Dr. Edward Lewis, a pediatrician in Rochester, New York, has cared for hundreds of children with obesity over the years in his medical practice. He may finally have a treatment for his medical condition: the powerful weight loss drug Wegovy.
But that doesn’t mean Dr. Lewis is prescribing it. Neither are most other pediatricians.
“I’m reluctant to prescribe medications that we don’t use on a daily basis,” Dr. Lewis said. And he added that he is not willing to use “a medication that is relatively new on the children’s scene.”
All regulators and medical groups have said these drugs are appropriate for children up to 12 years old. But, like Dr. Lewis, many pediatricians are hesitant to prescribe Wegovy to young people, fearful that too little is known about the long-term effects and mindful of past experiences. cases where problems arose years after a drug was approved.
twenty two percent of adolescents between 12 and 19 years old are obese. Research shows that it is unlikely that most will ever overcome the condition — Diet and exercise advice generally hasn’t helped. The reason, obesity researchers say, is that obesity is not caused by a lack of willpower. Rather, it is a chronic illness characterized by an overwhelming desire to eat.
Of particular concern to physicians are the 6 percent of children and adolescents with severe obesity, which is defined as having a body mass index equal to or greater than 120 percent of the 95th percentile for height and weight.
“We’re not talking about kids who are slightly overweight,” said Susan Yanovski, co-director of the obesity research office at the National Institute of Diabetes and Digestive and Kidney Diseases. This extreme obesity in adolescents, she said, often has “a really severe course.” These adolescents develop diabetes, heart disease, high blood pressure, kidney failure, and eye damage much earlier than adults with obesity.
“It’s terrifying,” Dr. Yanovski added.
The severity of health outcomes for obese adolescents prompted the American Academy of Pediatrics to recommend weight-loss drugs like Wegovy for teens in January, after the Food and Drug Administration approved it for people 12 and older.
When that happened, obesity medicine experts rejoiced, knowing full well the extent of the problem.
“We said, Wow, we finally have something we can offer,” Dr. Yanovski said.
Still, drugs like Wegovy are new and impediments to using them are increasing. Doctors also worry about the paucity of data on long-term safety. And those who want to prescribe Wegovy say they are beset by obstacles put up by health insurers along with serious and ongoing drug shortages.
The shortage could be alleviated, at least in part, if a similar drug, tirzepatide, from Eli Lilly and sold under the name Zepbound, is approved for younger people. It is being tested in adolescents with obesity, but a large clinical trial needed will not be completed until 2026. Eli Lilly is also testing the drug in children ages 6 to 11. That study is in its earliest phase.
For now, pediatricians in private practice and at academic medical centers say few, if any, of their patients are taking Wegovy. Depending on how safe the drug turns out to be, that hesitation to prescribe it could be a good thing or a missed opportunity.
Doctors are well aware that the history of medicine is replete with treatments, including for weight loss, that seemed wonderful until, with more experience, they stopped being so.
Offsetting that concern are the well-known long-term risks of obesity.
“This is the trade-off with adolescents,” said Dr. Jeffrey Flier, an endocrinologist and obesity and diabetes researcher at Harvard Medical School. “Pediatric obesity is a large and growing problem. What do you do about it?”
Medical specialists say pediatricians tend to be more cautious than other doctors when prescribing new medications and are less likely to prescribe drugs outside their usual arsenal. All of which limits the suggestion of obesity medications to adolescents.
Teenagers report that their attempts to control obesity can feel like a losing battle, made worse by frustration with simple diet and exercise advice and assurances that they will outgrow the condition over time.
That was the experience of Ann A., an 18-year-old high school student from New York City, who asked that only her middle name be used because of the stigma placed on anyone with obesity. For years, she despaired as her weight increased, her blood sugar rose to pre-diabetes levels, and her lipid levels rose abnormally. Her arduous attempts at diet and exercise, and even her summer at a weight-loss camp, were in vain. Each time she regained everything she lost and more.
