Pediatric Metabolic and Bariatric Surgery and Antiobesity Medications: Weighing Efficacy, Risks, and Future Directions

Obesity and obesity-related comorbid conditions are growing health care concerns among pediatric patients. Weight management has not traditionally been part of the scope of pediatric medical education and practice. However, over the last 2 decades, as the prevalence of obesity and severe obesity among children has risen significantly, the need for pediatric-specific weight management expertise has become clear. This expertise among pediatricians, obesity medicine specialists, pediatric surgeons, and bariatric surgical specialists continues to develop in the setting of rapidly emerging and expanding pharmacologic options for weight management. Although metabolic and bariatric surgery (MBS) has proven to be an effective strategy for weight loss in pediatric patients with severe obesity, some patients do not wish to undergo surgery. Among those who do undergo MBS, some fail to achieve adequate weight loss with MBS. As next-generation antiobesity medications (AOMs) are being developed, many questions are emerging about the integration and timing of their use among patients who are interested in MBS. This review focuses on what is known regarding the use of AOM in the management of severe obesity in pediatric patients who are also eligible for surgical treatment.

Epidemiology of Obesity in Childhood

Obesity in pediatric patients is defined as a body mass index (BMI) at or above the 95th percentile for age and gender. The Centers for Disease Control and Prevention has reported that among children in the United States who are 2–19 years of age, 19.7%, approximately 14.7 million children, have obesity.¹ The Centers for Disease Control and Prevention has identified age, race, ethnicity, and household income as significant factors affecting the prevalence of obesity. Among age groups, adolescent patients (aged 12–19 years) have the highest prevalence of obesity at 22.2%. Among different ethnic groups, Hispanic children have the highest obesity prevalence at 28.2%. Considering household income, children in homes at 130% or less of the Federal Poverty Level (FPL) have the highest obesity prevalence at 25.8%.¹

More recently the Robert Wood Johnson Foundation published data from 2022 to 2023 among children aged 6–17 years, reporting an overall obesity prevalence in this age group of 17%.² Black and Hispanic children had the highest prevalence (23.5% and 22.2%, respectively). Regarding income, children in households below 100% of the FPL had the highest prevalence at 21.2%, juxtaposed to 10.4% among children in households at or above 400% of the FPL.

Globally, the World Health Organization cites an increase in obesity from 2% in 1990 to 8% in 2022 for children aged 5–19 years.³ Further, a meta-analysis of data reported between 2020 and 2023 spanning 154 countries and 45 890 555 pediatric patients reports an 8.5% prevalence of pediatric obesity, representing a 1.5-fold increase in the global pediatric obesity prevalence between the time ranges of 2000–2011 and 2012–2023.⁴

Distinct Features of Pediatric Obesity

There are several features of obesity in children that are discretely different from adult-onset obesity. Obesity has a significant effect on several systemic hormonal axes, which impact the onset and progression of puberty in children. The associations underlying the connection between obesity in children, early-onset insulin resistance, and precocious puberty have been well described.⁵ More specifically, central lipid signaling is likely to contribute to obesity-associated precocious puberty.⁶

Pediatric onset obesity is more consistently associated with genetic causes compared with adult-onset obesity. There are several genetic pathways that have been implicated as contributory to pediatric-onset obesity. One well-described monogenic obesity-related allele in children is loss of function of the melanocortin 4 receptor gene.^7–10 In contrast, adult-onset obesity is rarely linked to a mutation in a single gene or a distinct congenital syndrome.

There are also distinct comorbid conditions that are unique to pediatric obesity compared with adult-onset obesity. Children with obesity are at risk of orthopedic complications, including Blount’s disease and slipped capital femoral epiphysis. In children with obesity there is a high prevalence of obstructive sleep apnea (OSA), which can severely affect performance in school as well as quality of life. Finally, type 2 diabetes mellitus (T2DM) has been shown to progress more rapidly in children with obesity to insulin dependence, including greater risk and severity of diabetes-related complications such as retinopathy and renal impairment than in adults.¹¹

An additional difference between the pediatric and adult population lies in their response to treatment. Treatment with MBS results in greater remission of chronic obesity-related diseases and better weight loss with lower risk procedures in the pediatric population compared with adults. Although prior head-to-head comparisons have found greater prevalence of comorbidities in adults, such as hypertension, OSA, gastroesophageal reflux, T2DM, and dyslipidemia, adolescent patients tend to lose more weight and have better rates of resolution of these comorbidities.^12,13

