Stephen Atkin and Eric Kilpatrick argue that the complexity of care is seldom covered in commercial testing, so managing the longer term risks of testosterone therapy will likely fall to the NHS.

In 2024, the UK testosterone replacement market was valued at around $205 million and is projected to reach $365 million by 2032. NHS figures show community dispensing increased by 52% from 2020/21 to 2024/25 alongside a ten-fold rise in testosterone gel prescriptions for women aged 50 and older in England between 2015 and 2022.

Private prescriptions are not recorded nationally, so the scale of private testosterone provision is unknown, explain the authors. However, several indicators suggest rapid growth: a proliferation of private and online clinics, subscription pricing of £100-375 a month (to cover ongoing monitoring, remote consultations, and home-delivered medication), and heavy marketing via social media, influencers and outdoor advertising.
The market is potentially large, they add. Declining testosterone and libido are natural aspects of ageing, and up to a fifth of men over 50 may report deficiency symptoms, although under 1% receive treatment in the NHS.

Diagnosis takes time and repeated testing. It is not established how consistently private providers do this, but they warn that rapid access subscription models built around marketing non-specific symptoms “are unsuitable to handle the complexity of the diagnostic process and risk unnecessary lifelong treatment and a resulting NHS monitoring burden.” For testosterone therapy in men, clinicians rely on professional society guidance with differing thresholds, they write, meaning NHS clinicians may see patients who have already started taking testosterone against a more permissive private threshold. They point to the longer term risks of testosterone therapy, such as heart and kidney problems that need ongoing monitoring which they say will likely fall to the NHS. There are also concerns about private off-label testosterone prescribing for women, mainly for low libido associated with menopause. As stated in official guidance, the responsibility of care rests exclusively with any private sector clinician who initiates treatment unless an NHS GP formally agrees to shared care, they explain. In practice, however, patients who started treatment privately may return to their GP informally for tests or managing side effects, leading to the NHS absorbing the workload without any formal agreement. The authors stress that testosterone replacement remains a valuable treatment for carefully selected patients, but say national data are needed to close the evidence gap on private prescribing of testosterone.

“A reporting framework for private prescribers and dispensing pharmacies could capture indications, patient numbers, monitoring, and transfers of care,” they write. “This would lead to transparent prescribing and demonstrable adherence to evidence based care, protecting patients while preserving access to effective treatment.”

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The study, published Oct. 1 in JAMA, is among the first to document a surge in new prescriptions for the popular diabetes and weight-loss medications, such as Ozempic and Zepbound, among postpartum women in the United States. It is the first to identify which clinical groups — women with diabetes, gestational diabetes, obesity, or no documented diagnosis — are driving this growth.

Researchers examined private insurance claims data for just over 1 million births during a seven-year period. The share of new mothers starting a GLP-1 prescription within six months of giving birth increased from .08% in the first half of 2018 to 1.9% by the first quarter of 2025—a 24-fold increase.

Women with type 2 diabetes had the highest rate of prescriptions. Among this group, the share starting a GLP-1 prescription increased from 2.3% to 16.9% (or about 1 in 6) over the same period.

The share of those with gestational diabetes who started a GLP-1 prescription also rose substantially, from 0.4% in mid-2021 to 2.7% in first quarter of 2025. Gestational diabetes, which develops during pregnancy among women who previously did not have diabetes, affects about 5% to 9% of pregnancies and greatly increases the risk of developing type 2 diabetes.

Prescribing increased fastest in relative terms among those diagnosed as obese or overweight before pregnancy, from 0.4% in the second half of 2021 to 3.9% in the first quarter of 2025.

More recently, women with diagnosed obesity or overweight have represented a greater share of postpartum GLP-1 users. Since the second half of 2024, this group accounted for 40% of new prescriptions among postpartum women, followed by 21% who lacked a documented qualifying diagnosis before giving birth. Most who did not have a pre-pregnancy diagnosis did receive one—usually obesity or overweight—before starting a GLP-1.

Patients are advised to stop using GLP-1s during pregnancy, and most postpartum women who started a GLP-1 did so at least three months after giving birth.

“Postpartum is a critical window for addressing metabolic risk after pregnancy, and we’re seeing GLP-1 use explode in this population. Because evidence on GLP-1 exposure during breastfeeding remains limited, rising postpartum initiation warrants further study,” said lead author and Schaeffer scholar Sih-Ting Cai.

