NUR 7074 Module 5 Adolescent Obesity Paper: Evaluating Comorbidities and Offering Intensive Treatment and Medication Example

No More Waiting: Treating Severe Obesity in a Teenager With Prediabetes

Student Name

M.S. in Nursing, Family Nurse Practitioner, Thomas Edison State University

NUR-7074: Adolescent and Early Adult Primary Care

Mentor Name

Month Day, Year

No More Waiting: Treating Severe Obesity in a Teenager With Prediabetes

The Patient

Jasmine Carter, an invented 15-year-old, came with her grandmother, who is her guardian, for a school physical. Her body mass index is 36, which is more than 120 percent of the 95th percentile for her age and sex, placing her in the category of severe obesity. Her blood pressure was 128/80. She had acanthosis nigricans on the back of her neck. She snores and is often tired at school. She eats school breakfast and lunch, snacks after school while her grandmother works and spends four to five hours a day on her phone. Both her mother and grandmother have type 2 diabetes. When I asked how she felt about her weight, she said she was tired of being teased and wanted to "do something."

How Common the Problem Is

Skinner et al. (2018) examined national survey data spanning 1999 through 2016 and reported no lasting decline in obesity among American children and teens over that time, that severe obesity remained common and had increased in some groups, and that rates were highest among Black and Hispanic youth and in adolescents. Severe obesity in adolescence carries a high risk of persisting into adulthood and of early type 2 diabetes, fatty liver disease, hypertension and sleep apnea.

What the Guideline Recommends

Hampl et al. (2023) reject watchful waiting. They recommend that clinicians evaluate and treat overweight and obesity promptly, using respectful, person-first language and recognizing obesity as a chronic disease shaped by genetics, environment and social conditions. For adolescents with obesity aged 10 and older, they recommend laboratory screening for lipid abnormalities, abnormal glucose metabolism and fatty liver disease. Treatment centers on intensive health behavior and lifestyle treatment, family-centered and delivered over at least 26 hours of contact in 3 to 12 months. From age 12, adolescents with obesity should be offered medication on top of this treatment, and should offer referral for evaluation for metabolic and bariatric surgery to adolescents 13 and older with severe obesity.

Screening Jasmine

An A1C of 6.1 percent placed her in the prediabetes range. Her ALT was 52, about twice the upper limit for girls, suggesting fatty liver disease. Her triglycerides were 190 and HDL 36. Her blood pressure was elevated for her age. Her loud snoring and daytime sleepiness suggested obstructive sleep apnea, and a sleep study was ordered. Her thyroid tests were normal.

Evidence for Medication

Weghuber et al. (2022) randomly assigned 201 teenagers with obesity, ages 12 through 17, to either placebo or a 2.4 mg semaglutide injection once a week, and every participant also received lifestyle counseling over the 68 weeks. Mean BMI fell by about 16 percent with semaglutide and rose slightly with placebo. Nearly three quarters of those on semaglutide lost at least 5 percent of their weight, compared with about one in five on placebo. Improvements were also seen in waist size, A1C, lipids and liver enzymes. Gastrointestinal side effects, such as nausea and vomiting, were more common with semaglutide, and a few participants developed gallstones.

Talking About Weight

I used person-first language, saying "a weight that is affecting your health," and avoided blame. I asked Jasmine what she wanted to change, and she named feeling less tired and being able to play basketball with her cousins. Motivational interviewing kept the focus on her goals and on changes she chose.

Family-Based Treatment

Jasmine and her grandmother were referred to the hospital's adolescent weight management program, which offers family-centered sessions with a dietitian, exercise specialist and psychologist over six months, meeting the guideline's intensity. In the meantime, they agreed on three changes: water instead of sweetened drinks, a planned after-school snack and putting her phone away an hour before bed to help her sleep.

Shared Decision on Medication

We discussed semaglutide as an addition to the program, including its likely benefit, weekly injections, nausea, the need for long-term use to maintain results and cost. Her grandmother worried about giving an injection to a teenager; Jasmine wanted to try it. They chose to start the program first and decide about medication at the next visit in one month, after checking insurance coverage. Metformin, which has a smaller effect on weight, was discussed as an option for her prediabetes.

Food and Daily Routine

Jasmine's grandmother works until 7 p.m., so afternoons are unsupervised and snacks come from a corner store. The program's social worker connected the family with SNAP benefits and a local after-school recreation program with a supervised snack, changes that address the setting in which Jasmine makes her choices.

Bullying and Mental Health

Teasing about weight is common and harmful. Jasmine's PHQ-A score was 6, and she was given the name of the school counselor and invited to talk with the program psychologist about the teasing.

Follow-Up

She will return in one month to review progress, her sleep study and the medication decision, and then monthly while starting treatment. Her A1C, ALT and lipid panel will be rechecked after three to six months. Her grandmother will be invited to every visit, and Jasmine will also have time alone with the clinician.

Limits

STEP TEENS was sponsored by the manufacturer and lasted 68 weeks; long-term effects of semaglutide in adolescents are unknown. Intensive programs are not available in every community. The patient is invented.

Conclusion

Skinner and colleagues showed that severe obesity remains common among teenagers, Hampl and colleagues called for prompt evaluation and treatment rather than waiting and Weghuber and colleagues showed that semaglutide can substantially lower BMI in adolescents. Comorbidity screening, respectful conversation, family-based treatment and a shared decision about medication give Jasmine care that takes her health and her goals seriously.

References

Hampl, S. E., Hassink, S. G., Skinner, A. C., Armstrong, S. C., Barlow, S. E., Bolling, C. F., Avila Edwards, K. C., Eneli, I., Hamre, R., Joseph, M. M., Lunsford, D., Mendonca, E., Michalsky, M. P., Mirza, N., Ochoa, E. R., Sharifi, M., Staiano, A. E., Weedn, A. E., Flinn, S. K., . . . Okechukwu, K. (2023). Clinical practice guideline for the evaluation and treatment of children and adolescents with obesity. Pediatrics, 151(2), Article e2022060640. https://doi.org/10.1542/peds.2022-060640

Skinner, A. C., Ravanbakht, S. N., Skelton, J. A., Perrin, E. M., & Armstrong, S. C. (2018). Prevalence of obesity and severe obesity in US children, 1999-2016. Pediatrics, 141(3), Article e20173459. https://doi.org/10.1542/peds.2017-3459

Weghuber, D., Barrett, T., Barrientos-Pérez, M., Gies, I., Hesse, D., Jeppesen, O. K., Kelly, A. S., Mastrandrea, L. D., Sørrig, R., & Arslanian, S. (2022). Once-weekly semaglutide in adolescents with obesity. New England Journal of Medicine, 387(24), 2245-2257. https://doi.org/10.1056/NEJMoa2208601