investigation as well. With the growing popularity of GLP-1 RAs, accessibility and affordability remain a challenge as monthly costs without insurance for liraglutide, semaglutide and tirzepatide are $1418, $892, and $974 respectively. This trend negatively impacts patients with obesity and DM as well as patients who can utilize it for off-label indications for conditions that benefit from weight loss such as obstructive sleep apnoea and non-alcoholic fatty liver disease. A substantial number of pharmaceutical and healthcare companies worldwide are conducting clinical trials on their GLP-1 RA biosimilars. Preliminary results from liraglutide biosimilars are promising, and several semaglutide biosimilars are currently being investigated. Future research should focus on conducting comparative head-to-head trials to determine the clinical outcomes between biosimilars and reference products.

The potential role of GLP-1 receptor agonists in osteoarthritis

Osteoarthritis (OA) is the most common form of arthritis, affecting over 500 million people globally. Current treatments are primarily symptom-focused, with no approved therapies to halt disease progression. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs), widely used in type 2 diabetes (T2D) and obesity, demonstrate significant weight loss and glucose-lowering effects and have been shown to possess anti-inflammatory properties. Given the central role of inflammation and metabolic dysfunction in OA, this review examines the potential utility of GLP-1 RAs in OA management, focusing on both indirect effects, such as weight reduction, and possible direct effects on inflammatory pathways and cartilage preservation. Clinical studies suggest that GLP-1 RAs may benefit people with OA by reducing weight, improving glycemic control, and modulating inflammatory markers relevant to OA progression. Notable findings include significant weight loss and pain reduction in people with knee OA (KOA) treated with semaglutide in the STEP-9 trial. In other studies, GLP-1 RAs have shown potential to lower oxidative stress and pro-inflammatory cytokines, such as tumor necrosis factor (TNF-α) and interleukin (IL)-6, with reductions in OA-related pain and functional impairment observed in some cohorts. However, results vary, with some studies showing limited effects, potentially linked to the degree of weight loss achieved. Although some studies report variability in pain relief, likely influenced by the degree of weight loss achieved, GLP-1 RAs have shown overall promise in reducing both OA symptoms and markers associated with disease progression. This emerging evidence supports the utility of GLP-1 RAs as a potential disease-modifying option for OA, offering a dual benefit in metabolic and joint health. Future research should focus on establishing the long-term efficacy and safety and elucidating the mechanism by which GLP-1 RAs influence OA pathology.

A preliminary randomized trial of a brief dissonance-based type 2 diabetes prevention programme for adults with pre-diabetes

OBJECTIVE

Conduct a preliminary randomized trial that compared a 6-week type 2 diabetes (T2D) prevention programme to an educational video control for adults with pre-diabetes.

METHODS

Adults (N = 62) with pre-diabetes were randomized to the group-delivered Project Health T2D or an educational video control, completing measures at pre-test, post-test and 3-month follow-up.

RESULTS

Participants randomized to the intervention versus control condition showed significantly greater reductions in body fat (d = 0.76, p = 0.002; d = 1.07, p < 0.001), weight (d = 0.59, p = 0.030; 0.65, p = 0.017) and body mass index (BMI = kg/m2; d = 0.60, p = 0.030; 0.67, p = 0.014), significantly greater increases in lean mass (d = 0.80, p = 0.003; 0.93, p = 0.001) at post-test and 3-month follow-up, respectively, and marginally greater reductions in glycated haemoglobin (HbA1c) (d = 0.54, p = 0.056), but not fasting plasma glucose at 3-month follow-up (d = 0.25, p = 0.364). Project Health T2D also produced a marginally greater 75% reduction in future onset of type 2 diabetes compared with educational controls, reducing incidence over the total 5-month observation period from 15% to 4% (odds ratio = 4.52, p = 0.096).

CONCLUSIONS

Project Health T2D produced encouraging reductions in body fat, weight and T2D incidence, and increases in lean mass, and is less intensive than other lifestyle modification T2D prevention programme, suggesting that it might be useful to evaluate in a fully powered efficacy trial with a longer follow-up.

