Selection of Antiobesity Medications Based on Phenotypes Enhances Weight Loss: A Pragmatic Trial in an Obesity Clinic

Early Life Energy Balance: The Development of Infant Energy Expenditure and Intake in the Context of Obesity

PURPOSE OF REVIEW

This review aims to provide a summary of the current knowledge on measurement tools and most recent evidence for prenatal and postnatal modulators of energy balance in young infants.

RECENT FINDINGS

The prevention of pediatric obesity depends upon curating the perfect imbalance of energy intake to energy expenditure, taking into consideration the energy needs for healthy growth. We summarize the recent evidence for the programming of fetal and infant metabolism influenced by maternal preconception health, prenatal metabolic milieu, and physical activity behaviors. In the early postnatal environment, caregiver feeding behaviors shape the extent of energy imbalance through dictating quantity and modality of infant energy intake. There are biological and behavioral contributors to improper infant energy imbalance. Furthermore, caregiver and clinician education on overfeeding and clinical tools to prescribe and monitor infant overgrowth are absent. Ultimately, the lack of high-quality and modern research of infant energy expenditure underpins the lack of advancement in clinical guidelines and the needed prevention of pediatric obesity.

Advances in Endoscopic Bariatric and Metabolic Therapies

This article presents an overview of endoscopic bariatric and metabolic therapies (EBMTs) as emerging minimally invasive interventions for obesity and its related comorbidities. It explores various gastric and small-bowel endoscopic procedures, including their mechanisms, clinical outcomes, and safety profiles.

Case report of a female western Indian vegetarian with obesity

Background

South Asians are defined as those indigenous to the Indian subcontinent - India, Pakistan, Sri Lanka, Nepal, Maldives, Bhutan, and Bangladesh. This ethnic group is a unique population with increased prevalence of metabolic syndrome even at a lower body mass index (BMI). Should they also have increased BMI, the risk for development of diabetes mellitus and cardiovascular complications are further magnified. Strong cultural perceptions about ideal body weight, lack of awareness about the race and ethnicity-specific risks, and knowledge gaps regarding different dietary patterns among the healthcare providers confound further the metabolic issues pertinent to South Asians living in North America.

Methods

In this case study of a South Asian patient, we present asynchronous co-management of obesity by an obesity specialist and the primary care provider in a university-based clinic.

Results

Intense lifestyle interventions including a custom-tailored Indian vegetarian meal plan and weekly injectable Semaglutide was offered to the patient as treatment plan. The patient lost 59 pounds, and BMI changed from 34.1 kg/m2 to 23.5 kg/m2.

Conclusion

Intensive lifestyle interventions with custom-tailored dietary changes, regular physical activity and behavior modifications combined with appropriate pharmacotherapy can be very successful in the management of obesity among South Asians living in North America.

A sympathetic paradigm shift for the role of NPY in obesity

Neuropeptide Y (NPY) is a powerful orexigenic factor in the brain. However, mice lacking NPY or NPY receptor Y1 (NPY1R) have minimal changes in basal food intake. In a study published in Nature, Zhu et al.1 demystify this paradox and show that central and peripheral NPY have antipodal roles in energy homeostasis.

Precision Medicine in Bariatric Procedures

Obesity is a multi-factorial disease that is influenced by genetic, epigenetic, and environmental factors. Precision medicine is a practice wherein prevention and treatment strategies take individual variability into account. It involves using a variety of factors including deep phenotyping using clinical, physiologic, and behavioral characteristics, 'omics assays (eg, genomics, epigenomics, transcriptomics, and microbiomics among others), and environmental factors to devise practices that are individualized to subsets of patients. Personalizing the therapeutic modality to the individual can lead to enhanced effectiveness and tolerability. The authors review advances in precision medicine made in the field of bariatrics and discuss future avenues and challenges.

Endobariatric systems: Strategic integration of endoscopic therapies in the management of obesity

The escalating obesity pandemic and its comorbidities necessitate adaptable and versatile treatment strategies. Endobariatric and metabolic therapies (EBMTs) can be strategically employed in a multipronged approach to obesity management, analogous to the way chess systems are employed to seize opportunities and thwart threats. In this review, we explore the spectrum of established and developing EBMTs, examining their efficacy in weight loss and metabolic improvement and their importance for a tailored, patient-centric approach. The complexity of obesity management mirrors the intricate nature of a chess game, with an array of tactics and strategies available to address the opponent's moves. Similarly, the bariatric endoscopist employs a range of EBMTs to alter the gastrointestinal tract landscape, targeting critical anatomical regions to modify physiological reactions to food consumption and nutrient assimilation. Gastric-focused EBMTs aim to reduce stomach capacity and induce satiety. Intestinal-focused EBMTs target hormonal regulation and nutrient absorption to improve metabolic profiles. EBMTs offer unique advantages of reversibility, adjustability and minimal invasiveness, allowing them to be used as primary treatments, adjuncts to pharmacotherapy or tools to address post-bariatric surgery weight recidivism. However, sub-optimal adoption of EBMTs due to lack of awareness, perceived costs and limited training opportunities hinders their integration into standard obesity management practices. By strategically integrating EBMTs into the broader landscape of obesity care, leveraging their unique advantages to enhance outcomes, clinicians can offer a more dynamic and personalized treatment paradigm. This approach, akin to employing chess systems to adapt to evolving challenges, allows for a comprehensive, patient-centric management of obesity as a chronic, complex and relapsing disease.

Clinician's Guide for Pediatric Anti-obesity Medications

The recent advent of highly effective anti-obesity medications (AOM) provides pediatric clinicians a powerful tool to augment the treatment of obesity and improve outcomes. The 2023 American Academy of Pediatrics guidelines state clinicians "should offer adolescents 12 years and older with obesity weight loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle treatment". This article will provide an update on the integration of AOM into practice, emphasizing clinical pearls and practical tips.

Anti-Obesity Medication in the Management of Children and Adolescents With Obesity: Recent Developments and Research Gaps

BACKGROUND

Paediatric obesity is a global public health concern. While in most countries the incidence keeps rising, the need for effective and long-term management for children and adolescents living with this chronic, relapsing disease is pressing. Health behaviour and lifestyle treatment (HBLT) is recommended as first-line treatment.

METHODS

Narrative review.

RESULTS

A new generation of recently approved anti-obesity medications (AOM) now has the potential to fill the gap between limited effects on body mass index (BMI) by HBLT alone and large effects by metabolic and bariatric surgery in adolescents with obesity aged 12 years and older. While, for semaglutide and phentermine/topiramate, effectiveness is substantial with relevant, but mostly mild to moderate adverse events, there is a gap in evidence regarding long-term effects and safety, effects on outcomes beyond BMI reduction and data for certain groups of patients, such as children < 12 years and minority groups. When integrating AOM treatment into national healthcare systems it should be offered as part of a comprehensive patient-centred approach.

CONCLUSION

This article summarizes recent AOM developments, integration into paediatric obesity management, and identifies research gaps.

