Adolescent experiences of anti-obesity drugs

The concept of treatment beliefs in children and adolescents with chronic health conditions: a scoping review

Children and adolescents with chronic health conditions are faced with ongoing challenges, making self-regulation crucial. As children grow up, they gradually develop differentiated beliefs about illness and treatment. While research indicates treatment beliefs as relevant factor on outcomes like adherence, the specific contents and dimensions of children's and adolescents' treatment beliefs remained unclear. This scoping review therefore aimed at the identification of treatment beliefs dimensions in children and adolescents with chronic health conditions, the underlying theoretical frameworks, and methodological operationalisation. Published literature was examined by applying systematic searches in electronic databases (Medline, PsycINFO, CINAHL) and comprehensive selection criteria, resulting in 49 included studies. The predominant treatment beliefs dimensions were necessity, concerns, perceived benefits and costs/barriers, and expectations. The latter can be differentiated into outcome, social, process, and structural expectations, and expectations of one's own role in the treatment process. In addition, dimensions that cover emotions and reasons for treatment were identified. The results are related to the methods and theoretical models applied, which were often adapted from adult research. However, additional and possibly more child-specific dimensions such as social expectations and emotions were found. This scoping review indicates several research gaps and discusses practical implications.

Parental Perceptions of Medication Use for the Treatment of Obesity in Youth

Background: This survey-based study identified views on antiobesity medications in youth referred to a weight management program. Methods: One parent completed a 14-item Research Electronic Data Capture (REDcap) survey regarding openness to medication use in youth with obesity at their first visit in a weight management program. Medical data were extracted from the medical records of all responders. Results: Ninety-four percent (116/125) of parents approached completed the survey (youths' demographic: mean age = 14.1 years old, 46.8% female, 68.8% Hispanic). Results indicate that 75% of parents surveyed were open to medication use. There was no difference in sex, age, insurance, severity of obesity, or family history between parents who were and were not open to medication (all p > 0.05). Hispanic ethnicity was associated with greater openness to medication use (odds ratio: 3.4, 95% confidence interval: 1.4-8.5, p = 0.007). Conclusions: These results highlight the importance of parental perceptions of medication use for obesity treatment and suggest a need for improved education about the role of medication in the management of pediatric obesity.

Evaluating potential predictors of weight loss response to liraglutide in adolescents with obesity: A post hoc analysis of the randomized, placebo-controlled SCALE Teens trial

BACKGROUND

As childhood obesity prevalence increases, determining which patients respond to anti-obesity medications would strengthen personalized approaches to obesity treatment. In the SCALE Teens trial among pubertal adolescents with obesity (NCT02918279), liraglutide 3.0 mg (or maximum tolerated dose) significantly reduced body mass index (BMI) standard deviation score on average versus placebo. That said, liraglutide effects on BMI reduction varied greatly among adolescents, similar to adults.

OBJECTIVES

To identify post hoc characteristics predictive of achieving ≥5% and ≥10% BMI reductions at 56 weeks with liraglutide versus placebo in adolescents from the SCALE Teens trial.

METHODS

Logistic regression analysis was performed in 251 adolescents treated with liraglutide (n = 125) or placebo (n = 126) for 56 weeks. Baseline characteristics (selected a priori) included sex, race, ethnicity, age, Tanner (pubertal) stage, glycemic status (hyperglycemia [type 2 diabetes/prediabetes] vs. normoglycemia), obesity category (Class II/III vs. I), severity of depression symptoms (Patient Health Questionnaire-9), and weight variability (weight fluctuations over time). The effects of early responder status (≥4% BMI reduction at week 16) on week 56 response were assessed using descriptive statistics.

RESULTS

Baseline characteristics did not affect achievement of ≥5% and ≥10% BMI reductions at week 56 in adolescents treated with liraglutide. Further, there was no association between weight variability and BMI reduction. Early liraglutide responders appeared to have greater BMI and body weight reductions at week 56 compared with early non-responders.

