New Frontiers in Obesity Treatment: GLP-1 and Nascent Nutrient-Stimulated Hormone-Based Therapeutics

Regional trends and disparities in newer GLP1 receptor agonist initiation among real-world adult patients eligible for obesity treatment

AIMS

To characterize trends in the initiation of newer anti-obesity medications (AOMs) and determine factors associated with their use among obese/overweight populations.

MATERIALS AND METHODS

This study utilized electronic health record data from OneFlorida+ (2015-2024). Adults eligible for AOMs were included, defined as having a body mass index (BMI) ≥30 kg/m2 or a BMI of 27-29.9 kg/m2 with at least one obesity-related comorbidity. The primary outcome was the initiation of newer AOMs, specifically glucagon-like peptide-1 receptor agonists (GLP-1 RAs) including liraglutide, semaglutide and tirzepatide. Trends across years were examined, and a multivariable logistic regression identified sociodemographic, clinical and healthcare utilization factors associated with AOM initiation.

RESULTS

Of 319,949 adults, 1.8% initiated newer AOMs. Semaglutide accounted for 77.9% of initiations, tirzepatide 19.7% and liraglutide 17.8%. Initiation trends showed liraglutide uptake peaked at 5% in 2018 but declined afterward, while semaglutide and tirzepatide uptake increased exponentially since 2022. Odds of initiation were lower for Black (aOR [95% CI]: 0.87 [0.80-0.94]) and Hispanic (0.84 [0.78-0.91]) groups versus Whites, and for Medicaid (0.69 [0.63-0.76]) and uninsured (0.81 [0.74-0.87]) patients versus privately insured. Higher odds were associated with being female, middle-aged, having more outpatient visits and visiting endocrinologists.

CONCLUSIONS

The initiation of newer AOMs among overweight and obese populations remains low, but uptake has increased exponentially since 2022. Our findings reveal significant disparities in obesity care, highlighting the importance of addressing inequities in AOM access to improve obesity outcomes.

Building Comprehensive Care Networks to Support Lifestyle Change in Patients Taking Obesity Management Medications

There is a sizable proportion of the U.S. population taking obesity management medications (OMMs), accessed through their primary care provider or a specialist. If healthcare providers are prescribing the medications as directed, and patients are taking the medications as directed, they should be doing so in combination with healthy lifestyle behaviors. Specialists in nutrition therapy, physical activity, behavioral counseling, and medical management should work together as a network providing truly comprehensive care. When trained, educated and credentialed in obesity care, this network of providers can coordinate and collaborate to build trust, combat weight stigma and bias, support lifestyle change, and achieve improved health outcomes.

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

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

Obesity: pathophysiology and therapeutic interventions

Over the past few decades, obesity has transitioned from a localized health concern to a pressing global public health crisis affecting over 650 million adults globally, as documented by WHO epidemiological surveys. As a chronic metabolic disorder characterized by pathological adipose tissue expansion, chronic inflammation, and neuroendocrine dysregulation that disrupts systemic homeostasis and impairs physiological functions, obesity is rarely an isolated condition; rather, it is frequently complicated by severe comorbidities that collectively elevate mortality risks. Despite advances in nutritional science and public health initiatives, sustained weight management success rates and prevention in obesity remain limited, underscoring its recognition as a multifactorial disease influenced by genetic, environmental, and behavioral determinants. Notably, the escalating prevalence of obesity and its earlier onset in younger populations have intensified the urgency to develop novel therapeutic agents that simultaneously ensure efficacy and safety. This review aims to elucidate the pathophysiological mechanisms underlying obesity, analyze its major complications-including type 2 diabetes mellitus (T2DM), cardiovascular diseases (CVD), non-alcoholic fatty liver disease (NAFLD), obesity-related respiratory disorders, obesity-related nephropathy (ORN), musculoskeletal impairments, malignancies, and psychological comorbidities-and critically evaluate current anti-obesity strategies. Particular emphasis is placed on emerging pharmacological interventions, exemplified by plant-derived natural compounds such as berberine (BBR), with a focus on their molecular mechanisms, clinical efficacy, and therapeutic advantages. By integrating mechanistic insights with clinical evidence, this review seeks to provide innovative perspectives for developing safe, accessible, and effective obesity treatments.

Perceptions of anti-obesity medications among people with obesity and healthcare providers in the US: Findings from the OBSERVE Study

OBJECTIVE

The objective of this study was to understand the perceptions of and drivers/barriers to antiobesity medication (AOM) use among people with obesity (PwO) and health care providers (HCPs) in the United States.

METHODS

In 2022, PwO and HCPs completed cross-sectional surveys that included questions on perceptions of obesity management and AOMs. Data were analyzed using descriptive statistics.

RESULTS

Survey participants (1007 PwO and 474 HCPs) emphasized the effectiveness of lifestyle change and the patient's responsibility to address obesity. PwO reported a willingness to take newly approved AOMs long term. HCPs believed that their patients would adhere to AOMs long term if they experienced success. Both PwO and HCPs perceived an increased effectiveness of a multimodal approach to combining AOMs with HCP-guided lifestyle intervention. Potential barriers to long-term use of AOMs for both groups included concerns regarding long-term side effects and outcomes, costs and insurance coverage, and perception of AOMs that do not align with treatment of a chronic disease.

CONCLUSIONS

PwO and HCPs are interested in new AOM options, but educational gaps remain as a barrier to recommended multimodal chronic care. Ongoing education that includes the known effectiveness and safety data of newer AOMs and pending outcome trials could improve shared decision-making in obesity care.

Activin B improves glucose metabolism via induction of Fgf21 and hepatic glucagon resistance

Orchestrated hormonal interactions in response to feeding and fasting play a pivotal role in regulating glucose homeostasis. Here, we show that in obesity, the production of follistatin-like 3 (FSTL3), an endogenous inhibitor of Activin B, in adipose tissue is increased in both mice and humans. The knockdown of FSTL3 improves insulin sensitivity and glucose tolerance in diabetic obese db/db mice. Notably, the overexpression of Activin B, a member of the TGFβ superfamily that is induced in liver sinusoidal endothelial cells by fasting, exerts multiple metabolically beneficial effects, including improvement of insulin sensitivity, suppression of hepatic glucose production, and enhancement of glucose-stimulated insulin secretion, all of which are attenuated by the overexpression of FSTL3. Activin B increases insulin sensitivity and reduces fat by inducing fibroblast growth factor 21 (FGF21) while suppressing glucagon action in the liver by increasing phosphodiesterase 4 B (PDE4B), leading to hepatic glucagon resistance and resultant hyperglucagonemia. Activin B-induced hyperglucagonemia enhances glucose-stimulated insulin secretion by stimulating glucagon-like peptide-1 (GLP-1) receptor in pancreatic β-cells. Thus, enhancing the action of Activin B which improves multiple components of the pathogenesis of diabetes may be a promising strategy for diabetes treatment.

Adipose tissue-targeting nanomedicines for obesity pharmacotherapy

The increasing global prevalence of obesity presents a substantial challenge to public health. Current nutrient-stimulated hormone (NuSH)-based therapeutics are hindered by receptor desensitization, muscle loss, and weight regain. The adipose tissue, the primary organ responsible for energy storage and metabolic management, is a promising target for obesity treatment. Nanomedicine holds promise to precisely deliver medication to the adipose tissue to maximize therapeutic efficacy and minimize off-target effects; indeed, various adipose tissue-targeting nanomedicines have shown impressive anti-obesity effects by optimizing drug pharmacokinetic profiles and reducing nonspecific distribution in preclinical studies. Here we examine the current state of the art of adipose tissue-targeting nanomedicines, offering insights into recent advances, future possibilities, and the remaining challenges associated with their application in obesity treatment.