Precision medicine for obesity: current evidence and insights for personalization of obesity pharmacotherapy

Obesity is a chronic and complex disease associated with increased morbidity, mortality, and financial burden. It is expected that by 2030 one of two people in the United States will have obesity. The backbone for obesity management continues to be lifestyle interventions, consisting of calorie deficit diets and increased physical activity levels, however, these interventions are often insufficient to achieve sufficient and maintained weight loss. As a result, multiple patients require additional interventions such as antiobesity medications or bariatric interventions in order to achieve clinically significant weight loss and improvement or resolution of obesity-associated comorbidities. Despite the recent advances in the field of obesity pharmacotherapy that have resulted in never-before-seen weight loss outcomes, comorbidity improvement, and even reduction in cardiovascular mortality, there is still a significant interindividual variability in terms of response to antiobesity medications, with a subset of patients not achieving a clinically significant weight loss. Currently, the trial-and-error paradigm for the selection of antiobesity medications results in increased costs and risks for developing side effects, while also reduces engagement in weight management programs for patients with obesity. The implementation of a precision medicine framework to the selection of antiobesity medications might help reduce heterogeneity and optimize weight loss outcomes by identifying unique subsets of patients, or phenotypes, that have a better response to a specific intervention. The detailed study of energy balance regulation holds promise, as actionable behavioral and physiologic traits could help guide antiobesity medication selection based on previous mechanistic studies. Moreover, the rapid advances in genotyping, multi-omics, and big data analysis might hold the key to discover additional signatures or phenotypes that might respond better to a certain intervention and might permit the widespread adoption of a precision medicine approach for obesity management.

Obesity treatment in adolescents and adults in the era of personalized medicine

In this multi-professional review, we will provide the in-depth knowledge required to work in the expanding field of obesity treatment. The prevalence of obesity has doubled in adults and quadrupled in children over the last three decades. The most common treatment offered has been lifestyle treatment, which has a modest or little long-term effect. Recently, several new treatment options-leading to improved weight loss-have become available. However, long-term care is not only about weight loss but also aims to improve health and wellbeing overall. In the era of personalized medicine, we have an obligation to tailor the treatment in close dialogue with our patients. The main focus of this review is new pharmacological treatments and modern metabolic surgery, with practical guidance on what to consider when selecting and guiding the patients and what to include in the follow-up care. Furthermore, we discuss common clinical challenges, such as patients with concurrent eating disorder or mental health problems, and treatment in the older adults. We also provide recommendations on how to deal with obesity in a non-stigmatizing way to diminish weight stigma during treatment. Finally, we present six microcases-obesity treatment for persons with neuropsychiatric disorders and/or intellectual disability; obesity treatment in the nonresponsive patient who has "tried everything"; and hypoglycemia, abdominal pain, and weight regain after metabolic surgery-to highlight common problems in weight-loss treatment and provide personalized treatment suggestions.

The impact of obesity on reproductive health and metabolism in reproductive-age females

Obesity is a highly prevalent chronic disease that impacts >40% of reproductive-aged females. The pathophysiology of obesity is complex and can be understood simply as a chronic energy imbalance whereby caloric intake exceeds caloric expenditure with an energy surplus stored in adipose tissue. Obesity may be categorized into degrees of severity as well as different phenotypes on the basis of metabolic health and underlying pathophysiology. Obesity and excess adiposity have a significant impact on fertility and reproductive health, with direct effects on the hypothalamic-pituitary-ovarian axis, the ovary and oocyte, and the endometrium. There are significant adverse pregnancy outcomes related to obesity, and excess weight gain before, during, and after pregnancy that can alter the lifelong risk for metabolically unhealthy obesity. Given the high prevalence and pervasive impact of obesity on reproductive health, there is a need for better and individualized care for reproductive-aged females that considers obesity phenotype, underlying pathophysiology, and effective and sustainable interventions to treat obesity and manage weight gain before, during, and after pregnancy.

Precision Nutrition for Management of Cardiovascular Disease Risk during Menopause

BACKGROUND

Women can spend up to 40% of their lives in the postmenopausal state. As women begin to transition into menopause, known as perimenopause, changes in hormonal concentrations and body composition dramatically increase overall cardiometabolic risk. Dietary patterns and interventions can be utilized to prevent and treat cardiovascular disease (CVD) and some dietary patterns over others may be more beneficial due to their specific effects on the health aspects of menopause. In this narrative review, we summarize key cardiovascular alterations that occur during the menopause transition and explore current dietary recommendations to address CVD risk as well as explore the new frontier of precision nutrition and the implications for nutrition prescription during menopause.

SUMMARY

Popular dietary interventions for CVD such as the Dietary Approaches to Stop Hypertension (DASH) diet and the Mediterranean diet (MED) have limited data in women following menopause. However, both diets improve CVD risk biomarkers of total cholesterol and low-density lipoprotein cholesterol as well as lower oxidative stress and inflammation and improve endothelial function. As the menopause transition increases the risk for developing metabolic syndrome, insulin insensitivity, and dyslipidemia, the DASH diet and MED may be impactful dietary strategies for mediating CVD risk in menopausal women. However, these are "one-size-fits-all" approaches that neglect individual characteristics such as genetic predisposition and environmental factors. Precision nutrition considers individual factors for nutrition prescription, spanning from evaluating food intake preferences and behaviors to deep phenotyping. Data from a large-scale investigation of the menopause transition suggests nutritional strategies that address postprandial glycemic responses, and the gut microbiome may attenuate some of the unfavorable effects of menopause on CVD risk factors.

KEY MESSAGES

Considering menopause, women are a clinical population that would greatly benefit from precision nutrition. Future research should explore the use of machine learning and artificial intelligence in a precision nutrition framework to modify the DASH diet and MED to address adverse effects that occur during the menopause transition are vital for supporting women's health as they age.

Effective and appropriate use of weight loss medication in pediatric obesity: a narrative review

Over the past few decades, there has been a notable increase in the incidence of pediatric obesity, which is a significant public health concern. Children who are obese have a greater risk of type 2 diabetes, hypertension, dyslipidemia, polycystic ovary syndrome, obstructive sleep apnea, and adult obesity. Lifestyle modification therapy is typically the initial approach to treat pediatric obesity. For patients who do not achieve success with lifestyle modification therapy alone, pharmacotherapy is the next logical treatment option. When selecting an anti-obesity medication (AOM), it is essential to first ascertain the medical background of the patient, including current medications and obesity-associated comorbidities. Evaluation of obesity phenotypes in patients may also be beneficial. AOMs for pediatric obesity include metformin, orlistat, glucagon-like peptide 1 agonists, phentermine, and the phentermine/topiramate combination. Sufficient lifestyle modification therapy should be administered before considering pharmacotherapy and continued after the initiation of AOM. To ensure healthy development, monitoring growth and puberty development during anti-obesity treatments is essential.

