GLP-1 agonists for obesity and type 2 diabetes in children: Systematic review and meta-analysis

GLP-1R agonists: recent advances, current gaps, and future challenges

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) emerged as a promising class of drugs and have been shown to be effective as a key regulator in managing glucose metabolism-associated diseases such as type 2 diabetes mellitus (T2DM), chronic kidney disease (CKD), cardiovascular effects, nephrological complications, diabetes, non-alcoholic fatty liver (NAFLD), as well as to control obesity. A few drugs included in GLP-1RA class are liraglutide, exenatide, and semaglutide. Most recent drug that is available in both oral and subcutaneous forms is semaglutide. Available, withdrawn, and investigational GLP-RAs are listed in this paper. This review article will also explore common side effects and safety profiles of both long-acting and short-acting GLP-1 RAs. Additionally, it will highlight the recent advances and ongoing challenges in the field of drug discovery related to GLP-1 receptor agonists.

Metabolic outcomes and safety of GLP-1 receptor agonists in children and adolescents with obesity: A systematic review and meta-analysis

BACKGROUND

Glucagon-like peptide 1 receptor agonists have been proven to be effective in adults with obesity. However, robust evidence on their effects on body weight, obesity-related metabolic changes, and safety in children and adolescents with obesity remains limited, making them a subpopulation with scant treatment options. Therefore, this meta-analysis aimed to determine more precise estimates of the efficacy and safety of glucagon-like peptide-1 agonists in pediatric obesity.

METHODS

Three databases were searched (PubMed, Embase, and Cochrane Central Register of Controlled Trials) for trials published until the half of September 2024. The search indexing terms included 3 categories: [1] obesity [2], youth, and [3] glucagon-like peptide-1 receptor agonist (GLP-1 RA). Randomized controlled trials in youth with obesity (age ≤ 18 years) that assessed anthropometric and metabolic parameters were included. A total of 2016 studies were retrieved, and 24 full-text articles were screened. The data were analyzed using both mean differences (MDs) and standardized mean differences (SMDs) with 95% CIs and odds ratios (ORs) with 95% CIs. We applied a random effects model. Our outcomes were body weight (BW), BMI, waist circumference (WC), lipid profile, Hb1Ac, fasting blood glucose (FBG), blood pressure, and side effects.

RESULTS

Eight studies comprised of 715 children and adolescents were included. On average, GLP-1 RA reduced BMI (SMD -0.67; 95% CI -0.8 to -0.41), BW (SMD -0.60; 95% CI -0.89 to -0.44), and WC (SMD -0.40; 95% CI -0.61 to -0.18). Although lipid profiles, HbA1c, and FBG were unaffected, GLP-1 RA was linked to a slight reduction in SBP (SMD -0.20; 95% CI -0.35 to -0.04) and an increase in HR (SMD + 0.26; 95% CI + 0.07 to +0.46), with no significant effect on DBP. Adverse effects, primarily nausea and vomiting, were more common in the intervention group, although trial withdrawal rates remained low.

CONCLUSIONS

Within this specific population, GLP-1 RAs exhibit significant reductions in BW, BMI, WC, and SBP. The analyses of lipid profiles, DBP, HbA1c, and FBG showed no significant changes. Also, the administration of these medications is concurrent with an elevated incidence of side effects, which are predominantly gastrointestinal and tolerable.

TRIAL REGISTRATION

PROSPERO identifier: CRD42024532845.

The Efficacy and Safety of GLP-1 RAs in the Modification of Cardiovascular Morbidity in Patients with Obesity Without Diabetes Mellitus: A Systematic Review and Meta-analysis of Randomized Controlled Trials Involving 32,884 Patients

BACKGROUND

Although the cardioprotective effects of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are well documented in patients with diabetes mellitus, their impact on cardiovascular outcomes in patients with obesity without diabetes remains under debate. Therefore, we conducted this systematic review and meta-analysis of randomized controlled trials (RCTs) to investigate the effects of GLP-1 RAs on cardiovascular outcomes in patients with obesity without diabetes.

METHODS

We systematically searched PubMed, Web of Science, SCOPUS, and Cochrane databases through December 26, 2023. We pooled dichotomous data using risk ratios (RRs) and continuous data using mean differences with 95% confidence intervals (CIs). We evaluated the quality of each study using the Cochrane RoB2 method, and the study protocol was registered on PROSPERO ID: CRD42024498538.

RESULTS

We included 19 RCTs with a total of 32,884 patients. Of these, 15 had a low overall risk of bias, two raised concerns, and two had a high risk of bias. There was no difference between GLP-1 RAs and placebo regarding cardiovascular mortality (RR 0.85; 95% CI 0.71-1.01; p = 0.07). However, compared with placebo, GLP-1 RAs significantly decreased the incidence of all-cause mortality (RR 0.82; 95% CI 0.72-0.93; p < 0.0001), non-cardiovascular mortality (RR 0.77; 95% CI 0.63-0.95; p = 0.01), and myocardial infarction (RR 0.73; 95% CI 0.62-0.86; p < 0.0001). Additionally, patients receiving GLP-1 RAs experienced significant overall weight loss (- 8.53 kg; 95% CI - 12.38 to - 4.68; p < 0.0001) and improvements in lipid profiles, including lower levels of total cholesterol (- 0.77 %; 95% CI - 1.03 to - 0.50; p < 0.0001), triglycerides (- 6.78 %; 95% CI - 8.11 to - 5.46; p < 0.0001), low-density lipoproteins (- 2.85 %; 95% CI - 3.74 to - 1.96; p < 0.0001), and very low-density lipoproteins (- 4.47 %; 95% CI - 5.56 to - 3.38; p < 0.0001). GLP-1 RAs also significantly increased the incidence of any adverse events (RR 1.11; 95% CI 1.05-1.16; p < 0.0001), with no difference regarding the incidence of serious adverse events. However, gastrointestinal adverse events were significantly more frequent in patients receiving GLP-1 RAs, with a higher risk of any gastrointestinal adverse events (RR 2.83; 95% CI 1.86-4.3; p < 0.001), nausea (RR 2.70; 95% CI 2.18-3.33; p < 0.001), diarrhea (RR 1.97; 95% CI 1.68-2.31; p < 0.001), vomiting (RR 3.85; 95% CI 3.32-4.48; p < 0.001), and constipation (RR 2.35; 95% CI 1.94-2.85; p < 0.001) than in those receiving placebo.

CONCLUSION

In obese patients without diabetes, GLP-1 RAs demonstrated substantial benefits in reducing cardiovascular risks, including all-cause mortality and myocardial infarction, and effectively promoted weight loss and improved lipid profiles and blood pressure control. However, their use is accompanied by a higher incidence of gastrointestinal adverse effects and heterogeneity in outcomes, highlighting the need for individualized treatment approaches.

REGISTRATION

PROSPERO identifier number: CRD42024498538.

Characterization of glucagon-like peptide-1 (GLP-1) agonist exposures reported to a single United States poison center

INTRODUCTION

Glucagon-like peptide-1 agonists have gained attention in recent years due to their efficacy in managing type II diabetes mellitus and their emerging role in weight management. The purpose of this study was to characterize glucagon-like peptide-1 agonist exposures reported to a single United States regional poison center over nine years, including causes of exposure, associated clinical effects, and potential areas for improving patient education and safety.

METHODS

This retrospective cohort study analyzed all poison center calls involving glucagon-like peptide-1 agonists submitted to a single United States regional poison center from 14 January 2014 to 1 May 2023. Data were abstracted from the electronic medical record of the poison center, including demographics, call volume, drug involved, type of exposure, frequency of hypoglycemia, and other side effects.

RESULTS

Two hundred and thirty-seven cases involving glucagon-like peptide-1 agonists were reported to the poison center. The annual number of cases increased sharply over this period. Most patients (n = 166, 70.0%) were females. Most calls (n = 164, 69.2%) were due to unintentional therapeutic errors. Semaglutide was the most frequently involved medication (n = 72, 36.0%). Hypoglycemia was identified in eight patients (3.4%). The lowest mean (±SD) blood glucose concentration in these hypoglycemic patients was 49.6 ± 23.7 mg/dL (2.76 ± 1.3 mmol/L).

DISCUSSION

Unintentional therapeutic errors were involved in 164 (69.2%) cases. Despite the generally mild clinical effects observed in this study, the occurrence of hypoglycemia in a subset of patients, often requiring hospitalization, is of concern. With reports of the acquisition of these medications through online platforms and poorly regulated compounding sources, this trend may pose public health risks.

CONCLUSIONS

This study demonstrates the increasing incidence of glucagon-like peptide-1 agonist exposures reported to a United States regional poison center, predominantly due to unintentional overdoses, which highlights the need for ongoing patient education.

