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We’re joined by Karla Lester, a pediatrician and certified life and weight coach. Together, we explore the journey of Lizzie and her mother, Jackie, as they navigate the complexities of health, weight, and familial dynamics. From Lizzie’s insulin resistance to Jackie’s journey towards a holistic understanding of metabolic health, we uncover the challenges and triumphs of their experience.

Karla Lester is a pediatrician, certified life and weight coach, and diplomate, American Board of Obesity Medicine.

She discusses the KevinMD article, “GLP-1 medications like Wegovy are effective metabolic health tools for teens with insulin resistance.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Karla Lester. She’s a pediatrician and a certified life and weight coach, and today’s KevinMD article is “GLP-1 medications like Wegovy are effective metabolic health tools for teens with insulin resistance.” Karla, welcome back to the show.

Karla Lester: Thanks for having me. I always appreciate the platform.

Kevin Pho: So Karla’s been on multiple times. Go to KevinMD.com/podcast to hear her story and prior episodes. But today let’s jump right into this most recent one, and for those who didn’t get a chance to read it, tell us what it’s about.

Karla Lester: Well, I’m, like Dr. Pho said, board certified in pediatrics. I’m also board certified in obesity medicine and a certified life and weight coach. And I have a platform called IME Community, which is coaching and advocacy. And then I started a metabolic telehealth practice for children and adolescents. It’s licensed in 15 states over the last year, and I’ve been prescribing GLP-1 medications as part of it.

And of note, and of importance, is that I don’t have any conflicts or disclosures or any ties to the pharmaceutical industry that produces these medications. But also, I created my whole platform based on, insulin resistance is the real epidemic we should be facing, and that was before myself even knowing, doing this work for so long, about the medications. So I always viewed these as a helpful adjunct, and that they treat the root cause of obesity, which is a side effect of insulin resistance.

So I thought, well, I’m a year into this, I’ve learned so much, and as we know, each patient is different, and there are so many things that I felt like I could share about the use of GLP-1 receptor agonist medications, especially in adolescents.

And so in the article I thought it would be best to go through a case, one of my patients, which is a compilation, really, of a lot of patients. It just shows how, especially when working with adolescents, but with any patient, how this is a chronic disease, it requires chronic care management, we’re going to meet them where they are, and it requires a whole approach to health.

Kevin Pho: All right. So I want you to talk about that case study, but just for some context, what are some of the guidelines from various board organizations about the role of GLP-1s in teens?

Karla Lester: Well, the FDA approved Wegovy, semaglutide, based on the STEP TEENS trial, for adolescents aged 12 to 17, as an anti-obesity medication. And it showed many positive outcomes, not just weight loss, but decreased waist circumference and also many improvements in biomarkers compared to placebo. So they’re very effective. So the FDA approved that.

And then also the American Academy of Pediatrics came forward with clinical practice guidelines that said, let’s intervene earlier, let’s make the diagnosis of obesity earlier. And then in the past we had these expert committee recommendations that called for a staged approach to treatment, and this is basically, do not pass Go, offer these interventions at even the first visit. Those were obviously very controversial.

But those are some guidelines that show these medications can be effective and should be a part of, especially when we’re treating adolescents. Because we all know that the data always shows, we just have, like, OK, it’s gotten worse, especially post pandemic, here we go with another round of increasing severe obesity in adolescents, and then absolutely nothing really to offer these teens except for just saying, OK, 80 percent are going to be obese adults.

And then the study that I look at all the time, and that I really base all my work around, is the TODAY2 study, which is an adolescent type 2 diabetes study that a lot of great information has come from. And really it shows that type 2 diabetes in adolescents is a more severe disease, they have early cardiovascular disease, and that it’s refractory and not as effectively treated with the medications that we’ve been using.

So for me, I really take this whole approach. And most of my patients, their parents find me on TikTok, and they look at my website and they download my insulin resistance guide in teens, and they’re like, there is something else going on here. Because I do have a lot of, and physicians can start to believe their patients, because I do have a lot of patients who do have a pretty balanced diet and they’re pretty active in sports, but they really are stuck at a weight and they may have other comorbidities.

And so yeah, there’s the guidelines, there’s the FDA approval, and then there’s studies like the TODAY2 study, which make it, it’s kind of almost a relief to have these medications, like the GLP-1 medications, that could actually treat the root cause.

Kevin Pho: So tell me about this case, then, that you wrote about in the article.

Karla Lester: Yeah, I wrote the article because I was wanting to do a year in review of teen metabolic health and all the things that have happened, but also a year in review of GLP-1 medications. Because I was like, I’m licensed in 15 states, every case is completely different, as far as causes, comorbidities, and contributing factors, which is what I look at, and then also how they respond to the treatment has been completely different.

So I had two patients come at the same time, both really similar, in ages, in BMI. And one’s labs showed more of an insulin resistance type of picture, and one had more genetic predisposition to metabolic syndrome, but relatively the same, and same BMI.

