Dr. Edward Lewis, a pediatrician in Rochester, N.Y., has seen hundreds of children with obesity over the years in his medical practice. He finally may have a treatment for their medical condition — the powerful weight loss drug Wegovy.
But that does not mean Dr. Lewis is prescribing it. Nor are most other pediatricians.
“I am reluctant to prescribe medications we don’t use on a day-to-day basis,” Dr. Lewis said. And, he added, he is disinclined to use “a medicine that is a relative newcomer to the scene in kids.”
Regulators and medical groups have all said that these drugs are appropriate for children as young as 12. But like Dr. Lewis, many pediatricians hesitate to prescribe Wegovy to young people, fearful that too little is known about long term effects, and mindful of past cases when problems emerged years after a drug was approved.
Twenty-two percent of adolescents age 12 to 19 have obesity. Research shows that most are unlikely to ever overcome the condition — advice to diet and exercise usually has not helped. The reason, obesity researchers say, is that obesity is not caused by a lack of will power. Instead, it is a chronic disease characterized by an overwhelming desire to eat.
Of particular concern to doctors are the 6 percent of children and adolescents with severe obesity, which is defined as having a body mass index at or above 120 percent of the 95th percentile for height and weight.
“We are not talking about kids who are mildly overweight,” said Susan Yanovski, co-director of the office of obesity research at the National Institute of Diabetes and Digestive and Kidney Diseases. Such extreme obesity in adolescents, she said, often has “a really severe course.” These teenagers develop diabetes, heart disease, high blood pressure, kidney failure and eye damage much earlier than adults with obesity.
“It is terrifying,” Dr. Yanovski added.
The seriousness of health outcomes for obese teenagers motivated the American Academy of Pediatrics to recommend weight loss drugs like Wegovy for adolescents in January, after the Food and Drug Administration approved it for people age 12 and older.
When that happened, experts in obesity medicine were elated, knowing full well the scope of the problem.
“We said, Wow, we finally have something we can offer,” Dr. Yanovksi said.
Still, drugs like Wegovy are new, and the impediments to using them are snowballing. Doctors also worry about the dearth of data on long-term safety. And those who want to prescribe Wegovy say that they are beset by roadblocks put up by health insurers along with severe and continuing drug shortages.
The shortages might be at least partly alleviated if a similar drug, tirzepatide, by Eli Lilly and sold under the name Zepbound, is approved for younger people. It is being tested in adolescents with obesity, but a necessary large clinical trial will not be completed until 2026. Eli Lilly is also testing the drug in children age 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 good, or a lost opportunity.
Doctors are all too aware that the history of medicine is replete with treatments, including for weight loss, that seemed wonderful until, with more experience, they weren’t.
Countering that worry 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 big and increasing problem. What do you do about it?”
Medical specialists say pediatricians tend to be more cautious than other doctors in prescribing new drugs and less likely to prescribe medicines outside their usual armamentarium. All of which limits their suggesting obesity medicines to teenagers.
Adolescents report that their attempts to control obesity can seem like a losing battle made worse by frustration with pat advice to diet and exercise and assurances that they will outgrow the condition.
That was the experience of Ann A., an 18-year-old high school student in New York City, who asked that only her middle name be used because of the stigma that clings to anyone with obesity. For years, she despaired as her weight crept up, her blood sugar rose to pre-diabetes levels and her lipid levels climbed abnormally high. Her strenuous attempts at diets and exercise, and even her summer at a weight loss camp, were to no avail. 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 I wasn’t eating well.”
Wegovy, made by Novo Nordisk, reduces appetite and food cravings. In a clinical trial, 132 adolescents who took the drug did much better than their adult counterparts. The incidence of side effects — mostly nausea and vomiting — was similar to the incidence in adults taking the drug.
But, as Dr. Yanovski noted, much about how the drugs work is unknown, and long-term effects may be different when treatment starts in adolescence.
That’s a concern for Dr. Winter Berry, a pediatrician in private practice in Syracuse, N.Y., who worries about “the dearth of data” on long-term use. She said that she and other pediatricians were not philosophically opposed to prescribing Wegovy. But, she said, “we want to do it well.”
“My colleagues and I feel we are not there yet,” she said.
For Dr. Ilene Fennoy, a professor of pediatrics at Columbia University Irving Medical Center, a big hurdle is health insurance.
For those with private insurance, doctors are often required to submit pre-approval forms — an obstacle that also hinders physicians who treat adults.
“Somebody has to sit down and put the data together,” Dr. Fennoy said, adding that “it’s not quick and easy.” That impediment, combined with uncertainty over the drug’s safety, has prompted some doctors to pull away.
For most of Dr. Fennoy’s patients, though, 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. The only exception is for adolescents who also have diabetes, in which case they can get another Novo Nordisk drug, Ozempic.
“If you don’t have diabetes but you have severe hypertension, you are out of luck in New York,” Dr. Fennoy said.
That is a hurdle that most adults with obesity do not face because there are far fewer adults insured through Medicaid than children.
Then there are the persistent drug shortages. Parents report calling dozens of pharmacies, only to be told that Wegovy is on back order.
One of Dr. Fennoy’s teenage patients weighs 450 pounds — so heavy he had to have hip surgery. “I got his Wegovy approved but his parents can’t find a pharmacy that has it,” Dr. Fennoy said.
“This is the landscape we are dealing with,” she said.
Some who have treated adolescents with Wegovy say it is not easy to broach the idea of taking the drug.
Dr. Ihuoma Eneli, the head of the section on nutrition at Children’s Hospital Colorado and professor of pediatrics at the University of Colorado School of Medicine, explained the problem she said she and other pediatricians were struggling with: “How do we reconcile the message when we tell a child that weight doesn’t define them, that it’s just a number,” and then, in the next breath, suggest that the child take a weight loss medication?
Dr. Eneli, an author of the guidelines from the American Academy of Pediatrics, says she tries to redirect the conversation to focus on the adolescent’s health — “not just physical health but psychosocial health as a reason to consider the medication.”
Sometimes, pediatricians decide the best solution is to avoid such issues by sending an adolescent 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, is not solving the problem.
“It is easy to say endocrine should do that, or G.I. should do that, or we should have a whole special clinic,” she said.
But, she said, it is not clear where to send the patients.
“Unlike most diseases, there isn’t a specialty home for obesity and therefore no one owns it,” Dr. Sisley said. “There isn’t a place to say, ‘OK, you fix the issue.’ It is easy to say, ‘Not me.’”
And, she added, so many adolescents have obesity that there just are not enough specialists available to help them.
For Ann, the teenager in New York, the outcome is a happy one. 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 the medical issues.
“I feel better not just physically but mentally,” she said.