Efficacy and Safety of Efpeglenatide in Patients With Type 2 Diabetes and Obesity: A Systematic Review

Efpeglenatide, a novel long-acting glucagon-like peptide-1 receptor agonist (GLP-1 RA), shows promise for the treatment of type 2 diabetes mellitus (T2DM) and obesity. This systematic review evaluated the efficacy and safety of efpeglenatide in patients with T2DM and obesity. Literature searches in PubMed, Scopus, and Web of Science focused on randomized controlled trials (RCTs), cohort studies, case-control studies, and longitudinal observational studies from 2019 to 2024. Eight studies met the inclusion criteria. The findings of these studies consistently indicate that efpeglenatide significantly reduces hemoglobin A1C (HbA1C), fasting plasma glucose (FPG), and body weight in patients with T2DM and obesity. Once-weekly dosing offers a convenient alternative to daily GLP-1 RAs and potentially improves adherence. Efpeglenatide also provides cardiovascular and renal benefits, particularly for high-risk patients, thus providing a comprehensive treatment option. The safety profile is similar to that of other GLP-1 RAs, with mild-to-moderate gastrointestinal side effects being the most common and a low risk of hypoglycemia, especially in patients not using insulin or sulfonylureas. Most studies show a low risk of bias and enhanced reliability. However, limitations include the need for long-term safety data and variations in study design. Future research should focus on cardiovascular outcomes, long-term safety, and improvements in quality of life to fully assess the benefits of efpeglenatide. In conclusion, efpeglenatide is a promising treatment for T2DM and obesity, offering effective glycemic control, weight reduction, cardiovascular and renal benefits, a favorable safety profile, and convenient dosing.

The Rise of Type 2 Diabetes in Children and Adolescents: An Emerging Pandemic

AIM

This review explores the increasing prevalence of Type 2 Diabetes Mellitus (T2DM) in children and adolescents, focusing on its etiology, risk factors, complications, and the importance of early detection and management. It also highlights the need for a multidisciplinary, family-centered approach in managing T2DM in pediatric populations, with an emphasis on nutrition, exercise, and lifestyle interventions.

MATERIALS AND METHODS

A literature review was conducted using PubMed, Google Scholar, and Scopus to incorporate studies from 2015 to 2024 on T2DM in youths/adolescents/children, focusing on epidemiology, risk factors, and prevention strategies. Studies on Type 1 Diabetes Mellitus (T1DM) or adult populations were excluded.

RESULTS

T2DM is a complex metabolic disorder with various societal, behavioral, environmental, and genetic risk factors. It accounts for one in three new childhood diabetes cases, with rising incidence among American Indian/Alaska Native, Black, and Hispanic/Latino children. The increase in T2DM incidence correlates with growing childhood obesity rates. Early onset significantly raises the risk of complications like retinopathy, nephropathy, neuropathy, cardiovascular diseases, nonalcoholic fatty liver disease, and obstructive sleep apnea. Early detection, screening, and treatment can prevent or delay these complications. A family-centered, multidisciplinary approach is essential for effective management, including lifestyle and behavioral support.

CONCLUSIONS

T2DM in children is a growing health concern with severe implications. Early detection and management, including nutrition and exercise counseling, are critical in reducing long-term complications. A multidisciplinary approach is vital for improving outcomes and minimizing morbidity and mortality.

Public health interventions against childhood obesity in China

China is confronted with the challenge of increasing childhood obesity. Although interventions for childhood obesity have been developed, their effectiveness and implementation can vary considerably across nations. In this paper, we review and consolidate the evidence on childhood obesity intervention strategies aimed at multiple levels and components across life, in China. School-based interventions, primarily delivered with group-based dietary and physical education, have shown potential efficacy and can be enhanced by integrating food environment reform and family support. However, most interventional studies were done in eastern and urban areas of China, which highlights the need for attention in regions with insufficient health resources where policies and initiatives are less accessible. In addition, the sparse reporting on implementation design and delivery might hinder the scalability of potentially effective strategies. Amid rapid social and economic development over the past few decades, China faces unique challenges on urbanisation, physical inactivity, and nutritional transitions, necessitating an updated policy agenda for primary prevention of childhood obesity. Structural longitudinal evaluations of public initiatives led by the government and organisations along with inclusive and equitable interventions targeting children of different ages, urban-rural regions, and different ethnic and socioeconomic groups are warranted. Tackling childhood obesity in China needs a cohesive approach that integrates social, economic, cultural, and environmental strategies, combining school-based, family-based, and individual-based approaches, and concerted efforts from multiple sectors and entities within China.

Efficacy of Glucagon-like Peptide-1 Receptor Agonists in Overweight/Obese and/or T2DM Adolescents: A Meta-analysis Based on Randomized Controlled Trials

Objective

The aim of this meta-analysis was to investigate the effect of glucagon-like peptide-1 receptor agonists (GLP-1RAs) on blood glucose and weight in adolescents with overweight/obesity and/or type 2 diabetes mellitus (T2DM) aged <18 years.

Methods

PubMed, Embase, Web of Science, and Cochrane Library were searched for all randomized controlled trials (RCTs) up to August 2023 comparing GLP-1RAs with placebo in overweight/obese and/or T2DM adolescents and extracted relevant data for meta-analysis.

Results

Fourteen RCTs were included in the meta-analysis with a total of 1,262 participants. Results revealed that the GLP-1RAs group had a more significant reduction in glycosylated hemoglobin A1c (HbA1c; risk difference (RD)=-0.34%, p<0.001) than the control group. However, there was no difference in fasting plasma glucose [fasting plasma glucose (FPG); RD=-2.07 mg/dL, p=0.065] between the two groups. Nonetheless, the experimental group that received exenatide showed no significant reduction in HbA1c (p=0.253) and FPG (p=0.611) between the two groups. The GLP-1RAs group had a more significant decline in body weight (RD=-4.28 kg, p=0.002) and body mass index (BMI) (RD=-1.63 kg/m2, p=0.002) compared to the control group. The experimental group was given liraglutide (RD=-2.31 kg, p=0.038) or exenatide (RD=-2.70 kg, p<0.001). Compared to the control group, the experimental group had a more significant drop in body weight than the control group. However, for the experimental group that received liraglutide, the BMI had a no significant reduction between the two groups (RD=-0.81 kg/m2, p=0.260). For the experimental group using exenatide, BMI declined more significantly in the intervention group than in the control group (RD=-1.14 kg/m2, p<0.001).

Conclusion

This study showed that GLP-1RAs reduced HbA1c, FPG, and weight loss in overweight/obese and/or T2DM adolescents. Liraglutide was better than exenatide in terms of glucose reduction. Nevertheless, in terms of weight control, exenatide was more effective than liraglutide.

The benefits of oral glucose-lowering agents: GLP-1 receptor agonists, DPP-4 and SGLT-2 inhibitors on myocardial ischaemia/reperfusion injury

Myocardial infarction (MI) is a life-threatening cardiovascular disease that, on average, results in 8.5 million deaths worldwide each year. Timely revascularization of occluded vessels is a critical method of myocardial salvage. However, reperfusion paradoxically leads to the worsening of myocardial damage known as myocardial ischaemia/reperfusion injury (MI/RI). Therefore, reducing the size of myocardial infarction after reperfusion is critical and remains an important therapeutic goal. The susceptibility of the myocardium to MI/RI may be increased by diabetes. Currently, some traditional antidiabetic agents such as metformin reduce MI/RI by decreasing inflammation, inhibiting oxidative stress, and improving vascular endothelial function. This appears to be a new direction for the treatment of MI/RI. Recent cardiovascular outcome trials have shown that several oral antidiabetic agents, including glucagon-like peptide-1 receptor agonists (GLP-1RAs), dipeptidyl peptidase-4 inhibitors (DPP-4is), and sodium-glucose-linked transporter-2 inhibitors (SGLT-2is), not only have good antidiabetic effects but also have a protective effect on myocardial protection. This article aims to discuss the mechanisms and effects of oral antidiabetic agents, including GLP-1RAs, DPP-4is, and SGLT-2is, on MI/RI to facilitate their clinical application.

The Antiobesity Effect and Safety of GLP-1 Receptor Agonist in Overweight/Obese Adolescents Without Diabetes Mellitus: A Systematic Review and Meta-Analysis

BACKGROUND

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs), particularly semaglutide, have become the leading anti-obesity drugs for adults, and a similar trend may follow in adolescents with its recent approval for this age group. However, there is a lack of comparative analysis on the weight loss effects and safety of GLP-1 RAs in obese or overweight pediatric and adolescent populations, especially those who are non-diabetic. This systematic review and meta-analysis aim to provide current evidence on the efficacy and safety of GLP-1 RAs as an anti-obesity treatment in obese or overweight non-diabetic pediatric and adolescent populations.