Genetic Evidence for Distinct Biological Mechanisms That Link Adiposity to Type 2 Diabetes: Toward Precision Medicine

We aimed to unravel the mechanisms connecting adiposity to type 2 diabetes. We used MR-Clust to cluster independent genetic variants associated with body fat percentage (388 variants) and BMI (540 variants) based on their impact on type 2 diabetes. We identified five clusters of adiposity-increasing alleles associated with higher type 2 diabetes risk (unfavorable adiposity) and three clusters associated with lower risk (favorable adiposity). We then characterized each cluster based on various biomarkers, metabolites, and MRI-based measures of fat distribution and muscle quality. Analyzing the metabolic signatures of these clusters revealed two primary mechanisms connecting higher adiposity to reduced type 2 diabetes risk. The first involves higher adiposity in subcutaneous tissues (abdomen and thigh), lower liver fat, improved insulin sensitivity, and decreased risk of cardiometabolic diseases and diabetes complications. The second mechanism is characterized by increased body size and enhanced muscle quality, with no impact on cardiometabolic outcomes. Furthermore, our findings unveil diverse mechanisms linking higher adiposity to higher disease risk, such as cholesterol pathways or inflammation. These results reinforce the existence of adiposity-related mechanisms that may act as protective factors against type 2 diabetes and its complications, especially when accompanied by reduced ectopic liver fat.

ARTICLE HIGHLIGHTS

The association between previous use of anti-obesity medication and semaglutide weight loss outcomes

AIMS

To compare weight loss outcomes between patients starting semaglutide who had previously been on another anti-obesity medication (AOM) compared to those who were AOM-naïve.

MATERIALS AND METHODS

We performed a retrospective study in patients with overweight or obesity taking semaglutide for weight loss for a duration of 3 to 12 months. Our primary endpoint was assessment of percentage of total body weight loss (TBWL) in patients who started semaglutide as their first AOM (AOM-naïve) compared to those who started semaglutide and had previously taken another AOM (non-AOM-naïve). The secondary outcome was a comparison of the proportions of patients achieving ≥5%, ≥10%, ≥15% and ≥20% TBWL between the groups. Our endpoints were analysed using independent t-tests and ANOVA/ANCOVA for continuous variables and Pearson's test for categorical variables.

RESULTS

This study included 305 patients. Outcomes of semaglutide treatment were superior in AOM-naïve patients (n = 231) compared to non-AOM-naïve patients (n = 74) at 3 (6.3% vs. 3.8%), 6 (10.6% vs. 6.7%), 9 (14.0% vs. 9.1%) and 12 months (14.3% vs. 10.6%; p < 0.0001 at 3, 6 and 9 months, and p = 0.01 at 12 months). A greater proportion of patients in the AOM-naïve group achieved a TBWL ≥ 15% (48% vs 21%; p = 0.02) and ≥20% (27% vs 4% p < 0.01) at 12 months.

CONCLUSION

The use of semaglutide in patients with previous intake of other AOMs was associated with inferior weight loss outcomes in comparison to patients who were AOM-naïve.

Cumulative effect of obesity phenotypes on body weight and body mass index

BACKGROUND

Obesity originates from an imbalance between energy intake and expenditure. Changes in energy intake components (satiation, postprandial satiety, emotional eating) and energy expenditure have been linked to obesity and are referred to as obesity phenotypes. We aim to study if these obesity phenotypes have a cumulative effect on body weight and body mass index (BMI).

SUBJECT/METHODS

This is a cross-sectional study of adult patients with obesity (BMI > 30 kg/m2) who completed the validated tests to measure the obesity phenotypes. A total of 464 were included in this study.

INTERVENTIONS/METHODS

We defined higher calories to fullness during an ad libitum meal as abnormal satiation, accelerated time to half gastric emptying with scintigraphy as abnormal postprandial satiety, higher anxiety score on the Hospital Anxiety and Depression Scale as hedonic eating behavior, and decreased percentage of measured resting energy expenditure as abnormal energy expenditure. The primary analysis was done on the number of phenotypes ( ≤ 1 and ≥ 2) with body weight and BMI using an independent t-test.

RESULTS

Our cohort included 464 patients (mean [SD] age 42.0 [10.9] years, 79% females, weight 111.2 [22.9] kg, BMI 38.9 [7.0] kg/m2). There were 294 patients who had ≤ 1 phenotype, and 170 patients with ≥ 2 phenotypes with no baseline demographical differences (i.e., age and sex). Having ≥ 2 phenotypes was associated with higher body weight (115 [25] kg vs. 109 [21] kg; p = 0.004), BMI (40 [8] kg/m2 vs. 38 [7] kg/m2; p = 0.02) and waist (118 [15] cm vs. 115 [13] cm; p = 0.04) and hip (129 [14] cm vs. 125 [13] cm; p = 0.01) circumferences compared to ≤ 1 phenotype.

CONCLUSION

Obesity phenotypes are associated with an additive effect on the body weight and BMI. Patients who have multiple obesity phenotypes may require a more aggressive approach to enhance weight loss.

Unraveling the Variability of Human Satiation: Implications for Precision Obesity Management

Satiation is the physiologic process that regulates meal size and termination, and it is quantified by the calories consumed to reach satiation. Given its role in energy intake, changes in satiation contribute to obesity's pathogenesis. Our study employed a protocolized approach to study the components of food intake regulation including a standardized breakfast, a gastric emptying study, appetite sensation testing, and a satiation measurement by an ad libitummeal test. These studies revealed that satiation is highly variable among individuals, and while baseline characteristics, anthropometrics, body composition and hormones, contribute to this variability, these factors do not fully account for it. To address this gap, we explored the role of a germline polygenic risk score, which demonstrated a robust association with satiation. Furthermore, we developed a machine-learning-assisted gene risk score to predict satiation and leveraged this prediction to anticipate responses to anti-obesity medications. Our findings underscore the significance of satiation, its inherent variability, and the potential of a genetic risk score to forecast it, ultimately allowing us to predict responses to different anti-obesity interventions.

Lessons Learned from Telemedicine in Adolescent Obesity: Results of a Pilot Study

The rising prevalence of obesity in children calls for new strategies for the provision of effective care by a multidisciplinary team. Telemedicine has overall proven to be an effective tool for promoting a healthy lifestyle. The main objective of the current paper is to present the protocol of our ongoing CardioMetabolic Prevention (CAMP) study and compare its design with published studies on telemedicine in paediatric obesity. Additionally, we analysed the preliminary anthropometric and laboratory data to test the efficacy of our 12-week intensive program that combines in-person and telemedicine support. The program demonstrated a positive impact on body mass index (BMI) and its z-scores in 21 adolescents, and BMI in 18 participating parents. However, we found no effect on body composition, waist circumference, cardiometabolic parameters, or fitness evaluated via a 6-min walk test in adolescents. In conclusion, the combination of in-person and telemedicine intensive support over 35 h delivered by a multidisciplinary team can be beneficial not only for adolescents with obesity but also for their parents. The ongoing CAMP study serves as a platform for precision medicine in future decisions regarding anti-obesity medication in adolescents with obesity.

