In 2023, the American Academy of Pediatrics (AAP) issued new guidelines on addressing childhood obesity, including the use of anti-obesity medications such as Wegovy and Ozempic – both approved for use in children ages 12 and older. We’ll examine the guidance as two childhood obesity medicine specialists weigh their opinions on medication-assisted obesity control.
Guests:
Claudia Fox, MD, MPH, Associate Professor of Pediatrics, Co-Director of the Center for Pediatric Obesity Medicine, University of Minnesota
Jason Langheier, MD, MPH, Founder & CEO, Foodsmart
Host/Producer: Carol Vassar
TRANSCRIPT
Announcer:
Welcome to Well Beyond Medicine, the world’s top-ranked children’s health podcast produced by Nemours Children’s Health. Subscribe on any platform at Nemourswellbeyond.org or find us on YouTube.
Carol Vassar, podcast host/producer:
Each week we’ll be joined by innovators and experts from around the world, exploring anything and everything related to the 85% of child health impacts that occur outside the doctor’s office. I’m your host, Carole Vassar, and now that you’re here, let’s go.
MUSIC:
Let’s go, Well Beyond Medicine.
Carol Vassar, podcast host/producer:
The Centers for Disease Control and Prevention reports that approximately one in five US children and adolescents have obesity. It’s an epidemic that is harming a broad cross-section of children with the potential to undermine their health and well-being across the lifespan. When one considers the multitude of factors that contribute to the obesity epidemic, biological, behavioral, social, economic, environmental, and cultural, treating the issue is complex, yet necessary for the health of our nation’s children, our future adults.
In 2023, the American Academy of Pediatrics came out with guidance on how to childhood obesity, and today we’ll examine one aspect of that guidance, the use of anti-obesity medications in children. Joining me to talk about this is Dr. Claudia Fox, associate professor of pediatrics and co-director of the Center for Pediatric Obesity Medicine at the University of Minnesota. She’ll help us to better understand AAP’s guidance in this area and GLP-1 receptor agonists and how they work in the body. We’ll also hear from Dr. Jason Langheier, CEO and founder of Foodsmart. Dr. Langheier is the founder and former director of the Nutrition and Fitness for Life Pediatric Obesity Program at Boston Medical Center.
First though, what does the American Academy of Pediatrics say in its 2023 guidance when it comes to tackling childhood obesity broadly, and with respect to anti-obesity medications specifically? Here’s Dr. Claudia Fox.
Claudia Fox, MD, University of Minnesota:
The American Academy of Pediatrics, in their most recent clinical practice guideline that was published in January of 2023, suggested that when faced with a child who has obesity, that we should be offering that child all interventions that are indicated or appropriate. In contrast to previous recommendations were to proceed in sort of this staged approach, where yes, we would start with diet and exercise first, see how that goes for a while. If that’s not working, then proceed to add on medication, and if that didn’t work, then proceed to metabolic and bariatric surgery. That staged approach is no longer recommended. In contrast, it is let’s provide the most intensive interventions that are available that are appropriate for the child that you have in front of you.
So if I have, say, a six-year-old whose BMI is just a little bit above the 95th percentile, we’re not talking about medications for that child, no. We’re going to talk about healthy eating, healthy activity, good sleep, mood regulation, those sorts of things. In contrast, if I have a 12-year-old who weighs 250 pounds and already has high blood pressure, I’m not going to talk about just diet and exercise with them on day one, no, we’re going to talk about medications as well, and even possibly weight loss surgery, all at that initial evaluation.
Carol Vassar, podcast host/producer:
As we talk about obesity medication in the pediatric world, are we talking about the new medications that have become kind of in fashion for adults, or are we talking about a class and group of medications that perhaps are specific to pediatrics, and how long have obesity medications been around for the pediatric set?
Claudia Fox, MD, University of Minnesota:
Yeah, so great questions. The medications that we’re talking about today are indeed the very same ones that have received lots of news for adults. So these are the GLP-1 receptor agonists, which are approved not only in adults, but some of them are also approved in children as young as age 12. We’re talking about medications like Wegovy, the generic is semaglutide. That is FDA approved for kids 12 and older. So yes, indeed, some of these are the very same medications. Another one is called Qsymia. Again, initially approved in adults, studies have been done to garner FDA approval in the younger population, so now that too is also FDA approved for kids 12 and older.
The FDA does mandate that drug manufacturers, when they do studies to seek approval for an intervention for an adult, it is also mandated that studies are done in children as well. And this is sort of an equity issue, right? You can’t just have treatments for adults, we need to also be treating children. So yes, for most of these newer medications, the studies start in adults and then go to adolescents, and then if it’s safe and effective in an adolescent, then they go down to the younger kids.