CONCLUSIONS

This secondary analysis suggests that adolescents with obesity may experience significant BMI reductions after 56 weeks of liraglutide treatment, regardless of their sex, race, ethnicity, age, pubertal stage, glycemic status, obesity category, severity of depression symptoms, or weight variability. Early response may predict greater week 56 response.

The treatment of obesity in children and adolescents: consensus position statement of the Italian society of pediatric endocrinology and diabetology, Italian Society of Pediatrics and Italian Society of Pediatric Surgery

This Position Statement updates the different components of the therapy of obesity (lifestyle intervention, drugs, and surgery) in children and adolescents, previously reported in the consensus position statement on pediatric obesity of the Italian Society of Pediatric Endocrinology and Diabetology and the Italian Society of Pediatrics. Lifestyle intervention is the first step of treatment. In children older than 12 years, pharmacotherapy is the second step, and bariatric surgery is the third one, in selected cases. Novelties are available in the field of the medical treatment of obesity. In particular, new drugs demonstrated their efficacy and safety and have been approved in adolescents. Moreover, several randomized control trials with other drugs are in process and it is likely that some of them will become available in the future. The increase of the portfolio of treatment options for obesity in children and adolescents is promising for a more effective treatment of this disorder.

Incorporation of patient and family values and preferences for health-related outcomes in paediatric obesity management: A systematic review

OBJECTIVE

A systematic review of value and preference studies conducted in children and their caregivers related to the estimated benefits and harms of interventions for managing paediatric obesity.

METHODS

We searched Ovid Medline (1946-2022), Ovid Embase (1974-2022), EBSCO CINAHL (inception to 2022), Elsevier Scopus (inception to 2022), and ProQuest Dissertations & Theses (inception to 2022). Reports were eligible if they included: behavioural and psychological, pharmacological, or surgical interventions; participants between (or had a mean age within) 0-18 years old with overweight or obesity; systematic reviews, primary quantitative, qualitative, or mixed/multiple methods studies; and values and preferences as main study outcomes. At least two team members independently screened studies, abstracted data, and appraised study quality.

RESULTS

Our search yielded 11 010 reports; eight met the inclusion criteria. One study directly assessed values and preferences based on hypothetical pharmacological treatment for hyperphagia in individuals with Prader-Willi Syndrome. Although not having reported on values and preferences using our a priori definitions, the remaining seven qualitative studies (n = 6 surgical; n = 1 pharmacological) explored general beliefs, attitudes, and perceptions about surgical and pharmacological interventions. No studies pertained to behavioural and psychological interventions.

CONCLUSION

Future research is needed to elicit the values and preferences of children and caregivers using the best available estimates of the benefits and harms for pharmacological, surgical, and behavioural and psychological interventions.

Medical treatment of weight loss in children and adolescents with obesity

Obesity remains one of the biggest health problems both in adults and children. Lifestyle modification, including diet and exercise, continues to be the mainstay of obesity prevention and treatment. Unfortunately, lifestyle modifications are often unsuccessful. Pharmacological treatment of obesity in pediatric patients can be applied in selected cases, and not before evidence of failure of the multidisciplinary lifestyle intervention. In this narrative review, we revised the most up-to-date evidence on medical treatment of weight loss in children and adolescents with obesity, including FDA- or EMA-approved and -experimented, not approved, drugs for pediatric population. Multidisciplinary treatment of childhood obesity, regulation of appetite control, energy balance and body weight were also discussed, in order to clarify the indications and mechanism action of drugs. Despite a substantial number of medications used for the treatment of obesity in adults, a limited number of drugs are approved by the drug regulatory agencies for pediatric population. Further research is needed to evaluate the efficacy and safety of novel pharmacological approaches for treatment of pediatric obesity in order to optimize weight management for children and adolescents and limit the development obesity-related comorbidities.

Bariatric Surgery in Adolescents: To Do or Not to Do?

