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Well Beyond Medicine: The Nemours Children's Health PodcastEp. 121: Weighing the Options: Anti-Obesity Medications for Kids?
Well Beyond Medicine: The Nemours Children's Health PodcastEp. 121: Weighing the Options: Anti-Obesity Medications for Kids?
Ep. 121: Weighing the Options: Anti-Obesity Medications for Kids?
Ep. 121: Weighing the Options: Anti-Obesity Medications for Kids?Update: 2025-02-17
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Description
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
Views expressed by guests do not necessarily reflect the views of the host or management.
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Transcript
00:00:00
Welcome to Well Beyond Medicine, the world's top ranked children's health podcast, produced by Nemoris Children's Health.
00:00:06
Subscribe on any platform at NemorisWell Beyond.org or find us on YouTube.
00:00:12
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.
00:00:24
I'm your host, Carol Vassar, and now that you're here, let's go!
00:00:28
Let's go!
00:00:30
Oh, oh, well beyond medicine.
00:00:36
The Centers for Disease Control and Prevention reports that approximately one in five U.S.
00:00:42
children and adolescents have obesity.
00:00:45
It's an epidemic that's harming a broad cross-section of children, with the potential to undermine their health and well-being across the lifespan.
00:00:54
And one considers the multitude of factors that contribute to the obesity epidemic, biological, behavioral, social, economic, environmental,
00:01:04
and cultural.
00:01:05
Treating the issue is complex, yet necessary for the health of our nation's children, our future adults.
00:01:13
In 2023, the American Academy of Pediatrics came out with guidance on how to treat childhood obesity, and today we'll examine one aspect of that guidance.
00:01:24
The use of anti-obesity medications in children.
00:01:28
Joining me to talk about this is Dr.
00:01:30
Claudia Fox, Associate Professor of Pediatrics and Co-Director of the Center for Pediatric Obesity Medicine at the University of Minnesota.
00:01:40
She'll help us to better understand AAP's guidance in this area, and GLP receptor agonists, and how they work in the body.
00:01:48
We'll also hear from Dr.
00:01:50
Jason Langhire, CEO and founder of FoodSmart.
00:01:53
Dr.
00:01:53
Langhire is the founder and former director of the Nutrition and Fitness for Life Pediatric Obesity Program at Boston Medical Center.
00:02:02
First, though, what does the American Academy of Pediatrics say in its 2023 guidance when it comes to tackling childhood obesity broadly,
00:02:12
and with respect to anti-obesity medications specifically?
00:02:16
Here's Dr.
00:02:17
Claudia Fox.
00:02:19
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,
00:02:36
that we should be offering that child, all interventions that are indicated or appropriate.
00:02:45
In contrast to previous recommendations, we're 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.
00:02:56
If that's not working, then proceed to add on medication, and if that didn't work, then proceed to metabolic and bariatric surgery.
00:03:06
That staged approach is no longer recommended.
00:03:10
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.
00:03:21
If I have, say, a six-year-old, whose BMI is just a little bit above the 95th percentile, or not talking about medications for that child, no, we're going to talk about healthy eating healthy activity,
00:03:34
good sleep, mood regulation, those sorts of things.
00:03:39
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,
00:03:52
no, we're going to talk about medications as well, and even possibly weight loss surgery, all at that initial evaluation.
00:04:02
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,
00:04:13
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?
00:04:25
Yeah, so great questions.
00:04:27
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,
00:04:40
which are approved not only in adults, but some of them are also approved in children as young as age 12.
00:04:48
We're talking about medications like wagovie.
00:04:52
The generic is semagletide, 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,
00:05:04
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.
00:05:16
The FDA does mandate that drug manufacturers when they do studies to seek approval for an intervention for an adult,
00:05:26
it is also mandated that studies are done in children as well, and this is sort of an equity issue, right?
00:05:34
You can't just have treatments for adults, we need to also be treating children.
00:05:39
So yes, for most of these newer medications, the studies start in adults and then go to adolescents, and then it's safe and effective in an adolescent, then they go down to the younger kids.
00:05:51
And it's with younger kids, that Dr.
00:05:54
Langhair 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.
