OBJECTIVE

To study the effect of exenatide on body composition and circulating cardiovascular risk biomarkers.

RESEARCH DESIGN AND METHODS

Metformin-treated patients with type 2 diabetes (N = 69) were randomized to exenatide or insulin glargine and treated for 1 year. Body composition was evaluated by dual-energy X-ray absorptiometry. Additionally, body weight, waist circumference, and cardiovascular biomarkers were measured.

RESULTS

Treatment with exenatide for 1 year significantly reduced body weight, waist circumference, and total body and trunkal fat mass by 6, 5, 11, and 13%, respectively. In addition, exenatide increased total adiponectin by 12% and reduced high-sensitivity C-reactive protein by 61%. Insulin glargine significantly reduced endothelin-1 by 7%. These changes were statistically independent of the change in total body fat mass and body weight.

CONCLUSIONS

Exenatide treatment for 1 year reduced body fat mass and improved the profile of circulating biomarkers of cardiovascular risk. No significant changes were seen with insulin glargine except a trend for reduced endothelin-1 levels.

Abdominal obesity is associated with both type 2 diabetes and metabolic complications (1), including elevations in several circulating biomarkers of cardiovascular risk (2). Most pharmacological glucose-lowering treatments increase body weight (3). Therefore, treatments that not only reduce A1C, but also improve other associated changes such as abdominal obesity are urgently needed (4).

We previously reported in Diabetes Care that exenatide improves glycemic control to the same extent as insulin glargine, although exenatide decreased and insulin glargine raised body weight (5). Herein we present additional data on associated changes in body composition and circulating levels of biomarkers of cardiovascular risk after 1 year of treatment.

Details on study design were reported previously (5). Patients were randomized to exenatide (n = 36) or insulin glargine (n = 33) added to their ongoing metformin therapy (baseline characteristics and patient disposition are shown in supplemental Fig. 1 in the online appendix available at http://care.diabetesjournals.org/cgi/content/full/dc09-2361/DC1). The study protocol was approved by each site's ethics review committee and was in accordance with the principles described in the Declaration of Helsinki. All participating patients gave their written informed consent prior to screening.

Dual-energy X-ray absorptiometry scan

Lean body and fat mass was assessed using dual-energy X-ray absorptiometry (DEXA) scans (Delphi A; Hologic, Waltham, MA) at baseline and after treatment. Trunk (abdominal) and limb (hip/leg) regions of interest were determined from a total body scan. Waist circumference was measured at the midline of the interval between the iliac crest and the lowest rib using the mean of two measurements prior to the DEXA scan.

Biochemical analyses

Cardiovascular risk biomarkers were collected at baseline and after 1 year of treatment. Serum was separated by centrifugation and stored at −80°C until analysis. All serum samples were analyzed in the Lundberg Laboratory for Diabetes Research using a single batch. Total adiponectin, high molecular weight (HMW) adiponectin, resistin, leptin, high-sensitive C-reactive protein (hs-CRP), interleukin (IL)-6, monocyte chemotactic protein (MCP)-1, and endothelin-1 were determined by commercial ELISAs (R&D Systems, Abingdon, U.K.).

Statistical analysis

Non-normally distributed data were log-transformed prior to statistical analysis, after which they approximated the normal distribution. All outcome measures are compared between the two treatment groups using an ANCOVA model including factors for treatment, investigative site, and baseline A1C stratum (≤8.5% or >8.5%), and baseline values of corresponding outcome measure as a covariate (5). Statistical analysis was performed using SPSS 16.0 for Mac OS X (SPSS, Chicago, IL). All inferential statistical tests were conducted at a significance level of 0.05 (two-sided).

Treatment for 1 year with exenatide resulted in a statistically significant reduction in total body fat mass (Table 1), mainly in the abdominal region, as illustrated by the decrease in trunk fat mass and waist circumference, in contrast to insulin glargine. Neither treatment significantly affected lean body mass.