Pediatric obesity is a multifaceted disease that can impact physical and mental health. It is a complex condition that interweaves biological, developmental, environmental, behavioral, and genetic factors. In most cases lifestyle and behavioral modification as well as medical treatment led to poor short-term weight reduction and long-term failure. Thus, bariatric surgery should be considered in adolescents with moderate to severe obesity who have previously participated in lifestyle interventions with unsuccessful outcomes. In particular, laparoscopic sleeve gastrectomy is considered the most commonly performed bariatric surgery worldwide. The procedure is safe and feasible. The efficacy of this weight loss surgical procedure has been demonstrated in pediatric age. Nevertheless, there are barriers at the patient, provider, and health system levels, to be removed. First and foremost, more efforts must be made to prevent decline in nutritional status that is frequent after bariatric surgery, and to avoid inadequate weight loss and weight regain, ensuring successful long-term treatment and allowing healthy growth. In this narrative review, we considered the rationale behind surgical treatment options, outcomes, and clinical indications in adolescents with severe obesity, focusing on LSG, nutritional management, and resolution of metabolic comorbidities.

Pediatric Metabolic and Bariatric Surgery

Childhood obesity can lead to comorbidities that cause significant decrease in health-related quality of life and early mortality. Recognition of obesity as a disease of polygenic etiology can help deter implicit bias. Current guidelines for treating severe obesity in children recommend referral to a multidisciplinary treatment center that offers metabolic and bariatric surgery at any age when a child develops a body mass index that is greater than 120% of the 95th percentile. Obesity medications and lifestyle counseling about diet and exercise are not adequate treatment for severe childhood obesity. Early referral can significantly improve quality and quantity of life.

Improving the assessment and management of obesity in UK children and adolescents: the PROMISE research programme including a RCT

Background

Five linked studies were undertaken to inform identified evidence gaps in the childhood obesity pathway.

Objectives

(1) To scope the impact of the National Child Measurement Programme (NCMP) (study A). (2) To develop a brief evidence-based electronic assessment and management tool (study B). (3) To develop evidence-based algorithms for identifying the risk of obesity comorbidities (study B). (4) To conduct an efficacy trial of the Healthy Eating and Lifestyle Programme (HELP) (study C). (5) To improve the prescribing of anti-obesity drugs in UK adolescents (study D). (6) To investigate the safety, outcomes and predictors of outcome of adolescent bariatric surgery in the UK (study E).

Methods

Five substudies – (1) a parental survey before and after feedback from the National Childhood Measurement Programme, (2) risk algorithm development and piloting of a new primary care management tool, (3) a randomised controlled trial of the Healthy Eating and Lifestyle Programme, (4) quantitative and qualitative studies of anti-obesity drug treatment in adolescents and (5) a prospective clinical audit and cost-effectiveness evaluation of adolescent bariatric surgery in one centre.

Results

Study A – before the National Childhood Measurement Programme feedback, three-quarters of parents of overweight and obese children did not recognise their child to be overweight. Eighty-seven per cent of parents found the National Childhood Measurement Programme feedback to be helpful. Feedback had positive effects on parental knowledge, perceptions and intentions. Study B – risk estimation models for cardiovascular and psychosocial comorbidities of obesity require further development. An online consultation tool for primary care practitioners is acceptable and feasible. Study C – the Healthy Eating and Lifestyle Programme, when delivered in the community by graduate mental health workers, showed no significant effect on body mass index at 6 months (primary outcome) when compared with enhanced usual care. Study D – anti-obesity drugs appear efficacious in meta-analysis, and their use has expanded rapidly in the last decade. However, the majority of prescriptions are rapidly discontinued after 1–3 months of treatment. Few young people described positive experiences of anti-obesity drugs. Prescribing was rarely compliant with the National Institute for Health and Care Excellence guidance. Study E – bariatric surgery appears safe, effective and highly cost-effective in adolescents in the NHS.

