Applications of SGLT2 inhibitors beyond glycaemic control

Sodium-glucose cotransporter 2 (SGLT2) inhibitors were initially developed for their glucose-lowering effects and have shown a modest glycaemic benefit in people with type 2 diabetes mellitus (T2DM). In the past decade, a series of large, robust clinical trials of these therapies have demonstrated striking beneficial effects for various care goals, transforming the chronic disease therapeutic landscape. Cardiovascular safety studies in people with T2DM demonstrated that SGLT2 inhibitors reduce cardiovascular death and hospitalization for heart failure. Subsequent trials in participants with heart failure with reduced or preserved left ventricular ejection fraction demonstrated that SGLT2 inhibitors have beneficial effects on heart failure outcomes. In dedicated kidney outcome studies, SGLT2 inhibitors reduced the incidence of kidney failure among participants with or without diabetes. Post hoc analyses have suggested a range of other benefits of these drugs in conditions as diverse as metabolic dysfunction-associated steatotic liver disease, kidney stone prevention and anaemia. SGLT2 inhibitors have a generally favourable adverse effect profile, although patient selection and medication counselling remain important. Concerted efforts are needed to better integrate these agents into routine care and support long-term medication adherence to close the gap between clinical trial outcomes and those achieved in the real world.

Challenging Clinical Perspectives in Type 2 Diabetes with Tirzepatide, a First-in-Class Twincretin

Tirzepatide is a first-in-class GIP/GLP-1 receptor agonist ('twincretin')-a single molecule that acts as an agonist at both glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptors. In the SURPASS clinical trial program in type 2 diabetes mellitus (T2D), tirzepatide was associated with unprecedented reductions in HbA1c, clinically significant weight loss and other metabolic benefits, combined with low rates of hypoglycaemia across a wide range of patient characteristics. The safety and adverse event rate for tirzepatide appears comparable to that of GLP-1 receptor agonists. Although results from dedicated cardiovascular (CV) and kidney trials are currently not available, information to date suggests that tirzepatide may have CV and kidney benefits in people with T2D. Tirzepatide has been approved for the treatment of T2D in the USA, United Arab Emirates, European Union, Japan and Australia. Here, we review how tirzepatide will fit into the T2D treatment continuum. We also consider future directions with tirzepatide in T2D, including its potential for targeting cardio-renal-metabolic disease in T2D, and discuss how tirzepatide-and other co-agonists in development-may challenge current approaches for management of T2D.

Motivations for participation in weight loss clinical trials

Males are under-represented in weight loss clinical trials, usually comprising fewer than one-quarter of participants. Our study aimed to investigate people's motivations for participating in weight loss trials and determine any relationship with gender. Eighty individuals from an existing registry for weight loss trials were contacted, of whom 24 (9 males, 15 females) agreed to participate in a 20-min semi-structured interview around their expectations and motivations for volunteering. Interviews were audio-recorded and transcribed in Zoom. A transcript of each interview was uploaded into NVivo for preliminary thematic analysis. Improved health was a common motivation for pursuing weight loss in all subjects regardless of gender. Male recruitment to weight loss trials was often influenced by advice from a healthcare professional to lose weight for the prevention of obesity-related comorbidities, whereas family and aesthetic expectations (e.g., clothes and fashion) were key elements of female participation. Identification of gender differences in motivations for volunteering in weight loss trials will help improve tailoring of recruitment strategies and interventions to enhance male participation in the future.

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.

Obesity, lifestyle behaviours and psychological effects of the COVID-19 lockdown: A survey of patients attending a tertiary weight loss clinic