Despite differences in healthcare systems, the overall prescription start rate among new U.S. mothers was similar to the rate among postpartum women in Denmark, as reported in in a JAMA study last year. The new study does not include mothers enrolled in Medicaid, which covers about 40% of U.S. births.

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The National Institutes of Health and American Heart Association-supported study, described July 27 in the journal Obesity, represents the latest findings from ongoing research led by Daisy Duan, M.D., an assistant professor of medicine and the study’s primary author, on how time-restricted eating without caloric restriction may change the body’s weight and other functions.

Other studies on time-restricted eating, Duan says, examined it with respect to either intentional or unintentional calorie restriction. The new study, she said, focused on whether restricted meal timing while ensuring consistent calorie intake would change other obesity-related factors, such as eating behavior, inflammation, and appetite hormones.

More than 100 million adults with obesity and 115 million adults with prediabetes in the United States are at an increased risk of cardiometabolic complications, such as high blood pressure, heart attack and stroke, and these numbers are expected to rise. Intermittent fasting — an umbrella term for structured patterns of fasting and eating that focus on changing when a person eats instead of reducing calories or avoiding certain foods — has broadly been linked to weight loss and may benefit individuals with either or both conditions.

Broadening clinical understanding of time-based dietary interventions, Duan’s team investigated whether health benefits linked to intermittent fasting and other time-based dietary plans are caused by weight loss alone or if other biological mechanisms are also involved.

In the 12-week study, a predominantly female (92%) and Black (92%) cohort of adults (ages 18–69 years) with obesity and prediabetes or diet-controlled type 2 diabetes were randomly assigned to a 10-hour time-restricted eating (TRE) schedule (19 adults) or a 16-hour usual eating pattern (UEP) schedule (20 adults).

All study participants received the same adapted Dietary Approaches to Stop Hypertension (DASH) diet — a heart-healthy diet that emphasizes limiting red meats, high-fat foods, sugar and salt intake — and the caloric intake of each person was personalized to maintain their starting weights.

All meals were prepared and provided by the Johns Hopkins ProHealth Clinical Research Unit in Baltimore, Maryland, under the supervision of research dieticians.

Before and after the study, participants provided fasting blood samples that were used to measure inflammation markers and appetite hormone levels and completed a Three-Factor Eating Questionnaire — a tool that captures how a person interacts with and thinks about food. The researchers used both to track and compare physical and psychological changes over time.

Notably, at the study’s conclusion, the researchers observed similar and modest weight loss in both the group that followed the time-restricted eating (median 2.7%) and the usual eating pattern (median 2.5%) meal schedules.

At the end of the study, participants from both groups reported greater restraint around food, a reduced tendency to eat when stressed, and a lower susceptibility to hunger overall after the study’s conclusion. However, the appetite hormones (ghrelin and leptin) and the inflammation markers (C reactive protein, cortisol and sRAGE) were comparable between TRE and UEP participants.

“We saw that people who followed a 10-hour time-restricted eating schedule lost weight and positively changed their eating habits without calorie restriction,” says Duan. “But we did not identify any unique, body-wide health benefits linked to the dietary strategy beyond that.”

Future directions for the research include exploring how time-restricted eating shapes weight loss maintenance in people who have successfully lost weight through other interventions, such as via GLP-1 receptor agonists.

In addition to Daisy Duan, researchers who authored the study are Susan Carnell, Scott J. Pilla, Stephanie T. Chung, Jeanne M. Clark and Nisa M. Maruthur.

The study authors have the following conflict-of-interest disclosures to share: Duan serves as a consultant for Rhythm Pharmaceuticals and receives honoraria from the American Diabetes Association. Carnell receives grant funding from Eli Lilly and Company. Clark participates on a Data Safety Monitoring Board for Eli Lilly and Company and serves on the advisory board of Novo Nordisk. Maruthur receives royalties from UpToDate. The other authors declare no conflicts of interest.

The study was supported by the National Institutes of Health (R03DK144349, R01DK126825, R01DK139324 and K23DK133690) and the American Heart Association (17SFRN33590069).

