GLP-1 Medications for Adolescent Obesity: Wegovy Approval and STEP TEENS Results

What Are GLP-1 Medications and How Do They Treat Adolescent Obesity?

GLP-1 (glucagon-like peptide-1) receptor agonists were originally developed for type 2 diabetes management but have demonstrated remarkable efficacy for weight loss. These medications work by mimicking the natural incretin hormone GLP-1, which slows gastric emptying, reduces appetite, and enhances satiety signaling in the brain. Semaglutide, marketed as Wegovy for weight management, received FDA approval for adolescents aged 12 and older in December 2022.

Liraglutide (Saxenda) was the first GLP-1 receptor agonist approved for adolescent obesity in 2020, also for patients aged 12 and older. However, semaglutide has shown substantially greater efficacy in clinical trials. The once-weekly injection schedule of Wegovy also offers a practical advantage over liraglutide's daily dosing, potentially improving adherence in the adolescent population.

The American Academy of Pediatrics (AAP) released updated clinical practice guidelines in January 2023 that marked a significant shift in pediatric obesity treatment. For the first time, the AAP explicitly recommended pharmacotherapy for children aged 12 and older with obesity (BMI at or above the 95th percentile), recognizing that lifestyle interventions alone are often insufficient for severe obesity.

What Did the STEP TEENS Trial Reveal About Semaglutide in Adolescents?

The STEP TEENS (Semaglutide Treatment Effect in People with Obesity – Teenagers) trial, published in the New England Journal of Medicine in 2022, was a randomized, double-blind, placebo-controlled study involving 201 adolescents aged 12 to 17 with obesity or overweight with at least one weight-related comorbidity. Participants received either semaglutide 2.4 mg or placebo via weekly subcutaneous injection for 68 weeks, alongside lifestyle intervention.

The results were striking: participants in the semaglutide group achieved a mean change in BMI of -16.1% from baseline, compared to just +0.6% in the placebo group. Furthermore, 73% of semaglutide-treated adolescents achieved at least 5% weight loss, and 62% achieved at least 10% weight loss. The treatment also improved cardiometabolic risk factors, including waist circumference and markers of glycemic control.

Adverse events were consistent with the known GLP-1 receptor agonist profile, primarily gastrointestinal symptoms including nausea, vomiting, and diarrhea. These effects were generally mild to moderate and tended to decrease over time. Importantly, the study found no adverse effects on linear growth, pubertal development, or overall nutritional status in adolescent participants.

What Do AAP Guidelines Recommend for Severe Pediatric Obesity?

The AAP Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity, published in January 2023, represented a paradigm shift from the previous "watchful waiting" approach. The guideline emphasizes that obesity is a chronic disease requiring proactive, evidence-based treatment rather than the expectation that children will simply "grow out of it." It recommends intensive health behavior and lifestyle treatment (IHBLT) with 26 or more hours of contact over 3 to 12 months as the foundation of treatment.

For adolescents aged 12 and older with obesity, the AAP recommends that clinicians offer pharmacotherapy in addition to IHBLT. Currently approved medications include semaglutide (Wegovy) and liraglutide (Saxenda), both GLP-1 receptor agonists. For adolescents aged 13 and older with severe obesity (BMI at or above 120% of the 95th percentile), the guideline recommends evaluation for metabolic bariatric surgery at experienced pediatric centers.

The guidelines stress the importance of addressing obesity early, noting that 80% of adolescents with obesity will continue to have obesity in adulthood. Treatment should be family-centered, culturally sensitive, and free from stigma. The AAP also acknowledges health disparities, noting that obesity disproportionately affects Black, Hispanic, and American Indian/Alaska Native children, and calls for equitable access to evidence-based treatments.

What Are the Long-Term Considerations for GLP-1 Use in Adolescents?

One of the most significant concerns with GLP-1 receptor agonists in adolescents is weight regain after treatment discontinuation. The STEP 1 trial extension in adults showed that participants regained approximately two-thirds of their weight loss within one year of stopping semaglutide, suggesting that long-term or indefinite treatment may be necessary to maintain benefits. This raises important questions about the feasibility and implications of lifelong medication use beginning in adolescence.

Cost remains a substantial barrier to access. Wegovy carries a list price of approximately $1,350 per month, and insurance coverage for anti-obesity medications in adolescents is inconsistent. Many commercial insurers and state Medicaid programs have coverage limitations or prior authorization requirements that can delay or prevent access. The AAP and obesity medicine organizations continue to advocate for improved insurance coverage of evidence-based obesity treatments.

Ongoing research is examining the safety and efficacy of GLP-1 receptor agonists in younger children (under age 12), combination approaches with other anti-obesity medications, and the optimal duration of treatment. Clinicians must weigh the significant benefits of early obesity treatment against the uncertainties of long-term medication use during critical developmental periods, including puberty and peak bone mass acquisition.