Incretin-Based Therapies and Lifestyle Interventions: The Evolving Role of Registered Dietitian Nutritionists in Obesity Care

The emergence of incretin-based therapies, specifically glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and glucose-dependent insulinotropic polypeptide (GIP), as a new class of obesity medications, is dramatically changing obesity care. Use of these medications, known categorically as anti-obesity medications, as part of comprehensive obesity management is associated with significantly greater weight loss and health benefits than found with earlier-generation obesity medications. The outcomes reported from medication trials were often achieved in conjunction with lifestyle counseling sessions by a registered dietitian nutritionist (RDN) or other qualified health care professional. Research demonstrates that evidence-based obesity care should incorporate lifestyle interventions. Counseling by an RDN, paired with incretin-based therapies, can play a critical role in supporting adherence to the medication regimen, preventing and managing adverse effects, supporting adequate nutrient intake, and establishing lifestyle behaviors for long-term weight and health management. To date, minimal research has been reported on the impact of incretin-based therapies on food and nutrient intake. Until that research is conducted, RDNs and other health care professionals can apply knowledge and experience from clients who have undergone other intensive treatments. This article provides considerations for lifestyle interventions, with a focus on medical nutrition therapy provided by RDNs for adults prescribed incretin-based therapies. RDNs have the education and training to provide medical nutrition therapy for people with overweight or obesity, as well as lifestyle counseling on physical activity, stress management, sleep hygiene, goal setting, and other behaviors associated with positive health outcomes. RDNs have a critical role in the integration of incretin-based therapies into obesity management.

Skeletal muscle growth to combat diabetes and obesity: the potential role of muscle-secreted factors

As the prevalence of obesity and metabolic disease continues to climb, the need for effective therapeutic interventions remains high. The growth of skeletal muscle (SkM) greatly influences systemic metabolism across the whole body, making this tissue an important therapeutic target to combat the rise of metabolic dysfunction. Transgenic rodent models of targeted SkM growth exhibit profound improvements in various remote tissues, including adipose tissue and the liver. It is currently unclear how selective stimulation of SkM growth alters the metabolism of distant tissues; however, evidence suggests that muscle-secreted factors may be involved. Here, we aim to provide basic biomedical researchers with a summary of the current knowledge regarding various muscle-secreted factors regulated by anabolic pathways and proteins in SkM, as well as their systemic metabolic effects, to implicate them in the whole-body metabolic effects of SkM growth. In this review, we also identify several knowledge gaps in this field, future directions of investigation, and implications for therapeutic interventions such as resistance exercise and pharmacology.

A Decade of Progress in Ultrasound Assessments of Subcutaneous and Total Body Fat: A Scoping Review

Body composition assessment by ultrasonography is a vivid research field. Ultrasound (US) can be used to quantify subcutaneous and visceral fat, to evaluate the quantity and quality of skeletal muscle, and to infer intracellular fat content. This scoping review aimed to summarize recent advancements in subcutaneous fat estimation using US and related applications. A systematic search was conducted on PubMed, MEDLINE, Scopus, Google Scholar, and Web of Science to identify original articles published in English between 1 January 2014 and 20 December 2024. A total of 1869 articles were screened based on their titles and abstracts, and 283 were retrieved for full-text evaluation. Our search and selection strategy resulted in 89 eligible documents. The literature discussed in this review suggests that US is a reliable and valid technique for measuring subcutaneous fat thickness at selected anatomic locations. Standardized measurement protocols enabled accurate subcutaneous adipose tissue (SAT) patterning in various populations (e.g., athletes, children, adults, and patients with anorexia nervosa). Further research is warranted to establish clinically relevant cutoff values. US-derived SAT thicknesses can also provide whole-body fat estimates of fat mass (FM), fat-free mass (FFM), and body fat percentage (%BF). To this end, prediction formulas were developed to ensure agreement with criterion measures given by laboratory techniques, or multicompartment models based on combinations thereof. The resulting assessments of global adiposity were reliable but inaccurate in certain populations (e.g., overweight and obese). Nevertheless, due to its high reliability, US might be used to track changes in body fat content during nutritional and/or lifestyle interventions. Future investigations will be needed to evaluate its accuracy in this respect and to improve the validity of whole-body fat estimation compared to multicompartment models.

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).

Type 2 diabetes: a contemporary view from the Asian lens

PURPOSE OF REVIEW

The aim of this article was to review the up-to-date evidence with regards to the unique features of the Type 2 diabetes (T2D) pathophysiology, complications, response to therapy with the possibility of precision medicine guiding therapeutic decision making in Asia.

