Parent and Guardian Opinions on Obesity Medications Use in Adolescents with Obesity and Related Comorbidities

Abstract

Background:

There are now four FDA-approved anti-obesity medications (AOMs) for youth ≥12 years, which can be effective therapies to treat obesity and obesity-related comorbidities.

Objectives:

This study describes parent/guardian (caregiver) openness to using AOMs for adolescents with obesity and evaluates factors that may contribute to openness.

Methods:

Caregivers of adolescents aged 12–17 years were surveyed. Self-reported height, weight, demographic information, family, and personal history of obesity or obesity-related comorbidities were collected. Participants rated their openness to starting an AOM for their child for obesity alone or obesity-related comorbidities on a 7-point Likert scale. A Likert rating of less than 4 was considered “less open” versus 4–7 was considered “more open.”

Results:

A total of 344 participants completed the survey. Average openness toward AOM use for obesity as the only indication (as opposed to comorbid conditions) was 3.2 ± 1.74. Caregivers who were knowledgeable that the FDA-approved AOM use in adolescents had greater odds of being open to using these medications compared with caregivers who were not knowledgeable (odds ratio: 2.18; 95% confidence interval: 1.25–2.86).

Conclusions:

Caregivers reported openness to starting an AOM if they had prior knowledge of these medications, highlighting the need for family education on AOM use and indications.

Introduction

Pediatric obesity, defined as body mass index (BMI) ≥95th percentile for age and gender, is a serious, chronic, biologically-based disease.¹ Affecting about one in five US adolescents, pediatric obesity significantly increases the risk of conditions like type 2 diabetes (T2D), hypertension, and cardiovascular disease in both childhood and adulthood.^2–7 Dietary and behavioral modifications alone often do not result in significant or sustained BMI reduction in adolescents with severe obesity or obesity-related comorbidities.^8,9 However, there are now four FDA-approved long-term anti-obesity medications (AOMs) for adolescents ≥12 years of age with obesity.^10–13 These AOMs can be effective adjuvant therapies to lifestyle and behavior modifications to manage both obesity and obesity-related comorbidities.^14–17 In January 2023, the American Academy of Pediatrics (AAP) updated their Clinical Practice Guidelines (CPGs) for pediatric obesity, which now included the use of AOMs.¹ The AAP currently recommends AOMs for adolescents with obesity who meet age, BMI, and other medical criteria while simultaneously treating obesity-related comorbidities, such as T2D or hypertension.¹ As three of the four FDA-approved AOMs have only been approved since 2020, there is a paucity of literature on acceptability or uptake of these medications by adolescents with obesity and their parents and guardians (caregivers). A recent survey-based study of caregivers of youth enrolled in a weight management program indicated 75% of participants were open to starting a medication for obesity for their child.¹⁸ In contrast, in a separate weight management clinic, when asking adolescents directly, only 25% selected “intensive therapy” (medically prescribed diets, bariatric surgery, or medications) as their first choice of therapy.¹⁹ However, both of these studies were completed prior to the release of the AAP guidelines and the subsequent media attention regarding pediatric obesity treatment that followed. In addition, these studies were only conducted in treatment-seeking patients and their caregivers and may not accurately capture the opinions of a more generalized population. The purpose of this cross-sectional survey of a general population of caregivers of adolescents (ages 12–17 years) was to (1) describe caregiver openness to AOM use for the treatment of obesity in adolescents and (2) assess what factors influence openness to AOM use (e.g., obesity-related health complications of the child, demographics and family history of obesity, obesity-related comorbidities, or AOM use).

Methods

Overview

This cross-sectional survey study was conducted at a large Midwestern state fair in August and September 2023 over 4 days.

Participants

All individuals who entered a university-affiliated research building on the fairgrounds could read information about study participation at the study booth.²⁰ Criteria for this study included parents, guardians, or primary caregivers of adolescents aged 12–17 years. Inclusion did not require adolescents to meet any specific BMI criteria or be present when the caregiver was completing the survey. Participants were enrolled as a convenience sample and on a “first come, first served” basis after they expressed interest in the study.

