Clinical Review & Education

JAMA | Review

Obesity in Adolescents
A Review
Aaron S. Kelly, PhD; Sarah C. Armstrong, MD; Marc P. Michalsky, MD, MBA; Claudia K. Fox, MD, MPH

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IMPORTANCE Obesity affects approximately 21% of US adolescents and is associated with CME at jamacmelookup.com
insulin resistance, hypertension, dyslipidemia, sleep disorders, depression, and
musculoskeletal problems. Obesity during adolescence has also been associated with an
increased risk of mortality from cardiovascular disease and type 2 diabetes in adulthood.

OBSERVATIONS Obesity in adolescents aged 12 to younger than 18 years is commonly defined as

a body mass index (BMI) at the 95th or greater age- and sex-adjusted percentile.
Comprehensive treatment in adolescents includes lifestyle modification therapy,
pharmacotherapy, and metabolic and bariatric surgery. Lifestyle modification therapy, which
includes dietary, physical activity, and behavioral counseling, is first-line treatment; as
monotherapy, lifestyle modification requires more than 26 contact hours over 1 year to elicit
approximately 3% mean BMI reduction. Newer antiobesity medications, such as liraglutide, Author Affiliations: Department of
semaglutide, and phentermine/topiramate, in combination with lifestyle modification therapy, Pediatrics and Center for Pediatric
Obesity Medicine, University of
can reduce mean BMI by approximately 5% to 17% at 1 year of treatment. Adverse effects vary, Minnesota Medical School,
but severe adverse events from these newer antiobesity medications are rare. Surgery Minneapolis (Kelly, Fox); Department
(Roux-en-Y gastric bypass and vertical sleeve gastrectomy) for severe adolescent obesity of Pediatrics, Department of
Population Health Sciences, Duke
(BMI ⱖ120% of the 95th percentile) reduces mean BMI by approximately 30% at 1 year. Minor
University, Durham, North Carolina
and major perioperative complications, such as reoperation and hospital readmission for (Armstrong); Duke Clinical Research
dehydration, are experienced by approximately 15% and 8% of patients, respectively. Institute, Duke Center for Childhood
Determining the long-term durability of all obesity treatments warrants future research. Obesity Research, Durham, North
Carolina (Armstrong); Department of
CONCLUSIONS AND RELEVANCE The prevalence of adolescent obesity is approximately 21% in Pediatric Surgery, Nationwide
Children’s Hospital and The Ohio
the US. Treatment options for adolescents with obesity include lifestyle modification therapy,
State University, College of Medicine,
pharmacotherapy, and metabolic and bariatric surgery. Intensive lifestyle modification Columbus (Michalsky).
therapy reduces BMI by approximately 3% while pharmacotherapy added to lifestyle Corresponding Author: Aaron S.
modification therapy can attain BMI reductions ranging from 5% to 17%. Surgery is the most Kelly, PhD, Center for Pediatric
effective intervention for adolescents with severe obesity and has been shown to achieve Obesity Medicine, Department of
Pediatrics, University of Minnesota
BMI reduction of approximately 30%.
Medical School, 717 Delaware St SE,
Room 370E, Minneapolis, MN 55414
JAMA. 2024;332(9):738-748. doi:10.1001/jama.2024.11809 ([email protected]).
Published online August 5, 2024. Section Editor: Kristin Walter, MD,
Deputy Editor.

O
besity is a disease characterized by excess body fat that gence of autonomy and independence. Advances in adolescent
impairs health.1 A body mass index (BMI, calculated as obesity treatments include US Food and Drug Administration (FDA)
weight in kilograms divided by height in meters squared) approval of 3 antiobesity medications since 2020.6-8 The American
at the 95th percentile or greater for age and sex based on standard- Academy of Pediatrics (AAP) published a Clinical Practice Guide-
ized growth curves is often used as a clinical screening tool to iden- line for the Evaluation and Treatment of Children and Adolescents
tify adolescents who may benefit from treatment.2 The prevalence With Obesity in 2023,2 which highlighted new themes regarding
of obesity in adolescents aged 12 to younger than 18 years old in the approach to management of obesity in adolescents (Box 1).
the US is approximately 21%.3,4 Obesity in adolescence strongly This Review summarizes the current evidence regarding the
predicts obesity in adulthood.5 Treatments for adolescent obesity epidemiology, pathophysiology, diagnosis, and treatment of ado-
include lifestyle modification therapy, pharmacotherapy, and meta- lescent obesity.
bolic and bariatric surgery (the prior terminology for surgery,
including weight loss surgery and bariatric surgery, has been
replaced by the term metabolic and bariatric surgery to acknowl-
Methods
edge the mechanisms of action of the surgical procedures). The
approach to treating obesity differs for adolescents compared with We searched PubMed for English-language articles published from
younger children or adults due to unique factors such as pubertal January 1, 2013, to April 1, 2024, including epidemiological, longitu-
development and psychosocial maturation including the emer- dinal, and cross-sectional studies, as well as randomized clinical trials,

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 Obesity in Adolescents: A Review Review Clinical Review & Education

comparative effectiveness studies, systematic reviews, meta-

analyses, narrative reviews, and clinical practice guidelines related Box 1. Contemporary Views of Adolescent Obesity From
to adolescent obesity. Additional studies were identified by review- the American Academy of Pediatrics Clinical Practice Guideline
ing reference lists from relevant articles. A total of 92 articles were for the Evaluation and Treatment of Children and Adolescents
With Obesity in 2023
selected for this review, consisting of 6 randomized clinical trials; 11
meta-analyses and systematic reviews; 38 epidemiological, longi- Parents and teenagers should not be blamed. Weight bias and
tudinal, population-based, and cross-sectional studies; 7 clinical stigma result from lack of understanding of the underlying
practice guidelines; 9 policy guidelines; and 21 narrative reviews. pathophysiology of obesity and lead to worse health outcomes.

