This prospective, open-label, single-arm, single-center interventional pilot trial aims to evaluate the efficacy and safety of low-dose semaglutide for weight loss and cardiometabolic improvement in obese Pakistani adults without type 2 diabetes mellitus. The study will be conducted at the Asian Institute of Medical Sciences (AIMS), Hyderabad, Sindh, Pakistan. A total of 60 obese adults aged 18 years or older with a body mass index (BMI) of 27.5 kg/m² or greater according to World Health Organization Asian cutoffs and without type 2 diabetes mellitus (fasting blood glucose <126 mg/dL and HbA1c <6.5%) will be enrolled. Eligible participants will receive once-weekly subcutaneous semaglutide following a standard dose titration schedule of 0.25 mg weekly for four weeks, 0.5 mg weekly for four weeks, and 1.0 mg weekly for the remaining 16 weeks, for a total treatment duration of 24 weeks. All participants will receive standardized lifestyle counseling, including a hypocaloric diet with a 500-750 kcal/day deficit and at least 150 minutes per week of moderate-intensity physical activity. The primary outcome is the percentage change in body weight from baseline to 24 weeks. Secondary outcomes include changes in body mass index, waist circumference, systolic and diastolic blood pressure, lipid profile (total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides), liver enzymes (alanine aminotransferase and aspartate aminotransferase), and quality of life. Safety will be assessed through continuous monitoring of adverse events and adverse drug reactions with causality assessment using the Naranjo Adverse Drug Reaction Probability Scale. Clinical and laboratory assessments will be conducted at baseline, 12 weeks, and 24 weeks. Data will be analyzed using descriptive and inferential statistics, including paired t-tests or non-parametric equivalents and repeated measures analysis, with a significance level of p < 0.05. The study will be conducted in accordance with Good Clinical Practice guidelines and the Declaration of Helsinki, with approval from the AIMS Institutional Review Board and written informed consent obtained from all participants. The trial aims to generate locally relevant clinical evidence on the effectiveness and safety of low-dose semaglutide for obesity management in non-diabetic Pakistani adults.

Obesity is a growing public health concern worldwide and is increasingly prevalent in Pakistan, contributing significantly to cardiovascular disease, metabolic syndrome, non-alcoholic fatty liver disease, hypertension, dyslipidemia, and reduced quality of life. Despite the rising burden of obesity in South Asian populations, access to evidence-based pharmacological treatment remains limited, and locally generated clinical data on anti-obesity medications in non-diabetic individuals are scarce. Semaglutide, a glucagon-like peptide-1 (GLP-1) receptor agonist, has demonstrated significant weight reduction and cardiometabolic benefits in multiple international clinical trials; however, most available evidence comes from Western populations and higher-dose formulations. In Pakistan, locally available lower-dose semaglutide formulations are increasingly being used in clinical practice, but their real-world effectiveness and safety in non-diabetic obese adults have not been systematically evaluated. This study aims to generate locally relevant clinical evidence to support the safe and effective use of semaglutide for obesity management in the Pakistani population.

This prospective, open-label, single-arm, single-center pilot interventional trial will be conducted at the Asian Institute of Medical Sciences (AIMS), Hyderabad, Sindh, Pakistan. The study will enroll 60 obese adults aged 18 years or older with a body mass index (BMI) of 27.5 kg/m² or greater according to World Health Organization Asian cutoffs and without type 2 diabetes mellitus, confirmed by fasting blood glucose less than 126 mg/dL and HbA1c less than 6.5% within three months prior to enrollment. Participants with a history of pancreatitis, medullary thyroid carcinoma, multiple endocrine neoplasia type 2, pregnancy or lactation, severe renal or hepatic impairment, current use of other anti-obesity medications, or known hypersensitivity to semaglutide will be excluded to ensure participant safety and minimize confounding factors.

Eligible participants will receive once-weekly subcutaneous low-dose semaglutide following a standardized dose titration schedule consisting of 0.25 mg weekly for the first four weeks, 0.5 mg weekly for the next four weeks, and 1.0 mg weekly for the remaining 16 weeks, for a total treatment duration of 24 weeks (six months). The medication will be administered under medical supervision, and participants will be educated on proper injection technique and adherence to the treatment regimen. In addition to pharmacological treatment, all participants will receive standardized lifestyle counseling, including a hypocaloric diet with a daily caloric deficit of 500-750 kcal and at least 150 minutes of moderate-intensity physical activity per week, in accordance with international obesity management guidelines.

