Like many GPs around the UK, Semiya Aziz has grown accustomed to seeing children as young as four or five who are obese. Knowing how best to address this delicate and complex issue with parents, given the time constraints of a 10-minute consultation, is a challenge for GPs, who are increasingly shouldering the burden of the UK’s burgeoning child obesity crisis.
“It’s very difficult to actually say, ‘Look, your child is overweight and needs to go on a programme,’” says Aziz, whose practice is in Palmers Green, north London. “There’s a big taboo with discussing it, as parents don’t want to upset their children. And GPs don’t have time in a short consultation to get those educational measures about healthy lifestyles across and delve into the child’s habits.”
Yet the numbers of overweight and obese children are continuing to rise. The latest data collected as part of the National Child Measurement Programme has found that more than 10% of four- to five-year-olds are now obese. For 10- to 11-year-olds, the figure is 23.4%.
GPs are seeing teenagers with high blood pressure, elevated cholesterol and type 2 diabetes – conditions more commonly associated with late middle age. Aziz is not alone in feeling concerned about the consequences for public health and society in general.
“It’s a huge problem and we aren’t addressing it,” she says. “It’s like a tsunami waiting to hit the UK in the coming years, because these medical problems are hitting a younger population. You’ve also got mental health problems because children are growing up being teased about being overweight.”
Many healthcare systems are now turning to the pharmaceutical industry for answers – in particular, the drug semaglutide, sold under brand names such as Wegovy for weight loss and Ozempic for type 2 diabetes. In December 2022, the US Food and Drug Administration (FDA) approved certain doses of the drug for over-12s, and in January, the American Academy of Pediatrics (AAP) updated its clinical obesity practice guidelines to include medication alongside lifestyle changes such as a low-calorie diet and exercise. Last month, the European Medicines Agency’s human medicines committee also approved semaglutide for use in adolescents aged 12 and over.
It is already clear that such a drug can help obese children lose weight. Last year, the results from a clinical trial called Step Teens, conducted by Novo Nordisk – the Danish pharmaceutical company that manufactures semaglutide – found that 12- to 18-year olds with obesity reduced their BMI by 16% after taking the drug for around 15 months.
US experts in child obesity point to the need for new solutions, with the latest data, collected between 2017 and 2020, suggesting that nearly 20% of all adolescents are obese.
“I think medications have to be part of the armamentarium of options for adolescents,” says Sarah Barlow, professor of paediatrics at the University of Texas Southwestern Medical Center in Dallas, and a co-author of the new AAP guidelines. “The more severe the obesity, the less likely that eating and activity changes alone are going to give a marked health benefit. If these lifestyle changes were wildly effective, we wouldn’t be talking about steps like medication.”
But specialists are concerned that such measures will lead to us becoming reliant on medications to tackle adolescent obesity, rather than government policymakers addressing the underlying causes. The UK is being more cautious, and while medical watchdog Nice had launched an appraisal into semaglutide for 12- to 17-year-olds, it was suspended last week after Novo Nordisk declined to supply the necessary evidence required to continue.
Aziz says that while she can see a use for medication in extreme, complex cases, where a patient might otherwise be offered bariatric surgery, there are questions about whether the NHS budget might be better spent on food and lifestyle education campaigns, as well as further obesity care programmes within schools and communities.
“It’s a slippery slope,” she says. “There are lots of positives about semaglutide, but I can’t see that it would be something I will be advocating. There is a huge need for community groups, and discussions around schools about food and diet.”
Safety fears
There is also the issue of potential side-effects. While semaglutide has made headlines, it is not the first obesity medication to have been considered for children. In the UK, a drug called orlistat – which works by blocking enzymes in your gut that digest fat – is licensed to help adolescents lose weight, but it is rarely prescribed by doctors because of the relatively modest benefits and the issues that can come with taking it, such as flatulence and rectal discharge.
Likewise, the FDA approved a drug branded as Qsymia, a combination of two existing medications, phentermine and topiramate, for over-12s with obesity in 2022. This also suppresses appetite but can have significant side-effects, from depression to joint pain to abnormalities in foetuses. “The topiramate can lead to sleepiness, maybe a little bit of cognitive impact,” says Barlow. “Plus, you have to be really careful with female patients of childbearing age.”
The possible side-effects of semaglutide include nausea, fatigue, heartburn and, in some rare cases, a painful condition called acute pancreatitis. Prof Keith Godfrey, the nutrition lead at the NIHR Southampton Biomedical Research Centre, says that while he can see a use for the drug in severe cases, he is concerned about the unknown impact on the many critical developmental processes that occur during adolescence.
“These treatments are an advance, but the long-term safety is untested, certainly in adolescence,” he says. “You can’t directly extrapolate from the data on adults, because there are special things about adolescents in terms of the body changes associated with puberty.”
