State of the Art Pediatrics: 2025: A New Year for Obesity Treatment

Column Authors:  Sarah Hampl, MD, FAAP | Director, Advocacy, Center for Children's Healthy Lifestyles & Nutrition

Brooke Sweeney, MD, FAAP, FACP, DABOM | Medical Director, Weight Management

Column Editor: Amita R. Amonker, MD, FAAP | Physician Advisor, Care Management and Utilization Review

The field of pediatric obesity treatment is rapidly growing, with new options to help patients improve health habits and achieve healthier weight in managing the chronic disease of obesity.

The foundation of the treatment “house” is intensive health behavior and lifestyle treatment.¹ Beyond evidence-based nutrition and physical activity recommendations and mental health topics (the “what”), this approach includes the “how” to make and sustain these healthy changes for the whole patient (mind, body, spirit and emotions), at home, school and other environments in a patient- and family-centered way. Using motivational interviewing¹ can aid shared decision-making and selection of achievable family goals. Requesting frequent follow-up visits is a part of treatment. Seeing patients regularly enables primary care providers (PCPs) to monitor health behavior changes and helps families adopt healthy changes. It also helps to sustain or improve emotional health as well as weight and body mass index (BMI). It supports patients in their whole person health journey. Involving other health professionals such as behavioral health providers and registered dietitians can be very helpful for patients needing mental health support and additional nutrition guidance.

Missouri Medicaid—HealthNet Division (MO HealthNet) is one of the first Medicaid systems in the United States to cover intensive health behavior and lifestyle treatment for children and adults. Their biopsychosocial obesity treatment benefit enables children ages 2 and older and their parents/caregivers to receive up to 29 hours of comprehensive family-based behavioral treatment and 2.25 hours of medical nutrition therapy over the course of a year. There are no associated co-pays and the treatment can be delivered in-person or virtually. Children and families can restart the next plan year if they do not complete the initial series of treatment visits.

Medications are recommended in children ages 12 and older with obesity for whom PCPs are considering advanced treatment (i.e., second level of the treatment “house”) as an adjunct to comprehensive health behavior and lifestyle treatment.¹ The class of obesity medications known as glucagon-like peptide receptor agonist (GLP-1RA) obesity medications primarily work by lowering appetite centrally and slowing gastric emptying. The percentage of weight loss achieved varies by individual and often exceeds that seen with intensive lifestyle treatment alone. In addition, numerous weight-related comorbidities can improve. Adverse effects seen are mostly gastrointestinal-related, including nausea, vomiting and constipation, though more serious adverse effects such as pancreatitis and gastroparesis can occur. These medications are contraindicated in those with a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia (MEN) type 2 and those with a history of anorexia or bulimia nervosa.²

Certain glucagon-like peptide-1 receptor agonist (GLP-1RA) obesity medications have been approved by the Food and Drug Administration (FDA) for obesity treatment in youth ages 12 and older, starting with liraglutide in 2022, followed by semaglutide in 2023. Tirzepatide (Zepbound®) is not yet approved for children under age 18, and approval is not expected for over a year, though studies are planned and in progress. As of this month, MO HealthNet’s Pharmacy will begin covering certain formulations of several of these medications for youth and adults with obesity, with or without diabetes. Liraglutide (Victoza®) is a once-daily injection, while dulaglutide (Trulicity®) and semaglutide (Ozempic®) are given once weekly. These medications will be covered without a required diagnosis or a prior authorization. Tirzepatide (Zepbound®) will be covered for the diagnosis of obesity with a prior authorization. While tirzepatide (Zepbound®) will be on MO HealthNet’s formulary for youth 12 and older, this medication is not yet FDA approved for children under the age of 18 and should be used with caution only in those under 18 years of age.