The primary objective of the study is to evaluate the percentage change in body weight from baseline to 24 weeks following low-dose semaglutide treatment. Secondary objectives include evaluating changes in body mass index, waist circumference, systolic and diastolic blood pressure, lipid profile (total cholesterol, low-density lipoprotein, high-density lipoprotein, and triglycerides), liver enzymes (alanine aminotransferase and aspartate aminotransferase), and quality of life over the study period. Safety and tolerability will be assessed through continuous monitoring of adverse events and adverse drug reactions, with causality assessment using the Naranjo Adverse Drug Reaction Probability Scale. Clinical and laboratory assessments will be conducted at baseline, 12 weeks, and 24 weeks to evaluate treatment response and safety outcomes.

Data will be collected using standardized case report forms and securely stored in a password-protected database. Statistical analysis will be performed using IBM SPSS Statistics software. Descriptive statistics will summarize baseline demographic and clinical characteristics. Continuous variables will be expressed as mean with standard deviation or median with interquartile range, and categorical variables will be expressed as frequencies and percentages. Changes in primary and secondary outcomes from baseline to follow-up visits will be analyzed using paired t-tests or non-parametric equivalents depending on data distribution, and repeated measures analysis will be used to assess trends across time points. A p-value of less than 0.05 will be considered statistically significant. As a pilot trial, the sample size of 60 participants is intended to assess feasibility, estimate treatment effect, and generate preliminary data for future multicenter randomized controlled trials.

The study will be conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. Ethical approval will be obtained from the Institutional Review Board of the Asian Institute of Medical Sciences prior to study initiation. Written informed consent will be obtained from all participants before enrollment, and participant confidentiality will be maintained through de-identification and secure data handling. The results of this study are expected to provide important real-world clinical evidence on the effectiveness and safety of low-dose semaglutide for obesity management in non-diabetic Pakistani adults and support future larger-scale clinical research in the region.

Inclusion Criteria:

• Adults aged 18 years or older.
• Body mass index (BMI ≥ 27.5 kg/m²) according to WHO Asian cut-offs.
• No diagnosis of type 2 diabetes mellitus, confirmed by:

Fasting blood glucose < 126 mg/dL, and HbA1c < 6.5% within three months prior to enrollment.

• Willingness and ability to provide written informed consent.
• Willingness to comply with study procedures, including weekly injections and lifestyle counseling.

Exclusion Criteria:

• History of pancreatitis.
• History or presence of medullary thyroid carcinoma or multiple endocrine neoplasia type 2 (MEN2).
• Pregnant or lactating women.
• Severe renal impairment (eGFR < 30 mL/min/1.73 m²) or hepatic impairment (ALT or AST > 3× upper limit of normal).
• Current use of other anti-obesity medications.
• Known hypersensitivity to semaglutide or any component of the formulation.
• Any condition that, in the investigator's opinion, would interfere with participation, adherence, or safety in the study.

De-identified individual participant data will be shared with qualified researchers upon reasonable request, starting 6 months after primary study publication for a period of 5 years. Shared data will include participant demographics, body weight, BMI, waist circumference, laboratory results, blood pressure, quality of life outcomes, and safety data. Supporting documents available for sharing include the study protocol, statistical analysis plan, informed consent form, and analytic code. Data requests must include a research proposal and data-sharing agreement approved by the AIMS Institutional Review Board. Participant confidentiality will be maintained through removal of all personal identifiers.

Start Date: Waiting 6 months after publication ensures that the primary investigators have time to finalize and publish the main study results before sharing data.

End Date: A 5-year period allows other qualified researchers sufficient time to request and use the de-identified data.

De-identified individual participant data will be available to qualified researchers with a scientific proposal and an approved data-sharing agreement from the AIMS Institutional Review Board. Shared data include baseline demographics, weight, BMI, waist circumference, blood pressure, lipid profile, liver enzymes, quality of life scores, and adverse events. Supporting documents include the study protocol, statistical analysis plan, informed consent form, and analytic code. Personal identifiers will be removed. Data will be shared electronically via secure file transfer or password-protected cloud after approval, for research purposes only. Access will begin 6 months after publication and continue for 5 years.