In this issue of Pediatrics, Chu and colleagues1 report that despite overall increasing use of glucagon-like peptide-1 receptor agonists (GLP-1RAs) for youth with type 2 diabetes mellitus (T2D), there remain significant disparities among medication dispensing patterns between publicly and commercially insured youth. Specifically, semaglutide, a GLP-1RA with greater impact on hemoglobin A1c (HbA1c) and weight reduction, was more often dispensed to youth with commercial insurance. In contrast, youth with public insurance were more likely to be prescribed alternative GLP-1RAs (eg, liraglutide, dulaglutide, and exenatide) with a lesser impact on diabetes-related outcomes. These findings highlight significant disparities in equitable access to the most-effective therapies among youth with T2D. These findings are notable because they highlight how disparities can compound in vulnerable populations. Not only are youth with social risk factors more likely to be diagnosed with T2D and more likely to be at risk for more-severe outcomes following diagnosis, but they are also less likely to have access to the most-efficacious therapies.2,3 Differences in prescribing patterns have the potential to further widen disparities in outcomes among at-risk youth.T2D is increasingly seen in youth, with a higher prevalence and disease burden among racial and ethnic minorities.2 Inequities stem from systemic racism, limiting access to healthy foods and safe activity.3 Adolescents with T2D have high rates of comorbidities; screening for hypertension, dyslipidemia, albuminuria, neuropathy, and retinopathy is recommended at diagnosis,4 with a greater risk in underserved youth.4,5 In the Treatment Options for Type 2 Diabetes in Adolescents however, they are still a relatively emerging therapy in the pediatric population. Although GLP1-RAs were first included for adults in the 2018 to 2019 American Diabetes Association (ADA) Standards of Care, they did not appear in the ADA Standards of Care for youth until 2020.7 The 2025 ADA Standards of Care recommend metformin as the first-line pharmacological agent and initiating basal insulin among those with an HbA1c level greater than 8.5% at diagnosis.4 Among youth who do not meet glycemic targets, noninsulin pharmacotherapy, including GLP-1RAs, should be initiated before intensifying or adding insulin therapy. Although insulin and GLP-1RA have similar impacts on HbA1c reduction,8 insulin has the potential consequence of increasing weight gain, which can lead to a vicious cycle of weight gain, resulting in increased insulin requirements and further weight gain. In contrast, GLP-1RAs work directly at the level of T2D pathophysiology by improving insulin sensitivity, increasing insulin secretion, and promoting weight reduction, which may ultimately reduce insulin requirements.The inclusion of GLP-1RAs in the ADA Standards of Care for youth-onset T2D is based on expert opinion, with a lack of adequate data from clinical trials preventing a higher grade of evidence. At the current time, only 3 GLP-1RAs are approved for the treatment of T2D in youth: daily liraglutide (resulting in a 1.3% change in HbA1c vs placebo)9 and weekly exenatide and dulaglutide (resulting in 0.85% and 1.4% changes in HbA1c, respectively).10,11 This is in comparison with the increased options available for adults with T2D, which include semaglutide (weekly GLP-1RA) and tirzepatide (weekly dual GLP-1/gastric inhibitory polypeptide receptor agonist). Semaglutide has not specifically been approved for the treatment of T2D in youth, although it is approved for the treatment of obesity among those aged 12 years or older. Among this population, semaglutide is associated with a 14.7% reduction in body mass index vs a 4.3% reduction on liraglutide and no significant reduction on dulaglutide, highlighting its greater efficacy.8–13The large population of youth with comorbid T2D and obesity receiving semaglutide therapy provides data in the pediatric population regarding its impact on dysglycemia. A 2025 review highlighting the safety and efficacy of GLP-1RAs in the pediatric population noted an absolute reduction in HbA1c in both the T2D trials and the obesity trials.14 These medications were well tolerated, with similar adverse events profile compared with the adult population. Although this was an extensive meta-analysis, the data only included 18 clinical trials. Further research is warranted regarding both the efficacy and safety of these medications in the pediatric population.Adult data demonstrate that GLP-1RAs have varying efficacy for both HbA1c and weight reduction. Semaglutide demonstrates a greater impact, with a 1.6% reduction in HbA1c,15 whereas dulaglutide and liraglutide had a lesser reduction (ie, 0.8% and 0.6%, respectively).9,11 Semaglutide is associated with a weight reduction of 15.8% compared with a 6.4% reduction on liraglutide and less than 5% on dulaglutide.16,17 Semaglutide has additional benefits relating to cardiovascular outcomes, renal disease, and cardiometabolic markers.18–20 Tirzepatide shows similar findings, in addition to the treatment of obstructive sleep apnea.21,22 Given this evidence of increasing efficacy, semaglutide and tirzepatide are deemed “highly effective obesity medications,”23 in contrast to earlier generation GLP1-RAs. It is notable that despite the more-severe disease course among youth with T2D, these medications with potential for greater efficacy have not yet been fully available in this population. Although safety and assessing long-term risks are critically important before approval among youth, we believe that incentives for labeling effective therapies for pediatric indications could lead to a decrease in the delay behind adult approval.Given the lag in US Food and Drug Administration (FDA) approval for these medications, it is essential to note that youth in this study receiving semaglutide were either receiving it for (1) treatment of obesity or (2) off-label treatment of T2D below the approved age range. This finding highlights the implications policy decisions may have, both at the level of pharmaceutical companies pursuing FDA approval and within insurance plans, regarding their influence on treatment decisions.Insurance barriers to care exist throughout the spectrum of effective treatment options available to youth with T2D. Among those with severe obesity and youth-onset T2D, metabolic bariatric surgery (MBS) has a greater impact on glycemic-, weight-, and comorbidity-related outcomes than medical therapy alone.24–26 As Chu and colleagues reported, insurance status is also a barrier to accessing MBS.27 This seems related primarily to differences in social disadvantage as opposed to race and ethnicity alone,28 highlighting the impact of structural factors on access to care among those at greatest risk. Although adolescents identifying as Black and Hispanic have increasing representation among pediatric patients undergoing MBS, they often have greater comorbidities at the time of surgery, which may reflect delayed access to care.29 There has been some suggestion that increasing diversity among adolescents undergoing MBS may be related to greater access, influenced by evolving clinical practice guidelines that include MBS.30 This highlights the importance of clinical practice guidelines in creating a foundation for access to care. As both rigorous advances and expert individuals inform clinical practice guidelines, we advocate for ongoing funding to support research that advances the care of individuals with youth-onset T2D.In conclusion, care for youth with obesity-related comorbidities, including T2D, occurs within a system rife with disparities. To maximize both efficacy and equity across all youth, further research is crucial to understand the impact of new therapies on clinical outcomes and their real-world implementation. The study by Chu and colleagues is an essential contribution to the literature, identifying how systemic factors may influence adolescents’ access to effective treatment options.
Whooten et al. (Mon,) studied this question.