At the November 2022 Obesity Week in San Diego, it was clear something big was happening. A late-breaking session released results of the STEP TEENS phase IIIa trial, showing 16 percent weight loss in adolescents with obesity treated with once-weekly semaglutide (Wegovy) for 68 weeks. The side effects were manageable and similar to those experienced in adults: nausea, vomiting, and constipation.
A month later, semaglutide received FDA approval for weight management in adolescents ages 12 and older. Just a month after that, the American Academy of Pediatrics (AAP) released the first-ever clinical practice guidelines for the treatment of children and adolescents with obesity, including pharmacological options when appropriate.
In the two years since, the game dramatically changed: thousands of adolescents have taken medications for the treatment of obesity. In fact, a research letter in JAMA showed a 600 percent increase in pharmacological treatment in the past three years, with nearly 61,000 U.S. adolescents having been started on medications.
Meanwhile, pediatric clinicians like myself are scrambling to familiarize themselves with the medications. We must help families decide when medication is most appropriate—and which one—while considering potential side effects, risks, benefits, and unknowns. Once we have cleared an often astronomical hurdle in insurance approval, we have to figure out which pharmacy has sufficient stock.
And then comes the billion-dollar question: What do we do when the medication is no longer an option for a patient? In my experience, that can happen due to shortages, lack of insurance coverage or inability to pay, significant side effects, or inability or unwillingness to continue the monthly behavioral coaching visits that our clinic requires.
The emotional weight of stopping GLP-1s
My patients know and fear that if the GLP-1 medication is no longer an option, the weight is very likely to come back.
For young patients who have been consistently taking the medication and have experienced significant weight loss and health benefits—and secondary gains like improved confidence, better body image, and increased mobility—the emotional impact of stopping medication should not be underestimated. I have witnessed the anxiety and distress this causes, and it can be intense.
Most have struggled for years with the impact of severe obesity and have tried to “eat less, move more” with little effect. After having experienced such significant changes on the medication, the thought of being without it and gaining back lost weight feels overwhelming.
But what does that mean for a young person who has 70-plus years of life in front of them? What are the ethical considerations, recognizing the many unknowns surrounding the medications, including how long they will be available?
Not every adolescent can stay on anti-obesity medication forever, especially in this age of poor access, extreme expense, and side effects. From when we write the first prescription, we need to be talking about and preparing for the day when the medication may not be there.
What do we say? How do we say it?
Prepare today for a day the medications may be stopped.
At my clinic, we have a steadfast commitment to prioritizing behavioral change for every patient we treat. Specifically, we focus on building and nurturing a healthy approach to nutrition, activity, sleep, media use, and social-emotional wellness, which includes things like stress management, mindfulness, and managing relationships. This is consistent with AAP recommendations on how pediatricians can promote healthy, active living, and recommendations from the U.S. Preventive Services Task Force that focus on intensive health behavioral lifestyle treatment—as opposed to medication—for addressing pediatric obesity.
With my patients, I discuss the pharmacological treatment options, including their benefits, risks, and unknowns. The unknowns include how long we will be able to use them and what may happen when they are stopped. We emphasize that medications are not stand-alone therapy; they must be used alongside behavioral intervention.
At the end of the day, while the behavioral changes may not result in the degree of weight loss that anti-obesity medications provide, they can help mitigate physical and mental comorbidities. And they help sustain positive health changes when the medications are stopped. Moreover, medically supervised behavior change intervention helps to reduce the risk of eating disorders and helps prevent teens from taking change into their own hands, which can prove devastating. Our goal is always to focus on and promote physical and mental health.
In sum, these are my recommendations for clinicians considering starting adolescents on anti-obesity medications:
- At the time of the initial prescription, prepare for the time when the medication will stop.
- Incorporate as intensive of a behavioral intervention as possible into the treatment plan to help optimize health behaviors, mitigate the changes that come with pharmacological treatment (such as loss of lean body mass), and provide consistency when there are gaps or stops in pharmacological treatment.
- Appreciate that obesity is a multifactorial complex chronic disease. Advocate for systems change to help in the prevention of obesity, decreased weight bias and stigma, and long-term access to evidence-based treatment, including behavioral interventions as well as pharmacological and surgical therapies.
GLP-1s will revolutionize adolescent obesity treatment. But they are not stand-alone therapy. A focus on intensive health behavior lifestyle intervention will support long-term health and wellness, even when medication may no longer be an option.
Natalie Muth is a pediatrician.