DOI: 10.1002/oby.70270

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In a Rutgers-led study published in the Journal of Exposure Science & Environmental Epidemiology, researchers conducted a survey of product usage among 143 students at Princeton High School in New Jersey. They found that more time on social media and greater engagement with beauty-related content predicted more usage. After researchers accounted for gender, grade, race, ethnicity and parents’ education, they found students who followed influencers with product lines reported using 30% more products in the previous 24 hours. Those who watched hair or beauty tutorials used 40% more.

It was a novel finding that researchers on the study team credited a pair of then-high school students, Gabrielle Kaputa and Vita Moss-Wang, who helped design and conduct the survey and suggested it include questions about social media usage.

“Social media turned out to be the most interesting part of our results,” said Emily Barrett, the George G. Rhoads Endowed Legacy Professor and vice chair of the Department of Biostatistics and Epidemiology at the Rutgers School of Public Health and the lead author of the study.

“We often hear that social media may hurt kids’ mental health and socioemotional development,” she added. “This study suggests another cause for concern: social media’s potential to increase the use of personal care products that often include hormone-disrupting and potentially carcinogenic chemicals.”

Barrett and her colleagues, who have conducted several studies of adult product use, see much need for more information about student usage patterns.

“Teenagers are a particularly interesting population to study because they are undergoing rapid changes, including in their hormone systems,” Barrett said. “It may be a sensitive period in which better product choices could reduce chemical exposure.”

Such products include soap, toothpaste, shampoo, deodorant, sunscreen, skin care products, fragrance and makeup. Some contain phthalates, parabens, phenols or other chemicals that may affect hormone signaling and cancer risk. Previous research has found that people who use more products tend to have higher levels of some of these chemicals in their bodies.

In this study, girls reported using a median of 14 products in the previous day, twice as many as boys. In addition to near universal reports of using soaps and toothpaste in the past day, 57% reported the use of fragrances, which often use endocrine-disrupting phthalates without reporting them on labels. Overall product use among the students was comparable to levels reported in adult studies.

The students voiced some concern about potential chemical exposure, but few took the necessary steps to minimize it. Nineteen percent regularly read ingredient lists, and 5% regularly used an app or website intended to identify healthier products.

“Teenagers don’t read labels, it turns out,” said Moss-Wang, who was a sophomore at Princeton High School when the project began and is now a sophomore at Wellesley College.

The unusual collaboration began when investigators from the Rutgers Center for Environmental Exposures and Disease approached the Princeton High School research program in 2023. Moss-Wang and Kaputa joined the team, helped design the survey and urged the researchers to explore social media. They also prepared research ethics materials, created a recruitment video and flyers, visited classes and tracked responses. A second recruitment wave reached high school students in Rutgers summer programs.

“Dr. Barrett allowed us to manage the high school population outreach and data collection,” said Kaputa, now a junior at the University of Connecticut. “We identified interesting aspects of social media exposure within our student questionnaires.” Both students used the data for a three-year research project and became coauthors of the scientific paper.

The professional researchers, meanwhile, are now doing follow-up research with focus groups to learn which accounts, messages and influencers shape teenagers’ choices.

Larger studies across more diverse communities could test whether the pattern holds and could pair product inventories with urine samples that measure chemical exposure. Researchers also want to learn whether trusted online voices can steer adolescents toward safer choices.

The study was supported by the National Institute of Environmental Health Sciences through the Rutgers Center for Environmental Exposures and Disease.

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Midlife women are at increased risk of a number of chronic illnesses such as type 2 diabetes mellitus as a result of hormone changes caused by menopause. Women in midlife commonly experience weight gain and a redistribution of fat to the midsection resulting in increased belly fat and an elevated risk of developing type 2 diabetes. The global prevalence of diabetes was estimated in 2024 at 10%, and that risk continues to increase with age.

Previous studies have shown a strong reciprocal relationship between menopause and the development of diabetes, identifying early menopause and the postmenopause stages as triggering factors. However, most previous studies have focused on menopause stage, age at menopause, or menopause timing rather than directly assessing menopause symptom burden. A new study involving nearly 300 women aged 40 to 64 years aimed to assess menopause symptoms using the Midlife Women’s Symptom Index and to examine whether type 2 diabetes is associated with the number and severity of menopause symptoms.

