Supplementary Appendix

This appendix has been provided by the authors to give readers additional information about their work.

Supplement to: Wilding JPH, Batterham RL, Calanna S, et al. Once-weekly semaglutide in adults with overweight
or obesity. N Engl J Med 2021;384:989-1002. DOI: 10.1056/NEJMoa2032183
STEP 1 Manuscript – Supplementary Appendix

SUPPLEMENTARY APPENDIX

CONTENTS

LIST OF INVESTIGATORS IN THE SEMAGLUTIDE TREATMENT EFFECT IN PEOPLE WITH OBESITY (STEP)
1 TRIAL .................................................................................................................................................... 3
SUPPLEMENTAL METHODS ..................................................................................................................... 5
INCLUSION AND EXCLUSION CRITERIA ............................................................................................... 5
PATIENT-REPORTED OUTCOMES ........................................................................................................ 8
Short Form36v2® Health Survey, Acute Version (SF-36) ................................................................ 8
Impact of Weight on Quality of Life-Lite Clinical Trials Version (IWQOL-Lite-CT) .......................... 8
ENDPOINTS ......................................................................................................................................... 9
Co-primary endpoints ..................................................................................................................... 9
Confirmatory secondary endpoints ................................................................................................ 9
Supportive secondary endpoints .................................................................................................... 9
Exploratory endpoints................................................................................................................... 10
LABORATORY TESTING ...................................................................................................................... 12
STATISTICAL ANALYSIS ...................................................................................................................... 14
Analysis and imputation methods to address the treatment policy and trial product estimands
for the primary and confirmatory secondary endpoints in the statistical testing hierarchy. ...... 15
SUPPLEMENTARY TABLES ..................................................................................................................... 17
Table S1. Baseline demographics and clinical characteristics in the DEXA subpopulation .............. 17
Table S2. Co-primary, Confirmatory and Selected Supportive Secondary Endpoints for the Trial
Product Estimand* ............................................................................................................................ 19
Table S3. Selected Supportive Secondary and Exploratory Endpoints for the Treatment Policy
Estimand* ......................................................................................................................................... 22
Table S4. Proportions of Participants Achieving a Clinically Meaningful Within-person
Improvement in Score from Baseline to Week 68 (%), Treatment Policy Estimand*†‡ .................... 23
Table S5. Supportive Secondary Endpoints Assessed in the DEXA Subpopulation for the Treatment
Policy Estimand* ............................................................................................................................... 24
Table S6. Supportive Secondary Safety Endpoints, On-treatment* ................................................. 26
SUPPLEMENTARY FIGURES ................................................................................................................... 27
Figure S1. Trial Design ....................................................................................................................... 27
Figure S2. Participant Flow ............................................................................................................... 28
Figure S3. Cumulative Distribution Plot of Change from Baseline to Week 68 in Body Weight ...... 29
Figure S4. Body Weight in Kilograms by Week ................................................................................. 30

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STEP 1 Manuscript – Supplementary Appendix

Figure S5. Semaglutide 2.4 mg Once Weekly Compared with Placebo on Selected Confirmatory
Secondary Endpoints* ...................................................................................................................... 31
Figure S6. Change from Baseline by Week in Diastolic Blood Pressure............................................ 32
Figure S7. Semaglutide 2.4 mg Once Weekly Compared with Placebo on Patient-reported
Outcomes for the SF-36 and IWQOL-Lite-CT .................................................................................... 33
Figure S8. Prevalence and Duration of Gastrointestinal Events by Severity .................................... 36
Figure S9. Time to First Onset of Adverse Events Leading to Permanent Trial Product
Discontinuation ................................................................................................................................. 38
REFERENCES .......................................................................................................................................... 39

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STEP 1 Manuscript – Supplementary Appendix

LIST OF INVESTIGATORS IN THE SEMAGLUTIDE TREATMENT EFFECT IN PEOPLE WITH

OBESITY (STEP) 1 TRIAL

Argentina: Marianela Aguirre Ackermann (Corrientes), Cecilia Luquez (Córdoba), Marcos Mayer
(Santa Rosa), Carla Musso (CABA), Susana Salzberg (Ciudad de Buenos Aires)

Belgium: Ides Colin (Boussu), Ann Mertens (Leuven), André Scheen (Liège), Jean-Paul Thissen
(Bruxelles), Luc Van Gaal (Edegem)

Bulgaria: Zhivka Asyova (Sofia), Anna-Maria Borissova (Sofia), Nickolay Botushanov (Plovdiv), Ivona
Daskalova (Sofia), Zdravko Kamenov (Sofia)

Canada: Adam Blackman (Toronto), Martin D'Amours (Quebec), Isabelle Labonte (Quebec),
Stephanie Li (Edmonton), Derek Lowe (Surrey), Sean Wharton (Hamilton), Sanaz Zarinehbaf-Asadi
(North York)

Denmark: Bjørn Richelsen (Aarhus N)

Finland: Kirsi Pietiläinen (Helsinki), Markku Savolainen (Oulu)

France: Sebastien Czernichow (Paris), Emmanuel Disse (Pierre Benite), Kamel Mohammedi (Pessac),
Arnaud Monier (Le Coudray), Christine Poitou-Bernert (Paris), Pierre Serusclat (Venissieux), Jean-
Francois Thuan (Narbonne)

Germany: Christel Contzen (Frankfurt), Moritz Mauro Erlinger (Stuttgart), Michael Esser (Essen),
Thomas Linn (Giessen), Jörg Lüdemann (Falkensee), Karsten Milek (Hohenmölsen), Nicoletta Nalazek
(Leipzig), Andrea Rinke (Bochum), Joachim Sauter (Wangen), Thomas Schürholz (Essen), Alexander
Segner (St. Ingbert-Oberwürzbach), Liana Vismane (Berlin), Ulrich Wendisch (Hamburg)

India: Syamasis Bandyopadhyay (Kolkata), Dipti Chand (Nagpur), Piyush Desai (Surat), Vaishali
Deshmukh (Pune), Yashdeep Gupta (New Delhi), P K Jabbar (Thiruvananthapuram), Dinesh Jain
(Ludhiana), Neelaveni K ( Hyderabad), Shriraam Mahadevan (Chennai), Rajesh Rajput (Rohtak),
Sudhakar Reddy (Secunderabad), Kongara Srikanth (Guntur), A Unnikrishnan (Pune)