New Frontiers in Nutritional and Therapeutic Interventions for Obesity Phenotypes

The heterogeneity among patients with obesity is particularly evident in the weight loss response to interventions such as diets, drugs, devices and surgery. Obesity can be "catalogued" into four phenotypes: hungry brain (abnormal satiety for alteration of gut-brain axis), emotional hunger (hedonic eating), hungry gut (abnormal duration of satiety for faster gastric emptying) and slow burning (slowing of the metabolic rate). Phenotypes are grafted onto this complexity, the recognition of which allows for personalized medicine and increasingly targeted therapies. Although there are no standardized treatment protocols, we present management options consisting of lifestyle modifications and pharmacologic therapies. Nutritional advice and encouragement of adequate physical activity lead to increased self-efficacy and promote a sense of well-being when coupled with psychological approaches involving mindful eating. In summary, obesity has a complex pathophysiology best addressed through a therapeutic process suited to the phenotype encountered and in synergy with multifactorial interventions.

Perspectives on Obesity Management and the Use of Anti-Obesity Medicine from US Employees and Employers: Results from the OBSERVE Study

Personal health factors and direct and indirect costs of obesity affect employers and employees. This research aimed to understand perceptions of obesity management and anti-obesity medications (AOMs) among employers and employees. In 2022, people with obesity and employers completed cross-sectional surveys about perceptions of obesity and its management, including AOMs. Data were analyzed with descriptive statistics. Data from 461 employed people with obesity (EwO) and 51 employer representatives (ER) were analyzed. Both EwO and ER acknowledged the impact of obesity on future health problems (88.3%; 100.0%) and perceived obesity as a disease (60.5%; 80.4%) to varied degrees. Both groups perceived an incremental value in combining self-directed lifestyle changes and AOMs (57.5%; 66.7%) and perceived healthcare provider-guided lifestyle change alongside AOMs as the most effective approach for maintaining long-term weight reduction (56.4%; 66.6%). More than two-thirds (68.6%) of ER expressed willingness to revisit their AOM coverage decisions, though cost of medication coverage (72.5%) and affordability of medications for employees (68.7%) were identified as barriers. ER believed that data showing reductions in premiums and claims at their organizations (78.4%) would be helpful in supporting the coverage of AOMs. While EwO and ER were receptive toward AOMs, organization-level barriers existed with AOM coverage. Evidence demonstrating the benefits of evidence-based obesity care, direct/indirect cost reductions, and the impact of obesity may address barriers to AOM coverage and improve obesity care and outcomes of their workforces.

Comfort Foods in the Twenty-First Century: Friend or Foe?

The comfort food (CF) concept emerged during the latter half of the twentieth century. Although not well defined, CF can be described as familiar foods that elicit feelings of well-being and play a role in social interactions and psychological health. These foods are often calorically dense and nutrient-poor, and overconsumption of some CF may contribute to negative metabolic health outcomes. This is particularly relevant when considering the global increase in obesity, leading to the development of therapeutics for improved weight control and metabolic health. In this review, we aim to (a) provide a historical perspective of the CF concept, (b) detail some genetic, developmental, and cultural factors that determine food preference, (c) discuss the influence of diet on the gut-brain connection, hormones, nutrient absorption, and microbiome diversity, and (d) provide a perspective detailing possible future directions in which food technology may enable a new generation of CF with enhanced palatability and nutrient profiles while contributing to well-being and environmental sustainability.

Next Steps in Efforts to Address the Obesity Epidemic

Obesity prevalence continues to rise globally at alarming rates, with adverse health and economic implications. In this state-of-the-art review, we provide an analysis of selected evidence about the current knowledge in the obesity literature, including a synthesis of current challenges in obesity and its determinants. In addition, we review past and current efforts to combat the obesity epidemic, highlighting both successful efforts and areas for further development. Last, we offer insights into the next steps to address the obesity epidemic and advance the field of obesity through both research and practice by (a) adopting a systems perspective, (b) fostering cross-sector and community collaborations, (c) advancing health equity, (d) narrowing the research-to-practice and research-to-policy gaps with multidisciplinary approaches, and (e) embracing complementary approaches for concurrent obesity prevention and treatment.

Tirzepatide for Obesity Treatment and Diabetes Prevention

BACKGROUND

Obesity is a chronic disease and causal precursor to myriad other conditions, including type 2 diabetes. In an earlier analysis of the SURMOUNT-1 trial, tirzepatide was shown to provide substantial and sustained reductions in body weight in persons with obesity over a 72-week period. Here, we report the 3-year safety outcomes with tirzepatide and its efficacy in reducing weight and delaying progression to type 2 diabetes in persons with both obesity and prediabetes.

METHODS

We performed a phase 3, double-blind, randomized, controlled trial in which 2539 participants with obesity, of whom 1032 also had prediabetes, were assigned in a 1:1:1:1 ratio to receive tirzepatide at a once-weekly dose of 5 mg, 10 mg, or 15 mg or placebo. The current analysis involved the participants with both obesity and prediabetes, who received their assigned dose of tirzepatide or placebo for a total of 176 weeks, followed by a 17-week off-treatment period. The three key secondary end points, which were controlled for type I error, were the percent change in body weight from baseline to week 176 and onset of type 2 diabetes during the 176-week and 193-week periods.

RESULTS

At 176 weeks, the mean percent change in body weight among the participants who received tirzepatide was -12.3% with the 5-mg dose, -18.7% with the 10-mg dose, and -19.7% with the 15-mg dose, as compared with -1.3% among those who received placebo (P<0.001 for all comparisons with placebo). Fewer participants received a diagnosis of type 2 diabetes in the tirzepatide groups than in the placebo group (1.3% vs. 13.3%; hazard ratio, 0.07; 95% confidence interval [CI], 0.0 to 0.1; P<0.001). After 17 weeks off treatment or placebo, 2.4% of the participants who received tirzepatide and 13.7% of those who received placebo had type 2 diabetes (hazard ratio, 0.12; 95% CI, 0.1 to 0.2; P<0.001). Other than coronavirus disease 2019, the most common adverse events were gastrointestinal, most of which were mild to moderate in severity and occurred primarily during the dose-escalation period in the first 20 weeks of the trial. No new safety signals were identified.

CONCLUSIONS

Three years of treatment with tirzepatide in persons with obesity and prediabetes resulted in substantial and sustained weight reduction and a markedly lower risk of progression to type 2 diabetes than that with placebo. (Funded by Eli Lilly; SURMOUNT-1 ClinicalTrials.gov number, NCT04184622.).

Chemerin loss-of-function attenuates glucagon-like peptide-1 secretion in exercised obese mice

AIMS

To investigate the role of chemerin reduction in mediating exercise-induced Glucagon-like peptide-1 (GLP-1) secretion and the amelioration of pancreatic β-cell function in obesity.

MATERIALS AND METHODS

Obesity models were established using wild-type and chemerin systemic knockout mice, followed by 8 weeks of moderate-intensity continuous aerobic exercise training. Serum chemerin levels, GLP-1 synthesis, glucose tolerance, pancreatic β-cell function, structure, and apoptosis were assessed. In vitro experiments were conducted on STC-1 cells, derived from murine intestinal endocrine cells, to evaluate GLP-1 secretion following exogenous chemerin treatment. Additionally, colonic tissue inflammation and apoptosis were analyzed using qPCR and TUNEL staining.

RESULTS

In obese wild-type mice, moderate-intensity aerobic exercise significantly reduced serum chemerin levels, enhanced GLP-1 secretion, and improved glucose tolerance, pancreatic β-cell structure, function, and apoptosis. These effects were absent in obese chemerin knockout mice. Exogenous chemerin treatment reduced GLP-1 secretion in STC-1 cells. Furthermore, the beneficial effects of exercise on colonic inflammation and apoptosis observed in wild-type mice were abolished in chemerin knockout mice.

