GLP-1 Receptor Agonists for Treatment of Pediatric Obesity: Behavioral Health Considerations

Abstract

Background:

Despite the rapid increase in glucagon-like peptide-1 receptor agonist (GLP-1) use for management of weight among adolescents (ages 12–18 years), there is limited guidance on associated behavioral health considerations. Adolescents on GLP-1 therapy represent a potentially vulnerable population at risk of experiencing medical and psychosocial effects of obesity and comorbidities, as well as side effects and behavioral implications of the medications.

Method:

This perspective discusses behavioral and psychosocial considerations for adolescents seeking GLP-1s. The limited and developing literature on the use of GLP-1s for pediatric obesity treatment was reviewed to evaluate key aspects of psychosocial functioning and health behavior engagement and to stimulate discussion, research, clinical innovation, and advocacy to support best practices for youth seeking GLP-1s to address weight concerns.

Results:

There is currently sparse research on the effects of GLP-1s on adolescents’ psychosocial functioning. In the context of clinical practice, it may be important to assess for symptoms of eating disorders/disordered eating behaviors, mood instability, and general psychosocial functioning as well as quality of life, social support, health behaviors, and readiness to change prior to the initiation of and throughout the course of GLP-1 treatment.

Conclusions:

This perspective serves as a call to action for research and clinical innovation to address the psychosocial effects of GLP-1s on adolescents. Screening, monitoring, and future research will be key to ensuring safe and effective use of GLP-1 therapy as well as optimal psychosocial outcomes for youth utilizing GLP-1 medications for obesity treatment.

Introduction

Pediatric obesity, a chronic health condition affecting almost 20% of youth in the United States, is projected to double in prevalence by 2050.^1,2 Multiple treatment approaches along a spectrum of weight-neutral to weight-focused have been posited to address the associated adverse physiological and psychosocial outcomes.³ While traditional obesity treatment tends to center on behavioral lifestyle modifications, the resulting body weight reduction is often modest and short-lived and may not lead to cardiometabolic health improvement.⁴ In light of these limitations, the American Academy of Pediatrics (AAP) recently released clinical practice guidelines recommending more aggressive treatment of pediatric obesity, including pharmacotherapy as an adjunct to intensive health behavior and lifestyle interventions.³ These new guidelines have been controversial, particularly those regarding the use of weight-loss medications in youth as young as 12 years. Major concerns include limited understanding of the long-term efficacy and safety of the medications for youth and the AAP guideline’s minimal reference to eating disorder (ED) screening and treatment referral.⁵

In 2023, Science named glucagon-like peptide-1 receptor agonists (GLP-1s) the Breakthrough of the Year.⁶ These drugs, which include liraglutide (Victoza and Saxenda), semaglutide (Ozempic and Wegovy), and tirzepatide (Mounjaro and Zepbound), stimulate insulin and inhibit glucagon release to help decrease blood sugar after food consumption.⁷ Originally developed as medications to treat type 2 diabetes, GLP-1s also promote weight loss by acting on the brain to increase feelings of satiety and slowing gastric emptying, thereby extending feelings of fullness. Wegovy and Saxenda are currently approved by the US Food and Drug Administration (FDA) for the treatment of obesity in adolescents ages 12 years and older, while Zepbound is approved to treat obesity in adults 18 years and older. Recent safety and efficacy findings suggest that Saxenda may soon be made available for children as young as 6 years old.⁸

Clinical practice guidelines highlight the importance of an interdisciplinary approach to treating pediatric obesity, with behavioral health being an integral part of the care team.^3,9,10 Behavioral health specialists (e.g., counselors, social workers, psychologists) have unique and specialized expertise to evaluate risks and benefits, potential contraindications, and behavioral barriers prior to prescribing GLP-1s and to support safe and effective use after these medications are prescribed.^11,12 Given the developmental and emotional stages that characterize childhood and adolescence, behavioral health specialists may also contribute strategies for adherence, addressing psychological well-being, and facilitating incorporation of healthy lifestyle behaviors within a family-based approach. Despite increased integration of behavioral health within pediatric health care settings, however, gaps in behavioral health support persist.^13,14

The popularity and early signs of effectiveness of GLP-1s likely will evince increasing volumes of child and adolescent patients considering weight-loss medications, many of whom will not be seen in an interdisciplinary weight management setting. To initiate and encourage discussions and research on best practices for all youth seeking GLP-1s for weight concerns, regardless of access to behavioral health support, the present perspective piece examines the limited and developing literature on behavioral health considerations associated with GLP-1 use in pediatric populations and outlines key considerations for future clinical innovation, advocacy, and research.

