Filling Gaps in the Options for Adolescent Obesity Care

It feels like adolescent obesity care is about ten years behind the recent progress in care for adults. Of course, we have the foundation of intensive behavioral support, though it’s hard to find effective programs for this age group. Very few options for pharmacotherapy are approved for teens. Finally, surgical treatment is becoming a bit less rare, but barriers litter the pathway to surgical care.

Despite all these problems, we see momentum building for better care. It’s especially noteworthy that JAMA this week chose to publish a clinical review on state of the art adolescent obesity care. It’s authored by three leaders of a growing group of clinicians and researchers intent on advancing the standard of care: Michelle Cardel, Ania Jastreboff, and Aaron Kelly.

Behavioral Care

Cardel et al tell us this foundation for obesity care must be intensive to be effective. Multi-disciplinary teams should be providing at least 26 contact hours of care over a period of two to twelve weeks. A primary care provider giving occasional advice to lose weight doesn’t really help. Even with intensive care, results are modest.

Anti-Obesity Medications

The gap in pharmacotherapy options is striking. Right now, the only well studied and approved option is orlistat. It’s effective, but many patients have problems with oil in their stools or gas. It can be messy.

Other than orlistat, phentermine has approval for teens 17 and older. But it’s only for short-term use. Since obesity is a chronic disease, this doesn’t make much sense. Unfortunately, it’s an older drug. It comes from a time when people thought obesity was only an acute problem. We know better now, but we don’t have the right studies for phentermine in chronic use.

Other drugs, approved for adults, are options that pediatric obesity specialists might use. But their use is far from commonplace.

The good news is that more options are coming. Setmelanotide may receive an approval later this year for youth with POMC-deficient obesity. Clinical development of liraglutide for adolescents with obesity is beating completion. Hopefully, other options will follow.

Surgery

For many teens with severe obesity, bariatric surgery probably offers the best efficacy. Centers that offer this kind of care are growing, but still few in number. And for most teens, it’s daunting. Though the risks are not as great as many people assume, they are real. Just like any surgery, complications are a worry. Patients have to be very careful about taking vitamin and mineral supplements to avoid nutritional deficiencies. And the possibility that a patient will need a follow-up surgery is real.

Bottom line, though, a gastric sleeve or gastric bypass can yield significant improvements in health and life for the right patient.

Closing the Gap

The real bottom line here is that teens with obesity have options. They’re not ideal, but they can be quite helpful. Even more important, though, is that more and better options are coming. Cardel et al sum it up well:

Obesity demands the rigor and quality of care, including lifelong treatment, afforded to other chronic diseases. Additional research funding support is needed to accelerate the development of novel mechanism-based and personalized therapeutic interventions and to assess the efficacy, safety, and long-term outcomes of existing antiobesity medications in large, long-term randomized clinical trials.

With more talented clinicians and researchers aiming for better care of these patients, we see a brighter future ahead.

Click here for the clinical review in JAMA and here for a recent detailed review of pharmacotherapy for adolescents with obesity.

Eugene, photograph © Garen Dibartolomeo

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October 2, 2019