Measures

Participants completed a written survey in English via the Research Electronic Data Capture (REDCap) system.²¹ Participants age, gender, race, ethnicity, highest education level, and family or personal history of obesity or obesity-related comorbidities (hypertension, hyperlipidemia, T2D, prediabetes), and height and weight (to calculate BMI) were self-reported. The height and weight of children were not collected, as they did not have to be present for caregivers to participate in the study. In lieu of having a measured or estimated BMI for children, caregivers were asked if they had any concerns that their child was gaining too much weight or if they were ever told their child was at risk for specific health complications (high blood pressure, high cholesterol, T2D/prediabetes, excess weight/overweight). Caregiver or familial use of AOMs, and openness to using AOMs for obesity by itself or for obesity-related comorbidities in their child were reported. The survey also asked if caregivers knew that there were FDA-approved medications for pediatric obesity and if they had heard of these four FDA-approved medications (phentermine-topiramate [Qsymia®], liraglutide [Saxenda®], semaglutide [Wegovy®], or orlistat [Alli®/Xenical®], and phentermine monotherapy). AOMs were described as “weight-loss medications” or “medications for weight-loss” for clarity in the survey, as this term is often used to describe AOMs in the media. All collected data were inputted and stored in REDCap. The survey was created and reviewed by pediatric obesity medicine content experts. This project was determined to be exempt from IRB review. Informed written consent was obtained from all participants prior to survey completion.

Statistical Analysis

Means, standard deviations, medians, and ranges for continuous variables and counts and frequencies for categorical variables were calculated. To assess openness, the survey utilized a 1–7 Likert scale, with 1 representing “not open at all” and 7 representing “very open.” The analysis then utilized logistic regression with a binary variable outcome, in which Likert ratings of less than 4 were considered “less open” and 4–7 were considered “more open.” Caregiver BMI, knowledge that AOMs are FDA-approved for adolescents, and personal experience/history with AOMs, obesity, or weight-related health complications were evaluated for associations with caregiver openness of utilization of AOMs. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were reported. All p-values are two-sided and evaluated at the 0.05 level for statistical significance. Analyses were completed in R (R Core Team, 2023), version 4.3.2.²²

Results

A total of 344 caregivers with children aged 12–17 years completed the survey (Table 1). Ninety-four caregivers (27.6%) noted concerns that their child was gaining too much weight. Of these respondents, 75% (n = 69) reported that they brought this concern up with their child’s physician. Regarding baseline awareness of AOMs, 59.9% (n = 206) of respondents had not heard of phentermine, phentermine-topiramate (Qsymia), liraglutide (Saxenda), semaglutide (Wegovy), or orlistat (Alli/Xenical). Among these medications, semaglutide (Wegovy) was the most recognized, with 23.5% (n = 81) of respondents having heard of semaglutide. However, when asked if participants knew that there were FDA-approved medications for kids ≥12 years of age to help with weight loss, only 19.1% (n = 65) reported being knowledgeable of this fact. Among those who knew of FDA-approved medications for adolescents, the news was the most frequently cited source of information (n = 27, 41.5%) as opposed to family/friends, social media, their physician, or their child’s physician.

Table 1.

