RxCe - Healthcare Team Role in Pediatric Obesity Materials

SHAPING FUTURES: THE HEALTHCARE TEAM’S ROLE IN

TREATING PEDIATRIC OBESITY

Faculty:

L. Austin Fredrickson, MD, FACP

L. Austin Fredrickson is an Associate Professor of Internal Medicine at Northeast Ohio Medical University, where he serves as core faculty and teaches diagnostics, therapeutics, clinical skills, and health humanities. He is board-certified in general internal medicine and practices rural primary care. 

Kristina (Tia) Neu, RN

Kristina (Tia) Neu is a licensed Registered Nurse and author currently developing in-service training for healthcare professionals. She is a National Board-Certified Health & Wellness and Lifestyle Medicine Coach. Her work experience includes several areas of the healthcare profession, including psychiatric nursing, medical nursing, motivational health coaching, chronic case management, dental hygiene, cardiac technology, and surgical technology.

Jennifer Salvon, RPh

Jennifer Salvon is a Massachusetts-based clinical pharmacist and freelance medical writer at Salvon Scientific. Experienced in many healthcare settings, including hospital, operating room, sterile products, clinical research, managed care, retail, and regional pharmacy operations. Jennifer writes on a variety of healthcare topics for publications and has extensive experience in continuing medical education and medical communications.

Kelsey Giara, PharmD, RPh

Kelsey Giara is a New Hampshire-based pharmacist and freelance medical writer. She writes about a variety of healthcare topics for various publications and has significant experience in continuing medical education, needs assessments, grant writing, and medical communications.

Pamela Sardo, PharmD, BS

Pamela Sardo, PharmD, BS, is a freelance medical writer and licensed pharmacist. She is the founder and principal at Sardo Solutions in Texas. Pam received her BS from the University of Connecticut and her PharmD from the University of Rhode Island. Pam’s career spans many years in retail, clinics, hospitals, long-term care, the Veterans Affairs system, and managed health care, with responsibilities across a broad range of therapeutic classes and disease states.

Abstract

Recent studies indicate that nearly one in five children and adolescents in the United States is affected by obesity, setting the stage for a potential health crisis. As obesity rates rise in the pediatric population, so do other medical conditions and chronic diseases. They include asthma, sleep apnea, fatty liver disease, gallstones and gallbladder disease, cardiovascular diseases, joint problems, menstrual abnormalities, metabolic diseases, and skin diseases. These conditions were more commonly seen in adulthood in prior decades. Not surprisingly, pediatric obesity leads to obesity in adulthood. Healthcare teams with a deep understanding of the diagnosis and screening, physical and mental burden, and available treatment options for obesity can make a significant difference in care and outcomes for this vulnerable patient population.

Accreditation Statements

In support of improving patient care, RxCe.com LLC is jointly accredited by the Accreditation Council^TM for Continuing Medical Education (ACCME^®), the Accreditation Council for Pharmacy Education (ACPE^®), and the American Nurses Credentialing Center (ANCC^®), to provide continuing education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 3 Interprofessional Continuing Education (IPCE) credits for learning and change.

Joint Universal Activity Number: The Joint Accreditation Universal Activity Numbers assigned to this activity are as follows:

Pharmacists: JA4008424-0000-26-026-H01-P

Pharmacy Technicians: JA4008424-0000-26-026-H01-T

Credits: 3 contact hour(s) (0.3 CEU(s)) of continuing education credit.

Credit Types:

IPCE Credits - 3 Credits

AAPA Category 1 Credit™️ - 3 Credits

AMA PRA Category 1 Credit™️ - 3 Credits

Pharmacy - 3 Credits

Type of Activity: Application

Media: Computer-Based Training (i.e., online courses)

Estimated time to complete activity: 3 contact hour(s) (0.3 CEU(s)), including Course Test and course evaluation.

Release Date: March 11, 2026 Expiration Date: March 11, 2029

Target Audience: This educational activity is for Physicians, Physician Assistants, Pharmacists, and Pharmacy Technicians

How to Earn Credit: From March 11, 2026, through March 11, 2029, participants must:

Read the “learning objectives” and “author and planning team disclosures;”

Take the “Educational Activity Pre-Test;”

Study the section entitled “Educational Activity;” and

Complete the Educational Activity Post-Test and Activity Evaluation. The Educational Activity Post-Test will be graded automatically. Following successful completion of the Educational Activity Post-Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)

CME Credit: Credit for this course will be uploaded to CPE Monitor^® for pharmacists. Physicians may receive AMA PRA Category 1 Credit™️ and use these credits toward Maintenance of Certification (MOC) requirements. Physician Assistants may earn AAPA Category 1 CME credit, reportable through PA Portfolio. All learners shall verify their individual licensing board’s specific requirements and eligibility criteria.

Statement of Need

Pediatric obesity is highly prevalent, affecting nearly one in five children and adolescents in the United States. The rates and severity are increasing and disproportionately impact racially and economically marginalized youth. Children with obesity experience early cardiometabolic disease, sleep apnea, orthopedic complications, and profound psychosocial burdens. These burdens include stigma, depression, bullying, and impaired quality of life. The impact of pediatric obesity often persists into adulthood. Evidence-based guidelines are available, but screening and health behavior and lifestyle treatments are underutilized. Practice gaps include a lack of uniform awareness of newer FDA-approved pharmacotherapies for adolescents, limited familiarity with pediatric obesity guidelines, and inconsistent use of family-centered, non-stigmatizing counseling. This activity aims to close gaps, improve healthcare team collaboration, enhance recognition of the burden, improve risk assessment, and promote appropriate treatment selection for pediatric and adolescent patients presenting with obesity.