METHOD

 We searched electronic databases from inception until January 2024 for randomized controlled trials (RCTs) that analyzed the weight loss effect of GLP-1 receptor agonists in adolescents with obesity or overweight without diabetes mellitus. Search results were screened, and eligible studies were included to perform a systematic review and meta-analysis using the Review Manager (RevMan) computer program Version 5.4.1 (The Cochrane Collaboration, 2020) with a random-effects model. The primary efficacy outcomes were changes in body weight, BMI, and BMI Z-score, while the secondary outcomes were the incidence of gastrointestinal adverse events, treatment discontinuation rate due to adverse events, and incidence of serious adverse events. The mean difference, odds ratio, and 95% confidence interval (CI) were used to present the meta-analysis results. Publication bias was visualized using a funnel plot. The quality of the studies was analyzed using Cochrane's Risk of Bias tool (RoB2).

RESULTS

A total of seven RCTs with 576 adolescent participants were included in the analysis. GLP-1 RAs significantly achieved greater weight loss than placebo, with a mean difference of -4.98 kg (-8.49, -1.46), I² = 99%, p = 0.006. Subgroup analysis showed that semaglutide had the most pronounced anti-obesity effect (mean difference of -17.70 kg (-18.89, -16.51), p < 0.00001), compared to liraglutide (mean difference of -2.26 kg (-5.17, 0.65), I² = 99%, p = 0.13) and exenatide (mean difference of -3.17 kg (-4.45, -1.90), I² = 0%, p < 0.0001). Similar results were obtained for other efficacy parameters such as BMI and BMI z-score. However, GLP-1 RA was associated with more gastrointestinal adverse events (such as nausea and vomiting) than placebo (3.06 (2.12, 4.42), I² = 0%, p < 0.00001), with incidence comparable among all GLP-1 RAs in the subgroup analysis. The overall risk of bias among included studies was either of 'some concern' or 'high risk.'

CONCLUSIONS

Our meta-analysis demonstrated that GLP-1 RAs had a superior anti-obesity effect compared to placebo or lifestyle modification in obese or overweight non-diabetic adolescents, particularly semaglutide, which had a more pronounced anti-obesity effect than liraglutide and exenatide, with tolerable gastrointestinal adverse effects.

Liraglutide, a glucagon-like peptide-1 receptor agonist, ameliorates inflammation and apoptosis via inhibition of receptor for advanced glycation end products signaling in AGEs induced chondrocytes

BACKGROUND

This study aimed to investigate functions of GLP-1R agonist by liraglutide (LIRA) and revealing the mechanism related to AGEs/RAGE in chondrocytes.

METHODS

To illustrate potential effect of GLP-1R agonist on AGEs induced chondrocytes, chondrocytes were administrated by AGEs with LIRA and GLP-1R inhibitor exendin. Inflammatory factors were assessed using ELISA. Real-time PCR was used to evaluate the catabolic activity MMPs and ADAMTS mRNA level, as well as anabolic activity (aggrecan and collagen II). RAGE expression was investigated by Western blotting. TUNEL, caspase3 activity and immunofluorescence were performed to test the apoptotic activity.

RESULTS

Our results showed that treatment with LIRA at > 100 nM attenuated the AGE-induced chondrocyte viability. Western bolt demonstrated that GLP-1R activation by LIRA treatment reduced RAGE protein expression compared with the AGEs groups. ELISA showed that LIRA hindered the AGEs-induced production of inflammatory cytokines (IL-6, IL-12 and TNF-α) in primary chondrocytes. AGEs induced catabolism levels (MMP-1, -3, -13 and ADAMTS-4, 5) are also attenuated by LIRA, causing the retention of more extracellular matrix (Aggrecan and Collagen II). TUNEL, caspase3 activity and immunofluorescence results indicated that LIRA inhibited the AGEs-induced production of inflammatory cytokines in primary chondrocytes and attenuated the caspase 3 level, leading to the reduced apoptotic activity. All the protective effects are reversed by exendin (GLP-1R blockers).

CONCLUSIONS

The present study demonstrates for the first time that LIRA, an agonist for GLP-1R which is commonly used in type 2 diabetes reverses AGEs induced chondrocyte inflammation and apoptosis through suppressing RAGE signaling, contributing to reduced catabolism and retention of more extracellular matrix. The above results indicate the possible effect of GLP-1R agonist on treating OA.

Tirzepatide ameliorates eating behaviors regardless of prior exposure to glucagon-like peptide receptor agonists in Japanese patients with type 2 diabetes mellitus

AIMS

To investigate effects of tirzepatide, a dual receptor agonist for glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 (GLP-1), on eating behaviors.

METHODS

Eating behaviors were evaluated by using a validated questionnaire survey in 33 Japanese patients with type 2 diabetes mellitus (T2DM) (mean age: 51.8 years) who were treated with tirzepatide (2.5 mg/week for 4 weeks and then 5.0 mg/week) for 6 months (M).

RESULTS

Treatment with tirzepatide significantly decreased median hemoglobin A1c (HbA1c) (baseline/3 M/6 M: 7.3 %/6.0 %/5.8 %), mean body weight (BW) (baseline/3 M/6 M: 87.7 kg/82.0 kg/79.6 kg) and mean relative score of eating behaviors (baseline/3 M/6 M: 57.0/50.7/45.9). In the GLP-1 receptor agonist (GLP-1RA) naïve group (n = 20, men/women: 13/7), HbA1c and BW were continuously decreased up to 6 M. Changes in eating behaviors were mainly observed in the first 3 M. In the GLP-1RA non-naïve group (n = 13, men/women: 8/5), reductions in HbA1c and BW were predominant in the first 3 M, and changes in eating behaviors were observed up to 6 M. There were no significant correlations of changes in scores of eating behaviors with changes in glycemic control or those in BW.

CONCLUSIONS

Tirzepatide ameliorates eating behaviors as well as glycemic management and obesity in Japanese patients with T2DM, and the patterns of improvement are partially dependent on prior exposure to GLP-1RAs.

Pediatric Pharmacology for the Primary Care Provider: Advances and Limitations

Despite >1 in 5 children taking prescription drugs in the United States, off-label drug use is common. To increase the study of drugs in children, regulatory bodies have enacted legislation to incentivize and require pediatric drug studies. As a result of this legislation, novel trial approaches, and an increase in personnel with pediatric expertise, there have been numerous advancements in pediatric drug development. With this review, we aim to highlight developments in pediatric pharmacology over the past 6 years for the most common disease processes that may be treated pharmacologically by the pediatric primary care provider. Using information extracted from label changes between 2018 and 2023, the published literature, and Clinicaltrials.gov, we discuss advances across multiple therapeutic areas relevant to the pediatric primary care provider, including asthma, obesity and related disorders, mental health disorders, infections, and dermatologic conditions. We highlight instances in which new drugs have been developed on the basis of a deeper mechanistic understanding of illness and instances in which labels have been expanded in older drugs on the basis of newly available data. We then consider additional factors that affect pediatric drug use, including cost and nonpharmacologic therapies. Although there is work to be done, efforts focused on pediatric-specific drug development will increase the availability of evidence-based, labeled guidance for commonly prescribed drugs and improve outcomes through the safe and effective use of drugs in children.

Reassessing type 2 diabetes in adolescents and its management strategies based on insulin resistance

With changes in lifestyle behaviors, including dietary structure and habits, the prevalence of Youth-onset Type 2 Diabetes Mellitus (YODM) has increased 2 to 3 times compared to 30 years ago. YODM patients experience complications earlier, progress faster, and exhibit more severe symptoms. However, limited and inconclusive direct evidence, coupled with poor patient compliance, poses challenges in the clinical management of YODM. Apart from the continuous decline in pancreatic β-cell function and quantity, tissue-specific insulin resistance (IR) is also a typical characteristic of YODM. The main mechanisms of IR in YODM involve different aspects such as obesity, dietary imbalance, abnormal substance metabolism, chronic inflammation, oxidative stress, and hormonal fluctuations during adolescence. For the comprehensive management of YODM, besides achieving good control of blood glucose levels, it may be necessary to apply the most appropriate methods considering the uniqueness of the patient population and the specifics of the disease. Early identification and detection of the disease are crucial. Precise screening of patients with well-functioning pancreatic insulin β-cells, primarily characterized by IR and obesity, represents the population most likely to achieve diabetes remission or reversal through lifestyle modifications, medications, or even surgical interventions. Additionally, considering potential emotional disorders or the impact of adolescent hormones in these patients, health education for patients and caregivers is essential to make them aware of the long-term benefits of well-controlled blood glucose. In conclusion, adopting comprehensive management measures to achieve diabetes remission or reversal is the ideal goal. Controlling high blood glucose, obesity, and other risk factors related to diabetes complications is the next priority to delay the occurrence and progression of complications. A comprehensive perspective on IR provides insights and references for identifying YODM and its management strategies.

Pharmacological interventions for the management of children and adolescents living with obesity-An update of a Cochrane systematic review with meta-analyses

IMPORTANCE

The effectiveness of anti-obesity medications for children and adolescents is unclear.