Barriers to the Management of Pediatric Obesity

Unique challenges exist in the treatment of pediatric obesity. Obesity treatment and weight management are not traditionally part of pediatric training, thus there are limited pediatric providers with the scope of practice to provide expert care for the pediatric population with obesity.¹⁴ In a 2023 study of clinician-perceived barriers to pediatric obesity management, most pediatricians cited a lack of confidence in addressing obesity, limited knowledge of community resources, and unfamiliarity with recommended treatment options.¹⁵ However, even after a quality improvement initiative that successfully increased prescription of weight management follow-up by pediatricians for appropriate patients, only 40% of patients who were prescribed this follow-up actually attended,¹⁶ pointing to other barriers in pediatric obesity management.

Perhaps the most difficult barrier is the lack of uniform societal acceptance of obesity as a chronic disease. Pediatric obesity is often blamed on the parents and the child for failure to limit food intake or encourage a healthy lifestyle However, childhood obesity is influenced by a variety of factors including complex interactions between genetics, epigenetic modification, environmental exposures, and other factors starting in utero and continuing across the life course. Despite this, children and families suffering from obesity continue to be victims of stigmatization, bullying, and rampant teasing within society. Alternatively, but also detrimental to achieving appropriate care for children with obesity is the “health at all sizes” movement against the treatment of obesity that has recently gained traction through social media and other means. This runs counter to the overwhelming evidence that obesity shortens the lifespan of children, and to data showing that 70% of children presenting to an MBS program have insulin resistance and OSA.^17,18 The philosophy behind this social movement, while encouraging confidence and self-esteem, fails to recognize and support the importance of seeking critically important treatment for this life-limiting chronic disease. Braddock et al published a guide for pediatricians regarding weight stigma and bias in 2023.¹⁹ This review concluded that assessing for personal weight bias, using people first language, building a welcoming clinic environment, providing culturally appropriate messaging around obesity, screening for trauma and bullying, and providing more education on obesity bias and treatment can help mitigate these stigmata.

Inequities in social drivers of health between children with and without obesity also pose barriers to effective weight management in children. Neighborhood characteristics such as limited access to safe outdoor spaces to play and exercise, limited access to public transportation to get to a gym or doctors’ appointments, and limited access to healthy food options are associated with higher childhood obesity prevalence.^20–22 Furthermore, household nutritional practices, such as breakfast skipping and limited family exercise, may impede successful weight management.²³

Within the health care system, there are also barriers to pediatric obesity care. There are often exclusions in insurance coverage for effective treatments of obesity for children under 18 years of age.²⁴ Prior authorizations for MBS and AOMs are required, frequently denied, and take significant administrative resources and time to pursue.²⁵ Medicaid, which is the major insurer of children, does not cover glucagon-like peptide-1 receptor agonists (GLP1-RAs) or MBS in many states,^24,26,27 leading to delays or inadequate treatment of obesity in this population. Where insurance coverage may exist, reimbursement rates for pediatric obesity care are poor and the time inadequate to address obesity during clinic visits,²⁸ such that primary care pediatricians are faced with significant barriers to initiating obesity care.

Finally, there are currently not enough dedicated pediatric obesity treatment centers that offer AOMs and MBS. In fact, most states do not have any comprehensive pediatric obesity treatment center, most centers offer only AOMs or only MBS, and wait times to be seen can be 2–12 months.^29–31 The 2023 American Academy of Pediatrics (AAP) Clinical Practice Guidelines for pediatric obesity recommend referral to a comprehensive pediatric obesity center for children with severe obesity. However, this recommendation cannot be followed in many parts of the country.³² Even among pediatric hospitals across the country, only a minority have comprehensive pediatric obesity treatment centers that offer both AOMs and MBS. The inability for pediatricians to refer patients for comprehensive care due to underfunding and lack of centers leads to delay and/or limited care for children with severe obesity.

The recent landscape shows promise for future advances in pediatric obesity care. Over the last 5 years, there has been a significant increase in the number of publications and funding for research addressing pediatric obesity.³³ Some of these studies focus on the efficacy of novel strategies to achieve improved care for obesity in children.^34–36 Others focus on further elucidating the genetic and epigenetic basis of early onset obesity.^37,38 Finally, there is an increasing body of literature that addresses safe and effective integration of MBS and AOMs into pediatric obesity care.^39,40