Learning Objectives: Upon completion of this educational activity, participants should be able to:

Recognize the growing prevalence and burden of pediatric obesity

Describe the immediate and long-term risks of obesity in childhood and adolescence

Discuss current FDA-approved pediatric obesity treatments

Define the healthcare team’s role in optimizing care for pediatric patients with obesity

Disclosures

The following individuals were involved in planning, developing, and/or authoring this activity: L. Austin Fredrickson, MD, FACP; Kristina (Tia) Neu, RN; Jennifer Salvon, RPh; Kelsey Giara, PharmD, RPh; and Pamela Sardo, PharmD, BS. None of the individuals involved in developing this activity has a conflict of interest or financial relationships related to the subject matter. There are no financial relationships or commercial or financial support relevant to this activity to report or disclose by RxCe.com or any of the individuals involved in the development of this activity.

Educational Activity Pre-Test

Which measurement is most commonly used to define pediatric obesity?

Waist circumference alone

Body mass index (BMI) for age and sex percentiles

Total body weight compared to adult standards

Skin thickness only

Children and adolescents with obesity are at increased risk for which mental health condition(s)?

Depression and anxiety

Autism spectrum disorder

Schizophrenia

Attention deficit/hyperactivity disorder

Which FDA-approved medication for pediatric obesity works by inhibiting fat absorption in the gastrointestinal tract?

Metformin

Liraglutide

Orlistat

Phentermine

Educational Activity

Shaping Futures: The Healthcare Team's Role in Treating

Pediatric Obesity

Introduction

In a world where video screens are replacing playgrounds and convenient, fast foods trump nutrition, the prevalence of pediatric obesity has reached staggering proportions and is expected to continue rising. The management and treatment of pediatric obesity present significant challenges due to its rising incidence and the need to address both emotional and physical health concerns. A multidisciplinary team is vital in pediatric obesity care, as it addresses the medical, behavioral, nutritional, and psychosocial factors affecting a child's health. Members, including pediatricians, nurses, dietitians, behavioral specialists, physical activity experts, social workers, and pharmacists, help optimize medications, provide counseling, and promote healthy habits to improve long-term outcomes.

Prevalence of Pediatric Obesity

Approximately one in five children and adolescents in the United States (U.S.) is affected by obesity, setting the stage for a potential health crisis.¹ Obesity prevalence increases with age. From 2000 to 2023, the prevalence of pediatric obesity among children aged 2 to 19 years increased from 13.9% to 21.1%.² Severe obesity in the same age group rose from 3.6% to 7%.²

Evidence also suggests that despite efforts to tackle this issue, obesity is still increasing.³ The coronavirus disease-19 pandemic significantly amplified obesity’s effect on children. The pandemic period was associated with a doubling in the rate of BMI increase compared to the pre-pandemic.⁴ Major disparities are also noted among children and adolescents with obesity, including lower parental education level, lower income, less access to healthier food options and safe physical activity opportunities, and a greater incidence of adverse childhood experiences.^1,4 Obesity prevalence also varies across ethnic and racial groups, with non-Hispanic Black children, Mexican American youth, and American Indian and Alaska Native children and adolescents experiencing higher rates of obesity compared to non-Hispanic white counterparts.⁴

Many people avoid discussing childhood obesity due to concerns that it may harm children's self-esteem or lead to disordered eating, such as anorexia, bulimia, or binge/emotional eating. Research shows that's not necessarily the case. Although obesity and unsupervised dieting increase the risk of weight changes and eating disorders among young people, evidence-based, supervised weight management reduces the chance of developing eating disorders both immediately and up to six years after treatment.⁴ Clinicians should stay informed about current guidelines for managing pediatric obesity to support better care and outcomes for these vulnerable patients.

Obesity Diagnosis and Screening in Pediatrics

Body mass index is a measurement of physical characteristics of the human body calculated by dividing a person’s weight (in kilograms) by the square of their height (in meters). Defining overweight and obesity in children requires consideration of body mass index (BMI).^5,6

Using BMI to measure childhood obesity is challenging, as a child’s body shape changes during normal growth.⁷ Body mass index only considers weight and height, which fails to differentiate between fat and fat-free mass (i.e., muscle and bone) and could exaggerate obesity measurements in large, muscular children. Clinicians often use waist circumference and skin-fold thickness in practice. While these methods are less accurate, they are reasonable for identifying risk. Despite its limitations, BMI is the most suitable clinical tool for screening excess adiposity and diagnosing overweight or obesity. Annual BMI measurement during well-child visits is recommended for tracking childhood overweight and obesity, though it may miss short-term weight changes.⁴

The Centers for Disease Control and Prevention (CDC) has a BMI calculator specific to pediatric patient.⁶ Using U.S. customary or metric units, healthcare professionals input the child’s physical characteristics: sex, age, height, and weight.⁶ Given that pediatric patients are actively growing, the ranges of height, weight, and BMI considered “normal” or “healthy” vary by age and sex.⁵ Before age 2, healthcare professionals do not assess BMI; they compare the infant’s weight and length percentiles separately.⁸

For pediatric patients aged 2 years and older, healthcare professionals consider BMI relative to others of the same sex and age, expressed as a percentile.^5,8 This percentile represents the percentage of children in the reference population who have a lower BMI than the child being assessed. For example, if a child’s BMI falls at the 75^th percentile, it means that the child’s BMI is higher than 75% of children of the same age and gender. Table 1 lists the percentiles and BMIs used to diagnose overweight or obesity in pediatric patients.

