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    How young is too young for GLP-1s? Bariatric surgery? Academic experts offer insights

    Pediatric prescriptions for some weight-loss medications jumped 700% during the past few years. Thousands of teens get bariatric surgery each year. What makes sense for kids diagnosed with obesity?

    Frankie McGinn, 17, is being treated for a basketball injury.

    Frankie McGinn, 17, pictured above being treated for a basketball injury, says she could not lose weight despite working out for hours daily — until she started taking a GLP-1 medication.

    Courtesy: Chrissy McGinn

    Frankie McGinn could not seem to lose weight no matter how hard she tried. The 16-year-old Chicago teen ate a healthy diet and played basketball seven days a week, several hours a day. Eventually, she became so uncomfortable in her body that she took to wearing baggy sweatshirts, and tried to avoid mirrors and windows at the shopping mall.

    Then, inspired by her mom’s success with semaglutide (Wegovy) — one of the glucagonlike peptide-1 (GLP-1) medications that’s been transforming weight-loss care — Frankie got a prescription as well. She had some nausea at times, and she’s needed to see a doctor at Lurie Children’s Hospital of Chicago monthly for monitoring. But the results have been dramatic.

    “I lost 42 pounds since March. I feel healthier, and I have more energy. I used to have to take a nap after school,” says Frankie, now 17. “I’m happier, and I have more confidence. I feel better in my body. [Medication] has helped me in so many ways.”

    In the United States, more than 14 million children and teenagers — roughly 1 out of 5 — are affected by obesity. That means their body mass index (BMI) is at the 95th percentile or above, increasing their risks of diabetes, heart disease, and other health problems, says Fatima Cody Stanford, MD, MPH, MPA, MBA, an obesity physician-scientist at Massachusetts General Hospital and Harvard Medical School in Boston.

    “I see children as young as 2 with obesity. I see teenagers who are sicker than my adult patients,” Stanford says.

    Such concerns are driving dramatic increases in pediatric obesity treatment. Prescriptions to young people for two GLP-1 medications — semaglutide and liraglutide (Saxenda) — jumped 700% between 2022 and 2024. Pediatric bariatric surgeries among young people rose nearly 20% between 2020 and 2021, according to the most recent data.

    Up until 2023, pediatricians were advised to apply a “watchful waiting” approach with patients diagnosed with obesity, and to recommend lifestyle treatments aimed at healthier eating and exercise habits. But that year, the American Academy of Pediatrics (AAP) released guidelines stating that providers should offer medications to patients 12 and older with obesity, alongside lifestyle treatment. Patients 13 and older diagnosed with severe obesity should be evaluated for bariatric surgery, the authors wrote.

    Criticism quickly ensued. Some pointed to evidence suggesting that not everyone diagnosed with obesity needs to lose weight to stay healthy and bemoaned the use of BMI, a controversial measure that is increasingly considered inadequate unless additional factors such as waist circumference are also evaluated. Others worried about the potential long-term risks of GLP-1s, which could require lifelong use given that weight usually returns when treatment ends.

    “These patients are taking medications during critical periods of development and growth,” says Dan Cooper, MD, a pediatrician and obesity researcher at the University of California, Irvine. “We don’t yet have studies on the long-term effects of GLP-1 therapies in teens, so young patients taking them are practically participants in a research study.” What’s more, Cooper and others say, GLP-1s are already being prescribed off label to children under age 12.

    Others note the potential psychological fallout of an increased emphasis on weight in a society already obsessed with thinness. “Imagine the trauma children will experience when they are told not only is their body diseased … but that they need medication or surgery to fix it,” reads a letter from the Collaborative of Eating Disorders Organizations, a coalition of local, national, and international groups focused on awareness of eating disorders and access to quality care.

    But some believe the increased focus on medical treatment could actually shift conversations away from fat-shaming.

    “Too often, people wrongly think obesity is the fault of the individual, when in reality some people have a strong genetic predisposition for it,” says Aaron Kelly, PhD, codirector of the Center for Pediatric Obesity Medicine at the University of Minnesota Medical School. “Treatment isn’t about blaming people for their behavior. It’s about providing care that can improve their lives.”

    Moving toward medications

    In a dramatic shift in pediatric weight-loss options, the Food and Drug Administration approved a GLP-1 medication — the daily injectable liraglutide — for kids 12 and up in 2020, and a second — the weekly injectable semaglutide — in 2022. Now, the agency is considering a request to approve liraglutide for children as young as 6.

    Unlike other weight-loss medications, GLP-1s mimic a gut-based, appetite-modulating hormone that decreases blood sugar levels and sends signals of fullness to the brain.

    GLP-1s can have powerful effects. In one study, nearly three-quarters of teens who received semaglutide experienced a weight loss of 5% or more — compared with 18% of patients who experienced that degree of weight loss who received a placebo. The medication group experienced a BMI drop of 16%, while the control group saw just a 0.6% reduction.

    “These medications can be life-changing,” says Kelly, who helped conduct pediatric semaglutide studies.

    GLP-1 medications also seem to have relatively few side effects. The most common ones — gastrointestinal issues like nausea and diarrhea — often resolve over time, says Kelly.

    Still, GLP-1s are not for everyone.

    “Before prescribing, providers need to consider the whole patient, including the child’s physical and emotional health and the environment they live in,” says Sarah Hampl, MD, a coauthor of the AAP guidelines, pediatrician at Children’s Mercy Kansas City, and professor of pediatrics at University of Missouri-Kansas City School of Medicine. “Typically, there is a pretty remarkable decrease in appetite, so close monitoring will be necessary to avoid inadequate nutrition and hydration.”

