Lizzie is a 13-year-old with a great sense of humor.
She tells it like it is, especially to her Mom, Jackie, who admits to being a bit of an Almond Mom (the parent who is stuck in a weight-focused diet culture). Jackie leads a very healthy lifestyle and has never had to deal with being overweight. Jackie is different from other Moms I work with because she isn’t telling me that information because she doesn’t want to be affiliated with being overweight. She genuinely wants to help her daughter, and every action she takes to help she recognizes comes from her own experience.
Also, Lizzie is a very picky eater, and Jackie blames herself because she has accommodated the pickiness. She wants her to be happy and feels like a burger and fries for dinner is better than trying to force Lizzie to eat something she’s not going to touch and then binge on whatever processed foods are in the house later.
Lizzie also has insulin resistance, which hasn’t been diagnosed, and Jackie hadn’t heard of it until she found me on TikTok. She thought this made so much sense. “Obesity is hormonal. It’s not simply caloric.”
“We’ve tried everything from personal trainers and dietitians, gone low-carb, and even gone to specialists and functional medicine doctors. Lizzie’s labs showed creeping Hemoglobin A1c, cholesterol levels have always been off, and her doctor said she has fatty liver disease. I feel so ashamed and like the pediatrician keeps saying the same thing. Portion control and more exercise. I’m constantly in her lane when she’s eating and can see that she’s also started to eat in secret in her room.”
“My Mom gives me looks all the time if I go for seconds.”
“Lizzie, are you sure you want to eat that?”
Jackie is also starting to notice that Lizzie complains about her clothes not fitting and they are getting into arguments about it. Jackie feels like it’s more than Lizzie’s health that’s at stake. If their interactions keep going like they are, their relationship is at stake too.
Lizzie has a strong genetic predisposition for insulin resistance, type 2 diabetes, metabolic syndrome, and obesity on the paternal side. I reviewed prior laboratory studies that were indicative of insulin resistance. Her starting BMI was 32.5, and her waist circumference was 45 inches. On exam, Lizzie has acanthosis nigricans, abdominal obesity, striae, and acne.
The results of the STEP TEENS phase 3 trial of once-weekly subcutaneous semaglutide 2.4 mg (Wegovy) in adolescents aged 12 up to 18 years old with obesity are very promising.
Published in November 2022 in the NEJM, the study showed that patients who received semaglutide vs. placebo had greater reductions in body weight and improvements in waist circumference, A1c, lipids (except HDL cholesterol), and ALT. Quality of Life measures were better in the semaglutide group. Adverse gastrointestinal events were greater with semaglutide compared with placebo.
GLP-1 exerts its main effect by stimulating glucose-dependent insulin release from the pancreatic islets, slowing gastric emptying, inhibiting post-meal glucagon release, and reducing food intake.
GLP-1 RA medications work by reducing the appetite and feelings of hunger, slowing the release of food from the stomach, and increasing feelings of fullness after eating. Some, like tirzepatide, have the added action of “quieting the mind” or stopping food noise through receptors in the brain.
Along with nutrition, behavior, and physical activity, medication options were discussed. Lizzie met the criteria for Wegovy. It was an uphill battle to get the prior authorization, and then the appeal was approved through the pharmacy plan. Then, the national shortage of Wegovy starting doses created another daunting obstacle. Jackie called around to what seemed like 100 pharmacies to find the starting dose before she finally found a pharmacy that had it.
Lizzie tolerated the medication well with minimal side effects. Over the next few months the dose was titrated up to the maximum dose of 2.4mg. Her weight stayed the same.
First, I coached Lizzie and Jackie to manage disappointment and reset expectations.
Next, let’s reassess all causes, comorbidities, and contributing factors. I did another Review of Systems.
Is Lizzie a non-responder? Or is the medication working and just not showing up on the scale? Are there metabolic health improvements that can be measured?
Is the medication bioavailable? Does Lizzie have PCOS? Is Lizzie taking other medications that are contributing? Does she need a sleep study? What about binge or loss of control eating?
Lab studies showed marked improvement in metabolic biomarkers. Her fasting lipid panel and AST and ALT levels were normalized, and her HgbA1c had decreased. I considered other contributing factors and noted that her free testosterone level was elevated.
What changes had she made with her nutrition? She was eating 1300 calories a day, the same as before starting the medication. Her body was stuck in metabolic adaptation.
I told them about food’s thermogenic effects, and they became more intentional about balancing protein/fat/fiber. Lizzie started losing weight slowly over the next few months.
LLizzie’sBMI has gone from 32.5 to 27.5, and her waist circumference has decreased by three inches. I will see Lizzie for a follow-up telehealth visit in three months, and Jackie will provide updates in the interim.
GLP-1 RA medications, as approved by the FDA, may be a helpful adjunct in your adolescent patient’s treatment plan, but they require a holistic approach to metabolic health.
Karla Lester is a pediatrician, certified life and weight coach, and diplomate, American Board of Obesity Medicine. She is founder, IME Community, and can be reached on Twitter @DrKarlaA, TikTok, Instagram @ime_community, Facebook, and YouTube.
