Young Adults With Early-onset Obesity Treated With Semaglutide (RESETTLE)

Introduction: The increasing prevalence of obesity is particularly pronounced among adolescents. Currently available treatment options consist of structured lifestyle interventions. However, 25 % of adolescents do not respond to lifestyle treatment, why new effective treatment strategies are needed. Therefore, the aim of this study is to investigate the effect of lifestyle interventions combined with the GLP-1 receptor agonist semaglutide to young adults with otherwise treatment resistant obesity. Methods and analysis: This is an investigator-initiated, randomized, placebo-controlled trial. 130-170 young adults (age 18-28) will be recruited from The Children's Obesity Clinic (TCOC), Department of Pediatrics, Holbæk Hospital. Based on their previous response to the TCOC protocol the participants will be divided in three groups: Group A: Non-responders: 55-75 young adults (BMI>30 kg/m2) who have not succeeded in losing weight during the structured lifestyle intervention (BMI SDS reduction <0.1) Group B: Insufficient responders: 55-75 young adults (BMI>30 kg/m2) who have succeeded in losing weight during the structured lifestyle intervention (BMI SDS reduction >0.25), but still have obesity. Group C: Excellent responders: 20 young adults, who have succeeded in losing weight during the structured lifestyle intervention (BMI SDS reduction >0.5) and no longer have obesity (BMI<30 kg/m2). Group A and B are randomized 2:1 to either semaglutide or placebo for 68 weeks. Group C will attend baseline examinations only and not undergo intervention. The primary endpoint is change in BMI from randomization to end-of-treatment. Ethics and dissemination: The trial has been approved by the Danish Medicines Agency (EudraCT 2019-002274-31) and by the ethical committee of the Capital Region of Denmark (H-20039422). The trial will be conducted in agreement with the Declaration of Helsinki and monitored to follow the guidelines for good clinical practice. Results will be submitted for publication in international peer-reviewed scientific journals.