MBS in Management of Pediatric Obesity

The use of MBS is well-established as safe and effective treatment for severe obesity in the pediatric population.⁴¹ The American Society of Metabolic and Bariatric Surgery Pediatric Guidelines and the AAP policy statement recommend the use of MBS, in the form of Laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB) in children with a BMI >120% of the 95th percentile with an obesity-related comorbidity or in children with a BMI >140% of the 95th percentile.^32,42 This recommendation is due to consistent data in the literature demonstrating long-term weight loss and improvement in obesity related comorbidities for this population. For example, the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study was a large pediatric prospective, longitudinal, observational study across five institutions which studied the short- and long-term outcomes of 260 adolescents undergoing MBS.^41,43 At 3 years after surgery, mean weight had decreased by 28% in patients who underwent RYGB and by 26% in those who underwent sleeve gastrectomy.⁴³ This work demonstrated sustained weight loss at 10 years, with an average decrease in BMI of 20.6% for RYGB and 19.2% after sleeve gastrectomy. The sleeve gastrectomy also has the advantage of future operative potential; if patients do not respond or regain weight after a sleeve gastrectomy, it is possible to convert a sleeve to a gastric bypass, or biliopancreatic diversion with duodenal switch.

These findings are also notable in that weight loss outcomes were similar between RYGB and sleeve gastrectomy (Table I). In contrast, in the adult population, observational studies have reported 5-year percent total weight loss outcomes of 25.5% for RYGB compared with 18.8% for sleeve gastrectomy.⁴⁴ Weight loss outcomes are also better in adolescents than adults, with percent weight loss at 1 year averaging approximately 24% in adults compared with 30% in adolescents in a single institutional comparison.⁴⁵ This study, as well as Teen-LABS, additionally noted improvement and resolution of obesity related comorbidities at 10 years, including T2DM (55% remission), hypertension (57% remission), and dyslipidemia (54% remission) based on Teen-LABS data.⁴¹ These rates are significantly higher than those observed in adults, with remission rates of 12%−18% for T2DM in the adult population.⁴⁶

Table I.

Comparison of Sleeve Gastrectomy and Roux-en-Y Gastric Bypass in Children with Obesity

MBS procedure	Average decrease in BMI	Surgery length	Hospital length of stay	Complications	Resolution of comorbidities	Vitamin/Nutrient deficiency
Sleeve gastrectomy	19.2%				=
RYGB	20.6%				=

Based on Teen-LABS data at 10 years after surgery.⁴¹

A study of the largest cohort of adolescents undergoing pediatric MBS reported outcomes of 2504 pediatric patients undergoing sleeve gastrectomy.⁴⁷ This study showed sustained weight loss, with 70% excess weight loss at 10 years, comorbidity resolution of 72% for T2DM, 58% for hypertension, and 57% for dyslipidemia. In addition to these excellent outcomes, adverse event rates were around 1%, with 27 adverse events noted, which were predominantly prolonged nausea and vomiting. This study also validated the concept that despite weight loss, vertical growth velocity is not impacted in children/adolescents undergoing MBS.

Although adverse events are low, there is a risk of vitamin/nutrient deficiency without proper supplementation and follow-up. In a 3-year follow-up of the Teen-LABS cohort, low ferritin levels were found in 57% of patients, and 8% of patients had a vitamin B12 deficiency.⁴³ Vitamin A deficiencies were found in 16% of patients who underwent gastric bypass (compared with 6% at baseline prior to surgery). At 10 years following surgery, vitamin deficiencies were significantly lower in patients following sleeve gastrectomy vs those undergoing gastric bypass.⁴¹ This underlines the importance of close follow-up of adolescent patients after bariatric surgery, as well as the need for preoperative nutrition education and compliance with postoperative vitamins.

The most remarkable finding in the Teen-LABS data is that 51% of pediatric patients maintained 32.8% total body weight loss at 10 years postoperation and only 11% saw a total body weight gain of 7.1%.⁴¹ There was no predictor of which group a patient would fall into, including type of operation, comorbid conditions, or lifestyle habits. However, weight loss at 6 months after surgery did predict 10-year weight loss. This allows for early intervention in patients who are not responding to MBS with adequate weight loss.

In summary, MBS has been demonstrated to be a safe and effective for treatment of both obesity as well as the obesity-related comorbidities of T2DM, hypertension, and dyslipidemia. Given that these are chronic conditions that can cause significant morbidity, treating them at an early age has significant long-term benefits compared with delaying treatment to adulthood. Weight loss at 6 months can allow for early intervention in patients who are not responding adequately to MBS.