Across all menopause stages, women in the diabetic group (diabetes and prediabetes) reported a higher prevalence of menopause symptoms. However, the difference was only statistically significant in the postmenopause stage. Similarly, although symptom severity was consistently higher in the diabetic groups across menopause stages, a statistically significant difference was observed only in the postmenopause stage.

These findings suggest the importance of integrating menopause symptom assessment and management into diabetes care for midlife women to improve quality of life. Additional longitudinal studies are recommended to further clarify the biological and psychosocial mechanisms linking glucose metabolism and menopause symptom burden in this population.

Survey results are published in the article “Association between type 2 diabetes mellitus and menopause symptoms among Korean midlife women.”

“This study demonstrates that women with diabetes may experience a greater burden of menopause symptoms. Prior research has also shown that cardiovascular risk factors, including diabetes, hypertension, and dyslipidemia, are associated with more frequent vasomotor symptoms, and women with a higher vasomotor symptom burden tend to have a less favorable cardiometabolic risk profile. Together, these findings not only highlight the need to recognize and address menopause symptoms in women with diabetes but also underscore the menopause transition as an important opportunity to identify and manage cardiovascular risk factors in all women,” says Dr. Stephanie Faubion, medical director for The Menopause Society.

For more information about menopause and healthy aging, visit www.menopause.org.

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Adults with type 2 diabetes and obesity have a high risk of fragility fractures, which are caused by low-energy trauma such as falling from standing height and are often the result of underlying bone weakness.

While GLP-1 receptor agonists can significantly reduce weight in users, there has been debate on whether rapid weight reduction could further weaken bones and make them more prone to fractures.

The new UCLA study, published in JAMA Network Open, used electronic health records of nearly 134,000 U.S. adults, ages 50-90, with type 2 diabetes to compare fracture risk of new users of GLP-1s to new users of another common diabetes medication, DPP-4 inhibitors.

Researchers found that GLP-1 receptor agonist use was associated with a 21% lower risk of fragility fracture over the 3-year study period compared to DPP-4 users, with the largest reductions occurring in fractures of the hip, femur and spine. A separate analysis found that the reduced risk was only associated with type 2 diabetes participants compared to a matching cohort of non-diabetic participants.

“Fractures are relatively uncommon, so very large studies are needed to detect a meaningful difference,” said Dr. Christopher Hamad. “Most previous studies were too small or were not designed to answer this question, and having data from more than 133,000 patients allowed us to better understand how GLP-1 medications may affect fracture risk and bone health.”

The authors noted that the findings come from a retrospective observational study and do not prove GLP-1s reduce fracture risk.  Prospective and translational studies are needed to confirm their mechanistic impacts and long-term effects on bone health.

Article: Hamad CD, Wiener J, Golzar A, et al. Glucagon-Like Peptide-1 Receptor Agonists and Fragility Fracture Risk in Type 2 Diabetes. JAMA Netw Open. 2026;9(7):e2625141. doi:10.1001/jamanetworkopen.2026.25141

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Researchers found that rates of gestational diabetes – a condition that develops during pregnancy and can cause serious complications for both mother and baby – increased from around eight per cent of pregnancies in 2018 to more than 12 per cent in 2022.

The sharpest rises were seen among some ethnic minority groups and women living in deprived areas.

Experts say the findings highlight an urgent need to strengthen maternity services and improve support for women at highest risk.

Gestational diabetes mellitus (GDM) is the most common complication arising during pregnancy. The condition occurs when the body cannot produce enough insulin to regulate blood sugar levels during pregnancy.

GDM is associated with an increased risk of complications including preterm birth, emergency Caesarean section and babies being born either larger or smaller than expected for their gestational age. It is also linked to long-term health risks for both mothers and their children.

Researchers analysed routinely collected NHS maternity data covering over 2.3 million mothers and around 2.8 million births across 184 hospitals in England between 2018 and 2022.

The highest increases in gestational diabetes were seen among Asian women, where rates reached around 23 per cent, and among women living in the most deprived areas, where they reached around 14 per cent.

The study also found marked inequalities in pregnancy outcomes across ethnic and socioeconomic groups. Black mothers were more likely to experience an emergency Caesarean birth, women living in deprived areas were more likely to give birth preterm, and Asian mothers were more likely to have babies born small for gestational age.