Background: The prevalence of obesity in adolescents has increased markedly in the past decades, thus entailing increased cumulative incidences of type 2 diabetes, cardiovascular disease, and chronic kidney disease (1). Adolescents with obesity are at a substantially elevated risk of developing morbid obesity and type 2 diabetes in early adulthood (2,3) and a recent large scale meta-analysis revealed that mortality increased approximately log-linearly with BMI over 25.0 kg/m² in all continents; and that this increment was greater in younger than older people (4). Furthermore, obesity increase the risk of stigmatization with respect to social relationships, entry into the job market, reduced self-esteem and other psychological problems (5). Thus, adolescents with obesity require particular medical attention. Since 2008, The Children's Obesity Clinic (TCOC), Department of Pediatrics, Copenhagen University Hospital Holbæk has treated more than 4000 children and adolescents with overweight or obesity using the TCOC protocol which includes regular counselling on diet, exercise, lifestyle and general health. The TCOC protocol has proven successful with a reduction in BMI standard deviation score (SDS) after 1.5 years of treatment obtained in 74% of the children and adolescents (6). In addition, significant improvements in lipid profile (7) the degree of hypertension (8), hepatic steatosis (9) and the presence of visceral fat (9) have been reported. However, approximately one in four of the children following the TCOC protocol do not achieve a reduction in BMI SDS. Furthermore, for the majority of children who reduce BMI SDS, obesity remains and represents a medical and personal issue. Lifestyle intervention is the method of choice for children with obesity, however, new effective treatment strategies for non-responders are urgently required. Glucagon-like peptide-1 (GLP-1) is secreted from endocrine cells in the intestine upon meal intake and reduces blood glucose and food intake in a dose-dependent manner (10-13). It has previously been shown that 1) people with obesity have impaired GLP-1 secretion already in the overweight state, indicating that low concentrations of GLP-1 may be part of obesity development (14), 2) weight loss induces a marked increase in GLP-1 response and this increase is part of a successfully maintained weight loss of >10 kg (15), 3) treatment with a GLP-1 receptor agonist (GLP-1 RA) facilitates long term weight loss maintenance (13 kg) accompanied by substantial improvement in metabolic health, compared to similar diet-induced weight loss maintenance (15-17),4) appetite sensation and eating behavior are important factors in maintenance of weight loss (18,19). Pathogenic mutations in the appetite-regulating melanocortin-4 receptor represent the most common cause of early-onset monogenic obesity that has been shown to be a type of obesity that is more resistant to lifestyle interventions (20) and even to bariatric surgery (21). Interestingly, this population is responsive to treatment with GLP-1 RA (liraglutide 3.0 mg daily) (22). This indicates that GLP-1 RA's can overrule lifestyle modification-resistant obesity due to the appetite-inhibiting effect. A new GLP1-1 RA (semaglutide) was approved by the European Medical Agency (EMA) for weight management in adults with obesity in January 2022. Placebo subtracted weight loss with semaglutide 2.4 mg was 13.9 % compared to 4.5% with liraglutide 3.0 mg after 68 weeks in adults with overweight or obesity (23). Thus, semaglutide has a potentially larger treatment effect also in young adults with childhood onset obesity. The treatment effect of semaglutide 2.4 mg in young adults with lifestyle-treatment-resistant childhood onset obesity is currently unknown, why the outcomes of this study is of high clinical and socioeconomic relevance. Study hypothesis: Treatment with a GLP-1 RA will facilitate weight loss in young adults with and without treatment-resistant childhood-onset obesity. Objectives: A) To treat young adults with obesity, who have been resistant to structured lifestyle intervention (TCOC protocol), with the GLP-1 RA, semaglutide 2.4 mg/ week. B) To treat young adults with obesity, who have responded with insufficient weight loss to the structured lifestyle intervention (TCOC protocol) and remain obese, with semaglutide 2.4 mg/ week. C) To identify underlying mechanisms of lifestyle-untreatable versus treatable childhood-onset obesity. Endpoints: Primary endpoint: 1. Change in BMI (weight in kg/height in m^2) from before to after semaglutide treatment in non-responders to TCOC protocol compared to placebo. Secondary endpoints: Change in body composition and body weight from before to after semaglutide treatment in non-responders to TCOC protocol compared to placebo Change in BMI (weight in kg/height in m^2), body composition and body weight from before to after semaglutide treatment in insufficient responders to TCOC protocol compared to placebo Compare BMI (weight in kg/height in m^2), body composition and body weight between excellent responders, non-responders and insufficient responders. Other prespecified endpoints: To determine the effect of GLP-1 RA treatment, and compare baseline data between the two intervention groups to excellent responders for the following outcomes: Circulating biomarkers of metabolic regulation to evaluate metabolic health (e.g. glucose and insulin for HOMA-IR and Matsuda index, HbA1c, lipids i.e. cholesterol, HDL, LDL, triglycerides, FFA and determination of glucose-tolerance status) will be measured. Furthermore, the investigator will measure blood pressure, pulse, and hip and waist circumference. Conventional Magnetic resonance imaging (MRI) and spectroscopy is used to assess effects on fat deposits in liver, viscera, and muscle. Site-specific bone- measurements, collection of bone markers (CTX and P1NP), and DEXA scans will be performed to assess bone-health. To explore the effects on appetite regulation and systemic markers of immuno- metabolism: Hormonal appetite regulation will be measured during meal tests and fasting (eg. GLP-1, Peptide YY, Glucagon, Leptin, Ghrelin, Liver-Expressed Antimicrobial Peptide 2 (LEAP2), Adiponectin) using our standard methodologies. In plasma samples various biomarkers of inflammation will be measured (eg sCD163, hsCRP, IL-1, IL- 1Rap IL-6, TNF-α, SAA1, SAA2, ORM1, ORM2) and oxidation (eg malonyldialdehyde, F2-Isoprostanes, etc.), IPS and metabolomics using plasma metabolomics and proteomics technique. To explore the effects on immuno-metabolic profile in human subcutaneous (sc) adipose tissue and gene expression profile of adipose tissue and in circulating inflammatory cells (PBMNCs). To explore the effect on food preferences and appetite sensation: Food preferences are assessed by a picture display test where standardized pictures of food items are shown Furthermore, the investigator will use eye tracking as well as galvanic skin response to record the participants' emotional response to the standardized food items using iMotion Software. Subjective appetite sensations will be obtained during a fixed standardized meal using electronic visual analogue scales (VAS) to record hunger, satiety, fullness, prospective food consumption, desire to eat something fatty, salty, sweet or savory, and palatability of the meals. To explore the effect on brain activation using magnetic resonance (MR) imaging: MR imaging of the brain will be conducted in a subset of participants by trained personnel at a registered clinical facility. An MRI scanner is composed of a long tube surrounded by a coil that forms a powerful magnetic field. Participants will be placed on an examination table in the centre of the tube in a supine position. By changing gradients in the magnetic field and transmitting radio waves, resonance of the atomic nuclei of the brain can be induced. During the scan the investigator will acquire both structural and functional information about the brain. The structural MRI sequences will provide a high-resolution anatomical image of the brain. A functional MRI (fMRI) scan provides the opportunity to track changes in e.g., blood oxygenation, which serve as an index for neural activation in different parts of the brain while the participants are at rest. This protocol includes morphological neuroimaging and resting-state fMRI. The MRI scanning session will last approximately one hour. To explore the genetic risk scores correlated to treatment response: All participants are chip genotyped to define polygenic risk scores. DNA material will be extracted from blood samples. The Infinium Global Screening Array will be used to analyze the array with Illumina Genome Studio before the bioinformatic removal of SNPs containing genes mentioned in the "American College Medical Genetics and Genomics" List. To explore the effect on the microbiota: The microbiome will be measured in fecal and saliva samples of participants. Furthermore, fecal and saliva samples were collected from the same individuals when they were children with obesity, allowing for comparison of potential differences already evident in childhood that may indicate later treatment response to lifestyle change and GLP-1RA treatment. To explore the effect on metabolomics in urine: Urine samples are collected at the two test days and will be stored frozen for later analyses for potential changes in the metabolomic profile.