Japan: Satoshi Inoue (Suita-shi, Osaka), Arihiro Kiyosue (Tokyo), Osamu Matsuoka (Tokyo), Hiraku
Ono (Chiba-shi, Chiba), Masamichi Yamada (Tokyo)

Mexico: Diego Espinoza Peralta (Hermosillo), Silvia Jimenez-Ramos (Guadalajara), Carlos Medina
Pech (Merida)

Poland: Pawel Bogdanski (Poznan), Malgorzata Jozefowska (Lodz), Agata Leksycka (Gdynia), Jaroslaw
Ogonowski (Szczecin)

Russian Federation: Diana Alpenidze (Saint-Petersburg), Olga Ershova (Yaroslavl), Marina

Kharakhulakh (Tomsk), Vadim Klimontov (Novosibirsk), Ludmila Ruyatkina (Novosibirsk), Marina
Sergeeva-Kondrachenko (Penza), Ekaterina Troshina (Moscow), Elena Zhdanova (Voronezh)

Taiwan: Kuo-Chin Huang (Taipei)

United Kingdom: Rachel Batterham (London), Matt Capehorn (Rotherham), Rhodri King (Taunton),
Michael Lean (Glasgow), Barbara McGowan (London), Khin Swe Myint (Norwich), Adrian Park
(Cambridge), Harpal Randeva (Coventry), Georgina Russell (Bristol), John Wilding (Liverpool)

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STEP 1 Manuscript – Supplementary Appendix

United States: Hanid Audish (Spring Valley), Darlene Bartilucci (Jacksonville), Harold Bays (Louisville),
Ronald Brazg (Renton), Robert Broker (Simpsonville), Kevin Cannon (Wilmington), Tira Chaicha-Brom
(Austin), Matthew Davis (Rochester), H. Jackson Downey (Jacksonville), Stephen Fehnel (West
Reading), Almena Free (Anniston), Amina Haggag (Anaheim), Mitzie Hewitt (Buckley), Priscilla
Hollander (Dallas), Misal Khan (Panama City), Karen Laufer (Plantation), Robert McNeill (Salisbury),
John Nardandrea, Jr (Ocala), Lisa Neff (Chicago), Kevin Niswender (Nashville), Patrick O'Neil
(Charleston), John Pullman (Butte), Marina Raikhel (Lomita), Scott Redrick (Crystal River), John Reed
III (Roswell), Michele Reynolds (Dallas), Luis Rivera-Colon (San Juan), Julio Rosenstock (Dallas), Erich
Schramm (Ponte Vedra), John Scott (Richmond), Stephanie Shaw (Round Rock), Vijay Shivaswamy
(Omaha), Timothy Smith (St. Peters), Joseph Soufer (Waterbury), Stephen Straubing (Chiefland),
Danny Sugimoto (Chicago), Phillip Toth (Indianapolis), Ralph Wade (Bountiful), Holly Wyatt (Aurora),
lan Wynne (Topeka).

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STEP 1 Manuscript – Supplementary Appendix

SUPPLEMENTAL METHODS

INCLUSION AND EXCLUSION CRITERIA

Inclusion criteria

Subjects are eligible to be included in the trial only if all of the following criteria apply:

• Informed consent obtained before any trial-related activities. Trial-related activities are any

procedures that are carried out as part of the trial, including activities to determine suitability

for the trial.

• Male or female, age ≥18 years at the time of signing informed consent.

• Body mass index (BMI) ≥30.0 kg/m2 or ≥27.0 kg/m2 with the presence of at least one of the

following weight-related comorbidities (treated or untreated): hypertension, dyslipidemia,

obstructive sleep apnea, or cardiovascular disease.

• History of at least one self-reported unsuccessful dietary effort to lose body weight.

Exclusion criteria

Subjects are excluded from the trial if any of the following criteria apply:

Glycemia-related:

• Glycated hemoglobin (HbA1c) ≥48 mmol/mol (6.5%) as measured by the central laboratory at

screening.

• History of type 1 or type 2 diabetes mellitus.

• Treatment with glucose-lowering agent(s) within 90 days before screening.

• Treatment with a glucagon-like peptide-1 receptor agonist within 180 days before screening.

Obesity-related:

• A self-reported change in body weight >5 kg (11 lbs) within 90 days before screening irrespective

of medical records.

• Treatment with any medication for the indication of obesity within the past 90 days before

screening.

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STEP 1 Manuscript – Supplementary Appendix

• Previous or planned (during the trial period) obesity treatment with surgery or a weight-loss

device. However, the following are allowed: (1) liposuction and/or abdominoplasty, if performed

>1 year before screening; (2) lap banding, if the band has been removed >1 year before

screening; (3) intragastric balloon, if the balloon has been removed >1 year before screening; or

(4) duodenal-jejunal bypass sleeve, if the sleeve has been removed >1 year before screening.

• Uncontrolled thyroid disease, defined as thyroid stimulating hormone >6.0 mIU/L or <0.4 mIU/L

as measured by the central laboratory at screening.

Mental health:

• History of major depressive disorder within 2 years before screening.

• Diagnosis of other severe psychiatric disorder (e.g. schizophrenia, bipolar disorder).

• A Patient Health Questionnaire-9 score of ≥15 at screening.

• A lifetime history of a suicidal attempt.

• Suicidal behavior within 30 days before screening.

• Suicidal ideation corresponding to type 4 or 5 on the Columbia-Suicide Severity Rating Scale

within the past 30 days before screening.

General safety:

• Use of non-herbal Chinese medicine or other non-herbal local medicine with

unknown/unspecified content within 90 days before screening.

• Presence of acute pancreatitis within the past 180 days prior to the day of screening.

• History or presence of chronic pancreatitis.

• Calcitonin ≥100 ng/L as measured by the central laboratory at screening.

• Personal or first-degree relative(s) history of multiple endocrine neoplasia type 2 or medullary

thyroid carcinoma.

• Renal impairment measured as estimated glomerular filtration rate value of <15 mL/min/1.73

m2 as defined by KDIGO 20121 by the central laboratory at screening.