RECENT FINDINGS

Asia is the epicenter of diabetes. There have been marked advances with genotyping and phenotyping of the Asian patient with T2D, particularly with young onset diabetes where early beta cell failure and rapid progression of complications are more frequent. As Asians have lower muscle mass and higher adiposity, sarcopenia is increasingly associated with diabetes. Response to lifestyle and pharmacotherapy are generally similar, but unique features exist with different populations. Across Asia, use of guideline directed medical therapy for cardio-renal protection are recommended, but uptake of these newer agents are suboptimal and barriers exist with regards to standardized care.

SUMMARY

Although many similarities have been observed across Asia, due to the heterogeneity of populations within Asia, further research is required to streamline and pave the way towards precision medicine. There is an urgent need for region wide consensus to minimize barriers to diabetes care and stigma in diabetes terminology across Asia.

GLP-1 and the Neurobiology of Eating Control: Recent Advances

Obesity is now considered a chronic relapsing progressive disease, associated with increased all-cause mortality that scales with body weight, affecting more than 1 billion people worldwide. Excess body fat is strongly associated with excess energy intake, and most successful anti-obesity medications (AOMs) counter this positive energy balance through the suppression of eating to drive weight loss. Historically, AOMs have been characterized by modest weight loss and side effects which are compliance-limiting, and in some cases life-threatening. However, the field of obesity pharmacotherapy has now entered a new era of AOMs based on analogues of the gut hormone and neuropeptide glucagon-like peptide-1 (GLP-1). The latest versions of these drugs elicit unprecedented levels of weight loss in clinical trials, which are now starting to be substantiated in real-world usage. Notably, these drugs reduce weight primarily by reducing energy intake, via activation of the GLP-1 receptor on multiple sites of action primarily in the central nervous system, although the most relevant sites of action, and the neural circuits recruited remain contentious. Here we provide a targeted synthesis of recent developments in the field of GLP-1 neurobiology, highlighting studies which have advanced our understanding of how GLP-1 signaling modulates eating, and identify open questions and future challenges we believe still need to be addressed to aid the prevention and/or treatment of obesity.

Prevention of cardiovascular disease in women with type 2 diabetes: the role of incretin mimetics and sodium-glucose cotransporter-2 inhibitors

Cardiovascular disease (CVD) is the leading cause of death among individuals with type 2 diabetes (T2D), with women experiencing a disproportionate risk of events compared with men. Women have an amplified burden of cardiovascular risk factors once T2D is diagnosed. Incretin mimetics now plays a central role in managing cardiovascular risk by improving glycemic control, promoting weight loss, and potentially exerting direct cardioprotective effects. Similarly, sodium-glucose cotransporter-2 inhibitors contribute to CVD prevention through various nonglucose-lowering mechanisms. Both classes of medications are integral to personalized treatment strategies aimed at addressing the heightened cardiovascular risk faced by women with diabetes. This mini-review addresses possible mechanisms underlying the increased cardiovascular risk and explores the role of incretin mimetics and SGLT2 inhibitors in mitigating CVD in women with T2D. Emphasizing personalized and sex-specific approaches in diabetes care is crucial for optimizing treatment outcomes and improving cardiovascular health.

Survodutide for treatment of obesity: rationale and design of two randomized phase 3 clinical trials (SYNCHRONIZE™-1 and -2)

OBJECTIVE

The objective of this study was to describe the rationale and design of two multinational phase 3 clinical trials of survodutide, an investigational glucagon and glucagon-like peptide-1 receptor dual agonist for the treatment of obesity with or without type 2 diabetes (T2D; SYNCHRONIZE-1 and -2).

METHODS

In these ongoing double-blind trials, participants were randomized to once-weekly subcutaneous injections of survodutide or placebo added to lifestyle modification. Survodutide doses are uptitrated to 3.6 or 6.0 mg, and dose flexibility is permitted. Participants (n = 726) in SYNCHRONIZE-1 (NCT06066515) have a baseline BMI ≥ 30 kg/m2 or ≥27 kg/m2 with at least one obesity-related complication but without T2D; participants (n = 755) in SYNCHRONIZE-2 (NCT06066528) have a baseline BMI ≥ 27 kg/m2 and T2D. The primary endpoints are percentage change in body weight and proportion of participants achieving ≥5% body weight reduction from baseline to week 76. Secondary endpoints include change in systolic blood pressure and measures of glycemia. A SYNCHRONIZE-1 substudy is evaluating changes in body composition and liver fat content using magnetic resonance imaging.

CONCLUSIONS

These trials are designed to provide robust evaluation of the efficacy, safety, and tolerability of survodutide for the treatment of obesity in the presence or absence of T2D.

