Nearly 1 of every 5 children or adolescents in the US were living with obesity as of 2020, a rate that has doubled or tripled in the past 30 years.

That striking rise of obesity among youth has reshaped pediatric care entirely, said Kenneth J. Cruse, MD, pediatrician at Manning Family Children’s  in New Orleans.

“The newest epidemic among our youth is obesity, which is increasing at an alarming rate,” Cruse said. “All age groups are affected, and it spans cultural differences.”

Worse, Cruse said, obesity brings with it comorbidities once seen only in adults, such as diabetes, hypertension, and dyslipidemia. These are now appearing routinely in children, he said.

Carolyn Jasik, MD, associate chief clinical officer at Verily, Alphabet Inc.’s life sciences and precision health company, said pubertal growth offers a distinctive window for resetting metabolic trajectory. She said that early adolescence, in particular, is a critical moment for targeting nutrition and activity.

“Early intervention would be lifestyle change, and that can be extremely helpful, especially in younger adolescents who are in the middle of rapid growth in height due to pubertal onset,” she said.

Sedentary habits in this world of increased screen time can pose an obstacle to these opportunities. The clinicians recommended that parents work with their adolescents to create dedicated time for aerobic exercise. Alvaro G. Flores Lopez, MD, pediatric gastroenterologist at Children’s Nebraska in Omaha, Nebraska, said that lifestyle changes such as exercise work best when embedded in a comprehensive treatment model.

“Obesity treatment usually entails a holistic integral plan, which can include lifestyle changes, mental health support such as psychotherapy, or more advanced treatments such as pharmacotherapy and bariatric surgery.”

Mehul Patel, MD, pediatrician at Children’s Memorial Hermann Pediatrics, Houston, said structured support is important for teens to maintain consistency with changing lifestyle habits. He said that they often start strong with new eating plans, for example, but then things begin to trail off.

“Within a couple of weeks, stress and lack of time can pull them off routine,” he said. “Unhealthy meals are often the fastest to prepare, so they fall back into those habits.”

Reframing the Goals of Treatment 

Clinicians across specialties said the aims of treatment for adolescents with obesity must be much broader than lowering weight. Joey Skelton, MD, professor of pediatrics and epidemiology and prevention at Wake Forest University School of Medicine in Winston-Salem, North Carolina, said weight loss alone is too narrow a goal. He stressed that health and well-being, not numbers, should guide the approach.

“Many of us think that weight loss is what leads to improved metabolic health and improved mental health,” he said. “While that can be true, long-term health and happiness will involve addressing physical and mental health, which can lead to weight loss.”

Adolescent developmental stages also shape how clinicians discuss goals. Jasik said younger teens often respond to short-term, concrete benefits, while older adolescents can think more about future risk.

“The overall framing of weight management in adolescents needs to be tailored to (the patient’s) cognitive development and ability to consider a future-forward mindset,” she said. “Older adolescents are able to understand future metabolic health, whereas younger teens may be more motivated by immediate benefits like energy level, athletic ability, and appearance.”

With this cohort of patients, it’s also important to remember that the appeal goes beyond the patient themselves. Evan Nadler, MD, MBA, founder of ProCare Consultants and TeleHealth, emphasized the importance of aligning goals between adolescents and their parents.

“The most important purpose of my initial visits with adolescents and their families is to connect personally with them,” said Nadler, former director of the childhood obesity program at Children’s National Hospital in Washington, DC. “So, if the patient is more concerned about weight loss but the parents are more concerned about long-term metabolic health, then I try to address both goals and affirm that both are important.”

He strives to gain a rapport with teens and adults alike.

“I almost always lead with humor. Bad ‘Dad jokes’ can go a long way in breaking the ice,” Nadler said.

Sadly, many families don’t make it to that point, with economic and systemic barriers standing in the way of early intervention. Flores Lopez cited limited access to healthy foods, safe exercise, mental health resources, limited school programs, lack of obesity medicine specialists, and lack of insurance coverage for obesity treatment as just a few of the barriers to access.

Pharmacotherapy: More Options, More Considerations 

The introduction of GLP-1 receptor agonists for adolescents has expanded treatment possibilities, though with serious limitations. The FDA approved the use of liraglutide for use in patients aged 12 years or older with obesity in 2020; 2 years later, it approved semaglutide for the same population. They are each available under strict restrictions concerning who meets the criteria for treatment, however.

Liraglutide, as sold under the brand name Saxenda by Denmark-based Novo Nordisk, requires a minimum body weight, which excludes smaller adolescents even if they have high BMI percentiles. The medication has a BMI requirement tied to adult equivalent BMI, which means the teen must be in the “obesity” category, rather than only overweight.

The requirement that these drugs be used in conjunction with lifestyle change, including both diet and activity, is explicit, not optional. If no BMI improvement is made, treatment must be discontinued. Saxenda cannot be used in adolescents with type 2 diabetes.

Semaglutide, as sold under the brand name Wegovy, is also a product of Novo Nordisk. In order to be approved for use of this product, 12- to 18-year-olds must have a BMI ≥ 95th percentile for age and sex; once again, advancement from overweight to obesity is required. As with the Saxenda, this medication must be used in addition to diet and physical activity modifications, emphasizing that lifestyle change remains central.

One other medication is approved for the treatment of adolescent obesity. Orlistat, an oral medication sold over the counter as alli by Haleon US Services Inc., and in a stronger prescription formulation as Xenical , distributed in the US by H2-Pharma, LLC.

Given that teens are in hormonal flux, and adolescents with obesity have high baseline rates of mental health disorders ranging from depression and anxiety to binge eating behaviors, body image distress, and past weight-related trauma compared with their peers, a complete evaluation is best practice in pediatric obesity treatment prior to onboarding any prescription. From there, Patel said setting expectations remains essential.

“Before prescribing anything, I always make it clear that there is no miracle pill or injection. Without diet, exercise, and consistency, medication will not work,” he s aid. 

For adolescents with severe obesity who do not respond to lifestyle changes or medication, bariatric surgery may also be considered. Cruse said that just like with the medication, criteria for these procedures are also strict.

“The most recent recommendations include surgery for adolescents with a BMI greater than 35 with a comorbidity or greater than or equal to 40 without a comorbidity,” Cruse said.

Reducing Stigma and Building Buy-In 

Clinicians said stigma around obesity itself and around medication remains one of the biggest barriers to treatment adherence. This is something that frequently requires education from the clinician, especially when it comes to adding medications for treatment.

“There is often a perception that someone is lazy or not willing to change their habits,” said Patel. “People assume weight loss drugs are an easy way out.”

This is critically important, he said, because for many teens with severe obesity, medication can make the early stages of lifestyle change possible.

“For a teen who weighs 250-300 pounds, exercise is genuinely hard. If medication can help drop that initial 20-30 pounds, then exercise and dietary changes become more doable,” Patel said.

Flores Lopez said families do better when they understand that obesity is a chronic disease, not a personal failure.

“Education can help reduce stigma and help families and caregivers approach these patients in a compassionate and empathetic manner,” he said.

Patel, Flores Lopez, Nadler, and Cruse reported having no disclosures. Jasik reported being employed by Verily and, as such, having a financial relationship with the company. She also reported holding stock from a former employer, Omada. Skelton reported serving as editor in chief of the peer-reviewed journal, Childhood Obesity, for which he receives financial support. He writes, edits, and reviews for UpToDate, for which he receives royalties. He also reported serving as a scientific advisor for TOPS Club, one of the oldest nonprofit, noncommercial networks of weight-loss support groups and wellness education organizations.