Will a telehealth model effectively engage adolescents with obesity and their parents to participate in their treatment plan?

Do GLP-1 agonist medications work to improve weight status and reduce or eliminate comorbidities in adolescents?

I’ve worked for over two decades as a community pediatrician to address the childhood and adolescent obesity epidemic. I can say with full certainty, when it comes to adolescents, we aren’t getting anywhere. With the COVID-19 pandemic, the rates of adolescents with obesity, eating disorders, mental health diagnoses, and health disparities have increased. It’s imperative that we adopt a new approach.

As a medical director of a weight management program at a children’s hospital, I found it was difficult to engage adolescents due to high attrition, low program adherence, and low attendance rates. There were no effective treatments offered other than bariatric surgery, but it is drastic and not feasible for most adolescent patients. When I was told to refer adolescents to the bariatric pathway at their first visit, I knew my values and vision didn’t align with a corporate profit-only driven system.

Approximately 14.4 million U.S. children and adolescents have obesity.1 The TODAY Study showed the incidence of type 2 diabetes in youth increased in parallel with obesity.2 In 2022, the FDA approved once-weekly semaglutide for adolescents with obesity.3

In 2023, the AAP released the Clinical Practice Guidelines (CPG) for the evaluation and treatment of children and adolescents with obesity.4 Pediatricians are called to integrate: Comprehensive obesity treatment; comprehensive patient history; family-based treatment; Intensive Health Behavior and Lifestyle Treatment (IHBLT); and longitudinal care.

Due to lack of obesity training, time, and minimal reimbursement for obesity services, it is not feasible for most pediatricians to implement the AAP Clinical Practice Guidelines. Many pediatricians will not prescribe GLP-1 medications for adolescents because of lack of experience and the time it takes to write prior authorizations and file appeals. Access issues should also include the lack of physicians who prescribe GLP-1 medications for adolescents.

When clinical obesity programs are available within communities, there are barriers that impact outcomes. Weight stigma, time out of school and work, and travel distance result in poor patient retention in clinical obesity programs.5 A telehealth model has potential to mitigate some of the barriers to treatment and improve weight management outcomes for children and adolescents.

Methods

To address access and to determine positive treatment outcomes, I founded Metabolic Telehealth for children and adolescents ages 5 to 21 years in 2022. The practice is licensed in 15 states. The model includes initial telehealth consultation, follow-up appointments, and medication checks. Initial consultation includes a comprehensive patient history and a treatment plan. The Health Yourself group coaching course supports family-centered behavior change as the IHBLT component. Program evaluation is measured using a database to evaluate demographics, accessibility, and treatment outcomes.

Results

Demographics:

• Of the 44 patients seen for consultation, 34 percent are from rural areas (population less than 10,000). 77 percent of patients identify as female and 23 percent identify as male.
• Of the different classes of obesity: 43 percent Class I obesity (BMI 30–34.9), 21 percent Class II obesity (BMI 35–39.9), and 16 percent Class III or severe obesity (BMI 40 or higher).
• 7 percent of patients had a BMI of 27 to 30 with a comorbidity, meeting the FDA criteria for prescribing semaglutide.
• The most common comorbidities are prediabetes and dyslipidemia.

Accessibility:

• 34 percent had one visit; 20 percent had two visits; 46 percent had three or more visits.

Treatment/outcomes:

• 38 (86.4 percent) patients were prescribed GLP-1.
• 20 of the 38 (53 percent) prior authorizations were denied by their insurance plan.
• 11 of the 20 denied (55 percent) opted to pay out of pocket for the GLP-1 medication.
• 20 patients with GLP-1 had three or more follow-up visits.
• 6 (30 percent) patients on GLP-1 had 20 percent or more BMI reduction.
• 4 (20 percent) had between 10 and 20 percent BMI reduction.
• 9 (45 percent) had between 1 to 10 percent BMI reduction.
• 1 (5 percent) patient increased BMI.

Almost all patients are managed on semaglutide. One patient has been treated with tirzepatide. The two most common side effects are nausea and constipation. Follow-up laboratory data is currently being gathered to determine reduction of comorbidities.

Conclusion

There is a need to develop novel approaches to treat children and adolescents with obesity and comorbidities. A telehealth model shows that barriers to treatment are reduced, weight status is improved, and comorbidities are reduced. The limitations with telehealth are that measurement of vital signs is self-reported and the physical examination is limited. The benefits showing improved health far outweigh the limitations.

Telehealth decreases weight stigma, a key factor when helping adolescents struggling with obesity and insulin resistance.

GLP-1 agonist medications are effective medications to treat adolescents with obesity and insulin resistance. They are not a singular fix, but should be considered an adjunct in the treatment plan which also includes nutrition, physical activity, behavior, and other medications. Long-term risk of use of the medications has not been studied in adolescents.

Future questions to study:

• Are there harms that are caused by treating adolescents with GLP-1 agonist medications?
• What are the obstacles to access?
• What are the ethical considerations of starting a potentially lifelong medication in an adolescent?

I do not prescribe compounded GLP-1 medications for adolescent patients. I have no conflicts with the pharmaceutical industry to disclose.

Karla Lester is a pediatrician, certified life and weight coach, and diplomate, American Board of Obesity Medicine. She is founder, IME Community, and can be reached on Twitter @DrKarlaA, TikTok, Instagram @ime_community, Facebook, and YouTube.

Dr. Karla is a child health advocate who has worked to address the childhood obesity epidemic for two decades on local, state, and national levels. Her vision is “creating community with compassionate connection.” She is a poet, an author of a children’s book, The Magical Everywhere, the poem, “Miracle of Will,” in JAMA, and is the grateful mom of three amazing young people.

Find Dr. Karla on TikTok, where she is disrupting the status quo in health care.