CONCLUSION

Reduction of chemerin is crucial for the beneficial effects of aerobic exercise on GLP-1 secretion and pancreatic β-cell function in obesity. The mechanisms behind these effects may involve improvements in colonic inflammation and apoptosis. These findings offer new insights into the molecular mechanisms through which exercise improves obesity-related metabolic dysfunction.

Nutrient-Stimulating Hormone-Based Therapies for Obesity

Obesity is a chronic disease with an increasing worldwide prevalence. Improving obesity is of paramount importance given its association with conditions such as type 2 diabetes, cardiovascular disease, and cancer among others. In the last decade, a new class of highly efficacious medications called nutrient-stimulating hormone (NuSH) therapies has emerged. This article highlights the effectiveness of the FDA-approved NuSH-based therapies-liraglutide, semaglutide, and tirzepatide-in long-term weight management. Ongoing trials are exploring novel mechanisms of action to simultaneously target multiple receptors involved in appetite and energy regulation, promising further advancements and additional treatment options in the field of obesity management.

Comparing clinical practice habits among obesity medicine physicians by patient, physician and clinic factors

Background

While clinical practice habits vary by patient, physician and clinic factors in primary care, limited research has examined whether differences exist in obesity medicine. Our objective was to compare practice habits by such factors among obesity medicine physicians certified by the American Board of Obesity Medicine (ABOM).

Methods

We conducted secondary analyses of cross-sectional data from the 2023 ABOM Practice Analysis Validation Survey. We included three obesity medicine practice habits - prescribing anti-obesity medications (AOMs), off-label prescribing of medications for weight reduction, and obesity medicine clinical practice hours (4-20 h/week versus >20 h/week). We included patient (patient population), physician (primary medical specialty, years of obesity medicine experience) and clinic factors (practice setting, geographic catchment, accepts insurance for obesity care). We conducted bivariate analyses using Χ2 tests.

Results

Among 565 ABOM-certified physicians, 71.5 % had primary medical specialties within primary care and 9.2 % predominantly treated children/adolescents with obesity. Overall, 97.5 % prescribed AOMs and 85.1 % prescribed off-label medications for weight reduction. Fewer physicians who predominantly treated children/adolescents prescribed AOMs compared to physicians with no or limited treatment of children (88.5 % versus 98.4 % and 98.5 %, respectively; p < 0.001). Overall, 41.4 % reported practicing obesity medicine >20 h/week, which was more likely to occur as years of obesity medicine experience increased (i.e., 21.9 ​% among physicians with 1-2 years of experience versus 58.5 ​% with 10+ years; p ​< ​0.001). No significant differences in practice habits occurred by primary medical specialty, practice setting, geographic catchment, or accepting insurance.

Conclusion

Our findings may suggest that ABOM-certified physicians have consistent obesity medication prescribing practices regardless of physician or clinic factors, which may be particularly important to patients seeking pharmacologic treatment. Most ABOM-certified physicians who predominantly treat children/adolescents prescribe obesity medications. These current rates are relatively higher than prior findings among pediatric ABOM-certified physicians, which might help support pharmacologic access for pediatric patients.

The Promise of Adjunct Medications in Improving Type 1 Diabetes Outcomes: Glucagon-Like Peptide Receptor Agonists

Type 1 diabetes (T1D) necessitates lifelong insulin therapy due to the autoimmune destruction of insulin-producing pancreatic beta cells. Despite advancements in diabetes technology and insulin formulations, maintaining optimal glycemic outcomes remains challenging in these individuals. Obesity, accompanied by insulin resistance, is common not only in type 2 diabetes (T2D) but also in many individuals with T1D. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs), approved for T2D and obesity, are now being explored for off-label use in individuals with T1D. This review examines their efficacy, safety, and potential benefits in T1D management. We reviewed articles published up to May 2024 from databases like PubMed and Scopus, mainly focusing on human studies of GLP-1 RAs in T1D, as well as cardiorenal and metabolic outcomes in individuals with T2D and obesity. Semaglutide and other GLP-1 RAs showed significant improvements in glycemic outcomes, hemoglobin A1c levels, reduced insulin doses, and notable weight loss. Studies in individuals with obesity and T2D showed significant improvements in lipid profile and offered cardiorenal protection. Common side effects include gastrointestinal issues, and while some studies reported hypoglycemia, hyperglycemia, and ketosis, others did not. Despite these challenges, GLP-1 RAs offer significant therapeutic benefits, making them a promising adjunct to insulin therapy for improving clinical outcomes in T1D management.

The pleiotropic effects of glucagon-like peptide-1 receptor agonists in patients with metabolic dysfunction-associated steatohepatitis: a review for gastroenterologists

INTRODUCTION

Glucagon-like peptide-1 receptor agonists (GLP-1RAs), and dual GLP-1/glucose-dependent insulinotropic peptide (GIP) or glucagon receptor agonists have emerged as promising agents to treat metabolic dysfunction-associated steatotic liver disease (MASLD)/metabolic dysfunction-associated steatohepatitis (MASH). Although the beneficial effects of GLP-1RAs on glycemic control and weight are well-established, clinicians may be unfamiliar with other potential benefits of this class.

AREAS COVERED

We examined the pleiotropic effects of GLP-1RAs and how they relate to gastroenterologists for MASLD/MASH treatment. Our narrative review of English articles included four GLP-1RAs (subcutaneous semaglutide, liraglutide, dulaglutide, and efpeglenatide), a dual GLP-1/GIP agonist (tirzepatide), a dual GLP-1/glucagon receptor agonist (survodutide), MASLD/MASH, related disorders, clinical management, treatment outcomes and landscape.

EXPERT OPINION

In Phase I - III trials, GLP-1RAs are associated with clinically relevant hepatic improvements including MASH resolution, liver fat reduction, and preventing worsening fibrosis. Effects on cardiometabolic parameters align with type 2 diabetes/obesity Phase III data, comprising substantial improvements in glycemic, weight, and cardiovascular outcomes. Promising data also suggest benefits in common comorbidities, including obstructive sleep apnea, polycystic ovary syndrome, chronic kidney disease, and heart failure with preserved ejection fraction.GLP-1RAs represent a valuable pharmacotherapeutic option for gastroenterologists managing individuals with MASLD/MASH and cardiometabolic comorbid conditions.

Role of Glucagon-Like Peptide-1 Receptor Agonists in People With Infertility and Pregnancy

Obesity is a chronic condition that causes significant morbidity and mortality in people in the United States and around the world. Traditional means of weight loss include diet, exercise, behavioral modifications, and surgery. New weight loss medications, glucagon-like peptide-1 receptor agonists, are revolutionizing the management of weight loss but have implications for fertility and pregnancy. Obesity is associated with infertility and may affect response to ovulation induction medications. In pregnancy, obesity increases the risks of spontaneous abortion, birth defects, gestational diabetes, hypertensive disorders of pregnancy, cesarean delivery, and stillbirth. Lifestyle changes alone for weight loss have not improved outcomes. Glucagon-like peptide-1 receptor agonists and new medications targeting gut hormones can help people achieve their weight loss goals but are contraindicated in pregnancy. Obstetrician-gynecologists should work with patients to manage these medications before they become pregnant, between pregnancies, and after delivery.

Safety profile of semaglutide versus placebo in the SELECT study: a randomized controlled trial

OBJECTIVE

The objective of this study was to assess safety of once-weekly subcutaneous semaglutide 2.4 mg versus placebo, beyond reduction in major adverse cardiovascular events, in patients with established cardiovascular disease and overweight or obesity.

METHODS

Safety data focused on serious adverse events (SAEs), all adverse events (AEs) leading to permanent treatment discontinuation irrespective of seriousness, and prespecified AEs of special interest irrespective of seriousness. Tests of treatment differences were determined by two-sided p values.