Table 1

Pediatric BMI Categories^2,4

BMI Category	Associated Percentile or BMI
Underweight	< 5^th percentile
Healthy weight	5^th percentile to < 85^th percentile
Overweight	85^th percentile to < 95^th percentile
Obesity	≥ 95^th percentile
Class 2 Obesity*	≥ 120% to < 140% of the 95^th percentile OR BMI ≥ 35 kg/m² to < 40 kg/m²
Class 3 Obesity*	≥ 140% of the 95^th percentile OR BMI ≥ 40 kg/m²

*Also referred to as severe obesity. BMI, body mass index.

Causes of Childhood Obesity

Obesity’s causes are complex and multifactorial. Genetics, lifestyle choices, and medication use all contribute.^1,7 Studies show that having an overweight mother and living in a single-parent household are associated with pediatric overweight and obesity.⁷ Social determinants of health, including childcare and school environments, neighborhood design, food security, and access to safe, convenient physical activity, also greatly impact the development of overweight and obesity in this population.^1,7

Overweight and obesity are largely a result of an imbalance between energy intake and expenditure, but increasing evidence shows that genetics contributes to obesity risk. Some studies suggest that BMI is 40% to 70% inherited, but less than 5% of childhood obesity cases are genetic.^4,7 People who are obese tend to have lower basal metabolic rates than those of a healthy weight. Various dietary habits contribute to the development of obesity, including fast food consumption, sugary beverages, snacking, and portion sizes.⁷

Fast-food restaurant menus often feature meals with a high calorie count but limited nutritional value. Some families, particularly those with both parents employed outside the home, choose fast-food establishments because their children prefer them and because they offer both convenience and affordability.⁷

Many individuals consider soda a sugary drink and fail to recognize that juice and other sweetened beverages also fall into this category.⁷ These are all less filling and are consumed more quickly than food, resulting in higher caloric intake.

Over the past decade, portion sizes have drastically increased, as has frequent snacking on high-calorie foods like chips, baked goods, and candy.⁷ These create energy imbalances leading to weight gain and, consequently, obesity.

Other lifestyle factors contributing to obesity include activity level, environmental influences, and socio-cultural factors:⁶

A sedentary lifestyle is one of the most significant risk factors for obesity. “Screen time” is a term used to describe watching TV, using or viewing computers, videos, or video games, and using mobile phones and other digital devices. Television (TV) and screen use have increased drastically in recent years; each additional hour of TV per day is associated with a 2% greater risk of childhood obesity.⁷

Children who watch TV tend to consume more of the advertised goods, including sweetened cereals, sugary beverages, and salty snacks.⁷ Studies indicate that screen time greater than 2 hours per day is associated with a 42% higher risk of overweight and obesity.⁴

Opportunities to be physically active and to do so safely have decreased in recent years. Parents are more likely to drive their children to school. Children who live in unsafe areas or who lack access to safe, well-lit walking routes have less opportunity for physical activity.⁷

Today, people tend to use food as a reward, to control others, and as part of socialization.⁷ This encourages unhealthy relationships with food, thus increasing the risk of obesity.

Not all weight gain is lifestyle-driven. Many commonly prescribed medications can contribute to clinically meaningful weight gain through complex metabolic, hormonal, and behavioral mechanisms. Medications commonly implicated in pediatric weight gain include glucocorticoids, sulfonylureas, insulin, thiazolidinediones, tricyclic antidepressants, and antiepileptic drugs.⁴ Second-generation antipsychotics (e.g., aripiprazole, clozapine, risperidone, quetiapine) are associated with rapid weight gain and comorbidities, including diabetes and dyslipidemia.⁴

The intricate pathophysiology of childhood obesity introduces significant challenges to effective treatment. Understanding the multifaceted factors contributing to obesity in children complicates the development of tailored interventions and hinders successful outcomes.

Defining the Burden of Pediatric Obesity

Pediatric obesity significantly increases the risk of serious short- and long-term health complications. Children and adolescents with obesity are more likely to develop cardiometabolic, respiratory, and orthopedic conditions compared with peers at a healthy weight. In addition to physical consequences, the psychosocial burden—including stigma, depression, and reduced quality of life—further underscores the urgency of early identification and comprehensive management.

Physical Health Consequences

As obesity rates rise, so do other medical conditions and chronic diseases. Pediatric obesity increases the risks of the following^7,9

Breathing issues, including asthma and sleep apnea

Cardiovascular diseases, including hypertension and hypercholesterolemia

Fatty liver disease

Gallstones and gallbladder disease

Joint issues, including osteoarthritis, musculoskeletal pain, and impaired balance

Menstrual abnormalities

Polycystic ovarian syndrome (PCOS)

Metabolic diseases, including glucose intolerance, insulin resistance, and type 2 diabetes mellitus (T2DM)

Obesity in adulthood

Skin conditions

Historically, many of these diseases were found only in adults, but now are present in pediatric patients with obesity.⁷ While most are preventable and may disappear when a child reaches a healthy weight, some maintain negative consequences through adulthood. Obesity also increases the risk of developing some forms of cancer.^7,9

Diabetes, sleep apnea, and cardiovascular disease are the most common health problems associated with childhood obesity.⁷ The incidence of diabetes among pediatric patients with diabetes is greater among children aged 10 years or older, those in early pubertal stages, and those with a family history of T2DM.⁴

Mental Health Impact

Beyond physical health, the psychological and social burden is profound. Children and adolescents with obesity experience higher rates of depression, anxiety, low self-esteem, body dissatisfaction, and weight-based bullying.^9-11 Stigma—whether encountered in school, healthcare settings, or social environments—can exacerbate mental health conditions, contribute to disordered eating behaviors, and create barriers to seeking care.⁹

Depression is the most frequently reported mental health condition associated with obesity. Depression risk is particularly elevated among pediatric females with obesity, who show higher odds of depression than normal-weight girls and often higher rates than males with obesity.¹² Adding complexity, some mental health medications, such as SSRIs and antipsychotics, may also cause weight gain.

