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- [00:00]
A
Hello, I'm Aaron Lohr and this is the Endocrine News podcast. We know obesity is an epidemic and there have been some very promising advances in the treatment of obesity. But what's good for an adult is not always good for a child or adolescent. Are pharmacotherapy and surgery effective obesity treatments for children? What other treatment options are available? What do the current guidelines tell us and where are we still missing information? These are all excellent questions and to help us answer them, we have two wonderful guests who took part in the Endocrine Society's recent Obesity Fellows Conference. Before I welcome our guests, let me first say that this episode is supported by an educational grant from Lily and Novo Nordisk. Thank you. And I also need to say that this episode is available for 0.5 CME credits and if you want those credits, you need to listen to this episode through the link provided in today's episode. Description with me today is Dr. Susan Wolford, Associate professor in the Child Health Education and Research center at the University of Michigan, and also with me is Dr. Sarah Geiger, a Clinical fellow at Cincinnati's Children's Hospital. Thank you both for being here.
- [01:28]
B
Thank you for having us.
- [01:30]
C
Thank you. It's a pleasure to be here.
- [01:32]
A
So what have been the significant updates in pediatric obesity over the past few years?
- [01:37]
C
One of the biggest developments in recent years was the release of the first ever clinical practice guidelines from the American Academy of Pediatrics for the Evaluation and Treatment of Childhood obesity, which were published in January 2023. Now prior to this we had the 2007 expert recommendations and these outlined different stages of treat with a focus on lifestyle interventions and an increasing intensity of care if previous stages were not effective over time. And in those days we only had two FDA approved medications for weight loss and pediatrics which were orlistat, which had a lot of side effects, and sibutramine which was taken off the market. So as you can tell, we really didn't have a lot to use. Where medications were concerned for bariatric surgery in adolescents, there were very limited data and so the threshold for using surgery was really quite high. However, between 2007 and 2023, new research emerged that informed the AAP guidelines and these CPGs, which are focused on children two years of age and older, are much more comprehensive with a greater body of evidence to inform the recommendations on screening and on lifestyle interventions, which are still the heart of the guideline. Though the recommendations for medication management and for surgery seem to have garnered much more media attention.
- [03:04]
A
I want to get to a little bit of what these guidelines have been telling us, these new ones. And I'm sure some of it has to do with assessment. So how does assessment of obesity in children, adolescents differ from adults?
- [03:13]
B
You've alluded to this a little bit, but we have a common phrase in pediatrics that children are not little adults. And so we definitely have some other things we need to think about. And so I would say the main difference in children compared to adults is that children and most adolescents are still growing, they're developing. And because of this, we have to really think about the trajectory of children's growth within their pubertal development, within their progress of their development, whenever we're thinking about our treatment plans. And so we also have to think about their nutritional needs for adequate brain and bone development, since this is also a really critical period for them, similar to adults. When we're assessing obesity, we do use BMI as our primary screening tool. However, rather than kind of thinking about raw BMI numbers, we think about BMI and percentiles, which are based on age and sex. We have different categories. So 85th to 95th percentile we consider overweight. Greater than the 95th percentile is obesity, and then greater than 120% of the 95th percentile we would consider to be severe obesity. And we do use CDC growth charts for this. Percentiles are mostly based on weight data, actually that came from kind of the 1960s and 1970s. However, we did have updated charts that came out in 2022 which better characterize patients who are at the more extreme ends of the BMI spectrum. So those were above the 97th percentile are now based on data from 1999 to 2016. So a little bit more updated. Something else that we think about in kids that I think is a little different from how we think about weight management in adults is that this population is at increased risk for disordered eating behaviors. We do know from research that self guided weight loss attempts in adolescents particularly are associated with disordered eating patterns, but notably participation in more of a structured weight management program. So working with a doctor dietitian does decreased risk for current and future eating disorder symptoms. So I would say those are the primary differences.
- [05:10]
A
What types of questions would you ask during an initial evaluation of a pediatric patient with obesity?