Among these higher-risk groups, a diagnosis of gestational diabetes was associated with a further increase in the risk of preterm birth.

Researchers say rising maternal age, increasing rates of obesity and improvements in data capture are likely contributors to the growing prevalence of gestational diabetes.

The study also found that changes to gestational diabetes screening introduced during the COVID-19 pandemic did not meaningfully affect overall trends in diagnosis. Experts say the rise in cases reflects broader underlying changes rather than changes in testing practice.

Rebecca Reynolds, Professor of Metabolic Medicine at the University of Edinburgh, said: “This the first time we have managed to estimate the number of women with gestational diabetes in the UK. The rising number of women being diagnosed is concerning and impacts on maternity services delivery which are already challenged. Importantly, gestational diabetes also increases risk of future type 2 diabetes and cardiovascular disease, so better preventative measures are needed to help support these women post partum.”

Dr Sonya Babu-Narayan, Clinical Director at the British Heart Foundation, said: “Big data research studies like this, which can now analyse millions of healthcare records, are uncovering a concerning rise in conditions which raise people’s chances of having a future heart attack or stroke. Gestational diabetes often goes away after pregnancy, but it can increase women’s risk of future cardiovascular disease. Healthcare professionals who want to fully understand people’s risk of heart attack and stroke should routinely ask women about risk factors unique to them, such as diabetes or high blood pressure in pregnancy – even if that pregnancy was decades earlier. If you are a woman who has had diabetes or high blood pressure during pregnancy, it is especially important to attend health checks when invited.”

The study is published in the journal BMJ Medicine: https://bmjmedicine.bmj.com/lookup/doi/10.1136/bmjmed-2025-002412 [URL will become active after embargo lifts]. It involved researchers from King’s College London, University of Glasgow, University of Warwick and researchers within the HDRUK Diabetes Data Catalyst, a partnership between British Heart Foundation Data Science Centre, Diabetes UK and Health Data Research UK. It was funded by the British Heart Foundation.

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In a new review published in The Journal of Clinical Endocrinology & Metabolism, researchers from LSU’s Pennington Biomedical Research Center examine the concept of “metabolically healthy obesity” and argue that a newer framework distinguishing preclinical obesity from clinical obesity provides a more biologically grounded and clinically actionable approach.

The review, “Does Metabolically Healthy Obesity Really Exist: Going Toward New Definitions,” was authored by Dr. Christian Rodriguez, postdoctoral researcher, and LSU Boyd Professor Dr. Eric Ravussin. The paper examines how the traditional classification of metabolically healthy obesity (MHO) and metabolically unhealthy obesity (MUO) has influenced treatment decisions and why the newer outline developed by the Lancet Diabetes & Endocrinology Commission on the Definition and Diagnosis of Clinical Obesity may offer a better path forward.

The traditional MHO/MUO framework generally classifies people with obesity based on the presence or absence of metabolic abnormalities. Under that approach, individuals with metabolically unhealthy obesity may be candidates for more intensive lifestyle interventions and pharmacotherapy, while those classified as having metabolically healthy obesity may initially receive structured lifestyle support, with more intensive treatment considered if their metabolic health worsens or other risk factors emerge.

The challenge is that the definition of MHO varies considerably across studies and is often not a stable condition. Individuals classified as having MHO may develop metabolic abnormalities over time, complicating treatment plans based on the assumption that their obesity is currently “healthy.”

“Metabolically healthy obesity helped researchers recognize that obesity does not affect every person in exactly the same way,” Dr. Ravussin said. “But the classification is difficult to use as a foundation for long-term treatment because the definitions vary and metabolic health can change. A person who is considered metabolically healthy today may not be metabolically healthy tomorrow.”

The preclinical/clinical obesity framework proposed by the Lancet Commission takes a different approach. Rather than defining obesity primarily by the presence or absence of a specific cluster of metabolic risk factors, it considers whether excess adiposity is causing dysfunction in organs or tissues or limiting a person’s ability to perform daily activities.

This means that preclinical obesity describes individuals with confirmed excess adiposity who do not currently have evidence of obesity-related organ or tissue dysfunction. These individuals may benefit from structured lifestyle interventions, regular monitoring of cardiometabolic health and shared decision-making about pharmacotherapy when individual risk is elevated.