Guardian and Parent Characteristics and Responses to Select Survey Questions

Variable
Total participants, N	344
Race, N (%)
Asian	19 (5.6)
Black/African American	2 (0.6)
Native American	3 (1.0)
White	292 (86.9)
Multiracial	20 (5.9)
Missing	8
Ethnicity, N (%)
Latino/Hispanic	20 (6.0)
Non-Latino/Hispanic	311 (94.0)
Missing	13
Parent/guardian BMI, mean ± SD (missing N)	28.5 ± 6.2 (34)
Parent/guardian BMI, median (range)	27.4 (17.8, 48.2)
Education, N (%)
Some high school	5 (1.5)
High school/General Educational Development (GED)	37 (10.9)
College graduate	158 (46.5)
Post graduate	140 (41.2)
Missing	4
Household income, N (%)
$0–$24,999	7 (2.1)
$25,000–$49,999	26 (7.7)
$50,000–$74,999	36 (10.7)
$75,000+	269 (79.6)
Missing	6
Personal history (select all that apply), N (%)
High blood pressure	60 (17.4)
High cholesterol	63 (18.3)
Type 2 diabetes or prediabetes	27 (7.8)
Overweight or obesity	127 (36.9)
Family history (select all that apply, N (%)
High blood pressure	177 (51.5)
High cholesterol	138 (40.1)
Type 2 diabetes or prediabetes	119 (34.6)
Overweight or obesity	133 (38.7)
Concerns about any of your children gaining too much weight, N (%)
Yes	94 (27.6)
No	247 (72.4)
Missing	3
Been personally prescribed any FDA-approved medication for weight loss, N (%)
Yes	21 (6.1)
No	322 (93.9)
Missing	1
Know that medications are FDA-approved for kids, 12 years and older, to help with weight loss, N (%)
Yes	65 (19.1)
No	275 (80.9)
Missing	4

BMI, body mass index; FDA, food and drug administration.

Percentages are calculated out of nonmissing data.

On average, caregivers tended to be less open to the use of AOMs for weight loss as the only indication for use, with a mean Likert rating of 3.2 ± 1.74 (Fig. 1). However, caregivers’ ratings reflected higher levels of openness to AOMs if their child were to have a weight-related health complication, such as T2D (4.6 ± 1.5), high blood pressure (4.4 ± 1.5), or high cholesterol (4.3 ± 1.5). Caregivers, on average, agreed that weight influences the risk of the aforementioned health complications (average Likert rating of 5.4 ± 1.4 on a scale from 1—not likely to 7—very likely). However, openness to the use of medications specifically indicated to treat specific weight-related health complications (for example, using antihypertensive medication to treat high blood pressure) was higher than openness to the use of AOMs to treat these weight-related health complications (Fig. 1).

Figure 1.

Caregiver openness to starting medication for their child by indication for the medication.

Among the factors evaluated for association with openness, only caregiver prior knowledge of AOMs/“weight-loss medications” for adolescents was statistically significant (Table 2). Caregivers who knew that medications are FDA-approved for adolescents to help with weight loss had 2.18 times greater the odds [p = 0.007, 95% CI (1.25, 3.87)] of being more open to using AOMs compared with caregivers who were not knowledgeable. Other factors, including caregiver BMI, caregiver personal experience with AOMs, and caregiver personal experience/history of weight-related health complications, were not significantly associated with increased odds of openness to AOM use.

Table 2.

Estimated Odds of Caregiver Openness to Anti-Obesity Medication Use From Logistic Regression

	Odds ratio	95% Confidence interval	p-Value
Caregiver BMI category: Overweight/obesity vs. Not overweight/obesity	1.20	(0.74, 1.94)	0.46
Caregiver weight loss medication use: Yes vs. No	1.41	(0.58, 3.54)	0.45
Caregiver knowledge of FDA approval of weight-loss medication for adolescents: Yes vs. No	2.18	(1.25, 3.87)	0.007
Caregiver history of obesity-related comorbidities Yes vs. No	0.87	(0.57, 1.33)	0.52

BMI, body mass index; FDA, food and drug administration.

Discussion

This cross-sectional survey at a large Midwest state fair describes the opinions of a nontreatment-seeking, general population of caregivers regarding the use of AOMs for obesity and obesity-related comorbidities in adolescents. Of the factors assessed in this survey, caregiver knowledge of the FDA-approved medications to treat obesity in adolescents ≥12 years of age was statistically significantly associated with being more open to using these medications. While this does not necessarily guarantee that a family will ultimately choose to use a medication, it highlights the importance of educating patients and their families regarding the use of AOMs as a potential therapeutic option for their child. As noted previously, a survey of caregivers of youth referred to a pediatric weight management clinic showed that 75% of participants were open to medication use if their provider recommended it.¹⁸ Age, severity of obesity, family history of obesity, obesity-related comorbidities, or AOM use did not impact whether caregivers were open to AOM use in their child in an obesity-treatment-seeking population, which was a similar finding as our study of a nontreatment-seeking population.¹⁸

