Diagnosis and Management of Pediatric Obesity

Educational Objectives

The goal of this program is to improve diagnosis and management of pediatric obesity. After hearing and assimilating this program, the clinician will be better able to:

1. Cite 2023 recommendations from the American Academy of Pediatrics for management of pediatric obesity.
2. List risk factors for metabolic dysfunction-associated steatotic liver disease in pediatric obesity.
3. Explain the mechanism of action of glucagon-like peptide-1 receptor agonists.
4. Optimize use of pharmacologic treatment of pediatric obesity in patients with cardiovascular disease.
5. Use topiramate in obese pediatric patients with epilepsy.

Summary

Definitions: weight stigma is the societal devaluation of a person because they are overweight or obese; in youth, this manifests as weight-based teasing, bullying, and social exclusion; it is tolerated because of a false belief that stigma and shame will motivate change; bias is our negative weight-related attitudes toward individuals with larger bodies, which can be explicit, implicit, or internalized; stigma and bias are not limited to peers or social interactions but are also found in health care settings, often leading to mistrust between physicians and patients; discrimination denotes unequal treatment because of weight and can arise in various social, professional, or health care contexts

Epidemiology of obesity: obesity affects 1 in 5, or approximately 14 million youth in the United States (comparable to or exceeding that of asthma); obesity disproportionately affects youth of color, those with higher social vulnerability, and LGBTQ+ youth; so, obesity is a health equity issue and is a complex chronic condition associated with progressive physical and mental health complications, lower quality of life, and premature mortality; treatment of childhood obesity, particularly among disproportionately affected groups, has the potential to significantly reduce inequities on a large scale through primary and secondary prevention

Implications of obesity: in pediatrics, obesity is associated with conditions such as hypertension (HTN), diabetes mellitus (DM), prediabetes, metabolic dysfunction-associated steatotic liver disease (MASLD; formerly known as nonalcoholic fatty liver disease), dyslipidemia, idiopathic intracranial hypertension (IIH; formerly known as pseudotumor cerebri), obstructive sleep apnea, polycystic ovary syndrome (PCOS), slipped capital femoral epiphysis (SCFE), and Blount disease; in adults, these risks often present as cardiovascular disease, liver failure, infertility (PCOS is the most common cause), joint replacement, several cancers, and psychological issues; a significant challenge in pediatric obesity is that complications are not always immediately visible, making it difficult to stress the importance of early intervention to health care administrations and patients

Physiology of obesity: energy regulation systems are structured to biologically resist weight loss; when weight is lost, the body reduces energy expenditure, increases appetite, and decreases satiety; these responses persist after weight loss stabilizes, making sustained weight loss difficult and weight regain common; this is called metabolic adaptation, a decrease in energy expenditure that exceeds the expected reduction based solely on weight loss

Guidelines for obesity: the 2023 guidelines from the American Academy of Pediatrics (AAP) were released by the Institute for Healthy Childhood Weight and consist of 13 key action statements; importantly, they acknowledged the role of social determinants of health and policy contributions in obesity; they removed the staged approach to treatment and expanded the role of the primary care provider; new guidelines recommend considering antiobesity medications and bariatric surgery earlier, which has received considerable public attention; the guidelines promote a conceptual model viewing obesity as a chronic, relapsing condition requiring lifetime management; this model considers structural and contextual factors alongside individual care; the guidelines are divided into 3 main categories of screening and diagnosis, evaluation for comorbidities, and treatment

Screening and diagnosis: screening guidelines remain unchanged, where height and weight are measured to calculate body mass index (BMI) using age and sex-specific growth charts; for children with a BMI <85th percentile, monitoring continues without immediate intervention; diagnostically, overweight is defined as a BMI between the 85th and 95th percentiles, obesity as >95th percentile, and severe obesity as >99th percentile or >120% of the 95th percentile; while addressing weight-related concerns, assess readiness to change and the family’s perception of the issue; building a trusted provider-patient relationship can facilitate nonstigmatizing weight discussions, which are more effective when conducted consistently across all growth chart reviews rather than targeting only children with higher BMIs; primary care providers should emphasize the complexity of obesity, acknowledging its genetic and environmental influences, and using neutral (BMI or excess weight) and people-first language reduces the stigma of obesity; an inclusive office environment that accommodates all body sizes reinforces this respectful approach; empathy is critical to fostering an ongoing, supportive relationship

