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¹ This list is the rapporteur’s summary of points made by the individual speakers identified, and the statements have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine. They are not intended to reflect a consensus among workshop participants.

The second session continued with presentations focused on mental and behavioral health considerations related to obesity treatment in adults, children, and adolescents. Jeanne Blankenship, Academy of Nutrition and Dietetics, joined Joseph Nadglowski, Obesity Action Coalition, to moderate the session.

MENTAL AND BEHAVIORAL HEALTH CONCERNS FOR ADULTS USING ANTI-OBESITY MEDICATIONS

Robyn Pashby, Health Psychology Partners, provided the perspective of an obesity-trained psychologist on the relationship between obesity and AOMs, which is underpinned by a complex constellation of factors (Figure 4-1). These encompass physical health factors—such as comorbidities that may need to be monitored (e.g., type 2 diabetes, gastrointestinal symptoms)—and cognitive factors, such as attention and executive function. Trauma is another contributor that includes both external weight stigma and internalized bias. She focused on four mental and behavioral health considerations experienced by adults who are treated with AOMs: nonspecific mental health concerns, ED and body image, food noise, and mood and suicidal ideation (SI).

Nonspecific Mental Health Concerns

Among patients receiving AOMs, common diagnoses include depression, anxiety, attention deficit/hyperactivity disorder (ADHD), posttraumatic stress disorder, obsessive–compulsive disorder, and suicidality. However, Pashby cited a host of nonspecific (“other”) mental health concerns that affect patients’ quality of life, mental health, and use and management of AOMs beyond diagnosable psychiatric conditions.

Among patients receiving AOMs in Pashby’s clinical practice, common concerns include the following:

• Obtaining the medication,
• Managing the logistics of the medication (e.g., travel, missed doses, dosing errors),
• Managing and enduring the medication’s side effects,
• Losing or not losing weight on the medication,
• Affordability and/or insurance coverage,
• Concerns about the provider’s power to revoke the medication,
• Concerns that the medication will stop working,
• Needing to talk about weight with providers,
• Needing to weigh,
• Talking to others about using medications,
• Feeling pressure to take medications for weight loss because it is “available,”
• Feeling like a “cheater” or “stealing” medications from others, and
• Navigating other medical issues (e.g., surgery).

Pashby noted the virtually no formal research in this area; the narrative around these issues—and including strategies to address them—is largely occurring on social media platforms (Arillotta et al., 2023). For instance, the “Ozempic” hashtag had been viewed 1.4 billion times on the TikTok social network platform as of March 2024. She called for more research on these nonspecific mental health considerations, because patient continuation and discontinuation of medications likely hinge on these “other” factors—and recommended that providers have broader psychological discussions with their patients. She also highlighted the need to increase the number of obesity-trained mental health professionals and integrate mental health into primary and specialty care settings.

EDs and Body Image

Turning to eating disorders (EDs) and body image, Pashby emphasized that all AOMs should be prescribed in conjunction with psychological, dietary, and behavioral support to navigate the relationships between disordered eating and obesity care. A major concern is that AOMs may be misused—intentionally and unintentionally—by individuals with a history of restrictive EDs or a strong drive for thinness. Research indicates that people at “normal” and higher weights are less likely to seek or be referred for ED treatment, said Pashby (Lebow et al., 2015; Sim et al., 2013). However, patients with a history of high weight account for a large percentage of those who are ultimately admitted for inpatient ED medical stabilization (up to 45 percent). Atypical anorexia, also known as “higher-weight anorexia nervosa,” is a new diagnosis in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), but it is rarely studied in people with obesity or those receiving AOMs. She noted that binge-eating disorder—the most common ED—has high comorbidity with obesity, but certain AOMs may be beneficial. For example, semaglutide has been associated with a significant reduction in binge-eating scale scores over time in comparison to other AOMs (Richards et al., 2023). In Pashby’s clinical practice, her patients on AOMs have reported reduced binge eating, food cravings, loss-of-control overeating, and concerns about body image and shape. She has also seen increases in confusion about fullness and hunger signals and increased restriction. Pashby recommended screening for disordered eating and disordered body image cognitions or behaviors, monitoring the rate of weight loss and restriction, differentiating between “pathological” and “nonpathological” dietary restriction, and observing patients as the effects of medication attenuate or people discontinue them (Richards and Khalsa, 2024).

and/or underactivity on mental health symptoms, (2) shared risk factors (e.g., toxic stress in early years, low socioeconomic status), (3) stigma related to obesity and mental health conditions that can exacerbate each problem independently and in combination, and (4) medications to treat mental health conditions, such as antipsychotics, which can lead to weight gain (Avila et al., 2015; Halfon et al., 2013; Nicol et al., 2016; Scott et al., 2008a,b; Simon et al., 2006).