00:06:03
So you're a kid who can change from zero to five, just through lifestyle, and the study from Corinne Lenders on Metformin showed that even with that generic drug you were better off just doing lifestyle in that earlier age bracket in particular.
00:06:15
So the fact that the American Academy of Pediatrics approved GLP1s, especially in zero to five years, I think is very short-sighted.
00:06:22
I don't think it was poorly intentioned.
00:06:23
It's certainly in certain circumstances, but instead of bariatric surgery, it might make sense, or if a kid's risk of heart failure, but only in really narrow settings, it shouldn't be broad-based.
00:06:32
So I think that can get refined a little bit more.
00:06:35
So how do these medications, the GLP1 receptor agonists, actually work in the human body?
00:06:41
Dr.
00:06:42
Fox explains, "The medications that have been more popular recently, that class of medications are called GLP1 agonists, and what that means is they act to sort of amplify or mimic the effect of GLP1.
00:07:00
GLP1 is a naturally-curring hormone.
00:07:04
It is secreted by our intestines in response to eating.
00:07:09
So when we eat food, our intestines secretes this hormone, and that hormone goes to our brain and says, "Okay, you should feel full now.
00:07:19
Stop eating."
00:07:20
Right?
00:07:21
And so this medication is administered by a small subcutaneous injection in an axiomimic, the effect of that hormone.
00:07:32
It helps enhance that sense of fullness or satiety to give you the sense like, "Yeah, you just ate, you should feel full."
00:07:40
So that's one medication, one class of medications.
00:07:44
There are others, most in general, act on the brain, which is our appetite, where our appetite centers are.
00:07:53
And they act to sort of decrease appetite, decrease hunger, decrease food cravings."
00:07:59
For his part, Dr.
00:08:01
Langhair sees the GLP1 receptor agonist medications as a medical marvel, that has concerns about how they are marketed, particularly when it comes to the messages of social media influencers.
00:08:14
These drugs were outgrowth of working the laboratory for many years.
00:08:17
I have a huge respect for them because they're neuroscience drugs, and as much as they're digestive health drugs, let's suppress appetite, and so there are wonderful innovations on the one hand.
00:08:28
On the other hand, while they're 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.
00:08:40
So you have social media influencers telling people and starting with adults first, "Hey, eat whatever you want, take ozempic, take wigovi, take manjaro."
00:08:49
And then you'll do great, but that's a lie.
00:08:52
I mean, literally FDA label says that you're supposed to do this with nutrition and lifestyle change.
00:08:58
It's right there on the FDA label.
00:09:00
And so you'll see some of these social media ads that will tell you, "Eat whatever you want, but then underneath it will say, "But do this with nutrition of its activity."
00:09:07
It's like literally the opposite message.
00:09:11
So it's not regulated, and it really should be.
00:09:13
Number one, number two, these drugs literally suppress your appetite.
00:09:17
So if you told people, "Take this, it will help you get better," but don't eat whatever you want.
00:09:22
Actually, just slowly start to acclimate your taste buds when you don't have an appetite for all the unhealthy food.
00:09:27
Because then when you're done taking the drug, you'll have changed your food environment.
00:09:32
And then this will last for a long run.
00:09:34
With achieving and maintaining a healthy weight is 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.
00:09:50
Fox.
00:09:50
So these newer medications are far more effective than our first generation medications.
00:09:57
I've been doing this work for about 15 years, and initially we were using medications such as metformin or topyramate ventramina.
00:10:09
We still use some of those medications, but the weight loss effects are pretty modest at about 5% BMI reduction.
00:10:18
These newer, newer age, third generation medications that we're seeing now, the injectables, the GLP ones are quite a bit more effective, comparatively,
00:10:30
either about 15, 16, 17% BMI reduction compared to, like I said, the earlier 5%.
00:10:39
So this translates, depending on a person's body size anywhere from 15 to 40 pounds kind of in that range,
00:10:50
so it can be quite a dramatic shift in a person's body weight.
00:10:57
Are there any risks, either short-term or long-term associated with obesity medication usage in the pediatric population?
00:11:05
That's also another great question.