In our sample, over a quarter of caregivers reported they had voiced concern regarding their child’s weight gain to their child’s physician. This highlights a potential opportunity for patient education regarding obesity treatment within a primary care clinic. Even if primary care providers are not yet comfortable prescribing AOMs,²³ this survey would suggest that education regarding the availability of and indications for AOMs, may influence caregiver openness to the use AOMs for their child’s obesity. AOM education in the primary care setting may be a starting point for then referring patients for specialty weight management/obesity care. Although there is increasing utilization of these medications by pediatric specialty providers,^24,25 lack of clinical experience or knowledge of AOMs is a barrier to initiation of pharmacotherapy by primary care physicians.^23,24,26 With the publication of the new AAP guidelines and FDA approval of multiple medications in recent years, the landscape of obesity treatment may shift, even in the primary care setting, which highlights a need for ongoing education of pediatric providers in all settings.

The general trend of caregivers being more open to medications specifically indicated for weight-related health complications as opposed to using AOMs to treat obesity (the significant underlying contributing factor) is consistent with what is observed in clinical practice. Families may be more open to starting a medication that treats T2D rather than using AOMs that could result in improvement in obesity, which then, in turn, improves insulin resistance and T2D. Studies using AOMs to specifically treat obesity-related comorbidities exist in adults,²⁷ but more research is needed in pediatrics. This concept is particularly important when it comes to approaching patient education on AOMs and their utility in not only BMI reduction but also improvement in comorbid conditions.

Strengths

This study included a large sample size of 344 participants to assess caregiver openness to AOM use in children. It also focused on caregivers of children who are within the age range of using FDA-approved medications (12–17 years), which makes it more relevant to clinical practice as outlined by the AAP CPGs. In addition, this survey was completed in 2023, after the publication of the AAP CPGs and after approval of multiple AOMs in pediatrics, including semaglutide 2.4 mg weekly, which was approved in December 2022. Both events were associated with broad media coverage, yet only 19% of respondents were aware that AOMs were approved for weight loss in children this age. Finally, this survey was directed at the general population as opposed to focusing on treatment-seeking families.

Limitations

Although the research building for conducting this survey was open to all attending the state fair, it tended to draw a demographic of caregivers with high levels of educational attainment, limiting generalizability.²⁸ However, this is a group that may be expected to have a higher health literacy, and even among this sample, awareness of medication options was relatively low at 19%. This may be due, at least in part, to low levels of concern among participating parents regarding their child’s weight gain. The survey was also conducted in a state (Minnesota) with the lowest rate of adolescent obesity in the United States (12.1% in youth aged 10–17 years).²⁹ In addition, the majority of respondents identified as non-Hispanic White, whereas pediatric obesity disproportionately affects people who identify as Black/African American, Hispanic, or Native American.¹ Therefore, the data are limited, as respondents of this survey may not need to utilize anti-obesity pharmacotherapy for their children. However, they have the potential to influence the mindset or culture of those around them. The study did not ask for adolescent perspectives on AOM use, as they were not necessarily present for caregiver participation. It is possible that adolescent perspectives may differ from guardian perspectives, which could be a topic of future study. Finally, the survey may have been limited by participant interpretation of the questions and the hypothetical nature of openness. For example, regarding openness to the use of AOMs if their child carried extra weight, multiple (n = 6) free text responses cited the fact that their child does not carry extra weight as a reason why they would not use these medications.

Conclusions

In a general population of caregivers of adolescents with high levels of educational attainment and high socioeconomic status, the vast majority of participants did not know that AOMs are FDA-approved and available for youth with obesity. Education regarding AOM use in pediatric obesity is imperative, as caregivers were more open to starting an AOM if indicated and/or desired for their child if they had prior knowledge of these medications.

Impact Statement

This article highlights that educating caregivers regarding anti-obesity medications approved for pediatric obesity may help to increase openness to these medications. Helping families understand the link between obesity and obesity-related comorbidities may also help increase openness to AOMs.