American Diabetes Association Professional Practice Committee, ElSayed NA, McCoy RG, Aleppo G, Balapattabi K, Beverly EA, Briggs Early K, Bruemmer D, Echouffo-Tcheugui JB, Eichorst B, Ekhlaspour L, Garg R, Hassanein M, Khunti K, Lal R, Lingvay I, Matfin G, Middelbeek RJ, Pandya N, Pekas EJ, Pilla SJ, Polsky S, Segal AR, Seley JJ, Stanton RC, Tanenbaum ML, Urbanski P, Bannuru RR. 5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Tackling suboptimal clinical response after metabolic bariatric surgery: Impact of tirzepatide on weight loss and body composition

INTRODUCTION

Insufficient weight loss (IWL) or weight regain (WR) after metabolic bariatric surgery remains a challenge in obesity management. Therefore, this study aimed to retrospectively evaluate the impact of adjunctive tirzepatide therapy over 6 months following sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB).

METHODS

Post-bariatric patients without type 2 diabetes with IWL or WR (n = 21) were analyzed. Key outcomes included changes in weight, BMI, waist circumference, body composition, basal metabolism, metabolic markers, and inflammatory markers. Subgroup analyses assessed differences based on sex, surgery type, and classification as IWL or WR. Linear regression was performed to identify predictors of weight loss outcomes.

RESULTS

At 6 months, mean total weight loss was 12.0 % ± 3.4 % (p < 0.001), with significant reductions in BMI, waist circumference, body fat percentage, and HbA1c. Basal metabolism declined proportionally with weight loss. Weight loss ≥ 5 % occurred in 100.0 % of patients, ≥ 10 % in 76.5 %, and ≥ 15 % in 23.5 %. Basal metabolism differences between RYGB and SG patients converged by 6 months. Male and female patients showed comparable weight loss and metabolic adaptation. IWL patients experienced less fat-free mass loss at 3 months compared to WR (p < 0.05). Baseline BMI nadir, prior weight regain, body composition, and chronic inflammation were significant predictors of weight loss outcomes.

DISCUSSION

Tirzepatide treatment significantly enhances weight loss and metabolic health in post-bariatric patients, regardless of surgery type or sex. Differences in fat-free mass loss highlight the need for tailored interventions in IWL and WR groups. Baseline factors, including inflammation and body composition, may help predict treatment success.

American Diabetes Association Professional Practice Committee, ElSayed NA, McCoy RG, Aleppo G, Balapattabi K, Beverly EA, Briggs Early K, Bruemmer D, Echouffo-Tcheugui JB, Ekhlaspour L, Garg R, Khunti K, Kushner RF, Lal R, Lingvay I, Matfin G, Pandya N, Pekas EJ, Pilla SJ, Polsky S, Segal AR, Seley JJ, Stanton RC, Bannuru RR. 8. Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Effects of liraglutide on body composition in people living with obesity or overweight: A systematic review

AIM

To evaluate the effect of liraglutide on body composition in people living with obesity or overweight.

METHODS

A systematic search was conducted in PubMed, Embase, and Cochrane Library databases up to June 10, 2024. Randomized controlled trials (RCTs) comparing liraglutide to placebo and reporting body composition outcomes were included.

RESULTS

Data from 15 studies involving 960 participants were analyzed. Liraglutide consistently demonstrated significant reductions in total weight, fat mass, and visceral adipose tissue (VAT) compared to placebo across the included studies. VAT reductions ranged from 12.49 % to 23 %, highlighting liraglutide's effectiveness in targeting visceral fat, a key factor in cardiometabolic risk. Fat mass reductions were also substantial and consistent, reinforcing the efficacy of liraglutide in improving overall body composition. In contrast, lean mass outcomes were more variable, with some studies reporting preservation or even gains in lean mass, while others indicated losses.

CONCLUSIONS

Liraglutide effectively reduces fat mass and VAT, supporting its use in managing obesity and related cardiometabolic risks. However, the inability to accurately calculate lean and fat mass proportions underscores the need for standardized reporting and availability of individual-level data. Future research should prioritize these elements and include muscle function assessments to better evaluate the clinical impacts of GLP-1 receptor agonists on body composition.

Müller T. Why are we still in need for novel anti-obesity medications?