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STEP 1 Manuscript – Supplementary Appendix

• History of malignant neoplasms within the past 5 years prior to screening. Basal and squamous

cell skin cancer and any carcinoma in-situ are allowed.

• Any of the following: myocardial infarction, stroke, hospitalization for unstable angina, or

transient ischemic attack within the past 60 days prior to screening.

• Subject presently classified as being in New York Heart Association Class IV.

• Surgery scheduled for the duration of the trial, except for minor surgical procedures, in the

opinion of the investigator.

• Known or suspected abuse of alcohol or recreational drugs.

• Known or suspected hypersensitivity to trial product(s) or related products.

• Previous participation in this trial. Participation is defined as signed informed consent.

• Participation in another clinical trial within 90 days before screening.

• Other subject(s) from the same household participating in any semaglutide trial.

• Female who is pregnant, breast-feeding, or intends to become pregnant, or is of child-bearing

potential and not using a highly effective contraceptive method.

• Any disorder, unwillingness, or inability, not covered by any of the other exclusion criteria, which

in the investigator’s opinion, might jeopardize the subject’s safety or compliance with the

protocol.

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STEP 1 Manuscript – Supplementary Appendix

PATIENT-REPORTED OUTCOMES

Short Form36v2® Health Survey, Acute Version (SF-36)

SF-36 is a generic patient-reported outcome (PRO) instrument measuring health-related quality of

life and general health status across disease areas. It consists of 36 questions (items) across eight

domains (physical functioning, role limitations due to physical health problems, bodily pain, general

health, vitality, social functioning, role limitations due to emotional problems, and mental health).

The SF-36 also provides two aggregated scores: the physical component summary (PCS) and mental

component summary (MCS), created by aggregating the eight domains according to the scoring

algorithm.2 SF-36 scores are norm-based scores, i.e. transformed to a scale where the 2009 US

general population has a mean of 50 and a standard deviation of 10. The lowest to highest scores

are 19.03 to 57.60 for the physical functioning domain, 6.11 to 79.67 for the PCS, and –3.83 to 78.75

for the MCS, reported as norm-based scores. An increase in score represents an improvement in

health status.

Impact of Weight on Quality of Life-Lite Clinical Trials Version (IWQOL-Lite-CT)

The IWQOL-Lite-CT is a 20-item PRO instrument used to assess weight-related physical and

psychosocial functioning in three composite scores (physical, physical function, and psychosocial)

and a total score.3 The range of possible scores for the IWQOL-Lite-CT is 0–100. Larger values on

composite scores as well as total scores of the IWQOL-Lite-CT indicate better patient functioning.

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STEP 1 Manuscript – Supplementary Appendix

ENDPOINTS

Co-primary endpoints

In order of hierarchical testing procedure:

• Change from baseline to week 68 in body weight (%).

• Subjects who after 68 weeks achieve (yes/no) body weight reduction ≥5% from baseline.

Confirmatory secondary endpoints

In order of hierarchical testing procedure:

• Subjects who after 68 weeks achieved (yes/no):

o Body weight reduction ≥10% from baseline.

o Body weight reduction ≥15% from baseline.

• Change from baseline to week 68 in:

o Waist circumference (cm).

o Systolic blood pressure (mmHg).

o SF-36 physical functioning score.

o IWQOL-Lite-CT physical function score.

Supportive secondary endpoints

Efficacy endpoints

• Change from baseline to week 68 in:

o Body weight (kg) and BMI (kg/m2).

o HbA1C (%, mmol /mol), fasting plasma glucose (mg/dL), and fasting serum insulin

(mIU/L).

o Diastolic blood pressure (mmHg).

o Lipids (mg/dL): total cholesterol, high-density lipoprotein cholesterol, low-density

lipoprotein cholesterol, very-low-density lipoprotein cholesterol, free fatty acids,

triglycerides.

o C-reactive protein (mg/L).

o Plasminogen activator inhibitor-1 activity (AU/mL).

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STEP 1 Manuscript – Supplementary Appendix

o Soluble leptin receptor (ng/mL) and leptin (ng/mL).

o SF-36 scores: role-physical, bodily pain, general health, vitality, social functioning,

role-emotional, mental health, PCS, MCS.

o IWQOL-Lite-CT: physical score, psychosocial score, and total score.

• Body composition (assessed by dual energy X-ray absorptiometry [DEXA]) in a subset of

participants:

o Total fat mass (%, kg).

o Total lean body mass (%, kg).

o Regional visceral fat mass (%, kg).

• Body weight (%, kg) in the DEXA subset of participants.

• Subjects who after 68 weeks achieved (yes/no):

o Body weight reduction ≥20% from baseline.

o Responder definition value for SF-36 physical functioning score and IWQOL-Lite-CT

physical function score.

Safety endpoints

• Number of treatment-emergent adverse events from baseline to week 75.

• Number of serious adverse events from baseline to week 75.

• Change from baseline to week 68 in:

o Pulse (bpm).

o Amylase (U/L).

o Lipase (U/L).

o Calcitonin (ng/L).

Exploratory endpoints

• Change from baseline to week 68 in:

o Glycemic category (normo-glycemia, prediabetes, type 2 diabetes).

o Antihypertensive medication (decrease, no change, increase).

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STEP 1 Manuscript – Supplementary Appendix

o Lipid-lowering medication (decrease, no change, increase).

o The Stanford Presenteeism Scale, total score.

o Fatty liver index score category (<30, ≥30 and <60, ≥60).

o International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short

Form, sum score (assessed in female subjects).

o Subjects who from randomization to week 68 discontinued randomized trial product

(yes/no).

o Time to permanent discontinuation of randomized trial product (weeks).

o Number of days/week with at least one entry in the food diary from baseline to week

68.

o Number of minutes/week of physical activity from baseline to week 68.