Lockdown measures due to coronavirus-19 disease (COVID-19) have impacted lifestyle factors. This study aimed to explore whether health and lifestyle behaviours changed during the 2020 COVID-19 lockdown among patients with obesity. A specifically designed online survey and the Depression Anxiety Stress Scale (DASS-21) were administered to patients scheduled to attend a tertiary weight management service between 6 June-12 August 2020. A total of 210 participants completed the survey; mean age (SD) was 52.1 (12.5) years, 69% female and 67% Caucasian. Only 1.4% had tested positive to COVID-19. There was a statistically significant increase in weight pre- and post-COVID-19 lockdown, with no sex differences. Most (61.3%) gained weight, 30.4% lost weight and 8.3% maintained. The majority changed their overall purchasing (88.4%) and eating behaviours (91.6%). Two-thirds (64%) reported they did some form of exercise during the lockdown. Of those, exercise declined in 56.8% and increased in 18%. DASS-21 scores were positively correlated to worry about COVID-19, eating fewer core foods and eating more convenient/treat foods and negatively correlated with exercise. The results provide insights into how and why behaviour change occurs during stressful periods like the COVID-19 pandemic. Although there was variability in individual weight trajectories, on average people with obesity gained weight and changed lifestyle behaviours during the COVID-19 lockdown period. Strategies and support for people with obesity are required at these times.

Obesity in South and Southeast Asia-A new consensus on care and management

Obesity is a chronic disease in which the abnormal or excessive accumulation of body fat leads to impaired health and increased risk of mortality and chronic health complications. Prevalence of obesity is rising rapidly in South and Southeast Asia, with potentially serious consequences for local economies, healthcare systems, and quality of life. Our group of obesity specialists from Bangladesh, Brunei Darussalam, India, Indonesia, Malaysia, Philippines, Singapore, Sri Lanka, Thailand, and Viet Nam undertook to develop consensus recommendations for management and care of adults and children with obesity in South and Southeast Asia. To this end, we identified and researched 12 clinical questions related to obesity. These questions address the optimal approaches for identifying and staging obesity, treatment (lifestyle, behavioral, pharmacologic, and surgical options) and maintenance of reduced weight, as well as issues related to weight stigma and patient engagement in the clinical setting. We achieved consensus on 42 clinical recommendations that address these questions. An algorithm describing obesity care is presented, keyed to the various consensus recommendations.

Understanding the confluence of injury and obesity in a Grade 2 obesity and above population

OBJECTIVE

Obesity and injury are major inter-related public health challenges. The objective of this study was to explore the perceptions of injury in people with severe obesity.

METHODS

A cross-sectional design was employed to capture injury perception and lifestyle habits via questionnaires. Weight (kg) and height (m) were measured by clinicians for patients attending a weight loss group program. Univariate, chi-square, ANOVA and ordinal regression analyses were undertaken.

RESULTS

There were 292 participants (67.1% female), mean age 49.3 years and Body Mass Index 47.2 kg/m² (range 30.7-91.9 kg/m²). Concern about having an injury was found in 83%, and 74.2% thought that weight would increase the likelihood of injury. A greater concern of being injured at baseline was associated with less weight loss at eight weeks (F=3.567; p=0.03). Depression, anxiety and sleepiness score were higher in those who reported greater 'Concern about having an injury'.

CONCLUSIONS

People with obesity fear injury and falling, which limits their willingness to exercise. Anxiety symptoms appear to exacerbate this connection.

IMPLICATIONS FOR PUBLIC HEALTH

In individuals with obesity, anxiety, sleepiness and depression are associated with a fear of being injured. Addressing fear and reducing anxiety may decrease barriers to participating in physical activity.

Metabolic effects of lipectomy and of adipose tissue transplantation

OBJECTIVE

The goal of this study was to review the metabolic effects of fat transplantation.

METHODS

Fat (adipose tissue [AT]) transplantation has been performed extensively for many years in the cosmetic reconstruction industry. However, not all fats are equal. White, brown, and beige AT differ in energy storage and use. Brown and beige AT consume glucose and lipids for thermogenesis and, theoretically, may provide greater metabolic benefit in transplantation. Here, the authors review the metabolic effects of AT transplantation.

RESULTS

Removal of subcutaneous human AT does not have beneficial metabolic effects. Most studies find no benefit from visceral AT transplantation and some studies report harmful effects. In contrast, transplantation of inguinal or subcutaneous AT in mice has positive effects. Brown AT transplant studies have variable results depending on the model but most show benefit.

