A national advisory organization has come down on the side of behavioral interventions, not obesity medications, to help children 6 and older with high BMI improve their health, wading into the debate over prescribing the blockbusters for kids before their long-term consequences are better understood.
On Tuesday, the United States Preventive Services Task Force issued recommendations encouraging clinicians to provide or refer children and adolescents 6 years or older with a high body mass index to comprehensive, intensive behavioral interventions. That counters last year’s recommendation by the American Academy of Pediatrics to consider obesity drugs for kids 12 and older whose weight tops growth charts, along with encouraging better nutrition, physical activity, and behavioral therapy from age 6 on up.
The USPSTF called evidence on the benefits of pharmacotherapy “inadequate” due to the small number of studies and limited data on long-term treatment harms, asserting that at least two years of follow-up are needed to gauge the long-term outcomes of drug therapy. That assessment would go beyond BMI to include metabolic health and psychosocial functioning, among other impacts.
Wanda Nicholson, task force chair and senior associate dean of diversity and inclusion at the George Washington University School of Public Health, said the evidence is clear to support high-intensity behavioral interventions to help children and adolescents lose weight and gain better quality of life. It’s less than clear for the four drugs discussed in the task force’s analysis of current research, she said. The drugs are semaglutide (sold as Wegovy for weight loss/Ozempic for diabetes), liraglutide (Saxenda/Victoza), orlistat (Xenical, Alli), and phentermine/topiramate (Qsymia).
“We believe we need more evidence to be able to make a recommendation for or against medications in children and adolescents,” she told STAT. “While there were trials evaluating the effectiveness of FDA-approved medications, there was a limited number of trials per medication from our review. And in addition, there was limited evidence on weight loss maintenance after medications were discontinued in children.”
In both children and adults, weight can be quickly regained after treatment stops.
A child’s BMI — a measure many view as flawed — is considered high if it’s at or above the 95th percentile for age or sex. Nearly 20% of U.S. children fall into that category. The prevalence of high BMI rises with age and is higher among Hispanic/Latino, Native American/Alaska Native, and non-Hispanic Black children and adolescents and among children from lower-income families. The dissonance between the USPSTF’s and the AAP’s positions does not address criticism voiced last year over whether the focus on weight instead of health is misplaced.
The groups agree on recommending intensive behavioral interventions for children 6 and up.
“I do want to emphasize again that we do have proven ways that clinicians can help children and adolescents to achieve a healthy weight and to remain healthy,” Nicholson said.
The mission of the USPSTF, a nongovernmental agency funded by the federal Agency for Healthcare Research and Quality, is to weigh medical evidence and advise how to solve health problems. The current recommendations carry a grade B, and the group reviews its guidance every five years. Grade B recommendations carry influence because a provision in the Affordable Care Act says patients should pay no out-of-pocket expenses for preventive services recommended by the USPSTF with a grade of A or B.
To make healthy and sustainable changes, patients on obesity medication do need support to change their eating habits and to cope with potential side effects, Sarah Armstrong, professor of pediatrics at Duke University, said. Chair of the AAP’s section on obesity, she is a co-author of the clinical practice guidelines that came out last year, and she co-wrote an editorial appearing Tuesday in JAMA with the task force statement.
To understand why AAP and USPSTF diverge on drug therapy, she suggests looking at the purposes the two groups serve.
“The USPSTF really focuses on interventions clinicians can initiate for long-term prevention of chronic disease. That’s literally what the ‘P’ stands for in USPSTF,” she told STAT. “We’re looking at the here and now: What do we need to treat obesity? Yes, we are looking at the same body of evidence. But we are looking at it through two different lenses.”
Pediatricians are seeing the complications of obesity every day, sometimes treating 10-year-olds with obesity who already have hypertension, diabetes, or liver disease, Armstrong said, so the evidence that pediatricians need is different.
Amanda Staiano, an associate professor of pediatric obesity and health behavior at the Pennington Biomedical Research Center of Louisiana State University, told STAT that both groups’ guidelines say intensive health behavior and lifestyle treatment should be offered to all children and adolescents with obesity. She also served on AAP’s clinical practice guideline authorship committee.
“The AAP explicitly states that drugs should not be a monotherapy,” Staiano said. “They are an adjunct to be used in combination with intensive health behavior and lifestyle treatment.”
Finding such programs can prove difficult.