Footnotes

Acknowledgments

The authors would like to acknowledge the participants, research coordinators, and staff at the University of Minnesota Center for Pediatric Obesity Medicine and Driven to Discover Program.

Authors’ Contributions

S.R., S.J., A.C.G., and M.O.B. collected the data. S.R., R.L.F., S.J., A.C.K.B., A.C.G., and M.O.B. analyzed the data and wrote the article.

Author Disclosure Statement

MOB receives research support from Dexcom and Abbot LLC.

Funding Information

M.O.B. received research support from Vivus Inc. (donated study drug), Abbot Inc., and Dexcom. This research was supported by K23DK129721 from the National Institute of Diabetes and Digestive and Kidney Diseases (M.O.B.). This research was also supported by the National Institutes of Health’s National Center for Advancing Translational Sciences under grant UM1TR004405.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health’s National Center for Advancing Translational Sciences.

References

Hampl

, Hassink

, Skinner

, et al. Clinical practice guideline for the evaluation and treatment of children and adolescents with obesity. Pediatrics, 2023; 151(2):e2022060640; doi: 10.1542/peds.2022-060640

Llewellyn

, Simmonds

, Owen

, et al. Childhood obesity as a predictor of morbidity in adulthood: A systematic review and meta-analysis. Obes Rev, 2016; 17(1):56–67; doi: 10.1111/obr.12316

Twig

, Yaniv

, Levine

, et al. Body-mass index in 2.3 million adolescents and cardiovascular death in adulthood. N Engl J Med, 2016; 374(25):2430–2440; doi: 10.1056/NEJMoa1503840

Abbasi

, Juszczyk

, van Jaarsveld

CHM

, et al. Body mass index and incident type 1 and type 2 diabetes in children and young adults: A retrospective cohort study. J Endocr Soc, 2017; 1(5):524–537; doi: 10.1210/js.2017-00044

Higgins

, Zemel

, Khoury

, et al. Visceral fat and arterial stiffness in youth with healthy weight, obesity, and type 2 diabetes. Pediatr Obes, 2022; 17(4):e12865; doi: 10.1111/ijpo.12865

Cali

, Caprio

. Ectopic fat deposition and the metabolic syndrome in obese children and adolescents. Horm Res, 2009; 71 (Suppl 1):2–7; doi: 10.1159/000178028

Schwimmer

, Deutsch

, Kahen

, et al. Prevalence of fatty liver in children and adolescents. Pediatrics, 2006; 118(4):1388–1393; doi: 10.1542/peds.2006-1212

Zeitler

, Hirst

, Pyle

, et al. TODAY Study Group. A clinical trial to maintain glycemic control in youth with type 2 diabetes. N Engl J Med, 2012; 366(24):2247–2256; doi: 10.1056/NEJMoa1109333

Danielsson

, Kowalski

, Ekblom

, et al. Response of severely obese children and adolescents to behavioral treatment. Arch Pediatr Adolesc Med, 2012; 166(12):1103–1108; doi: 10.1001/2013.jamapediatrics.319

10.

U.S. Food and Drug Administration. Highlights of prescribing information: Qsymia (phentermine and topiramate extended-release); 2013. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/nda/2012/022580Orig1s000LBL.pdf [Last accessed: November 12, 2024].

11.

Bacha

. FDA approval of GLP-1 receptor agonist (liraglutide) for use in children. Lancet Child Adolesc Health, 2019; 3(9):595–597; doi: 10.1016/S2352-4642(19)30236-6

12.

Novo Nordisk. FDA approves once-weekly Wegovy® injection for the treatment of obesity in teens aged 12 years and older; 2022. Available from: https://www.novonordisk-us.com/media/news-archive/news-details.html?id=151389 [Last accessed: November 12, 2024].

13.

U.S. Food and Drug Administration. Orlistat (marketed as Allli and Xenical) information; 2015. Available from: https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/orlistat-marketed-alli-and-xenical-information#:∼:text=Xenical%20(orlistat%20120mg)%20was%20approved,weight%20after%20prior%20weight%20loss [Last accessed: November 12, 2024].