CONCLUSIONS

Many technical improvements have optimized fat grafting and transplantation in cosmetic surgery. Transplantation of subcutaneous AT has the potential for significant metabolic benefits, although there are few studies in humans or using human AT. Brown AT transplantation is beneficial but not readily feasible in humans thus ex vivo "beiging" may be a useful strategy. AT transplantation may provide clinical benefits in metabolic disorders, especially in the setting of lipodystrophy.

Differences in weight loss outcomes for males and females on a low-carbohydrate diet: A systematic review

It has been widely demonstrated that there are a broad range of individual responses to all weight management regimens, often masked by reports of the mean. Identifying features of responders and non-responders to weight loss regimens enables a more tailored approach to the provision of weight management advice. Low-carbohydrate diets are currently popular, and anecdote suggests that males are more successful at losing weight using this approach. This is feasible given the physiological and socio-psychological differences between the genders. We analysed the extent and variation in weight change for males and females separately through a systematic search for all low-carbohydrate diet trials published since 1985. Very few studies compared weight loss outcomes by gender and, of those that did, most lacked supporting data. The majority of studies reported no gender difference but when a gender difference was found, males were more frequently reported as losing more weight than females on a low-carbohydrate diet. The lack of gender stratification in weight loss trials is concerning, as there are a range of gender-based factors that affect weight loss outcomes. This study highlights the importance of examining weight change for males and females separately, since as failure to do so may mask any potential differences, which, if detected, could assist with better weight loss outcomes.

A sustainable development goal framework to guide multisectoral action on NAFLD through a societal approach

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is a highly prevalent condition that requires a comprehensive and coordinated response across sectors and disciplines.

AIMS

In the absence of a multisectoral framework to tackle this condition, we developed one using the sustainable development goals (SDGs) as the basis for converging thinking about the design and delivery of public health responses.

METHODS

A multidisciplinary group identified the SDG targets and indicators for inclusion in the new framework through a two-stage process. Firstly, a core team of three researchers independently reviewed the 169 targets and 231 indicators of the SDGs to select a shortlist. Over two Delphi rounds, a multidisciplinary group of 12 experts selected which of the shortlisted targets and indicators to include. Respondents also provided written feedback on their selection. Targets and indicators with 75% or greater agreement were included in the final framework.

RESULTS

The final framework comprises 16 targets-representing 9% of all targets and 62% (16/26) of the shortlisted targets-and seven indicators, accounting for 50% (7/14) of the shortlisted indicators and 3% of all indicators. The selected targets and indicators cover a broad range of factors, from health, food and nutrition to education, the economy, and the built environment.

CONCLUSIONS

Addressing the challenge of NAFLD will require a re-envisioning of the liver health landscape, with greater focus on joined-up systems thinking and action. This new framework can help guide this process, including by outlining the stakeholders with whom the liver health community needs to engage.

The use of SGLT2 inhibitors in achieving glycaemic control in maturity-onset diabetes of the young type 3

SUMMARY

Maturity-onset diabetes of the young type 3 (MODY3) accounts for approximately 50% of cases of MODY. First-line treatment with sulfonylureas has been well established for individuals with MODY3. In contrast, the use of sodium-glucose co-transporter 2 (SGLT2) inhibitors in the treatment of individuals with MODY3 remains unclear. This case illustrates the in vivo effect of an SGLT2 inhibitor in a 30-year-old woman with MODY3 with poor glycaemic control despite the treatment with supramaximal doses of sulfonylurea and metformin. The addition of a SGLT2 inhibitor resulted in a rapid improvement in glycaemic control without any hypoglycaemic episodes. This case suggests that SGLT2 inhibitors may be an effective and potent treatment option in addition to sulfonylureas for individuals with MODY3.

LEARNING POINTS

Maturity-onset diabetes of the young type 3 (MODY3) arises from mutations in the hepatocyte nuclear factor-1alpha gene, which controls the expression of sodium-glucose co-transporter 2 (SGLT2) in the kidneys. Paradoxically, despite individuals with MODY3 having reduced expression of SGLT2, SGLT2 inhibitors induce higher glycosuria in individuals with MODY3 compared to individuals with type 2 diabetes mellitus. SGLT2 inhibitors may be an effective treatment for achieving glycaemic control in individuals with MODY3.