Effects of dietary fibre on metabolic health and obesity

Obesity and metabolic syndrome represent a growing epidemic worldwide. Body weight is regulated through complex interactions between hormonal, neural and metabolic pathways and is influenced by numerous environmental factors. Imbalances between energy intake and expenditure can occur due to several factors, including alterations in eating behaviours, abnormal satiation and satiety, and low energy expenditure. The gut microbiota profoundly affects all aspects of energy homeostasis through diverse mechanisms involving effects on mucosal and systemic immune, hormonal and neural systems. The benefits of dietary fibre on metabolism and obesity have been demonstrated through mechanistic studies and clinical trials, but many questions remain as to how different fibres are best utilized in managing obesity. In this Review, we discuss the physiochemical properties of different fibres, current findings on how fibre and the gut microbiota interact to regulate body weight homeostasis, and knowledge gaps related to using dietary fibres as a complementary strategy. Precision medicine approaches that utilize baseline microbiota and clinical characteristics to predict individual responses to fibre supplementation represent a new paradigm with great potential to enhance weight management efficacy, but many challenges remain before these approaches can be fully implemented.

Evaluating appetite/satiety hormones and eating behaviours as predictors of weight loss maintenance with GLP-1RA therapy in adolescents with severe obesity

INTRODUCTION

Whilst glucagon-like peptide-1 receptor agonists (GLP1-RAs) are effective for treating adolescent obesity, weight loss maintenance (WLM; preventing weight regain) remains a challenge. Our goal was to investigate appetite/satiety hormones and eating behaviours that may predict WLM with exenatide (a GLP1-RA) versus placebo in adolescents with severe obesity.

METHODS

Adolescents who had ≥5% body mass index (BMI) reduction with meal replacement therapy were randomized to 52 weeks of once-weekly exenatide extended release or placebo. In this secondary analysis, eating behaviours and appetite/satiety regulation hormones post-meal replacement therapy (pre-randomization to exenatide or placebo) were evaluated as possible predictors of WLM. Percent change in BMI from randomization to 52 weeks served as the primary measure of WLM.

RESULTS

The analysis included 66 adolescents (mean age 16.0 years; 47% female). Lower leptin response to meal testing was associated with greater WLM in terms of BMI percent change in those receiving exenatide compared to placebo (p = 0.007) after adjusting for sex, age and BMI. There were no other significant predictors of WLM.

CONCLUSIONS

Prior to exenatide, lower leptin response to meals was associated with improved WLM with exenatide compared to placebo. The mostly null findings of this study suggest that GLP1-RA treatment may produce similar WLM for adolescents with obesity regardless of age, BMI, sex and eating behaviours.

Obesity management: sex-specific considerations

Obesity is a global health issue that has grown to epidemic proportions. According to World Health Organisation (WHO), overweight and obesity are responsible for more than 1.2 million deaths in Europe each year, representing > 13% of the region's total mortality. Highly processed, calorie-dense foods and reduced physical activity are considered as primary drivers of obesity, but genetic predisposition also plays a significant role. Notably, obesity is more prevalent in women than in men in most countries, and several obesity-related comorbidities exhibit sex-specific pathways. Treatment indication depends on BMI (body mass index), as well as existing comorbidities and risk factors. To reduce obesity-associated comorbidities, a permanent reduction in body weight of (at least) 5-10% is recommended. Treatment guidelines suggest an escalating stepwise approach including lifestyle intervention, pharmacotherapy, and bariatric-metabolic surgery. As cumulative evidence suggests differences in weight loss outcomes, there is growing interest in sex-specific considerations in obesity management. However, most trials do not report weight loss or changes in body composition separately for women and men. Here, we discuss state-of-the-art obesity management and focus on current data about the impact of sex on weight loss outcomes.

The melanocortin-4 receptor pathway and the emergence of precision medicine in obesity management

Over the past few decades, there has been a global surge in the prevalence of obesity, rendering it a globally recognized epidemic. Contrary to simply being a medical condition, obesity is an intricate disease with a multifactorial aetiology. Understanding the precise cause of obesity remains a challenge; nevertheless, there seems to be a complex interplay among biological, psychosocial and behavioural factors. Studies on the genetic factors of obesity have revealed several pathways in the brain that play a crucial role in food intake regulation. The best characterized pathway, thus far, is the leptin-melanocortin pathway, from which disruptions are responsible for the majority of monogenic obesity disorders. The effectiveness of conservative lifestyle interventions in addressing monogenic obesity has been limited. Therefore, it is crucial to complement the management strategy with pharmacological and surgical options. Emphasis has been placed on developing drugs aimed at replacing the absent signals, with the goal of restoring the pathway. In both monogenic and polygenic forms of obesity, outcomes differ across various interventions, likely due to the multifaceted nature of the disease. This underscores the need to explore alternative therapeutic strategies that can mitigate this heterogeneity. Precision medicine can be regarded as a powerful tool that can address this concern, as it values the understanding of the underlying abnormality triggering the disease and provides a tailored treatment accordingly. This would assist in optimizing outcomes of the current therapeutic approaches and even aid in the development of novel treatments capable of more effectively managing the global obesity epidemic.

Appetitive and psychological phenotypes of pediatric patients with obesity

BACKGROUND

Obesity is a heterogeneous disease with variable treatment response. Identification of the unique constellation of contributors to obesity may allow for targeted interventions and improved outcomes.

OBJECTIVE

Identify empirically derived phenotypes of pediatric patients with obesity based on appetitive and psychological correlates of obesity.

METHODS

This cross-sectional study included patients aged 5-12 years who were treated in a weight management clinic and completed standard intake questionnaires including Child Eating Behavior Questionnaire (CEBQ), Vanderbilt ADHD Scale and Pediatric Symptom Checklist. Phenotypes were elicited using latent profile analysis of 12 indicators: eight CEBQ subscales, inattention, hyperactivity/impulsivity, internalizing and externalizing symptoms.

RESULTS

Parents/guardians of 384 patients (mean age 9.8 years, mean BMI 30.3 kg/m2 ) completed the intake questionnaires. A 4-phenotype model best fits the data. Hedonic Impulsive phenotype (42.5%) exhibited high food enjoyment and hyperactivity/impulsivity. Inattentive Impulsive phenotype (27.4%) exhibited overall low food approach and high food avoid behaviours, and highest inattention. Hedonic Emotional phenotype (20.8%) scored the highest on food enjoyment, internalizing and externalizing symptoms. Picky Eating phenotype (9.3%) scored the lowest on food approach, inattention, hyperactivity/impulsivity, internalizing and externalizing symptoms.

CONCLUSION

Appetitive traits and psychological symptoms appear to cluster in distinct patterns, giving rise to four unique phenotypic profiles, which, if replicated, may help inform the development of tailored treatment plans.

Effectiveness and safety of drugs for obesity

Recent publicity around the use of new antiobesity medications (AOMs) has focused the attention of patients and healthcare providers on the role of pharmacotherapy in the treatment of obesity. Newer drug treatments have shown greater efficacy and safety compared with older drug treatments, yet access to these drug treatments is limited by providers' discomfort in prescribing, bias, and stigma around obesity, as well as by the lack of insurance coverage. Now more than ever, healthcare providers must be able to discuss the risks and benefits of the full range of antiobesity medications available to patients, and to incorporate both guideline based advice and emerging real world clinical evidence into daily clinical practice. The tremendous variability in response to antiobesity medications means that clinicians need to use a flexible approach that takes advantage of specific features of the antiobesity medication selected to provide the best option for individual patients. Future research is needed on how best to use available drug treatments in real world practice settings, the potential role of combination therapies, and the cost effectiveness of antiobesity medications. Several new drug treatments are being evaluated in ongoing clinical trials, suggesting that the future for pharmacotherapy of obesity is bright.