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STEP 1 Manuscript – Supplementary Appendix

LABORATORY TESTING

The following central laboratory was used for testing in STEP 1:

• ICON Laboratory Services Inc. (all standard laboratory assessments for efficacy and safety, and

central storage of biological samples for future analyses of genetic and circulating biomarkers)

The following laboratory assessments were performed:

Laboratory Parameter Assay/system

assessment
Glucose Fasting plasma glucose Hexokinase/glucose-6-phosphate dehydrogenase assay
metabolism (Abbott ARCHITECT System)
HbA1c Calculation, ion exchange HPLC (BIO-RAD Variant II
Hemoglobin test), boronate affinity chromatography and
HPLC (Trinity Biotech Premier Hb9210)
Fasting serum insulin CMI (Abbott ARCHITECT System)
Lipids Cholesterol Enzymatic assay (Abbott ARCHITECT System)
HDL-C Accelerator selective detergent assay (Abbott ARCHITECT
System)
LDL-C
Liquid selective detergent assay (Abbott ARCHITECT System)
Triglycerides
Glycerol phosphate oxidase assay (Abbott ARCHITECT System)
VLDL-C
Calculated (Abbott ARCHITECT System)
Free fatty acids
Enzymatic assay (Abbott ARCHITECT System)
Biomarkers Plasminogen activator Synthetic chromogenic substrate method (STAGO STA
inhibitor-1 activity Analyzer)
CRP Turbidimetric/immunoturbidimetric assay (Abbott ARCHITECT
System)

Hematology Basophils All assessed by automated cytochemistry/microscopy

(Siemens Healthcare Diagnostics)
Eosinophils
Erythrocytes
Hematocrit
Hemoglobin
Leukocytes
Lymphocytes
Monocytes
Neutrophils
Thrombocytes
Biochemistry ALT NADH (without P-5’-P) assay (Abbott ARCHITECT System)
Albumin Bromcresol green assay (Abbott ARCHITECT System)

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STEP 1 Manuscript – Supplementary Appendix

Alkaline phosphatase Para-nitrophenyl phosphate assay (Abbott ARCHITECT System)

Amylase CNPG3 substrate assay (Abbott ARCHITECT System)
AST NADH (without P-5’-P) assay (Abbott ARCHITECT System)
Calcitonin Chemiluminescent immunometric assay (Siemens Healthcare
Diagnostics)
Creatine kinase N-acetyl-L-cysteine assay (Abbott ARCHITECT System)
Creatinine Enzymatic assay (Abbott ARCHITECT System)
GGT L-Gamma-glutamyl-3-carboxy-4-nitroanilide substrate assay
(Abbott ARCHITECT System)
Lipase Quinone dye assay (Abbott ARCHITECT System)
Potassium Ion-selective electrode diluted (indirect) assay (Abbott
ARCHITECT System)
Sodium Ion-selective electrode diluted (indirect) assay (Abbott
ARCHITECT System)
Thyroid-stimulating CMI (Abbott ARCHITECT System, Trinity Biotech Premier
hormone Hb9210)
Total bilirubin Diazonium salt assay (Abbott ARCHITECT System)
Urea Urease assay (Abbott ARCHITECT System)
Other tests eGFR Calculated using the CKD-EPI creatinine equation as defined by
KDIGO 20121 (Abbott ARCHITECT System)

ALT, alanine aminotransferase; AST, aspartate aminotransferase; CKD-EPI, Chronic Kidney Disease

Epidemiology Collaboration; CMI, chemiluminescent microparticle immunoassay; CNPG3,

2-chloro-4-nitrophenyl-a-D-maltotrioside; CRP, C-reactive protein; eGFR, estimated glomerular

filtration rate; GGT, gamma-glutamyl transferase; HbA1c, glycated hemoglobin; HDL-C, high-density

lipoprotein cholesterol; HPLC, high-performance liquid chromatography; KDIGO, Kidney Disease

Improving Global Outcomes; LDL-C, low-density lipoprotein cholesterol; NADH, nicotinamide

adenine dinucleotide; P-5’-P, pyridoxal-5’-phosphate; VLDL-C, very low-density lipoprotein

cholesterol

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STEP 1 Manuscript – Supplementary Appendix

STATISTICAL ANALYSIS

Two estimands were employed to assess treatment efficacy from different perspectives, and

accounted for intercurrent events and missing data differently, as described previously.4 All analyses

in the statistical hierarchy were based on the primary treatment policy estimand, which quantified

the average treatment effect in all randomized participants regardless of adherence to treatment or

starting rescue interventions (anti-obesity medications or bariatric surgery). Continuous endpoints

were analyzed using analysis of covariance, with randomized treatment as a factor and baseline

endpoint value as a covariate. Categorical endpoints were analyzed using logistic regression, with

the same factor and covariate. Missing data were imputed using a multiple imputation approach.5

The secondary trial product estimand quantified the average treatment effect in all randomized

participants assuming they remained on randomized treatment for the entire study duration and

without rescue interventions. For the trial product estimand, continuous endpoints were assessed

using a mixed model for repeated measurements (MMRM); categorical endpoints were assessed

using logistic regression with treatment as the only factor (for missing data, categorization was

based on values predicted from an MMRM).

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STEP 1 Manuscript – Supplementary Appendix

Analysis and imputation methods to address the treatment policy and trial product estimands for the primary and confirmatory secondary endpoints in

the statistical testing hierarchy.

Objective Endpoint Test order Endpoint type Estimand Statistical model Imputation approach Missing results at
week 68, n (%)
Primary endpoints
Primary % weight change 1 Continuous Treatment policy* ANCOVA RD-MI Placebo: 78 (11.9)
Semaglutide: 94 (7.2)
Trial product† MMRM - Placebo: 212 (32.4)
Semaglutide: 356 (27.3)
Primary 5% responders 2 Binary Treatment policy* LR RD-MI Placebo: 78 (11.9)
Semaglutide: 94 (7.2)
Trial product† LR MMRM Placebo: 212 (32.4)
Semaglutide: 356 (27.3)
Confirmatory secondary endpoints
Primary 10% responders 3 Binary Treatment policy* LR RD-MI Placebo: 78 (11.9)
Semaglutide: 94 (7.2)
Trial product† LR MMRM Placebo: 212 (32.4)
Semaglutide: 401 (30.7)
Primary 15% responders 4 Binary Treatment policy* LR RD-MI Placebo: 78 (11.9)
Semaglutide: 94 (7.2)
Trial product† LR MMRM Placebo: 212 (32.4)
Semaglutide: 356 (27.3)
Primary Waist circumference 5 Continuous Treatment policy* ANCOVA RD-MI Placebo: 80 (12.2)
change (cm) Semaglutide: 96 (7.4)
Trial product† MMRM - Placebo: 212 (32.4)