Targeting the insulin granule for modulation of insulin exocytosis

The pancreatic β-cells control insulin secretion in the body to regulate glucose homeostasis, and β-cell stress and dysfunction is characteristic of Type 2 Diabetes. Pharmacological targeting of the β-cell to increase insulin secretion is typically utilised, however, extended use of common drugs such as sulfonylureas are known to result in secondary failure. Moreover, there is evidence they may induce β-cell failure in the long term. Within β-cells, insulin secretory granules (ISG) serve as compartments to store, process and traffic insulin for exocytosis. There is now growing evidence that ISG exist in multiple populations, distinct in their protein composition, motility, age, and capacity for secretion. In this review, we discuss the implications of a heterogenous ISG population in β-cells and highlight the need for more understanding into how unique ISG populations may be targeted in anti-diabetic therapies.

Clinical usefulness of brief screening tool for activating weight management discussions in primary cARE (AWARE): A nationwide mixed methods pilot study

Objective

The Edmonton Obesity Staging System (EOSS) is based on weight related health complications among individuals with overweight and obesity requiring clinical intervention. We aimed to assess the clinical usefulness of a new screening tool based on the EOSS for activating weight management discussions in general practice.

Methods

We enrolled five General Practitioners (GPs) and 25 of their patients located nationwide in metropolitan areas of Australia to test the feasibility, acceptability, and accuracy of the new ‘EOSS-2 Risk Tool’, using cross-sectional and qualitative study designs. Diagnostic accuracy of the tool for the presence of EOSS ≥2 criteria was based on clinical information collected prospectively. To assess feasibility and applicability, we explored the views of GP and patient participants by thematic analysis of transcribed verbatim and de-identified data collected by semi-structured telephone interviews.

Results

Nineteen (76%) patients were aged ≥45 years, five (20%) were male, and 20 (80%) were classified with obesity. All 25 patients screened positive for EOSS ≥2 criteria by the tool. Interviews with patients continued until data saturation was reached resulting in a total of 23 interviews. Our thematic analysis revealed five themes: GP recognition of obesity as a health priority (GPs expressed strong interest in and understanding of its importance as a health priority); obesity stigma (GPs reported the tool helped them initiate health based and non-judgmental conversations with their patients); patient health literacy (GPs and patients reported increased awareness and understanding of weight related health risks), patient motivation for self-management (GPs and patients reported the tool helped focus on self-management of weight related complications), and applicability and scalability (GPs stated it was easy to use, relevant to a range of their patient groups, and scalable if integrated into existing patient management systems).

Conclusion

The EOSS-2 Risk Tool is potentially clinically useful for activating weight management discussions in general practice. Further research is required to assess feasibility and applicability.

REPRINT OF: CLASSIFICATION OF DIABETES MELLITUS

Executive Summary This document updates the 1999 World Health Organization (WHO) classification of diabetes. It prioritizes clinical care and guides health professionals in choosing appropriate treatments at the time of diabetes diagnosis, and provides practical guidance to clinicians in assigning a type of diabetes to individuals at the time of diagnosis. It is a compromise between clinical and aetiological classification because there remain gaps in knowledge of the aetiology and pathophysiology of diabetes. While acknowledging the progress that is being made towards a more precise categorization of diabetes subtypes, the aim of this document is to recommend a classification that is feasible to implement in different settings throughout the world. The revised classification is presented in Table 1. Unlike the previous classification, this classification does not recognize subtypes of type 1 diabetes and type 2 diabetes and includes new types of diabetes ("hybrid types of diabetes" and "unclassified diabetes").