Obesity - Standards, trends and advances

Obesity continues to be a significant global health concern, giving rise to various complications. This review article explores the current standards and emerging innovations in diagnosing and treating obesity, including recent disease name change, staging system or therapeutic goals. This narrative review has been based on recent scientific articles from PubMed database, limiting the scope of topics to current standards and upcoming developments and breakthroughs in the diagnosis and treatment of obesity. The educational and informative nature of the review has been maintained in order to make the information presented accessible to both researchers and clinical practitioners. The recognition of diverse obesity phenotypes has prompted a paradigm shift towards a complex and patient-centered approach to diagnosis and therapy. Pharmacotherapy for obesity is evolving rapidly, with ongoing research focusing on novel molecular targets and metabolic pathways. Promising developments include dual or triple incretin analogs, oral incretin drugs, neurotransmitter-based therapies, muscle mass-increasing treatments, and therapies targeting visceral adipose tissue browning. Despite current evidence-based international standards, the field of obesity diagnosis and treatment continues to expand, with new diagnostic tools and pharmacotherapies potentially replacing current practices. Therapeutic management should be tailored to individual patients, considering obesity phenotype, health status, lifestyle, and preferences. Looking ahead, the future holds promising opportunities for obesity management, but further research is required to assess the efficacy and safety of emerging therapies. A multifactorial and personalized approach will be pivotal in addressing the diverse challenges posed by obesity.

Common and ethnic-specific derangements in skeletal muscle transcriptome associated with obesity

BACKGROUND

Obesity is a common disease with a higher prevalence among African Americans. Obesity alters cellular function in many tissues, including skeletal muscle, and is a risk factor for many life-threatening diseases, including cardiovascular disease and diabetes. The similarities and differences in molecular mechanisms that may explain ethnic disparities in obesity between African and European ancestry individuals have not been studied.

METHODS

In this study, data from transcriptome-wide analyses on skeletal muscle tissues from well-powered human cohorts were used to compare genes and biological pathways affected by obesity in European and African ancestry populations. Data on obesity-induced differentially expressed transcripts and GWAS-identified SNPs were integrated to prioritize target genes for obesity-associated genetic variants.

RESULTS

Linear regression analysis in the FUSION (European, N = 301) and AAGMEx (African American, N = 256) cohorts identified a total of 2569 body mass index (BMI)-associated transcripts (q < 0.05), of which 970 genes (at p < 0.05) are associated in both cohorts, and the majority showed the same direction of effect on BMI. Biological pathway analyses, including over-representation and gene-set enrichment analyses, identified enrichment of protein synthesis pathways (e.g., ribosomal function) and the ceramide signaling pathway in both cohorts among BMI-associated down- and up-regulated transcripts, respectively. A comparison using the IPA-tool suggested the activation of inflammation pathways only in Europeans with obesity. Interestingly, these analyses suggested repression of the mitochondrial oxidative phosphorylation pathway in Europeans but showed its activation in African Americans. Integration of SNP-to-Gene analyses-predicted target genes for obesity-associated genetic variants (GWAS-identified SNPs) and BMI-associated transcripts suggested that these SNPs might cause obesity by altering the expression of 316 critical target genes (e.g., GRB14) in the muscle.

CONCLUSIONS

This study provides a replication of obesity-associated transcripts and biological pathways in skeletal muscle across ethnicities, but also identifies obesity-associated processes unique in either African or European ancestry populations.

Phentermine in the Modern Era of Obesity Pharmacotherapy: Does It Still Have a Role in Treatment?

PURPOSE OF REVIEW

This review provides an overview of the history, mechanism of action, and expected treatment effects of the anti-obesity medication (AOM), phentermine. It also includes a summary of recent research and practical guidance for prescribing clinicians.

RECENT FINDINGS

Recent research on phentermine is sparse and consists primarily of observational studies with methodologic limitations. These studies suggest that phentermine use is associated with clinically significant weight loss in adults and that the medication is generally well tolerated. Large-scale observational studies evaluating phentermine's safety have not identified an increased risk of cardiovascular events or elevations in blood pressure. There is no data to support the notion that phentermine is addictive. Although it remains the most commonly prescribed AOM in the USA, phentermine has little rigorous research to support its efficacy and safety in long-term treatment, which creates a dilemma with guideline-recommended chronic use of AOMs. While we await forthcoming conclusive data on this front, clinicians may consider using phentermine long-term in selected patients, if such prescribing is consistent with local regulatory statutes.

Precision Nutrition Unveiled: Gene-Nutrient Interactions, Microbiota Dynamics, and Lifestyle Factors in Obesity Management

BACKGROUND

Obesity is a complex metabolic disorder that is associated with several diseases. Recently, precision nutrition (PN) has emerged as a tailored approach to provide individualised dietary recommendations.

AIM

This review discusses the major intrinsic and extrinsic components considered when applying PN during the management of obesity and common associated chronic conditions.

RESULTS

The review identified three main PN components: gene-nutrient interactions, intestinal microbiota, and lifestyle factors. Genetic makeup significantly contributes to inter-individual variations in dietary behaviours, with advanced genome sequencing and population genetics aiding in detecting gene variants associated with obesity. Additionally, PN-based host-microbiota evaluation emerges as an advanced therapeutic tool, impacting disease control and prevention. The gut microbiome's composition regulates diverse responses to nutritional recommendations. Several studies highlight PN's effectiveness in improving diet quality and enhancing adherence to physical activity among obese patients. PN is a key strategy for addressing obesity-related risk factors, encompassing dietary patterns, body weight, fat, blood lipids, glucose levels, and insulin resistance.

CONCLUSION

PN stands out as a feasible tool for effectively managing obesity, considering its ability to integrate genetic and lifestyle factors. The application of PN-based approaches not only improves current obesity conditions but also holds promise for preventing obesity and its associated complications in the long term.

Type-2 diabetes mellitus remission prediction models after Roux-En-Y gastric bypass and sleeve gastrectomy based on disease severity scores

AIM

Metabolic and bariatric surgery (MBS) is considered one of the most effective interventions for weight loss and associated type-2 diabetes mellitus (T2DM) remission. Multiple scores including the Individualized Metabolic Surgery (IMS), DiaRem, advanced DiaRem, and Robert et al. scores, have been developed predict T2DM remission after MBS. We aim to validate each of these scores in our cohort of patients undergoing MBS with long-term follow-up and assess their efficacy based on procedure type and preoperative BMI.

METHODS

We conducted a multicenter cohort study including patients with T2DM undergoing either Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Areas under the receiver operating characteristics (ROC) curve (AUC) were calculated to assess the discriminatory ability of the four models to detect T2DM remission.