Behavioral Health Considerations and GLP-1s

Individual- and family-level health behavior changes are foundational to pediatric obesity treatment.^15,16 Behavioral techniques such as motivational interviewing and cognitive behavior therapy can facilitate implementation and maintenance of behaviors more aligned with a healthy lifestyle (e.g., regular exercise, optimal sleep). Prior to intervention, however, evaluation of psychosocial factors provides essential insights to inform treatment planning.¹⁷ For example, extant literature recommends assessment of adverse childhood experiences and social determinants of health, which may illuminate issues of access to health resources such as nutritious foods and safe spaces for exercise.¹⁸ Similarly, gathering information on cultural and family dynamics can shed light on beliefs related to feeding, eating, and weight status as well as treatment adherence/concordance.^19,20 Finally, psychosocial assessments can provide key guidance regarding appropriateness of pediatric obesity treatment approaches based on individual factors.

Bariatric and metabolic surgery, available to adolescents with severe obesity, may offer important lessons and insights on psychosocial considerations associated with adjunctive approaches to pediatric weight management.^21,22 Many adolescent bariatric surgery candidates must undergo comprehensive psychosocial assessment prior to surgery.²³ While similar guidelines do not yet exist in the case of prescribing GLP-1s, it may be important to assess motivation or readiness to engage in behavior change as well as screen for psychosocial factors that may facilitate or hinder change. Additional behavioral health factors to consider prior to the initiation of GLP-1 treatment and monitor throughout treatment include disordered eating behaviors, body image, depression, anxiety, quality of life, social support, and weight stigma.^24,25 While there is currently insufficient evidence to recommend specific screening or assessment protocols, Table 1 provides an overview of screening options as well as future directions for clinical and research innovations in GLP-1 treatment for pediatric obesity.

Table 1.

Psychosocial Considerations and Future Directions in GLP-1 Treatment for Pediatric Obesity

Psychosocial factor	Potential impact on GLP-1 treatment	Recommended screening/monitoring	Future research/clinical innovation
Disordered eating behaviors	Can impede weight loss efforts, exacerbate existing eating disorders, influence medication adherence	Pre-initiation: Eating disorder screening (e.g., EDE-Q, EAT-26) Ongoing: Monitor for changes in eating patterns, weight fluctuations, and related behaviors	Develop tailored interventions for patients with disordered eating who are prescribed GLP-1s. Explore the efficacy of combining GLP-1 treatment with specific psychological therapies (e.g., CBT-e, DBT).
Body image	Can lead to unhealthy weight loss behaviors, body dissatisfaction, and decreased self-esteem, impacting treatment adherence	Preinitiation: Assess body image concerns and body dysmorphia Ongoing: Monitor for changes in body image, self-perception, and related distress	Investigate the impact of GLP-1-induced weight loss on body image. Develop interventions to promote body positivity and resilience among youth prescribed GLP-1s.
Depression	Can affect motivation, treatment adherence, and overall well-being. May be exacerbated or improved with weight loss	Preinitiation: Standardized depression screening (e.g., PHQ-9) Ongoing: Monitor mood, assess for suicidal ideation, and provide support	Explore the relationship between GLP-1s, weight loss, and depressive symptoms. Investigate the benefits of integrating mental health services into GLP-1 treatment programs.
Anxiety	Can affect treatment adherence and may be exacerbated by weight loss or changes in body composition	Preinitiation: Anxiety screening (e.g., GAD-7) Ongoing: Monitor anxiety levels and provide support	Research the effect of GLP-1s on anxiety symptoms. Develop strategies to manage anxiety related to treatment and weight changes.
Health-related quality of life	Can be positively or negatively affected by weight loss and changes in health status	Preinitiation: Assess baseline quality of life (e.g., IWQoL—Kids) Ongoing: Monitor changes in quality of life throughout treatment	Investigate the long-term effects of GLP-1 treatment on quality of life. Develop interventions to maximize HRQoL improvements.
Social support	Lack of support can hinder treatment adherence and make behavior change more difficult.	Preinitiation: Assess the patient’s social support network Ongoing: Encourage building support systems and provide resources	Explore the role of social support in GLP-1 treatment outcomes. Develop programs to enhance social support for adolescent patients.
Weight stigma	Can negatively affect self-esteem, motivation, and treatment adherence	Preinitiation: Assess experiences of weight stigma (e.g., POTS) Ongoing: Provide a supportive and nonstigmatizing environment	Develop interventions to address internalized weight stigma in patients receiving GLP-1 therapy. Continue to explore ways to reduce weight stigma in health care settings.

