Visceral and Ectopic Fat Remodeling with Incretin-Based Therapies in Type 2 Diabetes: Human Imaging Evidence

Incretin-based therapies change the distribution of adipose tissue and ectopic lipid during weight loss. This narrative review examines human imaging evidence across abdominal, hepatic, pancreatic, cardiac and skeletal-muscle fat during treatment with selective glucagon-like peptide-1 (GLP-1) receptor agonists and dual- and triple-receptor agonists. Adults with type 2 diabetes are the primary population; findings from mixed diabetes populations and obesity-related disorders are identified separately. The central question is how depot responses relate to overall weight loss and organ outcomes. Hepatic fat has the most mature evidence, and visceral-fat reduction is supported across multiple studies. Tirzepatide provides the most extensive linked multi-depot imaging dataset, while recent survodutide findings extend GLP-1/glucagon imaging evidence to abdominal fat in obesity without diabetes. Cardiac and skeletal-muscle studies extend assessment to tissue composition and ventricular remodeling; pancreatic, renal sinus and other perivascular responses remain exploratory. Imaging modality, anatomical coverage, segmentation and endpoint definition vary across studies, and receptor comparisons are uneven in their populations, comparators and depots assessed. Remodeling is predominantly weight-associated, with selected studies identifying disproportionate hepatic or visceral responses. Imaging can connect these responses to the organ phenotype of interest: hepatic disease activity, cardiac structure or muscle composition. The next step is to test whether repeated depot measurements improve prediction of functional and clinical outcomes beyond routine weight and metabolic assessment.