Evaluation for comorbidities: a comprehensive history and physical examination are essential for children of all ages, but blood pressure (BP) measurements (recommended annually starting at age 3 yr) and laboratory screenings for comorbidities typically start at puberty or age 10 yr, whichever is sooner; the comprehensive history, social determinants of health, and mental and behavioral health screening are part of the evaluation of obesity; the AAP toolkit includes a 2-question tool to evaluate for food insecurity

Screening recommendations: lipid panel — the recommendation is to check a lipid panel in all children before puberty or age 10 yr, but it is advised sooner for children with DM, HTN, a family history of early cardiovascular disease (eg, myocardial infarction, sudden death, HTN), or exposure to smoking; liver function — consider transaminase levels in children with severe obesity, recognizing the possibility of MASLD under 10 yr for children with severe obesity or insulin resistance; DM — the guidelines recommend a screening age of 10 yr for overweight children with risk factors, such as a family history of type 2 DM, exposure to gestational diabetes, clinical features of insulin resistance (eg, acanthosis nigricans, central obesity), and psychotropic medications; screening for MASLD — risk factors include male sex, family history, central adiposity, insulin resistance features, the presence of sleep apnea, and the presence of dysglycemia; risk factors for the progression of MASLD include age >14 yr with higher or increasing alanine transaminase; liver transaminases are not sensitive or specific for the diagnosis of MASLD; it is a biopsy diagnosis and a diagnosis of exclusion; elevated baseline levels of aspartate aminotransferase and low-density lipoprotein, prediabetes or DM, sleep apnea, or increasing weight or waist circumference are risk factors for progression of MASLD; HTN — new guidelines advise monitoring for HTN annually; for children ≥13 yr of age, the definition aligns with adult guidelines; for children <13 yr of age, it is still percentile-based; tools like 24 hr ambulatory BP monitoring can expedite diagnosis and reduce the need for repeat office visits, especially if there is a high suspicion because of family history; obstructive sleep apnea — polysomnography is indicated if one symptom of disordered breathing is present (eg, snoring); PCOS — if there is irregular menstruation or other features of PCOS; depression — monitor for symptoms at all ages; conduct annual screenings for children ≥12 yr of age; SCFE — is more common in children 9 to 16 yr of age, boys, and Black, Hispanic, and American Indian individuals; it is bilateral in 20% to 80% of cases; Blount disease — is unilateral; risk factors include genetics, early ambulation, and ethnicity; IIH — risk factors include new-onset or progressive headache, especially with visual or neurologic symptoms or changes with position

Treatment: primary care providers should treat obesity and related comorbidities concurrently within the framework of a medical home chronic care model, using a family-centered and nonstigmatizing approach; intensive health behavior and lifestyle treatment (IHBLT) is recommended, requiring 26 contact hours over 3 to 12 mo, although few practices can meet this standard; pharmacotherapy for obesity is recommended starting at age 12 yr; bariatric surgery is an option for suitable candidates ≥13 of age; the guidelines were released before the trials of topiramate, phentermine, and semaglutide were published

Guidelines for medication: the AAP recommends that weight-loss medications be considered for children ≥12 yr of age with obesity or overweight with comorbidities; the guideline specifies using these medications only in conjunction with lifestyle and behavioral treatment; critics have argued that introducing medications for pediatric obesity is risky and reflects a push toward medicating children rather than addressing root issues; however, others see it as a proactive approach, emphasizing the complex factors driving childhood obesity; a question that often arises is whether treating pediatric obesity with medication merely reflects society’s discomfort with larger bodies; it is critical to address this issue with empathy, recognizing that while stigma, bias, and discrimination around body size exist, there is also a strong biological connection between obesity, cardiometabolic disease, and premature death; obesity is often associated with health consequences beyond metabolic health, including mechanical stress on joints, urinary incontinence, and mental health; there is a need for precision tools that can predict the development of obesity-related comorbidities and responses to treatment more accurately