GLP-1, glucagon-like peptide-1 receptor agonist; EDE-Q, Eating Disorder Examination Questionnaire²⁶; EAT-26, Eating Attitudes Test²⁷; PHQ-9, Patient Health Questionnaire²⁸; GAD-7, Generalized Anxiety Disorder 7-Item²⁹; HRQoL, Health-Related Quality of Life; IWQoL—Kids, Impact of Weight on Quality of Life—Kids³⁰; CBT-e, enhanced cognitive behavior therapy (transdiagnostic psychological treatment for eating disorders)³¹; DBT, dialectical behavior therapy.³²

Eating Disorders and Body Image

The co-occurrence of obesity and EDs among youth is an expanding area of clinical research.³³ ED risk factors, such as body dissatisfaction, mood disturbance, and unhealthful weight control behaviors (e.g., following rigid dietary rules, skipping meals to control weight/shape, eating to regulate emotions), are commonly reported among youth with obesity, thereby highlighting the importance of assessment of EDs (e.g., binge ED, [atypical] anorexia nervosa, bulimia nervosa, avoidant/restrictive food intake disorder [ARFID], and other specified feeding or eating disorder) in pediatric weight management settings.^34,35 Even when youth do not meet full diagnostic criteria for EDs, it is important to assess for disordered eating behaviors (e.g., dietary restriction or not responding to hunger/fullness cues to change weight/shape, rigidity around following dietary rules, preoccupation with food/weight/body image) that may reflect subclinical presentations of EDs. When youth present as being “picky eaters” (e.g., limited dietary variety lacking in fruits and vegetables, diet high in processed foods with low nutritional value), it may be helpful to screen for symptoms of ARFID to ensure young patients will have sufficient nutrients while prescribed a GLP-1. Diagnostic conceptualizations can inform clinical recommendations for adolescents seeking weight loss while engaging in disordered eating behaviors. While research suggests that structured and supervised weight management is likely to reduce ED risk for most adolescents, many studies have not included long-term follow-up, making it difficult to ascertain how disordered eating behaviors may manifest over time.³⁶

In accordance with standard clinical practice and to support informed decision-making, it is important that the potential risks and benefits of GLP-1 treatment for pediatric weight management be discussed with each patient and their family; though not examined in the context of weight management, preliminary literature speculates that GLP-1s may cause, maintain, or worsen disordered eating symptoms.^37,38 Of note, the effects of GLP-1s on hunger, satiety, and gastric emptying can decrease the frequency or regularity of eating,⁷ which could lend to purposeful, prolonged restriction to modify body size/shape. Likewise, anticipated side effects, including gastrointestinal distress and nausea, may also lead to food aversion and decreased interest in eating.^39,40 Such unintentional restrictions may be risk factors for EDs or disordered eating behaviors among youth. Prescribers are encouraged to screen for EDs or disordered eating behaviors prior to prescribing and monitor for onset of disordered eating behaviors after initiation of a GLP-1.⁴¹ Collaboration with behavioral health specialists, if available, can support nuanced assessment and monitoring of eating behaviors as well as shared decision-making regarding medication management. This interdisciplinary approach may promote safer and more effective use of these medications.