Carol Vassar, podcast host/producer:
And it’s with the younger kids that Dr. Langheier raises concerns about the wide sweep of AAP’s guidance when it comes to the use of the most recent generation of weight loss medications in children.
Jason Langheier, MD, Foodsmart:
So you’re a kid who can change from zero to five just through lifestyle, and the study from current lenders on Metformin showed that even with that generic drug you were better off just doing lifestyle in that earlier age bracket in particular. So the fact that the American Academy of Pediatrics approved GLP-1s, especially in zero to five year olds, I think is very short-sighted. I don’t think it was poorly intentioned, and certainly in certain circumstances instead of bariatric surgery it might make sense, or if a kid’s at risk of heart failure, but only in really narrow settings, it shouldn’t be broad-based. So I think that could get refined a little bit more.
Carol Vassar, podcast host/producer:
So how do these medications, the GLP-1 receptor agonists, actually work in the human body? Dr. Fox explains.
Claudia Fox, MD, University of Minnesota:
The medications that have been more popular recently, that class of medications are called GLP-1 agonists, and what that means is they act to amplify or mimic the effect of GLP-1. GLP-1 is a naturally occurring hormone, it is secreted by our intestines in response to eating. So when we eat food, our intestine secretes this hormone, and that hormone goes to our brain and says, okay, you should feel full now, stop eating. And so this medication is administered by a small subcutaneous injection and it acts to mimic the effect of that hormone. It helps enhance that sense of fullness or satiety to give you the sense, yeah, you just ate, you should feel full. So that’s one medication, one class of medications. There are others, most in general act on the brain, which is where our appetite centers are, and they act to decrease appetite, decrease hunger, decrease food cravings
Carol Vassar, podcast host/producer:
For his part. Dr. Langheier sees the GL-I receptor agonist medications as a medical marvel, yet has concerns on how they are marketed, particularly when it comes to the messages of social media influencers.
Jason Langheier, MD, Foodsmart:
These drugs were outgrowths of work in the laboratory for many years, so I have a huge respect for them because they’re neuroscience drugs in as much as their digestive health drugs that suppress appetite. And so they’re a wonderful innovation on the one hand. On the other hand, while they’re kind of a research masterpiece, our country doesn’t do a very good job of handling how marketing is done with pharma, and it becomes a free for all really quickly. So you have social media influencers telling people, and starting with adults first, hey, eat whatever you want, take Ozempic, take Wegovy, take Mounjaro, and then you’ll do great. But that’s a lie. I mean, literally the FDA label says that you’re supposed to do this with nutrition and lifestyle change, it’s right there on the FDA label.
And so you’ll see some of these social media ads that will tell you, eat whatever you want, but then underneath it it’ll say, but do this with nutrition and physical activity, it’s like literally the opposite message. So it’s not regulated and it really should be, number one. Number two, these drugs literally suppress your appetite. So if you told people, take this, it will help you get better, but don’t eat whatever you want, actually just slowly start to acclimate your taste buds when you don’t have an appetite for all the unhealthy food, because then when you’re done taking the drug you’ll have changed your food environment, and then this will last for a long run.
Carol Vassar, podcast host/producer:
With achieving and maintaining a healthy weight as the goal for all children, the latest generation of anti-obesity medications can and do help to achieve weight loss in children for whom obesity is chronic and its effects life-threatening, according to Dr. Fox.
Claudia Fox, MD, University of Minnesota:
So these newer medications are far more effective than our first generation medications. I’ve been doing this work for about 15 years and initially we were using medications such as metformin or topiramate, phentermine, we still use some of those medications, but the weight loss effects are pretty modest at about 5% BMI reduction. These newer, newer age third generation medications that we’re seeing now, the injectables of GLP-1s, are quite a bit more effective comparatively, these are about 15, 16, 17% BMI reduction compared to, like I said, the earlier 5%. So this translates, depending on a person’s body size, anywhere from 15 to 40 pounds, kind of in that range. So it can be quite a dramatic shift in a person’s body weight.
Carol Vassar, podcast host/producer:
Are there any risks either short-term or long-term associated with obesity medication usage in the pediatric population?
Claudia Fox, MD, University of Minnesota:
Yeah, that’s also another great question. So importantly, we have to recognize that the studies that have been conducted to date are relatively short in duration, on the order of roughly like a year, year and a half. What we know though is obesity is a chronic disease, so people who have obesity will require lifelong treatment, so they will be exposed to these medications for years at a time. Might not be the very same medication for years at a time, but some sort of intervention for years at a time.