Included articles were reviewed by the authors for quality and rel- Adolescent obesity is a chronic, progressive, and relapsing disease.
evance to a general medical audience and were prioritized based on The etiology of adolescent obesity is complex and multifactorial,
recent advances in the field. This review focuses on management including environmental, genetic, and psychosocial drivers.
of obesity; topics such as prevention of adolescent obesity were Obesity tracks strongly from adolescence to adulthood. “Watchful
deemed beyond the scope of this review. waiting” is no longer appropriate; treatment should be offered
immediately on diagnosis.
Treatment of adolescent obesity should be initiated as intensively
as possible; the entire spectrum of options should be considered.
Discussion Intensive health behavior and lifestyle therapy is required to attain
Epidemiology meaningful weight reduction.
The prevalence of obesity in US adolescents aged 12 to younger Multiple safe and effective antiobesity medications are available
than 18 years increased from 16.0% during 1999-2002 to 20.9% dur- for adolescents.
ing 2015-2018.3,4 During this time, the prevalence of severe obesity, Evidence supports the safety and long-term effectiveness of
defined as a BMI of 120% or greater of the 95th percentile or BMI metabolic and bariatric surgery in adolescents with severe obesity.
of 35 or greater 2,9 increased from 5.3% to 7.6% among US
adolescents.3,4 Obesity prevalence in the US differs by race and eth-
nicity, with higher prevalence in non-Hispanic Black (28%) and is also associated with a higher prevalence ratio (1.3 [95% CI, 1.2-
Mexican American (31%) adolescents as compared with non- 1.5]) of obesity among adolescents, with a 25.9% prevalence in food
Hispanic White adolescents (16%).4 Evidence suggests that social and insecure vs 19.5% prevalence in food secure participants, although
environmental factors, such as racism, trauma, poverty, and weight this association was not significant when controlling for race, eth-
stigma, may be associated with a higher prevalence of obesity.10-13 nicity, and income.19 Adverse childhood experiences, such as physi-
cal abuse, sexual abuse, or incarceration of a parent, also contrib-
Risk Factors ute to obesity risk. The accumulation of 4 or more adverse childhood
Risk factors for obesity in adolescence include genetic, environmen- experiences was associated with a 1.4- to 1.6-fold increase in risk for
tal, lifestyle, and social influences. Genetic risk is a major contributor; severe obesity in young adulthood (absolute rates not reported).20
twin studies have estimated the heritability of obesity to be be-
tween 40% and 70%.14 Polygenic (or “common”) obesity is associ- Pathophysiology
ated with hundreds of polymorphisms; advances in genomic sequenc- Obesity results from an imbalance between energy intake and ex-
ing have identified more than 750 loci that collectively account for 6% penditure leading to accumulation of excess body fat. Function-
of BMI variation.14 Current obesity in 1 or both parents correlates mod- altering gene variants, such as TMEM18, have been identified, which
estly with obesity by age 15 years (Pearson r = 0.29, P < .001),15 which regulate hunger, satiety, and energy.21 The pathophysiology of obe-
likely reflects both genetic and environmental risk. sity is characterized by dysregulated metabolism favoring positive en-
Several lifestyle behaviors and family structural factors are also ergy balance, intake that exceeds expenditure. Hormones such as
associated with obesity in adolescents. Adolescents who spend 2 ghrelin,leptin,peptideYY,gastricinhibitorypolypeptide,glucagon-like
hours or more per day in recreational screen time have an in- peptide 1 (GLP-1), pancreatic polypeptide, amylin, and cholecystoki-
creased risk (odds ratio, 1.67 [95% CI, 1.48-1.88]) of overweight or nin increase weight gain by influencing appetite, satiety, and food
obesity (absolute rates not reported).16 Short sleep duration is also palatability.22-24 Targetingthephysiologicalprocessespromotingbody
associated with higher BMI; in a systematic review and dose- fat storage, such as appetite, satiety, and cravings, may be an essen-
response meta-analysis of prospective cohort studies of children and tial component of effective obesity management.
adolescents, for every 1 hour per day additional increment in sleep
duration, the risk of overweight or obesity decreased by 21% (odds Clinical Presentation, Assessment, and Diagnosis
ratio, 0.79 [95% CI, 0.7-0.89]).17 The AAP recommends clinicians screen all adolescents for over-
Poverty is a risk factor for adolescent obesity; children who ex- weight and obesity using BMI as part of the annual well-child visit.2
perienced poverty before age 2 years were 2.3 times more likely to In 2022, the US Centers for Disease Control and Prevention (CDC)
have obesity at age 15.5 years (absolute rates not reported).18 Fac- released obesity-specific pediatric growth curves with updated BMI
tors that explain this association include high availability and low cost reference data through 2016 (https://www.cdc.gov/growthcharts/
of fast food and sugar-sweetened beverages, low neighborhood extended-bmi.htm). A BMI at or above the 85th percentile to
walkability, and household circumstances (eg, parental divorce, sub- less than the 95th percentile for age and sex is defined as overweight,
stance use) that cause stress and poor sleep.2 Food insecurity, de- BMI at or above the 95th percentile to less than 120% of the
fined as inadequate access to food or resources to purchase food, 95th percentile for age and sex is defined as class 1 obesity, BMI at

