Addressing the evidence behind various therapeutic options for adolescents with obesity

The Obesity SocietySep 30 2019

As rates of adolescent obesity continue to rise, choice of treatment needs to be guided by the severity of obesity, psychosocial factors, comorbidities and patient's age and pubertal status, according to a new paper published online in the Journal of the American Medical Association (JAMA).

"Rather than proceeding by chronological stages or phases, treatment should occur as an integrated continuum of care that begins with the least invasive, yet appropriately intensive treatment," writes author Michelle Cardel, PhD, MS, RD, FTOS, of the University of Florida College of Medicine in Gainseville. "All options should be discussed with the family, and it is critical to use patient-first language and terms preferred by adolescents, such as BMI, and to avoid terms such as fat." Ania Jastreboff, MD, PhD, of Yale University School of Medicine in New Haven, Conn., and Aaron Kelly, PhD, University of Minnesota Center for Pediatric Obesity Medicine in Minneapolis, also co-authored the paper.

In the paper, Cardel and colleagues address the evidence behind behavioral intervention, pharmacological and weight loss options. For the behavioral intervention, the study's authors recommend delivery of at least 26 contact hours over 2 to 12 months by an interdisciplinary team including a pediatrician, registered dietician, exercise physiologist and/or psychologist. Targeting the home environment may facilitate change, and involving the family is recommended. Changing one's diet to decrease portion sizes, consume less ultra-processed foods, sugar-sweetened beverages and other added sugars; eating more fruits, vegetables, and fiber; and eating meals with the family is also recommended.

On the pharmacological side, the U.S. Food and Drug Administration has approved two medications for adolescent obesity: orlistat, a lipase inhibitor for long-term use and phentermine, a norepinephrine and a reuptake inhibitor for short term use. In the largest randomized clinical trial, takers of orlistat experienced mild to moderate gastrointestinal problems. No randomized clinical trials of phentermine have been conducted in individuals younger than 17 years of age.

Filling the treatment gap between lifestyle modification therapy and bariatric surgery should be prioritized. Medications can help address the gap but we need to accelerate the pace of research evaluating the safety and efficacy of anti-obesity agents for children and adolescents."

Aaron Kelly, PhD, University of Minnesota Center for Pediatric Obesity Medicine in Minneapolis

The authors argue bariatric surgery is an effective treatment for adolescents with severe obesity. The TEEN Longitudinal Assessment of Bariatric Surgery (TEEN-LABS) reported a 3-year mean BMI reductions of 29 percent with Roux-en-Y gastric bypass and 27 percent with vertical sleeve gastrectomy among individuals aged 19 years or younger. The 5-year outcomes in the Roux-en-Y gastric bypass group demonstrated that the BMI reduction was largely sustained. The authors said long-term safety and effectiveness data in patients undergoing bariatric surgery during adolescence is lacking.

"Cardel and her co-authors have done a nice job summarizing the therapeutic options for adolescents with obesity. However, because almost 21 percent of adolescents aged 12-19 years have obesity, the challenge is not what to do, but how to do it. While primary care physicians are appropriately the frontline responders, the time required for joint decision-making with patients and the lack or reimbursement pose major obstacles to care," said William "Bill" Dietz, Past President of The Obesity Society and Director of the Sumner M. Redstone Global Center for Prevention and Wellness at the Milken Institute of Public Health at George Washington University in Washington, DC.

"As obesity medicine physicians and clinical providers we strive to provide the safest, most effective care across the lifespan for all patients with obesity. It is essential for us to approach each patient with compassion and understanding, supporting and guiding them through their life-long journey to better health," said Jastreboff.

In regards to conflict of interest disclosures, Cardel reports receiving grants from the National Insitutes of Health (NIH) during the conduct of the study. Jastreboff reported receiving personal fees from and serving as consultant for Novo Nordisk, Rhythm Pharmaceuticals, and Medtronic Diabetes. Kelly reported serving as unpaid advisor to Novo Nordisk, Vivus, Orexigen, Takeda and WW, and receiving research support from AstraZeneca for an NIH-funded clinical trial.