Table 1

Body composition, circulating cardiovascular risk biomarkers and percentage change from baseline

nBaselineEndpointPercentage change from baseline
LS meanBetween-treatment group differenceP
Total fat mass (kg)       
    Insulin glargine 28 29.9 ± 1.6 28.5 ± 1.9 −1% (−7% to +5%)   
    Exenatide 29 27.8 ± 1.4 25.4 ± 1.6 −11% (−18% to −5%) −10% (−16% to −4%) 0.003 
Total lean mass (kg)       
    Insulin glargine 28 60.1 ± 1.7 60.6 ± 1.8 0% (−1% to +2%)   
    Exenatide 29 57.8 ± 2.1 58.1 ± 2.4 0% (−2% to +1%) −1% (−3% to +1%) 0.480 
Trunk fat mass (kg)       
    Insulin glargine 28 17.8 ± 0.9 16.6 ± 1.1 −1% (−8% to +5%)   
    Exenatide 29 16.3 ± 0.8 14.8 ± 1.0 −13% (−18 to −7%) −11% (−18% to −4%) 0.002 
Body weight (kg)       
    Insulin glargine 29 94.1 ± 2.5 93.8 ± 2.7 −1% (−3% to +1%)   
    Exenatide 30 90.3 ± 2.4 86.4 ± 2.6 −6% (−8% to −3%) −5% (−7% to −2%) 0.001 
Waist circumference (cm)       
    Insulin glargine 29 106.9 ± 1.9 107.4 ± 2.0 +1% (−1% to +3%)   
    Exenatide 30 106.1 ± 1.9 100.6 ± 2.1 −5% (−7% to −3%) −6% (−8% to −4%) <0.001 
Leptin (μg/l)       
    Insulin glargine 29 7.79 ± 1.29 8.41 ± 1.53 +7% (−11% to +29%)   
    Exenatide 30 8.50 ± 1.32 7.45 ± 1.17 −14% (−27% to +2%) −19% (−34% to −1%) 0.045 
Total adiponectin (ng/ml)       
    Insulin glargine 29 4,648 ± 461 4,508 ± 436 −5% (−13% to +5%)   
    Exenatide 30 4,848 ± 432 5,314 ± 466 +12% (+3% to +21%) +17% (+6% to +30%) 0.004 
HMW adiponectin (ng/ml)       
    Insulin glargine 29 1,277 ± 221 1,321 ± 236 −0% (−24% to +31%)   
    Exenatide 30 1,571 ± 255 1,850 ± 273 +19% (−6% to +51%) +19% (−12% to +61%) 0.253 
hs-CRP (mg/l)       
    Insulin glargine 29 1.42 ± 0.27 1.38 ± 0.35 −20% (−50% to +27%)   
    Exenatide 30 1.81 ± 0.25 1.30 ± 0.22 −61% (−74% to −42%) −52% (−71% to −19%) 0.008 
IL-6 (pg/ml)       
    Insulin glargine 29 1.96 ± 0.21 2.17 ± 0.20 −4% (−26% to +25%)   
    Exenatide 30 2.11 ± 0.22 2.10 ± 0.25 −10% (−28% to +14%) −6% (−30% to +26%) 0.670 
MCP-1 (pg/ml)       
    Insulin glargine 29 1.22 ± 0.07 1.24 ± 0.07 −1% (−12% to +11%)   
    Exenatide 30 1.18 ± 0.09 1.21 ± 0.11 −4% (−13% to +7%) −2% (−14% to +12%) 0.728 
Resistin (ng/ml)       
    Insulin glargine 29 330 ± 15 329 ± 20 −3% (−13% to +7%)   
    Exenatide 30 316 ± 14 311 ± 16 −0% (−9% to +9%) +3% (−8% to +16%) 0.577 
Endothelin-1 (ng/ml)       
    Insulin glargine 29 2.57 ± 0.18 2.46 ± 0.19 −7% (−11% to −2%)   
    Exenatide 30 2.53 ± 0.19 2.53 ± 0.19 −1% (−5% to +3%) +6% (−1% to +12%) 0.045 
nBaselineEndpointPercentage change from baseline