Dietary adherence and program attrition during a severely energy-restricted diet among people with complex class III obesity: A qualitative exploration

Meal replacement Severely Energy-Restricted Diets (SERDs) produce ≥ 10% loss of body mass when followed for 6 weeks or longer in people with class III obesity (BMI ≥ 40 kg/m2). The efficacy of SERDs continues to be questioned by healthcare professionals, with concerns about poor dietary adherence. This study explored facilitators and barriers to dietary adherence and program attrition among people with class III obesity who had attempted or completed a SERD in a specialised weight loss clinic. Participants who commenced a SERD between January 2016 to May 2018 were invited to participate. Semi-structured in-depth interviews were conducted from September to October 2018 with 20 participants (12 women and 8 men). Weight change and recounted events were validated using the participants' medical records. Data were analysed by thematic analysis using line-by-line inductive coding. The mean age ± SD of participants was 51.2 ± 11.3 years, with mean ± SD BMI at baseline 63.7 ± 12.6 kg/m2. Five themes emerged from participants' recounts that were perceived to facilitate dietary adherence: (1.1) SERD program group counselling and psychoeducation sessions, (1.2) emotionally supportive clinical staff and social networks that accommodated and championed change in dietary behaviours, (1.3) awareness of eating behaviours and the relationship between these and progression of disease, (1.4) a resilient mindset, and (1.5) dietary simplicity, planning and self-monitoring. There were five themes on factors perceived to be barriers to adherence, namely: (2.1) product unpalatability, (2.2) unrealistic weight loss expectations, (2.3) poor program accessibility, (2.4) unforeseeable circumstances and (2.5) externalised weight-related stigma. This study highlights opportunities where SERD programs can be optimised to facilitate dietary adherence and reduce barriers, thus potentially improving weight loss outcomes with such programs. Prior to the commencement of a SERD program, healthcare professionals facilitating such programs could benefit from reviewing participants to identify common barriers. This includes identifying the presence of product palatability issues, unrealistic weight loss expectations, socio-economic disadvantage, and behaviour impacting experiences of externalised weight-related stigma.

Attitudes and Approaches to Use of Meal Replacement Products among Healthcare Professionals in Management of Excess Weight

Meal replacement product-based diets are an effective weight loss intervention used in the management of obesity. Historically, these diets have been underutilised by HealthCare Professionals (HCPs). An online survey of mixed methods design was distributed to HCPs to capture current perceptions and prescribing patterns of meal replacement products (MRPs) in the management of overweight and obesity. A total of 303 HCPs working in weight management across Australia began the survey and 197 (65%) completed it. While over 70% of HCPs have prescribed MRP currently or in the past, MRPs are only prescribed to a median 7% of patients seeking weight management treatment. Qualitative analysis identified potential barriers to MRP prescription, which include experience with patient non-compliance, perceived poor long-term weight loss durability and safety concerns regarding the product and its use as a total meal replacement program. Safety concerns are centred on the perceived risk of weight cycling and its potential negative psychological impact. MRP prescription is 66% more likely to occur if HCPs had formal training in the use of MRPs relative to those who did not, with a relative risk (RR) of 1.7 (95% CI 1.4, 2.0). This study highlights the potential barriers to the prescription of MRPs, which are centred around safety concerns. This also indicates that formal training may enhance the likelihood of prescribing MRPs, suggesting that once HCPs have a comprehensive understanding of the products and the evidence behind their use, their prescription is likely to be increased.

Small-protein Enrichment Assay Enables the Rapid, Unbiased Analysis of Over 100 Low Abundance Factors from Human Plasma

Unbiased and sensitive quantification of low abundance small proteins in human plasma (e.g. hormones, immune factors, metabolic regulators) remains an unmet need. These small protein factors are typically analyzed individually and using antibodies that can lack specificity. Mass spectrometry (MS)-based proteomics has the potential to address these problems, however the analysis of plasma by MS is plagued by the extremely large dynamic range of this body fluid, with protein abundances spanning at least 13 orders of magnitude. Here we describe an enrichment assay (SPEA), that greatly simplifies the plasma dynamic range problem by enriching small-proteins of 2-10 kDa, enabling the rapid, specific and sensitive quantification of >100 small-protein factors in a single untargeted LC-MS/MS acquisition. Applying this method to perform deep-proteome profiling of human plasma we identify C5ORF46 as a previously uncharacterized human plasma protein. We further demonstrate the reproducibility of our workflow for low abundance protein analysis using a stable-isotope labeled protein standard of insulin spiked into human plasma. SPEA provides the ability to study numerous important hormones in a single rapid assay, which we applied to study the intermittent fasting response and observed several unexpected changes including decreased plasma abundance of the iron homeostasis regulator hepcidin.