RESULTS

The proportion of patients with SAEs was lower with semaglutide versus placebo (33.4% vs. 36.4%; p < 0.001), primarily driven by cardiac disorders (11.5% vs. 13.5%; p < 0.001). The proportion of patients with AEs leading to discontinuation was higher with semaglutide versus placebo (16.6% vs. 8.2%; p < 0.001), a difference driven by gastrointestinal disorders (10.0% vs. 2.0%); however, proportions due to SAEs leading to discontinuation were similar (3.6% vs. 4.1%). Suicide/self-injury SAEs were low and balanced between groups (0.11% in both groups). Gallbladder-related disorders were more frequent with semaglutide versus placebo (2.8% vs. 2.3%; p = 0.04), mainly driven by cholelithiasis (1.4% vs. 1.1%), whereas proportions of cholecystitis were similar between groups (0.6% vs. 0.6%).

CONCLUSIONS

The long-term safety profile observed in the Semaglutide Effects on Cardiovascular Outcomes in People with Overweight or Obesity (SELECT) study is consistent with previously reported semaglutide studies. No new safety concerns were identified for once-weekly semaglutide 2.4 mg.

Advances in Oral Biomacromolecule Therapies for Metabolic Diseases

Metabolic diseases like obesity and diabetes are on the rise, and therapies with biomacromolecules (such as proteins, peptides, antibodies, and oligonucleotides) play a crucial role in their treatment. However, these drugs are traditionally injected. For patients with chronic diseases (e.g., metabolic diseases), long-term injections are accompanied by inconvenience and low compliance. Oral administration is preferred, but the delivery of biomacromolecules is challenging due to gastrointestinal barriers. In this article, we introduce the available biomacromolecule drugs for the treatment of metabolic diseases. The gastrointestinal barriers to oral drug delivery and strategies to overcome these barriers are also explored. We then discuss strategies for alleviating metabolic defects, including glucose metabolism, lipid metabolism, and energy metabolism, with oral biomacromolecules such as insulin, glucagon-like peptide-1 receptor agonists, proprotein convertase subtilisin/kexin type 9 inhibitors, fibroblast growth factor 21 analogues, and peptide YY analogues.

Body Fat and Visceral Fat Values in Spanish Healthcare Workers: Associated Variables

BACKGROUND/OBJECTIVES

Excessive body adiposity is a significant public health challenge on a global scale. This study aimed to investigate the association between various sociodemographic factors and healthy lifestyle habits and the presence or absence of elevated body adiposity levels.

METHODOLOGY

Two studies were conducted, a retrospective longitudinal study and a cross-sectional descriptive study. The analysis included 44,939 healthcare workers, categorised into four professional groups, to explore the relationship between age, sex, smoking, physical activity, and adherence to the Mediterranean diet and body adiposity, assessed as elevated body fat (BF) and visceral fat (VF) levels. Descriptive statistics encompassed categorical and quantitative variables, analysed using frequencies, Student's t-tests, chi-square tests, and multinomial logistic regression models. Associations, concordances, and correlations were further examined using logistic regression and Cohen's and Pearson's kappa coefficients.

RESULTS

Age, sex, and physical activity were the factors most strongly associated with elevated BF and VF levels. Odds ratios (ORs) indicated the following significant associations: individuals aged 60 years and older exhibited ORs of 6.71 (95% CI: 5.68-7.74) for BF and 12.18 (95% CI: 10.01-14.26) for VF; male sex was associated with ORs of 2.21 (95% CI: 2.06-2.36) for BF and 12.51 (95% CI: 11.29-13.74) for VF. Sedentary behaviour was linked to ORs of 3.69 (95% CI: 3.41-3.97) for BF and 4.20 (95% CI: 3.78-4.63) for VF. Among healthcare professionals, nursing assistants and orderlies demonstrated the highest levels of adipose tissue accumulation.

CONCLUSIONS

Elevated BF and VF levels among healthcare personnel are significantly associated by lifestyle factors, sex, and age, with the most pronounced risk observed in nursing assistants and orderlies. Further research focusing on the causal relationships between lifestyle behaviours and adiposity in this population will provide valuable insights and support the design of targeted preventive strategies to mitigate its prevalence.

Efficacy and safety of retatrutide, a novel GLP-1, GIP, and glucagon receptor agonist for obesity treatment: a systematic review and meta-analysis of randomized controlled trials

Background

Retatrutide is a novel triple agonist targeting the receptors of glucagon-like peptide 1 (GLP-1), gastric inhibitory polypeptide (GIP), and glucagon. We sought to assess the efficacy and safety of retatrutide in obese patients with or without diabetes.

Methods

PubMed, Scopus, Web of Science, and Cochrane databases were searched from inception until May 2024. Eligible studies comprised randomized controlled trials that compared retatrutide with placebo in obese patients. We excluded studies on healthy populations, non-English texts, single-arm studies, animal studies, and abstracts. RevMan software (version 5.4) was used for analysis, with subgroup evaluation by dose (4 mg, 8 mg, 12 mg).

Results

Three randomized controlled trials, encompassing 878 patients, satisfied our inclusion criteria. Retatrutide significantly reduced body weight (mean difference [MD]: -14.33%), body mass index (MD: -5.38), waist circumference (MD: -10.51 cm), fasting plasma glucose (MD: -23.51 mg/dL), hemoglobin A1c (MD: -0.91%), and systolic and diastolic blood pressure (MD: -9.88 mm Hg and -3.88 mm Hg, respectively), all with P values < 0.00001. No significant difference in adverse events was observed between the groups (relative risk: 1.11, P = 0.24).

Conclusion

Retatrutide demonstrated significant improvements in body weight and metabolic outcomes among adults with obesity and had an appropriate safety profile. However, additional large and long-term trials are required to establish these results.

Contemporary treatment patterns of overweight and obesity: insights from the Mass General Brigham health care system

OBJECTIVE

The objective of this study was to describe the prevalence of obesity, obesity-related conditions (ORCs), and antiobesity medication (AOM) eligibility and prescribing practice among eligible patients in a large health care system.

METHODS

In this cross-sectional analysis of the multicenter Mass General Brigham health care system (Boston, Massachusetts) spanning 2018 to 2022, adults eligible for AOMs (BMI ≥ 30 kg/m2 or BMI 27-29.9 kg/m2 with ≥1 ORC) were identified. Among those AOM-eligible, the prevalence of prescriptions for AOMs approved for long-term weight management was evaluated.

RESULTS

Of 2,469,474 adults (mean [SD], age 53 [19] years; 57% female; BMI 28.1 [6.3] kg/m2), a total of 1,110,251 (45.0%) were eligible for AOMs. Of these, 69.4% (31.2% of overall cohort) had BMI ≥ 30 kg/m2. AOM prescription was observed in 15,214 (1.4%) of all eligible patients, with female sex, younger age, higher BMI, commercial insurance, and greater ORC burden associated with higher prevalence of AOM prescriptions. Musculoskeletal disorders (54%) were the most common ORCs, with ≥2 ORCs observed in 62% of patients. Liraglutide 3.0 mg and semaglutide 2.4 mg were the most frequently prescribed AOMs (58% and 34% of all AOMs, respectively).

CONCLUSIONS

Although nearly one-half of all patients in a large health care system were AOM-eligible by guidelines and regulatory labeling, only 1% of those who were eligible were prescribed AOMs.

Trends and Disparities in Newer GLP1 Receptor Agonist Initiation among Real-World Adult Patients Eligible for Obesity Treatment

Aims

To characterize trends in the initiation of newer anti-obesity medications (AOMs) and determine factors associated with their use among obese/overweight populations.