On the other hand, clinical obesity is defined by excess adiposity accompanied by obesity-related organ or tissue dysfunction or significant limitations in daily activities. For these individuals, evidence-based pharmacotherapy and, when appropriate, metabolic or bariatric surgery may be considered alongside treatment of the specific health problems associated with obesity.

Importantly, the framework also changes how treatment success may be evaluated. Rather than measuring success solely by the amount of weight lost, the goal is to improve or resolve the organ or tissue dysfunction that defines a person’s clinical obesity.

“Moving from the question ‘Is this person metabolically healthy or unhealthy?’ to ‘Is excess adiposity affecting the function of the body?’ gives us a more clinically meaningful way to think about obesity,” Dr. Rodriguez said. “The framework allows us to identify people who may benefit from prevention and monitoring while also recognizing when obesity has progressed to a disease state requiring more intensive treatment.”

The new approach builds on the work of the Lancet Diabetes & Endocrinology Commission on the Definition and Diagnosis of Clinical Obesity. Three Pennington Biomedical researchers – Dr. Ravussin, Dr. Philip Schauer and Dr. John Kirwan – served on the 56-member international Commission that developed the new method for defining and diagnosing obesity.

The authors note that it is still evolving and will require additional research to validate its diagnostic criteria and develop tools for consistent implementation in clinical practice and public health. The review concludes that the concept of metabolically healthy obesity has helped advance understanding of the biological diversity of obesity but is limited by inconsistent definitions, its potentially temporary nature and its focus on a relatively narrow set of metabolic risk factors.

About the Pennington Biomedical Research Center

The Pennington Biomedical Research Center is at the forefront of medical discovery as it relates to understanding the triggers of obesity, diabetes, cardiovascular disease, cancer and dementia. Pennington Biomedical has the vision to lead the world in promoting nutrition and metabolic health and eliminating metabolic disease through scientific discoveries that create solutions from cells to society. The Center conducts basic, clinical and population research, and is a campus in the LSU System.

The research enterprise at Pennington Biomedical includes over 600 employees within a network of 44 clinics and research laboratories, and 16 highly specialized core service facilities. Its scientists and physician-scientists are supported by research trainees, lab technicians, nurses, dietitians and other support personnel. Pennington Biomedical is a globally recognized state-of-the-art research institution in Baton Rouge, Louisiana. For more information, see www.pbrc.edu.

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Generic semaglutide, a glucagon-like peptide-1 receptor agonist (GLP-1RA), has recently become available in Canada after regulatory exclusivity for semaglutide expired in Canada in January 2026—years earlier than expected in the US and countries in Europe. Patients with type 2 diabetes and high cardiorenal risk are recommended to initiate a GLP-1RA and/or a sodium-glucose cotransporter-2 inhibitor (SGLT2i) according to Canadian and international guidelines.

The authors estimate that between 1.3 and 2.1 million people living in Canada may meet the Canadian Cardiovascular Society criteria for type 2 diabetes patients eligible to use GLP-1RAs or SGLT2is. The estimated annual cost of providing GLP-1RAs to all indicated patients would be $3.35 to $5.31 billion at pre-generic 2025 semaglutide prices. In Canada, these costs are typically paid by provincial or private drug insurance plans, but may be paid out-of-pocket when the drugs are not covered by a patient’s insurance plan.

“The high cost of brand-name versions of these GLP-1RAs has been a significant barrier to patients and provincial insurers. Anticipated price reductions from the introduction of generic semaglutide could substantially alter the health economic value of programs aimed at initiating SGLT2i and GLP-1RA therapies for patients with type 2 diabetes and high cardiorenal risk,” says first author of the study Ethan McNally, BA, McGill University School of Population and Global Health.

Using a health economic microsimulation model to project lifetime costs, quality-adjusted life years (QALYs), and the burden of cardiovascular and renal comorbidities for this high-risk patient group, the investigators examined how the cost-effectiveness of GLP-1RAs changes across a range of possible prices.

