Cost-Effectiveness of Pharmacotherapy for the Treatment of Obesity in Adolescents

Risk Factors for Adverse Cardiac Events in Individuals Prescribed Stimulants Across the Lifespan

INTRODUCTION

Prescription stimulants are an effective FDA approved treatment for attention deficit hyperactivity disorder (ADHD) however their safety has come under scrutiny. Multiple studies demonstrate safe use in pediatric populations, but prescriptions are increasing to adults and it is not evident which comorbidities might place people at risk of adverse outcomes. The aim of this study is to identify risk factors of adverse cardiovascular events for individuals exposed to stimulants across the lifespan.

METHODS

We conducted a case control study utilizing the TriNetX research network database. Individuals were included for study if they were younger than 90 years old and prescribed stimulants between January 1, 2010 and December 31, 2020. We utilized summary statistics, chi2, and multivariate logistic regression to identify risk factors for cardiovascular events.

RESULTS

Of the 987,762 individuals prescribed stimulants, 49,902 experienced an adverse cardiovascular event. Individuals with atherosclerotic heart disease had the highest odds of adverse events (aOR = 36.7, p < .001). Hypertension (aOR = 2.78 p < .001), cocaine use (aOR = 1.64 p < .001), and anxiety (aOR = 1.46 p < .001) were also strongly predictive of adverse outcomes, but risk varied by age.

CONCLUSIONS

Atherosclerotic heart disease and its antecedents pose the greatest risk for cardiovascular events for people prescribed stimulants. Mental health diagnoses are also independent predictors and age may be an effect modifier of these relationships. ADHD was not an independent risk factor for major adverse cardiovascular events when controlling for other biopsychosocial variables in adult populations. Additional research focused on predictive models and prospective studies may be warranted to better inform clinical decisions regarding stimulant prescriptions for the broad demographic of patients that may benefit from these medications.

Metabolic dysfunction-associated steatotic liver disease (MASLD) in children with obesity: An Obesity Medicine Association (OMA) and expert joint perspective 2025

Introduction

This Obesity Medicine Association (OMA) Expert Joint Perspective examines steatotic liver disease (SLD), which is composed of metabolic dysfunction-associated steatotic liver disease (MASLD), and metabolic dysfunction-associated steatohepatitis (MASH) in children with obesity. The prevalence of obesity is increasing, rates have tripled since 1963 from 5 % to now 19 % of US children affected in 2018. MASLD, is the most common liver disease seen in children, can be a precursor to the development of Type 2 Diabetes (T2DM) and is the primary reason for liver transplant listing in young adults. We must be vigilant in prevention and treatment of MASLD in childhood to prevent further progression.

Methods

This joint clinical perspective is based upon scientific evidence, peer and clinical expertise. The medical literature was reviewed via PubMed search and appropriate articles were included in this review. This work was formulated from the collaboration of eight hepatologists/gastroenterologists with MASLD expertise and two physicians from the OMA.

Results

The authors who are experts in the field, determined sentinel questions often asked by clinicians regarding MASLD in children with obesity. They created a consensus and clinical guideline for clinicians on the screening, diagnosis, and treatment of MASLD associated with obesity in children.

Conclusions

Obesity and the comorbidity of MASLD is increasing in children, and this is a medical problem that needs to be addressed urgently. It is well known that children with metabolic associated chronic disease often continue to have these chronic diseases as adults, which leads to reduced life expectancy, quality of life, and increasing healthcare needs and financial burden. The authors of this paper recommend healthy weight reduction not only through lifestyle modification but through obesity pharmacotherapy and bariatric surgery. Therefore, this guidance reviews available therapies to achieve healthy weight reduction and reverse MASLD to prevent progressive liver fibrosis, and metabolic disease.

Estimated Costs and Cost-Effectiveness of a Pediatric Weight Management Program

Importance

Childhood obesity remains a significant public health challenge, with ongoing racial, ethnic, and socioeconomic disparities in its prevention and treatment. Economic evaluations of pediatric obesity interventions are essential for guiding resource allocation in health care settings.

Objective

To develop and analyze a simulation model of the Connect for Health program to estimate the costs of implementing the program and assess its cost-effectiveness.

Design, Setting, and Participants

This economic evaluation used a Markov cohort model based on the Connect for Health randomized clinical trial (RCT) conducted from June 2014 through March 2016 and the Connect for Health implementation study conducted at 2 academic medical centers in Boston, MA. The study first estimated costs of implementation for new sites, and then simulated program implementation in a cohort that mirrored the RCT population. Data were analyzed from October 2023 to March 2025.