Inadequate nutrition intake may result from appetite suppression associated with GLP-1RAs, so it is important to review current nutrition habits before prescribing and educate adolescents and families about healthful nutrition intake, regular meals with protein despite loss of appetite and at least 80-100 oz of water daily.^3-4 It is also important to assess emotional health and the possibility of disordered eating before starting any obesity treatment, including medication.¹ Adolescents should be followed frequently to assess nutrition and physical activity habits in the context of health behavior and lifestyle treatment, assess for malnutrition and other adverse effects, and monitor emotional health, weight and BMI.^3-4 Again, frequent visits are a part of treatment and this should be mutually agreed upon before treatment starts.

Specifically, inadequate protein intake may lead to loss of lean muscle, while inadequate fluid intake can result in dehydration. Most micronutrient deficiencies can be addressed with the use of a daily complete multivitamin.³ Advising strength training twice a week can mitigate potential muscle mass loss,⁵ while increasing fluid and fiber intake can help prevent constipation. Monitoring how adolescents are feeling about their changing bodies is also important, as self-esteem and body image may or may not improve. Additionally, depression, anxiety and disordered eating habits can appear or reappear.^6-7 Patients who are consistently losing more than 2 pounds per week should have a detailed nutrition history performed, and medication may need to be adjusted or withheld. In contrast, adolescents who begin to experience higher appetite, plateau of weight loss, or weight gain may be candidates for dose escalation, combination therapy using more advanced behavioral interventions, additional medication, or consideration for bariatric surgery if still experiencing severe obesity.

Many adolescents (and their parents) want to know if they will need to be on obesity medication for the rest of their lives. The answer at this time is that we do not know. Most patients regain weight if these medications (or lifestyle treatment) are discontinued, due to the body’s physiologic tendency to return to its previous weight set-point. However, it is hoped that if a patient can maintain a lower body weight for several months at a certain dose of obesity medication, medication may be able to be tapered, and treatment adjusted for maintenance.

In summary, it is an exciting time for children and families with obesity and the clinicians who care for them. There are more treatment options for PCPs to offer families. We are here to partner with you as you care for these youth.

For more information about intensive health behavior and lifestyle treatment, clinic capacity-building, obesity medications, and more, see: https://www.aap.org/en/patient-care/institute-for-healthy-childhood-weight/clinical-practice-guideline-for-the-evaluation-and-treatment-of-pediatric-obesity/supporting-the-implementation-of-the-cpg-recommendations/

For more information about the MO HealthNet biopsychosocial obesity treatment benefit, see: https://mydss.mo.gov/media/pdf/biopsychosocial-treatment-obesity-training

For more information about the MO HealthNet obesity medication policy change, see: https://mydss.mo.gov/media/pdf/glucagon-peptide-1-glp-1-receptor-agonists-indicated-obesity-pdl-edit and https://mydss.mo.gov/media/pdf/glp-1-receptor-agonists-combination-agents-indicated-diabetes-pdl-edit 

References:

1. Hampl SE, Hassink SG, Skinner AC, et al. American Academy of Pediatrics Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity. Pediatrics. 20231;151(2):e202206.
2. Ozempic prescribing information. November 2024. https://www.novo-pi.com/ozempic.pdf
3. Almandoz JP, Wadden TA, Tewksbury C, et al. Nutritional considerations with antiobesity medications. Obesity (Silver Spring). 2024;32(9):1613-1631.
4. Wadden TA, Chao AM, Moore M, et al. The role of lifestyle modification with second-generation anti-obesity medications: comparisons, questions, and clinical opportunities. Curr Obes Rep. 2023;12(4):453-473.
5. Jakicic JM, Rogers RJ, Church TS. Physical activity in the new era of antiobesity medications. Obesity (Silver Spring). 2024;32(2):234-236. PMID: 37849057. doi:10.1002/oby.23930
6. Hunsaker SL, Garland BH, Rofey D, et al. A multisite 2-year follow up of psychopathology prevalence, predictors, and correlates among adolescents who did or did not undergo weight loss surgery. J Adolesc Health. 2018;63(2):142-150.
7. Gow ML, Tee MSY, Garnett SP, et al. Pediatric obesity treatment, self-esteem, and body image: a systematic review with meta-analysis. Pediatr Obes. 2020;15(3):e12600.