- [05:16]
C
During the initial evaluation with a patient with excess weight, there are really a huge number of factors that need to be covered, but let's just consider them within three buckets. If we start with their history, one needs to explore the patient's weight trajectory and the factors that might have impacted that, including their family history with a particular focus on weight related conditions, along with their medication history, specifically those that might contribute to excess weight, and then their past medical history, including adverse childhood experiences and mental health diagnoses such as depression. And then we can move on to current conditions. And we conduct a review of systems with a particular focus on signs and symptoms of comorbidity, such as diabetes and sleep apnea and metabolic dysfunction associated with fatty liver disease or polycystic ovarian syndrome, idiopathic intracranial hypertension and hypertension. So all of these things should be assessed in addition to psychosocial stressors that should be addressed. And then following that, we want to explore lifestyle factors that might contribute to excess weight, starting possibly with diet, which involves not just the content. And of course, for content, we could use a simple dietary recall and ensure that we address factors such as sugar, sweetened beverages and fast food, things of that nature. But we also want to explore who prepares the meals and who does the shopping, whether families have access to healthy options and whether families eat meals together. And then beyond the dietary intake, we want to think about patients physical activity. And that should be addressed by looking at both the type and the frequency, and where possible, the intensity of their activity and the barriers that they face when they try to engage in physical activity. On the other side of that, we have to look at sedentary activity. And so the time spent in screen time and then hours and timing of sleep are also important. And when we think about these lifetime factors, we must not forget readiness to change. And here we have to explore the patient's readiness to change and the family's readiness to change as it relates to specific behaviors, not just the general desire to change or a general desire to reduce weight. And when we consider these factors, it is key to think about the child within the context of their family in a weight evaluation.
- [07:49]
A
As an endocrinologist, what other factors do you consider?
- [07:53]
B
As endocrinologists, we definitely think about endocrine causes of obesity, including things like glucocorticoid excess, hypothyroidism and growth hormone deficiency. However, I think it's important to note that less than 1% of obesity is due to a primary endocrine disorder. So in pediatrics, one of our major clues towards these endocrine causes of obesity would be poor linear growth. We know that in obesity, due to an endocrine cause, linear growth will almost always be negatively impacted. And so that's a big clue. Looking at the growth chart on the other Hand, in primary obesity, we much more often will see normal or even increased linear growth velocity. The two caveats to this from an endocrine standpoint would be Albright hereditary osteodystrophy, which presents with increased growth velocity in the first two to three years of life, as well as acquired hypothesis obesity, which would typically be due to an intracranial tumor surgery or radiation. And so this is where history and review of systems are especially helpful. If the history is not consistent with an endocrine cause of obesity, the value of screening for endocrine causes is pretty low. And actually, the Endocrine Society guidelines would recommend against routine screening in this case. Outside of primary endocrine causes, though, we do also think about genetic causes of obesity. And there are different types of genetic causes. So polygenic and monogenic. Polygenic is going to be much more common. 40 to 70% of obesity risk seems to be polygenic, based on heritability studies. And then monogenic or syndromic forms of obesity are much more rare. And they're typically associated with other symptoms, including developmental delays, short stature, or dysmorphic features. And so the primary monogenic forms of obesity to be aware of, and again, these are all still quite rare, would be things like melanocortin 4 receptor deficiency, leptin deficiency, POM C deficiency. And then we think about syndromic forms of obesity, things like Prader, Willi and Barde Beetle. Typically, these syndromes are going to be associated with early onset of severe obesity. And so this is going to be children who are basically above the growth curve for BMI, usually before age 5. One of the other factors we would typically see in these patients is hyperphagia, which is not something that I feel like I learned about in medical school in terms of how to ask about. But when we are asking about it in the history, we think about things like insatiable hunger. Children will be strongly preoccupied with food, and they may even become distressed when they are denied food, even if they very recently ate and reasonably shouldn't be hungry based on what they've had. And so these are kind of all things that we would think about if we're worried about monogenic forms of obesity. So in children who do have this early onsets of your obesity and hyperphagia, we will often consider offering genetic testing.
- [10:42]
A
We touched about this a little bit already, but which comorbidities do you tend to see in pediatric patients with obesity?
- [10:49]
B
Dr. Wolford? I think touched on this a little bit already, but we do definitely see prediabetes and type 2, particularly in the endocrine space. And I think because of increasing rates of pre diabetes, particularly in adolescents. The AAP guidelines do recommend diabetes screening in all patients with obesity at age 10 as well as those who are in the overweight category if they have risk factors. And so that would be a first or second degree relative with type 2 diabetes, history of mom having gestational diabetes during pregnancy or signs of insulin resistance. And screening could include a fasting glucose level or a glucose tolerance test, or most frequently a hemoglobin A1C. And this timing of age 10 does make sense. Since the incidence of prediabetes increases with puberty, we see that a lot of the pubertal hormone changes can lead to a decrease in insulin sensitivity. And outside of pre diabetes and diabetes, we do see a number of other comorbidities, things like pcos, hypertension, steatohepatitis, sleep apnea. So because of all these comorbidities, the AAP guidelines do recommend blood pressure monitoring for all patients as well as fasting lipids for all patients with overweight and obesity at age 10. Also alt monitoring for patients with obesity at age 10 or older or for those who are overweight if they have other risk factors for metabolic dysfunction associated spatohepatitis. So definitely looking for multiple, multiple comorbidities in this group. If screening is normal, the recommendations are to repeat at least every two years. I think it's important to note though that even in the absence of these comorbidities, early interventions are recommended for all children and adolescents with obesity. Trying to prevent these comorbidities from happening in the first place.
