#175: Live! Small Doses, Big Changes: Updates in Obesity Medicine with GLP-1s

April 22, 2026 | By Joan Park

Audio

Recorded live at Grand Rounds at the Johns Hopkins Children’s Center—our first episode from the stage! In this episode, Dr. Stephanie Green joins the team to discuss the rapidly evolving treatment landscape for pediatric obesity. We discuss GLP-1 receptor agonists, focusing on how these medications work, when they should be used, and how clinicians can integrate them into comprehensive obesity care.

Obesity Management and GLP-1 Pearls

1. Pediatric obesity is a chronic disease with biological drivers, not simply a behavioral issue.
2. GLP-1 receptor agonists work by increasing satiety and decreasing appetite, primarily through hypothalamic pathways.
3. Semaglutide (weekly) and liraglutide (daily) are currently the main GLP-1 medications approved for adolescents with obesity.
4. A slow titration strategy significantly reduces gastrointestinal side effects.
5. Perfection is the enemy of good. Small, sustainable changes- combined with appropriate medical therapy- can significantly improve pediatric metabolic health

Pediatric Obesity and GLP-1 Notes 

Talking with Patients about Weight Management

Discussing weight with children and families requires careful framing and shared decision-making. Dr. Green recommends using growth charts to guide the conversation. Her suggested approach:

1. Ask permission before discussing the growth chart
2. Start with the height chart. This can be less triggering than weight
3. Explain percentiles and trends over time 
4. Discuss genetic influences on height and weight
5. Use BMI percentiles as a screening tool
6. Focus on health outcomes rather than weight numbers. Patients can be healthy at many body sizes. Health should be evaluated using labs, vitals, and comorbidities, not BMI alone. 

Starting GLP-1 Agonists

Lifestyle therapy alone is less effective both with increasing obesity and as children get older. Watchful waiting is not an effective therapy for most patients. The 2023 AAP guidelines recommend considering anti-obesity medications: 

• Age ≥12 for patients with obesity
• Age 8-11 in select cases

Dr. Green offers pharmacotherapy when patients have Class 2 obesity (120% of the 95th percentile for BMI) or Class 3 obesity (140% of the 95th percentile for BMI) OR Class 1 obesity (95th percentile for BMI) with comorbidities. Consider delaying medication if 1) BMI is stable; 2) Lifestyle changes are effective; 3) No comorbidities are present

GLP-1 agonists mimic the natural incretin hormone that regulates appetite. Effects include: 

• Delay gastric emptying, prolonging fullness
• Reduce appetite signaling
• Reduce craving for calorie-dense foods
• Help prevent the metabolic slowdown seen in calorie restriction alone. 

GLP-1 Medications in Pediatrics

Treatment Goals 

A good benchmark to work towards is 5-10% improvement in BMI. Dr. Green avoids a specific target weight as that can be triggering for some patients. Many patients respond before reaching the maximum dose. Typical safe weight loss is 1-2 lbs/month in young children and 1 lb/week in adolescents. Rapid weight loss (>2 lb/week) should prompt dose reduction. Continue to evaluate comorbidities through treatment. 

Side Effects

Start at the lowest dose and titrate slowly to minimize side effects. (Per Dr. Green, you don’t need to go as fast as what’s written on the manufacturer’s box!) The most common side effects are gastrointestinal: nausea (especially 12-48 hours after injection), diarrhea, and constipation. Serious but rare side effects are pancreatitis and gallbladder disease. 

Monitoring Nutrition

Reduced appetite can lead to micronutrient deficiencies. Dr. Green monitors Vitamin D and C, Iron and Folate. Many patients benefit from multivitamins with minerals. 

Rapid weight loss may lead to loss of lean muscle mass. Dr. Green recommends consuming 15-30 g of protein per meal and at least 3 resistance-training sessions per week. 

Contraindications 

Contraindications for GLP-1 therapy include pregnancy and a family history of medullary thyroid carcinoma and MEN type 2 syndrome. Use with caution in patients with prior episodes of pancreatitis. 

Disordered eating should be assessed before prescribing. Ask about binge eating, emotional eating, and night eating. Studies suggest GLP-1 may reduce disordered eating behaviors by addressing underlying metabolic dysregulation. Patients with suspected eating disorders should be referred to therapy. 

Duration of Therapy

Most patients require long-term treatment. If medications are stopped, appetite often increases, and some weight regain is typical. 

Insurance Cost and Barriers 

GLP-1s can be expensive and often require prior authorization. Dr. Green recommends documenting comorbidities (OSA, PCOS, diabetes risk) and referencing clinical guidelines. Some brands have discounts if purchasing out-of-pocket.

If not affordable, consider less expensive oral medications such as Metformin, Topiramate, Phentermine, or Lisdexamfetamine. (Stay tuned for a follow-up episode on these non-GLP-1 agents!) 

Links

Healthy Families Culinary Medicine Program

Goal

Listeners will gain practical skills to initiate and manage pharmacologic treatment for pediatric obesity, particularly GLP-1 agonists.

Learning Objectives

After listening to this episode, listeners will…  

1. Explain the mechanism of action of GLP-1 agonists and their role in appetite regulation
2. Identify when GLP-1 should be considered for pediatric obesity
3. Recognize common side effects and contraindications associated with GLP-1 therapy in children.
4. Describe dosing strategies and monitoring for GLP-1s.
5. Integrate GLP-1 therapy into comprehensive obesity care, combining lifestyle interventions, monitoring, and patient/family counseling.

Disclosures

Dr. Green reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Park J, Green S, Chiu C, Masur S. “#175: Live! Small Doses, Big Changes: Updates in Obesity Medicine with GLP-1s”. The Cribsiders Podcast. https:/www.thecribsiders.com/ 22 April 2026.