Standard baseline data collections in obesity management clinics: A Delphi study with recommendations from an expert panel

We aimed to develop an expert consensus on standardizing data collections in specialist obesity management clinics in Australia. A panel of 16 experts participated in a structured consensus-driven Delphi process to reach agreement on a minimum set of baseline patient data collections for consideration in specialist obesity services. The panel included surgeons, clinicians, allied health professionals (dietician, exercise physiologist, psychologist), a bariatric nurse and obesity researchers. We produced a recommended list of core and useful data items that should comprise the baseline patient data set. Consensus was achieved for recommended measures of demographic, anthropometric, biochemical, weight-loss history, medication, medical history and comorbidity data items using a 70% agreement threshold. In this iterative process, there was also consideration of specific data items for patients referred for bariatric surgery. We present the first expert panel consensus on recommendations for a minimum and standard set of baseline patient data collections in obesity management services in Australia. These may be relevant to other countries with similar obesity management service models. Implementation of these recommendations should facilitate data pooling for clinical audits and research collaborations across clinics seeking to improve the quality of specialist obesity care.

Proteomic Analysis of Human Plasma during Intermittent Fasting

Intermittent fasting (IF) increases lifespan and decreases metabolic disease phenotypes and cancer risk in model organisms, but the health benefits of IF in humans are less clear. Human plasma derived from clinical trials is one of the most difficult sample sets to analyze using mass spectrometry-based proteomics due to the extensive sample preparation required and the need to process many samples to achieve statistical significance. Here, we describe an optimized and accessible device (Spin96) to accommodate up to 96 StageTips, a widely used sample preparation medium enabling efficient and consistent processing of samples prior to LC-MS/MS. We have applied this device to the analysis of human plasma from a clinical trial of IF. In this longitudinal study employing 8-weeks IF, we identified significant abundance differences induced by the IF intervention, including increased apolipoprotein A4 (APOA4) and decreased apolipoprotein C2 (APOC2) and C3 (APOC3). These changes correlated with a significant decrease in plasma triglycerides after the IF intervention. Given that these proteins have a role in regulating apolipoprotein particle metabolism, we propose that IF had a positive effect on lipid metabolism through modulation of HDL particle size and function. In addition, we applied a novel human protein variant database to detect common protein variants across the participants. We show that consistent detection of clinically relevant peptides derived from both alleles of many proteins is possible, including some that are associated with human metabolic phenotypes. Together, these findings illustrate the power of accessible workflows for proteomics analysis of clinical samples to yield significant biological insight.

Transient diabetes insipidus in a post-partum woman with pre-eclampsia associated with residual placental vasopressinase activity

This case illustrates the exceedingly rare phenomenon of transient diabetes insipidus, in association with pre-eclampsia, occurring in the post-partum period following an in vitro fertilisation pregnancy, in an otherwise well 48-year-old lady. Diabetes insipidus can manifest during pregnancy, induced by increased vasopressinase activity secreted by placental trophoblasts and usually manifests in the third trimester. This presentation elucidates not only the intricate balance between the physiology of pregnancy and hormonal homeostasis, but also the importance of post-partum care as the physiological changes of pregnancy still hold pathological potential in the weeks immediately following delivery.

Current and emerging pharmacotherapies for obesity in Australia

BACKGROUND

Obesity is a major issue in Australia and globally. Many individuals struggle to maintain weight loss with lifestyle modification, and adjunctive pharmacotherapy may help. Historically, there have been limited pharmacotherapies for managing obesity. In addition, previous treatments such as phentermine-fenfluramine, rimonabant and sibutramine were withdrawn due to safety issues, resulting in lingering safety concerns.