LS meanBetween-treatment group differenceP
Total fat mass (kg)       
    Insulin glargine 28 29.9 ± 1.6 28.5 ± 1.9 −1% (−7% to +5%)   
    Exenatide 29 27.8 ± 1.4 25.4 ± 1.6 −11% (−18% to −5%) −10% (−16% to −4%) 0.003 
Total lean mass (kg)       
    Insulin glargine 28 60.1 ± 1.7 60.6 ± 1.8 0% (−1% to +2%)   
    Exenatide 29 57.8 ± 2.1 58.1 ± 2.4 0% (−2% to +1%) −1% (−3% to +1%) 0.480 
Trunk fat mass (kg)       
    Insulin glargine 28 17.8 ± 0.9 16.6 ± 1.1 −1% (−8% to +5%)   
    Exenatide 29 16.3 ± 0.8 14.8 ± 1.0 −13% (−18 to −7%) −11% (−18% to −4%) 0.002 
Body weight (kg)       
    Insulin glargine 29 94.1 ± 2.5 93.8 ± 2.7 −1% (−3% to +1%)   
    Exenatide 30 90.3 ± 2.4 86.4 ± 2.6 −6% (−8% to −3%) −5% (−7% to −2%) 0.001 
Waist circumference (cm)       
    Insulin glargine 29 106.9 ± 1.9 107.4 ± 2.0 +1% (−1% to +3%)   
    Exenatide 30 106.1 ± 1.9 100.6 ± 2.1 −5% (−7% to −3%) −6% (−8% to −4%) <0.001 
Leptin (μg/l)       
    Insulin glargine 29 7.79 ± 1.29 8.41 ± 1.53 +7% (−11% to +29%)   
    Exenatide 30 8.50 ± 1.32 7.45 ± 1.17 −14% (−27% to +2%) −19% (−34% to −1%) 0.045 
Total adiponectin (ng/ml)       
    Insulin glargine 29 4,648 ± 461 4,508 ± 436 −5% (−13% to +5%)   
    Exenatide 30 4,848 ± 432 5,314 ± 466 +12% (+3% to +21%) +17% (+6% to +30%) 0.004 
HMW adiponectin (ng/ml)       
    Insulin glargine 29 1,277 ± 221 1,321 ± 236 −0% (−24% to +31%)   
    Exenatide 30 1,571 ± 255 1,850 ± 273 +19% (−6% to +51%) +19% (−12% to +61%) 0.253 
hs-CRP (mg/l)       
    Insulin glargine 29 1.42 ± 0.27 1.38 ± 0.35 −20% (−50% to +27%)   
    Exenatide 30 1.81 ± 0.25 1.30 ± 0.22 −61% (−74% to −42%) −52% (−71% to −19%) 0.008 
IL-6 (pg/ml)       
    Insulin glargine 29 1.96 ± 0.21 2.17 ± 0.20 −4% (−26% to +25%)   
    Exenatide 30 2.11 ± 0.22 2.10 ± 0.25 −10% (−28% to +14%) −6% (−30% to +26%) 0.670 
MCP-1 (pg/ml)       
    Insulin glargine 29 1.22 ± 0.07 1.24 ± 0.07 −1% (−12% to +11%)   
    Exenatide 30 1.18 ± 0.09 1.21 ± 0.11 −4% (−13% to +7%) −2% (−14% to +12%) 0.728 
Resistin (ng/ml)       
    Insulin glargine 29 330 ± 15 329 ± 20 −3% (−13% to +7%)   
    Exenatide 30 316 ± 14 311 ± 16 −0% (−9% to +9%) +3% (−8% to +16%) 0.577 
Endothelin-1 (ng/ml)       
    Insulin glargine 29 2.57 ± 0.18 2.46 ± 0.19 −7% (−11% to −2%)   
    Exenatide 30 2.53 ± 0.19 2.53 ± 0.19 −1% (−5% to +3%) +6% (−1% to +12%) 0.045 

Data are means ± SEM (body composition measures) or geometric means ± SEM (cardiovascular biomarkers) and body weight change–adjusted least-squares mean percentage change (95% CI) from baseline. LS, least-squares.