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 Clinical Review & Education Review Obesity in Adolescents: A Review

or above 120% of the 95th percentile (or BMI ⱖ35, whichever is ment (Figure). Evidence-based obesity treatment includes life-
lower) to less than 140% of the 95th percentile for age and sex is style modification, pharmacotherapy, and metabolic and bariatric
defined as class 2 severe obesity, and BMI at or above 140% of the surgery (Table 2).2,8,28,41-44 A stepped approach to care is no lon-
95th percentile for age and sex (or BMI ⱖ40, whichever is lower) is ger recommended; obesity becomes more severe and comorbidi-
defined as class 3 severe obesity.2 Recent criticisms of using BMI to ties accumulate over the adolescent years. Thus, adolescents should
guide obesity management include that it is unable to distinguish be offered obesity treatment at the time of diagnosis, and all medi-
between fat and fat-free mass, thus, is only an estimate of adiposity. cally indicated treatment options should be discussed with the pa-
While not a direct measure of adiposity, BMI is validated in diverse tient and caregivers using shared decision-making to create a treat-
US adolescents, is age- and sex-normed, and has moderate sensitivity ment plan.2 Box 2 addresses questions commonly asked by clinicians
(70%-80%) and high specificity (95%) for excess adiposity regarding adolescent obesity care.2,45,46
compared with reference standard dual-energy radiograph
absorptiometry. 25 BMI is also important in guiding additional Lifestyle Modification Therapy
screening for comorbidities. During adolescence, obesity is Lifestyle modification refers to changes in nutrition, physical activ-
associated with hypertension, metabolic dysfunction–associated ity, sleep, or other daily habits that are obesity risk factors to re-
steatotic liver disease, dyslipidemia, sleep disorders, musculoskeletal duce BMI and improve overall health. Lifestyle modification can be
problems, depression, anxiety, and eating disorders.2 Compared with individual, group-based, commercial (eg, WeightWatchers), com-
adolescents with overweight, those with severe obesity have a higher munity-based (eg, YMCA), or supported by the health care system.
prevalence of high total cholesterol level (10.8% vs 19.4%, P = .008), The systematic evidence review47 underlying the 2023 AAP Clini-
low high-density lipoprotein cholesterol level (7.8% vs 23%, cal Practice Guideline did not identify high-quality evidence for rec-
P < .001), high triglyceride level (12.2% vs 29%, P = .002), high ommending specific health behaviors as a stand-alone strategy to re-
systolic and diastolic blood pressure (0.3% vs 3.8%, P < .001), and duce BMI. However, many lifestyle recommendations have overall
high glycated hemoglobin level (15.6% vs 24.3%, P = .003).26 health benefit and are endorsed by professional organizations. These
The US Preventive Services Task Force (USPSTF)27 and the AAP lifestyle recommendations include reducing sugar-sweetened
recommend clinicians use CDC sex- and age-specific BMI growth beverages,48,49 engaging in 60 minutes of moderate to vigorous
curves to screen for obesity from ages 2 to 18 years.28 Before physical activity daily,50,51 and limiting social media use and overall
engaging in discussions about obesity, clinicians should seek screen time, although without specifying an upper limit of use.52
permission to address the topic and assess the adolescent’s Motivational interviewing, a collaborative, person-centered form
preferences for discussing weight and BMI to reduce stigma and of communication, aims to elicit and strengthen motivation for be-
improve the therapeutic relationship.29 havior change. It can be delivered by various members of the health
The Institute for Healthy Childhood Weight, affiliated with the care team53 and is commonly included as a component of compre-
AAP, provides a 1-page algorithm summarizing the evaluation of ado- hensive lifestyle modification therapy2 because it supports patient
lescents diagnosed with overweight or obesity (https://www.aap.org/ preferences and autonomy, reduces patient perceptions of clini-
en/patient-care/institute-for-healthy-childhood-weight/). This cian weight bias, and decreases clinician burnout.54 However, sys-
algorithm includes standard components of the adolescent annual tematic reviews and meta-analyses have demonstrated a lack of ef-
visit (ie, a comprehensive history, physical examination, and blood fect of motivational interviewing alone in reducing BMI in adolescents
pressure) as well as obesity-specific recommendations based on risk. with obesity.55,56
For example, adolescents with obesity have a higher risk of depression More intensive forms of lifestyle modification are an impor-
than healthy weight peers (relative risk, 1.32 [95% CI, 1.09-1.60]) tant component of obesity treatment in adolescents. The USPSTF
(absolute rates not reported)30; thus, clinicians should screen (updated in June 2024)41 and CDC, which conducted systematic re-
adolescents with overweight and obesity for depression, using a views informing the 2023 AAP Clinical Practice Guideline,27,28,47 both
validated screening tool such as the Patient Health Questionnaire 9.31 reported that longitudinal care is required to observe effective-
The presence of snoring on review of systems suggests possible ness; “longitudinal” was defined as the number of contact hours over
sleep apnea, and although there are no questionnaires or physical up to 12 months. Overall, 35% of the studies demonstrated a de-
examination findings that predict sleep apnea, it is present in up to crease in BMI, including 25% of studies with low-intensity interven-
60% of adolescents with obesity.32 The prevalence of hypertension tions (<5 contact hours), 35% of studies with moderate-intensity
is higher in adolescents with obesity and overweight (31.4% and 18. interventions (5-25 contact hours), and 71% of studies with high-
2%, respectively) as compared with healthy weight peers (11.9%, intensity interventions (26-51 contact hours). The magnitude of treat-
P < .001).33 Annual laboratory testing for adolescents with obesity ment effect on BMI reduction was modest, with the greatest BMI
includesscreeningfortype2diabetes(hemoglobinA1c,fastingglucose, changes (3% to 5%) observed in high-intensity interventions deliv-
or oral glucose tolerance test), metabolic dysfunction–associated ered over at least 3 to 12 months. The most effective interventions
steatotic liver disease (alanine aminotransferase), and cholesterol included nutrition and physical activity components and peer sup-
(fasting lipid panel).2 The full evaluation recommendations are port groups, and were delivered in person.47 While these pooled re-
included in the algorithm referenced above and summarized in sults included studies of children, the largest reduction in BMI oc-
Table 1.2,31,34-40 curred in adolescents.47 Lifestyle treatment appears to be least
effective for adolescents with the most severe forms of obesity,57
Obesity Care and Treatment Options suggesting this group may benefit from medical or surgical treat-
The Obesity CARE continuum includes classification of severity, as- ment. All studies observed a significant heterogeneity in treat-
sessment of risk, respect for autonomy, and engagement in treat- ment response, which is common across all obesity treatments.58

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 Table 1. Obesity-Related Comorbidities and Complications and Their Signs, Symptoms, Risk Factors, and Screening Tests