Godfrey describes the children who might receive semaglutide as being merely “the tip of the iceberg” of the child obesity crisis. He feels that policymakers need to focus much more on addressing the origins of child obesity, many of which begin long before birth. Godfrey says there is a growing amount of research suggesting that children born to an obese mother, and perhaps even an obese father, are far more predisposed to becoming obese themselves because of various molecular switches that have been turned on during their development in the womb.
“If you do detailed studies using MRI, you can see that babies born to obese mothers already have high levels of fats in their abdomen,” he says. “These babies develop into overweight children and continue to be overweight adolescents unless they follow a high-quality diet or work hard at being physically active.”
There is also evidence that other lifestyle factors, such as malnutrition during pregnancy, and even smoking before pregnancy, can predispose an infant to becoming obese.
Godfrey is now working with the Labour MP Siobhain McDonagh and the charity Children’s Alliance to try to get policymakers to incorporate new guidelines for pre-pregnancy care into their political manifestos ahead of the next election. Earlier this year they tabled a motion before parliament which has so far been supported by MPs including John McDonnell, Caroline Lucas and Sir Peter Bottomley.
“The problem is, if you try to tackle some of these things in pregnancy, or after birth, it’s too late,” says Godfrey. “To address child obesity, we need more education and support for mothers to get themselves in better shape for pregnancy, and also interconception care between pregnancies.”
Without better care, such as programmes dedicated to assisting mothers in leading a healthy lifestyle while they are looking after a newborn baby, Godfrey fears that the child obesity crisis will only continue.
“The harsh reality is that a mother’s level of physical activity and her diet get acutely worse when her priority becomes looking after her baby,” he says. “The system isn’t set up for enabling mums to lose the weight they put on during pregnancy, so they enter the second pregnancy in a worse physical condition, which makes those children more likely to be predisposed to obesity.”
Hoping for the best
Novo Nordisk has received criticism for its extensive PR campaign to progress its semaglutide injections for adults, which involved paying more than £21.7m to health organisations and professionals over the course of three years. The company has since been suspended by the pharmaceutical trade body and lost its partnership with the Royal College of Physicians after a row over its sponsorship of weight-loss courses that promoted its medicines.
The impartiality of the recently suspended Nice appraisal of semaglutide for adolescents had been questioned after data collected by the Observer found that seven of the 26 organisations involved in helping Nice come to a decision had received payments from the company. Two UK children’s hospitals who advocated that Nice should consider making obesity medications available to children on the NHS were also found to have received funding from Novo Nordisk. The company has previously stated: “The insinuation that Novo Nordisk has deliberately acted outside of ethical or legal standards and proper processes is unfounded and misleading.”
There is no suggestion the payments broke any rules, while the recipients of the funding say that it did not influence their decision-making. A Nice spokesperson told the Observer that members of the independent committee that helps Nice make decisions are aware of any potential conflict of interest declarations from relevant stakeholders. “We understand that stakeholders represent their organisations’ view,” the spokesperson said. “Our process takes this into account, and we collect financial and other interests according to our policy.”
Aziz predicts many GPs will be reluctant to prescribe the drug, even if authorised by Nice, because the burden of dealing with children suffering from side-effects will fall on primary care services that are already chronically overstretched.
“I think a lot of GPs will be cautious, because they know there will be a whole set of scenarios following on from prescribing a child semaglutide,” she says. “There will also need to be support regarding diet, exercise and follow-ups, and who will be providing all that?”
Robert Lustig, a paediatric endocrinologist who led the University of California, San Francisco paediatric obesity programme for 17 years, describes semaglutide as a way of bypassing the main problem, rather than actively dealing with it.
“It’s a Band-Aid,” he says. “Giving a medicine just to do weight loss is basically closing your eyes and hoping for the best.”
Lustig feels that to really tackle child obesity, investing in education and care programmes alone is not enough, as it is both a socioeconomic problem and a public health one, with statistics showing that rates of child obesity are worsening in deprived communities. Given the impact of the cost of living crisis on many communities, he believes that the only real solution is taxes on ultra-processed foods, which can be used to subsidise healthier options and make them more affordable for poorer families.
“The UK’s soft drinks tax was a start,” he says. “It would be much less risk and much greater benefit if governments subsidised real food by taxing ultra-processed food. That would be a zero-sum game for the government and the population. You would [create] trillions a year and get better weight loss and resolution of all these associated diseases.”
If countries continue to go down the medicalisation path, Lustig fears there could be long-reaching psychological consequences for many children. “By medicalising the problem, and basically telling the kids they need medicine when they don’t, you’re setting them up to feel like they’re not in control,” he says.
Aziz fears that if semaglutide is approved for adolescents, it will be a gateway for more obesity drugs and a culture of quick fixes.
“It needs to be used only in extreme situations, where the child is assessed psychologically and socially before being offered the drug,” she says. “It shouldn’t be widespread. That would be defeating the object of health, and we will hit the NHS budget even worse. What I can’t understand is that we never go back to basics. We go to the end problem rather than the root cause.”