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STEP 1 Manuscript – Supplementary Appendix

Semaglutide: 356 (27.3)

Secondary Systolic blood 6 Continuous Treatment policy* ANCOVA RD-MI Placebo: 81 (12.4)
pressure change Semaglutide: 96 (7.4)
(mmHg)
Trial product† MMRM - Placebo: 212 (32.4)
Semaglutide: 356 (27.3)
Secondary SF-36 physical 7 Continuous Treatment policy* ANCOVA RD-MI Placebo: 86 (13.1)
functioning score Semaglutide: 103 (7.9)
change
Trial product† MMRM - Placebo: 216 (33.0)
Semaglutide: 364 (27.9)
Secondary IWQOL-Lite-CT 8 Continuous Treatment policy* ANCOVA RD-MI Placebo: 86 (13.1)
physical function Semaglutide: 105 (8.0)
score change
Trial product† MMRM - Placebo: 216 (33.0)
Semaglutide: 366 (28.0)

*Designated as the primary estimand.

†Designated as the secondary estimand.

ANCOVA, analysis of covariance; FAS, full analysis set; IWQOL-Lite-CT, Impact of Weight on Quality of Life-Lite Clinical Trials Version; LR, logistic regression;

MMRM, mixed model for repeated measurements; RD-MI, multiple imputation using retrieved subjects; SF-36, Short Form36v2® Health Survey, Acute

Version.

Test order refers to the order of the endpoint in the statistical test hierarchy. All analyses were performed using the full analysis set.

See Section 2.3 in the Statistical Analysis Plan for a description of imputation methods.

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STEP 1 Manuscript – Supplementary Appendix

SUPPLEMENTARY TABLES

Table S1. Baseline demographics and clinical characteristics in the DEXA subpopulation

DEXA subpopulation
Semaglutide Placebo once Overall study
2.4 mg once weekly Total population
weekly (N=95) (N=45) (N=140) (N=1961)*
Age – years 50 ± 12 52 ± 13 51 ± 12 46 ± 13
Female sex – n (%) 72 (75.8) 34 (75.6) 106 (75.7) 1453 (74.1)
Race – n (%)
White 75 (78.9) 41 (91.1) 116 (82.9) 1472 (75.1)
Black or African American 18 (18.9) 3 (6.7) 21 (15.0) 111 (5.7)
Asian 1 (1.1) 1 (2.2) 2 (1.4) 261 (13.3)
Other† 1 (1.1) 0 1 (0.7) 117 (6.0)
Hispanic or Latino ethnic group 2 (2.1) 6 (13.3) 8 (5.7) 236 (12.0)
– n (%)
Body weight – kg 98.3 ± 15.9 98.7 ± 12.1 98.4 ± 14.7 105.3 ± 21.9
BMI
Mean – kg/m2 34.8 ± 3.6 35.0 ± 3.6 34.8 ± 3.6 37.9 ± 6.7
2
<30 kg/m – n (%) 7 (7.4) 4 (8.9) 11 (7.9) 117 (6.0)
2
≥30 – <35 kg/m – n (%) 41 (43.2) 17 (37.8) 58 (41.4) 643 (32.8)
2
≥35 – <40 kg/m – n (%) 43 (45.3) 23 (51.1) 66 (47.1) 614 (31.3)
≥40 kg/m2 – n (%) 4 (4.2) 1 (2.2) 5 (3.6) 587 (29.9)
Waist circumference – cm 109.4 ± 10.6 111.0 ± 10.1 109.9 ± 10.4 114.7 ± 14.6
Glycated hemoglobin – % 5.7 ± 0.4 5.7 ± 0.3 5.7 ± 0.3 5.7 ± 0.3
Body composition (DEXA)
Total fat mass‡
Kg 42.1 ± 10.1 43.3 ± 9.2 42.5 ± 9.8 –
% 43.4 ± 7.5 44.6 ± 8.1 43.8 ± 7.7 –
§
Regional visceral fat mass
Kg 1.3 ± 0.6 1.5 ± 0.7 1.3 ± 0.6 –
% 33.8 ± 9.9 36.3 ± 12.3 34.6 ± 10.7 –
‡
Total lean body mass
Kg 52.4 ± 11.6 51.5 ± 10.8 52.1 ± 11.3 –
% 53.9 ± 7.4 52.7 ± 7.7 53.5 ± 7.5 –

All data presented as mean ± standard deviation, unless indicated otherwise.

*Overall study population data included for comparative purposes. Additional baseline demographic

and clinical characteristics for the overall study population are described in Table 1 in the main

manuscript.

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STEP 1 Manuscript – Supplementary Appendix

†Including American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, Other and

Not Applicable, the latter of which is how race was recorded in France.

‡
Percentages calculated for total fat mass and lean body mass as the respective values divided by

total body mass.

§
Visceral fat mass was calculated in the L4 region (males or females), android region (males only), or

in the gynoid region (females only), depending on the methodology of the scanner available at

participating study sites. Percentage visceral fat mass values are relative to the area assessed, not

total body mass.

BMI, body mass index; DEXA, dual energy X-ray absorptiometry.

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STEP 1 Manuscript – Supplementary Appendix

Table S2. Co-primary, Confirmatory and Selected Supportive Secondary Endpoints for the Trial