Materials and methods

This retrospective study utilized electronic health record data from OneFlorida+ (2015-2024). Adults eligible for AOMs were included, defined as having a BMI ≥30 kg/m² or a BMI of 27-29.9 kg/m² with at least one obesity-related comorbidity. The primary outcome was the initiation of newer AOMs, specifically glucagon-like peptide-1 receptor agonists (GLP-1 RAs) including liraglutide, semaglutide, and tirzepatide. Trends across years were examined, and a multivariable logistic regression identified sociodemographic, clinical, and healthcare utilization factors associated with AOM initiation.

Results

Of 319,949 adults, 1.8% initiated newer AOMs. Semaglutide accounted for 77.9% of initiations, tirzepatide 19.7%, and liraglutide 17.8%. Initiation trends showed liraglutide uptake peaked at 5% in 2018 but declined afterward, while semaglutide and tirzepatide uptake increased exponentially since 2022. Odds of initiation were lower for Black (aOR (95% CI): 0.87 [0.80- 0.94]) and Hispanic (0.84 [0.78-0.91]) groups vs. Whites, and for Medicaid (0.69 [0.63-0.76]) and uninsured (0.81 [0.74-0.87]) patients vs. privately insured. Higher odds were associated with being female, middle-aged, having more outpatient visits, and visiting endocrinologists.

Conclusions

The initiation of newer AOMs among overweight and obese populations remains low, but uptake has increased exponentially since 2022. Our findings reveal significant disparities in obesity care, highlighting the importance of addressing inequities in AOM access to improve obesity outcomes.

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.

Decoding Obesity Management Medications and the Journey to Informed Treatment Choices for Patients

Incretin-based obesity management medications (OMMs) fill a treatment gap in a stepped-care model between lifestyle change alone and metabolic bariatric surgery, resulting in weight loss of 15% to 20% of body weight. Public interest in and demand for OMMs has recently increased dramatically. Unfortunately, cost and access to OMMs remain a significant barrier for many patients. Although these medications have the potential to produce large weight loss outcomes, many unanswered questions remain regarding informed choice and optimization of obesity care protocols, especially for patients with a body mass index of 35 kg/m2 or higher who may be considering various intervention options such as lifestyle changes, OMMs, endoscopic weight loss procedures, and/or metabolic bariatric surgery. When considering strategies to aid patients in decision making about obesity treatment, several considerations warrant discussion because patients may have unrealistic perceptions about risk vs efficacy and may hold numerous misconceptions about long-term behavior change and outcomes. This article outlines considerations for informed obesity treatment decision making and reviews aspects of obesity treatment specific to OMMs, including adverse effects, patient expectations for treatment outcome, equitable access to care, the impact of weight bias on patient care, the risk of weight recurrence, and the need for long-term multicomponent treatment to achieve weight loss and weight maintenance.

Exenatide administration time-dependently affects the hepatic circadian clock through glucagon-like peptide-1 receptors in the central nervous system

Accumulating evidence indicates that disruption of the circadian clock contributes to the development of lifestyle-related diseases. We have previously shown that exenatide, a glucagon-like peptide-1 (GLP-1) receptor agonist, can strongly affect the molecular clocks in the peripheral tissues. This study aimed to investigate the effects of its dosing time and the central nervous system-specific GLP-1 receptor knockdown (GLP1RKD) on the hepatic clock in mice treated with exenatide. Male C57BL/6J and GLP1RKD mice were housed under a 12-h/12-h light/dark cycle, and feeding was restricted to either the light period (L-TRF) or the first 4 h in the dark period (D-TRF). In parallel, exenatide was administered 4-5 times, once daily either at the beginning of the dark (ZT 12) or light period (ZT 0), and we assessed the mRNA expression rhythms of clock genes in the liver thereafter. Exenatide administration at ZT 12 counteracted the phase shift effect of the L-TRF on the hepatic clock of wild-type mice, whereas the dosing at ZT 0 enhanced its effect. However, exenatide did not influence the phase of the hepatic clock under D-TRF regardless of the dosing time. The effect of exenatide in wild-type mice weakened in GLP1RKD mice. These results showed that exenatide dosing time-dependently affects the hepatic circadian clock through the central GLP-1 system. Exenatide administration at the beginning of the active period (i.e., in the morning for humans) might prevent disruption of the peripheral clocks caused by irregular eating habits.

GLP-1 receptor agonists in patients with chronic kidney disease and either overweight or obesity

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have emerged as game-changers across the cardiovascular-kidney-metabolic (CKM) spectrum: overweight/obesity, type 2 diabetes mellitus (T2DM) and associated chronic kidney disease (CKD) and cardiovascular disease (CVD). Liraglutide, semaglutide and tirzepatide are European Medicines Agency approved to improve metabolic control in T2DM and to decrease weight in persons with obesity [body mass index (BMI) ≥30 kg/m2] or with overweight (BMI ≥27 kg/m2) associated with weight-related comorbidities such as hypertension, dyslipidaemia, CVD and others. Additionally, liraglutide and semaglutide are approved to reduce CVD risk in patients with CVD and T2DM. Semaglutide is also approved to reduce CVD risk in patients with CVD and either obesity or overweight and in phase 3 clinical trials showed kidney and cardiovascular protection in patients with T2DM and albuminuric CKD (FLOW trial) as well as in persons without diabetes that had CVD and overweight/obesity (SELECT trial). Thus, nephrologists should consider prescribing GLP-1 RAs to improve metabolic control, reduce CVD risk or improve kidney outcomes in three scenarios: patients with overweight and a related comorbid condition such as hypertension, dyslipidaemia or CVD, patients with obesity and patients with T2DM. This review addresses the promising landscape of GLP-1 RAs to treat persons with overweight or obesity, with or without T2DM, within the context of CKD, assessing their safety and impact on weight, metabolic control, blood pressure and kidney and cardiovascular outcomes, as part of a holistic patient-centred approach to preserve CKM health.

Duties, tasks, knowledge and skills of an obesity medicine physician: A practice analysis

Background

Given the evolving nature of obesity medicine, periodic evaluation of its clinical practice is needed to ensure that certification requirements address real-world experience. Practice analysis is a systematic approach to define a field's body of knowledge, and its results can inform the content outline and examination blueprint for a certification examination. This study describes the 2023 practice analysis conducted by the American Board of Obesity Medicine (ABOM).

Methods

Initially, 14 obesity medicine physicians participated in a practice analysis panel, resulting in 3 duties and 30 tasks required for competent practice of obesity medicine physicians. Each task included steps, knowledge, skills, and abilities needed to perform the task. ABOM then recruited 645 certified obesity medicine physicians from its database to participate in a validation survey to rate the frequency [scale: never (0) to very frequently (5)] and importance [scale: not important (0) to very important (3)] of each task. Survey participants could also provide open-ended comments.

Results

Among validation survey participants (n = 645), the most common primary medical specialties reported were internal medicine (46.0 %), family medicine (33.8 %), and pediatrics (11.2 %). Years practicing obesity medicine varied with 45.3 % reporting 1-4 years, 26.0 % 5-9 years, and 28.7 % ≥ 10 years in practice. Most tasks were performed frequently (mean score ≥4.0) and rated as important (mean score ≥2.0). All tasks were retained based on the frequency and importance ratings. Survey results informed the weighting in the examination blueprint.

Conclusion

There was consensus among practicing ABOM-certified physicians who participated in the validation survey in the tasks required for competent obesity medicine practice. Our practice analysis approach was a structured process that engaged obesity medicine physicians and captured the breadth and depth of knowledge required for obesity medicine. The new content outline and examination blueprint developed will be implemented with the 2025 ABOM certification exam administration.

