Drugs to lose weight: the WHO defined how they can be used by children and adolescents

Weight loss drugs are a global craze. And as more and more focus is being placed on "recreational" use to lose a few kilos or in populations that do not require it, the World Health Organization (WHO) made a new warning: minors under 10 years old must not use them under any circumstances, and in adolescents with obesity they should only be indicated if they have more problems and if other interventions have failed. The WHO disseminated its new guidelines for managing obesity in children and adolescents this Wednesday. They are two extensive documents, with which the United Nations health agency wants to give tools to health professionals and public policy makers to face one of the great epidemics of this century. According to the WHO, 93.1 million children aged 5 to 14 and 80.6 million adolescents and young adults aged 15 to 24 live with obesity. And by 2030, this total figure will rise to 250 million, in a context where global obesity rates in the entire population have tripled since 1975. In Argentina, the latest official data says that 20.4% of children between 5 and 17 years old have obesity (in addition to 20.7% overweight). But that statistic is outdated: it corresponds to the 2nd National Nutrition and Health Survey, which was conducted seven years ago. The UN recommends in these new guidelines an interdisciplinary approach to try to stop the advance of this statistic, which has a direct impact on the increase of several non-communicable diseases such as diabetes, cardiovascular events, and cancer. And in this regard, it has a section for trendy drugs: GLP-1 analogs. These medications, for which semaglutide and tirzepatide are approved in Argentina, produce in the body the same effects as GLP-1, a hormone that is released when we eat and that regulates appetite, among other processes. In Argentina, semaglutide for obesity management is authorized from age 12 and tirzepatide, only from age 18. According to the UN, the use of these and other similar drugs is growing among adolescents. A team from the University of California analyzed a database of prescriptions from 93.6% of pharmacies in the United States and detected that between 2020 and 2023 the sale of GLP-1 analogs for adolescents increased by almost 600%, while the rest of the drugs fell by 3%. In the press conference where they presented the guidelines, Lawrence Grummer-Strawn, head of the WHO's Nutrition and Food Safety Unit, admitted that they are particularly concerned about these age groups because "if a GLP-1 or other medication is started very early in children, when does it stop? We really do not have evidence that this can be used as a temporary treatment and then switch to a diet later. And if we get children used to it from the beginning, we do not address the physical activity environment or dietary factors, but resort to a drug and this increases these costs throughout a very long life. Furthermore, we do not know what the long-term consequences of the side effects are." In the guide for adolescents, the WHO suggests that these drugs should be used between 10 and 19 years old only if the patient has obesity and complications related to this disease, such as type 2 diabetes, insulin resistance, uncontrolled hypertension, alterations in lipid metabolism, or mental health problems. In these cases, it is recommended only after a "structured and supervised program of multimodal lifestyle modification" has failed. This includes dietary, physical activity, and personalized behavioral interventions for at least six months. "Drugs must be prescribed in a multidisciplinary setting after a close evaluation of physical development and psychological stability, adherence to healthy diet and physical activity habits, along with strict monitoring of potential adverse effects and long-term follow-up," the report warns. However, this recommendation is "conditional" because the quality of the evidence is "low". The WHO explains that the findings on these treatments showed small to moderate benefits, but that the time followed for the patients was short to identify possible adverse effects, as the studies were short in duration and mostly in high-income countries. Regarding children under 10 years old, and also "conditional" due to the lack of sufficient studies in this population, the recommendation is more emphatic: no use of obesity medications in boys under 9 years old. "There is a lack of evidence both on the benefits and on the potential consequences of the different medications on normal growth, development, psychological parameters, and mental health," they highlight. In the case of children with obesity, the recommendation is a supervised plan that works on lifestyle, considering the age, gender, and general health status of the patient, as well as their sleep habits, sedentary patterns, cultural context, and the child's interests and preferences, and involves their parents or caregivers. The same is indicated in general for adolescents. "The field of pharmacotherapy for obesity management is evolving rapidly. New therapeutic options with different mechanisms of action, doses, routes of administration, and treatment durations are under investigation for adults and adolescents," anticipates the WHO. And it focuses on one of the fundamental topics of these therapies: their access. "The introduction of new weight loss drugs into the market can lower costs and improve availability, although costs may still be high for users and require the commitment of health services and payers. Effective multisectoral collaboration is required to create policies that sustain a continuous and accessible supply of drugs for obesity when they are needed," the documents emphasize. Also in the conference, Luz María De-Regil, director of the Department of Nutrition, highlighted that the guidelines have three key messages. "The first, the basis of obesity care for children and adolescents is support for healthy eating, physical activity, and behavioral change, with significant involvement of parents and caregivers. Second, for those under 10 years old, the WHO does not recommend medications for obesity, bariatric surgery, or weight loss devices. And third, for adolescents there are additional treatment options, but clearly under defined conditions," she summarized. How the treatment in Argentina Marianela Ackerman, nutritionist, diabetologist, and vice-president of the Argentine Society of Nutrition (SAN), explained to Clarín that in Argentina a patient aged 12 or older with a body mass index equal to or greater than the 95th percentile for age and sex can be a candidate for semaglutide. In adolescents, the treatment for obesity is different than in an adult "because we are treating a person who is still growing, with ongoing bone maturation and pubertal development. Any treatment must preserve development and adequate nutrition. That is why we do not indicate restrictive diets: the approach must be integral, interdisciplinary, and sustained over time." In children, a lot is worked on regarding food and eating behavior, that is, the relationship with food. And the role of the family is fundamental so that they can sustain the changes. The doctor also admits that the duration of treatment is one of the topics that must be discussed with adults when prescribing a medication. "When we use a drug, we should not think of it as a three-month treatment and stop it. We cannot state that an adolescent who starts with medication today necessarily has to receive it for their whole life because we do not have studies today that allow us to say that. We do know that when an effective treatment is stopped, there is an important tendency to regain weight, but it does not have to have to do with the medication itself but with a chronic disease in which the treatment works when it is carried out," the specialist assures. For her, it is at this point that the focus should be placed: on the fact that obesity is a chronic disease. And that when prescribing a drug to an adolescent "one must consider this perspective of long-term treatment, their growth, their preferences." Medication, she stresses, is always evaluated based on risks and benefits and is a tool that adds to all those required for the interdisciplinary approach to obesity, in which the patient is permanently reevaluated. "The question should be what it means to leave obesity without effective treatment during adolescence and for the patient to reach adulthood with the disease and probably more complications," she points out.