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Pediatrician and certified life and weight coach Karla Lester discusses her article, “An effective treatment using an effective care delivery model: Using telehealth to treat adolescents with obesity with GLP-1 medications.” She shares her frustration with traditional in-person obesity programs that see high attrition and offer few effective treatments beyond surgery. Karla explains how she founded her own practice, Metabolic Telehealth, to implement the latest AAP guidelines by combining a new care delivery model with new medical treatments. The conversation explores her initial data, which shows how telehealth can reduce barriers like weight stigma and travel time, leading to better patient retention. It also highlights the effectiveness of GLP-1 medications, with 95 percent of her long-term patients seeing a BMI reduction. However, she also reveals a critical obstacle: over half of all insurance prior authorizations for these vital medications are denied, forcing many families to pay out of pocket. The core message is that while this telehealth model is effective, systemic change is needed to ensure all adolescents have access to this life-changing care.

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Transcript

Kevin Pho: Hi and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Karla Lester, a pediatrician and life and weight coach. Today’s KevinMD article is “An effective treatment using an effective care delivery model: Using telehealth to treat adolescents with obesity with GLP-1 medications.” Karla, welcome back to the show.

Karla Lester: Hey, thanks for the platform as always. Happy to be here.

Kevin Pho: All right, so tell us what this latest article is about.

Karla Lester: Well, adolescent obesity is a huge problem in the U.S., and it has been for decades. I’m a pediatrician, board-certified in obesity medicine, and a life and weight coach. I’ve been working on this issue, as I’ve been on KevinMD talking about it. Numerous issues come up when working on childhood obesity, and one of the things that I noticed and almost felt like a failure in was the area of adolescent obesity. It felt like time after time when I was seeing patients, when I was a medical director of a weight management program at a children’s hospital, adolescents would come in and we just were not being effective. Things would get worse, the rates of severe obesity went up, especially during the pandemic.

When I left my position, got board-certified in obesity medicine, became a life and weight coach, and started my coaching platform, I was like, “The biggest issue facing our teens is not only chronic obesity but the epidemic of insulin resistance,” which is what we’re not talking about enough. And then the TODAY2 study came out, which studies type 2 diabetes in adolescents. And really, it’s a different disease than in adults. It’s more severe, medications aren’t as effective, and teens diagnosed within one to two years have early cardiovascular disease. And I’m like, this is the emergency.

So I thought, “I’ve got to create a platform, a model. Finally, I’m going to figure it out and be impactful and helpful for teens struggling with obesity, insulin resistance, and metabolic syndrome.” So I started a telehealth practice. Then the FDA approved the use of Wegovy for adolescents 12 to 17 as an anti-obesity medication. The American Academy of Pediatrics came out with their clinical practice guidelines, and so I thought, “You know, I’m just going to do this. I’m going to figure out how to use these medications. I’m going to see if telehealth is an effective model to decrease stigma in the treatment of adolescents with obesity.”

I wrote this article because I spent some time reflecting and creating a database, looking at my program to see if it indeed is effective. And it is.

Kevin Pho: So before talking about the platform, just in general, Wegovy and adolescent teen obesity treatments. Tell us about your workflow and when you would consider using Wegovy.

Karla Lester: Well, I always follow the FDA guidelines, which were defined by the STEP TEENS trial: adolescents 12 to 17 with a BMI of 30 or above, or a BMI of 27 to 30 with a comorbidity. So that’s first of all; they have to meet the FDA criteria.

One of the things that’s really important for all of us physicians who do this work, of which there aren’t very many, is that we need to have more of these kinds of platforms and more of us leaning into being willing to prescribe these medications, which are the most effective metabolic health tools I’ve ever used in my work with adolescents with obesity. This is because there are so many nefarious bad actors who are telehealth companies. They prescribe compounded medications, which are dangerous. If you’re an adult, that’s not my business. I understand the access issues. But for adolescents, we really don’t need to go there. I’ve learned a lot from being on TikTok; there’s just a black market out there. And parents don’t always have their teens’ best interests at heart; a lot of them are stuck in diet culture. So it’s going to be up to us as physicians to adhere to these recommendations and these guidelines.

That’s the first thing. Then there are so many access issues that come up. When I first started prescribing them, it was a wonder to get approval for prior authorization for Wegovy from insurance. And then there was a national shortage of Wegovy, so nobody was getting it. And then there are obviously so many issues with insurance not covering it or not covering it long-term. But anyway, starting with the FDA criteria, most patients have tried different things, and they have been, I wouldn’t say unsuccessful, but it’s because they probably have longstanding insulin resistance or chronic obesity that they definitely need the medication part of obesity treatment: nutrition, physical activity, behavior, and medication. And there are other medications, but they just haven’t been as effective in actually improving weight status and reducing comorbidities.