Maternal mental health disorders increase the risk of anxiety among children with obesity, and elevated psychological or psychosocial stress within families may play a role in the development of childhood obesity. Although some studies have identified associations between attention-deficit/hyperactivity disorder (ADHD) and childhood obesity, the strength of association remains inconsistent, and the overall evidence is inconclusive. Childhood obesity is reliably linked to lower health-related quality of life (HRQoL) compared with peers of lower body weight.¹³

Pediatric patients with obesity face significant hardships, including negative stereotypes, discrimination, bullying, and social marginalization.¹⁴ They are more likely to be socially isolated, with fewer reciprocated friendships and less time spent with peers, which is associated with lower participation in active play and greater engagement in sedentary, screen-based activities.¹⁵ Youth with obesity are at increased risk for sexual harassment and harassment based on race/ethnicity, socioeconomic status, and gender.⁴ Racism is also associated with an increased prevalence of obesity.⁴

Research shows that individuals as young as 2 years old experience weight-related discrimination.¹⁴ They frequently encounter exclusion from various activities, especially competitive ones requiring physical exertion.⁶ Children with overweight or obesity often have reduced cardiorespiratory fitness and experience breathlessness during exercise, which can limit their ability to keep up with peers and may reduce their participation in physical activities.¹⁶ These social challenges, in turn, erode their self-esteem, diminish their self-confidence, and contribute to negative body image.

Academic performance is also affected by pediatric obesity. Children who are overweight and obese are four times more likely to report problems at school than those of a healthy weight.¹² Children with overweight and obesity have higher rates of school absence.¹⁴

Collectively, these adverse consequences of overweight and obesity can have profound and detrimental effects on children and adolescents. This can also trigger a vicious cycle wherein children and adolescents protect themselves from bullying and stigma by retreating to safe places, such as their homes, where they often seek comfort in food.⁶

Economic Impact

Pediatric obesity imposes substantial economic costs through higher healthcare spending, lost productivity, and long-term disease burden. Experts project that annual direct and indirect health care costs exceed $13 billion. Children with obesity incur significantly higher annual medical costs than their healthy-weight peers due to more clinic visits, medications, and hospitalizations. Direct medical costs account for $1.3 billion annually.¹⁷

Beyond direct medical expenses, pediatric obesity generates indirect costs through caregiver time off work, reduced productivity, and long-term impacts on education and earnings.¹⁸ Children with obesity are more likely to have school absenteeism, which is associated with lower future income, while caregivers may lose wages due to frequent medical appointments and illness episodes.¹⁸

Managing Pediatric Obesity

The most current comprehensive guideline for treating children and adolescents with obesity in the U.S. is the 2023 American Academy of Pediatrics (AAP) Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity.⁴ The guideline replaces the prior ‘watchful waiting’ approach by recommending active, early treatment of pediatric obesity and its comorbidities.

The guideline outlines the following:⁴

Core treatment approach

Lifestyle and behavioral treatment

Pharmacotherapy

Metabolic and bariatric surgery

The core treatment approach emphasizes a family-centered, non-stigmatizing framework for chronic disease. It should acknowledge biological, social, and structural factors that affect health. A comprehensive evaluation, including history, mental/behavioral health, physical exam, and labs for glucose, liver function, and lipids, is necessary to guide individualized treatment planning.⁴

Lifestyle and Behavioral Treatment

Lifestyle and behavioral treatment is the foundation and first-line therapy for pediatric obesity, and needs to be intensive, family-based, and long-term. Promoting healthier habits supports positive outcomes for children and adolescents with obesity. Dietary and lifestyle modifications are crucial to mitigate the challenges posed by pediatric obesity.

Intensive health behavior and lifestyle treatment (IHBLT) is a structured program that educates and supports families to change nutrition, physical activity, and behaviors to improve weight status and comorbidities.⁴ This involves multidisciplinary, intensive care involving a team of healthcare professionals with training in obesity, dieticians, exercise specialists, and behavioral health professionals.

Inpatients or outpatients undergoing IHBLT receive longitudinal treatment. Ideally, treatment should involve 26 or more contact hours for 3 to 12 months. Treatment can be individual, group-based, or a combination of both. The strongest evidence supports in-person treatment, but growing evidence suggests the utility of virtual therapy.⁴ Table 2 below outlines the suggested core components of IHBLT.

Interventions use behavior change techniques, including goal setting, self-monitoring (e.g., food/activity logs), stimulus control (changing the home food and screen environment), problem-solving, and positive reinforcement. Programs are explicitly family-centered. Caregivers attend sessions, model behaviors, and help modify the home environment, recognizing that children’s habits are shaped by family systems.

Table 2

Core Components of IHBLT⁴

Component	Target
Nutrition	Emphasis on reducing energy-dense, ultra-processed foods and sugar-sweetened beverages, increasing fruits, vegetables, and whole foods, regular meals, and appropriate portions.
Physical Activity	Aim for at least 60 minutes/day of moderate-to-vigorous activity, reduce prolonged sitting, and build more movement into daily routines.
Sedentary behavior and screens	Use behavioral strategies to cut recreational screen time. Examples: limiting to 2 hours/day, removing TVs from bedrooms, setting media curfews
Sleep and routines	Address short or irregular sleep, bedtime routines, and evening habits that promote snacking and screen use.