Depression and Anxiety

Although the FDA requires a warning on Saxenda and Wegovy regarding risk for depression and suicidal thoughts, no causal links have been reported.⁴² In fact, the Semaglutide Treatment Effect in People with Obesity (STEP) TEENS trial, in which adolescents with obesity were randomly assigned to receive semaglutide or placebo, demonstrated no group differences on measures of depression or suicide risk.⁴ Nevertheless, the risk of psychosocial concerns, such as depression, anxiety, social and peer difficulties, and weight-based bullying/teasing, is well-documented among youth with obesity.^25,43 These youth are also more likely to experience lower self-esteem and greater body dissatisfaction, furthering their risk of experiencing mental health concerns.⁴⁴ While research on the relation between GLP-1s and risk of suicidality is nascent, it is important to screen for mood and anxiety concerns and monitor these concerns throughout the course of treatment to make appropriate treatment referrals as needed.⁴⁵

Health-Related Quality of Life

Health-related quality of life (HRQoL), a gauge of physical, psychological, and social well-being and functioning, has demonstrated negative associations with pediatric obesity.⁴⁶ Youth with excess weight are more likely to report lower levels of physical functioning, social functioning, and body esteem.⁴⁷ HRQoL is also an important marker of improvement in weight management,⁴ as studies have shown that weight loss and associated health improvements are associated with improved quality of life.⁴⁸ In the STEP TEENS trial, weight-related quality of life, as measured by the Impact of Weight on Quality of Life—Kids,³⁰ was improved in the semaglutide group; this result was a function of improvement in physical comfort. It may be helpful to monitor HRQoL throughout the course of the GLP-1 treatment. It is important to note that weight/obesity-specific HRQoL measures may have greater sensitivity and specificity for use as outcome measures among pediatric patients being treated with GLP-1s.

Social Support

Youth with obesity are particularly susceptible to the influence of family, friends, and peers as well as more ambiguous entities such as social media.⁴³ Tremendous misinformation exists regarding diet, exercise, weight loss, and weight-loss medications. However, social support (or lack thereof) has been found to be an important moderator of such outcomes among children and adolescents. For instance, Ievers-Landis and colleagues found that family and friend discouragement of healthy eating is a predictor of lower body esteem and weight-related quality of life among youth with obesity.⁴⁹ This underscores the importance of assessing social support for adolescents considering GLP-1s as a treatment for obesity. In terms of monitoring, it is important to evaluate how youth taking GLP-1s for weight management are treated as their weight status changes over time. Extant literature suggests that individuals experience differential treatment at higher versus lower weights.⁵⁰ Youth may benefit from behavioral health support as they navigate societal responses to weight and body shape.

Weight Bias and Stigma

Defined as negative attitudes and interactions related to weight, weight bias is an unfortunate aspect of daily life for many youth with obesity that is associated with psychosocial distress, disordered eating, avoidance of health care services, physical inactivity, and weight gain.^50,51 Weight bias and stigma are perpetuated by the societal assumption that body weight is a matter of personal responsibility that should be controlled with diet and exercise.⁵² In addition to stigma, prejudice, and discrimination from peers, family members, media, and the health care system, youth may also experience internalized weight bias in which they apply negative weight-related stereotypes to themselves and engage in self-blame.⁵³

Increasing use of GLP-1s for weight management among adolescents along with the general controversy surrounding the use of these medications illuminates a potential double stigma. In the bariatric surgery literature, double stigma refers to patients who experience stigma related to both carrying excess weight and the decision to undergo weight-loss surgery.^54–56 Emerging literature suggests that individuals taking GLP-1s may be viewed as taking a “shortcut” or “easy way out” to weight loss.^11,57–60 Further complicating matters, if youth discontinue these medications, they are likely to regain weight,⁶¹ which may add to internalized weight bias and shame.^62–64 Youth who are on GLP-1s may experience additional weight stigma where they experience judgment from others about why they remain at an elevated weight despite being on a medication.^57,59

As public interest in GLP-1s rises, especially for cosmetic purposes and in popular media,⁶⁵ it becomes increasingly important to address bias and stigma experienced by patients and promulgated within the health care system. Some actionable steps include using weight-inclusive language, considering the social determinants of health that contribute to weight status, and emphasizing the importance of health and wellness over an exclusive focus on weight or weight loss.