Key Economic Modeling Outcomes

Guided by the commonly used threshold of $50,000 per QALY in Canada, the most important findings are as follows:

• At a 60% reduction from the 2025 pre-generic semaglutide price paid by the Quebec provincial drug plan, combined GLP-1RA and SGLT2i therapy may become the preferred strategy for this guideline-indicated cohort of patients, compared to either therapy alone or other standard-of-care therapies.
• At a 70% price reduction, GLP-1RA is predicted to be cost-effective compared to non-SGLT2i standard-of-care therapies (cost-effectiveness ratio [CER] of $22,700). SGLT2i is still predicted to be preferred over GLP-1RA alone, but dual therapy is predicted to be more cost-effective than either option alone (CER of $31,700 for dual therapy vs. SGLT2i alone).

Given the rapid growth of GLP-1RA usage and their high costs, this analysis may provide evidence for reimbursement and formulary decisions. “Many provincial public drug plans limit GLP-1RA and SGLT2i reimbursement to patients who fail to meet glycemic targets. Multiple clinical guidelines now recommend these therapies for patients with type 2 diabetes at high cardiorenal risk, regardless of blood sugar levels. Given that our findings suggest that generic pricing may be cost-effective, payers could explore adjusting reimbursement criteria,” notes lead investigator Abhinav Sharma, MD, PhD, DREAM-CV Lab, Research Institute, and Centre for Outcome Research & Evaluation, McGill University Health Centre.

These findings may generalize internationally, once generic semaglutide becomes available in other countries.

Co-lead investigator Alton Russell, PhD, McGill University School of Population and Global Health, and Centre for Outcome Research & Evaluation, McGill University Health Centre, concludes, “Our results are encouraging and provide further economic justification for the use of these therapies among appropriate patients with type 2 diabetes in Canada, which will significantly improve the quality of life, lower hospitalization costs, and ultimately protect patients from heart failure and kidney disease progression.”

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Although the absolute risk is low, awareness of this potential effect may help to inform shared treatment decisions, say the researchers.

Alopecia has been reported as a possible side effect of GLP-1 receptor agonists, particularly semaglutide and tirzepatide. However, studies assessing the risk of alopecia associated with GLP-1 receptor agonists compared with other diabetes drugs are lacking.

To address this, researchers used electronic patient data from the University of Pennsylvania Health System (Penn Medicine) to compare rates of alopecia in adults with type 2 diabetes who started using GLP-1 receptor agonists or other types of diabetes drugs known as SGLT-2 inhibitors, or DPP-4 inhibitors.

In total, 12,004 patients using GLP-1 receptor agonists were compared with 15,221 using SGLT-2 inhibitors and a further 11,964 GLP-1 users were compared with 11,233 DPP-4 inhibitor users between January 2019 and September 2024.

Compared with SGLT-2 inhibitor users, GLP-1 receptor agonist users were younger (mean age 58 v 65), had a higher body mass index (36.2 v 32.3), and lower rates of cardiovascular and chronic kidney diseases. Similarly, GLP-1 users were younger (mean age 58 v 67) and had a higher body mass index (36.2 v 31.3) than DPP-4 inhibitor users.

After adjusting for potentially influential factors including age, sex, ethnicity, pre-existing conditions, other medication use, and body mass index, use of GLP-1 receptor agonists was associated with a 37% higher risk of alopecia than use of SGLT-2 inhibitors (6.91 v 5.04 per 1,000 person years) and a 68% higher risk than use of DPP-4 inhibitors (6.53 v 3.89 per 1,000 person years).

Further analyses indicated that the association was specific to non-scarring alopecia (where hair follicles remain intact, leaving the potential for regrowth) with an increased risk of 53% and 72% compared with SGLT-2 inhibitors and DPP-4 inhibitors, respectively.

The authors point out that rapid weight loss is a well established trigger of hair shedding and can also lead to iron or zinc deficiencies, which disrupt the hair growth cycle. Hormonal changes may also be relevant, they note, although further studies are needed to clarify the underlying mechanisms.

They also acknowledge several study limitations. For example, a lack of clinical information limited their ability to assess details such as severity, extent, duration and reversibility of alopecia after stopping treatment. Nor can they rule out the possibility that other unmeasured factors may have influenced their results.

However, they say this was a rigorous study based on high quality data from a large representative cohort and results were consistent after additional analyses, suggesting they are reliable.

As such, they conclude: “Our findings extend previous anecdotal safety signals and provide more systematic evidence to inform clinical awareness of this potential adverse effect.”