When advising patients and caregivers about nutrition and physical activity, healthcare professionals should note that children learn by modeling others.⁶ Availability of and repeated exposure to healthy foods is crucial to developing preferences. Evidence also suggests that families who eat meals together consume more healthy foods, whereas eating out or watching television while eating is associated with higher fat intake.⁷

Different parental feeding methods also affect children's attitudes towards food choices and their overall dietary habits. The AAP describes four general parenting styles related to feeding:⁴

Authoritative: responsive and warm with high expectations

Authoritarian: not responsive, but with high expectations

Permissive or indulgent: responsive and warm but lenient with few rules

Negligent: not responsive with few rules

Studies show that the authoritative parenting style is the most effective way to prevent excessive weight gain.^4,7 Under authoritative feeding, parents determine which foods are offered, allowing the child to choose, and providing the rationale for healthy options is associated with positive cognitions about healthy foods and healthier intake. Children from authoritative parenting homes tend to eat healthier foods, be more physically active, and have healthier BMIs than children raised in homes with other parenting styles.²

Authoritarian feeding, conversely, tends to initiate the opposite of its desired effect. Complete restriction of “junk food” is associated with an increased desire for unhealthy food, thus increased weight and BMI.⁷ An authoritarian parent may not respond to a child’s cues for energy intake, negating the child’s ability to self-regulate their own energy intake and increasing the likelihood of overindulging when presented with the opportunity to eat.⁴

Pharmacotherapy

Clinicians may prescribe weight loss medication to adolescents aged 12 and older with obesity, after careful consideration of the risks and benefits. Pharmacotherapy should supplement health behavior and lifestyle treatments and is recommended for severe obesity or related conditions. It works best when combined with ongoing behavioral interventions.⁴

FDA-Approved Medications

The therapeutic landscape of pediatric obesity has shifted significantly in recent years, with the U.S. Food and Drug Administration (FDA) expanding the number of medications approved for chronic weight management in children and adolescents. These approvals reflect a growing recognition of obesity as a chronic, biologically mediated disease, not simply a consequence of lifestyle choices.

This underscores the role of pharmacotherapy in comprehensive treatment. Understanding which agents are FDA-approved, their age indications, mechanisms of action, efficacy, and safety profiles is essential. Medications currently approved for use in children and adolescents 12 years and older include orlistat, liraglutide, semaglutide, and an extended-release phentermine/topiramate product.⁴ Table 3 lists available medications with dosing, clinical pearls, and adverse effects. Additional discussion of each drug follows.

Table 3

Pediatric Obesity Medications^4,19-22

Generic (Brand)

Dosing

Clinical Pearls

Common Adverse Effects

Orlistat (Xenical®)

120 mg capsules

120 mg PO TID with high-fat meal

Decrease in fat-soluble vitamin absorption; pts should take a daily multivitamin with vitamins A, D, E, and K

Abdominal pain

Bloating,

Flatulence

Oily discharge

Steatorrhea

Liraglutide (Saxenda®)

18 mg/0.3 ml multi-dose

Auto-injector pen

Initial: 0.6 mg SC once daily for 1 week

Increase as tolerated by 0.6 mg/day increments at weekly intervals to a target dose of 3 mg once daily

If dose increase is not tolerated, consider lowering to the previous level

If the 3 mg is not tolerated, reduce to 2.4 mg daily

Discontinue if the 2.4 mg dose is not tolerated.

After 12 weeks, assess BMI; if weight is not reduced by ≥1% from baseline, discontinue therapy

Nausea/vomiting

Diarrhea

Abdominal pain

Constipation

Decreased appetite

Dizziness

Headache

Fatigue

Injection-site reactions

Semaglutide (Wegovy®)

0.25 mg/0.5 mL 0.5 mg/0.5 mL

1 mg/0.5 mL

1.7 mg/0.75 mL 2.4 mg/0.75 mL

Auto-injector pen

Weeks 1-4: 0.25 mg SC weekly

Weeks 5-8: 0.5 mg SC weekly

Weeks 9-12: 1 mg SC weekly

Weeks 13-16: 1.7 mg SC weekly

Maintenance: 2.4 mg SC weekly

If 2.4 mg is not tolerated, may decrease to 1.7 mg

Use as an adjunct to diet and exercise

Escalate slowly over at least 16 weeks to minimize GI side effects

If dose increase is not tolerated, consider delaying the increase for an additional 4 weeks

weekly on the same day each week, at any time of the day, with or without meals

Nausea/vomiting

Diarrhea

Abdominal pain

Constipation

Decreased appetite

Dizziness

Headache

Fatigue

Injection-site reactions

Phentermine/ topiramate (Qsymia®)

3.75 /23 mg

7.5/46 mg

11.25/69 mg

15/92 mg

Extended-

release capsule

3.75/23 mg once daily for 14 days

Increase to 7.5/ 46 mg once daily;

Assess BMI after 12 weeks of therapy:

If BMI is lower by ≥3% from baseline, continue current dose

If BMI is lower <3% from baseline, increase to 11.25/69 mg once daily for 14 days

Then increase to 15/92 mg once daily

After 12 weeks at the highest dose, if BMI is lower by ≥5% from baseline, continue

If BMI reduced by <5%, discontinue

Depression

Anxiety

Dizziness

Joint pain

Fever

Gastric and pancreatic lipases are enzymes involved in dietary fat digestion. Orlistat acts locally in the gastrointestinal tract to inhibit fat absorption. Undigested fat is excreted in feces, reducing calorie absorption and creating a calorie deficit that contributes to weight loss.¹⁹ Orlistat is limited by modest efficacy and frequent gastrointestinal adverse effects.