    Such considerations worry Cooper. “Caloric intake impacts the production of growth hormones, bone building, and puberty. The biological clock of development is quite detailed, delicate, and not completely understood. We need to be careful about altering those processes in young people,” he says.

    Hampl agrees that there is a need to better understand the developmental impacts of GLP-1s. Meanwhile, though, she doesn’t want that to stall their use.

    “We on the front lines are seeing the very real risks of obesity right now, and we should not deprive patients of medications that can reduce or even remove those risks entirely,” she says.

    The surgical option

    The need for pediatric bariatric surgery does not disappear with the advent of GLP-1s, though it may decline, says Thomas Inge, MD, PhD, a professor of surgery and pediatrics at the Northwestern Feinberg School of Medicine and surgeon in chief at Lurie Children’s Hospital in Chicago.

    “Think about a 16-year-old patient who weighs 400 pounds. Even the best possible response to medication is unlikely to produce enough weight loss,” he says. Also, medications don’t work at all for a small subset of patients.

    Approximately 2,200 bariatric surgeries are performed among young people annually in the United States, using different approaches. One, gastric sleeve surgery, removes around 80% of the stomach, causing the patient to feel fuller sooner and reducing hormonal signals that impact appetite and metabolism. Another, gastric bypass, similarly reduces stomach size but also bypasses part of the small intestine to decrease calorie absorption.

    Surgery offers numerous potential benefits. In one nationwide study, teens maintained a 20% decrease in BMI a decade after surgery. They also experienced complete recovery from type 2 diabetes and heart disease as well as other positive health outcomes.

    Performing surgery earlier in life may be better in some significant ways. For example, research shows that after surgery, 1 out of 4 adults still required diabetes medication — but none of the adolescents needed it.

    So, how young is too young? It depends on the patient, says Inge, who has operated on an 8-year-old.

    “If we have a young child with major health problems — say, it looks like they’re heading for a liver or kidney transplant — we should be offering them treatment,” he believes.

    Certainly, bariatric surgery for young people is no simple matter.

    The process differs by institution, but the American Society for Metabolic and Bariatric Surgery offers guidelines. Generally, it entails months of medical and behavioral preparation, including a mental health assessment, explains Evan Nadler, MD, an adjunct associate professor at the George Washington University School of Medicine and Health Sciences in Washington, D.C., who has performed hundreds of pediatric bariatric surgeries.

    Like any surgery, bariatric procedures carry such risks as infection. And life shifts dramatically, at least for a while. “While they’re recovering, patients are eating just three to five bites of food, three to five times a day. So, they really need to focus on such steps as making sure they consume enough protein and drink 64 ounces of water a day,” Nadler notes.

    It requires long-term work too, such as taking daily vitamins that “become like medication,” says Inge. Some patients may also need weight-loss medication, and some may require additional surgeries.

    Rebecca Cayman is glad she underwent bariatric surgery at Children’s National Hospital in Washington, D.C., several years ago, at age 17. In high school, Cayman, now a medical researcher, gained around 80 pounds in just three months, partly due to her polycystic ovary syndrome.

    “I was constantly having intense food cravings. After breakfast, I wanted lunch right away. There was so much ‘food noise.’ That all disappeared with surgery,” she says. “For the first time in years, I felt like my body wasn’t fighting against me anymore.”

    Taking better care of kids

    Given the growing interest in weight-loss medication and surgery for young people, much needs to happen to protect their well-being, researchers and clinicians say.

    For one thing, access to care needs to improve, says Inge. “Insurers may cover GLP-1s, which are expensive, one month but not the next, and they come up with a lot of obstacles to surgical care,” he says. Plus insurers often fail to cover the gold standard for behavior change, intensive health behavior and lifestyle treatment — a holistic, in-depth approach that engages an entire family for at least 26 hours of fitness and nutrition training — which can sometimes eliminate the need for additional care.

    Stanford worries about equity issues. “Unfortunately, the populations who would benefit the most — those tend to be of lower socioeconomic position and racial and ethnic minority populations — are the ones who have the hardest time accessing care.”

    Research on pediatric obesity is another crucial concern, says Nadler. “I’d like to know how long we should try lifestyle changes, or whether they may not be necessary at all in some cases, before starting medications. For patients who may need both medication and surgery, which one should we recommend first? How do we create the optimal plan for each patient?”

    Research should also further explore the psychological impact of weight-loss treatment, including the risk of eating disorders, say those involved.

    “There just isn’t much evidence suggesting that bariatric surgery in adolescence increases eating disorders,” says Margaret Zeller, PhD, a pediatric psychologist and researcher at Cincinnati Children’s Hospital Medical Center. But GLP-1 treatment for obesity is far less clear. “We don’t have that track record in teens — or really even adults — yet.”

    Better scientific understanding is only part of the equation, though. Frontline providers also need better training in addressing excess weight among kids, says Cooper. There’s been progress — the creation of obesity-related curricula and competencies, for example. But some areas, such as how best to motivate kids to exercise, have remained meager, he says.

    For her part, Cayman would like physicians to learn more about how to avoid inadvertent fat-shaming.

    “Some providers made me feel like I wasn’t doing enough to lose weight, like it was my fault,” she says. “Ideally, there would be more body positivity. There would be a sense that you can love your body at any size, while also focusing on working to improve your health.”

    Zeller, too, hopes for a greater emphasis on promoting health and preventing disease.

    “We need to start young to help build healthy lifestyles and environments. We need to support providers and families in creating a culture of health,” she says. “We must not lose sight of prevention. After all, that’s what pediatrics is all about.”