Pediatric Research Update: Shifts in US Pediatric Obesity Treatment After the AAP Guidelines

Each month, the OMA Pediatric Committee reviews a pediatric-focused obesity research update to help keep you up to date about the latest findings. This month’s article examines real-world changes in pediatric obesity treatment following the 2023 AAP Clinical Practice Guideline, highlighting trends in nutrition counseling and the use of anti-obesity pharmacotherapy among children and adolescents in the U.S.

Article Summary

A recent study by Rodriguez et al. (2025) reviewed differences in pediatric obesity treatment before and after the release of the 2023 AAP Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity.

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Article Review

This January marks the three-year anniversary of the release of the monumental AAP Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity. This 100-page document was greatly anticipated, coming more than 15 years after 2007 Expert Committee Recommendations. When it was released in 2023, it was the AAP’s first Clinical Practice Guideline for the treatment of obesity and the first comprehensive review of graded evidence related to obesity treatment. It focused on defining obesity as a chronic disease, acknowledging its biological and social drivers, addressing and reducing weight stigma, and advocating for early and intense treatment including the use of pharmacotherapy and bariatric surgery for adolescents.

According to the guideline, Intensive health behavior and lifestyle treatment (IHBLT) is considered first-line therapy, but is often only associated with small changes in weight and access to programs is frequently limited. In addition to IHBLT, the guideline recommends offering pharmacotherapy for adolescents aged 12 years and older with obesity (BMI > 95^th percentile), and metabolic and bariatric surgery for patients 13 years and up with severe obesity (BMI > 120% of the 95^th percentile).

Despite being a rigorous review of evidence-based literature from experts in various fields of pediatric obesity, the AAP Clinical Practice Guideline was met with disapproval. After its release, headlines spread concern about dangers like eating disorders, weight stigma, inappropriate use of obesity medications, and unknown risks of long-term use of obesity medications and bariatric surgery.

These concerns, combined with historically low rates of obesity pharmacotherapy use in pediatrics prompted a recent study by Rodriguez et al. (2025) to look at changes in obesity treatment for children and adolescents, specifically nutrition counseling and pharmacotherapy before and after the release of the AAP guideline.

Methods

This real-world retrospective cohort study utilized electronic health records (EHR) from Truveta, a database of 30 U.S. Health care systems and over 100 million patients. Eligible patients selected were children and adolescents aged 8-17 years who had an office visit between January 2021 and December 2024, a BMI percentile meeting obesity criterion (>95^th percentile), were eligible for obesity treatment, had no evidence of recent treatment and no previous or concurrent Type 2 Diabetes.

Comorbidities, treatment history, and prior medications prescribed for each patient were assessed for the year before their first visit or index visit. The study measured rates of two obesity treatments, nutrition counseling or referral and pharmacotherapy over a one-year period.

Numbers of patients with nutrition counseling or referrals and receiving obesity medications in the last 30 days and last 90 days were collected before (preguideline) and after (postguideline) January 1, 2023. Obesity medications included on and off-label use of metformin, orlistat, phentermine, topiramate, phentermine-topiramate, liraglutide, semaglutide and any other GLP-1-based drug. Lisdexamfetamine was not included due to it’s predominant use for ADHD and supply disruptions during the study period.

The study included 114,506 (36.9%) children 8-11 years and 195,997 (63.1%) adolescents 12-17 years. Mean age was 13.2, 45.9% of patients were female, 4.4% were Asian, 14.6% were Black or African American, 1.6% were Native Hawaiian or Pacific Islander, 55.4% were white, 11.6% were other races, and 12.4% had unknown race. Mean BMI percentile was 97.4, 23.2% had Class II obesity, and 12.5% had Class III obesity. Visits occurred with various types of providers, including pediatricians 52.6%, family or internal medicine practitioners 21.4%, physician assistants or nurse practitioners 13.4% and residents 8.8%.

Results

Prior to the guidelines only 9.7% of patients had evidence of a nutrition referral within 14-90 days after the index visit and 0.4% of patients received pharmacotherapy within 14 days of the index visit. After the release of the AAP guidelines no significant change was observed in nutritional counseling or referral (odds ratio 1.05). Nutrition referral was more likely in patients of Asian or Black race compared with white race and for visits with pediatricians compared to other clinicians. Significant increases were observed in prescribing of obesity medications (odds ratio 1.65) along with monthly prescribing trends after the AAP guideline release. Pharmacotherapy use was more likely in female patients, adolescents compared to children and patients with higher BMI. Metformin was the most commonly prescribed medication, but use of this medication decreased over the course of the study, initially making up 80.2% of all medications prescribed and dropping to 63% in the postguideline period. Semaglutide prescribing increased from 2.5% in the preguideline period to 26.8% in the postguideline period.

Conclusions

The strengths of this study include a large, diverse and generalizable pediatric population from various healthcare settings and the identification of patients by actual BMI measurements obtained with height and weight as opposed to billing codes for BMI. Limitations include the methods for obtaining obesity treatment data which may be inconsistent for example, if patients received care from providers not included in this data set, if discussions about nutrition were not documented by providers, or if patients received another form of IHBLT instead of nutrition referral (like a program at their YMCA).

The rate of nutrition referral was far greater than pharmacotherapy, but did not change much after release of the AAP guideline. Increased reliance on nutrition referral may be easier for clinicians since there are many barriers to using pharmacotherapy including time constraints, clinician training and comfort with obesity medications, lack of insurance coverage, family engagement, limited social support, environmental and societal barriers to behavior change, and weight stigma.

The increase in obesity medication prescribing observed in this study after 2023 suggests the AAP guidelines may be associated with an increase in pharmacotherapy use. These changes in prescribing could be attributed to multiple factors including the release of the AAP guidelines, increasing availability of FDA approved medications for the indication of pediatric obesity, and greater acceptance and availability. The authors note the release of the AAP guidelines occurred during a period of increasing interest in GLP-1 medications and the approval of semaglutide for use in pediatric patients 12 years and up in December of 2022.

Regardless of the increases in obesity medication prescribing observed in this study, the overall rates of obesity treatment with nutrition and pharmacotherapy are still incredibly low.

Looking Ahead

In addition to standardizing obesity medicine education for clinicians during training, further research is needed to understand clinician decision making around obesity medication use, as well as the effects of long-term use of GLP-1 medications. Advocacy work is needed to improve coverage for obesity medication for eligible pediatric patients. Lastly, the accessibility of IHBLT programs (beyond nutrition referral) must be improved in order to support the long-term health and behavior lifestyle changes needed to treat obesity.

Pediatricians are facing a growing obesity epidemic that is not going away with nutrition or IHBLT alone. As more obesity medications are developed and approved for use in pediatrics it is imperative that pediatricians start building their knowledge, confidence and resources to prescribe and manage obesity pharmacotherapy.