OBJECTIVE

To update the evidence on the benefits and harms of anti-obesity medication.

DATA SOURCES

Cochrane CENTRAL, MEDLINE, ClinicalTrials.gov and WHO ICTRP (1/1/16-17/3/23).

STUDY SELECTION

Randomized controlled trials ≥6 months in people <19 years living with obesity.

DATA EXTRACTION AND SYNTHESIS

Screening, data extraction and quality assessment conducted in duplicate, independently.

MAIN OUTCOMES AND MEASURES

Body mass index (BMI): 95th percentile BMI, adverse events and quality of life.

RESULTS

Thirty-five trials (N = 4331), follow-up: 6-24 months; age: 8.8-16.3 years; BMI: 26.2-41.7 kg/m2. Moderate certainty evidence demonstrated a -1.71 (95% confidence interval [CI]: -2.27 to -1.14)-unit BMI reduction, ranging from -0.8 to -5.9 units between individual drugs with semaglutide producing the largest reduction of -5.88 kg/m2 (95% CI: -6.99 to -4.77, N = 201). Drug type explained ~44% of heterogeneity. Low certainty evidence demonstrated reduction in 95th percentile BMI: -11.88 percentage points (95% CI: -18.43 to -5.30, N = 668). Serious adverse events and study discontinuation due to adverse events did not differ between medications and comparators, but medication dose adjustments were higher compared to comparator (10.6% vs 1.7%; RR = 3.74 [95% CI: 1.51 to 9.26], I2 = 15%), regardless of approval status. There was a trend towards improved quality of life. Evidence gaps exist for children, psychosocial outcomes, comorbidities and weight loss maintenance.

CONCLUSIONS AND RELEVANCE

Anti-obesity medications in addition to behaviour change improve BMI but may require dose adjustment, with 1 in 100 adolescents experiencing a serious adverse event.

The efficacy and safety of GLP-1 receptor agonists in youth with type 2 diabetes: a meta-analysis

BACKGROUND

Glucagon-like peptide 1 receptor agonists have been proven to be effective in adults with diabetes and children with obesity. However, children with type 2 diabetes constitute an underrepresented subpopulation with limited treatment options. This meta-analysis aimed to determine more precise estimates of the efficacy and safety of glucagon-like peptide-1 agonists in pediatric type 2 diabetes mellitus.

METHODS

Three databases were searched (PubMed, Embase, and Cochrane Central Register of Controlled Trials) for trials published until the end of March 2024. The search indexing terms included 3 categories: [1] type 2 diabetes mellitus [2], youth, and [3] glucagon-like peptide-1 receptor agonist (GLP-1 RA). Randomized controlled trials in youth with type 2 diabetes (age ≤ 18 years) that assessed anthropometric and metabolic parameters were included. A total of 1119 nonduplicate studies were retrieved, and 137 full-text articles were screened. The data were analyzed using mean differences (MDs) with 95% CIs and odds ratios (ORs) with 95% CIs. For outcomes with low heterogeneity, a fixed-effects model was used. Otherwise, we applied a random effects model. Our outcomes were Hb1Ac, fasting blood glucose (FBG), blood pressure, weight, and side effects.

RESULTS

Five studies comprehending 415 children and adolescents were included. On average, GLP-1 RA reduced HbA1c levels (-1.01%; 95% CI, -1.26 to -0.76), fasting blood glucose levels (-1.88 mmol/L; 95% CI, -2.51 to -1.26), and body weight (-1.6 kg; 95% CI, -2.83 to -0.36). No significant reductions in systolic blood pressure (MD -0.19 mmHg; 95% CI, -3.9 to 3.52 mmHg) or diastolic blood pressure (MD 0.3 mmHg; 95% CI, -2.33 to 2.93 mmHg) were observed. Despite a higher incidence of side effects, withdrawal rates from the studies remained low.

CONCLUSIONS

Within this specific population, GLP-1 RAs exhibit a notable association with substantial reductions in HbA1c, FBG, and body weight. The administration of these medications is concurrent with an elevated incidence of side effects, which are predominantly gastrointestinal and tolerable.

TRIAL REGISTRATION

PROSPERO identifier: CRD42023393020.

Are treatment options used for adult-onset type 2 diabetes mellitus (equally) available and effective for children and adolescents?

Youth-onset type 2 diabetes mellitus (T2DM), influenced by an increase in obesity, is a rising problem worldwide. Pathophysiological mechanisms of this early-onset T2DM include both peripheral and hepatic insulin resistance, along with increased hepatic fasting glucose production accompanied by inadequate first and second-phase insulin secretion. Moreover, the incretin effect is reduced. The initial presentation of type 2 diabetes can be dramatic and symptoms may overlap with those of type 1 diabetes mellitus. Therefore, immediate therapy should address hyperglycemia and associated metabolic derangements irrespective of ultimate diabetes type, while further therapy adjustments are prone to patients' phenotype. New agents with proven glycemic and beyond glycemia benefits, such as Glucagon-like polypeptide 1 receptor agonists and Sodium-glucose cotransporter-2 inhibitors, used in the adult population of T2DM patients, might become increasingly important in the treatment armamentarium. Moreover, metabolic surgery is an option for markedly obese (body mass index > 35 kg/m2) children and adolescents suffering from T2DM who have uncontrolled glycemia and/or serious comorbidities when lifestyle and pharmacologic interventions fail. In this mini-review, we will discuss the potential of treatment options considering new data available from randomized control trials, including individuals with adult-onset type diabetes mellitus.

Exenatide for obesity in children and adolescents: Systematic review and meta-analysis

Objectives: There is no curative treatment for childhood obesity. We aim to synthesize published Randomized Controlled Trials (RCTs) evidence on the efficacy of exenatide in obese children and adolescents. Methods: We conducted a comprehensive search and analysis of relevant studies in popular databases such as PubMed, Web of Science, Embase, and Cochrane Library. Our focus was on RCTs that examined the effectiveness of exenatide for treating obesity in children. We primarily assessed changes in body weight, body mass index (BMI), fasting plasma glucose (FPG), or HbA1c levels. Additionally, we considered any adverse events reported during the treatment period, with particular attention to hypoglycemia. To evaluate the quality of RCTs included in our study, we employed the Cochrane bias assessment tool. Results: Five studies met the inclusion criteria. A group of 100 children were assigned to receive treatment with exenatide. Compared with controls, exenatide therapy reduced body weight and BMI by -0.6% (95% CI -0.93, -0.27), -1.11% (95% CI -1.91, -0.31), respectively. Undesirable consequences encompass gastrointestinal symptoms, with the majority of instances being characterized by mild severity. Conclusion: Exenatide demonstrates efficacy in the treatment of pediatric and adolescent obesity. Systematic Review Registration: PROSPERO https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=413706.

Glucagon-like Peptide-1 Receptor Agonists-A Potential New Medication for Pediatric Metabolic-Dysfunction-Associated Steatotic Liver Disease (MASLD)

Metabolic-dysfunction-associated steatotic liver disease (MASLD) is the most common liver disease in children in the US and, if untreated, may progress to end-stage liver disease. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have shown improvement in MASLD markers in adults with type 2 diabetes mellitus (T2DM). Currently, there is a lack of medications available for the treatment of pediatric MASLD. We aimed to provide preliminary data on the effects of GLP-1 RAs on markers of MASLD in a retrospective study, in an effort to bridge this gap in the pharmacotherapies available. Nine patients from a T2DM clinic who met the following inclusion criteria were included in this study: patients diagnosed with pre-diabetes or T2DM, prescribed a GLP-1 RA in the prior 12 months, and having alanine aminotransferase (ALT) elevated to twice the upper limit of the normal range, indicating evidence of MASLD. The average change between baseline and the first measurement after starting a GLP-1 RA was calculated for ALT, hemoglobin A1c, and BMI. ALT decreased by an average of 98 points. A1c decreased by an average of 2.2 points. BMI decreased by an average of 2.4 points. There was greater reduction in ALT and A1c compared to BMI, suggesting that improvement in MASLD may be independent of weight loss. This is a preliminary study that shows potential, and prospective studies are needed to evaluate the effects of GLP-1 RAs in the management of pediatric MASLD.