Glucagon-like peptide-1 receptor agonist-based agents and weight loss composition: Filling the gaps

Excess adiposity is at the root of type 2 diabetes (T2D). Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have emerged as first-line treatments for T2D based on significant weight loss results. The composition of weight loss using most diets consists of <25% fat-free mass (FFM) loss, with the remainder from fat stores. Higher amounts of weight loss (achieved with metabolic bariatric surgery) result in greater reductions in FFM. Our aim was to assess the impact that GLP-1RA-based treatments have on FFM. We analysed studies that reported changes in FFM with the following agents: exenatide, liraglutide, semaglutide, and the dual incretin receptor agonist tirzepatide. We performed an analysis of various weight loss interventions to provide a reference for expected changes in FFM. We evaluated studies using dual-energy X-ray absorptiometry (DXA) for measuring FFM (a crude surrogate for skeletal muscle). In evaluating the composition of weight loss, the percentage lost as fat-free mass (%FFML) was equal to ΔFFM/total weight change. The %FFML using GLP-1RA-based agents was between 20% and 40%. In the 28 clinical trials evaluated, the proportion of FFM loss was highly variable, but the majority reported %FFML exceeding 25%. Our review was limited to small substudies and the use of DXA, which does not measure skeletal muscle mass directly. Since FFM contains a variable amount of muscle (approximately 55%), this indirect measure may explain the heterogeneity in the data. Assessing quantity and quality of skeletal muscle using advanced imaging (magnetic resonance imaging) with functional testing will help fill the gaps in our current understanding.

Effects of once-weekly subcutaneous retatrutide on weight and metabolic markers: A systematic review and meta-analysis of randomized controlled trials

Aim

To assess the effects of once-weekly subcutaneous retatrutide on weight and metabolic markers and the occurrence of side effects in patients with overweight, obesity and/or type 2 diabetes (T2D).

Methods

PubMed, Embase, Cochrane Library, and ClinicalTrials.gov databases were systematically searched for placebo-controlled, randomized clinical trials (RCTs) published up until February 23, 2024. Weighted mean differences (WMDs) for continuous outcomes and risk ratios (RRs) for binary endpoints were computed, with 95 % confidence intervals (CIs).

Results

A total of three studies were included, comprising 640 patients, of whom 510 were prescribed retatrutide. Compared with placebo, retatrutide significantly reduced body weight (WMD -10.66 kg; 95 % CI -17.63, -3.69), body mass index (WMD -4.53 kg/m2; 95 % CI -7.51, -1.55), and waist circumference (WMD -6.61 cm; 95 % CI -13.17, -0.05). In addition, retatrutide significantly increased the proportion of patients who achieved a weight reduction of ≥5 % (RR 2.92; 95 % CI 2.17-3.93), ≥10 % (RR 9.32; 95 % CI 4.56-19.06), ≥15 % (RR 18.40; 95 % CI 6.00-56.42), and ≥20 % (RR 16.61; 95 % CI 4.17-66.12).

Conclusions

In this meta-analysis, the use of once-weekly subcutaneous retatrutide was associated with a significant reduction in body weight and improvement of metabolic markers in patients with overweight, obesity and/or T2D, compared with placebo, with an increase in non-severe gastrointestinal and hypersensitivity adverse events. Phase 3 RCTs are expected to shed further light on the efficacy and safety of once-weekly subcutaneous retatrutide over the long term.

Optimizing nutrition, diet, and lifestyle communication in GLP-1 medication therapy for weight management: A qualitative research study with registered dietitians

Background

This qualitative study used semi-structured interviews to examine registered dietitians' perspectives on diet, nutrition, and lifestyle communication for patients on GLP-1 medications for obesity management.

Methods

Through in-depth interviews with registered dietitians, this research identifies elements that could improve both the efficacy of GLP-1 medication therapies and patient adherence.

Results

indicate that a comprehensive approach, integrating patient communication with proactive management of side effects and ongoing lifestyle counseling, is essential for optimizing treatment outcomes.

Conclusion

Key findings include the importance of using visual and metaphorical aids to improve understanding, the necessity for structured lifestyle programs, and the pivotal role of personalized diet plans. These insights offer valuable directions for enhancing patient care and formulating clinical practices around the use of GLP-1 receptor agonist medications.

Association of glucagon-like peptide-1 receptor agonists with suicidal ideation and self-injury in individuals with diabetes and obesity: a propensity-weighted, population-based cohort study

AIMS/HYPOTHESIS

Regulators worldwide are reviewing safety data on glucagon-like peptide-1 receptor agonists (GLP-1RA), following reports by the Icelandic Medicines Agency in July 2023 of suicidal ideation and self-injury (SIS) in individuals taking liraglutide and semaglutide. We aimed to assess the risk of SIS in new users of GLP-1RA when compared with sodium-glucose cotransporter 2 inhibitors (SGLT-2i) users, prescribed to treat type 2 diabetes in individuals with obesity.

METHODS

This is a cohort study combining several population-wide databases and covering a Spanish population of five million inhabitants, including all adults with obesity who initiated treatment with either GLP-1RA or SGLT-2i for type 2 diabetes from 2015 to 2021. To estimate the comparative effect of GLP-1RA on the risk of SIS, we employed a new user, active comparator design and we carried out multivariable Cox regression modelling with inverse probability of treatment weighting (IPTW) based on propensity scores. We performed several stratified and sensitivity analyses.

RESULTS

We included 3040 patients initiating treatment with GLP-1RA and 11,627 with SGLT-2i. When compared with patients treated with SGLT-2i, those in the GLP-1RA group were younger (55 vs 60 years old, p<0.001), had more anxiety (49.4% vs 41.5%, p<0.001), sleep disorders (43.2% vs 34.1%, p<0.001) and depression (24.4% vs 19.0%, p<0.001), and were more obese (35.1% of individuals with BMI ≥40 vs 15.1%, p<0.001). After propensity score weighting, standardised mean differences between groups were <0.1 for all covariates, showing adequate balance between groups at baseline after adjustment. In the main per-protocol analyses we found no evidence that GLP-1RA increased the incidence of SIS (HR 1.04; 95% CI 0.35, 3.14). Intention-to-treat analyses resulted in an HR of 1.36 (95% CI 0.51, 3.61). In analyses excluding individuals with no BMI information and using imputation for BMI missing values, respective HRs were 0.89 (95% CI 0.26, 3.14) and 1.29 (95% CI 0.42, 3.92). Stratified analyses showed no differences between subgroups.

CONCLUSIONS/INTERPRETATION

Our findings do not support an increased risk of SIS when taking GLP-1RA in individuals with type 2 diabetes and obesity; however, the rarity of SIS events and the wide uncertainty of effect size (although null, effect may be compatible with a risk as high as threefold) calls for a cautious interpretation of our results. Further studies, including final evaluations from regulatory bodies, are called for to discard a causal link between GLP-1RA and suicidality.

Obesity and Asthma: Implementing a Treatable Trait Care Model

Recognition of obesity as a treatable trait of asthma, impacting its development, clinical presentation and management, is gaining widespread acceptance. Obesity is a significant risk factor and disease modifier for asthma, complicating treatment. Epidemiological evidence highlights that obese asthma correlates with poorer disease control, increased severity and persistence, compromised lung function and reduced quality of life. Various mechanisms contribute to the physiological and clinical complexities observed in individuals with obesity and asthma. These encompass different immune responses, including Type IVb, where T helper 2 cells are pivotal and driven by cytokines like interleukins 4, 5, 9 and 13, and Type IVc, characterised by T helper 17 cells and Type 3 innate lymphoid cells producing interleukin 17, which recruits neutrophils. Additionally, Type V involves immune response dysregulation with significant activation of T helper 1, 2 and 17 responses. Finally, Type VI is recognised as metabolic-induced immune dysregulation associated with obesity. Body mass index (BMI) stands out as a biomarker of a treatable trait in asthma, readily identifiable and targetable, with significant implications for disease management. There exists a notable gap in treatment options for individuals with obese asthma, where asthma management guidelines lack specificity. For example, there is currently no evidence supporting the use of incretin mimetics to improve asthma outcomes in asthmatic individuals without Type 2 diabetes mellitus (T2DM). In this review, we advocate for integrating BMI into asthma care models by establishing clear target BMI goals, promoting sustainable weight loss via healthy dietary choices and physical activity and implementing regular reassessment and referral as necessary.