Comorbidity/complication Signs and symptoms Risk factors Screening test(s)

jama.com
Metabolic
Diabetes Polyuria, polydipsia, unexpected weight loss, fatigue, Family history, maternal gestational diabetes, polycystic ≥10 y old: fasting plasma glucose (≥126 mg/dL), 2-h oral
new-onset enuresis; acanthosis nigricans, skin tags ovary syndrome, hypertension, dyslipidemia, metabolic glucose tolerance test (≥200 mg/dL), or glycated
dysfunction–associated steatotic liver disease, small for hemoglobin (hemoglobin A1c) (≥6.5%)34
gestational age
Metabolic dysfunction–associated steatotic liver disease Often asymptomatic; jaundice in severe cases; Male sex, Hispanic or Asian race and ethnicity, ≥10 y old: alanine aminotransferase (ALT); exclude other
(formerly nonalcoholic fatty liver disease) hepatomegaly obstructive sleep apnea, diabetes/prediabetes, causes of transaminitis if ALT ≥2 × upper limit of normal
Obesity in Adolescents: A Review

dyslipidemia or ALT ≥52 IU/L for males and ALT ≥44 IU/L for females
for ≥3 mo, or ALT >80 IU/L35
Dyslipidemia Often asymptomatic; xanthoma or xanthelasma with Family history of cardiovascular disease, diabetes, ≥10 y old: fasting lipid profile, including total
familial hypercholesterolemia hypertension, cigarette smoking (≥170 mg/dL), low-density lipoprotein (≥110 mg/dL),
and high-density lipoprotein (<45 mg/dL) cholesterol
levels, and triglyceride level (≥90 mg/dL)36
Hypertension Often asymptomatic, headache, blurry vision, dizziness, Family history Blood pressure ≥95th percentile (ages 1-12 y) or
nosebleeds with severely elevated blood pressure ≥130/80 mm Hg (ages ≥13 y)
Polycystic ovary syndrome Acne, hirsutism, alopecia, oligoamenorrhea or Family history, insulin resistance Total testosterone, free testosterone, sex
amenorrhea hormone–binding globulin; to rule out other causes of
hyperandrogenism and ovarian dysfunction:
17-hydroxyprogesterone, dehydroepiandrosterone
sulfate, androstenedione, luteinizing hormone,
follicle-stimulating hormone, estradiol, prolactin, free
thyroxine, thyroid-stimulating hormone, pregnancy test37
Nonmetabolic
Depression Irritability, fatigue, insomnia, excessive sleeping, decline Family history, bullying Patient Health Questionnaire 931
in academic performance, flat affect
Obstructive sleep apnea Snoring, apnea, fatigue, nocturnal enuresis, difficulty Family history, adenotonsillar hypertrophy, Polysomnogram with at least 1 symptom2
focusing/concentrating allergic rhinitis
Idiopathic intracranial hypertension Headache, nausea, vomiting, vision loss, diplopia, Ophthalmological examination38
tinnitus, papilledema
Slipped capital femoral epiphysis Hip, groin, thigh, or knee pain; limp Bilateral hip x-ray39

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Blount disease Painful genu varus (bow-legged) deformity Leg x-ray40

SI conversion factors: To convert alanine aminotransferase to μkat/L, multiply by 0.0167; cholesterol to mmol/L, multiply by 0.259; glucose to mmol/L, multiply by 0.0555; and triglyceride to mmol/L, multiply by 0.0113.

© 2024 American Medical Association. All rights reserved.