Equity Issues

Demand for GLP-1s has been so great that until very recently, semaglutide and tirzepatide were included on the FDA’s drug shortage list.⁶⁶ While it seems that these medications are readily available to celebrities, social media personalities, and well-resourced individuals, youth most affected by excess weight may experience limited access.⁶⁷ Inequitable access to GLP-1s reflects the disproportionate burden of excess weight on youth from racial/ethnic minoritized and low-income backgrounds and highlights systemic factors that perpetuate poor health in these communities.^68,69 Fewer than a third of Medicaid policies cover this class of medications for weight loss, and out-of-pocket costs, estimated at more than $1400 per month, are prohibitive for most patients and families.^70,71

Beyond issues of affordability, implicit and explicit biases held by health care clinicians may influence inequitable prescribing of GLP-1s.⁷² Moreover, efficacy of GLP-1s depends on behavioral lifestyle management, as these medications work most effectively when youth have access to nutritious foods and safe exercise options.³ This presents a predicament in which certain youth lack access to both effective treatment options as well as the components of healthy lifestyle behaviors. Many payors discontinue coverage of GLP-1s if a certain threshold of weight loss is not achieved within the first months of treatment, which may be difficult without recommended dietary and exercise practices. This coverage strategy may also elevate the value of weight loss over the importance of behavioral lifestyle change. Nevertheless, research shows that individuals who discontinue GLP-1s may regain almost 70% of weight lost while taking the medication, and health improvements do not persist once the medication is stopped.⁶¹ These findings suggest that youth being prescribed GLP-1s may need to take this medication for the rest of their lives, although long-term effects are currently unknown. A more nuanced understanding of the psychosocial implications associated with GLP-1 use among youth as well as acknowledgment of limiting systemic barriers will inform advocacy efforts to make these medications more equitably accessible.

Conclusions

The meteoric increase in GLP-1 prescriptions for weight management among youth highlights myriad concerns that require further study.⁷³ Foremost, there is limited research on the long-term effects and implications of GLP-1 treatment, and it is currently unknown how helpful and/or harmful GLP-1s may be for youth over time. Given the complexity of behavioral health concerns related to pediatric obesity, a proactive approach⁷⁴ is warranted to illuminate and elucidate the nuanced psychosocial implications associated with GLP-1 therapy among youth. Clinicians, researchers, and advocates are encouraged to examine how factors such as intensive behavioral health treatment behaviors (e.g., eating behaviors, sleep patterns, physical activities), psychosocial functioning (e.g., stress management, emotion regulation, self-acceptance, body acceptance), psychiatric comorbidities (including EDs), and systemic barriers overlay the rapidly evolving weight-loss medication landscape for pediatric patients and their families. As future research and clinical protocols are developed to better understand the behavioral considerations over the course of GLP-1 treatment, it will be important to maintain a focus on health behaviors beyond sole emphasis on weight or weight loss to avoid inadvertent reinforcement of weight stigma.

Impact Statement

This perspective examines the limited and developing literature on behavioral health considerations associated with glucagon-like peptide-1 receptor agonist (GLP-1) use in pediatric populations and outlines key psychosocial and behavioral considerations for safe and effective use of GLP-1 treatments in youth as well as future clinical innovation, research, and advocacy.

Informed Consent Statement

An informed consent statement is not applicable because there were no human subjects; this article is based exclusively on published literature.

Authors’ Contributions

G.B.J.: Conceptualization, writing—original draft, writing—review and editing. A.E.: Writing—original draft. C.E.I.-L.: Writing—original draft. E.C.: Writing—original draft. K.G.: Writing—original draft. M.S.: Writing—original draft. E.T.B.: Conceptualization, supervision, writing—original draft, writing—review and editing.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No external or intramural funding was received.