Exposure

The Connect for Health pediatric weight management program.

Main Outcomes and Measures

Outcomes include costs associated with program implementation and the incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY) gained.

Results

This study used a cohort of 2494 individuals to mirror the RCT population and included 1178 female participants (47%), a mean (SD) age of 8.0 (3.0) years, and a mean (SD) body mass index z score of 1.91 (0.56). The costs of implementing the Connect for Health program in primary care settings were estimated at $58 000 in 1-time startup costs and $1300 in ongoing monthly costs. The economic model showed that the Connect for Health strategy had an ICER of $10 554 per QALY gained over 2 years compared with no intervention. The study found a threshold of 534 children in a cohort was needed to effectively amortize costs.

Conclusions and Relevance

In this economic evaluation of a pediatric weight management program, the Connect for Health program was estimated to be cost-effective. These findings are important for health care systems that serve children who are less likely to receive obesity-related care in making decisions about program adoption.

Efficacy of Oral Medication in Weight Loss Management: A Systematic Review and Network Meta-Analysis

PURPOSE

This systematic review was conducted to determine which type of oral medication for obesity provides the best weight loss effect.

METHODS

This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guideline. For this systematic review, we used 3 databases for journal searches: PubMed, ScienceDirect, and Scopus. This study only included randomized controlled trials or open-label clinical trials. There was no year limit used in the journal search for this systematic review.

FINDINGS

Eighteen randomized controlled trials, with a total population of 12,259 patients, were included. Of 18 studies, 15 were used for network meta-analysis. Based on the results of the network meta-analysis, weight loss was found in phentermine/topiramate (mean difference [MD], -3.28; 95% CI, -4.47 to -2.09), semaglutide (MD, -2.92; 95% CI, -4.38 to -1.46), phentermine (MD, -2.31; 95% CI, -3.82 to -0.81), naltrexone/bupropion (MD, -1.68; 95% CI, -2.87 to -0.49), topiramate (MD, -1.67; 95% CI, -2.86 to -0.48), and orlistat (MD, -1.44; 95% CI, -2.32 to -0.55). There were no significant differences among the groups. However, compared with placebo, all oral obesity therapies provide better benefits in weight loss (MD, -2.12; 95% CI, -2.64 to -1.59; P ≤ 0.00001).

IMPLICATIONS

Oral antiobesity drugs provide better weight loss than placebo. However, some side effects can be incurred by utilizing the drug for weight loss, especially related to the gastrointestinal system. Nonetheless, in clinical settings, consideration should be given to particular patients to reduce risk of side effects.

Early Reinitiation of Obesity Pharmacotherapy Post Laparoscopic Sleeve Gastrectomy in Youth: A Retrospective Cohort Study

BACKGROUND

Bariatric surgery is the most effective intervention for severe pediatric obesity, but a subset of youth experience suboptimal weight loss and/or recurrent weight gain. Early re-initiation of obesity pharmacotherapy postoperatively may improve outcomes, though this has not been evaluated in pediatric populations.

METHODS

A retrospective cohort study at a tertiary care children's hospital evaluated the safety and efficacy of reintroducing obesity pharmacotherapy within six weeks after laparoscopic sleeve gastrectomy (LSG). Youth were offered obesity pharmacotherapy reinitiation at their 2-week postoperative visit. The study compared outcomes between 25 youth who chose early obesity pharmacotherapy reinitiation and 21 who received standard care without restarting medication. Primary outcomes included weight trajectory, eating behaviors, complications, readmissions, and reoperation rates, analyzed using independent t-tests, Chi-squared tests, and logistic regressions.

RESULTS

Between November 2023 and July 2024, 53 youth had surgical consults, and 46 (86% conversion rate; mean age 16.5 ± 1.9 years, mean BMI 53 ± 9.7 kg/m2; 70% (32/46) female, 80% (37/46) Hispanic, 87% (40/46) publicly insured) underwent LSG, with 93% (43/46) using obesity pharmacotherapy preoperatively. Mixed-effects multivariate regression, adjusting for baseline BMI, age, and sex, revealed that early reinitiation (5.1 weeks [IQR 3.7, 8.4]) significantly reduced BMI, percent BMI, percent total weight loss (TWL), and percent excess weight loss (EWL) at 3 and 6 months compared to standard care, with no significant differences in complications or readmissions. At 6 months, the mean differences were: %BMI: -6.5% (95% CI: -9.13, -3.86), p < 0.001; %TWL: -5.9% (95% CI: -8.52, -3.25), p < 0.001; %EWL: Reinitiators: -45.5% vs. standard care: -39.4%; mean difference: -8.2% (95% CI: -14.69, -1.63), p < 0.001. Early reinitiation also resulted in a significant reduction in emotional overeating at 3 and 6 months compared to standard care, with mean differences of -2.5 points (95% CI: -3.29, -1.76), p < 0.001, and -3.5 points (95% CI: -4.38, -2.69), p < 0.001, respectively on self-reported eating behavior questionnaires.