00:11:07
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 or a half.
00:11:19
What we know though is obesity is a chronic disease, so people who have obesity will require lifelong treatment.
00:11:28
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.
00:11:42
Back to your point in terms of safety, so we don't really know what are the very long-term effects of these medications on a person,
00:11:55
whether they're an adult or a child, and a little bit more data in adults because these medications have been around quite a bit longer and used for adults,
00:12:05
very new yet in the pediatric population.
00:12:09
In terms of what we know about sort of short-term side effects, it's mostly nausea-vomiting diarrhea for the GLP ones.
00:12:21
The other medications have a 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.
00:12:33
But generally, most of the medications are very well tolerated.
00:12:38
The question remains though, is what are the longer term effects?
00:12:44
Yet studies in adults using GLP ones, have given Dr.
00:12:47
Langhire, reason to proceed with caution with regard to their use in children for the long term.
00:12:53
Here's why you don't want to take a GLP one 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.
00:13:02
You don't want that.
00:13:03
I mean, the other studies on 44-year-olds and 60-year-olds are when you have accelerated aging because of loss of muscle mass.
00:13:09
You don't want a drug that accelerates your aging even more, and that's a little bit what GLP ones do.
00:13:13
They help you lose weight, but they accelerate your aging.
00:13:16
Let's talk about parents.
00:13:18
Parents, ultimately, for their children make the decisions with regard to the medications they take.
00:13:23
They play a huge role in deciding whether or not their child should take an obesity medication.
00:13:29
How have you seen this received in the parent group and how are they supported in making the decision one way or the other?
00:13:36
Yeah.
00:13:37
You know, it's very variable.
00:13:40
Some parents, the experience of already been on the medications and have had success so they want that experience for their children.
00:13:53
Others have been on medications and have had negative experiences for whatever reason.
00:13:59
Those have too many side effects or it wasn't helpful and then therefore they don't want it for their children.
00:14:05
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.
00:14:30
They have internalized this bias that obesity is my fault as a parent and therefore what we need and what we need to do is just work harder and I need to take my kid to the parks more and we need to start doing meal preps and that alone is going to help my child achieve a healthier body size.
00:14:54
The reality is that is not going to be the case for particularly kids who have severe forms of obesity.
00:15:02
You can meal prepped till you're blue in the face if you are not addressing that underlying physiology with the medication, it will be very hard to achieve clinically significant indurable weight reduction and so that to me is heartbreaking because these parents,
00:15:22
they want the best for their children, yet they really have internalized this bias that obesity is my fault.
00:15:33
I in some way am responsible for my child's weight status when we know that at its core is a genetic and that genetics determines your physiology.
00:15:43
Is there a stigma against prescribing this medication in some way shape or form?
00:15:50
Oh for sure, there are people who are absolutely against it.
00:15:55
What are the objections?
00:15:57
That the risks are too high, we don't know enough about medications.
00:16:02
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.
00:16:15
They are trying desperately to lose weight and turn to unhealthy eating strategies, whether it is restriction, going long periods of time without eating,
00:16:27
some will try purging, some will try various, you know, over the counter weight loss strategies.
00:16:37
So these kids are desperate for effective treatment strategies.
00:16:43
Medications help normalize appetite, normalize eating behaviors such that you don't always feel hungry and don't always have to be so intentive and into every more so that you are eating.
00:17:00
But you can eat a healthy amount of food and feel satisfied with your day.
00:17:07
I want to ask about the kids, children's mental health, their self esteem, being on this medication, not being on this medication.
00:17:17
How does it affect children both positively and negatively as they consider or maybe go on obesity medication?
00:17:26
Yeah, so from a research perspective, if you look at what has been, what is in the medical literature, there's a very little research that addresses what are the effects of obesity medications on children's mental health.
00:17:45
There is quite a bit of data that looks at the effect of these medications in terms of risk for causing spikes in depression,
00:17:57
anxiety, or eating disorders.
00:18:00
That research suggests that the medications do not adversely affect children's mental health in terms of increased risk of depression,
00:18:11
anxiety, or eating disorders.