Mental Health Considerations in RCTs of AOMs in Youth

Wilfley discussed mental health considerations related to the RCTs that have been conducted for FDA-approved pharmacotherapy treatments for children and adolescents (e.g., orlistat, liraglutide, semaglutide, phentermine and topiramate). Across those RCTs, stringent exclusion criteria were used for mental health conditions, including depression, suicidality, schizophrenia, bipolar disorder, EDs, substance use disorder, and ADHD. Consequently, clinical practitioners routinely prescribe AOMs to youth not represented in the RCTs (Chanoine et al., 2005; Kelly et al., 2020, 2022; Maahs et al., 2006; Weghuber et al., 2022). Although the limited data collected for psychosocial outcomes as part of these RCTs suggest that the AOMs were not associated with adverse psychosocial outcomes, she cautioned that these observations are based on homogeneous samples within short-term studies. Wilfley explained that AOMs can have variable mood effects in different types of patients. To illustrate, she presented a pair of case reports depicting two potential pathways for patients with semaglutide-associated depression (Li et al., 2023). In one case, the patient had no history of mood disorder and developed depression-like symptoms after initiating semaglutide injections; the symptoms improved once the drug was withdrawn. In the other case, the patient had a history of a psychiatric disorder but was stable when starting semaglutide, after which they had an increase in mood deterioration; their mood improved after discontinuing the treatment. Wilfley added that there are also cases in which treatment with GLP-1 medication positively impacts the patient’s mood.

Medical Complications and Consequences of Rapid Weight Loss

There is increased understanding and recognition that rapid weight loss is associated with a range of medical complications and consequences, noted Wilfley. Unique medical complications of starvation may be present in children and adolescents with weight loss despite presenting at healthy or above healthy weights. Failure of adequate energy intake or weight gain in a growing child or adolescent may have the same medical complications as overt weight loss, she explained. For instance, children and adolescents with

inadequate energy intake may be at risk for serious medical complications, including medical instability and refeeding syndrome. Thus, for AOMs or treatments involving changes in dietary intake and the potential for rapid weight loss, it is important to monitor patients during nutritional rehabilitation. For example, refeeding risk—which may be present in patients at any presentation weight with inadequate energy intake—is associated with refeeding hypophosphatemia, hypokalemia, hypomagnesemia, and thiamine deficiency (Tanner, 2023).

Wilfley highlighted new criteria from the American Society for Parenteral and Enteral Nutrition on refeeding risk in children and adolescents, which defines weight loss as failure to gain weight as expected and energy insufficiency as 7 or more consecutive days of inadequate protein or energy intake (less than 75 percent of estimated needs). She added that according to the Society for Adolescent Health and Medicine’s proposed classification, adolescents and young adults are at severe risk of malnutrition with a rapidity of weight loss greater than 5 percent in 1 month, 7.5 percent in 3 months, or greater than 10 percent in 6 months. Malnutrition can cause potentially irreversible medical complications that include negative impact on linear growth, bone deposition, and brain maturation.

Bariatric surgery is also associated with mental and physical health concerns among adolescents, said Wilfley. Although it is an effective treatment option for many adolescents with severe obesity and positively impacts weight-related quality of life—particularly physical aspects—ongoing monitoring and assessment before and after surgery is critical for mental health outcomes. For instance, it has been linked to increased risk of alcohol use disorder and associated diseases, lower percent BMI change at follow-ups in individuals with postoperative loss-of-control eating, and increased suicide risk in adults (Alvarado-Tapias et al., 2023; Beamish et al., 2023; Decker et al., 2022; Goldschmidt et al., 2018; White et al., 2023; Williams et al., 2020).

Intensive Health, Behavior, and Lifestyle Treatment (IHBLT) and Mental Health Outcomes

Evidence-based IHBLT is recommended by the American Academy of Pediatrics (AAP) as a foundation in mental health outcomes, said Wilfley. She clarified that this is not dieting. To illustrate, she parsed the relationship between self-directed dieting by patients with obesity and health-related outcomes (Cardel et al., 2022). Self-directed dieting tends to lead to unsustainable disordered eating behaviors, including severe avoidance of certain types of foods and cycles of severe restriction and excessive intake. She described this process as a gateway to EDs and low self-esteem. In contrast, supervised evidence-based treatments for obesity focus on increasing sustainable, healthy behaviors to achieve sustainable improvements in

health outcomes and self-worth, such as meal planning and regular eating schedules, improved diet quality without restriction, self-monitoring, and movement that brings joy. Family-based treatment is a robust IHBLT that can serve as an important intervention to prevention and early treatment of EDs, Wilfley continued. It can improve psychosocial function—particularly ED-related attitudes and behaviors—through a range of strategies: (1) developing healthy energy-balance behaviors and routines, (2) increasing positive parenting and a positive shared home environment, (3) promoting positive body image and self-esteem, (4) increasing supportive family and peer networks, and (5) creating and choosing environmental and community contexts to promote overall physical and mental well-being (Epstein et al., 2023; Wilfley et al., 2007, 2017).