Back to your point though in terms of safety, so we don’t really know what are the very long-term effects of these medications on a person, whether they’re an adult or a child. They have a little bit more data in adults because these medications have been around quite a bit longer and used for adults. Very new yet in the pediatric population. In terms of what we know about short-term side effects, it’s mostly nausea, vomiting, diarrhea for the GLP-1s. The other medications have sort of a different side effect profile where we might see more like some tingling in the fingers or toes, some potential risk for high blood pressure, but generally most of the medications are very well tolerated. The question remains though is what are the longer-term effects?
Carol Vassar, podcast host/producer:
Yet studies in adults using GLP-1s have given Dr. Langheier reason to proceed with caution with regard to their use in children for the long-term.
Jason Langheier, MD, Foodsmart:
Here’s why you don’t want to take a GLP-1 forever, because it leads to loss of bone density and some studies show that half of the weight loss comes from loss of muscle mass, you don’t want that. I mean the other studies on 44 year olds and 60 year olds, or when you have accelerated aging because of loss of muscle mass, you don’t want a drug that accelerates your aging even more, and that’s a little bit what GLP-1s do. They help you lose weight, but they accelerate your aging.
Carol Vassar, podcast host/producer:
Let’s talk about parents. Parents ultimately, for their children, make the decisions with regard to the medications they take, they play a huge role in deciding whether or not their child should take an obesity medication. How have you seen this received in the parent group and how are they supported in making the decision one way or the other?
Claudia Fox, MD, University of Minnesota:
Yeah, it’s very variable. Some parents have the experience of already been on the medications and have had success, so they want that experience for their children. Others have been on medications and have had negative experiences for whatever reason, had too many side effects or it wasn’t helpful and then therefore they don’t want it for their children.
I think for me, some of the more challenging situations are where the family is very resistant to medications because they have internalized this fallacy that if they just worked harder at exercising and eating better, that the child’s weight will come down. They have internalized this bias that obesity is my fault as a parent, and what we need to do is just work harder, and I need to take my kid to the park some more and we need to start doing meal preps, and that alone is going to help my child achieve a healthier body size.
The reality is that is not going to be the case for particularly kids who have severe forms of obesity. You can meal prep until you’re blue in the face, if you are not addressing that underlying physiology with a medication it will be very hard to achieve clinically significant and durable weight reduction. And so that to me is heartbreaking because these parents, they want the best for their children, yet they really have internalized this bias that obesity is my fault, I in some way am responsible for my child’s weight status, when we know that at its core it’s agenetic and that genetics determines your physiology.
Carol Vassar, podcast host/producer:
Is there a stigma against prescribing this medication in some way, shape, or form?
Claudia Fox, MD, University of Minnesota:
Oh, for sure. There are people who are absolutely against it.
Carol Vassar, podcast host/producer:
What are the objections?
Claudia Fox, MD, University of Minnesota:
That the risks are too high, we don’t know enough about medications. I hear a lot about the risk of possibly creating eating disorders in children, and to that I would say many children who come to our clinic already have disordered eating behaviors. They are trying desperately to lose weight and turn to unhealthy eating strategies, whether it is restriction, going long periods of time without eating, some will try purging, some will try various over-the-counter weight loss strategies. So these kids are desperate for effective treatment strategies. Medications help normalize appetite, normalize eating behaviors such that you don’t always feel hungry and don’t always have to be so attentive and in tune to every morsel that you are eating, that you can eat a healthy amount of food and feel satisfied, move on with your day.
Carol Vassar, podcast host/producer:
I want to ask about the kids, children’s mental health, their self-esteem being on this medication, not being on this medication, how does it affect children both positively and negatively as they consider or maybe go on obesity medication?
Claudia Fox, MD, University of Minnesota:
Yeah, so from a research perspective, if we look at what is in the medical literature, there’s very little research that addresses what are the effects of obesity medications on children’s mental health. There is quite a bit of data that looks at the effect of these medications in terms of risks for causing spikes in depression, anxiety, or eating disorders. That research suggests that the medications do not adversely affect children’s mental health in terms of increased risk of depression, anxiety, or eating disorders.
However, in terms of improving it, that really hasn’t been demonstrated in a research perspective. I can tell you anecdotally though, many of my patients do feel better. They’re going to school now, they’re participating in sports now, they’re participating in school activities, they feel more accepted by their peers. That’s a whole commentary on society, but that is the reality. At the same time, it’s also very important to recognize that the prevalence of depression and anxiety in children who have especially severe forms of obesity are quite high, and obesity treatment is not a treatment for depression or anxiety, those kids really need specific treatment for depression or anxiety, medications, psychotherapy, et cetera. So we can’t expect that an obesity medication is going to treat a mental illness.
Carol Vassar, podcast host/producer:
That makes total sense, makes complete sense. I want to talk about follow-up care and monitoring. I’m assuming that is necessary. When a child is prescribed obesity medications, what does that look like?
