Endocrine News Podcast Episode 97: Childhood Obesity Treatment

Podcast: Endocrine News Podcast
Host: Aaron Lohr, Endocrine Society
Guests: Dr. Susan Wolford, University of Michigan; Dr. Sarah Geiger, Cincinnati Children's Hospital
Date: February 12, 2025

Overview

This episode delves into recent advances and persistent challenges in the treatment of childhood obesity. With new clinical practice guidelines, a rapidly evolving pharmacotherapy landscape, and rising media attention on surgical and medication interventions, the conversation centers on what’s new, what works, and where the gaps remain in pediatric obesity care. Drs. Susan Wolford and Sarah Geiger, both informed by participation in the Endocrine Society's Obesity Fellows Conference, provide expert insights for clinicians handling complex cases.

Key Discussion Points & Insights

1. Recent Advances & Updated Guidelines

• First AAP Clinical Practice Guidelines (CPG) Released 2023.
  • Prior: 2007 recommendations focused largely on staged lifestyle interventions, with few FDA-approved pharmacologic options and limited surgical data.
  • Now: 2023 guidelines are more comprehensive, integrating expanded evidence for screening, lifestyle interventions, medications, and surgery.
  • Quote (Dr. Geiger, 01:36):

    “These CPGs…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.”

2. Pediatric vs. Adult Assessment of Obesity

• Children are not “little adults”:
  • Assessment must consider ongoing growth, nutritional needs, pubertal development.
  • Use of BMI percentiles (age and sex-adjusted):
    • 85th-95th percentile: Overweight

    • 95th percentile: Obesity

    • 120% of the 95th percentile: Severe obesity

• Growth trajectory is a clue in differentiating primary vs. secondary causes.
  • Disordered eating risk is higher with self-guided weight loss, less with structured, supervised programs.
  • CDC growth charts have been updated (2022) for extreme BMI percentiles (using 1999–2016 data).
• Quote (Dr. Wolford, 03:13):

  "Children and most adolescents are still growing...we have to really think about the trajectory of children's growth within their pubertal development..."

3. Pediatric Obesity Evaluation: What to Ask

• Three “buckets” in the initial evaluation:
  1. History: Weight trajectory, family history (especially weight-related conditions), medication use, mental health, adverse childhood events.
  2. Current Conditions: Comorbidities (diabetes, sleep apnea, fatty liver disease, PCOS, hypertension).
  3. Lifestyle Factors: Diet (including who prepares/buys food), physical/sedentary activity, screen time, sleep, readiness for/family support of change.
• Context of the family is critical.
• Quote (Dr. Geiger, 05:16):

  "It is key to think about the child within the context of their family in a weight evaluation."

4. Endocrine and Genetic Causes

• Primary endocrine causes are rare (<1%).
  • Look for poor linear growth as a red flag.
  • Polygenic obesity is far more common (40–70% risk), but rare monogenic conditions (e.g., MC4R, leptin deficiency, POMC deficiency, Prader-Willi, Bardet-Biedl) are considered in early/severe onset with hyperphagia.
• Genetic testing should be considered in early, severe, hyperphagic cases.
• Quote (Dr. Wolford, 07:53):

  "...in pediatrics, one of our major clues towards these endocrine causes of obesity would be poor linear growth...in primary obesity, we much more often will see normal or even increased linear growth velocity."

5. Comorbidities

• Frequent comorbidities:
  • Prediabetes/type 2 diabetes
  • PCOS
  • Hypertension
  • Sleep apnea
  • Steatohepatitis
• AAP screening recommendations:
  • Diabetes screening at age 10+ or earlier if risk factors
  • BP and fasting lipids for all at age 10+
  • ALT for those at risk of fatty liver
• Early intervention is warranted even with no comorbidities.
• Quote (Dr. Wolford, 10:49):

  "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..."