Her mother took her from doctor to doctor but, Ann said, the advice was the same: “It was always that she didn’t eat well.”
Wegovy, made by Novo Nordisk, reduces appetite and food cravings. in a clinical trial, 132 teenagers who took the drug had much better results than their adult counterparts. The incidence of side effects (mainly nausea and vomiting) was similar to the incidence in adults taking the drug.
But, as Dr. Yanovski noted, much is unknown about how the medications work, and long-term effects may be different when treatment begins in adolescence.
That’s a concern for Dr. Winter Berry, a pediatrician in private practice in Syracuse, New York, who worries about “the paucity of data” on long-term use. He said she and other pediatricians were not philosophically opposed to prescribing Wegovy. But, she said, “we want to do it right.”
“My colleagues and I feel that we are not there yet,” he said.
For Dr. Ilene Fennoy, a professor of pediatrics at Columbia University Irving Medical Center, a big obstacle is health insurance.
For those with private insurance, doctors are often required to submit prior approval forms, a hurdle that also hampers doctors who treat adults.
“Someone has to sit down and put the data together,” Dr. Fennoy said, adding that “it’s not quick or easy.” That impediment, combined with uncertainty about the drug’s safety, has led some doctors to withdraw.
However, for most of Dr. Fennoy’s patients, Wegovy is out of the question because they rely on Medicaid. In New York, as in most other states, Medicaid does not pay for Wegovy, no matter how severe the obesity is. The only exception is for teenagers who also have diabetes, in which case they may receive another Novo Nordisk medicine, Ozempic.
“If you don’t have diabetes but have severe hypertension, you’re going to be out of luck in New York,” Dr. Fennoy said.
That’s a hurdle most adults with obesity don’t face because there are far fewer adults insured through Medicaid than children.
Then there is the persistent shortage of medicines. Parents report calling dozens of pharmacies and being told Wegovy is backordered.
One of Dr. Fennoy’s teenage patients weighs 450 pounds, so much so that he had to undergo hip surgery. “I got approved for his Wegovy, but his parents can’t find a pharmacy that carries it,” Dr. Fennoy said.
“This is the scenario we face,” he said.
Some who have treated teenagers with Wegovy say the idea of taking the medication is not easy to approach.
Dr. Ihuoma Eneli, chief of nutrition at Children’s Hospital Colorado and professor of pediatrics at the University of Colorado School of Medicine, explained the problem she and other pediatricians were struggling with: “How do we reconcile the message When do we tell a child that weight does not define him, that it is just a number” and then, in the next breath, suggest that he take a weight loss medication?
Dr. Eneli, author of the American Academy of Pediatrics guidelines, says she is trying to redirect the conversation to focus on adolescent health: “not just physical health but psychosocial health as a reason to consider medication.”
Sometimes pediatricians decide that the best solution is to avoid these problems by sending a teen to a pediatric endocrinologist or other specialist.
That, said Dr. Stephanie Sisley, a pediatric endocrinologist and obesity medicine specialist at Baylor College of Medicine and Texas Children’s Hospital, doesn’t solve the problem.
“It’s easy to say that the endocrine system should do that, or the GI should do that, or that we should have a completely special clinic,” he said.
But, he said, it’s unclear where to send patients.
“Unlike most diseases, there is no specialized home for obesity and therefore no one owns it,” Dr. Sisley said. “There’s no place to say, ‘Okay, fix the problem.’ It’s easy to say, ‘Not me.’”
He added that there are so many obese teens that there simply aren’t enough specialists available to help them.
For Ann, the New York teenager, the result is happy. She is now being treated by Dr. Dina Peralta-Reich, an obesity medicine specialist in New York, who told her that her obesity was not her fault and suggested Wegovy.
Now, Ann said, her life has changed. She has lost 50 pounds and the shame that accompanied her weight is gone, as are her medical problems.
“I feel better not only physically but also mentally,” he said.