- [12:35]
A
Let's shift gears a little bit and talk about interventions. What interventions are recommended for obesity in pediatric patients?
- [12:43]
C
The recommendations are still heavily focused on starting with healthy behavior and lifestyle interventions. And so the guidelines state that pediatric providers should provide OR refer Children 6 years of age or older with overweight or obesity for intensive health, behavior and lifestyle treatment and that they can consider such a Referral for children 2 to 5 years Years of age. And so these programs should be face to face and they can be offered in person or virtual. They should be family based and multi component, which means they should incorporate nutrition and physical activity along with mental health and parenting skills. And these interventions often will utilize motivational interviewing and or a cognitive behavioral therapy approach. And they should consist of at least 26 contact hours over three to 12 months. Now, the guidelines acknowledge that while primary care providers are on the front line and are encouraged to actually provide these lifestyle interventions, often adequate Time isn't built into the clinic visits to actually deliver this care. And so they do make mention of things that could help, such as the increased opportunity to use technology and connections with the community. They also note that in all cases, any intervention for weight management really must be considered within a life course approach. And this expectation needs to be set with families as well, because the evidence shows that the response to treatment is often undulating with weight loss during intensive treatments and some degree of weight gain in the periods in between.
- [14:27]
A
So are there any common challenges associated with these lifestyle interventions?
- [14:32]
C
Wow, what a great question. There are lots of challenges with such interventions, and for patients it's difficult because these interventions take a significant amount of time, as mentioned previously, 26 contact hours at a minimum. We have to consider transportation needs and often insurance coverage is really quite poor. In addition to this, there's frequently a mismatch between the patient or the family expectations and the results attained, with patients hoping for more dramatic weight loss than is usually achieved. Furthermore, it's important to think about the fact that health behaviors are heavily influenced by the social determinants of health, including things like food insecurity. Patients often have limited access to healthy fresh foods or to places where they can be physically active and be safe at the same time. By contrast, there's the sort of lower cost and greater convenience and greater marketing of ultra processed foods which are not what we want. And so these factors are significant hurdles for some families who are attempting to make healthy lifestyle choices.
- [15:44]
A
We all know there's been a lot of recent focus in the media on medications and in pediatric obesity. So which medications are available to children and adolescents?
- [15:54]
B
Great question, something that we're getting asked about a lot. So there are still fewer options in children and adolescents for medication than there are in adults, but we definitely have seen more options in the market in recent years. However, before I kind of jump into some of these options, I will note it is pretty challenging to get insurance coverage for many of these options, and so I will still say it is a minority of children with obesity who are on medications currently. So the currently approved options by the FDA include Orlistat, which has been on the market for decades, but like Dr. Wolford mentioned earlier, we very rarely will use in pediatrics due to side effects. Another medication that is FDA approved is Phentermine Topiramate. This is approved for patients 12 and older with obesity. Phentermine acts as a stimulant and increases availability of more epinephrine, which ultimately decreases appetite. And then topiramate acts through gaba modulation and can be helpful with increasing satiety and decreasing binge eating. Interestingly, even though the combination of this medication is FDA Approved for patients 12 and up, the separate medications are not officially approved for obesity management. That being said, it is definitely something that will be used off label in adolescents separately. Often that is going to be a more cost effective option. And then More recently, certain GLP1 receptor agonists have also been approved for adolescents. So both liraglutide and semaglutide are now approved for weight loss in patients who are 12 or older. However, just because these medications are FDA approved in adolescents does not mean that they are widely available to a lot of our patients, particularly due to challenges with insurance coverage. So currently Medicaid only covers GLP1 receptor agonists in 13 states, which is notable since approximately 50% of children nationally are insured by Medicaid. So that is definitely a barrier. And then I think in pediatrics an important one to talk about, although not a very common medication, is satmelanitide. This is a notable newer medication in pediatrics which is a melanocortin 4 receptor agonist. It is approved only in very specific monogenic forms of obesity, and these forms of obesity include POM C deficiency, PCSK1 deficiency, leptin receptor deficiency and Barde beetle syndrome. It can be quite effective in this small subset of patients. However, depending on the dose, the annual cost can be hundreds of thousands of dollars. So definitely a barrier there. And then side effects to be aware of would include hyperpigmentation, which makes sense given increased stimulation of the melanocortin 4 receptor, as well as some GI side effects, things like nausea, diarrhea, ABD pain. But some patients have done very well on zeolanotide. There are other medications that are not formally FDA approved for weight loss, but that will sometimes think about if there's other comorbidities. One of the common ones will be metformin, which is approved for type 2 diabetes in patients who are 10 or older. Metformin can lead to a modest amount of weight loss and so we will sometimes prescribe it in patients with pcos or pre diabetes as well with the hope that it will help in addition to lifestyle interventions. A final one is listexamphetamine, which is approved for ADHD treatment in patients who are six or older. Interestingly, it's also approved for binge eating disorder in patients who are 18 or older but not in adolescence. But it can be a nice option in patients who would already be on medication for ADHD Anyway, that could be a good choice for them.