14.

Kelly

, Bensignor

, Hsia

, et al. Phentermine/topiramate for the treatment of adolescent obesity. NEJM Evid, 2022; 1(6); doi: 10.1056/evidoa2200014

15.

Weghuber

, Barrett

, Barrientos-Pérez

, et al. STEP TEENS Investigators. Once-weekly semaglutide in adolescents with obesity. N Engl J Med, 2022; 387(24):2245–2257; doi: 10.1056/NEJMoa2208601

16.

Kelly

, Auerbach

, Barrientos-Perez

, et al. NN8022-4180 Trial Investigators. A randomized, controlled trial of liraglutide for adolescents with obesity. N Engl J Med, 2020; 382(22):2117–2128; doi: 10.1056/NEJMoa1916038

17.

Chanoine

, Hampl

, Jensen

, et al. Effect of orlistat on weight and body composition in obese adolescents: A randomized controlled trial. JAMA, 2005; 293(23):2873–2883; doi: 10.1001/jama.293.23.2873

18.

Smith

, Hegedus

, Naguib

, et al. Parental perceptions of medication use for the treatment of obesity in youth. Child Obes, 2023; 19(6):428–433; doi: 10.1089/chi.2022.0088

19.

Suarez

, Skinner

, Truong

, et al. Advanced obesity treatment selection among adolescents in a pediatric weight management program. Child Obes, 2022; 18(4):237–245; doi: 10.1089/chi.2021.0190

20.

Demerath

, Spector

. Driven to discover research facility at the Minnesota state fair: 2023. Annual report; 2023. Available from: http://d2d.umn.edu/wp-content/uploads/2023/11/2023-Annual-Report.pdf [Last accessed: November 12, 2024].

21.

Harris

, Taylor

, Thielke

, et al. Research Electronic Data Capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform, 2009; 42(2):377–381; doi: 10.1016/j.jbi.2008.08.010

22.

Team

, C . R: A language and environment for statistical computing. R Foundation for Statistical Computing. Vienna, Australia; 2024. Available from: https://www.r-project.org/ [Last accessed: November 12, 2024].

23.

Chivate

, Schoemer

, Ragavan

, et al. Primary care perspectives on prescribing anti-obesity medication for adolescents. Pediatr Obes, 2024; 19(8):e13146; doi: 10.1111/ijpo.13146

24.

Borzutzky

, King

, Fox

, et al. Trends in prescribing anti-obesity pharmacotherapy for paediatric weight management: Data from the power work group. Pediatr Obes, 2021; 16(1):e12701; doi: 10.1111/ijpo.12701

25.

Bensignor

, Wolf

, Rudser

, et al. Glucagon-like peptide-1 receptor agonist prescribing patterns in adolescents with type 2 diabetes. Diabetes Obes Metab, 2022; 24(7):1380–1384; doi: 10.1111/dom.14681

26.

Gourgari

, Huerta-Saenz

, Tonyushkina

, et al. Use of glucagon-like peptide-1 receptor agonists for pediatric patients with obesity and diabetes: The providers’ perspectives. Pediatr Diabetes, 2021; 22(6):872–875; doi: 10.1111/pedi.13234

27.

Lingvay

, Sumithran

, Cohen

, et al. Obesity management as a primary treatment goal for type 2 diabetes: Time to reframe the conversation. Lancet, 2022; 399(10322):394–405; doi: 10.1016/S0140-6736(21)01919-X

28.

University of Minnesota School of Public Health. D2D participant demographics; 2021: Available from: http://d2d.umn.edu/wp-content/uploads/2021/10/D2D_Demographics_2015-19.pdf [Last accessed: November 12, 2024].

29.

Robert Wood Johnson Foundation. State of childhood obesity: Ages 10-17; 2024. Available from: https://stateofchildhoodobesity.org/demographic-data/ages-10-17/ [Last accessed: November 12, 2024].