Claudia Fox, MD, University of Minnesota:
There aren’t standards right now with regard to how frequently a child should come back to the clinic, and I think different programs do it differently, but you’re right, they all do some form of monitoring, whether it’s by the physician, the nurse, the dietitian, somebody on the team, and you’re monitoring them pretty regularly. Initially it might be every couple of weeks, then it could be monthly, and then as things are looking okay, spreading out to every couple of months. I think most as a standard would not go longer than six months, and that would be a very long stretch without seeing a child to check in on how they’re doing. Remember, these are kids who are largely growing in height as well, so they do change pretty rapidly, so it is very much appropriate to be seeing these kids about every couple of months to make sure that things are going as we expect.
Carol Vassar, podcast host/producer:
Dr. Langheier adds that having a step-up-and-step-down approach to starting and stopping anti-obesity medications with a strong emphasis on behavioral changes is also warranted.
Jason Langheier, MD, Foodsmart:
So people should really have step-up-and-step-down therapies, and I think that’s starting to happen with the healthcare world. You should try to put the right lifestyle changes in place, you should get a food script, you should try to change your food environment. And for some people you’ll start to change your outcomes without a GLP-1, but then others will still need extra help. Great, get that extra help, but then keep trying to change your food environment with your food script. So in other words, every time you get a GLP-1 script, you should get a food script, and then people shouldn’t come off those drugs until they’ve actually made progress at changing their food environment and their eating behavior, because people are very likely to regain not only the weight they lost, but more weight than they lost, and only 25% of people are on a GLP-1 by the end of one year because of all the challenges.
And so if we do this the wrong way, we’re basically investing five to 15K year on people to make them sicker. If we do this the right way, we’re investing in helping them change their life forever, if you pair a food script with a GLP-1. And so I hope that health plans, employers, and health systems and the drug makers will continue to work together to get that right set of step-up-and-step-down therapies in place.
Carol Vassar, podcast host/producer:
Real quick, from a broader perspective, a public health perspective, how do these treatment strategies address the issue, the huge issue of childhood obesity, short-term and long term?
Claudia Fox, MD, University of Minnesota:
The issue is extremely complex, clearly. I think the medications offer treatment on the individual level. They help children and their families achieve better health, better longevity, better quality of life. They don’t address the problem at large of pediatric obesity.
Carol Vassar, podcast host/producer:
Is it possible it’s a piece of the puzzle?
Claudia Fox, MD, University of Minnesota:
It’s absolutely a piece of the puzzle. It is the part of the puzzle that is addressing how do we limit really significant morbidity and premature mortality that is certainly going to come from untreated pediatric obesity. Think about all the children that we have who have very, very high BMIs, many of those are going to go on to be adults with diabetes, cardiovascular disease. If we can treat it in childhood, we do have the opportunity to really decrease the burden of those diseases on society as a whole. It doesn’t get at the prevention of obesity back in really primordial phases, if you will, but the medications do have the opportunity to really impact cost to society, I would say.
I think it’s important to recognize that you can’t expect some children to achieve a healthy body weight with diet and exercise alone. It does work for some children, but that doesn’t mean that just because it works for some children that we should completely exclude the possibility of using medications for others for whom it’s not working.
Carol Vassar, podcast host/producer:
Dr. Claudia Fox is associate professor of pediatrics and co-director of the Center for Pediatric Obesity Medicine at the University of Minnesota. We also heard from Dr. Jason Langheier, CEO and founder of Foodsmart.
MUSIC:
Well Beyond Medicine.
Carol Vassar, podcast host/producer:
Thanks to both Dr. Fox and Dr. Langheier for helping us highlight two sides of the vibrant discussions around the use of anti-obesity medications in children, and as always, thanks to you for listening. Hear our entire conversation with Dr. Jason Langheier in our next episode of the Well Beyond Medicine Podcast, where he discusses his work at Foodsmart and the origins of his passion for fighting childhood obesity, which have their roots in his own hardscrabble childhood. Don’t miss it.
In fact, don’t ever miss an episode of the podcast. Go right now to NemoursWellBeyond.org and subscribe to it, like more than 30,000 of your friends, neighbors, and colleagues. You’ll get the podcast delivered to you fresh each and every Monday morning. There you can also leave a review and suggest podcast episode ideas. That’s NemoursWellBeyond.org. And don’t forget, the podcast is available on your favorite podcast app, including the Nemours YouTube channel.
Thanks to the team that goes above and beyond to help bring you this podcast each and every week, Susan Masucci, Cheryl Munn, and Lauren Teta. I’m Carol Vassar, and remember, we can change children’s health for good well beyond medicine.
MUSIC:
Let’s go, Well Beyond Medicine.