RESULTS

A total of 503 patients (67 % females, mean age 53.5 [11] years, BMI 46.2 [8.8] kg/m2) with T2DM were included. The majority (78 %) underwent RYGB, while the rest (28 %) had SG. All four scores predicted T2DM remission in our cohort with an ROC AUC of 0.79 for IMS, 0.78 for both DiaRem and advanced-DiaRem, and 0.75 for Robert et al. score. Specific subgroups for each of these scores demonstrated higher T2DM remission rates after RYGB compared to SG.

CONCLUSION

We demonstrate the ability of the IMS, DiaRem, advanced-DiaRem and Robert et al. scores to predict T2DM remission in patients undergoing MBS. T2DM remission rates was demonstrated to decrease with more severe IMS, DiaRem and advanced-DiaRem scores and lower Robert et al. scores.

The role of gastric function in control of food intake (and body weight) in relation to obesity, as well as pharmacological and surgical interventions

PURPOSE

The objectives of this review are to summarize the role of gastric motor functions in the development of satiation (defined broadly as postprandial fullness) and satiety (reduced appetite or postponing desire to eat after a meal) and their impact on weight change. The specific topics are the methods of measurement of gastric emptying and accommodation and their impact on food intake, satiation, and satiety. A second focus contrasts bariatric surgery to endoscopic gastroplasty that alter gastric emptying and incretin responses in markedly divergent manners.

BACKGROUND

The hormone, GLP-1, retards gastric emptying and increases gastric accommodation through vagally-mediated effects. Indeed, these effects provide the basis for the association of altered gastric emptying in the appetite and weight loss responses to pharmacological interventions particularly by those acting on receptors of incretin agonists such as liraglutide and the dual agonists, tirzepatide and cotadutide, all of which retard gastric emptying. In fact, retardation of gastric emptying and gastrointestinal adverse effects have been shown to contribute in part to the weight loss in response to this class of pharmacological agents.

SUMMARY

The motor functions of the stomach are relevant to postprandial fullness and to interventions aimed at weight loss in people with obesity.

Pharmacotherapy for obesity: moving towards efficacy improvement

Obesity is a chronic, recurring, progressive disease and a major public health problem associated with several other diseases that lead to disability, morbidity, and mortality. The prevalence of obesity has increased at pandemic levels, along with increasing weight-related comorbidities and deaths worldwide. Lifestyle interventions alone provide clinically significant long-term weight loss in only a small proportion of individuals, and bariatric surgery is not suitable or desirable for all patients. Historically, anti-obesity medications achieved a mean efficacy with weight loss between 5 and 10%, which significantly impacted several comorbidities and risk factors, but the average efficacy of these medications remained lower than that expected by both patients and health care professionals and eventually curbed long-term use. Moreover, there is no direct evidence on the impact of anti-obesity medications on cardiovascular outcomes. Semaglutide is a newer anti-obesity medication that changes the overall landscape, as phase 3 studies show a mean weight loss near the 15% threshold and significant proportions of patients with a weight loss of greater than 20%. In this review, we focus on the currently available anti-obesity medications, discuss the results of semaglutide, and present perspectives on the future of obesity treatment after semaglutide.

Maladaptive Eating Behaviours, Generalised Anxiety Disorder and Depression Severity: A Comparative Study between Adult Women with Overweight, Obesity, and Normal Body Mass Index Range

(1) Background: Causes of obesity are multifactorial and include genetic predisposition as well as behavioural, psychological, social, and hormonal influences. We aimed to compare adult women with normal weight, overweight, and obesity, with a focus on maladaptive eating behaviours, the presence of generalised anxiety disorder, and the severity of depression. Additionally, we explored the context of anti-obesity pharmacotherapy and the status of bariatric surgery. (2) Methods: The sample was composed of 1105 adult women. The following measures, through the Computer-Assisted Web Interview (CAWI), were used in the present study: the Three Factor Eating Questionnaire (TFEQ-R18), the 7-item Generalised Anxiety Disorders Scale (GAD-7), and the 9-item Patient Health Questionnaire (PHQ-9). (3) Results: All domains of the TFEQ-R18 had correlations with Body Mass Index (BMI). There was a weak negative association between BMI and Cognitive Restraint (r = -0.172, p < 0.001) and a weak positive relationship between BMI and Uncontrolled as well as Emotional Eating (r = 0.165, p < 0.001; r = 0.191, p < 0.001, respectively). Women who screened positive for anxiety scored lower in the Cognitive Restraint domain (10.11 ± 3.58, p = 0.042) and higher in the Uncontrolled Eating (12.69 ± 6.04, p < 0.001) and Emotional Eating (5.29 ± 2.75, p < 0.001) domains. Similarly, women screening positive for depression had lower scores in Cognitive Restraint (9.88 ± 3.61, p < 0.001) and higher scores in Uncontrolled Eating (12.64 ± 6.09, p < 0.001) and Emotional Eating (5.31 ± 2.71, p < 0.001). A significant association between liraglutide and semaglutide administration and Cognitive Restraint was observed. (4) Conclusions: Individualised treatment for obesity should consider the existing and confirmed association between maladaptive eating behaviours and generalised anxiety disorder, as well as the severity of depression influencing the BMI altogether. The use of anti-obesity pharmacotherapy needs further exploration because the evidence for the use of liraglutide and semaglutide in terms of positive associations with eating behaviours is encouraging.

My Diet Study: protocol for a two-part observational, longitudinal, psycho-biological study of dieting in Australian youth

Introduction

Self-directed dieting (i.e., unsupervised) is very common among adolescents and young adults but has had almost no direct research. This paper describes the protocol for the My Diet Study, a two-arm observational investigation of the natural progression of dieting among young people over a period of 6-months. The study aims to examine the links between self-directed dieting, general physiological and psychological metrics of wellbeing (e.g., depressive symptoms) and biomarkers of gut-brain axis functions (e.g., microbiome and hormones) that are predicted to influence diet adherence through appetite, mood and metabolism regulation.

Methods

Young people aged 16-25, intending to start a diet will be invited to participate in this observational study. For Part 1 (psychological arm), participants will be asked to complete a set of questionnaires and diaries at the beginning of every month for 6 months, to assess overall mental (e.g., psychological distress, disordered eating) and physical (e.g., weight) health, perceived diet success, food intake and gastrointestinal movements. For Part 2 (biological arm), a subsample of 50 participants will be asked to provide feces, blood and saliva for bio-sampling each month for the first 3-months of their participation in Part 1.

Discussion

The My Diet Study will be the first longitudinal, observational study of dieting in young people combining in-depth psychological and biological data. It is anticipated that the findings will yield psychological & biological information about the impacts and effectiveness of self-directed dieting in young people, inform a framework for advice on safety in dieting among young people and help to establish the potential for biomarkers for risk management and improvement of diet-based lifestyle interventions.

Identifying obesity subtypes: A review of studies utilising clinical biomarkers and genetic data

Obesity is a complex and multifactorial condition that poses significant health risks. Recent advancements in our understanding of obesity have highlighted the heterogeneity within this disorder. Identifying distinct subtypes of obesity is crucial for personalised treatment and intervention strategies. This review paper aims to examine studies that have utilised clinical biomarkers and genetic data to identify clusters or subtypes of obesity. The findings of these studies may provide valuable insights into the underlying mechanisms and potential targeted approaches for managing obesity-related health issues such as type 2 diabetes.