Glucagon-like peptide-1 (GLP-1) is a hormone that plays a key role in regulating blood sugar levels, hunger, and fullness. GLP-1 receptors in the central nervous system are in the hypothalamus, which regulates food intake.²³ Initially developed to treat T2DM, GLP-1 receptor agonists are also effective for weight loss. They reduce appetite and hunger, delay gastric emptying, and enhance satiety after meals.²³ Liraglutide and semaglutide are GLP-1 receptor agonists approved to treat obesity.⁴

A recent randomized controlled trial found that daily liraglutide injections were more effective than placebo in promoting weight loss among patients aged 12 years and older with obesity who did not respond to lifestyle interventions.²⁴ This study reported a significant difference in body weight loss, approximately 4.5 kg, or a 5% BMI reduction after 1 year of treatment.²⁴

In the phase 3 STEEP TEENS placebo-controlled trial, patients taking semaglutide experienced a significant decrease in BMI (16.1%) compared with a 0.6% increase in the placebo group.²⁵ The trial also showed that 77% of patients using semaglutide achieved a BMI reduction of 5% or more compared to only 20% of those in the placebo arm.²⁵

Phentermine, a central norepinephrine uptake inhibitor, non-selectively inhibits serotonin and dopamine reuptake and reduces appetite.^4,26 Topiramate is a carbonic anhydrase inhibitor approved to treat epilepsy and headache. It also suppresses appetite through mechanisms that are unclear.^4,26 Both drugs administered in mid and top doses, along with lifestyle therapy, may provide a significant reduction in BMI and waist circumference, and improve levels of triglycerides and HDL-C in adolescents with obesity.²⁶

A Risk Evaluation and Mitigation Strategy (REMS) is a safety program required by the U.S. Food and Drug Administration (FDA) for certain medications with serious safety concerns to help ensure that the benefits of the drug outweigh its risks.²⁷ REMS programs are implemented when specific risks cannot be adequately managed through standard labeling alone. Depending on the medication, REMS requirements may include²⁷

prescriber and pharmacy certification

patient education and counseling

restricted distribution systems

laboratory monitoring

documentation of safe-use conditions

These programs are necessary to promote appropriate prescribing, dispensing, and patient monitoring, thereby minimizing preventable harm while maintaining access to important therapies for patients who may benefit from them.

The Qsymia (phentermine/topiramate extended-release) Risk Evaluation and Mitigation Strategy (REMS) program is designed to prevent fetal exposure to topiramate, which is associated with an increased risk of oral clefts when used during pregnancy.²⁸ Because of this teratogenic risk, the REMS focuses on ensuring that Qsymia is prescribed and dispensed only under conditions that promote appropriate patient selection, counseling, and monitoring. The program emphasizes confirming that patients are not pregnant prior to initiation and that those of reproductive potential are informed of the risks and the need for effective contraception throughout therapy.²⁸

Key elements of the Qsymia REMS include certification of pharmacies authorized to dispense the medication, provider counseling requirements, and mandatory patient education. Prescribers must counsel patients about the risk of congenital malformations, the importance of pregnancy testing before treatment and monthly thereafter, and the need for consistent contraception. Pharmacies must be certified and ensure that each dispensed prescription is accompanied by a Medication Guide reinforcing these safety messages.²⁸ These measures aim to mitigate teratogenic risk while allowing appropriate use of Qsymia in patients with obesity or overweight requiring pharmacologic therapy.

Clinicians should note that phentermine/topiramate is a controlled substance due to risks of dependence and abuse.²² Patients and caregivers should be counseled on the following:

Understand the medication: Educate themselves about the prescribed medication, its purpose, and potential risks.

Monitor behavior and physical changes: Watch for sudden behavioral shifts or physical symptoms.

Secure medications: Store them in a secure location to prevent unauthorized access.

Communicate openly: Maintain open dialogue with your children about their medication and encourage them to report concerns.

Seek professional help: If misuse is suspected, contact a healthcare provider promptly for guidance and intervention.

Off-Label Therapies

Many healthcare professionals use metformin, an antidiabetic agent prescribed off-label in patients 10 years and older, for several indications, including prediabetes, polycystic ovarian syndrome (PCOS), and prevention of weight gain when using atypical antipsychotic drugs.⁴ Metformin decreases glucose production in the liver, decreases intestinal glucose absorption, and increases insulin sensitivity, thus reducing blood glucose levels. Studies show that adolescents taking metformin ER (extended-release) 2000 mg daily experienced a reduction in BMI of about 1 kg/m, compared with a slight increase in BMI among teens in a lifestyle-only program.^4,29,30

Metformin is available in immediate- and extended-release formulations, and the recommended starting dose is 500 mg once or twice daily. Clinicians can gradually increase the dose to a maximum daily dose of 2500 mg.^4,29 Gastrointestinal adverse effects, including bloating, nausea, flatulence, and diarrhea, are common and dose-dependent. Given its limited and inconsistent efficacy, healthcare professionals should consider metformin as a supplementary choice when combined with IBHLT, particularly when other indications for use apply.^2,29

Exenatide, a GLP-1 receptor agonist administered through weekly injections, is FDA-approved for children aged 10 to 17 years with T2DM. Studies have demonstrated varying degrees of BMI reduction (ranging from 0.9 to 1.18 kg/m²) in children as young as 8 years.⁴ However, it is also associated with significant AEs, including nausea, hypoglycemia, diarrhea, and other gastrointestinal upset.³¹ The drug is not approved for patients with obesity without T2DM.