Pediatric Obesity Pharmacotherapy: State of the Science, Research Gaps, and Opportunities

Pediatric obesity is a major public health problem, affecting nearly 20% of children and adolescents living in the United States. In 2023, the American Academy of Pediatrics released its first clinical practice guideline for the evaluation and management of child and adolescent obesity and recommended integrating health behavior and lifestyle interventions with pharmacological treatment when medically indicated. However, there is a limited evidence base to guide antiobesity medication treatment decisions in clinical practice and limited data on long-term safety during this critical period of growth and development in youth. Thus, in November of 2023, the National Institute of Diabetes and Digestive and Kidney Diseases sponsored a workshop to identify knowledge gaps and opportunities for research on the use of pharmacotherapy for obesity in children and adolescents. Leading scientific and clinical experts in obesity pathophysiology and treatment, pharmacotherapy, clinical trial design, and health equity and disparities, among others, identified gaps in clinical trial design, guidance for clinical use of medications in children and adolescents, additional treatment outcomes beyond body fat or weight, and improvement in care delivery. Adolescent patients and caregivers with lived experience of obesity and weight management were also invited to participate in a panel discussion, providing personal perspectives on living with obesity, clinical care considerations, and research needs. This article summarizes the workshop proceedings on the state of the science and identifies gaps and opportunities for future research to inform optimal and equitable medical management of children and adolescents with obesity.

Innovative Glucagon-based Therapies for Obesity

Obesity poses a significant global health challenge, with an alarming rise in prevalence rates. Traditional interventions, including lifestyle modifications, often fall short of achieving sustainable weight loss, ultimately leading to surgical interventions, which carry a significant burden and side effects. This necessitates the exploration of effective and relatively tolerable pharmacological alternatives. Among emerging therapeutic avenues, glucagon-based treatments have garnered attention for their potential to modulate metabolic pathways and regulate appetite. This paper discusses current research on the physiological mechanisms underlying obesity and the role of glucagon in energy homeostasis. Glucagon, traditionally recognized for its glycemic control functions, has emerged as a promising target for obesity management due to its multifaceted effects on metabolism, appetite regulation, and energy expenditure. This review focuses on the pharmacological landscape, encompassing single and dual agonist therapies targeting glucagon receptors (GcgRs), glucagon-like peptide-1 receptors (GLP-1Rs), glucose-dependent insulinotropic polypeptide receptors (GIPRs), amylin, triiodothyronine, fibroblast growth factor 21, and peptide tyrosine tyrosine. Moreover, novel triple-agonist therapies that simultaneously target GLP-1R, GIPR, and GcgR show promise in augmenting further metabolic benefits. This review paper tries to summarize key findings from preclinical and clinical studies, elucidating the mechanisms of action, safety profiles, and therapeutic potential of glucagon-based therapies in combating obesity and its comorbidities. Additionally, it explores ongoing research endeavors, including phase III trials, aimed at further validating the efficacy and safety of these innovative treatment modalities.

GLP-1 programs the neurovascular landscape

Readily available nutrient-rich foods exploit our inherent drive to overconsume, creating an environment of overnutrition. This transformative setting has led to persistent health issues, such as obesity and metabolic syndrome. The development of glucagon-like peptide-1 receptor (GLP-1R) agonists reveals our ability to pharmacologically manage weight and address metabolic conditions. Obesity is directly linked to chronic low-grade inflammation, connecting our metabolic environment to neurodegenerative diseases. GLP-1R agonism in curbing obesity, achieved by impacting appetite and addressing associated metabolic defects, is revealing additional benefits extending beyond weight loss. Whether GLP-1R agonism directly impacts brain health or does so indirectly through improved metabolic health remains to be elucidated. In exploring the intricate connection between obesity and neurological conditions, recent literature suggests that GLP-1R agonism may have the capacity to shape the neurovascular landscape. Thus, GLP-1R agonism emerges as a promising strategy for addressing the complex interplay between metabolic health and cognitive well-being.

Population-Level Interest in Glucagon-Like Peptide-1 Receptor Agonists for Weight Loss Using Google Trends Statistics in a 12-Month Retrospective Analysis: An Infodemiology and Infoveillance Study

Obesity is an exacerbated public health challenge, increasing the risk of several diseases and mortality while deteriorating the quality of life. There is significant dedication to exploring obesity therapies using glucagon-like peptide-1 (GLP-1) agonists, which have shown efficacy in reducing the number of deaths and complications associated with type 2 diabetes. This research aimed to examine the recent search popularity of GLP-1 agonists using Google Trends at both national (in Iraq) and global levels. To quantify relative search volume (RSV), the total search query activity has been transformed to a percentage scale ranging from 0% to 100%. The word "Ozempic" was chosen because of its extensive coverage in social media and web/print publications pertaining to this subject matter. A comparative search was performed targeting the phrases "Wegovy," "Saxenda," and "Mounjaro" to identify a novel combination GLP-1 agonist from August 2023 to August 2024. The present study demonstrated a statistically significant difference in the RSV among the four drugs (P < 0.0001) nationally and globally. In Iraq, the highest RSV for Ozempic was documented in Duhok, followed by Sulaymaniyah and Erbil. A comparable RSV profile has been noted for Saxenda, while substantial interest in Wegovy is seen in Ninawa. Meanwhile, globally, the highest RSV for Ozempic was recorded in Canada, the United States of America, and Australia. A distinct RSV profile has been observed for Saxenda, with heightened search interest recorded in Latin America, Poland, Sweden, and Australia. By contrast, Mounjaro received search interest primarily in Greenland and the United States, while Mounjaro search interest was noted in Canada, the United States, and Australia. This study demonstrates a significant and growing public interest in GLP-1 agonists, namely, Ozempic, Saxenda, Wegovy, and Mounjaro. As the use of GLP-1 agonists for weight loss becomes more common, more knowledge, understanding, and continuous scientific research will make it more convenient to obtain the best patient outcomes.

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

ABSTRACT

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

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

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

GLP-1 receptor agonists and weight loss in schizophrenia - past, present, and future

PURPOSE OF REVIEW

People with schizophrenia experience three to five times higher prevalence of diabetes and obesity than the general population, contributing to a 20-year reduced lifespan. The impacts of weight gain extend beyond physical health, affecting people's self-esteem, quality of life, and triggering treatment nonadherence, leading to relapse and deteriorations in health. Clinical guidelines recommend patients with antipsychotic-induced weight gain are treated with cognitive behaviour therapy and lifestyle changes; however, effective treatments for obesity in schizophrenia are critically lacking. Glucagon-like peptide-1 receptor agonists (GLP-RAs) have shown large effects in weight loss in the general population; however, effects are less clear in people with schizophrenia. This review aims to assess the clinical trials that have been completed, are in progress, and directions for future trials.

RECENT FINDINGS

To date, six clinical trials have been completed, four of which have published their findings. Three further trials are currently in progress.

SUMMARY

Results from completed trials suggest that GLP-1RAs decrease weight in people with schizophrenia, however effect sizes are mostly smaller than studies based on the general population. Future trials could focus on dual or triple agonist agents, and/or explore the effects of GLP-1 s at antipsychotic medication commencement, to potentially prevent antipsychotic weight gain.