Kevin Pho: Yeah, and you mentioned TikTok, and I do see you on TikTok trying to push back on a lot of this obesity and dietary misinformation that’s out there. And sometimes they have no choice but to turn to those sources, right? Because it’s very difficult to get Wegovy. You mentioned in your article over half of prior authorizations are denied by insurance. So in those cases where they just cannot get a GLP-1 agonist, what are the next steps for them?

Karla Lester: Well, I developed my entire telehealth practice and all of my coaching platform before I had ever heard of these medications, let alone the FDA approving them. So there’s so much that we can do. Like I said, there are other medications depending on what’s going on with the patient, but really it’s about getting health data and focusing on metabolic health.

I had a patient yesterday who is not able to cover the deductible to get Wegovy. I fought really hard and worked with insurance, and we got approval. We were so excited. But this is a patient who, since she was age 10, had severe insulin resistance. I mean, she’s like a walking poster child for insulin resistance. She went to a pediatric endocrinologist, and the mom asked about metformin. This child has PCOS, she’s got severe hirsutism, acne, and dysmenorrhea. She has chronic obesity as well. She’s got pre-diabetes and elevated LFTs. She’s got the whole thing: metabolic syndrome. And they said, “Absolutely not. Eat less, move more.” And she’s an athlete and a good eater. There was just so much bias there.

But I said, “This is what it is: insulin resistance.” We went through all the labs. I prescribed her spironolactone, I prescribed her oral contraception, hormonal treatment, and metformin. And with changes that she and her mom made working together, she’s lost 17 pounds. She’s had a marked improvement in her symptoms and on her exam. And once they can get coverage for the Wegovy, can afford it, and get that deductible down, then we’ll start that and add to it. So there are things you can do. There are other medications, nutrition, behavior, and physical activity.

Kevin Pho: So tell us about your telehealth platform. How does it work?

Karla Lester: Well, it’s a completely digital platform. I really wasn’t thinking that it would be; I thought it’d be more referral-based. But every time I ask, “How did you find me?” they say they can just schedule online at drcarlamd.com, Karla with a K, or on my coaching platform, IMecommunity.com, which has a link to it. So I do get parents who find me on my website. They Google it. They want to find a doctor who will treat their teen with Wegovy. Many doctors are uncomfortable with it, their pediatricians, even specialists, or they’ll say, “Absolutely not. That’s too drastic.”

Kevin Pho: And why do you think that is? Why do you think so many pediatricians are hesitant to prescribe Wegovy?

Karla Lester: Well, one of the issues, and that’s a big access issue, is that patients don’t have doctors who are willing to write prescriptions. I think there’s a lot of time that goes into it. Obviously, prior authorizations and appeals, as we all know, are a pain. There’s a lack of expertise in obesity medicine, of course. We’re afraid we’re going to cause an eating disorder or trigger something, and that’s what I think a lot of doctors worry about. So my hope is that we can do more education and that my database that I’ve created, which looks at outcomes, reductions in BMI, and improvements in biomarkers that happen even before the weight loss, as well as improved accessibility and improvements in quality of life, will be information that helps pediatricians start to really take on the writing of these prescriptions.

Kevin Pho: So when people find you through your coaching website and sign up for an appointment, tell us about the process that entails.

Karla Lester: OK, thank you. That was your question. So they find me on TikTok, and they’ll be like, “Oh, I’m sorry I found you on TikTok.” I’m like, “Everyone does.” And I think it’s great for doctors to be on social media because I showed up to listen and learn when I got on TikTok. They have a chance to get to know me, and there’s an accessibility there. They know my philosophy, and they will watch my videos. Then they can schedule the appointment. It’s a 50-minute consultation, and we go through all the information, all their past medical history. Pediatric obesity is so complex; each patient is completely nuanced, individual, and unique. So we spend that 50 minutes, and then I always get lab studies and make referrals to work up comorbidities. So I look at causes, comorbidities, and contributing factors.

And then they get access to my Healthier Self group coaching course. The other thing that is a barrier for pediatricians prescribing the medications is because these organizations, like the AAP, of which I’m a proud member, and the section on obesity, put so much burden on community pediatricians. When they came out with their guidelines, it’s like, “Oh, you need to have a whole intensive healthy lifestyle and behavioral treatment.” I’ve developed those with my nonprofit in the community. It takes tons of grant funding and work, and there’s no reimbursement, so it’s not feasible for doctors to create all of that. Adult doctors don’t get that kind of burden put on them. I think that’s one of the reasons why pediatricians are like, “Well, if I have to do all that at the same time I’m prescribing these, it’s impossible.”

