New research reveals that patients who eat in response to food cues lose more weight on GLP-1 therapy, pointing to external eating behavior as a powerful predictor of treatment success.
Study: Association between eating behavior patterns and the therapeutic efficacy of GLP-1 receptor agonists in individuals with type 2 diabetes: a multicenter prospective observational study. Image credit: Ekaterina Markelova/Shutterstock.com
A new study published in Frontiers in Clinical Diabetes and Healthcare reports that changes in external eating behavior may influence the glucose-lowering and body weight management efficacy of glucagon-like peptide-1 receptor agonists in type 2 diabetic patients.
Background
In the current study, researchers aimed to understand the relationship between eating behaviors and the therapeutic efficacy of GLP-1RAs in patients with type 2 diabetes.
Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are widely used medications for type 2 diabetes and obesity. These medications have shown high effectiveness in reducing blood glucose levels and triggering clinically meaningful weight loss.
Despite well-established therapeutic efficacy, the glucose- and body weight-lowering effects of GLP-1RAs exhibit substantial interindividual variability. Emerging evidence suggests that individuals' eating behaviors may influence their response to GLP-1RA therapy.
Eating behavior is significantly associated with managing type 2 diabetes and obesity. Various psychosocial, behavioral, and environmental factors are potential determinants of eating behavior. Certain eating behaviors, including external eating, emotional eating, and restrained eating, have been linked to overeating and weight gain.
External eating behavior refers to food intake triggered by external stimuli, such as the sight or smell of food. In contrast, emotional eating behavior is defined as food intake triggered by negative emotions, such as anxiety and depression. These two eating behaviors are associated with excessive intake of high-calorie foods and weight gain.
On the other hand, restrained eating behavior is defined as the conscious restriction of food intake to control body weight. Restrained eating is often linked to better weight control, but when done in excess or poorly managed, it can trigger overeating. In this study, restrained eating showed no significant connection to long-term outcomes.
Study design
The study included a total of 92 diabetic patients who were receiving GLP-1RA therapy from four institutions in Japan.
The participants were assessed for changes in clinical parameters, including fasting blood glucose and glycated hemoglobin, body weight, body fat percentage, and eating behaviors over 12 months. Specifically, the assessments were conducted at baseline (initiation of GLP-1RA therapy) and at 3 months and 12 months post-therapy initiation.
Key findings
The trial showed that the 12-month GLP-1RA therapy significantly improved glycated hemoglobin (a measure of glycemic control), body weight, and body fat percentage in diabetic patients. At the same time, skeletal muscle mass was preserved despite weight loss. The therapy also led to significant reductions in liver enzymes and total cholesterol, with HDL cholesterol increasing and triglycerides showing a non-significant improving trend, rather than uniformly improving the whole lipid profile.
The analysis of dietary intake revealed significant reductions in total calorie and macronutrient intake following GLP-1RA therapy. External eating behavior scores persistently improved at 3- and 12-months post-treatment.
Emotional eating behavior showed a significant initial reduction at month 3, which returned to the baseline pattern by 12 months. In contrast, restrained eating behavior showed a transient increase at month 3, which returned to the baseline pattern by 12 months.
Among the three eating behaviors analyzed, a higher baseline external eating behavior score was associated with greater body weight reduction at month 12, and a tendency towards improved glycemic outcomes.
Notably, there was some variability between different GLP-1RAs: dulaglutide, oral semaglutide, and injectable semaglutide all significantly reduced both HbA1c and body weight, while liraglutide improved HbA1c but did not lead to significant weight reduction, likely due to the smaller number of participants receiving this drug.
Study significance
The study findings demonstrate that GLP-1RAs can significantly improve glycemic control and reduce body weight and body fat percentage in diabetic patients after 12 months of treatment in real clinical settings. Besides metabolic improvements, GLP-1RA therapy can substantially reduce external eating behavior, which is a key psychological factor linked to overeating and obesity.
The association between external eating behavior and clinical outcomes observed in the study suggests that external eating behavior scores may serve as a useful behavioral predictor of GLP-1RA therapeutic efficacy and help guide personalized therapeutic strategies in clinical practice. The observed reduction in external eating behavior scores suggests that GLP-1RAs may help suppress overeating triggered by external stimuli, such as the appearance, aroma, or food availability.
Existing evidence demonstrates hyperactivation of reward-related brain regions in obese individuals in response to visual food stimuli. GLP-1RAs have been found to suppress this hyperactivation, which could help to explain the observed reduction in external eating behavior following GLP-1RA therapy. Furthermore, previous studies have shown that individuals with high emotional eating behavior exhibit less suppression of neural responses to food stimuli during GLP-1RA therapy, which can potentially reduce their treatment responsiveness. This may help explain the lack of association observed between emotional eating behavior and long-term clinical outcomes.
It is indicated that participants with higher baseline external eating scores experienced a significantly greater reduction in body weight but only a tendency towards improved glycemic control following GLP-1RA therapy. Mechanistic evidence indicates that GLP-1RAs reduce blood glucose levels by increasing insulin secretion and decreasing glucagon secretion. Since these pathways are unaffected by eating behaviors, only a tendency towards improved glycemic control has been observed among participants with higher baseline external eating behavior.
Because of the observational study design, the study could not determine the causality of observed associations. Furthermore, the study analysis did not consider lifestyle factors, psychological conditions, or socioeconomic status as potential confounding factors, which may influence the findings.
The study analyzed self-reported data on eating behaviors, which may introduce recall bias or social desirability bias. The study population mainly included highly motivated individuals who were more inclined to engage in lifestyle modifications and adhere to treatment, which may restrict the generalizability of the findings to a broad range of diabetic populations.
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