Weight Loss
Sonya Collins
Use of weight loss medications is on the rise among adolescents with obesity, but the number of prescriptions account for very few of the U.S. adolescents for whom the drugs are indicated, according to CDC’s June 5 Morbidity and Mortality Weekly Report. Morbidity and Mortality Weekly Report.
“Several factors contribute to the low prescription rate: limited long-term safety data; access barriers; provider hesitancy; and a preference for lifestyle interventions over pharmacotherapy,” said Jennifer Clements, PharmD, a clinical professor at the University of South Carolina College of Pharmacy. “Finally, stigma around obesity treatment in youth may discourage families from pursuing medications.”
Adolescent obesity far outpaces prescribing
About 1 in 5 adolescents between the ages of 12 years and 17 years has obesity. To address this public health concern, in 2022, FDA expanded approval of two weight loss medications, semaglutide (Wegovy) and phentermine + topiramate extended release (Qsymia), to adolescents aged 12 years to 17 years with obesity, defined as a BMI ≥95th percentile.
On the heels of these expanded approvals, in 2023, the American Academy of Pediatrics released a clinical practice guideline calling for pediatric health care providers to “offer adolescents 12 years and older with obesity weight loss pharmacotherapy, according to medication indications, risks and benefits, as an adjunct to health and lifestyle treatment.”
The recent CDC report found that while total prescriptions for weight loss medications for adolescents have increased by about 300%, this only amounts to prescriptions for 0.5% of adolescents with obesity.
Critical barriers
The findings likely highlight broad sweeping access barriers.
“Cost and reimbursement are the most challenging barrier to the use of obesity treatment medications,” said Sarah Barlow, MD, a pediatric gastroenterologist who oversees obesity care at UT Southwestern Medical Center.
Research presented at the 2024 Endocrine Society Annual Meeting found that Medicaid covered only 29% of GLP-1 receptor agonist prescriptions for adolescents with obesity who did not have T2D. Private insurance did marginally better at 41% of prescriptions.
Crucial information lacking
While the American Academy of Pediatrics stands behind obesity medication for adolescents, including injectables, “pediatric providers lack experience and comfort using injectable obesity medications,” Barlow said.
Beyond experience, many providers point out the lack of long-term data available.
“Limited long-term safety data for GLP-1 receptor agonists in adolescents raises prescriber caution, as these drugs are relatively new for pediatric use,” said Clements.
This is a key concern given that adolescent patients may be starting these medications while they are still growing and will be taking them long term.
Lack of safety data shines a light on the many unknowns related to managing young patients on obesity medications. Barlow cites several open questions, such as:
- When is weight loss too rapid?
- How much muscle mass loss is too much?
- What are physical activity recommendations to preserve muscle?
- How should providers monitor bone health?
- How much protein do adolescents on these medications need?
Family concerns and misconceptions
A small study by Smith and colleagues published in Childhood Obesity in 2023 found that just a third of parents of children with obesity knew that medication was an option. Those who do know may hold stigmatizing beliefs that prevent them from asking about it.
Adolescents themselves also may not seek pharmacotherapy. “Concern about weight may be low among some patients,” Barlow said. “Class 1 obesity is so common now that patients may not have health concerns about their weight.”
Medication may not be for everyone
American Academy of Pediatrics guidelines, Barlow said, “do not mean that every adolescent with any level of obesity should have a prescription. They mean that these medications, based on the evidence, should be a consideration. The more severe the obesity and associated medical conditions, the more valuable these medications will be to improve health.”
“Pharmacotherapy is not first-line for most adolescents with obesity. Prescribing should be reserved for severe cases—that is a BMI greater than or equal to 120% of 95th percentile—with comorbidities, such as type 2 diabetes or hypertension, where benefits outweigh risks,” she said. ■