METHODS

This is a narrative review of published data examining four new pharmacotherapy options for weight management in Australia. Of four new therapeutic options, three may be approved in Australia shortly and one - liraglutide 3.0mg - was approved in December 2015. Liraglutide is a glucagon-like peptide-1 receptor agonist that appears to act by increasing satiety and reducing food intake. Lorcaserin is a selective agonist of the serotonin_2C receptor, which mediates anorectic activity. The naltrexone/bupropion extended release (ER) combination utilises synergistic effects of the two component drugs, mediated via neurons in the hypothalamus, to reduce energy intake. Phentermine/topiramate ER combines the appetite suppressant phentermine with topiramate, an anti-epileptic with appetite-suppressant effects. All can result in meaningful improvements in obesity-related diseases, including diabetes and cardiovascular disorders) in large phase 3 trials, with efficacy demonstrated over 3 years for liraglutide 3.0 mg and 1-2 years for the rest.

CONCLUSIONS

The landscape of obesity treatment is changing rapidly. Of the new therapeutic options presented, all options have associated adverse events requiring long-term safety data, but the availability of new options is a welcome development.

Use of metformin earlier in pregnancy predicts supplemental insulin therapy in women with gestational diabetes

The use of metformin in gestational diabetes is safe and effective, yet some women require additional insulin therapy to achieve glycaemic targets. We found a significant association between earlier gestational age at initiation of metformin therapy and the necessity for supplemental insulin in women treated with metformin during pregnancy.

Cross-species gene expression analysis identifies a novel set of genes implicated in human insulin sensitivity

OBJECTIVE

Insulin resistance (IR) is one of the earliest predictors of type 2 diabetes. However, diagnosis of IR is limited. High fat fed mouse models provide key insights into IR. We hypothesized that early features of IR are associated with persistent changes in gene expression (GE) and endeavored to (a) develop novel methods for improving signal:noise in analysis of human GE using mouse models; (b) identify a GE motif that accurately diagnoses IR in humans; and (c) identify novel biology associated with IR in humans.

METHODS

We integrated human muscle GE data with longitudinal mouse GE data and developed an unbiased three-level cross-species analysis platform (single gene, gene set, and networks) to generate a gene expression motif (GEM) indicative of IR. A logistic regression classification model validated GEM in three independent human data sets (n=115).

RESULTS

This GEM of 93 genes substantially improved diagnosis of IR compared with routine clinical measures across multiple independent data sets. Individuals misclassified by GEM possessed other metabolic features raising the possibility that they represent a separate metabolic subclass. The GEM was enriched in pathways previously implicated in insulin action and revealed novel associations between β-catenin and Jak1 and IR. Functional analyses using small molecule inhibitors showed an important role for these proteins in insulin action.

CONCLUSIONS

This study shows that systems approaches for identifying molecular signatures provides a powerful way to stratify individuals into discrete metabolic groups. Moreover, we speculate that the β-catenin pathway may represent a novel biomarker for IR in humans that warrant future investigation.

Legal foundations of adaptive licensing

In April 2012, MIT's Center for Biomedical Innovation and the European Medicines Agency (EMA) cosponsored a workshop on legal foundations of adaptive pharmaceuticals licensing. Past and present attorneys from the US Food and Drug Administration (FDA), the EMA, and Health Sciences Agency Singapore (HSA) found that existing statutes provided authority for adaptive licensing (AL). By contrast, an attorney from Health Canada identified gaps in authority. Reimbursement during initial phases of adaptive approaches to licensing was deemed consistent with existing statutes in all jurisdictions.

Adiposity and insulin resistance in humans: the role of the different tissue and cellular lipid depots

Human adiposity has long been associated with insulin resistance and increased cardiovascular risk, and abdominal adiposity is considered particularly adverse. Intra-abdominal fat is associated with insulin resistance, possibly mediated by greater lipolytic activity, lower adiponectin levels, resistance to leptin, and increased inflammatory cytokines, although the latter contribution is less clear. Liver lipid is also closely associated with, and likely to be an important contributor to, insulin resistance, but it may also be in part the consequence of the lipogenic pathway of insulin action being up-regulated by hyperinsulinemia and unimpaired signaling. Again, intramyocellular triglyceride is associated with muscle insulin resistance, but anomalies include higher intramyocellular triglyceride in insulin-sensitive athletes and women (vs men). Such issues could be explained if the "culprits" were active lipid moieties such as diacylglycerol and ceramide species, dependent more on lipid metabolism and partitioning than triglyceride amount. Subcutaneous fat, especially gluteofemoral, appears metabolically protective, illustrated by insulin resistance and dyslipidemia in patients with lipodystrophy. However, some studies suggest that deep sc abdominal fat may have adverse properties. Pericardial and perivascular fat relate to atheromatous disease, but not clearly to insulin resistance. There has been recent interest in recognizable brown adipose tissue in adult humans and its possible augmentation by a hormone, irisin, from exercising muscle. Brown adipose tissue is metabolically active, oxidizes fatty acids, and generates heat but, because of its small and variable quantities, its metabolic importance in humans under usual living conditions is still unclear. Further understanding of specific roles of different lipid depots may help new approaches to control obesity and its metabolic sequelae.