AOMs Management of Pediatric Obesity

Next generation AOMs have only recently been approved in children (liraglutide in 2021 and semaglutide in 2022) yet have shown promising results in the treatment of obesity. Traditional medications such as phentermine, topiramate, combination phentermine/topiramate, orlistat, and metformin offered some impact on weight loss, but are quickly being overtaken by GLP-1 RAs due to their larger impact on weight loss as well as their impact on obesity-related comorbidities of diabetes and prediabetes.^48–51 In addition, GLP-1 RA medications have been shown to improve metabolic-associated steatotic liver disease (MASLD) as well as cardiometabolic risk in adults.^52,53 The use of these medications in the United States is rapidly increasing; based on a database that encompasses 93.6% of United States pharmacies, between 2020 and 2023, the number of patients under 25 years of age dispensed a GLP1 RA increased from 8722 to 60,567.⁵⁴ GLP-1 RAs work to treat obesity and T2DM by decreasing gastric emptying and acting on targets in the central nervous system to promote satiety.⁵⁵ The common GLP-1 RAs used in children are detailed in Table II.

Table II.

Glucagon-like peptide-1 Receptor Agonists Used for Children with Obesity

Medication	Mechanism of action	Average %TBWL	Approval year in children	Administration schedule	Side effects
Liraglutide	GLP-1 receptor agonist	5%51	2021	Daily subcutaneous injection, start with 0.6 mg increase to maximum of 3 mg daily	Nausea, vomiting, diarrhea, constipation, gallstones33
Semaglutide	GLP-1 receptor agonist	16%49	2022	Weekly subcutaneous injection, start with 0.25 mg and increase up to 2.4 mg	Nausea, vomiting, diarrhea, constipation, gallstones, pancreatitis
Exenatide	GLP-1 receptor agonist	4%56	2021	Twice daily subcutaneous injection, start with 5mcg twice daily up to 10mcg twice daily	Nausea, vomiting, diarrhea
Tirzepatide	GLP-1 and GIP (glucose-dependent insulinotropic polypeptide) receptor agonist	Pending adolescent clinical trials 20.9% in adults57	Adults only currently, pending approval adolescents	Weekly subcutaneous injection, start with 2.5 mg and increase up to 15 mg	Nausea, vomiting, diarrhea, constipation, gallstones, pancreatitis

%TBWL, percent total body weight loss.

Liraglutide was approved in 2021 after publication of a randomized, double-blind, placebo-controlled 56-week trial including 125 patients in the treatment group and 126 in the control group.⁵¹ This study found an estimated 4.64%−5.31% reduction in BMI compared with placebo, with a subsequent rise in BMI after stopping the medication during their 26-week follow-up period. Around 65% of patients reported gastrointestinal adverse events and 2.4% of patients experienced a serious adverse event (postprocedural hemorrhage, myositis, and suicide).

Semaglutide, approved in 2022 for adolescents, has been shown to have better weight loss outcomes. In a randomized, double-blind, placebo-controlled trial comparing 180 patients, authors found that semaglutide resulted in a 16.1% reduction in BMI compared with 0.6% gain with placebo.⁴⁹ In this study, incidence of gastrointestinal adverse events was 62% with an 11% rate of serious adverse events, which included 3 patients with cholelithiasis, 2 with appendicitis, and 1 event of gastritis, cholecystitis, abdominal pain, vomiting, urinary retention, depression, COVID-19, sleep apnea syndrome, and abnormal hepatic function.

For many patients and their pediatricians, medications are far more acceptable than surgery for the treatment of obesity. These biases are cultural and historical and need to be addressed with better education regarding the improvement in quality of life, the significant weight loss, and the cost-effectiveness of MBS in youth.⁵⁵ Access to centers that offer MBS is limited, so often GLP-1RA may be the only treatment available. Response to medications and surgery is variable, however we do not know if preoperative use of GLP-1RA medications will adversely affect the weight loss seen after surgery.^40,58–60 GLP-1 RAs offer a significant advancement in treatment of obesity for children and can be used alone or synergistically with surgery to help patients reach a healthy body weight.

A meta-analysis comparing 11 randomized controlled trials of GLP-1 RAs including 953 adolescent patients with overweight or obesity found that semaglutide had the greatest effect in reducing weight compared with placebo, followed by exenatide. Dulaglutide and liraglutide were effective at reducing hemoglobin A1c and fasting blood glucose respectively but had less of an impact on weight loss.⁵⁶ None of these four GLP-1 RAs had an increased risk of diarrhea, headache, and abdominal pain compared with placebo, but liraglutide was more likely to cause nausea, vomiting, hypoglycemia, and injection-site reactions compared with placebo.