CONCLUSION

Early obesity pharmacotherapy reinitiation after LSG was safe and well tolerated, improving weight outcomes without negatively impacting complication or readmission rates.

Anti-Obesity Medication in the Management of Children and Adolescents With Obesity: Recent Developments and Research Gaps

BACKGROUND

Paediatric obesity is a global public health concern. While in most countries the incidence keeps rising, the need for effective and long-term management for children and adolescents living with this chronic, relapsing disease is pressing. Health behaviour and lifestyle treatment (HBLT) is recommended as first-line treatment.

METHODS

Narrative review.

RESULTS

A new generation of recently approved anti-obesity medications (AOM) now has the potential to fill the gap between limited effects on body mass index (BMI) by HBLT alone and large effects by metabolic and bariatric surgery in adolescents with obesity aged 12 years and older. While, for semaglutide and phentermine/topiramate, effectiveness is substantial with relevant, but mostly mild to moderate adverse events, there is a gap in evidence regarding long-term effects and safety, effects on outcomes beyond BMI reduction and data for certain groups of patients, such as children < 12 years and minority groups. When integrating AOM treatment into national healthcare systems it should be offered as part of a comprehensive patient-centred approach.

CONCLUSION

This article summarizes recent AOM developments, integration into paediatric obesity management, and identifies research gaps.

The role of glucagon-like peptide-1 receptor agonists (GLP1-RAs) in the management of the hypertensive patient with metabolic syndrome: a position paper from the Korean society of hypertension

Obesity is the one of the most important components of metabolic syndrome. Because obesity related hypertension accounts for two thirds of essential hypertension, managing obesity and metabolic syndrome is a crucial task in the management of hypertension. However, the current non-pharmacological therapies have limitations for achieving or maintaining ideal body weight. Recently, glucagon-like peptide-1 receptor agonists (GLP1-RAs) have demonstrated excellent weight control effects, accompanied by corresponding reductions in blood pressure. GLP1-RAs have shown cardiovascular and renal protective effects in cardiovascular outcome trials both in primary and secondary prevention. In this document, the Korean Society of Hypertension intends to remark the current clinical results of GLP1-RAs and recommend the government and health-policy makers to define obesity as a disease and to establish forward-looking policies for GLP1-RA treatment for obesity treatment, including active reimbursement policies.

Semaglutide for management of obesity in adolescents: efficacy, safety, and considerations for clinical practice

PURPOSE OF REVIEW

The purpose of this review is to describe the existing limited data related to the use of semaglutide in adolescents with obesity, supplementing with findings from adult studies of semaglutide use.

RECENT FINDINGS

Semaglutide, as a once weekly subcutaneous injection for weight management, effectively reduces body mass index (BMI) while improving hyperglycemia, elevated alanine aminotransferase levels, hyperlipidemia, and quality of life in youth with obesity. As of this review, only one large randomized clinical trial of semaglutide in youth has been completed, with a follow-up duration of 68 weeks. Thus, long-term data on the safety in adolescents is limited, particularly regarding the risks of cholelithiasis, pancreatitis, suicidal ideation, and disordered eating. Due to the cost of semaglutide, particularly in the United States, limited cost effectiveness analyses have demonstrated unfavorable incremental cost-effectiveness ratios for semaglutide relative to phentermine-topiramate as an alternative antiobesity medication in adolescents.

SUMMARY

Semaglutide represents an important advance in the pediatric obesity management, with clear short-term reductions in BMI and improvement in metabolic parameters. However, its long-term safety and efficacy for youth with obesity remain to be demonstrated. Additional research is needed to assess trends in utilization and adherence to minimize the risk of worsening socioeconomic disparities in pediatric obesity.

Contrasting obesity: is something missing here?