Product Estimand*†

Semaglutide
2.4 mg Placebo Treatment comparison for
once weekly once weekly semaglutide vs. placebo
(N=1306) (N=655) [95% CI]
Co-primary endpoint assessed in the overall population
Body weight change from baseline to –16.86 –2.44 ETD: –14.42 [–15.29; –13.55]
week 68 – %
Body weight reduction ≥5% – proportion 92.4 33.1 OR: 37.0 [28.0; 49.0]
of participants (%) at week 68
Confirmatory secondary endpoints assessed in the overall population
Body weight reduction ≥10% – proportion of 74.8 11.8 OR: 30.0 [22.5; 40.0]
participants (%) at week 68
Body weight reduction ≥15% – proportion of 54.8 5.0 OR: 31.8 [21.0; 48.3]
participants (%) at week 68
Waist circumference change from baseline to –15.22 –4.48 ETD: –10.75 [–11.61; –9.88]
week 68 – cm
Systolic blood pressure change from baseline to –7.08 –1.14 ETD: –5.93 [–7.19; –4.68]
week 68 – mmHg
SF-36 physical functioning score change from 2.56 0.50 ETD: 2.06 [1.43; 2.70]
baseline to week 68
IWQOL-Lite-CT physical function score change 16.08 6.51 ETD: 9.57 [7.71; 11.44]
from baseline to week 68
Selected supportive secondary endpoints assessed in the overall population
Body weight reduction ≥20% – proportion of 34.8 2.0 OR: 42.2 [20.8; 85.6]
participants (%) at week 68
Body weight change from baseline to week 68 – –17.4 –2.7 ETD: –14.7 [–15.6; –13.7]
kg
BMI change from baseline to week 68 – kg/m2 –6.27 –0.95 ETD: –5.33 [–5.65; –5.00]
Glycated hemoglobin change from baseline to –0.50 –0.16 ETD: –0.34 [–0.37; –0.31]
week 68 – percentage-points
Fasting plasma glucose change from baseline to –9.90 –1.00 ETD: –8.90 [–9.84; –7.96]
week 68 – mg/dL
Diastolic blood pressure change from baseline to –2.99 –0.59 ETD: –2.40 [–3.28; –1.52]
week 68 – mmHg
Lipids ratio to baseline at week 68‡
Total cholesterol 0.96 1.00 ETR: 0.96 [0.94; 0.97]
HDL cholesterol 1.05 1.02 ETR: 1.03 [1.02; 1.05]
LDL cholesterol 0.96 1.01 ETR: 0.95 [0.93; 0.98]
VLDL cholesterol 0.76 0.92 ETR: 0.82 [0.79; 0.85]
Free fatty acids 0.81 0.92 ETR: 0.88 [0.82; 0.94]
Triglycerides 0.76 0.92 ETR: 0.82 [0.79; 0.86]
‡ 0.42 0.80 ETR: 0.52 [0.47; 0.57]
CRP ratio to baseline at week 68

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STEP 1 Manuscript – Supplementary Appendix

Supportive secondary endpoints assessed in the DEXA subpopulation

N=95 N=45
Body composition change from baseline to
week 68 (DEXA)
Total fat mass
Kg change –10.40 –1.17 ETD: –9.23 [–12.72; –5.74]
Percentage-points change in total fat mass –4.19 –0.19 ETD: –4.00 [–6.27; –1.73]
proportion§
Regional visceral fat mass¶
Kg change –0.47 –0.03 ETD: –0.45 [–0.60; –0.30]
Percentage-points change in regional visceral –2.65 0.58 ETD: –3.23 [–5.35; –1.10]
fat mass proportion‖
Total lean body mass
Kg change –6.92 –1.48 ETD: –5.44 [–7.07; –3.81]
Percentage-points change in total lean body 3.61 0.11 ETD: 3.50 [1.35; 5.64]
mass proportion§

*The trial product estimand assesses treatment effect if trial product was taken as intended (i.e. if all

participants adhered to treatment and did not receive rescue intervention). Treatment policy

estimand data are reported in Table 2. Denominators for the percentages of participants observed

to have body-weight reduction of ≥5%, ≥10%, ≥15%, and ≥20% at week 68 are the numbers of

participants for whom data were available from the week 68 visit — 1059 participants in the

semaglutide group and 499 participants in the placebo group.

†All analyses in the statistical hierarchy were based on the primary treatment policy estimand and P

values are therefore not reported.

‡Data presented as ratio to baseline and estimated treatment ratio (ratios to baseline and

corresponding baseline values were log-transformed prior to analysis).

§
Percentage-point changes in total fat mass and lean body mass proportions, which are calculated as

the respective values divided by total body mass.

¶
Visceral fat mass was calculated in the L4 region (males or females), android region (males only), or

in the gynoid region (females only), depending on the methodology of the scanner available at

participating study sites.

20
STEP 1 Manuscript – Supplementary Appendix

‖
Percentage-point changes in visceral fat mass proportions, which are the visceral fat mass relative

to the area assessed, not total body mass.

Endpoints were analyzed using a mixed model for repeated measurements.

BMI, body mass index; CI, confidence interval; CRP, C-reactive protein; DEXA, dual energy X-ray

absorptiometry; ETD, estimated treatment difference; ETR, estimated treatment ratio; HDL, high-

density lipoprotein; IWQOL-Lite-CT, Impact of Weight on Quality of Life-Lite Clinical Trials Version;

LDL, low-density lipoprotein; OR, odds ratio; SF-36, Short Form36v2® Health Survey, Acute Version;

VLDL, very-low-density lipoprotein.

21
STEP 1 Manuscript – Supplementary Appendix

Table S3. Selected Supportive Secondary and Exploratory Endpoints for the Treatment Policy

Estimand*

Treatment comparison
Semaglutide 2.4 mg Placebo for semaglutide vs. placebo
once weekly once weekly [95% CI]

Overall population
N=1306 N=655

Fasting serum insulin – pmol/L, ratio to 0.74 0.93 ETR: 0.79 [0.74, 0.83]
baseline at week 68

Alanine aminotransferase – ratio to 0.76 0.94 ETR: 0.81 [0.77, 0.86]

baseline at week 68†

Aspartate aminotransferase – ratio to 0.89 0.99 ETR: 0.90 [0.88, 0.93]

baseline at week 68†

Antihypertensive medication – %

Decreased 14 5

No change 53 62

Increased 12 22

Stopped 20 11

Lipid lowering medication – %

Decreased 4 5

No change 69 63

Increased 10 20

Stopped 17 12

*The treatment policy estimand assesses treatment effect regardless of treatment discontinuation

or rescue intervention; see Supplementary Appendix, Table S4 for corresponding data for the trial

product estimand (assesses treatment effect assuming all participants adhered to treatment and did

not receive rescue intervention). Supportive secondary endpoint analyses were not adjusted for

multiplicity and P values are therefore not reported for these endpoints.

†
Not a prespecified endpoint.

CI, confidence interval; ETR, estimated treatment ratio.

