Teens on GLP-1s: Bariatric Surgery Down Three-Fold, GLP-1 Monotherapy Now 96% of Adolescent Obesity Treatment (JAMA Pediatrics)

About 9% of US adolescents ages 12-18 currently meet criteria for severe obesity (BMI at or above 120% of the 95th percentile for age and sex, or BMI ≥ 35). That proportion has more than doubled over the past two decades. Severe obesity in adolescence tracks strongly into adulthood, elevates lifetime cardiovascular and metabolic risk, and is associated with substantial psychosocial burden.

Through 2020, the primary evidence-based treatment for severe adolescent obesity that consistently produced substantial long-term weight loss was metabolic and bariatric surgery (MBS), most commonly sleeve gastrectomy or Roux-en-Y gastric bypass. The American Academy of Pediatrics (AAP) 2023 Clinical Practice Guideline formally endorsed MBS as an appropriate option for adolescents with severe obesity, alongside intensive health behavior and lifestyle treatment and adjunctive pharmacotherapy.

The pharmacologic landscape then shifted quickly. The FDA approved Wegovy (semaglutide) for adolescents ages 12+ in December 2022. The FDA approved Zepbound (tirzepatide) for adolescents ages 12+ in early 2025. Insurance coverage expanded unevenly but substantially. Real-world clinical practice adapted.

On July 20, 2026, JAMA Pediatrics published a study by UT Southwestern Medical Center researchers documenting how substantially real-world adolescent obesity treatment has shifted in three and a half years. The study analyzed 204,000+ US adolescents and young adults ages 13-25 treated for obesity between May 2022 and January 2026 using the Epic Cosmos electronic health record database. Two findings anchor the paper:

1. The share of these patients using only GLP-1 receptor agonist drugs (GLP-1 monotherapy) rose from 88.2% (May-November 2022) to 96.1% (June 2025-January 2026)

2. The share of these patients undergoing metabolic and bariatric surgery (MBS) fell from 11.6% to 3.7% over the same period

Combined GLP-1 + MBS use remained rare across the study window at approximately 0.2%. This piece explains what the study measured, why the numbers matter, what they do and do not tell parents making decisions today, and what questions to bring to a pediatric or adolescent-medicine appointment.

The Epic Cosmos database aggregates de-identified electronic health record data from health systems that use Epic (the largest US electronic health record vendor). Cosmos currently covers approximately 260 million patient records across 200+ health systems.

The UT Southwestern researchers extracted records from patients ages 13-25 treated for obesity between May 2022 and January 2026. The starting cutoff (May 2022) predates Wegovy's adolescent FDA approval (December 2022), which gives the study a genuine 'before' baseline. The ending cutoff (January 2026) captures the current landscape after Wegovy has been available for adolescents for three years and after Zepbound became available for adolescents in early 2025.

Each patient in the cohort had at least one recorded encounter for obesity diagnosis and at least one of three treatment interventions in the 12 months after that encounter:

• GLP-1 receptor agonist prescription (semaglutide, tirzepatide, liraglutide, or dulaglutide)
• Metabolic and bariatric surgery procedure (sleeve gastrectomy, Roux-en-Y gastric bypass, or adjustable gastric band)
• Both a GLP-1 prescription and MBS within the 12-month window (combined-modality use)

The researchers then binned the observations into six-month analysis windows (May-November 2022, December 2022-May 2023, June-November 2023, and so on through the six windows ending January 2026) and computed the share of patients in each window who received GLP-1 monotherapy, MBS monotherapy, or the combination.

The headline results:

• GLP-1 monotherapy share: 88.2% (window 1) rising to 96.1% (window 6)
• MBS monotherapy share: 11.6% (window 1) falling to 3.7% (window 6)
• Combined GLP-1 + MBS: approximately 0.2% (approximately constant across the window)

Secondary analyses stratified by age subgroup (13-17 ages vs 18-25 ages) and by baseline BMI showed similar directional trends, though the magnitude of the MBS decline was larger in the 18-25 subgroup than in the strict adolescent 13-17 subgroup.

The study is retrospective and observational. It does not include information on which patients would have been eligible for MBS under 2023 AAP guidelines (the surgical option is generally recommended for adolescents with BMI ≥ 40 or BMI ≥ 35 with obesity-related comorbidities). It does not track long-term outcomes for either treatment path. It documents what happened, not whether the pattern is clinically optimal.