Management of pediatric obesity as a pathway towards kidney transplantation

Obesity is an increasing problem in pediatrics, leading to cardiovascular, metabolic and psychosocial complications. Additionally, for patients with chronic kidney disease (CKD), obesity can lead to CKD progression towards end-stage renal disease (ESRD) needing renal-replacement therapy (RRT). It is well-established that the optimal type of RRT for children with ESRD is kidney transplantation, as it provides significantly better life expectancy and quality of life. Unfortunately, pediatric patients with CKD/ESRD and obesity face barriers getting to kidney transplantation and often remain on dialysis for a long time, which negatively impacts their life expectancy and quality of life. One barrier to kidney transplant is that Body Mass Index (BMI) is still considered by most transplant centers as the main criterion for obesity assessment, although more recent evidence suggests that BMI is not the best measure of adiposity. Clearcut evidence is lacking that obesity has a long-term negative impact upon the graft. Another barrier to transplant can be bias on the part of referring providers that can deter or delay referral to an obesity treatment program. Our article describes the barriers that pediatric obese patients with CKD and ESRD face in their way towards kidney transplantation. In addition, our article encourages pediatric nephrologists to early refer their patients with CKD and ESRD who suffer from obesity to a specialized obesity treatment program and/or bariatric surgery. Our article also describes the treatment options for pediatric patients with CKD and ESRD who suffer from obesity in order to make them eligible for a kidney transplant.

Exploration of the potential association between GLP-1 receptor agonists and suicidal or self-injurious behaviors: a pharmacovigilance study based on the FDA Adverse Event Reporting System database

BACKGROUND

Establishing whether there is a potential relationship between glucagon-like peptide 1 receptor agonists (GLP-1RAs) and suicidal or self-injurious behaviors (SSIBs) is crucial for public safety. This study investigated the potential association between GLP-1RAs and SSIBs by exploring the FDA Adverse Event Reporting System (FAERS) database.

METHODS

A disproportionality analysis was conducted using post-marketing data from the FAERS repository (2018 Q1 to 2022 Q4). SSIB cases associated with GLP-1RAs were identified and analyzed through disproportionality analysis using the information component. The parametric distribution with a goodness-of-fit test was employed to analyze the time-to-onset, and the Ω shrinkage was used to evaluate the potential effect of co-medication on the occurrence of SSIBs.

RESULTS

In total, 204 cases of SSIBs associated with GLP-1RAs, including semaglutide, liraglutide, dulaglutide, exenatide, and albiglutide, were identified in the FAERS database. Time-of-onset analysis revealed no consistent mechanism for the latency of SSIBs in patients receiving GLP-1RAs. The disproportionality analysis did not indicate an association between GLP-1RAs and SSIBs. Co-medication analysis revealed 81 cases with antidepressants, antipsychotics, and benzodiazepines, which may be proxies of mental health comorbidities.

CONCLUSIONS

We found no signal of disproportionate reporting of an association between GLP-1RA use and SSIBs. Clinicians need to maintain heightened vigilance on patients premedicated with neuropsychotropic drugs. This contributes to the greater acceptance of GLP-1RAs in patients with type 2 diabetes mellitus or obesity.

Profiles of Intestinal Flora in Breastfed Obese Children and Selecting Functional Strains Against Obesity

SCOPE

Breast milk has the potential to prevent childhood obesity by providing probiotics, but there are still instances of obesity in breastfed children.

METHODS AND RESULTS

This study investigates the difference in intestinal flora structure between breastfed children with obesity (OB-BF) and normal-weight breastfed children (N-BF). Building upon this foundation, it employs both cell and mouse models to identify an antiobesity strain within the fecal matter of N-BF children and explore its underlying mechanisms. The results reveal a reduction in lactobacillus levels within the intestinal flora of OB-BF children compared to N-BF children. Consequently, Lactobacillus plantarum H-72 (H-72) is identified as a promising candidate due to its capacity to stimulate glucagon-like peptide-1 (GLP-1) secretion in enteroendocrine cells (ECCs). In vivo, H-72 effectively increases serum GLP-1 concentration, reduces food intake, regulates the expression of genes related to energy metabolism (SCD-1, FAS, UCP-1, and UCP-3), and regulates gut microbiota structure in mice. Moreover, the lipoteichoic acid of H-72 activates toll-like receptor 4 to enhanced GLP-1 secretion in STC-1 cells.

CONCLUSIONS

L. plantarum H-72 is screened out for its potential antiobesity effect, which presents a potential and promising avenue for future interventions aimed at preventing pediatric obesity in breastfed children.

A Propolis-Derived Small Molecule Tectochrysin Ameliorates Type 2 Diabetes in Mice by Activating Insulin Receptor β

SCOPE

Propolis has been found to decrease glucose levels and increase insulin sensitivity in type 2 diabetes. However, the active ingredient responsible for these effects and its regulating mechanism are not fully understood.

METHODS AND RESULTS

To address this, molecular docking screening is used to screen the effective hypoglycemic ingredient in propolis and found that tectochrysin (TEC) has a high affinity to the insulin receptor (IR), highlighting its potential for glycemic control. In vivo tests show that TEC decreases glucose levels and enhances insulin sensitivity in db/db mice. By hyperinsulinemic euglycemic clamp test, this study further finds that TEC promotes glucose uptake in adipose tissue and skeletal muscle, as well as inhibits hepatic gluconeogenesis. Moreover, it finds that TEC promotes glucose uptake and adipocytes differentiation in 3T3-L1 cells like insulin, suggesting that TEC exerts an insulin mimetic effect. Mechanistically, pharmacology inhibition of IRβ abolishes the effects of TEC on glucose uptake and the phosphorylation of IR. The study further demonstrates that TEC binds to and activates IRβ by targeting its E1077 and M1079.

CONCLUSION

Therefore, this study sheds light on the mechanism underlying propolis' potential for ameliorating type 2 diabetes, offering a natural food-derived compound as a promising therapeutic option.

Prediabetes in children and adolescents: An updated review

Prediabetes, the precursor of type 2 diabetes mellitus, is an intermediate stage between normal glucose homeostasis and overt diabetes. This asymptomatic metabolic state is increasingly prevalent in pediatric population and is very difficult to detect without appropriate screening. Studies have shown that a certain proportion of children with prediabetes will develop diabetes in a few years. Even more alarming is the evidence that youth-onset diabetes has a more aggressive clinical course with progressive beta-cell decline and accelerated end-organ damage. Despite its importance, several aspects involving prediabetes in childhood are disputed or unknown. This review presents the latest insights into this challenging entity and outlines a simplified screening approach to aid clinical practice. In summary, childhood prediabetes is an important clinical condition indicating the need for proper screening and timely intervention.

Semaglutide ameliorates cognition and glucose metabolism dysfunction in the 3xTg mouse model of Alzheimer's disease via the GLP-1R/SIRT1/GLUT4 pathway

Disorders of brain glucose metabolism is known to affect brain activity in neurodegenerative diseases including Alzheimer's disease (AD). Furthermore, recent evidence has shown an association between AD and type 2 diabetes. Numerous reports have found that glucagon-like peptide-1 (GLP-1) receptor agonists improve the cognitive behavior and pathological features in AD patients and animals, which may be related to the improvement of glucose metabolism in the brain. However, the mechanism by which GLP-1 agonists improve the brain glucose metabolism in AD patients remains unclear. In this study, we found that SIRT1 is closely related to expression of GLP-1R in hippocampus of 3xTg mice. Therefore, we used semaglutide, a novel GLP-1R agonist currently undergoing two phase 3 clinical trials in AD patients, to observe the effect of SIRT1 after semaglutide treatment in 3XTg mice and HT22 cells, and to explore the mechanism of SIRT1 in the glucose metabolism disorders of AD. The mice were injected with semaglutide on alternate days for 30 days, followed by behavioral experiments including open field test, new object recognition test, and Y-maze. The content of glucose in the brain was also measured by using 18FDG-PET-CT scans. We measured the expression of Aβ and tau in the hippocampus, observed the expression of GLUT4 which is downstream of SIRT1, and tested the Glucose oxidase assay (GOD-POD) and Hexokinase (HK) in HT22 cells. Here, we found in the 3xTg mouse model of AD and in cultured HT22 mouse neurons that SIRT1 signaling is involved in the impairment of glucose metabolism in AD. Semaglutide can increased the expression levels of SIRT1 and GLUT4 in the hippocampus of 3xTg mice, accompanied by an improvement in learning and memory, decreased in Aβ plaques and neurofibrillary tangles. In addition, we further demonstrated that semaglutide improved glucose metabolism in the brain of 3xTg mice in vitro, semaglutide promoted glycolysis and improved glycolytic disorders, and increased the membrane translocation of GLUT4 in cultured HT22 cells. These effects were blocked by the SIRT1 inhibitor (EX527). These findings indicate that semaglutide can regulate the expression of GLUT4 to mediate glucose transport through SIRT1, thereby improving glucose metabolism dysfunction in AD mice and cells. The present study suggests that SIRT1/GLUT4 signaling pathway may be an important mechanism for GLP-1R to promote glucose metabolism in the brain, providing a reliable strategy for effective therapy of AD.

Natural exosomes-like nanoparticles in mung bean sprouts possesses anti-diabetic effects via activation of PI3K/Akt/GLUT4/GSK-3β signaling pathway

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a chronic metabolic disease characterized by hyperglycemia and insulin resistance. Mung bean sprouts are traditionally considered a "folk" hypoglycemic food and their pharmacological effects and underlying mechanisms warrant further investigation.