Melanocortin 4 (M4) receptors in the brain regulate hunger, satiety, and energy expenditure.⁴ Setmelanotide, an M4 receptor agonist, is FDA-approved for chronic weight management in patients 6 years and older with monogenic or syndromic obesity due to genetic medical conditions.³² Patients with the indicated genetic conditions experience hyperphagia (an extreme, insatiable hunger). The daily dose is 1 to 3 mg subcutaneously once daily, and results in a 12% to 25% weight loss over 1 year in a small, uncontrolled study of patients with these rare deficits.⁴ Setmelanotide may cause skin hyperpigmentation, injection site reactions, nausea, headache, diarrhea, abdominal pain, vomiting, depression, and spontaneous penile erection. The drug is not indicated for use in patients with general obesity.³²

Lisdexamfetamine is a stimulant approved for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children 6 years and older and binge eating disorder in adults. Clinicians use lisdexamfetamine off-label for children with obesity.^4,29 The drug’s mechanism of action for weight loss is like that of phentermine’s. Lisdexamfetamine is a controlled substance and carries risks for dependence.

Metabolic and Bariatric Surgery

The most severe forms of pediatric obesity — those that fall into class 2 severe obesity or worse — represent an “epidemic within an epidemic.”⁴ Large, well-designed prospective observational studies have compared adolescents who undergo bariatric surgical treatment to nonsurgical controls. Data suggest that weight loss surgery is safe and effective for pediatric patients.⁴ Eligibility for weight loss surgery relies heavily on shared decision-making between the surgery team, the patient, and the patient’s caregivers, but initial criteria include the following:⁴

Class 2 obesity: clinically significant disease, including T2DM, nonalcoholic fatty liver disease, gastroesophageal reflux disease, obstructive sleep apnea, cardiovascular disease risks (hypertension, hyperlipidemia, insulin resistance), and depressed health-related quality of life

Class 3 obesity: comorbid conditions not required, but are commonly present

Among pediatric patients who undergo metabolic or bariatric surgery, up to 15% and 8% experience minor and major perioperative risks, respectively.⁴ Up to one-quarter of patients require subsequent procedures within 5 years of the original surgery. Vitamin deficiencies are common after weight-loss surgery and require long-term monitoring and potential intervention.⁴ While surgery is not appropriate for all patients with severe obesity, evidence shows that those who do undergo these procedures experience good outcomes and improved quality of life.³³

The Healthcare Team’s Role in Treating Pediatric Obesity

Managing pediatric obesity requires a multidisciplinary team because it is a chronic, complex disease influenced by biological, behavioral, psychological, social, and environmental factors, and no single professional can address all effectively. Evidence and guidelines indicate that the most effective interventions are comprehensive and intensive, delivered by teams that integrate medical, nutritional, behavioral, physical activity, and pharmacotherapy expertise.^4,34,35

Pediatric obesity is associated with early cardiometabolic disease, sleep apnea, orthopedic problems, and psychosocial issues, necessitating management beyond weight alone. Causes span genetics, neuroendocrine regulation, family behaviors, mental health, environment, and social determinants. Treatment by a single clinician is inadequate. Reviews and program evaluations indicate that treatment is most successful when delivered within structured, multidisciplinary pediatric weight-management services.

Guidelines, including the 2023 AAP clinical practice guideline, describe obesity as a chronic disease and recommend management using a chronic care model, explicitly calling for multidisciplinary teams and coordinated care.⁴ These guidelines endorse intensive health behavior and lifestyle treatment delivered by trained professionals, often in dedicated programs that integrate nutrition, physical activity, behavioral therapy, pharmacotherapy, and, when indicated, bariatric surgery.

A minimal team consists of a pediatrician or obesity-trained clinician, a registered dietitian, and a behavioral or mental health professional. Additional roles include a nurse, exercise specialist, social worker, psychologist, and pharmacist, depending on resources and patient needs.^35,36 Table 4 outlines team members and focus areas.

Table 4
Pediatric Obesity Team Members

Team Member	Treatment Focus
Pediatrician/obesity clinician	Diagnosis Comorbidity screening Overall care plan Pharmacotherapy initiation Bariatric surgery
Nurses	Identify at-risk patients Assist in comorbidity screening Monitor progress Coordinate care collaboration Education and counseling
Registered dietitian	Nutrition assessment Individualized meal planning Caregiver and child education on healthy eating patterns
Behavioral/mental health professional	Behavior change strategies Family dynamics Mental health conditions Coping skills
Physical activity specialist	Activity prescriptions Adaptation for physical limitations Promotion of enjoyable movement opportunities
Social worker/community health worker	Address social determinants Linking families to community and school resources Advocacy
Pharmacist	Medication review Screen for medications that may contribute to weight gain Optimization of obesity and comorbidity drugs Interaction checks Monitoring Patient counseling
Pharmacy technician	Prior authorizations Refill coordination Inventory Reminder systems Support medication reconciliation

Effective pediatric obesity care depends on an integrated, family-centered team where each discipline brings essential expertise. Clearly defining and valuing each team member's roles facilitates coordinated, ongoing care that meets children and families where they are. This collaborative model not only improves safety and clinical outcomes but also addresses stigma, supports behavior change, and makes it more feasible for families to sustain healthy habits over time.³⁷

Another pharmacotherapy consideration is the need for dose adjustments of other drugs for patients with obesity. Many drugs use weight-based dosing in pediatrics, but differences in body composition compared to a healthy weight may affect drug pharmacokinetics (i.e., absorption, distribution, metabolism, and excretion) in youth with obesity.³⁸ Lipophilic (fat-soluble) drugs may have a larger volume of distribution (Vd) in patients with excess fat. Hydrophilic (water-soluble) drugs have a similar or slightly increased Vd due to decreased lean body mass and blood volume, and a lower percentage of total body water. Fatty liver infiltration may reduce hepatic drug clearance, thereby affecting loading doses, dosage intervals, plasma half-lives, and times to reach steady-state concentration.³⁸

The Pediatric Pharmacy Advocacy Group recommends the following for weight-based dosing in pediatrics:³⁸

For patients who weigh less than 40 kg, use weight-based dosing

For patients weighing 40 kg or more, use weight-based dosing unless the dose exceeds the recommended adult dose for the specific indication

Pharmacists can flag patients' profiles whose doses should be monitored as they lose weight, and technicians can ask the patient or parent whether the patient’s weight has changed significantly since their last visit to the pharmacy. For patients approaching 40 kg from either direction, pharmacy technicians can also gently remind them to provide a current weight.