The 88.2% → 96.1% GLP-1 monotherapy shift and the 11.6% → 3.7% MBS decline together describe a substitution effect: adolescents and young adults who would previously have received bariatric surgery are now receiving GLP-1 receptor agonist therapy instead.

The magnitude of the substitution is substantial. If the population of adolescents and young adults treated for obesity were held constant, the study documents roughly three-quarters of the previous MBS population moving to pharmacotherapy. That is a change of clinical decision-making pattern, driven by:

FDA adolescent approvals. Wegovy (semaglutide) was FDA-approved for adolescents ages 12+ in December 2022. Zepbound (tirzepatide) was FDA-approved for adolescents ages 12+ in early 2025. Prior to those approvals, only liraglutide (Saxenda) was FDA-approved for adolescents (approval expanded in 2020), and it produced substantially less weight loss than the newer agents. The approvals created a legitimate pathway for prescribing GLP-1s to a population that had previously been managed with lifestyle intervention or, for severe cases, surgery.

Family and adolescent preference. MBS is major surgery with lasting anatomical consequences. GLP-1 therapy involves weekly injection (or oral tablet, for Rybelsus). All else equal, most families and adolescents given a choice prefer a medication to a surgery.

Payer coverage expansion. Insurance coverage for GLP-1 receptor agonists in adolescents has expanded, though unevenly, since the 2022-2023 approvals. Coverage varies substantially by state, plan, and specific product. Medicaid coverage patterns differ from commercial coverage.

Practice guideline evolution. The 2023 AAP guideline endorsed pharmacotherapy alongside surgery. Subsequent updates and specialty-society guidance have continued to position GLP-1 receptor agonists as first-line for many adolescents with severe obesity, reserving MBS for cases where pharmacotherapy is inadequate or contraindicated.

What the substitution does not tell us is whether the clinical outcomes are equivalent or superior for the substituted patients. Bariatric surgery in adolescents has produced 25-30% sustained body weight loss at 5-year follow-up in Teen-LABS registry data, with major improvements in cardiovascular risk factors, sleep apnea, and quality of life. GLP-1 receptor agonist trials in adolescents (STEP TEENS for semaglutide, SURMOUNT-ADOLESCENTS for tirzepatide) have documented 15-20% weight loss at 68 weeks, with substantial metabolic improvement. Whether the longer-term surgical durability outperforms the pharmacologic option over 10 or 20 years is not yet established, in either direction, in adolescent-specific data.

The JAMA Pediatrics study documents what real-world clinical practice looks like in the aggregate. It does not automatically translate into the right decision for any individual adolescent.

For a family navigating adolescent obesity treatment options in 2026, the landscape includes:

Intensive health behavior and lifestyle treatment. The foundational recommendation for all adolescents with obesity is 26+ hours of comprehensive behavior and lifestyle treatment over 3-12 months, ideally delivered through a multi-disciplinary program combining nutrition, exercise, and behavioral therapy. This is not a stand-alone treatment for severe obesity but is the appropriate starting point and remains recommended even when pharmacotherapy or surgery is also part of the plan.

GLP-1 receptor agonist pharmacotherapy. Semaglutide (Wegovy) and tirzepatide (Zepbound) are the primary options for adolescents ages 12+. Weekly subcutaneous injection. Documented weight loss of approximately 15-20% at 68 weeks in adolescent trials. Common side effects (nausea, gastrointestinal symptoms) that typically improve over the first 8-12 weeks of dose escalation. Insurance coverage for adolescents is substantial but variable; out-of-pocket cost without coverage can be substantial ($800-1,200/month list). Duration of treatment is ongoing; weight typically returns partially when the drug is stopped.

Metabolic and bariatric surgery. Sleeve gastrectomy is the most common adolescent MBS procedure. Documented sustained weight loss of 25-30% at 5-year follow-up in Teen-LABS registry. Improves cardiovascular risk factors, resolves diabetes in many cases, resolves sleep apnea, and produces sustained improvement in quality of life measures. Requires lifelong nutritional monitoring, vitamin supplementation, and follow-up. Considerable procedural risk in the immediate perioperative period, though rare serious adverse outcomes.

Combined GLP-1 + MBS use. Rare in the current data (about 0.2%) but is an active clinical research question. Some patients who have inadequate response to MBS in the years after surgery are being offered GLP-1 receptor agonists as adjunctive therapy. Data on this combined approach is limited but growing.