So there’s so many access issues to getting these medications, so we can’t put all our eggs in that basket, any of us physicians who treat patients with obesity. But with this particular patient, the mom and I went through a lot with prior authorization appeals to get approval. So we’re really excited. Then the national shortage of the Wegovy starting doses started, and it was another nightmare. It’s like, here we go again.

So the mom found a pharmacy, we got her started, she tolerated it perfectly fine, we ramped up on the dose to the 2.4 milligrams just as on schedule, no problem. And she had no weight loss. Whereas another patient, same situation, mom was able to find the starting dose of Wegovy, she started on the starting dose, she’s lost 50 pounds over the course of eight months and absolutely really didn’t do anything else.

But I was looking at this case when my patient presented for follow-up. And first, as a coach, we managed expectations, and we allowed disappointment. It’s OK to be disappointed, but we’re not going to make it mean anything.

First of all, is this medication bioavailable to you? Are you actually getting the injection, are you doing it properly? She was having some side effects. Does it matter where she’s getting it? So we’re troubleshooting and problem solving along the way.

The other thing is, what are you noticing? She was noticing less craving, she was noticing some appetite suppression from before. Then we went to all the nutrition stuff. Well, what are you eating? She’s a very picky eater, so she had not changed or adapted her diet at all, except for adding in some protein. But they were kind of stuck in diet culture, and she was only getting 1,300 calories a day, and so it was like, your body is just stuck.

So we talked about thermogenic effects of food, how to increase your metabolism, rev it up with food, and do more balance of protein, healthy fats, and fiber. But also I was like, let’s check some labs, let’s see what other comorbidities may be going on, does she have PCOS? Checked the labs, and they were so improved.

So it’s like, maybe the weight loss hadn’t started yet, but her insulin resistance, she was becoming more insulin sensitive, more insulin responsive. And her mom was thrilled, because she’d been going to the pediatrician for so long and feeling that shame that we as parents feel, that, oh my gosh, my daughter’s cholesterol is high and the family has heart disease and all these issues. So she was like, oh my gosh, this is amazing. And so it is working, we just hadn’t seen weight loss.

So then what happened was, as she made some changes with the food and was starting to tweak and get a balance, and then was on that 2.4 for a longer period of time, and she had all the other health behaviors in place, sleep and stress reduction, doing self-care, she’s physically active, so she started to notice weight loss. So she went from a BMI of, I think, 32.5 to around 28 or 27, something. So it’s clearly working.

Kevin Pho: What are some unique issues teens have when you’re considering GLP-1 medications for them?

Karla Lester: We have to manage their expectations, that’s the main thing, because it depends on the patient. And this patient was really cool, I mean, she was disappointed that she wasn’t losing weight, and so was her mom, especially after all that we had done.

But it’s also like, it’s going to be slow most likely. It’s the rare patient where it’s not going to be. And you have to do all of the other things in order to get the results.

But the reality is, I’ve treated patients now with Wegovy, Ozempic, Zepbound, and Mounjaro too. And I would say 20 percent of my patients have pre-diabetes or an actual diagnosis of type 2 diabetes, and it is so hard for insurance to cover. It’s so frustrating for all of us physicians, but for teens too, if they’re in that loophole of, their insurance won’t cover anti-obesity meds, but they have pre-diabetes according to adult criteria, and they won’t cover Mounjaro or Ozempic because they don’t meet the adult criteria for type 2 diabetes, which is not appropriate based on the TODAY2 study.

But anyway, if they don’t kind of dial in with all of the health behaviors and really focus on everything, they may not get results, or it won’t be sustainable if for some reason they can’t take it.

And so I think managing expectations is one thing. But then I also have a lot of patients that it’s really just not that big of a deal. And I have some that, they take the dose, and I’ve had one where she took the beginning dose and she developed abdominal pain and she just didn’t like it. I mean, it was fine, she had one episode of vomiting, but she decided, I’m not taking that again. She doesn’t want it.

So you can have a side effect, and so you have to talk about all the possibilities. And then also I really frame it up to look at all of health, and that there’s other medications that we can use. Just because you try it and maybe it’s not effective doesn’t mean that it won’t be effective later on if you try a different one as you get older, or that there aren’t other things that we need to look at going on.

And so I don’t have a lot of drama about it. I also don’t talk to them about taking it long term. A lot of people say, why would you start them on something that they have to take for the rest of their life? Well, welcome to pediatrics.

Kevin Pho: Now, for those pediatricians that are listening to this, what are some characteristics of teen patients that would make them think that a GLP-1 may be the right medicine for that patient?

Karla Lester: Well, first of all, for community pediatricians, I was one for quite a while, and it’s really hard to have the time to write the prior authorizations, to do the appeals, to help the families navigate the shortages and side effects. It’s really hard. So I think that the AAP clinical practice guidelines are not that feasible for a general pediatrician.