- [19:30]
A
And what is the role of bariatric surgery for adolescents with obesity?
- [19:35]
C
Over the past couple of decades, bariatric surgery has become more accepted in pediatrics as we have more evidence that supports its use initially with the Roux En Y and increasingly with this vertical sleeve gastrectomy. So, similar to adults, studies with adolescents typically demonstrate substantial weight loss and improvements or even resolution of comorbidities like type 2 diabetes. So in a cohort study comparing adults and adolescents who underwent the Roux En Y bypass procedure, adolescents maintained 26% of their weight loss five years after surgery, which did not differ significantly from the weight loss in adults. And notably, of those adolescents who had type 2 diabetes, 86% experienced remission after surgery compared to only 53% of adults. So we see that bariatric surgery can be really beneficial in adolescents and it works because of a few mechanisms. 1 Naturally, as one might anticipate the mechanical restriction from reducing the size of the stomach along with the changes in absorption plus the increased levels of GLP1 and peptide YY, the hormones that are produced in the guide gut that increased satiety and the decreased levels of the appetite stimulating hormone ghrelin. So in keeping with this evidence of the benefits in adolescents, the AAP in these new clinical practice guidelines indicate that for those patients for whom other things have not been effective, bariatric surgery should be considered for patients 13 years or older if they have severe obesity. And so the two groups that are defined are those who have class 2 obesity, so a BMI equal to or greater than 35 or equal to or greater than 120% of the 95th percentile if they have comorbidities or those with class 3 obesity. So a BMI greater than or equal to 40 or 140% of the 95th percentile if they don't have comorbidity. It's interesting to note that there is no firm lower age limit, but the 2017 Endo Society guidelines recommend that patients should be Tanner 4 or Tanner 5 and nearly at their adult height. Along with those factors, there are some additional things that have to be considered for patients who are thinking about bariatric surgery and prior to surgery they should undergo a psychological evaluation, particularly looking for eating disorders and for issues that would be red flags such as substance abuse and suicidality. They should be able to understand the risks and benefits of surgery. And as young adults can be a challenging group to keep engaged in care, attention should be paid to their ability to follow up because there are risks in the short term postoperatively, but there are even those long term potential concerns related to micronutrient deficiencies associated with malabsorption. So we want to be able to keep those adolescents engaged in care. One should also consider the impact of bone health and ensure that calcium and vitamin D are optimized and encourage resistance training and periodic DEXA scans to deal with this particular issue. Other post operative risks include the increased risk of substance abuse, as I indicated earlier, particularly among those who have alcohol use prior to surgery, and patients will also experience increased fertility after surgery. And so there's a need to ensure that there's adequate contraception plan in place as well. Finally, for those who are undergoing bariatric surgery, they should also be engaged in lifestyle interventions. I know I keep mentioning those, but they are so important, important. And this would include nutrition changes under the guidance of a dietitian and they should be engaged in a physical activity program.
- [23:57]
A
So far we've been talking about things that we know and with our last question we're going to talk about maybe there's some things that we don't know. So what are some ongoing questions in the field of pediatric obesity?
- [24:08]
B
Lots of questions still to be answered. One of the big ones, I think is that the current guidelines only cover age 2 and older. Thinking about infants and toddlers still really important. Thinking about how we can prevent obesity in the first place, knowing that once we get to the point where children have obesity, it can be really hard to get them back into healthy weight range. And not just thinking about this in infants, but also thinking about during pregnancy impacts of maternal health as well. And so I think thinking about in these younger children how we can prevent obesity in the first place is still something that we have not cracked the code on.
- [24:47]
C
There are a number of questions that need to be addressed. One of them is how we can effectively address the health disparities that we see in childhood obesity and how we can target the social determinants of health. We also need to focus on these lifestyle interventions and how to make them cost effective and sustainable while maintaining efficacy.
- [25:12]
A
This has been fantastic. We're out of time, but I just want to extend my gratitude to Drs. Wolford and Geiger for being our guest today, just sharing all this wonderful information. Thank you so much for being here.
- [25:24]
B
Thank you so much for having us. This was a great conversation.
- [25:27]
C
Thank you so much.
- [25:29]
A
And that's all for this episode. I hope you enjoyed it. If you did, be sure to check out the On Demand courses available from the 2024 Obesity Fellows Conference. We'll provide a link in today's episode Description we'll be back soon with another fascinating dive into the world of endocrinology. Until then, thanks for listening. Endocrine News Podcasts are a free service of the Endocrine Society. To learn more or to become a member, visit the society's website at www.endocrine.org.