From the pioneering moment in 1987 when the insulinotropic effect of glucagon-like peptide 1 (GLP-1) was first demonstrated in humans, to today's pharmaceutical gold rush for GLP-1-based treatments of obesity, the journey of GLP-1 pharmacology has been nothing short of extraordinary. The sequential conceptual developments of long-acting GLP-1 receptor (GLP-1R) mono-agonists, GLP-1R/glucose-dependent insulinotropic polypeptide receptor (GIPR) dual-agonists, and GLP-1R/GIPR/glucagon receptor (GcgR) triple agonists, have led to profound body weight-lowering capacities, with benefits that extend past obesity and towards obesity-associated diseases. The GLP-1R/GIPR dual-agonist tirzepatide has demonstrated a remarkable 23% body weight reduction in individuals with obesity over 72 weeks, eclipsing the average result achieved by certain types of bariatric surgery. Meanwhile, the GLP-1R/GIPR/GcgR triple-agonist retatrutide achieves similar body weight loss (∼25%) in just two-thirds of the time, potentially surpassing the efficacy of Roux-en-Y gastric bypass. These remarkable achievements rightfully raise the question whether and why there is still need for novel anti-obesity medications (AOMs) in the future.

Recent achievements and future directions of anti-obesity medications

Pharmacological management of obesity long suffered from a reputation of a 'Mission Impossible,' with inefficient weight loss and/or unacceptable tolerability. However, the tide has turned with recent progress in biochemical engineering and the development of long-acting agonists at the receptor for glucagon-like peptide-1 (GLP-1), and with unimolecular peptides that simultaneously possess activity at the receptors for GLP-1, the glucose-dependent insulinotropic polypeptide (GIP) and glucagon. Some of these novel therapeutics not only improve body weight and glycemic control in individuals with obesity and type 2 diabetes with hitherto unmet efficacy and tolerable safety, but also exhibit potential therapeutic value in diverse areas such as neurodegenerative diseases, fatty liver disease, dyslipidemia, atherosclerosis, and cardiovascular diseases. In this review, we highlight recent advances in incretin-based therapies and discuss their pharmacological potential within and beyond the treatment of obesity and diabetes, as well as their limitations in use, side effects, and underlying molecular mechanisms.

Health implications of racial differences in serum growth differentiation factor levels among men with obesity

Growth differentiation factor (GDF15) has been considered a biomarker and recently a hormonal driver for diseases in different populations. However, the role of GDF15 as a biomarker of health outcomes in obese men from different racial/ethnic background has not been evaluated. The objective of this study was to investigate the racial/ethnic differences on the relationship between GDF15 and markers of glucometabolic status, hormonal profile, body composition and bone mineral density (BMD) in obese men. One hundred ninety-three obese men from diverse racial/ethnic backgrounds were enrolled. BMD and body composition were measured by dual energy X-ray absorptiometry. Serum GDF15, osteocalcin, C-terminal telopeptide, sclerostin, adiponectin, leptin, estradiol, testosterone, follicle-stimulating hormone, luteinizing hormone, 25-hydroxyvitamin D, lipid profile, and hemoglobin A1C (A1C) were measured. Non-African Americans (NAA) had significantly higher GDF15 level than African Americans (AA). Level was also higher in patients with type 2 diabetes (T2DM). In both the groups GDF15 correlated with A1C and lean mass. However. GDF15 correlated  with body fat, LDL total cholesterol and femoral neck BMD only in NAA and with appendicular lean mass only in AA. Ethnicity, total cholesterol and T2DM were found to be independent predictors of GDF15. We conclude that GDF15 may influence glucometabolic status, body composition and bone parameters which may affect cardiovascular risk and osteoporosis  between races.

Role of GLP1-RA in Optimizing Weight Loss Post-Bariatric Surgery: A Systematic Review and Meta-Analysis

Bariatric surgery is a widely used intervention for significant weight loss, yet some patients face challenges with insufficient weight loss or weight regain post-surgery. To address this issue, adjunctive treatments like glucagon-like peptide-1 receptor agonists (GLP1-RAs) are being explored for their potential to enhance weight loss outcomes. This meta-analysis was conducted to evaluate the effectiveness of GLP1-RAs in improving weight loss after bariatric surgery compared to a placebo. By systematically reviewing and analyzing data from three randomized controlled trials (RCTs) involving 130 patients, we found that GLP1-RA therapy, particularly liraglutide (1.8-3 mg), significantly reduced mean BMI and body weight percentage at six months. Future studies should explore newer GLP1-RAs with weekly dosing and include longer follow-up periods to assess the durability of these outcomes.