In the United States, 1 in 5 (over 14 million), children and adolescents are affected by obesity. There are various contributing factors to excess weight gain in this patient population including behavior, genetics, certain medications, child care and school environments. Obesity related problems that can occur in children are high blood pressure, high cholesterol, type 2 diabetes and breathing problems such as asthma and sleep apnea. If a child experiences obesity while they’re young, most of the time, it will continue into adulthood.
The days of “watchful waiting” or delaying treatment to see if children and adolescents outgrow obesity are over as excess weight gain continues to increase among this group. The American Academy of Pediatrics (AAP) has recommended that certain drugs can be used for weight loss treatment in children mostly 12 years (some even younger) and up.
Metformin
Although metformin is used in the treatment of Type 2 diabetes, it has many other indications not approved by the FDA including weight loss. In fact, only a modest reduction in BMI was shown in adults in a 2020 meta-analysis. However, studies with both adolescents and children showed conflicting results in lowering BMI when taking metformin. Metformin works on diabetes by decreasing glucose production in the liver which reduces glucose levels in the blood and also increases insulin sensitivity in the cells. The adverse effects of this medication include nausea, bloating, flatulence and diarrhea which can be immensely uncomfortable especially for young children.
Orlistat (Alli ®, Xenical ®)
Orlistat works by blocking fat absorption in the intestine by inhibiting an enzyme called lipase. Currently it is approved for children 12 years of age and older. Although studies have shown it worked well in lowering BMI in adolescents, the adverse effects of this medication has caused this medication to be unfavorable in the pediatric population. The side effects include steatorrhea, fecal urgency and flatulence.
Glucagon-like peptide-1 receptor agonists (GLP-1 agonist)
GLP-1 agonist was originally approved for the treatment of Type 2 diabetes. Liraglutide (Victoza ®), dulaglutide (Trulicity ®), exenatide (Bydureon ®) and semaglutide (Wegovy ®) are a part of this class of medications and mainly work by slowing gastric emptying thus causing a decrease in hunger. Because of appetite reducing effects, these medications have recently gained immense popularity in people without diabetes who are overweight or obese or looking to drop extra pounds which has caused them to become short in supply throughout the country.
Recently, the FDA has approved liraglutide for treatment of obesity in children 12 years or older. Exenatide is currently approved in children ages 10 to 17 with type 2 diabetes. The adverse effects of this class include nausea and vomiting, there is also a risk of medullary thyroid cancer in patients with a family history of this condition.
Phentermine
Phentermine works by inhibiting the reuptake of norepinephrine, serotonin and dopamine thus reduces appetite in patients who are obese. Adverse effects of this medication include elevated blood pressure, dizziness, headache, tremor, dry mouth and stomach ache. Because of these effects, this is a short term option (3 months) for patients adolescents aged 16 years or older. And if after 3 months there is no reduction in weight, another weight loss option should be considered.
Topiramate
Topiramate was originally used as an anti-seizure medication and for migraines but also has appetite suppressing effect, especially when combined with phentermine (Qsymia ®). The major adverse effects of topiramate is cognitive slowing which can interfere with school and day to day life activities. It also is associated with birth defects and patient counseling must be completed upon patient starting, especially if they are child-bearing age.
Lisdexamfetamine (Vyvanse ®)
Lisdexamfetamine has a similar mechanism to phentermine however is a stimulant used in ADHD for patients aged 6 and older. This medication also has an indication for treatment of binge eating disorder in patients aged 18 and older and can be used off-label for obesity in children. However, there is no data that has reviewed the safety or efficacy for childhood obesity.
Although medications can help in the treatment of obesity in children, it is important to remember lifestyle modifications should always be in the forefront of therapy. Exercising, eating a healthy diet and avoiding processed foods can have a huge effect in the weight loss of children. Also developing healthy habits while young can allow children to maintain them during adulthood which leads to a long, healthy and successful life.
Reference:
1. Sarah E. Hampl, Sandra G. Hassink, Asheley C. Skinner, Sarah C. Armstrong, Sarah E. Barlow, Christopher F. Bolling, Kimberly C. Avila Edwards, Ihuoma Eneli, Robin Hamre, Madeline M. Joseph, Doug Lunsford, Eneida Mendonca, Marc P. Michalsky, Nazrat Mirza, Eduardo R. Ochoa, Mona Sharifi, Amanda E. Staiano, Ashley E. Weedn, Susan K. Flinn, Jeanne Lindros, Kymika Okechukwu; Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics February 2023; 151 (2): e2022060640. 10.1542/peds.2022-060640.
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