Review Clinical Review & Education

(Reprinted) JAMA September 3, 2024 Volume 332, Number 9

741
 Clinical Review & Education Review Obesity in Adolescents: A Review

ance of health care.62 Adolescence is a critical developmental pe-

Figure. Adolescent Obesity CARE Framework
riod, and teenagers are currently influenced by social media, which
Classify severity idealizes thinner bodies and whose use is associated with high lev-
els of body dissatisfaction.63 Eating disorders, in particular binge eat-
Measure height and weight using age- and sex-specific CDC body
mass index (BMI) growth curves to classify obesity severity ing disorder, are more common in adolescents with obesity com-
Consider genetic testing if severe obesity onset before age 5 y pared with healthy weight peers (9.3% vs 2.1% in males; 20.2% vs
8.4% in females).64 A 2019 systematic review with 2589 partici-
Overweight: BMI ≥85th to <95th percentile
Obesity: BMI ≥95th to <120% of the 95th percentile pants reported that evidence-based lifestyle modification therapy
Severe obesity: BMI ≥120% of the 95th percentile in the context of residential camps, community programs, hospital
settings, and other supervised individual or group programs de-
creased the risk for disordered eating.65
Assess risk
Pharmacotherapy
Assess medical and mental health risks
Prior to 2020, orlistat was the only FDA-approved medication for
Comprehensive medical and family history
Review of systems chronic treatment of obesity in adolescents. After 2020, several ran-
Physical examination domized clinical trials examining the safety and efficacy of antiobe-
Validated screening (eg, depression, social drivers of health)
Targeted laboratory screening (eg, ALT, lipids, HbA1c for adolescents
sity medications in adolescents have been published (Table 3).6-8,42
with obesity or overweight with risk factors) These studies examined liraglutide,6 phentermine/topiramate,7
Assess lifestyle behaviors using a non–weight-biased and semaglutide,8 and setmelanotide for patients with specific types of
strengths-based approach, identifying healthy behaviors
on which to build monogenic obesity and syndromic obesity. While the AAP Clinical
Practice Guideline did not include all of these pharmacotherapy trials
in their recommendations due to the timing of the evidence re-
Respect autonomy view, it provided guidance that pediatric clinicians “should” offer FDA-
Explore patient and family preference for discussing weight approved antiobesity medications to adolescents with obesity aged
Use patient-centered communication to enhance motivation 12 years or older according to medication indications and risks.2 The
for change AAP recommended antiobesity medications be used with the most
Use patient-first and nonstigmatizing language and images intensive lifestyle modification therapy available and should not be
in clinical settings
Use shared decision-making when exploring treatment options withheld if the recommended 26 hours or more of lifestyle therapy
is not available. All clinical trials to date have included lifestyle modi-
fication therapy; there is no evidence supporting antiobesity medi-
Engage in treatment cations used as monotherapy.
Address comorbidities, complications, and social drivers of health
(eg, food insecurity resources) GLP-1 Receptor Agonists (Liraglutide and Semaglutide)
Offer intensive health behavior and lifestyle treatment Liraglutide was FDA approved in 2020 for adolescents with obe-
(>26 h over 3-12 mo period) as available in the community
sity aged 12 years and older. Liraglutide is a short-acting GLP-1 re-
Offer antiobesity medications per FDA-approved indications,
currently for adolescents aged ≥12 y with obesity ceptor agonist (GLP-1 RA) developed to treat type 2 diabetes and is
Offer referral to a high-quality, comprehensive metabolic and FDA approved for this indication in children aged 10 years and
bariatric surgery program with adolescent experience as available older.66 In addition to its glycemic mechanisms of action, GLP-1 RAs
for adolescents aged ≥13 y with obesity with comorbidities or
complications, or with severe obesity with or without comorbidities act on the hypothalamus to suppress appetite, enhance satiety cen-
trally (hind brain) and peripherally (potentially slowing gastric emp-
tying), and may also act on reward pathways in the brain.67,68 The
BMI is calculated as weight in kilograms divided by height in meters squared.
ALT indicates alanine aminotransferase; CDC, Centers for Disease Control and obesity treatment dose of liraglutide, 3 mg, daily subcutaneous in-
Prevention; FDA, Food and Drug Administration; and HbA1c, hemoglobin A1c. jection was evaluated in a 56-week randomized clinical trial of 251
adolescents with obesity aged 12 to 18 years.6 The treatment phase
Although lifestyle modification does not result in the largest BMI was followed by a 26-week follow-up period in which liraglutide/
reduction as compared with other treatment options, it is recom- placebo was withdrawn. In the treatment phase, the mean placebo-
mended for all adolescents with obesity. However, lifestyle treat- subtracted difference in change in BMI was −4.64% (95% CI, −7.14%
ment programs that meet high-intensity criteria are not widely to –2.14%). At 56 weeks, 43.3% vs 18.7% of participants achieved a
accessible.59 Clinic-community partnerships, where clinicians screen 5% or greater BMI reduction in the liraglutide vs placebo group and
for obesity and treat comorbidities and community partners provide 26.1% vs 8.1% achieved a 10% or greater BMI reduction. During the
space, staffing, and convenient locations, may address access barri- follow-up period (from week 56-82), both groups experienced
ers to exercise and nutrition programs. These partnerships an increase in the BMI standard deviation score (0.22 vs 0.07 with
(eg, YMCA, municipal parks and recreation) have potential to im- liraglutide vs placebo, respectively).
prove implementation, effectiveness, and sustainability of intensive Semaglutide, 2.4 mg, another GLP-1 RA, was approved by the
health behavior and lifestyle treatment for adolescent obesity.60,61 FDA in 2022 for obesity in adolescents aged 12 years and older. Sema-
Stigmatization of adolescents with obesity is common, occurs glutide has a longer half-life than liraglutide, enabling weekly dos-
across multiple settings (ie, school, home, health care, sports), and ing. A randomized clinical trial of semaglutide vs placebo in 201 par-
may result in binge eating behaviors, social isolation, and avoid- ticipants aged 12 to 18 years reported a mean placebo-subtracted

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 Obesity in Adolescents: A Review Review Clinical Review & Education

Table 2. Components of Comprehensive, Evidence-Based Obesity Care for Adolescents

Approach Eligible patients Description or examples Mean BMI reduction Other considerations
Intensive health BMI ≥85th percentile Involves frequent contact (≥26 h) over a period About 3% at 12 mo28,41 Higher frequency of contact
behavior and lifestyle of 3-12 mo between the patient/family and a (average of 1 h/wk over 1 y) is
treatment2 multidisciplinary treatment team including associated with greater BMI
clinicians trained in lifestyle-related fields2 reduction (about 5%-10% at
Interactions can be individual, group-based, or 12 mo) and improvement in
both; face to face has strongest evidence with some cardiometabolic risk
some evidence supporting virtual2 factors28
Consists of health education and skill building,
along with behavior modification and
counseling addressing healthier eating and
physical activity habits (eg, reduction of
sugar-sweetened beverages, meals that are
nutrient dense but not calorically dense
balanced in protein and carbohydrates and low
in concentrated fat, reduction of sedentary
behavior, 60 min of daily physical activity)2
Pharmacotherapy2 BMI ≥95th percentile FDA approved for long-term use About 3% (orlistat 60-120 mg Administer concurrent with
• Orlistat (60-120 mg 3 times daily orally) 3 times daily orally)42 to about lifestyle modification therapy
• Liraglutide (0.6-3.0 mg once daily 17% (semaglutide, 2.4 mg, See Table 3 for additional details
subcutaneously) once weekly subcutaneously)8 including adverse effects and
• Semaglutide (0.25-2.4 mg once weekly at 12-16 mo contraindications
subcutaneously)
• Phentermine/topiramate extended release
(3.75/23 mg to 15/92 mg once daily orally)
FDA approved for short-term use
• Phentermine (8 mg daily to 8 mg 3 times
daily or 15-37.5 mg once daily orally)
Commonly used off-label
• Metformin (500-2000 mg daily orally)
• Topiramate (25-100 mg daily orally)
Metabolic and BMI ≥120% of the Roux-en-Y gastric bypass About 30% at 12 mo with Minor (ie, hospital readmission
bariatric surgery2 95th percentile or Vertical sleeve gastrectomy effects sustained for for management of dehydration)
BMI ≥35 (whichever at least 5 y43 and major (ie, abdominal
is lower) and reoperation) perioperative
obesity-related complications (30 d) occur in
complication 15% and 8% of patients,
(eg, type 2 diabetes, respectively, while 13%
obstructive sleep underwent additional abdominal
apnea, hypertension); operations by 3 y44
BMI ≥140% of the Long-term monitoring is
95th percentile or necessary for nutritional
BMI ≥40 (whichever deficiencies and bone health2
is lower) Administer concurrent with
lifestyle modification therapy

Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); FDA, US Food and Drug Administration.

treatment effect on BMI of −16.7% (95% CI, −20.3% to −13.2%).8 achieved by 5.4% in the placebo group vs 38.9% and 46.9% in the
At 68 weeks, 73% of participants randomized to semaglutide had mid- and highest-dose phentermine/topiramate groups, respec-
a 5% or greater BMI reduction and 62% had a 10% or greater BMI tively. An at least 10% BMI reduction was achieved by none in the pla-
reduction while 18% in the placebo group had a 5% or greater cebo group vs 31.5% and 42.5% in the mid- and highest-dose
BMI reduction and 8% had a 10% or greater BMI reduction. The most phentermine/topiramate groups, respectively. Patients should be
common adverse effects of GLP-1 RAs are nausea, vomiting, and di- monitored for the emergence or worsening of depressed mood (in the
arrhea (Table 3), which can be mitigated by eating slowly, eating adolescent trial, 0%, 1.9%, and 4.4% developed depression in the pla-
smaller meals, and avoiding high-fat and high-sugar foods. Dose de- cebo, mid-, and highest-dose groups, respectively), and female ado-
escalation may also be needed. lescents should receive counseling on pregnancy prevention while tak-
ing this medication, given its teratogenicity.
Phentermine/Topiramate In summary, the newer antiobesity medications appear safe and
Combination phentermine/topiramate extended release was ap- effective in adolescents. However, there are few randomized clini-
proved by the FDA in 2022 for adolescents with obesity aged 12 years cal trials and currently published trials are of relatively short dura-
and older. Phentermine may reduce appetite via its action as a nor- tion. Future research should examine longer-term outcomes and po-
epinephrine reuptake inhibitor; the mechanism by which topira- tential adverse effects of these medications. Further, the decision
mate reduces appetite and enhances satiety is not well understood.69 regarding the choice of medication should include consideration of
A 56-week, randomized clinical trial of 227 participants aged 12 to 17 the patient’s obesity severity, comorbidities and medication pref-
years reported a mean placebo-subtracted treatment effect of −8.1% erences, and the medication’s effectiveness, cost, availability, and
in BMI (95% CI, −11.92% to −4.31%) for mid-dose phentermine/ adverse effects. Additionally, because of their high cost and limited
topiramate (7.5 mg/46 mg) and a −10.44% change in BMI (95% CI, coverage by public insurance, concerns have been raised that anti-
−13.89% to −6.99%) for the highest dose of phentermine/ obesity medications may increase racial and ethnic disparities in the
topiramate (15 mg/92 mg).7 An at least 5% BMI reduction was prevalence of adolescent obesity.70

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 Clinical Review & Education Review Obesity in Adolescents: A Review