Three groups will be identified based on their previous response to structured lifestyle interventions. Non-responders (group A) and insufficient responders (group B) are randomized 2:1 to either Semaglutide 2.4 mg/ week sc or placebo for 68 weeks. Group C (excellent responders) will attend baseline examinations only and not undergo intervention.

The above-mentioned are masked in terms of semaglutide/placebo. Statistical analysis of primary outcome will be blinded to the assessor.

Semaglutide: 2.4 mg/week SC, concentration: 3.0 mg/ml) in combination with TCOC treatment (i.e. diet/weight consultations).

Semaglutide: 2.4 mg/week SC, concentration: 3.0 mg/ml) in combination with TCOC treatment (i.e. diet/weight consultations).

The TCOC protocol is a chronic care, family-based and multidisciplinary childhood obesity treatment program involving behavior-changing techniques, based on current guidelines for best-practice and authoritative recommendations involving a multidisciplinary tertiary team of health care professionals.

Participants will be instructed to initiate at 0.24 mg SC once weekly for 4 weeks, and in 4 week intervals, increase the dose until a dose of 2.4 mg is reached. In case of prolonged side effects the dose may be adjusted to lower than 2.4mg/week.

Weight will be measured to the nearest 0.1 kg. The same set of scales should ideally be used throughout the trial. Weight should be measured in a fasting state without shoes and wearing light indoor clothes. Height will be measured to the nearest 0.1 cm.

Change in body composition (fat mass and fat free mass) and body weight from before to after semaglutide treatment in non-responders to TCOC protocol compared to placebo

Body composition: Dual-energy X-ray absorptiometry scans will be performed in fasting state to measure body fat percentage (%).

Change in BMI (weight in kg/height in m^2), body composition (fat mass and fat free mass) and body weight from before to after semaglutide treatment in insufficient responders to TCOC protocol compared to placebo.

Dual-energy X-ray absorptiometry scans will be performed in fasting state to measure fat mass and lean mass (kg)

Compare BMI (weight in kg/height in m^2), body composition (fat mass and fat free mass) and body weight between excellent responders, non-responders and insufficient responders.

Dual-energy X-ray absorptiometry scans will be performed in fasting state to measure fat mass and lean mass (kg)

Waist circumference, the midpoint between lowest rib and iliac crest, and hip circumference, the level of the great trochanters, will be measured in duplicate to the nearest 0.1 cm after gentle expiration.

Blood pressure (systolic/diastolic) will be measured in duplicate from the non-dominant arm with a digital blood pressure monitor in sitting position after at least 5 min of rest (mmHg).

Pro-inflammatory (e.g. IL-6, IL1b, MCP-1, resistin, leptin, chemerin, etc.) and anti-inflammatory (e.g. adiponectin) adipocytokines.

From blood samples, DNA material will be extracted and analyzed using the Infinium Global Screening Array and Illumina Genome Studio

Inclusion Criteria: Age 18-28 years The period from the initial treatment with TCOC protocol until inclusion in the study must be within 10 years. Group A: BMI>30. Non-responders: No BMI SDS reduction (<0.1 BMI SDS) during TCOC protocol for more than one year and still have obesity (BMI>30). Group B: BMI>30. Insufficient responders: BMI SDS reduction >0.25 BMI SDS during TCOC protocol for more than one year, but still have obesity (BMI>30). Only baseline examination: Group C: BMI<30. Excellent responders: BMI SDS reduction >0.5 BMI SDS during TCOC protocol for more than one year and no longer have obesity (BMI<30). Exclusion Criteria: Participants diagnosed with known serious chronic illness including type 1 or 2 diabetes (or a randomly measured fasting plasma glucose > 7 mmol/l) Angina pectoris, coronary heart disease, congestive heart failure (NYHA III-IV) Severe renal impairment (creatinine clearance (GFR) <30 mL/min) Severe hepatic impairment Inflammatory bowel disease Diabetic gastroparesis Cancer Chronic obstructive lung disease Psychiatric disease, a history of major depressive or other severe psychiatric disorders Use of medications causing clinically significant weight gain or loss Previous bariatric surgery A history of idiopathic acute pancreatitis A family or personal history of multiple endocrine neoplasia type 2 or familial medullary thyroid carcinoma Pregnancy, expecting pregnancy or breastfeeding. If a study participant is in doubt whether she could be pregnant, a urine pregnancy test is performed. Women with reproductive potential who are not using adequate contraceptive methods (combined oral contraceptive pill, progestin-only contraceptive pill, condoms, intrauterine device, injection, implant, or sterilization). Adequate contraception must be used throughout the study period and at least 2 months after discontinuation of trial medication (semaglutide will be present in the circulation for 5-7 weeks after the last dose). Allergy to any of the ingredients/excipients of the study medication: Semaglutide, disodium phosphate dihydrate, propylene glycol, phenol, hydrochloric acid, sodium hydroxide.

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