The fight against obesity is largely based on recommendations about lifestyle and therapies to initiate weight loss and, hopefully, to achieve and maintain an ideal weight. The failure of this approach is witnessed by the steady increasing rates of obesity worldwide. Lifestyle modifications yield mild weight loss with poor results in the long-term. The pharmaceutical industry is engaged to produce the best anti-obesity drugs, and this market is projected to grow massively. Guidelines on pharmacological and surgical approach to obesity are continuously developed, taking into account that benefits are counterbalanced by high costs, are limited to the period of drug intake, and potential adverse effects are possible, such as pancreatitis, gastroparesis, and bowel obstruction. Meantime, people living with obesity might simply think that taking the "magic pill" or undergoing bariatric surgery can change their life. In the long term, this tendency might lead to scarce cost-effectiveness, increasing adverse effects and inequities in the most vulnerable age classes. Furthermore, the main actors responsible for generating an obesogenic world will continue undisturbed to produce negative effects. Obesity is not only generated from voluntary individual behaviors, and no guideline can truly counteract the detrimental effects of environmental factors driving the progressive rise of obesity globally. Unsustainable food production, packaging and marketing, environmental pollution, widely diffused endocrine disrupting chemicals, and climate change are largely neglected by health professionals and generate food insecurity and malnutrition. The complexity of obesity cannot be managed only pointing to individual responsibilities of people living with obesity. There is a missing link here, and this war cannot be won in the absence of effective primary prevention measures involving changes in food production and marketing, and decreased release of toxic chemicals into the environment.

Cost-effectiveness analysis of individual-level obesity treatment in paediatrics: A scoping review

OBJECTIVES

This scoping review informs a health economics perspective on the treatment of paediatric obesity. The results detail recently published research findings on the cost-effectiveness of paediatric obesity treatments and identify key characteristics of cost-effective interventions.

METHODS

A structured search was applied to six databases with no data restriction through March 2023: Medline, Embase, Cochrane CENTRAL, CINAHL, and PsycINFO. Studies that included a cost analysis of an individual level, weight management intervention (behavioural, pharmacotherapy, and surgical) in youth, with obesity, ages 2 to 21 years were eligible for inclusion.

RESULTS

Of the 4371 records identified in the initial search, 353 underwent full-text review, 39 studies met the pre-specified inclusion criteria. The majority were published after 2010 (n = 36/39, 92%) and applied to high-income countries (n = 39/39, 100%). Thirty-five of the studies assessed the cost-effectiveness of lifestyle interventions (90%), and four studies assessed surgical outcomes (10%). No pharmacotherapy studies met eligibility criteria. Although the outcome measures differed across the studies, all four surgical interventions were reported to be cost-effective. Thirty of the 35 (85%) lifestyle modification studies were reported to be cost-effective compared to the study comparator examined.

CONCLUSIONS

There is a small amount of evidence that individual-level paediatric obesity treatment interventions are cost-effective and, in some cases cost-saving, with most of this work conducted on behavioural interventions. The economic evaluation of paediatric obesity interventions poses various methodologic challenges, which should be addressed in future research to fully use the potential of economic evaluation as an aid to decision-making.

The Effect of Saffron Kozanis (Crocus sativus L.) Supplementation on Weight Management, Glycemic Markers and Lipid Profile in Adolescents with Obesity: A Double-Blinded Randomized Placebo-Controlled Trial

Global rates of adolescent obesity have led the World Health Organization to consider the disease a pandemic that needs focus. In search of new anti-obesity agents, Crocus sativus, popularly known as saffron, is a nutraceutical agent, praised for its beneficial effects. The study aimed to investigate the possible effect of Kozanis saffron administration on weight management of obese prediabetic adolescents. Seventy-four obese prediabetic adolescents participated in a double-blind placebo-controlled trial of three arms, randomly assigned to receive either Kozanis saffron (n = 25, 60 mg/day), metformin (n = 25, 1000 mg/day) or a placebo (n = 24), for twelve weeks. Anthropometry, glycemic markers and lipid profiles were investigated at baseline and post-intervention. Saffron supplementation significantly reduced the weight z-score, BMI, BMI z-score and waist circumference (WC) of obese adolescents; however, this reduction was less significant compared to the effect of metformin. Metformin administration offered a significantly more profound improvement in anthropometry compared to saffron administration. Saffron administration also provided significant improvements in weight, weight z-scores, BMI values, BMI z-scores and WCs compared to the placebo. Saffron supplementation failed to change any glycemic marker, but provided a significant reduction in fasting triglyceride levels and also a significant increase in fasting HDL levels. Saffron Kozanis constitutes a promising nutraceutical option for adolescents and children with obesity and prediabetes in need of weight management.