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Researchers found that many online GLP-1 RA prescription vendors did not require any interaction with a clinician, instead relying largely on patient-reported questionnaires. According to the study, these questionnaires may fail to capture important elements of a patient’s clinical and social history.

Several findings pointed to limited safety oversight. Investigators observed multiple GLP-1 RA prescriptions being issued by the same clinicians, prescriptions granted even when required photos were missing, and prescriptions completed in five minutes or less.

The findings add to growing scrutiny of the direct-to-consumer telehealth market, which has expanded rapidly alongside surging demand for weight-loss and diabetes medications.

The study’s corresponding author is Reshma Ramachandran, MD, MPP, MHS, of Yale University. The full study is available in JAMA (doi:10.1001/jama.2026.9131).

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The randomized clinical trial, which enrolled 400 participants with Type 1 diabetes ages 7 to 25 in Bangladesh and Tanzania, found that the long-acting analogue insulin glargine was associated with less time spent in dangerous hypoglycemia and fewer nighttime low blood sugar events – but those benefits didn’t emerge until a year into the trial. The findings point to a more complicated picture than a simple head-to-head win for newer insulin.

“The real question is not simply whether newer insulin is better, but whether the benefits we observed are compelling enough to inform purchasing, access and guideline decisions in places where choices are constrained,” said lead author Jing Luo, M.D., M.P.H., associate professor of medicine at Pitt. “That is the conversation this study helps move forward.”

At six months, researchers found no evidence of differences between the insulin analogue glargine and older human insulin in the trial’s co-primary outcomes: time spent in very low glucose range and time spent in the target glucose range. At 12 months, however, participants assigned to glargine spent less time in very low glucose range and had fewer nocturnal hypoglycemic events than those assigned to usual care. Researchers did not find meaningful differences in time in range, HbA1c, diabetic ketoacidosis, severe hypoglycemic events or symptomatic hypoglycemic events at 12 months.

Although glargine did not improve the study’s primary outcomes at six months, the 12-month data suggest that benefits related to serious hypoglycemia may emerge more gradually in real-world, low-resource care settings. Glargine was also associated with lower total daily insulin use and fewer injections per day, factors that may matter to patients, families and health systems alike.

The World Health Organization added long-acting insulin analogues such as glargine to its Model List of Essential Medicines in 2021. Still, Type 1 diabetes care remains profoundly unequal worldwide. Of an estimated 9.5 million people living with Type 1 diabetes globally, about 3.2 million are treated exclusively with older human insulins, most of them in low- and middle-income countries. While long-acting insulin analogues such as glargine are widely used in higher-income settings, their higher cost and limited availability have slowed broader adoption elsewhere.

“In many parts of the world, children do not have access to the therapies considered standard elsewhere,” said Luo. “These findings add new data to a global debate over whether health systems with constrained resources should prioritize access to newer insulin formulations despite their higher cost.”

Researchers say additional study is needed to better understand longer-term glycemic outcomes after patients in low-resource settings switch from older human insulin to analogue insulin.

Co-authors include Chung-Chou H. Chang, Ph.D., Christina M. Lalama, M.S., Jill Kirsch, M.S., Abigail Foulds, Ph.D., and Bruce L. Rollman, M.D., M.P.H., all of Pitt; Sylvia Kehlenbrink, M.D., of Brigham and Women’s Hospital; Éimhín Ansbro, M.Sc., of the London School of Hygiene and Tropical Medicine; Margaret L. Prust, M.P.H. and Alana Garvin, M.P.H., both of the Clinton Health Access Initiative; Bedowra Zabeen, M.B.B.S. and Ajmina Hasan Flabe, M.S., M.P.H., both of the Diabetic Association of Bangladesh; Edna Majaliwa, M.D., of the Tanzania Diabetes Association and Muhimbili National Hospital; Kaushik Ramaiya, M.D., of the Tanzania Diabetes Association and Shree Hindu Mandal Hospital; Neema Kayange, M.D., of the Catholic University of Health and Allied Sciences – Bugando; Renatus Fabiano Nyarubamba, M.D., M.P.H., of the Tanzania Diabetes Association; and Graham D. Ogle, M.B.B.S., of Life for a Child, Australia.

The study was funded by the Leona M. and Harry B. Helmsley Charitable Trust.

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