PURPOSE

This study aimed to investigate the anti-diabetic effects of the exosomes-like nanoparticles in mung bean sprouts (MELNs) and explore the related molecular mechanisms.

RESULTS

MELNs were isolated using a differential centrifugation-polyethylene glycol (PEG) method, and the identification of MELNs were confirmed by PAGE gel electrophoresis, agarose gel electrophoresis, thin-layer chromatography (TLC), and transmission electron microscopy (TEM). In the high-fat diet/streptozotocin (HFD/STZ) mouse model, MELNs ameliorated the progression of T2DM by increasing oral glucose tolerance test (OGTT) and insulin tolerance test (ITT) results, decreasing the fasting blood glucose level, and reducing the serum triglycerides (TG) and total cholesterol (TC). Histopathological examinations indicated MELNs diminished inflammatory infiltration of hepatocytes and amplified the area of islet B cells. In addition, MELNs decreased the oxidative stress levels in liver tissue and had good biocompatibility. In vitro experiments verified that MELNs improved the viability of glucosamine (GlcN) induced insulin-resistant hepatocytes. Furthermore, this study also revealed that MELNs upregulated GLUT4 & Nrf2 and down-regulated GSK-3β via activating the PI3K/Akt signaling pathway, promoting the production of antioxidant enzymes, such as HO-1 and SOD, to reduce oxidative stress.

CONCLUSION

MELNs mitigated the progression of type 2 diabetes in HFD/STZ mouse model. The underlying molecular mechanism is related to PI3K/Akt/GLUT4/GSK-3β signaling pathway.

Evaluating potential predictors of weight loss response to liraglutide in adolescents with obesity: A post hoc analysis of the randomized, placebo-controlled SCALE Teens trial

BACKGROUND

As childhood obesity prevalence increases, determining which patients respond to anti-obesity medications would strengthen personalized approaches to obesity treatment. In the SCALE Teens trial among pubertal adolescents with obesity (NCT02918279), liraglutide 3.0 mg (or maximum tolerated dose) significantly reduced body mass index (BMI) standard deviation score on average versus placebo. That said, liraglutide effects on BMI reduction varied greatly among adolescents, similar to adults.

OBJECTIVES

To identify post hoc characteristics predictive of achieving ≥5% and ≥10% BMI reductions at 56 weeks with liraglutide versus placebo in adolescents from the SCALE Teens trial.

METHODS

Logistic regression analysis was performed in 251 adolescents treated with liraglutide (n = 125) or placebo (n = 126) for 56 weeks. Baseline characteristics (selected a priori) included sex, race, ethnicity, age, Tanner (pubertal) stage, glycemic status (hyperglycemia [type 2 diabetes/prediabetes] vs. normoglycemia), obesity category (Class II/III vs. I), severity of depression symptoms (Patient Health Questionnaire-9), and weight variability (weight fluctuations over time). The effects of early responder status (≥4% BMI reduction at week 16) on week 56 response were assessed using descriptive statistics.

RESULTS

Baseline characteristics did not affect achievement of ≥5% and ≥10% BMI reductions at week 56 in adolescents treated with liraglutide. Further, there was no association between weight variability and BMI reduction. Early liraglutide responders appeared to have greater BMI and body weight reductions at week 56 compared with early non-responders.

CONCLUSIONS

This secondary analysis suggests that adolescents with obesity may experience significant BMI reductions after 56 weeks of liraglutide treatment, regardless of their sex, race, ethnicity, age, pubertal stage, glycemic status, obesity category, severity of depression symptoms, or weight variability. Early response may predict greater week 56 response.

Weight loss efficiency and safety of tirzepatide: A Systematic review

OBJECTIVE

Tirzeptide is a novel glucagon-like peptide-1 receptor (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) drug, which shows good efficiency for weight loss. Therefore, we aim to investigate the efficacy and safety of tirzepatide for weight loss in type 2 diabetes mellitus (T2DM) and obesity patients in this meta-analysis study.

METHODS

Cochrane Library, PubMed, Embase, Clinical Trials, and Web of Science were searched from inception to October 5, 2022. All randomized controlled trials (RCTs) were included. The odds ratio (OR) was calculated using fixed-effects or random-effects models by Review Manager 5.3 software.

RESULTS

In total, ten studies (12 reports) involving 9,873 patients were identified. A significant loss body weight in the tirzepatide group versus the placebo by -9.81 kg (95% CI (-12.09, -7.52), GLP-1 RAs by -1.05 kg (95% CI (-1.48, -0.63), and insulin by -1.93 kg (95% CI (-2.81, -1.05), respectively. In sub-analysis, the body weight of patients was significantly reduced in three tirzepatide doses (5 mg, 10 mg, and 15 mg) when compared with those of the placebo/GLP-1 RA/insulin. In terms of safety, the incidence of any adverse events and adverse events leading to study drug discontinuation was higher in the tirzepatide group, but the incidence of serious adverse events and hypoglycaemia was lower. Additionally, the gastrointestinal adverse events (including diarrhea, nausea, vomiting and decreased appetite) of tirzepatide were higher than those of placebo/basal insulin, but similar to GLP-1 RAs.

CONCLUSION

In conclusion, tirzeptide can significantly reduce the weight of T2DM and patient with obesity, and it is a potential therapeutic regimen for weight-loss, but we need to be vigilant about its gastrointestinal reaction.

Current Treatment Options, Including Diet, Exercise, and Medications: The Impact on Histology

Paralleling the rise in obesity and diabetes, nonalcoholic fatty liver disease (NAFLD) is now the most prevalent chronic liver disease worldwide. Nonalcoholic steatohepatitis (NASH), the progressive form of NAFLD, may progress to cirrhosis, hepatic decompensation, and hepatocellular carcinoma. Despite its public health treat, no approved pharmacotherapies for NAFLD/NASH currently exist. Although the armamentarium of therapies for NASH is limited, current treatment options include life-style modification and the use of medications to treat metabolic comorbidities. This review addresses current approaches to the treatment of NAFLD/NASH, including the impact of diet, exercise, and available pharmacotherapies on the histologic features of liver injury.

Treatment strategy for children and adolescents with type 2 diabetes-based on ISPAD Clinical Practice Consensus Guidelines 2022

The principles of treatment for children and adolescents with type 2 diabetes include dietary and exercise management. For dietary management, a relatively modest dietary regimen with an appropriate energy source composition is recommended. Moderate- to vigorous-intensity aerobic activity is recommended for at least 60 min/d. Family members are encouraged to modify their lifestyles. Some patients fail to improve hyperglycemia through dietary and exercise management and eventually require pharmacological treatment. If the patient is metabolically stable (HbA1c level < 8.5% [69 mmol/mol]), metformin is the first-line treatment of first choice. In a case with ketosis or HbA1c of more than 8.5% (69 mmol/mol), insulin will be required initially with once daily basal insulin (0.25-0.5 units/kg). The goal of the initial treatment is to attain an HbA1c level < 7.0% (53 mmol/mol). If the glycemic goal is not attained, the addition of a second agent should be considered. However, the use of antihyperglycemic drugs in pediatric patients is limited in most countries. Therefore, the efficacy and safety of these drugs used in adult patients, including GLP-1 receptor agonists and SGLT2 inhibitors, should be evaluated in pediatric patients worldwide.

Adolescents with Type 2 Diabetes: Overcoming Barriers to Effective Weight Management

The prevalence of type 2 diabetes (T2DM) among children and adolescents has remarkably increased in the last two decades, particularly among ethnic minorities. Management of T2DM is challenging in the adolescent population due to a constellation of factors, including biological, socioeconomic, cultural, and psychological barriers. Weight reduction is an essential component in management of T2DM as weight loss is associated with improvement in insulin sensitivity and glycemic status. A family centered and culturally appropriate approach offered by a multidisciplinary team is crucial to address the biological, psychosocial, cultural, and financial barriers to weight management in youth with T2DM. Lifestyle interventions and pharmacotherapy have shown modest efficacy in achieving weight reduction in adolescents with T2DM. Bariatric surgery is associated with excellent weight reduction and remission of T2DM in youth. Emerging therapies for weight reduction in youth include digital technologies, newer GLP-1 agonists and endoscopic procedures.

Metabolic Consequences of Pediatric Obesity: A Review of Pathophysiology, Screening, and Treatment

The prevalence of pediatric obesity has been increasing during the last 30 years, and the subsequent metabolic consequences of obesity, which were mainly seen in adults, are now presenting in childhood. Type 2 diabetes, prediabetes, metabolic syndrome, and nonalcoholic fatty liver disease are serious metabolic ramifications of pediatric obesity; pediatricians need to be familiar in screening and treatment of these metabolic issues. This review will discuss the inflammation and insulin resistance involved in obesity that can lead to these conditions. We will explore the pathophysiology of type 2 diabetes and prediabetes, metabolic syndrome, and nonalcoholic fatty liver disease and review screening and treatment modalities. Finally, we will highlight other important endocrine related comorbidities in pediatric obesity, including polycystic ovary syndrome, precocious puberty, and early accelerated growth. [Pediatr Ann. 2023;52(2):e62-e67.].