In univariate analysis, the reduction in body weight in the exenatide arm was significantly correlated with the changes in leptin (r = 0.580, P = 0.001) and hs-CRP (r = −0.590, P = 0.001). No statistically significant univariate correlation was found between changes in body weight and other biomarkers. Interestingly, changes in all circulating biomarkers did not correlate with the changes in total body fat mass (total adiponectin: Pearson χ2 test, r = −0.224, P = 0.106; HMW adiponectin: r = 0.057, P = 0.694; leptin: r = 0.229, P = 0.106; hs-CRP: r = −0.023, P = 0.872).

After multivariate analysis and statistical adjustment for body weight change, exenatide increased total adiponectin and decreased hs-CRP concentrations, whereas insulin glargine did not (Table 1). Insulin glargine reduced endothelin-1 concentrations, whereas exenatide did not. No statistically significant effect of either treatment on HMW adiponectin, IL-6, MCP-1, and resistin was observed.

The crude between–treatment group differences remained statistically significant after additional multivariate adjustment for total body fat mass change: total adiponectin +16% (95% CI: +5% to +28%), P = 0.004; leptin −20% (−34% to −2%), P = 0.028; hs-CRP −48% (−69% to −13%), P = 0.015; and body weight change (Table 1): total adiponectin +17% (95% CI +6% to +30%), P = 0.004; leptin −19% (−34% to 0%), P = 0.045; hs-CRP −52% (−71% to −19%), P = 0.008.

This study showed that exenatide reduced body fat mass and improved the profile of circulating cardiovascular biomarkers. The changes in the different biomarkers could not be fully attributed to the observed changes in body fat mass and body weight. Direct effects of glucagon-like peptide 1 (GLP-1) receptor agonists on adipocyte function have been described in both animal experimental studies and in vitro studies in normal human adipocytes (rev. in 6); however, as a significant univariate correlation between change in body weight (not with fat mass) and cardiovascular biomarkers was present, our relatively small population may influence the statistical power of our study.

Animal studies have also demonstrated beneficial effects of exenatide on visceral fat mass (7) and circulating adiponectin (8), leptin (9), and CRP (10) concentrations. However, to the best of our knowledge, controlled clinical studies on the long-term effects of GLP-1 receptor agonists on body composition and biomarkers of cardiovascular risk have not previously been reported.

A recent 3-month study comparing exenatide to insulin glargine in 56 patients with type 2 diabetes has a design comparable to our 1-year study. Similar to our findings, this study showed that exenatide treatment was associated with reduced hs-CRP, without affecting the IL-6 levels (11).

Subanalysis of the Liraglutide Effect and Action in Diabetes (LEAD)-3 study data reported that liraglutide treatment for 52 weeks compared with treatment with glimiperide reduced DEXA-measured total fat tissue mass (12). Lean tissue mass was also reduced after 1 year of treatment, but as glimiperide also reduced lean tissue mass, this reduction was not statistically significantly different between the groups. Twenty-six-week data from the LEAD-2 study was used to show that the observed reduction in fat mass was mainly a result of a reduction in visceral fat (12). Unfortunately, this study did not report the effects of body composition on circulating biomarkers. Serum leptin, hs-CRP, and IL-6 concentrations did not change in a 14-week placebo-controlled study with liraglutide 1.9 mg (13).