6. Interventions

6.1. Lifestyle Interventions

• First-line:
  • Intensive, face-to-face, family-based, multi-component (~26+ hours/3–12 months)
  • Emphasis on nutrition, physical activity, mental health, parenting skills
  • Must be delivered with a life-course approach; families should expect an undulating trajectory with weight loss and regain.
• Challenges:
  • High time commitment, transportation, insurance coverage, modest effects vs. expectations, social determinants.
• Quote (Dr. Geiger, 14:32):

  "There are lots of challenges...transportation needs and often insurance coverage is really quite poor...health behaviors are heavily influenced by the social determinants of health..."

6.2. Pharmacotherapy

• FDA-approved options:
  • Orlistat (rarely used: GI side effects)
  • Phentermine/topiramate (12+ years; can be cost-effective off-label separately)
  • GLP-1 agonists: Liraglutide, Semaglutide (12+ years), but limited by cost and insurance (Medicaid covers only in 13 states).
  • Setmelanotide (for rare monogenic obesity: POMC, PCSK1, LEPR deficiencies, Bardet-Biedl) – extremely expensive.
• Other options:
  • Metformin (for T2DM, modest weight loss, may be used in PCOS, prediabetes).
  • Lisdexamfetamine (approved for ADHD≥6y and binge eating in adults, sometimes considered if ADHD present).
• Quote (Dr. Wolford, 15:54):

  "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...it is pretty challenging to get insurance coverage for many of these options..."

6.3. Bariatric Surgery

• Increasingly accepted; supports:
  • Significant weight loss, remission of comorbidities (e.g., 86% diabetes remission in adolescents vs. 53% adults in one study).
  • Current AAP guidelines: Consider for >13 yrs with severe obesity after failed interventions.
  • No strict lower age. Endocrine Society: Preferably Tanner stage 4/5, near adult height.
  • Must include psychological evaluation, ability to adhere to follow-up, micronutrient monitoring, attention to bone health, and contraception counseling for increased fertility post-op.
• Quote (Dr. Geiger, 19:34):

  "Bariatric surgery can be really beneficial in adolescents...adolescents maintained 26% of their weight loss five years after surgery...86% experienced remission after surgery compared to only 53% of adults..."

Emerging and Unanswered Questions

• Addressing obesity prevention early, including infants and during pregnancy.
• Reducing health disparities and attending to social determinants of health.
• Making lifestyle interventions cost-effective and sustainable.
• Quote (Dr. Wolford, 24:07):

  "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..."

Notable Quotes & Memorable Moments

• “Children are not little adults.” (Dr. Wolford, 03:13)
• “We must not forget readiness to change… the child within the context of their family...” (Dr. Geiger, 07:49)
• “<1% of obesity is due to a primary endocrine disorder.” (Dr. Wolford, 07:53)
• “...the AAP guidelines do recommend diabetes screening in all patients with obesity at age 10…” (Dr. Wolford, 10:49)
• “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.” (Dr. Geiger, 14:32)
• “It is a minority of children with obesity who are on medications currently.” (Dr. Wolford, 15:54)
• “Bariatric surgery… adolescents maintained 26% of their weight loss five years after surgery…86% experienced remission [of T2D].” (Dr. Geiger, 19:34)

Timestamps of Key Sections

• 01:31 | Major updates in pediatric obesity, new AAP guidelines
• 03:13 | Differences in pediatric vs. adult obesity assessment
• 05:16 | Initial evaluation: history, comorbidities, lifestyle
• 07:53 | Endocrine and genetic causes
• 10:49 | Common comorbidities and recommended screenings
• 12:42 | Recommended interventions: lifestyle, challenges
• 15:54 | Pharmacotherapies: what’s available, who gets them
• 19:34 | Bariatric surgery: criteria, effectiveness, caveats
• 24:07 | Unanswered questions and future directions

Overall Tone & Takeaways

The conversation is authoritative yet empathetic, consistently stressing the complexity and individuality of pediatric obesity care. While optimistic about new tools and approaches, Drs. Wolford and Geiger continually acknowledge the ongoing barriers of access, health equity, and the enduring primacy of family and behavioral context in both assessment and intervention.

For more information or CME credit, listeners are directed to the episode description and Endocrine Society website.