Exploring Future Research Needs

Wilfley concluded by highlighting a set of research needs to build the knowledge and practice around mental health considerations related to treatment with AOMs in youth. She suggested including broader samples that are representative of youth with obesity and mental health comorbidities in evaluating AOMs and establishing a system for screening and monitoring all youth who receive them for possible ED and mental health safety concerns. Ongoing studies would benefit from optimized assessment tools that include comprehensive psychosocial measures collected routinely at all time points. She recommended evaluating IHBLTs as a complement to AOMs at the intensity (i.e., dose and duration) required to build and sustain long-term lifestyle habits, given that patterns of physical activity to preserve muscle mass, coupled with high-quality dietary nutrition, are critical and can be sustained within the family context. She also called for assessing the risk for EDs associated with AOMs and developing standards for safe titration based on the rapidity and extent of weight loss. Finally, she highlighted the need to overcome barriers to reimbursement for comprehensive care for obesity and address social needs (e.g., food insecurity), adverse childhood experiences, and stigma related to obesity.

DISCUSSION

Potential Opportunities to Improve Obesity Care

Nadglowski asked about opportunities to improve obesity care for adults, adolescents, and children. Pashby suggested strengthening the provider–patient relationship. For example, obesity physicians should build trust with their patients, listen to their patients talk about their lived experiences, and foster long-term provider–patient partnerships to collaboratively

determine the best treatment path and then reevaluate that path over time. Wilfley underscored the importance of early intervention and identifying—and addressing—issues that may be contributing to excess weight gain (e.g., ED, unmet social needs). Digital care could also help to broaden access to evidence-based psychosocial treatments for patients and families, she added. Pashby emphasized that all providers engaged in obesity treatment should be trained in trauma-informed care to create a safe space for patients to share their concerns and experiences, including any adverse side effects of complications from AOMs. Specifically, she suggested that all providers should be trained in how to interact with patients who have lived with internalized weight bias, had traumatic life experiences, have mental health conditions, or simply had the experience of living with larger bodies in the current culture.

Collaborative Care for Obesity Treatment

To improve interprofessional collaboration around AOMs and health outcomes, Pashby recommended integrating mental and behavioral health into a range of care settings—from obesity specialty care to primary care to hospitals—and noted that mental health providers often have different relationships with patients than physicians do, because they tend to see patients more frequently. Wilfley commented that in Missouri, Medicaid has worked to establish a collaborative care model for individuals with obesity that includes a physician or PCP, behavioral health specialist, and registered dietitian; the provider encourages them to work together by the payer. Because of that cost-share, Medicaid patients can now access that care for free. She added that Missouri has also established interdisciplinary training and workgroups that span different areas of obesity care.

Impact of Non-Evidence-Based Approaches to Addressing Obesity

Nadglowski asked about the impact on patients’ lives of non-evidence-based approaches to addressing obesity. Wilfley said that youth—who are in a reward-focused phase of brain development—are particularly vulnerable to obesity-related bullying and victimization, which can create a strong drive for thinness. This is exacerbated by excessive use of social media and the prevalent use of diet products, which are advertised heavily to this age group. Even when youth receive optimal obesity care, she continued, concerns arise related to AOMs, such as side effects, poor tolerability, barriers to access, and lack of robust support structures. She added that the shame of rapid weight regain may contribute to heightened vulnerability and risk of suicidality. A balance will need to be struck between profiting from the potential of these medications and ensuring they are as safe as possible,

she continued. Pashby highlighted the importance of supporting patients in making informed, autonomous decisions about how and when they choose to use AOMs; she suggested further exploring the psychological factors that influence people’s maintenance or discontinuation of the medication (e.g., body image, disordered eating history). She noted that patients of any age may fall victim to non-evidence-based “snake oil treatments” that prey on their vulnerabilities, because of the psychological history that comes with living in a larger body. She called for research on strategies to reduce internalized weight bias and implementing decision-making factors that imbue patients with confidence in evidence-based care, so they are less tempted by non-evidence-based approaches.

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