Obesity: A Review of Pathophysiology and Classification

Obesity is a chronic, multifactorial, and morbid disease. In the United States, 69% of adults are overweight or have obesity, and the global prevalence of obesity is increasing. Obesity is influenced by genetic, neurologic, metabolic, enteric, and behavioral processes. It remains a key modifiable risk factor for many comorbid diseases, including cardiovascular disease, diabetes mellitus, and cancer. Whereas there are recent and significant advances in obesity therapy, including diets, lifestyle modifications, pharmacotherapies, endoscopic procedures, and bariatric surgeries, there is an immense need for a better understanding of the heterogeneity in the pathophysiologic process of obesity and outcomes. Here we review salient pathophysiologic mechanisms underlying the development and morbidity of obesity as well as pathophysiologically based classification systems that inform current obesity management and may inform improved and individualized management in the future.

The New Zealand eating behavior questionnaire - Validation study for a novel assessment tool to describe actionable eating behavior traits

Individualised management of obesity remains challenging and, to date, most treatment is based on clinical judgement. This study aimed to develop and validate a novel questionnaire-based tool to identify three pre-defined eating behavior (EB) traits, emotional eating, reduced satiety (constant hunger) and reduced satiation (feasters) that may predict selective medication response given their targeted actions. We recruited 977 individuals from a tertiary academic diabetes clinic to participate in this two-phase validation study. Participants self-reported weight management activities and were asked to self-assess their EB characteristics. The initial questionnaire included 42 visual analogue scale questions. In Phase I, 729 participants completed the questionnaire, including Māori (11.8%) and Pacific peoples (19.3%). After random division of the study sample, Exploratory Factor Analysis (EFA) confirmed a three-factor model as the best fit. Stepwise removal of items with inadequate factor loading retained 27 of 42 items, which accounted for 96% of the variance. Confirmatory Factor Analysis (CFA), performed on the second half of the sample, demonstrated good model fit with the final 27-item questionnaire. Internal consistency was high for factor (α = 0.82-0.95) and demographic subgroups, and similar to those obtained in the EFA. Test-retest reliability in a subset of 399 participants who repeated the questionnaire after a four-week interval (Phase II) showed moderate to good reliability. Participants classified into one of three EB types based on the highest median score among the factors. Test-retest reliability was robust for emotional eaters (71.25%) and constant hunger (68.9%). The correlation between aggregate EB score (sum of three EB scores) and BMI was significant (Spearman rho = 0.314, P = .0005). The questionnaire reliably identified three distinct EB traits, which may be informative for precision medicine applications for obesity management.

New insights in the mechanisms of weight-loss maintenance: Summary from a Pennington symposium

Obesity is a chronic disease that affects more than 650 million adults worldwide. Obesity not only is a significant health concern on its own, but predisposes to cardiometabolic comorbidities, including coronary heart disease, dyslipidemia, hypertension, type 2 diabetes, and some cancers. Lifestyle interventions effectively promote weight loss of 5% to 10%, and pharmacological and surgical interventions even more, with some novel approved drugs inducing up to an average of 25% weight loss. Yet, maintaining weight loss over the long-term remains extremely challenging, and subsequent weight gain is typical. The mechanisms underlying weight regain remain to be fully elucidated. The purpose of this Pennington Biomedical Scientific Symposium was to review and highlight the complex interplay between the physiological, behavioral, and environmental systems controlling energy intake and expenditure. Each of these contributions were further discussed in the context of weight-loss maintenance, and systems-level viewpoints were highlighted to interpret gaps in current approaches. The invited speakers built upon the science of obesity and weight loss to collectively propose future research directions that will aid in revealing the complicated mechanisms involved in the weight-reduced state.

Precision medicine of obesity as an integral part of type 2 diabetes management - past, present, and future

Obesity is a complex and heterogeneous condition that leads to various metabolic complications, including type 2 diabetes. Unfortunately, for some, treatment options to date for obesity are insufficient, with many people not reaching sustained weight loss or having improvements in metabolic health. In this Review, we discuss advances in the genetics of obesity from the past decade-with emphasis on developments from the past 5 years-with a focus on metabolic consequences, and their potential implications for precision management of the disease. We also provide an overview of the potential role of genetics in guiding weight loss strategies. Finally, we propose a vision for the future of precision obesity management that includes developing an obesity-centred multidisease management algorithm that targets both obesity and its comorbidities. However, further collaborative efforts and research are necessary to fully realise its potential and improve metabolic health outcomes.

Towards an adiposity-related disease framework for the diagnosis and management of obesities

Obesity is a complex disease that relapses frequently and associates with multiple complications that comprise a worldwide health priority because of its rising prevalence and association with numerous complications, including metabolic disorders, mechanic pathologies, and cancer, among others. Noteworthy, excess adiposity is accompanied by chronic inflammation, oxidative stress, insulin resistance, and subsequent organ dysfunction. This dysfunctional adipose tissue is initially stored in the visceral depot, overflowing subsequently to produce lipotoxicity in ectopic depots like liver, heart, muscle, and pancreas, among others. People living with obesity need a diagnostic approach that considers an exhaustive pathophysiology and complications assessment. Thus, it is essential to warrant a holistic diagnosis and management that guarantees an adequate health status, and quality of life. The present review summarizes the different complications associated with obesity, at the same time, we aim to fostering a novel framework that enhances a patient-centered approach to obesity management in the precision medicine era.

Individualised prescription of medications for treatment of obesity in adults

Obesity continues to increase in prevalence globally, driven by changes in environmental factors which have accelerated the development of obesity in individuals with an underlying predisposition to weight gain. The adverse health effects and increased risk for chronic disease associated with obesity are ameliorated by weight loss, with greater benefits from larger amounts of weight reduction. Obesity is a heterogeneous condition, with the drivers, phenotype and complications differing substantially between individuals. This raises the question of whether treatments for obesity, specifically pharmacotherapy, can be targeted based on individual characteristics. This review examines the rationale and the clinical data evaluating this strategy in adults. Individualised prescribing of obesity medication has been successful in rare cases of monogenic obesity where medications have been developed to target dysfunctions in leptin/melanocortin signalling pathways but has been unsuccessful in polygenic obesity due to a lack of understanding of how the gene variants associated with body mass index affect phenotype. At present, the only factor consistently associated with longer-term efficacy of obesity pharmacotherapy is early weight loss outcome, which cannot inform choice of therapy at the time of medication initiation. The concept of matching a therapy for obesity to the characteristics of the individual is appealing but as yet unproven in randomised clinical trials. With increasing technology allowing deeper phenotyping of individuals, increased sophistication in the analysis of big data and the emergence of new treatments, it is possible that precision medicine for obesity will eventuate. For now, a personalised approach that takes into account the person's context, preferences, comorbidities and contraindications is recommended.