Staiano studies intensive health behavior and lifestyle obesity treatment programs that include telehealth behavioral and lifestyle counseling and can incorporate apps, wearables, AI chatbots, and games to meet families where they are. She hears some but not all families say they’re excited to have more treatment options available. She’s also seen many adolescents improve their health with medication, including weight loss, better heart and metabolic health measured by lab values, and better quality of life.
More evidence on new and powerful GLP-1 drugs will likely emerge over the next few years and inform more specific guidance for nutrition and physical activity recommendations, Armstrong said, among them questions on how to maintain muscle mass. “What we do in the meantime is we strongly recommend very close clinical monitoring for children who are on these medications so that we can make these recommendations and change things in real time.”
Staiano acknowledges rapid change in obesity medicine as medications become more available. “I expect the next task force convening will have much more evidence to inform a recommendation,” she wrote. “We also need longer term follow-up for studies. Many of these drugs will likely involve long-term administration for patients to keep the weight from returning.”
USPSTF guidance from 2017 focused on screening before intervention, but the new statement instead moves directly to behavioral methods to promote a healthy weight while stopping short of suggesting GLP-1 drugs such as Wegovy. It’s a recognition that screening has become a routine part of primary care.
Those intensive behavioral interventions, intended to help children achieve a healthy weight while improving their quality of life, entail 26 or more hours over one year with a health professional. That might mean physical activity, support for weight-related behavior change, and information about healthy eating.
Behavioral treatments and drug therapies can and should coexist, Armstrong said. In her 20 years at Duke, she’s seen an evolution from dispensing advice on diet and exercise in printed handouts to engaging children and families in cooking classes to prepare more nutritious meals or playing games with peers to amp up active hours. Ensuring families have access to those approaches can be a challenge.
“Just like any chronic disease, which obesity most certainly is, there are a number of treatments that are available and that have to be tailored to the individual,” she said. “Think of adolescent depression. We would never say, ‘Oh, should we do therapy or medication,’ and pit them against each other somehow. We do them together.”
Samar Mahamud Hafida, an adult endocrinologist and weight management specialist at Boston Medical Center who directs the transition clinic for teens and adolescents with obesity and diabetes, also compared obesity to other diseases for which drug treatment is standard and side effects are managed.
“Why is this such a specific and special issue to just weight loss medication? That can happen with antibiotics, that can happen with vaccines, that can happen with chemotherapy,” she said. “Everything has a side effect, everything. That doesn’t mean we should give up and say, ‘No way, we’re not going to do this.’ It means that the clinicians need to know how to navigate, how to mitigate that.”
About half of the teenagers with obesity she sees in her clinic come after asking their doctors about obesity drugs. “This is a generation now that understands that it’s not my fault,” she said. Most of the other referrals come from parents, while the fewest come from clinicians, typically after diabetes or liver problems have worsened.
“A government entity is telling clinicians that there’s not enough evidence to give them. What do you think is going to happen? It’s going to get even worse,” Hafida said about obesity. “This is the time where we can influence long-term outcomes. I just find it appalling, really just terrible.”
Experts agree that children with obesity have a serious disease for which there are available treatments — but not which ones.
“We know from lots of evidence what untreated obesity looks like over time. So we need to act now,” Armstrong said. “Viewing obesity as a disease means you wouldn’t wait for that long-term data because we have treatments that work right now.”
Doctors writing another editorial, published Tuesday in JAMA Network Open, see some daylight in the USPSTF recommendations, quoting this passage: “Clinicians should understand the evidence but individualize decision-making to the specific patient or situation.” That doesn’t prohibit health care practitioners from prescribing obesity medications, Roohi Kharofa, Nancy Crimmins, and Amy Shah of Cincinnati Children’s Hospital Medical Center argue.
“The time to prevent and intervene on childhood obesity is now,” they write. While the need to start with intensive lifestyle therapy is clear, they add, for many patients, that alone may not be enough to prevent serious outcomes. “In these instances, pharmacotherapy and/or bariatric surgery may need to be considered to improve health outcomes in youth with obesity.”
Nicholson said both AAP and her task force support screening and favor intervention, noting that surgery is outside the USPSTF’s scope. “The task force is calling for more research on benefits and harms of medications in children and adolescents, and we look forward to being able to identify the evidence and being able to update our recommendations.”
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