Effect of glucagon-like peptide-1 receptor agonists on glycemic control, and weight reduction in adults: A multivariate meta-analysis

AIMS

To explore the effect of glucagon-like peptide-1 receptor agonist (GLP-1 RAs) on glycemic control and weight reduction in adults.

METHODS

Databases were searched from August 2021 to March 2022. Data were analyzed using mean difference (MD) values with 95% confidence intervals (CIs). Both random-and fixed-effect models were employed. Heterogeneity was explored using pre-specified subgroup analyses and meta-regression. Structural equation modeling fitting was used for the multivariate meta-analysis.

RESULTS

A total of 31 double-blind randomized controlled trials with 22,948 participants were included in the meta-analysis. The MD and 95% CI of the pooled GLP1-RA-induced change in the glycated hemoglobin level was -0.78% (-0.97%, -0.60%) in the random-effects model and -0.45% (-0.47%, -0.44%) in the fixed-effect model, with a high heterogeneity (I2 = 97%). The pooled body weight reduction was -4.05 kg (-5.02 kg, -3.09 kg) in the random-effects model and -2.04 kg (-2.16 kg, -1.92 kg) in the fixed-effect model (I2 = 98%). The standardized pooled correlation coefficient between HbA1c levels and body weight was -0.42. A negative correlation between glycemic control and weight reduction was obtained.

CONCLUSION

Long-acting GLP-1 RAs significantly reduced the glycated hemoglobin level and body weight in adults.

The efficacy and safety of dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 agonists in pediatric patients with type 2 diabetes: a systematic review

BACKGROUND

The incidence of type 2 diabetes mellitus (T2DM) in the pediatric population is increasing. There is a great need to develop more drugs for pediatric T2DM. Glucagon-like peptide-1 (GLP-1) agonists and dipeptidyl dipeptidase-4 (DPP-4) inhibitors have been approved for adults with T2DM and they might be effective in youths due to the similar pathogenic defects associated with T2DM. Here we aim to evaluate the efficacy and safety of GLP-1 agonists and DPP-4 inhibitors in pediatric patients with T2DM.

CONTENTS

We performed a systematic review including trials comparing GLP-1 agonists and DPP-4 inhibitors against placebo in pediatric T2DM. This project was conducted based on the quality of reporting of meta-analyses (QUOROM) statement. Embase, PubMed, and Cochrane library were searched by two independent investigators for selecting relevant studies.

SUMMARY AND OUTLOOK

Five RCTs with a total sample size of 237 children were included. GLP-1 agonists showed superiority in glycemic improvement than placebo for pediatric T2DM. The advantage of DPP-4 inhibitors versus placebo for glycemic improvement is still unclear. GLP-1 agonists and DPP-4 inhibitors were well tolerated in pediatrics and further strictly designed trials are needed.

Systematic Review and Meta-Analysis of the Efficacy and Safety of Metformin and GLP-1 Analogues in Children and Adolescents with Diabetes Mellitus Type 2

Diabetes mellitus type 2 (DMT2) is one of the most frequent glucose metabolism disorders, in which serum glucose concentrations are increased. In most cases, changes in lifestyle and diet are considered as the first step in addressing its therapy. If changes in lifestyle and diet fail, drugs, such as metformin, must be added. Lately, apart from metformin or insulin, the FDA has approved the use of glucagon-like peptide-1 (GLP-1) analogues for children and adolescents. Little is known about their efficacy and safety at this young age. The main aim of this systematic review/meta-analysis was to assess the safety and efficacy of metformin and GLP-1 analogues, exenatide and liraglutide, compared with placebos or other antidiabetic drugs used for DMT2 in children and adolescents. Metformin did not seem to demonstrate pharmacologic superiority, while GLP-1 analogues were found superior to placebos. GLP-1 analogues may be considered a useful alternative for the treatment of DMT2 in children and adolescents.

The Influence of Abdominal Adiposity and Physical Fitness on Obesity Status of Portuguese Adolescents

The aim of this study was to verify the relationship between abdominal adiposity and physical fitness in the obesity status of Portuguese adolescents. BMI, abdominal adiposity, and physical fitness tests from the FITescola^® were evaluated in a total of 654 Portuguese adolescents, aged 10-19 years old-male: n = 334 (51%), female: n = 320 (49%). For the final model, BMI was positively related with age (β = 0.25), abdominal adiposity (β = 0.313), horizontal jump (β = -0.100), 40 m maximal velocity (β = 0.274), and aerobic fitness (β = -0.250, R² = 0.75, F = 382.2, and p = 0.0001). We conclude that higher age and abdominal adiposity are positively related with a higher adolescent BMI. Furthermore, lower horizontal jump distances and worse times on the 40 m maximal velocity were inversely related with a higher adolescent BMI, and lower aerobic fitness was inversely related with a higher adolescent BMI.

Signaling pathways in obesity: mechanisms and therapeutic interventions

Obesity is a complex, chronic disease and global public health challenge. Characterized by excessive fat accumulation in the body, obesity sharply increases the risk of several diseases, such as type 2 diabetes, cardiovascular disease, and nonalcoholic fatty liver disease, and is linked to lower life expectancy. Although lifestyle intervention (diet and exercise) has remarkable effects on weight management, achieving long-term success at weight loss is extremely challenging, and the prevalence of obesity continues to rise worldwide. Over the past decades, the pathophysiology of obesity has been extensively investigated, and an increasing number of signal transduction pathways have been implicated in obesity, making it possible to fight obesity in a more effective and precise way. In this review, we summarize recent advances in the pathogenesis of obesity from both experimental and clinical studies, focusing on signaling pathways and their roles in the regulation of food intake, glucose homeostasis, adipogenesis, thermogenesis, and chronic inflammation. We also discuss the current anti-obesity drugs, as well as weight loss compounds in clinical trials, that target these signals. The evolving knowledge of signaling transduction may shed light on the future direction of obesity research, as we move into a new era of precision medicine.

Optimization of accelerated solvent extraction of ellagitannins in black raspberry seeds using artificial neural network coupled with genetic algorithm

This study aimed to identify ellagitannins in black raspberry seeds (BRS) and to optimize accelerated solvent extraction of ellagitannins using an artificial neural network (ANN) coupled with genetic algorithm. Fifteen monomeric and dimeric ellagitannins were identified in BRS. For ANN modeling, extraction time, extraction temperature, and solvent concentration were set as input variables, and total ellagitannin content was set as output variable. The trained ANN had a mean squared error value of 0.0102 and a regression correlation coefficient of 0.9988. The predicted optimal extraction conditions for maximum total ellagitannin content were 63.7% acetone, 4.21 min, and 43.9 °C. The actual total ellagitannin content under the optimal extraction conditions was 13.4 ± 0.0 mg/g dry weight, and the prediction error was 0.75 ± 0.27%. This study is the first attempt to analyze the composition of ellagitannins in BRS and to determine optimal extraction conditions for maximum total ellagitannin content from BRS.

Cardiovascular disease in type 2 diabetes mellitus: progress toward personalized management

Cardiovascular diseases (CVDs) are the main cause of death among patients with type 2 diabetes mellitus (T2DM), particularly in low- and middle-income countries. To effectively prevent the development of CVDs in T2DM, considerable effort has been made to explore novel preventive approaches, individualized glycemic control and cardiovascular risk management (strict blood pressure and lipid control), together with recently developed glucose-lowering agents and lipid-lowering drugs. This review mainly addresses the important issues affecting the choice of antidiabetic agents and lipid, blood pressure and antiplatelet treatments considering the cardiovascular status of the patient. Finally, we also discuss the changes in therapy principles underlying CVDs in T2DM.

Sex Differences in Response to Treatment with Glucagon-like Peptide 1 Receptor Agonists: Opportunities for a Tailored Approach to Diabetes and Obesity Care

The available data suggest differences in the course of type 2 diabetes mellitus (T2DM) between men and women, influenced by the distinguishing features of the sex. Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) are a relatively new class of antidiabetic drugs that act by mimicking the function of endogenous glucagon-like peptide 1. They constitute valuable agents for the management of T2DM as, in addition to exerting a strong hypoglycemic action, they present cardiorenal protective properties, promote weight loss, and have a good safety profile, particularly with respect to the risk of hypoglycemia. Due to the precedent of studies having identified sexual dimorphic elements regarding the action of other antidiabetic agents, ongoing research has attempted to examine whether this is also the case for GLP-1 RAs. Until now, sex differences have been observed in the impact of GLP1-RAs on glycemic control, weight reduction, and frequency of adverse events. On the contrary, the question of whether these drugs differentially affect the two sexes with respect to cardiovascular risk and incidence of major adverse cardiovascular events remains under investigation. Knowledge of the potential sex-specific effects of these medications is extremely useful for the implementation of individualized therapeutic plans in the treatment of T2DM. This narrative review aims to present the available data regarding the sex-specific action of GLP-1 RAs as well as to discuss the potential pathophysiologic mechanisms explaining these dissimilarities.