The right answer for any individual adolescent depends on:

• Baseline BMI severity (BMI 35-39 vs BMI 40+ vs BMI 50+ implies different treatment intensity)
• Presence of obesity-related comorbidities (type 2 diabetes, sleep apnea, non-alcoholic fatty liver disease, hypertension, joint problems)
• Family history and genetic factors
• Response to intensive behavioral treatment
• Family preferences and values
• Insurance coverage and financial considerations
• Access to a multi-disciplinary adolescent obesity program

A specialist pediatric or adolescent-medicine consultation, ideally with an obesity-medicine specialist or an adolescent bariatric program, is the appropriate venue for that individualized evaluation. The population-level substitution effect the JAMA Pediatrics paper documents is not itself guidance for what any specific adolescent should do.

Long-term outcomes for the substituted population. The study captures 44 months of real-world use. It does not follow individual patients for 5, 10, or 20 years. The clinical question that matters most for adolescents (which treatment produces the best sustained weight loss, metabolic health, and psychosocial function into adulthood) requires follow-up that this study does not have.

Weight regain trajectory after GLP-1 discontinuation. Adult GLP-1 discontinuation studies (STEP-4 for semaglutide, SURMOUNT-4 for tirzepatide) have documented substantial weight regain over 1-2 years after stopping therapy. Adolescent-specific discontinuation data is limited. If GLP-1 therapy is a lifelong treatment (which it may be for adolescents who lose substantial weight on it), the long-term implications differ from a short-term intervention.

Whether MBS is being underused for the appropriate population. MBS produces greater sustained weight loss than pharmacotherapy in most head-to-head comparisons in adults. In the highest-BMI adolescent subgroup (BMI 50+), it's plausible that the current substitution pattern under-treats some patients who would benefit more from surgery. The study does not stratify by BMI severity in enough detail to answer this.

How access shapes the pattern. Adolescent MBS is only available at accredited pediatric bariatric surgery centers, which are concentrated in urban academic medical centers. Adolescents in rural areas or in health systems without an adolescent MBS program have less access to surgery even when it might be clinically indicated. Insurance coverage barriers also apply. Some portion of the MBS decline may reflect access constraints rather than clinical judgment.

Adolescent-specific safety questions. Both semaglutide and tirzepatide are approved in adolescents based on 68-week trials in the low thousands of patients. Rare adverse events (pancreatitis, gallbladder disease, thyroid concerns from rodent studies) show up more clearly at large post-marketing scale. Adolescent-specific post-marketing pharmacovigilance is still accumulating.

The mental health and eating-behavior dimensions. GLP-1 receptor agonists affect appetite regulation in ways that overlap with mechanisms relevant to disordered eating. Adolescent-specific data on the interaction between GLP-1 therapy and eating disorders (anorexia nervosa, avoidant/restrictive food intake disorder, binge eating disorder) is limited. The presence of an active eating disorder is a relative contraindication to GLP-1 initiation.

What is my child's BMI class? Severity matters. BMI at or above 120% of the 95th percentile (severe obesity, sometimes labeled Class 2) versus BMI at or above 140% of the 95th percentile (Class 3) implies different treatment intensity recommendations.

What obesity-related comorbidities does my child already have? Type 2 diabetes, sleep apnea, non-alcoholic fatty liver disease, hypertension, dyslipidemia, and psychosocial burden all shift the treatment calculus. A comprehensive metabolic evaluation, including a fasting glucose and lipid panel, is the appropriate starting point.

Are we at a comprehensive obesity treatment program? Multi-disciplinary programs combining nutrition, behavioral therapy, and medical management produce better outcomes than fragmented care. If care to date has been through a general pediatric practice without dedicated obesity expertise, a referral to a pediatric obesity or adolescent bariatric program is worth requesting.

Which GLP-1 receptor agonist would you prescribe and why? Semaglutide (Wegovy) and tirzepatide (Zepbound) are the primary FDA-approved options for adolescents. Tirzepatide typically produces greater weight loss but has more limited long-term adolescent safety data. Semaglutide has longer adolescent post-marketing experience. Prescribers make individualized choices based on comorbidities, insurance coverage, and family preference.

What is our plan if pharmacotherapy is inadequate? GLP-1 receptor agonists produce substantial weight loss for most adolescents who start therapy, but not for all. If weight loss at 6-12 months is substantially below what was expected, what's the next step? Options include tirzepatide (if starting on semaglutide), higher-dose management, combination pharmacotherapy, or referral for MBS evaluation.