Discovery of novel glucagon-like peptide 1/cholecystokinin 1 receptor dual agonists

The combined use of gastrointestinal hormones for treating metabolic diseases is gaining increasing attention. The potential of developing novel dual agonists targeting both cholecystokinin 1 (CCK-1) receptor and glucagon-like peptide 1 (GLP-1) receptor to improve the treatment of type 2 diabetes and obesity have not been fully explored. In this investigation, we reported a series of novel GLP-1/CCK-1 receptor co-agonists constructed by linking the C-terminus of a GLP-1 receptor agonist (bullfrog GLP-1) to the N-terminus of a CCK-1 receptor selective agonist NN9056. In comprehensive in vitro assays, these co-agonists exhibited complete agonistic potency on GLP-1 and CCK-1 receptor. Remarkably, 1f displayed superior hypoglycemic and insulinotropic effects when compared to NN9056 and semaglutide. Evaluation in Kunming and diet-induced obesity (DIO) mice unveiled significant acute and enduring hypoglycemic effects of 1f. Administration of 1f to DIO mice resulted in substantial weight loss, normalized lipid metabolism, and enhanced glucose regulation. These preclinical observations strongly advocate for the therapeutic potential CCK-1 and GLP-1 pathways could be harnessed in a single fusion peptide, yielding a promising combination therapy strategy for treating metabolic disorders.

Semaglutide for management of obesity in adolescents: efficacy, safety, and considerations for clinical practice

PURPOSE OF REVIEW

The purpose of this review is to describe the existing limited data related to the use of semaglutide in adolescents with obesity, supplementing with findings from adult studies of semaglutide use.

RECENT FINDINGS

Semaglutide, as a once weekly subcutaneous injection for weight management, effectively reduces body mass index (BMI) while improving hyperglycemia, elevated alanine aminotransferase levels, hyperlipidemia, and quality of life in youth with obesity. As of this review, only one large randomized clinical trial of semaglutide in youth has been completed, with a follow-up duration of 68 weeks. Thus, long-term data on the safety in adolescents is limited, particularly regarding the risks of cholelithiasis, pancreatitis, suicidal ideation, and disordered eating. Due to the cost of semaglutide, particularly in the United States, limited cost effectiveness analyses have demonstrated unfavorable incremental cost-effectiveness ratios for semaglutide relative to phentermine-topiramate as an alternative antiobesity medication in adolescents.

SUMMARY

Semaglutide represents an important advance in the pediatric obesity management, with clear short-term reductions in BMI and improvement in metabolic parameters. However, its long-term safety and efficacy for youth with obesity remain to be demonstrated. Additional research is needed to assess trends in utilization and adherence to minimize the risk of worsening socioeconomic disparities in pediatric obesity.

Investigational and emerging gastric inhibitory polypeptide (GIP) receptor-based therapies for the treatment of obesity

INTRODUCTION

One billion people live with obesity. The most promising medications for its treatment are incretin-based therapies, based on enteroendocrine peptides released in response to oral nutrients, specifically glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP). The mechanisms by which GLP-1 receptor agonism cause weight reduction are becoming increasingly understood. However, the mechanisms by which GIP receptor-modulating medications cause weight loss remain to be clarified.

AREAS COVERED

This review describes GLP-1 and GIP physiology and explores the conflicting data regarding GIP and weight management. It details examples of how to reconcile the contradictory findings that both GIP receptor agonism and antagonism cause weight reduction. Specifically, it discusses the concept of 'biased agonism' wherein exogenous peptides cause different post-receptor signaling patterns than native ligands. It discusses how GIP effects in adipose tissue and the central nervous system may cause weight reduction. It describes GIP receptor-modulating compounds and their most current trials regarding weight reduction.

EXPERT OPINION

Effects of GIP receptor-modulating compounds on different tissues have implications for both weight reduction and other cardiometabolic diseases. Further study is needed to understand the implications of GIP agonism on not just weight reduction, but also cardiovascular disease, liver disease, bone health and fat storage.

A Comprehensive Review of Emerging Therapies for Type 2 Diabetes and Their Cardiovascular Effects

The discovery of inhibitors for sodium-glucose cotransporter 2 (SGLT2) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) has significantly improved type 2 diabetes management. Large-scale clinical studies have shown that both SGLT2 inhibitors and GLP-1 RA enhance cardiovascular health. Benefits include reduced cardiovascular disease risk, lower mortality, fewer heart failure hospitalizations (SGLT2 inhibitors), and stroke prevention (GLP-1 RA). Additionally, these drugs slow chronic kidney disease progression. This comprehensive treatment targets vascular events. Despite differences, both drug classes are crucial. GLP-1 RA mainly reduce stroke risk, while SGLT2 inhibitors alleviate heart failure. Our findings, based on a literature review, will address the renal and cardiac effects of SGLT2 inhibitors and GLP-1 RA in both diabetics and non-diabetics, highlighting their combined benefits for heart conditions.

Role of Uremic Toxins, Oxidative Stress, and Renal Fibrosis in Chronic Kidney Disease

Affecting millions of people worldwide, chronic kidney disease is a serious medical problem. It results in a decrease in glomerular filtration rate below 60 mL/min/1.73 m, albuminuria, abnormalities in urine sediment and pathologies detected by imaging studies lasting a minimum of 3 months. Patients with CKD develop uremia, and as a result of the accumulation of uremic toxins in the body, patients can be expected to suffer from a number of medical consequences such as progression of CKD with renal fibrosis, development of atherosclerosis or increased incidence of cardiovascular events. Another key element in the pathogenesis of CKD is oxidative stress, resulting from an imbalance between the production of antioxidants and the production of reactive oxygen species. Oxidative stress contributes to damage to cellular proteins, lipids and DNA and increases inflammation, perpetuating kidney dysfunction. Additionally, renal fibrogenesis involving the accumulation of fibrous tissue in the kidneys occurs. In our review, we also included examples of forms of therapy for CKD. To improve the condition of CKD patients, pharmacotherapy can be used, as described in our review. Among the drugs that improve the prognosis of patients with CKD, we can include: GLP-1 analogues, SGLT2 inhibitors, Finerenone monoclonal antibody-Canakinumab and Sacubitril/Valsartan.

Outcomes and Management of Re-Establishing Bariatric Patients

BACKGROUND

Lifelong follow-up after metabolic and bariatric surgery (MBS) is necessary to monitor for patient outcomes and nutritional status. However, many patients do not routinely follow-up with their MBS team. We studied what prompted MBS patients to seek bariatric care after being lost to follow-up and the subsequent treatments they received.

STUDY DESIGN

A retrospective cohort study of patients after MBS who had discontinued regular MBS follow-up but represented to the MBS clinic between July 2018 and December 2022 to re-establish care. Patients with a history of a sleeve gastrectomy (SG), Roux-En-Y gastric bypass (RYGB), and adjustable gastric banding (AGB) were included.

RESULTS

We identified 400 patients (83.5% women, mean age 50.3 ± 12.2 years at the time of re-establishment of bariatric care), of whom 177 (44.3%) had RYGB, 154 (38.5%) had SG, and 69 (17.2%) had AGB. Overall, recurrent weight gain was the most common reason for presentation for all three procedures (81.2% in SG, 62.7% in RYGB, and 65.2% in AGB; p < 0.001). Patients who underwent SG were more likely to undergo a revision MBS compared with patients who underwent RYGB (16.9% vs 5.8%, p < 0.001), whereas patients who underwent RYGB were more likely to undergo an endoscopic intervention than patients who underwent SG (17.5% vs 7.8%, p < 0.001). The response to antiobesity medication agents, specifically glucagon-like peptide-1 receptor agonists drugs, was better in patients who underwent RYGB, than that in patients who underwent SG.

CONCLUSIONS

This study highlights recurrent weight gain as the most common reason for patients after MBS seeking to re-establish care with the MBS team. SG had a higher rate of revision MBS than RYGB, whereas endoscopic interventions were performed more frequently in the RYGB group. Antiobesity medication agents, especially glucagon-like peptide-1 receptor agonists drugs, were more effective in patients who underwent RYGB.