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STEP 1 Manuscript – Supplementary Appendix

Table S4. Proportions of Participants Achieving a Clinically Meaningful Within-person

Improvement in Score from Baseline to Week 68 (%), Treatment Policy Estimand*†‡

Treatment comparison
Semaglutide 2.4 mg Placebo for semaglutide vs. placebo
once weekly once weekly [95% CI]

SF-36 physical functioning (≥3.7 points) ‡ 40.0 27.0 OR: 2.08 [1.60, 2.70]

IWQOL-Lite-CT physical function (≥14.6 51.2 32.9 OR: 2.72 [2.14, 3.47]
points) ‡

SF-36 scores are norm-based scores (transformed to a scale where the 2009 US general population

has a mean of 50 and a standard deviation of 10).

*The treatment policy estimand assesses treatment effect regardless of treatment discontinuation

or rescue intervention; see Supplementary Appendix, Table S4 for corresponding data for the trial

product estimand (assesses treatment effect assuming all participants adhered to treatment and did

not receive rescue intervention). Supportive secondary endpoint analyses were not adjusted for

multiplicity and P values are therefore not reported for these endpoints.

†
Not a prespecified endpoint.

‡
Threshold values for clinically meaningful within-patient improvements (responder thresholds) are

anchor-based obesity-specific thresholds.

CI, confidence interval; IWQOL-Lite-CT, Impact of Weight on Quality of Life-Lite Clinical Trials

Version; OR, odds ratio; SF-36, SF-36v2® Health Survey acute version.

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STEP 1 Manuscript – Supplementary Appendix

Table S5. Supportive Secondary Endpoints Assessed in the DEXA Subpopulation for the Treatment

Policy Estimand*

Treatment comparison
Semaglutide 2.4 mg Placebo for semaglutide vs. placebo
once weekly once weekly [95% CI]
N=95 N=45
Body composition change from baseline to
week 68 (DEXA)
Total fat mass
Kg change –8.36 –1.37 ETD: –6.99 [–9.79; –4.19]
Percentage-points change in total fat –3.48 –0.19 ETD: –3.29 [–4.94; –1.65]
mass proportion†
Regional visceral fat mass‡
Kg change –0.36 –0.10 ETD: –0.27 [–0.39; –0.15]
Percentage-points change in regional –1.99 –0.01 ETD: –1.98 [–3.69; –0.27]
visceral fat mass proportion§
Total lean body mass
Kg change –5.26 –1.83 ETD: –3.43 [–4.74; –2.13]
Percentage-points change in total lean 3.04 0.09 ETD: 2.94 [1.40; 4.49]
body mass proportion†

*The treatment policy estimand assesses treatment effect regardless of treatment discontinuation

or rescue intervention; see Supplementary Appendix, Table S4 for corresponding data for the trial

product estimand (assesses treatment effect assuming all participants adhered to treatment and did

not receive rescue intervention). Supportive secondary endpoint analyses were not adjusted for

multiplicity and P values are therefore not reported for these endpoints.

†
Percentage-point changes in total fat mass and total lean body mass proportions, which are

calculated as the respective values divided by total body mass.

‡
Visceral fat mass was calculated in the L4 region (males or females), android region (males only), or

in the gynoid region (females only), depending on the methodology of the scanner available at

participating study sites.

§
Percentage-point changes in visceral fat mass proportions, which are the visceral fat mass relative

to the area assessed, not total body mass.

24
STEP 1 Manuscript – Supplementary Appendix

Continuous endpoints were analyzed using analysis of covariance, with randomized treatment as a

factor and baseline endpoint value as a covariate, and a multiple imputation approach for missing

data.5 Categorical endpoints were analyzed using logistic regression, with the same factor and

covariate.

CI, confidence interval; DEXA, dual energy X-ray absorptiometry; ETD, estimated treatment

difference.

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STEP 1 Manuscript – Supplementary Appendix

Table S6. Supportive Secondary Safety Endpoints, On-treatment*

Semaglutide 2.4 mg Placebo

once weekly once weekly
N Mean N Mean
Pulse – bpm
Baseline 1306 72 ± 10 655 72 ± 10
Week 68 1059 75 ± 9 499 71 ± 10
Change from baseline to week 68† 1306 3.52 655 –0.74
Estimated treatment difference 4.26 [3.38; 5.15]
(semaglutide vs. placebo) [95% CI]†
Amylase – U/L
Baseline 1306 48 (35.7) 655 48 (35.5)
Week 68 1053 55 (37.3) 497 49 (35.9)
Ratio to baseline at week 68 1053 1.14 (21.6) 497 1.03 (21.4)
Lipase – U/L
Baseline 1306 25 (53.8) 654 25 (52.6)
Week 68 1053 36 (59.4) 497 24 (51.4)
Ratio to baseline at week 68 1053 1.41 (49.3) 496 0.97 (37.3)
Calcitonin – ng/L
Baseline 1306 1.4 (77.3) 655 1.3 (77.4)
Week 68 1050 1.4 (77.5) 497 1.3 (70.8)
Ratio to baseline at week 68 1050 0.99 (37.6) 497 0.95 (40.9)

Data are descriptive statistics presented as arithmetic mean ± standard deviation or geometric mean

(coefficient of variation), unless indicated otherwise.

*During treatment with trial product (any dose of trial medication administered within the previous

2 weeks [i.e. any period of temporary treatment interruption with trial product was excluded]).

†Trial product estimand data (assesses treatment effect if trial product was taken as intended [i.e. if

all participants adhered to treatment and did not receive rescue intervention]) analyzed using a

mixed model for repeated measurements.

CI, confidence interval.

26
STEP 1 Manuscript – Supplementary Appendix

SUPPLEMENTARY FIGURES

Figure S1. Trial Design

*As an adjunct to lifestyle intervention (–500 kcal/day diet with 150 min/week physical activity).

†
End of trial for the main phase.

OW, once weekly; s.c., subcutaneous.

27
STEP 1 Manuscript – Supplementary Appendix

Figure S2. Participant Flow

Among treatment completers in the semaglutide group, 89.6% were receiving the 2.4 mg maintenance dose at

week 68, 4.4% were receiving a dose between 1.7 mg and <2.4 mg, and 5.2% were receiving a semaglutide

dose <1.7mg; the remainder did not have a dose reported at this timepoint. Among treatment completers in

the placebo group, 98.0% completed treatment with the placebo equivalent of the semaglutide 2.4 mg dose;

the remainder were on a lower dose or did not have a dose reported at this timepoint.