Of particular interest in our study was the finding that the changes in biomarkers of cardiovascular risk appeared to be independent of the changes in body fat mass. Recently, Chung et al. reported exendin-4 directly increased adiponectin mRNA levels and secretion in 3T3-L1 adipocytes (14). In that study, exendin-4 also decreased mRNA levels of IL-6 and MCP-1 (14). Additionally, we (15) and others (10) have previously reported beneficial effects of exenatide on hepatic steatosis, which also may contribute to a reduction in CRP.

In conclusion, we found that exenatide treatment for 1 year led to a reduced total fat mass, including visceral fat, while lean body mass was not significantly altered. Additionally, the circulating levels of adiponectin, leptin, and hs-CRP showed an improved profile that appeared to be independent of the changes in fat mass. In contrast, no significant changes in body composition or circulating biomarkers were seen with insulin glargine.

Clinical trial reg. no. NCT00097500, clinicaltrials.gov.

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

This study was sponsored by Amylin Pharmaceuticals, Inc., and Eli Lilly and Company.

M.C.B. is a speaker for Eli Lilly and Company. M.D. is a consultant and speaker for Eli Lilly and Company. Through M.D., the VU University Medical Center in Amsterdam has received research grants from Amylin Pharmaceuticals and Eli Lilly and Company. B.E. has served on the advisory board and is a speaker for Eli Lilly Sweden. R.M.S. is an employee of Eli Lilly and Company. R.J.H. is an employee and stockholder of Eli Lilly and Company. M.R.T. is a speaker for Eli Lilly and Company. H.Y.J. serves as a consultant for Amylin Pharmaceuticals. Through M.R.T. and H.Y.J. the Helsinki University Central Hospital has received research grants from Amylin Pharmaceuticals and Eli Lilly and Company. U.S. served on the advisory board and is a speaker for Amylin Pharmaceuticals, Inc. Through U.S. the Sahlgrenska University Hospital has received research grants from Amylin Pharmaceuticals and Eli Lilly and Company.

No other potential conflicts of interest relevant to this article were reported.

The study was collectively initiated and designed by the investigators from the three study sites. The investigators had full access to the trial data and had control over the statistical analysis and interpretation of the study results. M.C.B. collected and researched data, wrote the manuscript, and contributed to the discussion. M.D. researched data, contributed to the discussion, and reviewed/edited the manuscript. B.E. collected data, contributed to the discussion, and reviewed/edited the manuscript. A.C. collected data and reviewed/edited the manuscript. R.M.S. contributed to discussion and reviewed/edited the manuscript. R.J.H. researched data, contributed to the discussion, and reviewed/edited the manuscript. M.R.T. contributed to the discussion and reviewed/edited the manuscript. H.Y.J. contributed to the discussion and reviewed/edited the manuscript. U.S. researched data, contributed to the discussion, and reviewed/edited the manuscript.

Parts of this study were presented in abstract form at the 69th Scientific Sessions of the American Diabetes Association, New Orleans, Louisiana, 5–9 June 2009.

The authors thank the subjects for participating in the study.