Counseling and Education

Weight-related discussions can be sensitive, but avoiding them may delay care and harm the patient-provider relationship. Evidence suggests that having conversations about obesity facilitates effective treatment.⁴

Motivational Interviewing

Motivational Interviewing (MI) is a patient-centered counseling approach that aims to identify and strengthen a patient's intrinsic motivation for change, rather than relying on a traditional, prescriptive approach.⁴ Motivational Interviewing guides families to select a behavior for change based on their own priorities and feasibility. It does not impose specific goals but celebrates successful changes in chosen behaviors, ranging from dietary improvements to physical activity and other relevant areas. As patients enter adolescence, the emphasis in MI transitions from parental motivation alone to patient motivation with or without concurrent parental motivation.⁴

Motivational Interviewing involves four key processes:⁴

Engaging: In the initial stages of getting to know the patient, establish a collaborative role and an understanding of the patient's issues through open-ended questions, affirmations, nonjudgmental graphics, and empathy.

Focusing: Early, when the desire to change weight status is expressed, identify appropriate, productive strategies for weight loss. Control gradually shifts from caregivers to patients, necessitating increased patient involvement in readiness assessments, particularly during adolescence.

Evoking: When behavior change is desired, empower patients and families by recognizing diverse motivations beyond health, such as athletic performance or self-image, through evaluating values, goals, and barriers to readiness.

Planning: When embarking on change, assess the patient's knowledge and available resources, and offer support and guidance in choosing strategies. Also, healthcare professionals should support patients in addressing setbacks and relapses, helping them get back on track with appropriate approaches, given the challenges of obesity treatment.

Non-Stigmatizing Language

One of the most important aspects of counseling patients and caregivers about obesity is safeguarding pediatric patients’ emotional well-being and respecting their independence and freedom to make choices. Clinicians should follow two general rules for respectfully addressing BMI and weight-related issues:⁴

Ask for permission: Request consent to discuss the patient's BMI and/or weight, respecting their autonomy and comfort level with this topic.

Be respectful: Use non-stigmatizing language, avoiding negative judgment or bias, to maintain an open dialogue, including person-first language and neutral terms. Table 5 lists examples of these concepts.

Table 5

Non-Stigmatizing Language in Pediatric Obesity Care⁴

SAY THIS	NOT THAT
First-Person Language
Child with obesity My patient is affected by obesity	Obese child My patient is obese
Neutral Terms
Unhealthy weight Gaining too much weight for age	Obese Morbidly obese Large Fat Chubby

Discussing BMI with children, adolescents, and families, even when using non-stigmatizing language and preferred terms, can still trigger strong emotional reactions like sadness or anger. Recognizing and validating these emotions while emphasizing the need to focus on the child’s health can strengthen healthcare relationships, build trust, and support ongoing care.

Patient Case

A 13-year-old girl, B.H., presents for a well-child visit with her mother, accompanied by her pediatrician. Her diet includes fast food (usually 3 times a week), sweetened beverages, and minimal fruit and vegetables. She spends 4 hours daily on her phone or watching videos. Her BMI is 33 kg/m².

How should the conversation about her BMI begin?

Her pediatrician asks permission to discuss her weight, using the term 'unhealthy weight’ rather than ‘obese.’ Discussion uncovers there is a family history of type 2 diabetes. Laboratory evaluation reveals elevated fasting glucose and dyslipidemia.

What is the next step?

The pediatrician diagnoses her condition as obesity with emerging cardiometabolic risk. B.H. is referred to a multidisciplinary weight-management program with a dietitian, a behavioral health professional, and a physical activity specialist.

What is a logical initial treatment?

The team initiates behavior, diet, and lifestyle treatment with family-based nutrition counseling and a gradual increase in physical activity toward a goal of 60 minutes per day, while limiting screen time.

After six months of lifestyle treatment, there is limited improvement in BMI.

What are the pharmacologic options to consider adding?

Shared decision-making with the family indicates that this patient is not a candidate for phentermine/topiramate because they do not have a car, making return visits for monitoring difficult. Expected medication benefits and potential adverse effects are discussed, including the need for long-term coordinated follow-up with the team. When considering liraglutide or semaglutide, the pediatrician prescribes liraglutide.

Summary

Pediatric obesity is a growing health crisis. Obesity is a multifaceted issue with many contributing and exacerbating factors. As obesity rates rise in the pediatric population, so do other medical conditions and chronic diseases that were historically seen only in adulthood. Pediatric patients with obesity suffer significant mental health consequences that last into adulthood.

Maintaining an open, respectful dialogue with patients and caregivers about pediatric obesity is a crucial skill. A well-rounded treatment team with a deep understanding of the condition’s diagnosis and screening, physical and mental burden, and available treatment options can broach this difficult topic and make a significant difference in care and outcomes for this vulnerable patient population.

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The information provided in this course is general in nature, and it is designed solely to provide participants with continuing education credit(s). This course and materials are not meant to substitute for the independent, professional judgment of any participant regarding that participant’s professional practice, including but not limited to patient assessment, diagnosis, treatment, and/or health management. Medical and pharmacy practices, rules, and laws vary from state to state, and this course does not cover the laws of each state; therefore, participants must consult the laws of their state as they relate to their professional practice.

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