DEXA, dual energy X-ray absorptiometry; s.c., subcutaneous.

28
STEP 1 Manuscript – Supplementary Appendix

Figure S3. Cumulative Distribution Plot of Change from Baseline to Week 68 in Body Weight

Cumulative distribution plot of observed percentage change from baseline over time in body weight for participants in the full analysis set during the in-trial

observation period* (A) and on-treatment observation period† (B).

*From randomization to last contact with trial site, regardless of treatment discontinuation or rescue intervention.

†During treatment with trial product (any dose of trial medication administered within the previous 2 weeks [i.e. any period of temporary treatment

interruption with trial product was excluded]).

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STEP 1 Manuscript – Supplementary Appendix

Figure S4. Body Weight in Kilograms by Week

Observed mean body weight (kg) over time for participants in the full analysis set during the in-trial
observation period.* Error bars are ± standard error of the mean. N numbers represent the number of
participants with available data contributing to the means at each visit.

*From randomization to last contact with trial site, regardless of treatment discontinuation or rescue
intervention.

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STEP 1 Manuscript – Supplementary Appendix

Figure S5. Semaglutide 2.4 mg Once Weekly Compared with Placebo on Selected Confirmatory Secondary Endpoints*

Observed mean change from baseline over time in waist circumference (A), and systolic blood pressure (B) for participants in the full analysis set during the in-trial

observation period.† Error bars are ± standard error of the mean. N numbers represent the number of participants with available data contributing to the means at each

visit.

*The secondary confirmatory endpoints of achievement of weight loss ≥10% and ≥15% are reported in the results text and in Figure 1; secondary confirmatory endpoints of

SF-36 and IWQOL-Lite-CT are reported in Figure S7.

†
From randomization to last contact with trial site, regardless of treatment discontinuation or rescue intervention.

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STEP 1 Manuscript – Supplementary Appendix

Figure S6. Change from Baseline by Week in Diastolic Blood Pressure

Data presented as observed mean change from baseline over time in diastolic blood pressure in the

full analysis set during the in-trial observation period (from randomization to last contact with trial

site, regardless of treatment discontinuation or rescue intervention). Error bars are ± standard error

of the mean. N numbers represent the number of participants with available data contributing to

the means at each visit.

32
STEP 1 Manuscript – Supplementary Appendix

Figure S7. Semaglutide 2.4 mg Once Weekly Compared with Placebo on Patient-reported Outcomes for the SF-36 and IWQOL-Lite-CT

33
STEP 1 Manuscript – Supplementary Appendix

34
STEP 1 Manuscript – Supplementary Appendix

Observed mean change from baseline over time in SF-36 physical functioning score (A), and IWQOL-Lite-CT physical function score (B) for participants in the

full analysis set during the in-trial observation period.† Error bars are ± standard error of the mean. N numbers represent the number of participants with

available data contributing to the means at each visit.

†
From randomization to last contact with trial site, regardless of treatment discontinuation or rescue intervention.

Panels (C–F) are data presented as estimated treatment differences for semaglutide vs. placebo (boxes) and associated 95% CIs (whiskers) for participants

in the full analysis set based on the treatment policy estimand‡ for (C) and (E), and the trial product estimand$ for (D) and (F). SF-36 scores are norm-based

scores, which were transformed to a scale where the 2009 US general population has a mean of 50 and a standard deviation of 10.

‡
Assesses treatment effect regardless of treatment discontinuation or rescue intervention. Endpoints were analyzed using analysis of covariance, with

randomized treatment as a factor and baseline endpoint value as a covariate, and a multiple imputation approach for missing data.5

$
Assesses treatment effect if trial product was taken as intended (i.e. if all participants adhered to treatment and did not receive rescue intervention).

Endpoints were analyzed using a mixed model for repeated measurements.

CI, confidence interval; ETD, estimated treatment difference; IWQOL-Lite-CT, Impact of Weight on Quality of Life-Lite Clinical Trials Version; SF-36, Short

Form36v2® Health Survey, Acute Version.

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STEP 1 Manuscript – Supplementary Appendix

Figure S8. Prevalence and Duration of Gastrointestinal Events by Severity

Figure presents the proportion of participants receiving semaglutide or placebo who reported nausea (A), diarrhea (B), vomiting (C), or constipation (D)

events classed as mild, moderate, or severe, over the course of the treatment period and the median duration of the event. Data are on-treatment

observation period data (during treatment with trial product [any dose of trial medication administered within the previous 49 days (i.e. any period of

temporary treatment interruption with trial product was excluded)]). Adverse events were classified by severity as mild (easily tolerated, causing minimal

36
STEP 1 Manuscript – Supplementary Appendix

discomfort and not interfering with everyday activities), moderate (causes sufficient discomfort and interferes with normal everyday activities) or severe

(prevents normal everyday activities).

37
STEP 1 Manuscript – Supplementary Appendix

Figure S9. Time to First Onset of Adverse Events Leading to Permanent Trial Product

Discontinuation

Data are on-treatment observation period data (during treatment with trial product [any dose of

trial medication administered within the previous 49 days (i.e. any period of temporary treatment

interruption with trial product was excluded)]).

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STEP 1 Manuscript – Supplementary Appendix

REFERENCES

1. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical

practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl

2013;3:1-150.

2. Ware JE Jr., Gandek B. Overview of the SF-36 Health Survey and the International Quality of Life

Assessment (IQOLA) Project. J Clin Epidemiol 1998;51(11):903-12.

3. Kolotkin RL, Williams VSL, Ervin CM, et al. Validation of a new measure of quality of life in obesity

trials: Impact of Weight on Quality of Life-Lite Clinical Trials version. Clin Obes 2019;9:e12310.

4. Wharton S, Astrup A, Endahl L, et al. Estimating and interpreting treatment effects in clinical trials

for weight management: implications of estimands, intercurrent events and missing data. Int J Obes

2020; In press.

5. Kushner RF, Calanna S, Davies M, et al. Semaglutide 2.4 mg for the treatment of obesity: key

elements of the STEP trials 1 to 5. Obesity 2020;6:1050-61.

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