番茄社区

This story is part of a series called "Ozempic: Weighing the Risks and Benefits." It was produced in part through a grant from the .

When Fatima Cody Stanford, MD, MPH, MPA, attended a holiday party thrown by two patients she was treating for obesity, she noticed something unusual about the way their 6-year-old daughter gave the house tour.

"She would take me to a room, and she's like, 'OK, the quickest way to the kitchen from here is this way,'" said Stanford, of Massachusetts General Hospital in Boston. "Her entire focal point ... was, 'How's the quickest way to the kitchen.'"

Stanford now treats the girl, who is around 13 years old, for obesity. "She's just wired a different way," Stanford told 番茄社区, noting part of the consideration for using new GLP-1 agonists in this patient.

The girl responded better than expected, first with liraglutide (Saxenda), then with semaglutide (Wegovy), losing 23% of her body weight. Stanford said she has been enjoying sports for the first time and carries a newfound confidence.

"It's been interesting to watch her trend down the growth chart to being a kid without obesity," she said.

As optimism for GLP-1 receptor agonists for weight loss has grown, so too has their use in children. Currently, liraglutide and semaglutide are the only two GLP-1 drugs FDA-approved to treat obesity in kids ages 12 and up.

Total prescriptions for those two drugs written by pediatric and adolescent medicine specialists rose from 3,448 in October 2022 to 24,435 in September of 2024 -- about a sevenfold increase in 2 years -- according to a 番茄社区 analysis of data from Symphony, a prescription drug database.

Total prescriptions for all GLP-1 drugs prescribed by pediatric and adolescent medicine specialists have more than doubled during that time, from 59,868 to 125,538. These numbers reflect 11 GLP-1 drug brands, many of which are approved for type 2 diabetes, and do not include GLP-1 drugs prescribed to children by primary care physicians or family medicine practitioners, or at compounding pharmacies.

Many obesity specialists told 番茄社区 they generally feel comfortable prescribing GLP-1 drugs to children if they have ruled out most other options, and if the family is involved in ongoing lifestyle interventions.

However, they acknowledged the uncertainties of putting kids on a drug regimen that may last a lifetime, and that lacks long-term data -- especially on critical questions like effects on bone density. And other experts remain entirely uncomfortable with these rapid changes in obesity treatment.

Proceeding With Caution

Both liraglutide and semaglutide were shown in clinical trials to reduce body mass index (BMI) in kids ages 12 to 17 to a greater extent than placebo. Liraglutide won a pediatric obesity indication for kids 12 and up in December 2020, and semaglutide did so in December 2022.

In September, results from the SCALE Kids trial showed liraglutide cut BMI in kids ages 6 to 11 better than placebo, and Novo Nordisk is seeking to to kids in this age group. Novo Nordisk and Eli Lilly have ongoing trials of and (Zepbound), respectively, in this age group underway.

Last year, the American Academy of Pediatrics (AAP) issued an updated for children and adolescents with obesity, recommending the use of pharmacotherapy for adolescents 12 and up, including GLP-1 agonists. In certain circumstances, they wrote, healthcare professionals may offer them to children 8 and up.

Sarah Hampl, MD, of the University of Missouri-Kansas City School of Medicine and lead author of the AAP guidelines, emphasized the role of other interventions that accompany medication.

"It was recommended, not in isolation or not as a monotherapy, but as adjunct or addition to intensive health behavior and lifestyle treatment," Hampl told 番茄社区.

She said AAP "needed to comment on [pharmacotherapy], because it can be a very effective form of treatment -- again, as an adjunct -- and these kids, especially with severe obesity, they have some really serious and real comorbidities right here and now, in their childhood."

Stanford, for her part, does not prescribe GLP-1 agonists earlier than age 12, she said. If she had a younger patient with hyperphagia -- a condition marked by extreme and persistent feelings of hunger -- she said she would "still have some significant discomfort" prescribing GLP-1 agonists.

"I would still probably use my other drugs where we do have some data, like a topiramate or metformin, or if they have very severe obesity, I would wonder if they had something else," such as proopiomelanocortin (POMC) deficiency or leptin receptor deficiency, she said.

A child visiting her center would work with dietitians and a psychology team so that "we're doing all the behavioral things that are not really on the biology side," she said.

Stanford monitors her adolescent patients on GLP-1 agonists carefully. In the absence of long-term data, bone quality in particular is something she keeps an eye on. Bariatric surgery, which brings on a similar degree of weight loss as GLP-1 agonists, can lead to , and she wondered if similar effects will emerge with the GLP-1 drugs.

Family medicine doctors may take an even more cautious approach, using weight-loss drugs as a last resort.

Tochi Iroku-Malize, MD, MPH, MBA, former board chair of the American Academy of Family Physicians, told 番茄社区 that the group's position mostly aligns with that of the U.S. Preventive Services Task Force, which this year recommended comprehensive, intensive behavioral health interventions for children 6 and older with obesity instead of weight-loss medication.

"When we're starting with children, they have a longer way to go than adults when it comes to using these medications," Iroku-Malize told 番茄社区. Children's bodies are still growing and developing, "so we don't yet know what the long-term effects of taking the weight-loss medications are, and whether the young patients would have to continue taking them indefinitely to maintain their weight," she said.

Still, she said using medication to treat pediatric obesity is not out of the question. "On the other side of it is that for those children who have obesity, and to the point that they are at risk of developing some other condition that could increase their morbidity and mortality, and they've tried the other methods and it's not working, and they're still at risk, then this may be an option," Iroku-Malize said. "But we have to pay attention to what's going on and not use it lightly."

Emphasizing Lifestyle Changes

Others stress a bigger focus on root issues, like physical activity and nutrition -- including Dan Cooper, MD, a pediatrician at the University of California Irvine. Cooper and colleagues have published on the in children, including possible long-term effects on growth and development, abuse among patients with eating disorders or in competitive sports, and insufficient or excessive prescription in populations with high rates of obesity and poor fitness.

Though he has not ruled out the use of GLP-1 drugs in kids, he said there's an urgent need to engage with lifestyle and behavioral interventions more meaningfully.

Experts were careful in interviews to emphasize the role of diet and exercise for anyone who starts a GLP-1 drug. The trials that led to approval of semaglutide and liraglutide to treat obesity in adolescents provided regular nutrition and physical activity counseling, and in both trials, participants were "encouraged" to get 60 minutes of daily moderate- to high-intensity physical activity, they said.

But few children have access to lifestyle interventions like those used in the trials, and in real life, they often fall short, Cooper said.

He explained that even when a physician tells a pediatric patient to exercise, specific instructions are rarely given, and there's not usually much follow-up. There are other barriers at play too, he said.

He noted that in his community in Santa Ana, California, there are very few parks. "Parents don't want the kids to play because it's unsafe on the streets," he said. "The schools don't have the budget for after-school programs."

"Don't get me wrong, I'm not blaming the pediatricians. I'm a pediatrician," he said. "I mean, we're the best doctors on the planet. But it's very, very tough to do these things."

Scott Bowman, a friend of Cooper's, is a physical education specialist and the author of the state's . He agreed that GLP-1 agonists don't get at the root of a complicated systemic problem: a tenuous relationship between kids and exercise.

Bowman has helped schools organize family "Olympics," and thinks professional sports teams should channel their excess funds into more community fitness programs.

While he says it's not an either-or decision, Bowman would rather have "lifelong physical activity than lifelong medication," he said. "We just have to start thinking outside the box."

Correction: Tochi Iroku-Malize, MD, MPH, MBA, is the former board chair of the American Academy of Family Physicians, not the president-elect.

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