1.
Jensen
MD
.
Role of body fat distribution and the metabolic complications of obesity
.
J Clin Endocrinol Metab
2008
;
93
:
S57
63
2.
Diamant
M
,
Lamb
HJ
,
van de Ree
MA
,
Endert
EL
,
Groeneveld
Y
,
Bots
ML
,
Kostense
PJ
,
Radder
JK
.
The association between abdominal visceral fat and carotid stiffness is mediated by circulating inflammatory markers in uncomplicated type 2 diabetes
.
J Clin Endocrinol Metab
2005
;
90
:
1495
1501
3.
Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group
.
Lancet
1998
;
352
:
837
853
4.
Defronzo
RA
.
Banting Lecture. From the triumvirate to the ominous octet: a new paradigm for the treatment of type 2 diabetes mellitus
.
Diabetes
2009
;
58
:
773
795
5.
Bunck
MC
,
Diamant
M
,
Cornér
A
,
Eliasson
B
,
Malloy
JL
,
Shaginian
RM
,
Deng
W
,
Kendall
DM
,
Taskinen
MR
,
Smith
U
,
Yki-Järvinen
H
,
Heine
RJ
.
One-year treatment with exenatide improves beta-cell function, compared with insulin glargine, in metformin-treated type 2 diabetic patients: a randomized, controlled trial
.
Diabetes Care
2009
;
32
:
762
768
6.
Kim
W
,
Egan
JM
.
The role of incretins in glucose homeostasis and diabetes treatment
.
Pharmacol Rev
2008
;
60
:
470
512
7.
Szayna
M
,
Doyle
ME
,
Betkey
JA
,
Holloway
HW
,
Spencer
RG
,
Greig
NH
,
Egan
JM
.
Exendin-4 decelerates food intake, weight gain, and fat deposition in Zucker rats
.
Endocrinology
2000
;
141
:
1936
1941
8.
Li
L
,
Yang
G
,
Li
Q
,
Tan
X
,
Liu
H
,
Tang
Y
,
Boden
G
.
Exenatide prevents fat-induced insulin resistance and raises adiponectin expression and plasma levels
.
Diabetes Obes Metab
2008
;
10
:
921
930
9.
Pérez-Tilve
D
,
González-Matías
L
,
Alvarez-Crespo
M
,
Leiras
R
,
Tovar
S
,
Diéguez
C
,
Mallo
F
.
Exendin-4 potently decreases ghrelin levels in fasting rats
.
Diabetes
2007
;
56
:
143
151
10.
Ding
X
,
Saxena
NK
,
Lin
S
,
Gupta
NA
,
Gupta
N
,
Anania
FA
.
Exendin-4, a glucagon-like protein-1 (GLP-1) receptor agonist, reverses hepatic steatosis in ob/ob mice
.
Hepatology
2006
;
43
:
173
181
11.
Horton
ES
,
Cohen
A
,
Gibson
H
,
Lamparello
B
,
Herzlinger
S
,
McFarland
L
.
Effects of exenatide vs insulin glargine on cardiovascular risk factors in subjects with type 2 diabetes
.
Diabetologia
2009
;
52
:
S298
S299
12.
Jendle
J
,
Nauck
MA
,
Matthews
DR
,
Frid
A
,
Hermansen
K
,
Düring
M
,
Zdravkovic
M
,
Strauss
BJ
,
Garber
AJ
:
LEAD-2 and LEAD-3 Study Groups
.
Weight loss with liraglutide, a once-daily human glucagon-like peptide-1 analogue for type 2 diabetes treatment as monotherapy or added to metformin, is primarily as a result of a reduction in fat tissue
.
Diabetes Obes Metab
2009
;
11
:
1163
1172
13.
Courrèges
JP
,
Vilsbøll
T
,
Zdravkovic
M
,
Le-Thi
T
,
Krarup
T
,
Schmitz
O
,
Verhoeven
R
,
Bugáñová
I
,
Madsbad
S
.
Beneficial effects of once-daily liraglutide, a human glucagon-like peptide-1 analogue, on cardiovascular risk biomarkers in patients with Type 2 diabetes
.
Diabet Med
2008
;
25
:
1129
1131
14.
Kim Chung le
T
,
Hosaka
T
,
Yoshida
M
,
Harada
N
,
Sakaue
H
,
Sakai
T
,
Nakaya
Y
.
Exendin-4, a GLP-1 receptor agonist, directly induces adiponectin expression through protein kinase A pathway and prevents inflammatory adipokine expression
.
Biochem Biophys Res Commun
2009
;
390
:
613
618
15.
Tushuizen
ME
,
Bunck
MC
,
Pouwels
PJ
,
van Waesberghe
JH
,
Diamant
M
,
Heine
RJ
.
Incretin mimetics as a novel therapeutic option for hepatic steatosis
.
Liver Int
2006
;
26
:
1015
1017

Supplementary data