It is important to note that obesity is a chronic condition, and based on adult literature, patients must continue to take GLP-1 RAs even after weight loss has been achieved, or weight is likely to be regained.⁶¹ In addition, the response to medications is variable, although maximum total body weight loss is higher with GLP-1 RAs compared with older medications. Despite the efficacy of these treatments, some patients with severe obesity may never be able to reach a healthy body weight with GLP-1 RA treatment or MBS treatment alone, and may need a combination of therapies over their lifetime.

Side effects of GLP-1RAs are typically gastrointestinal in nature, and include nausea, vomiting, diarrhea, constipation, and gallstones.⁵⁶ Rare possible complications include development of medullary thyroid cancer in patients with MEN type 2. However, the long-term side effects are not yet known given the recent approval of these medications in this age group.

GLP-1 RAs are high-cost medications that can be difficult to obtain (due to variations in insurance coverage, high co-pay, and high demand leading to low availability).^62,63 Cost effectiveness analyses in adults have found that bariatric surgery is more cost effective than GLP-1 RAs.^64,65 In one study, authors estimated that a LSG costs approximately $15,000 and a RGYB $18,000, and monthly cost of a GLP-1 RA is approximately $1300. Thus within 9 months a sleeve gastrectomy “breaks even” with the cost of a GLP-1 RA, and within 12 months a RYGB will.⁶³ A cost-effectiveness analysis that considered incremental cost-effectiveness ratios and quality-adjusted life years found that bariatric surgery has an incremental cost-effectiveness ratio of $91,032 over 5 years, making it cost-effective if the willingness to pay threshold is set at $100,000 per quality-adjusted life years.⁶⁵ Finally, recent work comparing MBS, MBS with the addition of GLP-1 RAs, and GLP-1 RAs alone found that MBS in combination with GLP-1 RA use is likely to be the most cost-effective strategy.⁶⁷

Although the exact prevalence of GLP-1 RA prescription and MBS among adolescents is unknown due to lack of a centralized database, a cross-sectional study analyzing claims from 17 million adults found that there was a 132.6% increase in patients prescribed GLP-1 RAs from the last 6 months of 2022 compared with the last 6 months of 2023.⁶⁸ This suggests use of GLP-1 RAs is widely increasing in adults, and pharmacy dispensing data have demonstrated the rapid increase in the adolescent and young adult patient as well since the approval of GLP1-RAs in the last 3 years for this population.⁶⁹ After the AAP recommended use of approved AOMs in the treatment of pediatric obesity in 2023, there was a large spike in the dispensing rates of GLP1-RAs.⁵⁴ Moreover, it is likely that as new pharmacologic agents are approved in the pediatric population, their use will continue to increase. Future considerations in pediatric patients who achieve excellent weight loss with GLP-1 RAs will be whether such patients can wean down on their GLP-1 RA dosing or discontinue GLP-1RAs and still maintain a reduced weight.

AOMs with MBS in Management of Pediatric Obesity

Several groups of pediatric patients with obesity appear to be benefitting from the most recent strategies that combine use of AOMs and MBS. Although there are not yet robust publications or data-driven practice guidelines, there are several scenarios in which a combination therapy approach of MBS and AOMs have been employed with good success.^40,70

Preoperative AOM therapy has been utilized in patients who are considered too high risk to undergo surgery due to extremes in BMI or extreme obesity-related comorbid conditions. These patients can often lose adequate weight with AOM therapy to render them acceptable candidates for MBS. Other patients start with AOM therapy due to a preference not to undergo surgery, and if they fail to achieve adequate weight loss, they proceed to MBS. Unfortunately, emerging observational data in adults suggest that preoperative GLP-1 RA medications may affect the 1-year weight loss following LSG, reducing the overall weight loss of surgery alone.^58,59 If this holds true, the timing of use of GLP1-RA medications may be best held until after surgery in patients who will clearly need both medications and surgery to reach a healthy weight, such as for those with a BMI >50 kg/m2 with comorbidities.