Staff in Australian nursing homes: their qualifications, experience and attitudes

This paper is based upon findings from a study carried out by the Institute of Nursing Research between 1989 and 1990. The major objective of the study was to determine the impact of staffing mix on nursing home residents' quality of care and life as measured against the standards set out in 'Living in a Nursing Home'. An additional objective was to identify if there are any factors which may constrain or influence optimality. 'Skills mix' is sometimes used to describe the ratio of different levels of staff in terms of qualifications. The literature suggests, however, that such factors are only one dimension of skills mix in terms of the skills which people bring into their work in nursing homes. Other factors include the numbers of staff; the mix of staff in terms of level of qualification; the life experience of staff; and the educational experience of staff. This paper examines the findings of the study in the light of staff characteristics based on the criteria identified.

Quality of care in nursing homes: from the resident's perspective

This paper derives from a study conducted by the Deakin Institute of Nursing Research between 1988 and 1990, whose major objective was to determine the impact of staffing mix on nursing resident's quality of care and life. Resident satisfaction with life in the nursing home is a key element in determining the quality of care and quality of life provided. Both the literature review and the study objectives supported the view that resident outcome can be collected through assessing the quality of care and the quality of life, through assessment by informed observers using instruments derived from explicitly stated standards, and through eliciting the perceptions of residents themselves. A schedule designed to measure satisfaction with care was developed and resident interviews were undertaken using this measure and the Life Satisfaction Index (A). The majority of responses to the resident satisfaction schedule were positive. The high percentage of positive responses did not correlate with the observations of the research assistants and there was some concern that while residents were able to assess care they were reluctant to criticize the staff or their behaviour.

Skills mix in Australian nursing homes

This study investigated the relationships between skills mix, resident dependency and the quality of care and life of residents in a stratified random sample of 200 non-government homes in four Australian states. The study considered various measures of skills mix including the qualifications of the staff (staffing mix), the exposure of staff to in-service training and the leadership style of the director of nursing. The only relationships found between staffing mix (that is, the proportion of qualified and unqualified staff) related to the positive effect of therapy staff on the variety of experience of residents. Significant relationships between a number of other components of skills mix and the outcomes of care were found. Specifically, exposure to in-service training of staff and the leadership style of the director of nursing affected quality of care. State enrolled nurses were found to be significantly less satisfied with their work than registered nurses or untrained nurse assistants. Further studies are suggested in these areas and a review of skills mix in relation to them is recommended.

Management and leadership in Australian nursing homes

This paper is based on the outcomes of a study undertaken by Deakin Institute of Nursing Research for the Department of Community Services and Health between 1988 and 1990 (1). The study, which looked at the relationship between skills mix and resident outcomes, involved gathering data from 200 nursing homes in four Australian states using questionnaires and a case study approach. One of the major findings related to the importance of the management and leadership style on the outcome of quality of care and life within the nursing home. The pivotal role of the senior nurse (ie the director of nursing or charge nurse) in affecting high quality is consistently reported in the literature and this was confirmed by the study. Factors drawn from the quantitative and qualitative parts of the study, which make an important contribution to the quality of care experienced by residents, included the director of nursing's attitude, commitment and interpersonal skills. Also important were the ideology of the staff, team cohesiveness and positive attitude and an overall staffing environment which adheres to an agreed philosophy and is stable, satisfied and friendly. All of these were found to be influenced by the senior nurse.