Anyway, I developed a Healthier Self online group coaching course that satisfies that evidence base of contact hours that they need, and so they get access to that. I don’t have a subscription model, so they follow up when they need to. I make recommendations, and then once we get the labs back, I’ll determine what medication would be best for them. Then I’ll write a prior authorization if they meet the criteria for Wegovy. I have some older teens that do tirzepatide, and we’ll see what happens. I follow up usually every four weeks, then every two months, and then every three months on a regular basis. The patients in my database who do well, have improved outcomes, and have better health are the ones who have a higher level of parent engagement, which seems intuitive, but it’s like the number of visits and the number of communications between us. Those are the patients who do really well.

Kevin Pho: As you know, with the GLP-1 agonists, they have to be prescribed long-term. In the adult population, I prescribe them sometimes lifelong. So how do you navigate that conversation in the pediatric population?

Karla Lester: Yeah. This is such an ethical issue, GLP-1s in adolescents. I mean, I can’t think of a more charged medical ethics issue. One of the things is I say, “Welcome to pediatrics.” That’s what we’ve been asked our whole careers. Before we had the Affordable Care Act, it would be, “Is it going to be a preexisting condition, and they’ll never get insurance, or they’ll never get a job?” Are we going to withhold a diagnosis of asthma or its treatment? So I say we cross that bridge when we come to it. I do tell patients we’re learning; it’s a chronic issue, it’s a chronic disease, and a lot of patients will require long-term treatment.

On the other hand, I’ve had other teens who don’t need it long-term, and they decide, “OK, I’m done.” It’s not just about weight. During adolescence, you have a blip of increased insulin resistance, and that may be something that helped them get through that, and then they’re kind of on track. So it depends on each patient. I have others that are going to stay on it long-term. And I say, “We don’t know the long-term effects on nutrition, on bone mineralization, on growth, on your relationship with food.” There are obviously a lot of research and studies that need to be done. Surprisingly, the FDA kind of went ahead and approved them without having any long-term studies, even in adults. But we’ll cross that bridge when we come to it. I decided I’m not going to gatekeep these tools.

Kevin Pho: As far as you know, are there any other pediatricians that are doing this? Because if they don’t have board-certified pediatricians online prescribing legitimate Wegovy, as we talked about earlier, they’re just going to find compounded medications and other things that probably aren’t as legitimate. Is your model scalable? Do you know anyone else that’s doing this online?

Karla Lester: I don’t know of anyone else who has the same model that I have. I think it’s not—just like a lot of things in pediatrics—I’m not doing this for the money. I say I’m not doing it for the money because if I were, I wouldn’t be doing it. But I think, obviously, at children’s hospitals where you have weight management programs, they’re prescribing the medications, but the accessibility may not be there. They may not have a lot of the knowledge or be as focused on insulin resistance or how to use the medications as much as I believe I am, just because of what I’ve learned and leaned into.

I think my model is scalable. I’m licensed in 15 states right now, and I hope it will grow, and I’ll figure it out as it does. What I would love to have happen is that we have a specialty consultant model where they come and see me, I get them started and going, I get all the group coaching and supports that need to happen in place, and then they can follow up with their primary care doctor long-term. I can kind of hand them off, and they can take care of the long-term issues that come up and touch base with me as needed.

One of the things that I found in my database, which was really awesome, was that a third of my patients are from rural communities. So they don’t have these programs available to them, or they have waitlists that are six to 12 months long, even to get into a pediatric specialist who would be willing, if they are, to write a prescription. So it’s hard to find somebody. And I have a lot of parents who reach out to me and say, “Are you licensed in my state? Oh, I wish you were.” And I can’t. And they say, “Who do you know in my state who can help me? Who’s like you?”

Kevin Pho: We’re talking to Karla Lester, a pediatrician and certified life and weight coach. Today’s KevinMD article is “Using telehealth to treat adolescents with obesity with GLP-1 medications.” Karla, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Karla Lester: Well, I want us all to be open to novel approaches to treating adolescents with obesity, insulin resistance, and metabolic syndrome because this is a true emergency and crisis that we’re seeing now. We have to be able to create models like mine that use telehealth and are using the most up-to-date, effective tools like the GLP-1 medications. The research-to-practice gap is, on average, 17 years. So are we going to have another two generations of adolescents who enter young adulthood without any effective models to help them reach young adulthood without the burden of type 2 diabetes, chronic liver disease, and shortened lifespans?

Kevin Pho: Karla, as always, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.