Postoperative AOM therapy is increasingly utilized for patients who undergo MBS and either do not reach their goal percent total body weight loss, who experience increasing hunger cues despite MBS, or who initially lose adequate weight postoperatively but then regain weight.⁴⁰ For these patients, prior to the advent of GLP-1 RAs, the main option was conversion from a LSG to a RYGB. GLP-1 RAs allow additional nonoperative options for patients with insufficient weight loss or weight regain following MBS.⁷⁰ Although optimal pharmacologic strategies following MBS in pediatric patients remains unclear, evidence from adult bariatric literature suggests that following weight regain after MBS, use of 3 or more AOMs is most effective in restoring goal weight.⁷⁰ Another study in adult bariatric patients demonstrated that those with known genetic obesity had a higher rate of weight regain following MBS and benefitted from initiation of postoperative AOM therapy.⁷¹ Given that pediatric-onset obesity is more often linked to known genetic alleles, and the Teen-LABS data showing that 49% of MBS patients will experience inadequate weight loss or weight regain at 10 years, the pediatric population with obesity may benefit from MBS with postoperative AOM therapy.⁴¹

New research from Vidmar et al from a pediatric multidisciplinary weight center has shed additional light on use of AOM therapy after MBS.⁴⁰ In a retrospective cohort study analyzing adolescent patients who were on preoperative AOM therapy, (including phentermine, topiramate, metformin, liraglutide, semaglutide, and tirzepatide) early reinitiation of medical therapy resulted in greater weight loss compared with patients who stopped AOMs after surgery. Patients were offered the opportunity to restart their medications at the 2-week postoperative visit, and those who were classified as “early initiators” had a 6.5% greater BMI reduction at 6 months compared with those who did not restart.

Future work will need to focus on selection of patients who stand to benefit most from MBS followed by AOM therapy, optimal timing of AOM therapy initiation in relation to surgery, and whether preoperative AOM therapy adversely affects the success of post-MBS weight loss.

Conclusions

Childhood obesity is an epidemic, and we have not yet identified the primary trigger for the development of obesity, nor do we have effective preventative measures. The combination of lifestyle therapy, MBS and AOMs can help patients with severe obesity reach a healthy body weight, resolve the significant comorbidities associated with obesity, reverse end organ injury caused by excess body fat, and minimize the risk of falling victim to bullying and social bias.⁷² Overall, achieving the goal of a healthy body weight in children with obesity results in not only significant improvements in quality of life, but also a longer life expectancy.⁷³

MBS can be performed safely in pediatric patients with significantly fewer complications than in older age groups.⁷⁴ Furthermore, the LSG has equivalent weight loss and comorbidity resolution to the RYGB in pediatric patients with lower risk of vitamin deficiency and 30-day complications. Finally, children with severe obesity have more aggressive T2DM, leading to early insulin dependence and onset of diabetes-related comorbidities and organ damage. They also have a high incidence of OSA, MASLD, and early cardiac mortality. All of these obesity-associated comorbidities show improvement or resolution following MBS Despite this, 11% of patients are likely to have continued weight gain following MBS but may benefit from adjunct therapy with AOMs.⁴¹

AOMs can be used by pediatricians as well pediatric obesity medicine specialists making them far more accessible to patients. In most patients with class I obesity and many with class II obesity, these medications will likely result in a healthy body weight. They have been shown to improve cardiometabolic risk, T2DM, and MASLD, but must continue to be taken to maintain these improvements.^52,53,61 Further, there remain significant barriers to their use in patients without insurance coverage, with high copays, and with potential side effects. Unfortunately, despite their demonstrated benefits, in the adult literature, 46%−65% of patients taking these meds will stop them in the first year.⁵⁹

The optimal timing and order of MBS and AOMs remain unknown. Future research will need to focus on the long-term outcomes of AOMs, as little is known about long-term effects in children. In addition, future inquiry will need to aim at determining whether preoperative AOM affects the risks and/or outcomes of MBS, as well as determine the optimal postoperative use of these medications. Finally, anecdotal observation has suggested that post-MBS use of GLP-1 RAs appears to have a synergistic effect leading to more significant weight loss than when either one is used alone.

Continued support for national policies that mandate insurance coverage for both MBS and AOMs in combination for pediatric patients is required to encourage the development of more multidisciplinary pediatric weight management programs to effectively address the growing pediatric obesity epidemic and combat stigma regarding obesity.

Glossary

AOM

Antiobesity medication

BMI

Body mass index

CDC

Centers for Disease Control and Prevention

FPL

Federal Poverty Level

GLP1-RA

Glucagon-like peptide-1 receptor agonist

LSG

Laparoscopic sleeve gastrectomy

MASLD

Metabolic-associated steatotic liver disease

MBS

Metabolic and bariatric surgery

OSA

Obstructive sleep apnea

RYGB

Roux-en-Y gastric bypass

T2DM

Type 2 diabetes mellitus

Teen-LABS

Teen-Longitudinal Assessment of Bariatric Surgery