According to the recent AAP Clinical Practice Guideline, deter-

Box 2. Questions Commonly Asked by Clinicians Regarding mination of eligibility for metabolic and bariatric surgery requires an
Adolescent Obesity Care individualized and multidisciplinary approach.2,46,80 Table 2 sum-
marizes patient eligibility criteria.
If intensive lifestyle treatment is not an option, are antiobesity Knowledge gaps related to micronutrient deficiencies, long-
medications still recommended?
term durability of weight loss, the potential need for subsequent
Yes, clinicians should provide the highest level of lifestyle support
available when starting antiobesity medications. Such support
operative interventions, and psychosocial benefits and harms of
could include frequent office visits, meeting with a registered metabolic and bariatric surgery are the focus of ongoing research.
dietician, and/or engagement in a community program that fo- Limited data suggest postsurgical micronutrient deficiencies,81,82
cuses on fitness and nutrition. including iron deficiency (45% to 71%) and deficiencies of vita-
Will adolescents with obesity need to continue taking medications
min B12 (20%) and vitamin D (41%),83 and long-term bone health
indefinitely? secondary to decreased bone mineral density84 require further
Limited evidence suggests that weight regain develops after study.45,46,79,81,85 Additionally, limited data suggest metabolic
withdrawal of antiobesity medications. However, determining and bariatric surgery may not affect rates of depression, anxiety, or
whether medication dose can be reduced (or withdrawn suicidal ideation among adolescents.86-88
altogether) in some patients requires further research.
In summary, evidence supports metabolic and bariatric sur-
What is the youngest age for which metabolic and bariatric surgery gery as a safe and effective intervention for adolescents with se-
can be considered? vere obesity to achieve substantial weight reduction and improve-
Based on current evidence, eligibility guidelines from the American ments in obesity-related complications and comorbidities.
Academy of Pediatrics (AAP) recommend referral to a
comprehensive multidisciplinary obesity treatment program with
Prognosis
surgical capabilities for patients 13 years of age or older.2 However,
the AAP also acknowledges there is limited evidence supporting Obesity in adolescence often persists into adulthood and is associ-
surgical treatment of children younger than 13 years, which may be ated with adverse health outcomes later in life. A longitudinal study
considered on an individual basis.2,45,46 of 2392 individuals observed that 100% of adolescents with a BMI
at the 99th percentile or greater had class 1 obesity (BMI ⱖ30) in
adulthood, 88% had class 2 obesity (BMI ⱖ35), and approximately
65% had class 3 obesity (BMI ⱖ40).5 Adolescent obesity increases
Metabolic and Bariatric Surgery the risk of mortality from cardiovascular disease and type 2 diabe-
Metabolic and bariatric surgery, performed on approximately 1300 tes in adulthood. A longitudinal study of 2.3 million Israeli adoles-
to 1900 adolescents annually in the US,71-73 leads to reduction in cents tracked the number of deaths attributed to cardiovascular
mean BMI of up to 30% at 3 to 8 years.43,44,74 Metabolic and bar- causes. Adolescents with a BMI at the 95th percentile or greater at
iatric surgery is also associated with improvements and/or resolu- a mean age of 17.3 years had an increased risk of cardiovascular mor-
tion of hypertension, type 2 diabetes, dyslipidemia, and obstruc- tality with a hazard ratio of 3.5 (95% CI, 2.9 to 4.1) compared with
tive sleep apnea, and improvements in weight-related quality of the reference group in the fifth to 24th BMI percentiles over 40 years
life.44,45,74-78 The Teen–Longitudinal Assessment of Bariatric Sur- of follow-up.89 In the same cohort, individuals with a mean BMI at
gery (Teen-LABS) Study enrolled 242 adolescents with severe obe- the 95th percentile or greater at a median age of 18.4 years had in-
sity at 5 US centers between 2007 and 2012 who received meta- creased mortality from type 2 diabetes with a hazard ratio of 17.2
bolic and bariatric surgery.44 The 30-day rate of major complications (95% CI, 11.9 to 24.8) compared with the fifth to 24th BMI percen-
(eg, reoperation) was 8% and the minor complication rate (eg, hos- tile reference group.90
pital readmission for dehydration) was 15%.79 At 3-year follow-up,
mean weight had decreased by 28% (95% CI, 25% to 30%) among Practical Considerations and Application of the Evidence
participants who underwent Roux-en-Y gastric bypass, and by 26% Clinicians should be supportive and compassionate, and engage in
(95% CI, 22% to 30%) among those who underwent vertical sleeve nonstigmatizing communication with adolescent patients and their
gastrectomy.44 Another prospective observational study of 58 ado- families.91 Implementation of the treatment recommendations out-
lescents with a preoperative mean BMI of 58.5 who underwent lined in the AAP Clinical Practice Guideline may include clinician train-
Roux-en-Y gastric bypass reported a −29.2% BMI reduction at mean ing in motivational interviewing and partnering with community or-
follow-up of 8 years (SD, 1.6; range, 5.4-12.5 years).74 A study com- ganizations to provide intensive health behavior and lifestyle
paring 5-year outcomes among 161 Teen-LABS participants under- treatment. The newer antiobesity medications are expensive (sema-
going Roux-en-Y gastric bypass vs a cohort of 396 adult partici- glutide costs about $1300 per month); private insurance coverage
pants from the Longitudinal Assessment of Bariatric Surgery (LABS) is variable, and most state Medicaid plans do not cover antiobesity
consortium, who self-reported being affected by severe obesity as medications. Lack of Medicaid coverage is particularly concerning
adolescents, showed that members of the adolescent cohort who because obesity disproportionately affects adolescents from low so-
underwent metabolic and bariatric surgery were more likely to have cioeconomic backgrounds, who are most likely to lack private in-
remission of type 2 diabetes (86% vs 53%) and hypertension (68% surance. Currently, about two-thirds of private insurers and most
vs 41%) compared with their adult counterparts.43 These data raise state Medicaid plans cover metabolic and bariatric surgery for
the possibility that the differential degree of cardiometabolic health adolescents,92 yet there are a limited number of comprehensive ado-
improvement observed among adolescents compared with adults lescent bariatric centers, limiting access for many adolescents who
may be an important consideration for timing of surgery. meet criteria for surgery.

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 Obesity in Adolescents: A Review Review Clinical Review & Education

Table 3. Antiobesity Medications for Adolescents, Ordered by Efficacy

Most common
Treatment outcomes: adverse events 30-d
mean BMI reduction (treatment Cost, $
a
Medication FDA approval Dosing and additional benefits vs placebo) Monitoring Contraindications (dose)b
Semaglutide, Ages ≥12 y; Starting dose: 0.25 mg Treatment: −16.1% Gastrointestinal Blood glucose if Personal or family 1301
2.4 mg (once BMI ≥95th weekly subcutaneous Placebo: +0.6% (61.7% vs 41.8%) also taking insulin history of (2.4 mg)
weekly percentile for 4 wk Difference: −16.7% with Nausea (42% vs Heart rate medullary thyroid
subcutaneous Titration: 0.5 mg weekly 2.4 mg at 68 wk 18%) Dehydration carcinoma or
injection)8 for 4 wk, then 1 mg Improvements in Vomiting (36% especially with multiple
weekly for 4 wk, then cardiometabolic risk vs 10%) severe endocrine
1.7 mg weekly for 4 wk, factors (glycosylated Diarrhea (22% gastrointestinal neoplasia
then 2.4 mg weekly hemoglobin, lipids, vs 19%) symptoms syndrome type 2
and alanine Worsening or
aminotransferase) and emergence of
weight-related quality suicidal ideation
of life Signs or
symptoms of
gall bladder or
pancreatic
disease
Phentermine/ Ages ≥12 y; Starting dose: 3.75 mg/ Treatment (15/92 mg): Incidence ≥4% Heart rate Pregnancy, 149
topiramate BMI ≥95th 23 mg daily for 14 d; then −7.1% and greater than Insomnia glaucoma, (15
extended release percentile 7.5 mg/46 mg daily for Placebo: +3.3% placebo: Suicidal ideation hyperthyroidism mg/92
7.5 mg/46 mg 12 wk Difference: −10.4% with depression, Cognitive mg)
(mid-dose) or If BMI has not decreased by 15 mg/92 mg at 56 wk dizziness, impairment
15 mg/92 mg 3% from baseline, increase About 20% decrease in arthralgia, Metabolic acidosis
(high-dose) to 11.25 mg/69 mg daily triglycerides and about influenza, and
(once daily oral)7 for 14 d, then 15 mg/92 mg 10% increase in HDL ligament sprain
daily cholesterol with both
doses of phentermine/
topiramate
Liraglutide, 3 mg Ages ≥12 y; Starting dose: 0.6 mg/d Treatment: −4.3% Nausea (42.4% Blood glucose if Personal or family 1008
(once daily body weight subcutaneous Placebo: +0.4% vs 14.3%) also taking insulin history of (3 mg)
subcutaneous >60 kg Titration: increase dose by Difference: −4.6% with Vomiting (34.4% Heart rate medullary thyroid
injection)6 and BMI 0.6 mg every 4 wk to 3 mg at 56 wk vs 4.0%) Dehydration carcinoma or
corre- maximum tolerated dose or No significant Diarrhea (22.4% especially with multiple
sponding to 3 mg/d improvements in vs 14.3%) severe endocrine
30 for adults cardiometabolic risk gastrointestinal neoplasia
factors or symptoms syndrome type 2
weight-related quality Worsening or
of life emergence of
suicidal ideation
Signs and
symptoms of
gall bladder or
pancreatic
disease
Orlistat, Ages ≥12 y; 120 mg by mouth 3 times At 1 y: Treatment: Gastrointestinal: Take multivitamin Pregnancy, 532
120 mg42 BMI ≥95th daily with meals (also −0.55 fatty/oily stool, supplement 2 h chronic (120 mg)
percentile available over-the-counter Placebo: +0.31 50.3% vs 8.3%; apart from dose malabsorption,
as 60 mg 3 times daily with No clinically significant oily spotting, 29% cholestasis
meals) improvements in vs 3.9%; oily
cardiometabolic risk evacuation,
factors 23.3% vs 1.7%;
abdominal pain,
21.9% vs 11%
b
Abbreviations: BMI, body mass index (calculated as weight in kilograms divided Data taken from Veterans Affairs’ Office of Procurement, Acquisition, and
by height in meters squared); FDA, Food and Drug Administration; Logistics (https://www.va.gov/opal/nac/fss/pharmPrices.asp).
HDL, high-density lipoprotein.
a
See full prescribing information for each medication for more details on
adverse effects and monitoring.

