New medical guideline features 10 recommendations, including one in favour of GLP-1 receptor agonists, the class of drugs that contains semaglutide, better known as the Type 2 diabetes medication Ozempic. Boxes of Ozempic and Wegovy are seen at a pharmacy in London, England, on March 8, 2024.Hollie Adams/Reuters
Doctors caring for young people with obesity should provide nutritional and exercise advice, but should also consider offering weight-loss drugs and bariatric surgery to teenagers, according to the first new Canadian guideline on the treatment of pediatric obesity in nearly 20 years.
The clinical practice guideline, which provides advice to doctors on how to treat children with obesity, was published Monday in the Canadian Medical Association Journal. It features 10 recommendations, including one in favour of GLP-1 receptor agonists, the class of drugs that contains semaglutide, better known as the Type 2 diabetes medication Ozempic.
Wegovy, a higher-dose version of semaglutide marketed for weight management, is approved in Canada for children 12 and up.
“We want to make sure that, based on what we know and the evidence out there in the science, that youth and families have access to all the tools in the toolbox,” said Sanjeev Sockalingam, the scientific director of Obesity Canada, the health charity that helped develop the guideline.
There has been a sea change in the treatment of obesity since the last time Canadian experts published advice on caring for children and teens with the chronic disease in 2007. The most dramatic shift has been the rise of glucagon-like peptide-1 (GLP-1) receptor agonists, medications that mimic a naturally occurring hormone to suppress hunger and muffle the food noise that stalks many people who struggle with their weight.
In clinical trials involving adults, semaglutide and some of its cousins have been shown to have benefits beyond diabetes control and weight loss, including reductions in the risks of heart attacks and strokes, kidney disease, peripheral artery disease and fatty liver disease, among other afflictions.
But there is less clinical trial evidence in people under 18, as is often the case in drug development. The new guideline, for example, cites only one study of semaglutide in adolescents aged 12 to 18. It found teens taking the drug lost, on average, 16 per cent of their body weight – a result far superior to lifestyle interventions and a placebo.
“I would love to see some long-term follow-up,” said Katherine Morrison, a pediatric endocrinologist at McMaster Children’s Hospital and a member of the guideline panel. “There’s many questions we don’t have answered. When is the best time to start them? How do you wean off?”
Nonetheless, she prescribes semaglutide to teens with obesity. The availability of effective medications has changed her practice, although not as much as people might assume, she said. “It’s still absolutely critical that I understand the journey that a family has taken to arrive in my clinic, and then I have an open conversation and discussion with them,” Dr. Morrison said.
The guideline’s authors are careful to say that weight-loss medications and surgery should be offered in combination with nutrition, exercise and psychological support for parents and children, who can be discriminated against at school, online and in the health care system.
Because weight stigma often follows children – considered to be anyone under 18 – into their doctors’ offices, the guideline paper features nine “good practice statements” for how medical professionals can treat young patients with obesity in a non-judgmental, non-stigmatizing way.
The Canadian advice comes more than two years after the American Academy of Pediatrics published a guideline in the United States that endorsed intensive behavioural interventions for children with obesity, as well as medications and surgery for some teens.
The American instructions were a departure from the old paradigm of “watchful waiting,” or declining to treat children for obesity until they are adults.
“There’s no evidence to say that watchful waiting is a beneficial strategy,” said Geoff Ball, associate chair of research in the pediatrics department at the University of Alberta’s Faculty of Medicine and Dentistry and co-chair of the Canadian guideline panel. “We have evidence to show that interventions, when they’re provided, can be effective at improving health outcomes for kids with obesity. So why would you hold those back?”
The target audience for the Canadian guideline is health care providers who treat children who are obese as defined by World Health Organization growth charts, which take into account children’s height, age and gender.
The guideline group began its work by surveying health care providers and the families of children with obesity about their priorities for treatment, which turned out to be health-related quality of life and the relief of anxiety and depression more than weight loss alone.
The panel then reviewed the literature and made recommendations. They came out in favour of nutrition interventions, physical activity and psychological interventions alone or in combination with each other, but they did not dictate how children should exercise or what they should eat.
When it came to food, Dr. Morrison said studies showed that no particular diet – whether it be low-fat, low-carb or any other trendy eating pattern – was better than any other. Children who received professional support to eat healthy foods fared better than those who didn’t.
The guideline panel said it was neither for nor against weight-management technologies such as pedometers and smartphone apps. The group recommended doctors “consider” GLP-1s, as well as medications from the class that includes metformin, and two types of weight-loss surgeries for teens 13 and up.
They recommended against lipase inhibitors, a class that includes orlistat, sold under the brand name Xenical.
One criticism of the guideline is that it recommends interventions that are out of reach for many Canadians, an issue the panel members said they are keenly aware of.
Spots in comprehensive, publicly funded childhood obesity clinics are scare, hospitals performing weight-loss surgeries on teens are few, and expensive GLP-1 medications are often not covered for weight loss by private or public drug plans.
“That is a big problem – and the problem, I think, speaks to the weight bias around these medications,” said Yoni Freedhoff, medical director of the Bariatric Medical Institute in Ottawa. He was not involved in the development of the guideline.
Ian Patton, 40, looks back now on his time growing up as a child with obesity and wishes he had had some of the options laid out in the new clinical practice guideline. He underwent bariatric surgery a decade ago and now takes a GLP-1 medication, which has helped him to be an active father to his two children.
“If I had access to evidence-informed care around obesity early on as a child, I’m sure my parents would have appreciated that,” said Mr. Patton, the director of advocacy and public engagement for Obesity Canada. “They would have been able to better support me, and I would have been better off. I might not have struggled as much as I did.”
The new guideline was funded through a position that Dr. Ball holds as Alberta Health Services Chair in Obesity Research. Obesity Canada, which supported the guideline development, receives funding from companies that make weight-loss drugs, including Wegovy-maker Novo Nordisk.
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