A phenotypic approach to obesity treatment

Obesity is a chronic disease that increases morbidity and mortality and adversely affects quality of life. The rapid rise of obesity has outpaced the development and deployment of effective therapeutic interventions, thereby creating a global health crisis. The presentation, complications, and response to obesity treatments vary, yet lifestyle modification, which is the foundational therapeutic intervention for obesity, is often "one size fits all." The concept of personalized medicine uses genetic and phenotypic information as a guide for disease prevention, diagnosis, and treatment and has been successfully applied in diseases such as cancer, but not in obesity. As we gain insight into the pathophysiologic mechanisms of obesity and its phenotypic expression, specific pathways can be targeted to yield a greater, more sustained therapeutic impact in an individual patient with obesity. A phenotype-based pharmacologic treatment approach utilizing objective measures to classify patients into predominant obesity mechanism groups resulted in greater weight loss (compared with a non-phenotype-based approach) in a recent study by Acosta and colleagues. In this review, we discuss the application of lifestyle modifications, behavior therapy and pharmacotherapy using the obesity phenotype-based approach as a framework.

Progression to Obesity: Variations in Patterns of Metabolic Fluxes, Fat Accumulation, and Gastrointestinal Responses

Obesity is a multifactorial disorder that is remarkably heterogeneous. It presents itself in a variety of phenotypes that can be metabolically unhealthy or healthy, associate with no or multiple metabolic risk factors, gain extreme body weight (super-responders), as well as resist obesity despite the obesogenic environment (non-responders). Progression to obesity is ultimately linked to the overall net energy balance and activity of different metabolic fluxes. This is particularly evident from variations in fatty acids oxidation, metabolic fluxes through the pyruvate-phosphoenolpyruvate-oxaloacetate node, and extracellular accumulation of Krebs cycle metabolites, such as citrate. Patterns of fat accumulation with a focus on visceral and ectopic adipose tissue, microbiome composition, and the immune status of the gastrointestinal tract have emerged as the most promising targets that allow personalization of obesity and warrant further investigations into the critical issue of a wider and long-term weight control. Advances in understanding the biochemistry mechanisms underlying the heterogenous obesity phenotypes are critical to the development of targeted strategies to maintain healthy weight.

Tirzepatide once weekly for the treatment of obesity in people with type 2 diabetes (SURMOUNT-2): a double-blind, randomised, multicentre, placebo-controlled, phase 3 trial

BACKGROUND

Weight reduction is essential for improving health outcomes in people with obesity and type 2 diabetes. We assessed the efficacy and safety of tirzepatide, a glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptor agonist, versus placebo, for weight management in people living with obesity and type 2 diabetes.

METHODS

This phase 3, double-blind, randomised, placebo-controlled trial was conducted in seven countries. Adults (aged ≥18 years) with a body-mass index (BMI) of 27 kg/m2 or higher and glycated haemoglobin (HbA1c) of 7-10% (53-86 mmol/mol) were randomly assigned (1:1:1), using a computer-generated random sequence via a validated interactive web-response system, to receive either once-weekly, subcutaneous tirzepatide (10 mg or 15 mg) or placebo for 72 weeks. All participants, investigators, and the sponsor were masked to treatment assignment. Coprimary endpoints were the percent change in bodyweight from baseline and bodyweight reduction of 5% or higher. The treatment-regimen estimand assessed effects regardless of treatment discontinuation or initiation of antihyperglycaemic rescue therapy. Efficacy and safety endpoints were analysed with data from all randomly assigned participants (intention-to-treat population). This trial is registered with ClinicalTrials.gov, NCT04657003.

FINDINGS

Between March 29, 2021, and April 10, 2023, of 1514 adults assessed for eligibility, 938 (mean age 54·2 years [SD 10·6], 476 [51%] were female, 710 [76%] were White, and 561 [60%] were Hispanic or Latino) were randomly assigned and received at least one dose of tirzepatide 10 mg (n=312), tirzepatide 15 mg (n=311), or placebo (n=315). Baseline mean bodyweight was 100·7 kg (SD 21·1), BMI 36·1 kg/m2 (SD 6·6), and HbA1c 8·02% (SD 0·89; 64·1 mmol/mol [SD 9·7]). Least-squares mean change in bodyweight at week 72 with tirzepatide 10 mg and 15 mg was -12·8% (SE 0·6) and -14·7% (0·5), respectively, and -3·2% (0·5) with placebo, resulting in estimated treatment differences versus placebo of -9·6% percentage points (95% CI -11·1 to -8·1) with tirzepatide 10 mg and -11·6% percentage points (-13·0 to -10·1) with tirzepatide 15 mg (all p<0·0001). More participants treated with tirzepatide versus placebo met bodyweight reduction thresholds of 5% or higher (79-83% vs 32%). The most frequent adverse events with tirzepatide were gastrointestinal-related, including nausea, diarrhoea, and vomiting and were mostly mild to moderate in severity, with few events leading to treatment discontinuation (<5%). Serious adverse events were reported by 68 (7%) participants overall and two deaths occurred in the tirzepatide 10 mg group, but deaths were not considered to be related to the study treatment by the investigator.

INTERPRETATION

In this 72-week trial in adults living with obesity and type 2 diabetes, once-weekly tirzepatide 10 mg and 15 mg provided substantial and clinically meaningful reduction in bodyweight, with a safety profile that was similar to other incretin-based therapies for weight management.

FUNDING

Eli Lilly and Company.

The DECON pilot project investigates predictive markers for successful bariatric surgery

Obesity is a chronic, multifactorial disease which is linked to a number of adverse endocrinological and metabolic conditions. Currently, bariatric surgery is one of the most effective treatments for individuals diagnosed with severe obesity. However, the current indications for bariatric surgery are based on inadequate metrics (i.e., BMI) which do not account for the complexity of the disease, nor the heterogeneity among the patient population. Moreover, there is a lack of understanding with respect to the biological underpinnings that influence successful and sustained weight loss post-bariatric surgery. Studies have implicated age and pre-surgery body weight as two factors that are associated with favorable patient outcomes. Still, there is an urgent medical need to identify other potential factors that could improve the specificity of candidate selection and better inform the treatment plan of patients with obesity. In this report, we present and describe the cohort of the DECON pilot project, a multicenter study which aims to identify predictive biomarkers of successful weight loss after bariatric surgery.

When Eating Intuitively Is Not Always a Positive Response: Using Machine Learning to Better Unravel Eaters Profiles

BACKGROUND

The aim of the present study was to identify eaters profiles using the latest advantages of Machine Learning approach to cluster analysis.

METHODS

A total of 317 participants completed an online-based survey including self-reported measures of body image dissatisfaction, bulimia, restraint, and intuitive eating. Analyses were conducted in two steps: (a) identifying an optimal number of clusters, and (b) validating the clustering model of eaters profile using a procedure inspired by the Causal Reasoning approach.

RESULTS

This study reveals a 7-cluster model of eaters profiles. The characteristics, needs, and strengths of each eater profile are discussed along with the presentation of a continuum of eaters profiles.

CONCLUSIONS

This conceptualization of eaters profiles could guide the direction of health education and treatment interventions targeting perceptual and eating dimensions.