Limitations
This review has limitations. First, this was not a systematic review Conclusions
so relevant studies may have been missed. Second, the authors did
not perform formal quality assessment of the included studies. Third, The prevalence of adolescent obesity is approximately 21% in
the patient populations included in the studies of lifestyle modifi- the US. Treatment options for adolescents with obesity include life-
cation therapy, pharmacotherapy, and metabolic and bariatric sur- style modification therapy, pharmacotherapy, and metabolic and bar-
gery may differ in terms of obesity severity and comorbidities, mak- iatric surgery. Intensive lifestyle modification therapy reduces BMI
ing it difficult to directly compare results among these interventions. by approximately 3% while pharmacotherapy added to lifestyle
Fourth, much of the literature did not provide results regarding the modification therapy can attain BMI reductions from 5% to 17%.
percentage of individuals achieving various target weight reduc- Metabolic and bariatric surgery is the most effective and durable
tions, making it difficult to provide data about the effectiveness of treatment for adolescents with severe obesity, achieving BMI re-
interventions. duction of approximately 30%.

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 Clinical Review & Education Review Obesity in Adolescents: A Review

ARTICLE INFORMATION 9. Kelly AS, Barlow SE, Rao G, et al; American Heart central control of appetite and body weight
Accepted for Publication: May 31, 2024. Association Atherosclerosis, Hypertension, and regulation. Proc Natl Acad Sci U S A. 2017;114(35):
Obesity in the Young Committee of the Council on 9421-9426. doi:10.1073/pnas.1707310114
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Conflict of Interest Disclosures: Dr Kelly reported Council on Clinical Cardiology. Severe obesity in weight. N Engl J Med. 1995;332(10):621-628. doi:
engaging in unpaid consulting and educational children and adolescents: identification, associated 10.1056/NEJM199503093321001
activities, as well as serving as an unpaid health risks, and treatment approaches: a scientific
investigator for Novo Nordisk; engaging in unpaid statement from the American Heart Association. 23. Maclean PS, Bergouignan A, Cornier MA,
consulting activities and serving as an unpaid Circulation. 2013;128(15):1689-1712. doi:10.1161/CIR. Jackman MR. Biology’s response to dieting: the
investigator for Boehringer Ingelheim, Lilly, and 0b013e3182a5cfb3 impetus for weight regain. Am J Physiol Regul Integr
Vivus; and receiving donated drug/placebo from Comp Physiol. 2011;301(3):R581-R600. doi:10.1152/
10. Pichardo MS, Ferrucci LM, Molina Y, Esserman ajpregu.00755.2010
Novo Nordisk and Vivus for National Institute of DA, Irwin ML. Structural racism, lifestyle behaviors,
Diabetes and Digestive and Kidney Diseases– and obesity-related cancers among Black and 24. Sumithran P, Prendergast LA, Delbridge E, et al.
funded clinical trials. Dr Armstrong reported serving Hispanic/Latino adults in the United States: Long-term persistence of hormonal adaptations to
as chair for the American Academy of Pediatrics a narrative review. Cancer Epidemiol Biomarkers Prev. weight loss. N Engl J Med. 2011;365(17):1597-1604.
(AAP) Section on Obesity from 2021 to 2023 and as 2023;32(11):1498-1507. doi:10.1158/1055-9965.EPI- doi:10.1056/NEJMoa1105816
a member of the AAP Clinical Practice Guidelines 22-1147 25. Freedman DS, Sherry B. The validity of BMI as
Writing Committee. Dr Michalsky reported an indicator of body fatness and risk among
receiving personal fees from Intuitive Surgical Inc 11. Struck S, Stewart-Tufescu A, Asmundson AJN,
Asmundson GGJ, Afifi TO. Adverse childhood children. Pediatrics. 2009;124(suppl 1):S23-S34.
and Lilly USA LLC. Dr Fox reported receiving doi:10.1542/peds.2008-3586E
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Submissions: We encourage authors to submit
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contact Kristin Walter, MD, at kristin.walter@ modifiable risk factors for obesity among low et al; US Preventive Services Task Force. Screening
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