Possibility of Venous Serum Cl- Concentration ([Cl-]s) as a Marker for Human Metabolic Status: Correlation of [Cl-]s to Age, Fasting Blood Sugar (FBS), and Glycated Hemoglobin (HbA1c)

The HCO3- concentration in venous serum ([HCO3-]s) is a factor commonly used for detecting the body pH and metabolic conditions. To exactly detect [HCO3-]s, the venous CO2 pressure should be kept as it is in the vein. The [HCO3-]s measurement is technically complicated to apply for huge numbers of almost heathy persons taking only basic medical examinations. The summation of [HCO3-]s and the venous serum Cl- concentration ([Cl-]s) is approximately constant; therefore, we studied if [Cl-]s could be a marker detecting metabolic conditions instead of [HCO3-]s. Venous blood was obtained from persons taking basic medical examinations (the number of persons = 107,630). Older persons showed higher values of [Cl-]s, fasting blood sugar (FBS), and glycated hemoglobin (HbA1c) than younger ones. [Cl-]s showed positive correlation to age and negative correlation to FBS and HBA1c. The negative correlation of [Cl-]s to FBS/HbA1c was obvious in persons with high FBS/HbA1c, leading us to an idea that persons with high FBS/HbA1c show high [HCO3-]s, which might be caused by low activity of carbonic anhydrase in the lung observed in persons with diabetes mellitus under acidotic conditions. Taken together, an easily measured serum electrolyte, [Cl-]s, could be a useful marker estimating metabolic conditions.

Nonalcoholic fatty pancreas disease: An emerging clinical challenge

Nonalcoholic fatty pancreas disease (NAFPD) is an emerging disease that has gained an increasing amount of attention in recent years. It describes fat accumulation in the pancreas with insignificant alcohol consumption, but the pathogenesis is largely unknown. A wide range of terms have been used to describe the phenomenon of pancreatic fat accumulation, but NAFPD remains an under-recognized and non-independent disorder. Obesity, age, sex, race, and unhealthy lifestyle are established independent risk factors for NAFPD, which is strongly associated with metabolic syndrome, type 2 diabetes, pancreatitis, pancreatic fistula, pancreatic cancer, and nonalcoholic fatty liver disease. At present, imaging techniques are common diagnostic aids, but uniform criteria and consensus are lacking. Therapeutically, healthy diet, weight loss, and exercise are the mainstays to reduce pancreatic fat accumulation. It can be seen that there is a limited understanding of NAFPD at this stage and further exploration is needed. Previous studies have revealed that NAFPD may directly affect diagnosis and clinical decision-making. Therefore, exploring the pathophysiological mechanism and clinical associations of NAFPD is a major challenge for researchers and clinicians.

The relevance of adhesion G protein-coupled receptors in metabolic functions

G protein-coupled receptors (GPCRs) modulate a variety of physiological functions and have been proven to be outstanding drug targets. However, approximately one-third of all non-olfactory GPCRs are still orphans in respect to their signal transduction and physiological functions. Receptors of the class of Adhesion GPCRs (aGPCRs) are among these orphan receptors. They are characterized by unique features in their structure and tissue-specific expression, which yields them interesting candidates for deorphanization and testing as potential therapeutic targets. Capable of G-protein coupling and non-G protein-mediated function, aGPCRs may extend our repertoire of influencing physiological function. Besides their described significance in the immune and central nervous systems, growing evidence indicates a high importance of these receptors in metabolic tissue. RNAseq analyses revealed high expression of several aGPCRs in pancreatic islets, adipose tissue, liver, and intestine but also in neurons governing food intake. In this review, we focus on aGPCRs and their function in regulating metabolic pathways. Based on current knowledge, this receptor class represents high potential for future pharmacological approaches addressing obesity and other metabolic diseases.

MRI measures of hypothalamic injury are associated with glucagon-like peptide-1 receptor agonist treatment response in people with hypothalamic obesity

AIM

To evaluate whether neuroimaging-delineated regions of hypothalamic injury are associated with a differential treatment response to a glucagon-like peptide-1 receptor agonist (GLP-1RA) in patients with hypothalamic obesity (HO).

MATERIALS AND METHODS

We performed a prespecified secondary analysis of a randomized, multicentre, double-blind, placebo-controlled trial of people aged 10-25 years with hypothalamic injury and HO randomized to the GLP-1RA exenatide once-weekly (ExQW) or placebo for 36 weeks. Subjects underwent MRI prior to enrolment and the degree of hypothalamic damage was assessed using an integrative hypothalamic lesion score (HLS). Mammillary body (MB) damage was specifically determined. The main clinical endpoints were % change in body mass index (BMI) and change in % body fat. Nested ANCOVA models including a treatment × imaging measure interaction were compared using partial F-tests to assess whether the effect of ExQW treatment differed by severity of hypothalamic damage.

RESULTS

Complete data were available in 35/42 randomized participants (placebo, n = 15; ExQW, n = 20). ExQW-treated patients with worse HLS or bilateral MB damage had greater reductions in % body fat at 36 weeks (interaction coefficient estimates for HLS: -0.9%, 95% CI -1.6% to -0.2%, p = .02; for MB damage: -7.4%, 95% CI -10.1% to -4.7%, p < .001, respectively) but not for BMI % change. Similarly, patients with more damaged and smaller MB cross-sectional areas had greater reductions in % body fat following ExQW (interaction coefficient estimate 0.3%, 95% CI 0.2%-0.4%, p < .001).

CONCLUSIONS

In people with HO, greater hypothalamic damage as determined by MRI, in particular MB injury, is associated with greater reductions in adiposity following GLP-1RA treatment.

Diagnosis, treatment and prevention of type 2 diabetes mellitus in children and adolescents

During the last two decades, there have been several reports of an increasing incidence of type 2 diabetes mellitus (T2DM) in children and adolescents, especially among those belonging to minority ethnic groups. This trend, which parallels the increases in prevalence and degree of pediatric obesity, has caused great concern, even though T2DM remains a relatively rare disease in children. Youth T2DM differs not only from type 1 diabetes in children, from which it is sometimes difficult to differentiate, but also from T2DM in adults, since it appears to be an aggressive disease with rapidly progressive β-cell decline, high treatment failure rate, and accelerated development of complications. Despite the recent research, many aspects of youth T2DM still remain unknown, regarding both its pathophysiology and risk factor contribution, and its optimal management and prevention. Current management approaches include lifestyle changes, such as improved diet and increased physical activity, together with pharmacological interventions, including metformin, insulin, and the recently approved glucagon-like peptide-1 analog liraglutide. What is more important for everyone to realize though, from patients, families and physicians to schools, health services and policy-makers alike, is that T2DM is a largely preventable disease that will be addressed effectively only if its major contributor (i.e., pediatric obesity) is confronted and prevented at every possible stage of life, from conception until adulthood. Therefore, relevant comprehensive, coordinated, and innovative strategies are urgently needed.

Roles of interstitial fluid pH and weak organic acids in development and amelioration of insulin resistance

Type 2 diabetes mellitus (T2DM) is one of the most common lifestyle-related diseases (metabolic disorders) due to hyperphagia and/or hypokinesia. Hyperglycemia is the most well-known symptom occurring in T2DM patients. Insulin resistance is also one of the most important symptoms, however, it is still unclear how insulin resistance develops in T2DM. Detailed understanding of the pathogenesis primarily causing insulin resistance is essential for developing new therapies for T2DM. Insulin receptors are located at the plasma membrane of the insulin-targeted cells such as myocytes, adipocytes, etc., and insulin binds to the extracellular site of its receptor facing the interstitial fluid. Thus, changes in interstitial fluid microenvironments, specially pH, affect the insulin-binding affinity to its receptor. The most well-known clinical condition regarding pH is systemic acidosis (arterial blood pH < 7.35) frequently observed in severe T2DM associated with insulin resistance. Because the insulin-binding site of its receptor faces the interstitial fluid, we should recognize the interstitial fluid pH value, one of the most important factors influencing the insulin-binding affinity. It is notable that the interstitial fluid pH is unstable compared with the arterial blood pH even under conditions that the arterial blood pH stays within the normal range, 7.35-7.45. This review article introduces molecular mechanisms on unstable interstitial fluid pH value influencing the insulin action via changes in insulin-binding affinity and ameliorating actions of weak organic acids on insulin resistance via their characteristics as bases after absorption into the body even with sour taste at the tongue.