Future work and limitations

Work is needed to evaluate behaviour and body mass index change in the National Childhood Measurement Programme more accurately and improve primary care professionals’ understanding of the National Childhood Measurement Programme feedback, update and further evaluate the Computer-Assisted Treatment of CHildren (CATCH) tool, investigate delivery of weight management interventions to young people from deprived backgrounds and those with significant psychological distress and obtain longer-term data on anti-obesity drug use and bariatric surgery outcomes in adolescence.

Trial registration

Current Controlled Trials ISRCTN99840111.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 8, No. 3. See the NIHR Journals Library website for further project information.

ASMBS pediatric metabolic and bariatric surgery guidelines, 2018

The American Society for Metabolic and Bariatric Surgery Pediatric Committee updated their evidence-based guidelines published in 2012, performing a comprehensive literature search (2009-2017) with 1387 articles and other supporting evidence through February 2018. The significant increase in data supporting the use of metabolic and bariatric surgery (MBS) in adolescents since 2012 strengthens these guidelines from prior reports. Obesity is recognized as a disease; treatment of severe obesity requires a life-long multidisciplinary approach with combinations of lifestyle changes, nutrition, medications, and MBS. We recommend using modern definitions of severe obesity in children with the Centers for Disease Control and Prevention age- and sex-matched growth charts defining class II obesity as 120% of the 95th percentile and class III obesity as 140% of the 95th percentile. Adolescents with class II obesity and a co-morbidity (listed in the guidelines), or with class III obesity should be considered for MBS. Adolescents with cognitive disabilities, a history of mental illness or eating disorders that are treated, immature bone growth, or low Tanner stage should not be denied treatment. MBS is safe and effective in adolescents; given the higher risk of adult obesity that develops in childhood, MBS should not be withheld from adolescents when severe co-morbidities, such as depressed health-related quality of life score, type 2 diabetes, obstructive sleep apnea, and nonalcoholic steatohepatitis exist. Early intervention can reduce the risk of persistent obesity as well as end organ damage from long standing co-morbidities.

Survey of antiobesity drug prescribing for obese children and young people in UK primary care

OBJECTIVES

Antiobesity drug (AOD) prescribing in children and young people (CYP) in primary care is rising with high rates of discontinuation. Little is known about prescribing in this group in terms of patient demographics and comorbidities, reasons for initiation and discontinuation, or adherence to national guidelines.

DESIGN

Questionnaire survey to general practitioners (GPs) identified using a nationally representative primary care database covering 6% of UK population.

SETTING

UK-wide primary care.

PARTICIPANTS

Patients were eligible if prescribed an AOD aged ≤18 years between 2010 and 2012. A total of 151 patients from 108 unique practices were identified via national prescribing database, with responses for 119 patients (79%) from 84 practices; 94 of 119 (79%) were eligible for inclusion.

PRIMARY AND SECONDARY OUTCOMES

Survey of GP prescribing habits of AODs to CYP. We audited orlistat usage against the National Institute for Health and Care Excellence (NICE) guidance.

RESULTS

47% were prescribed metformin, 59% orlistat and 5% both drugs. Orlistat was largely prescribed by GPs independently (49/55 prescriptions, 89%) and metformin by GPs on specialist recommendation (12/44, 27%). Orlistat was largely prescribed in those over 16 years of age without physical comorbidities. Metformin was initiated for treatment of polycystic ovarian syndrome (70%), insulin resistance (25%) and impaired glucose control (9%). Median supply of metformin was 10.5 months (IQR 4-18.5 months) and 2.0 months (1.0-4.0) for orlistat (p≤0.001). Drug terminations were largely due to families not requesting repeat prescriptions. NICE guidance adherence was low; 17% of orlistat prescriptions were initiated by specialists, and 56% had evidence of obesity-related comorbidity. GPs reported lower confidence in prescribing AOD to CYP compared with adults (10-point Likert score median 3 vs 8, p<0.001).

CONCLUSIONS

Prescribing of AOD in primary care is challenging with low adherence to NICE guidance. Further work is needed to better support GPs in the use of AOD in CYP.