IMPORTANCE: With the approval of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) for pediatric obesity, families are increasingly considering pharmaceutical treatment alongside lifestyle optimization for their children, although how caregivers will make these decisions remains unexplored. This is especially important in contexts where food insecurity may limit the feasibility of lifestyle change and adjunct therapy could improve outcomes.
OBJECTIVE: To explore how caregivers make decisions regarding the inclusion of GLP-1 RAs for pediatric obesity treatment in the context of food insecurity.
DESIGN, SETTING, AND PARTICIPANTS: In this qualitative study, eligible participants were caregivers (aged ≥18 years) of children (aged <18 years) with obesity and metabolic dysfunction-associated steatotic liver disease who screened positive for moderate-severe food insecurity between July 1, 2022, and October 31, 2023. Caregivers were recruited from pediatric gastroenterology clinics of a regional academic health care system. Semistructured interviews via telephone or video were offered in participants' preferred language between December 1, 2023, and April 30, 2024.
MAIN OUTCOMES AND MEASURES: The main outcome was factors influencing caregiver decisions regarding medication use for their child's metabolic disease. Interview transcripts were translated to English as needed, then thematically analyzed inductively by 2 research investigators to identify themes within an array of caregivers' decision-making processes.
RESULTS: Of 37 eligible caregivers, 21 completed interviews, 20 of which were included in the analysis. Of the 20 caregiver participants (19 [95%] mothers; mean [SD] age, 40.5 [6.1] years), 18 (90%) were born outside the US, 13 (65%) had not completed high school, and 15 (75%) used a language other than English in clinical settings. Of the 20 child patients, 18 (90%) were male, and mean (SD) age at interview was 12.9 (2.9) years. All caregivers had received lifestyle-related recommendations from their child's physicians and had been referred to dietetics; 10 (50%) had met with a dietitian. Twelve (60%) desired adjunct pharmacotherapy for their child. Three common themes influenced caregiver decision-making about GLP-1 RA use: (1) prior experience with lifestyle change, (2) trust in the safety and efficacy of GLP-1 RAs, and (3) values regarding optimal care for children. An updated conceptual framework was applied to illustrate caregivers' decision-making.
CONCLUSIONS AND RELEVANCE: In this qualitative study, children's caregivers experiencing food insecurity expressed interest in both lifestyle-only and medication-inclusive approaches, with decisions shaped by lived experience, perceptions of safety, and values. Shared decision-making conversations in clinical settings that acknowledge these influences-and address barriers to both treatment options-could foster more family-centered, equitable, and effective pediatric obesity care.