But definitely for anyone 12 and up, and especially if their BMI is 27 and they have a comorbidity, or their BMI is 30, then they meet the criteria for a GLP-1 medication.

Obviously I do a lot of screening, a lot of talking about disordered eating, mental health issues, and all of that has to be taken into account. And as a pediatrician you would get those referrals in to make sure that they’re getting treatment for their mental health diagnosis, and especially if they have disordered eating, which I find a lot of my patients have some spectrum of disordered eating.

So I think they should consider it for any teen. And parents know about it, many of the parents are taking them and they do fine, and so then the teen will be like, I want that.

One thing I will say is that, for sure, I am very against, and all my pediatric colleagues who do this work are all against, using compounded GLP-1 medications, especially for adolescents. I feel like if you’re an adult you get to make that decision for yourself, but I definitely don’t prescribe compounded meds, and I wouldn’t let a parent talk me into that.

Kevin Pho: So when we talk to adult patients, we talk about how GLP-1s are a longer term medication, because the weight tends to come back if you stop those medications. You alluded to this earlier. When that issue comes up, when you talk to teen patients, in terms of how long they need to be taking these medications, what do you say to them? How do you manage those expectations? Just give us an example of that particular scenario, in terms of how long they may need to take these medications.

Karla Lester: Well, I do tell them, and they understand, that it’s a chronic disease and it requires chronic management. And I also say that the medications are a helpful adjunct, they’re one part of the puzzle, and so we have to take advantage of taking these medications.

And then they also have a real reality check when they work with me about, there’s accessibility issues, what if you have a side effect, what if you have something else going on, you can’t take it? There’s always going to be different things, so we’ll cross that bridge when we come to it.

And I have a patient who has really had a lot of success on the 0.25 milligrams of Wegovy, who I was alluding to earlier, and we literally have this conversation every follow-up appointment, and we talk about what maintenance is going to look like. And I really feel like we just have to kind of cross that bridge when we come to it, and just hope that as things progress and there’s more research done in adolescents with GLP-1 medications, my hope is that we will start having indication for pre-diabetes, that they’ll have different indicators for adolescents with pre-diabetes, fatty liver disease, and also PCOS.

Kevin Pho: Now, you mentioned side effects. In general, what are some side effects that teens need to consider? Are there any side effects that teens may be more susceptible to when it comes to GLP-1s?

Karla Lester: Yeah, I think the number one that I would say is nausea, and it’s never been too bad. The teens who I’ve worked with have reported waves of nausea, maybe like the day of or the next day. And then some have reported some appetite suppression just like the first day after taking the dose, but they know that they’ll make up for it later, so they don’t worry too much about it, because we don’t restrict calories. This isn’t diet culture.

I’ve only had a couple patients who’ve had actual episodes of vomiting from it, and it’s maybe been one, and when they first started it, and then they were OK.

And then the issue with constipation obviously is one that we want to stay on top of, because teens just kind of on a foundational basis aren’t always getting their quality macronutrients, so they’re not always vigilant about getting fiber in. So making sure that they are getting their protein in, getting their hydration, getting their fiber in, and maybe they take supplements. But I have had some that struggle with constipation before, and we really talk about how we need to go into taking this medication with getting on board with your hydration and your fiber and maybe other treatments.

But luckily I’ve only had one patient who was like, I’m not taking it, and she made that decision for herself, and good for her. I like, good for you to make that decision. Nobody knows how you feel, and everybody feels different with it.

One of the tricky things is, I’ve had a couple patients on GLP-1s that have had gastrointestinal illnesses that are viral, and maybe they got that right after the injection, and so they’re like, oh no, is this the medication? And then we figure out that it’s just the virus. But that can be a little bit tricky too.

Kevin Pho: We’re talking to Karla Lester. She’s a pediatrician and a certified life and weight coach. Today’s KevinMD article is “GLP-1 medications like Wegovy are effective metabolic health tools for teens with insulin resistance.” Karla, as always, we’ll end with some of your take-home messages to the KevinMD audience.

Karla Lester: Well, what I want is for physicians to be open to all treatments that are available, to really just start the conversation, start learning more about GLP-1 medications and teens, and really help them have more of a metabolic health approach, so that they learn more about insulin resistance.

And us as physicians, we’re not taught that much about it, but look at the TODAY2 study to learn more about type 2 diabetes in adolescents and how these medications are potentially going to be really helpful.

And the other thing is, assess your patients. So get their labs. Don’t just think that they’re going to grow out of it, or be wary that you’re going to cause harm if you have that discussion. This is something that these teens are really suffering with, and their parents really don’t know how to move forward to help them. So really be the one to get labs, to talk about it, to learn more about insulin resistance, to learn more about medications and maybe how you could start prescribing them within your practice.

And also, they’re here to stay, so there’s going to be a lot more data and research coming out about these medications used in teens, so we might as well get used to it.

Kevin Pho: Karla, thanks again for sharing your perspective and insight, and thanks for coming back on the show.

Karla Lester: Thank you.