00:18:13
However, in terms of improving it, there really hasn't been demonstrated in a research perspective.
00:18:21
I can tell you anecdotally though, many of my patients do feel better, they're going to school now.
00:18:30
They're participating in sports, now they're participating in school activities, they feel more accepted by their peers.
00:18:37
That's a whole sort of commentary on society, but that is the reality.
00:18:42
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.
00:18:53
Obesity treatment is not a treatment for depression or anxiety.
00:18:58
Those kids really need specific treatment for depression or anxiety, medications, psychotherapy, etc.
00:19:06
We can't expect that an obesity medication is going to treat a mental illness.
00:19:13
That makes total sense, complete sense.
00:19:15
I want to talk about follow-up care and monitoring.
00:19:19
I'm assuming that is necessary, when a child is prescribed obesity medications, what does that look like?
00:19:25
There are standards right now with regard to how frequently a child should come back to the clinic.
00:19:32
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,
00:19:43
the dietician, somebody on the team, and the your monitoring them pretty regularly.
00:19:50
Initially, it might be every couple of weeks and it could be monthly and then as things are looking okay, spreading out to every couple of months.
00:19:59
I think most as a standard would not go longer than six months at all, and that would be a very long stretch without seeing a child to check in on how they're doing.
00:20:11
However, these are kids who are largely growing and 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.
00:20:28
Dr.
00:20:29
Langhair adds that having a step up and step down approach to starting and stopping anti-obesity medications with the strong emphasis on behavioral changes is warranted.
00:20:40
The people should really have step up and step down therapies, and I think that's starting to happen with the health care world.
00:20:46
You should try to put the right lifestyle changes in place.
00:20:49
You should get a food script.
00:20:50
You should try to change your food environment.
00:20:51
For some people, you'll start to change your outcomes without a JLP1, but then others will still lead extra help, great, get that extra help, but then keep trying to change your food environment with your food script.
00:21:00
In other words, every time you get a JLP1 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.
00:21:10
They're eating behavior because people are very likely to regain not only the way they lost but more weight than they lost, and only 25% of people are on a JLP1 by the end of one year because of all the challenges.
00:21:23
If we do this the wrong way, we're basically investing five to 15K a year in people to make them sicker.
00:21:30
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 JLP1.
00:21:37
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.
00:21:46
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?
00:22:01
The issue is extremely complex, clearly.
00:22:06
I think the medications offer treatment on the individual level.
00:22:13
They help children and their families achieve better health, better longevity, better quality of life.
00:22:23
They don't address the problem at large of pediatric obesity.
00:22:29
Is it possible it's a piece of the puzzle?
00:22:32
It's absolutely a piece of the puzzle.
00:22:35
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.
00:22:54
Think about all the children that we have who are very, very high BMI's.
00:22:59
And those are going to go on to be adults with diabetes, cardiovascular disease.
00:23:05
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.
00:23:17
It doesn't get at the prevention of obesity, you know, back in the really primordial phases if you will,
00:23:28
but the medications do have the opportunity to really impact cost to society I would say.
00:23:37
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.
00:23:48
It does work for some children, but that doesn't mean that just because it works for some children, we should completely exclude the possibility of using medications for others for whom it's not working.
00:24:03
Dr.
00:24:03
Claudia Foxx is Associate Professor of Pediatrics and Co-Director of the Center for Pediatric Obesity Medicine at the University of Minnesota.
00:24:13
We also heard from Dr.
00:24:15
Jason Langhire, CEO and Founder of Food Smart.
00:24:20
Thanks to both Dr.
00:24:21
Foxx and Dr.
00:24:21
Langhire for helping us highlight two sides of the vibrant discussions around the use of anti-obesity medications in children.
00:24:30
And as always, thanks to you for listening.
00:24:33
Here are entire conversation with Dr.
00:24:35
Jason Langhire in the next episode of the Well-Beyond Medicine podcast, where he discusses his work at Food Smart and the origins of his passion for fighting childhood obesity,
00:24:46
which have the roots in his own hard-scrabble childhood.
00:24:50
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00:24:51
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00:24:54
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00:25:29
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00:25:35
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00:25:36
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00:25:41
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