Is MBS an option we should be considering now? For adolescents with BMI ≥ 40 or BMI ≥ 35 with significant comorbidities, MBS evaluation is appropriate to consider alongside pharmacotherapy. The pediatric bariatric program can walk through the surgical option in detail without commitment to proceed.

What is our long-term plan? GLP-1 therapy for adolescents is currently framed as a chronic, ongoing treatment (like other chronic-disease medications), not a short-term intervention. What does that look like into young adulthood and adulthood? What is the plan if insurance coverage changes? What is the plan if weight loss plateaus?

How do we monitor for adverse events? Both surgery and pharmacotherapy require ongoing monitoring. What follow-up cadence is planned? What symptoms warrant immediate contact?

The single most important unresolved clinical question for adolescents on GLP-1 receptor agonists is: what happens to weight when the drug is stopped?

Adult data is clear enough to be worrying in this context. In the STEP-4 semaglutide discontinuation trial, adults who lost substantial weight on semaglutide and then switched to placebo regained approximately two-thirds of the lost weight over 68 weeks. In the SURMOUNT-4 tirzepatide discontinuation trial, adults who lost weight on tirzepatide and switched to placebo regained about half the lost weight over 88 weeks.

Adolescent-specific discontinuation data is limited. The mechanistic expectation is that adolescents would experience similar weight regain when GLP-1 therapy is stopped, because the underlying biology of appetite regulation is not materially different by age. But adolescent-specific studies are needed to confirm this and to characterize any age-specific patterns.

The practical implication is that GLP-1 receptor agonist therapy for adolescent obesity is currently framed as a chronic, ongoing intervention rather than a time-limited weight loss cycle. Families and adolescents starting therapy should understand this framing at the point of decision, and prescribers should be explicit about it. That framing has cost implications, insurance-coverage implications, and long-term commitment implications that differ from a short-term intervention.

One of the reasons that MBS remains an appropriate consideration for adolescents with severe obesity despite the substitution effect the JAMA Pediatrics study documents is that MBS produces sustained weight loss without ongoing pharmacologic exposure. For adolescents whose family situation, insurance coverage, or personal values weigh against a lifelong-medication approach, surgery is still a reasonable option to evaluate rather than dismiss.

The JAMA Pediatrics study documents a real and substantial shift in adolescent obesity treatment over the past three and a half years. Two-thirds of the previous adolescent bariatric surgery population has migrated to GLP-1 receptor agonist pharmacotherapy. That is a large change in clinical practice, driven by legitimate developments (FDA adolescent approvals, real-world efficacy, family preference, coverage expansion) rather than by any single guideline change.

What the study cannot tell you is whether the shift is clinically optimal for every adolescent involved in it. The paper documents what practice looks like in the aggregate. It does not follow individual patients over the 5, 10, or 20-year time frames that matter most for lifetime cardiovascular and metabolic health. It does not adjudicate whether the current pattern under-treats severe cases who would benefit more from surgery, or over-medicalizes moderate cases who could be well managed with intensive lifestyle treatment alone.

For a family navigating adolescent obesity today, the practical takeaways are:

• Intensive behavioral treatment and nutrition programming remain the foundation regardless of pharmacotherapy or surgery decisions
• GLP-1 receptor agonist pharmacotherapy is now the default first-line option for severe adolescent obesity in most US clinical practices, with substantial evidence supporting 15-20% weight loss at 68 weeks and manageable side-effect profiles
• MBS remains an appropriate option for adolescents with BMI ≥ 40 or BMI ≥ 35 with significant comorbidities, particularly for families and adolescents who prefer a one-time intervention over lifelong pharmacotherapy
• The right answer for any individual adolescent depends on the specific clinical picture, family preferences, insurance and access constraints, and the availability of specialty care
• Long-term follow-up is essential regardless of which treatment path is chosen; obesity in adolescence tracks into adulthood without ongoing attention

What the field urgently needs, and what this study cannot provide, is longer-term follow-up data on adolescents who take the pharmacotherapy route. Where are the 88.2% of 2022 adolescents now? What weight, what metabolic health, what quality of life do the 96.1% of 2025 adolescents have in 2030, 2035, and 2040? Those questions will be answered by prospective cohort studies over the coming decade. Families making decisions in 2026 do so without that long-term evidence, using the best short-term evidence and clinical judgment available.