Focus on health: a common query is whether pharmacologic interventions for obesity can align with principles of weight inclusivity; although telling a patient that the focus is not on their weight alone but on their health might sound contradictory, the core message is about promoting physical and mental health over specific numbers on the scale; respectful care for every individual, regardless of body size, is essential, and treatment plans should always prioritize shared decision-making with patients

Eating disorders: concerns have also been raised about whether antiobesity medications could increase the risk for eating disorders in young patients; this is an area where data are still emerging, but current evidence suggests obesity itself and self-guided weight loss efforts may increase disordered eating behaviors; structured and supervised obesity programs, however, tend to decrease eating disorder symptoms; this highlights the importance of pairing medication with behavior change strategies, such as routine meals, mindfulness around hunger and fullness, and eating in structured settings, all of which align with practices commonly used to treat eating disorders

Pathophysiology: multiple external factors influence eating behaviors, including taste, availability, reward mechanisms, and social cues; metabolic factors and early life events also play a significant role; the body tends to defend a set weight, meaning weight loss efforts often need sustained support, making long-term use of medication alongside behavioral intervention necessary

Mechanism of action: topiramate and phentermine act on the hypothalamus, helping to regulate hunger and satiety; glucagon-like peptide-1 (GLP-1) receptor agonists work by slowing gastric emptying, increasing satiety, decreasing hunger, and increasing β-cell function; bupropion and naltrexone act at the brain level; setmelanotide, a melanocortin-4 receptor (MC4R) agonist, is for genetic forms of obesity

Liraglutide: was the first GLP-1 agonist approved for children >12 yr of age with obesity; it is administered as a daily subcutaneous injection and has shown a median BMI reduction of 4.6% over 56 wk; data showed there were no significant cardiometabolic benefits, but these may be harder to detect in children because they have fewer cardiometabolic issues; in a trial there were no significant adverse effects; it is not covered by many insurance carriers and costs ≈$1000 monthly; there is significant variation in treatment effects

Phentermine: acts as a stimulant that reduces appetite through norepinephrine reuptake inhibition and provides a mild boost in energy expenditure; it is approved for ages ≥16 yr for short-term treatment; contraindications include cardiovascular disease, monoamine oxidase inhibitor use, glaucoma, drug abuse, pregnancy, pulmonary HTN, and the use of other stimulants; side effects include elevated BP and heart rate, dry mouth (most common), and insomnia; it is not typically covered by insurance and is relatively inexpensive

Topiramate: is a gamma-aminobutyric acid (GABA) and dopamine modulator, and a partial carbonic anhydrase inhibitor, and is especially beneficial for behavioral eating and cravings; although not approved for obesity as a monotherapy, topiramate is approved for epilepsy in children ≥2 yr of age and migraines for ≥12 yr of age; dosages used for obesity are less than maximum doses for seizures; contraindications include acute myopia, glaucoma, suicidal behavior or ideation, and metabolic acidosis; side effects include paresthesia (temporary), cognitive slowing, and sleepiness; phentermine is usually administered in the morning and topiramate in the evening to reduce these side effects

Combination of phentermine and topiramate (Qsymia): has been studied in adolescents over a 52-wk trial (Hsia et al [2020]), showing a BMI reduction of 8% to 10% and improvements in triglyceride levels and high-density lipoprotein; side effects were generally comparable to placebo; insurance coverage varies; the cost is ≈$200

Semaglutide: is a newer GLP-1 receptor agonist approved for youth ≥12 yr of age with obesity or with overweight and comorbidity; administered weekly subcutaneously; semaglutide showed an average weight loss of 16.7% in a 68-wk trial (Weghuber et al [2022]), along with improvements in waist circumference, hemoglobin A_1C, lipid levels, and liver enzymes; while gastrointestinal side effects are common, they typically diminish over time; it is not currently approved by most insurance, and availability is limited

Efficacy vs cost: semaglutide shows the highest weight loss and health benefits, though it comes at a high cost; phentermine and topiramate also provide clinically significant weight loss and comorbidity improvements but are much more affordable; liraglutide is less effective in weight reduction; orlistat, despite approval by the US Food and Drug Administration, is rarely used because of its minimal efficacy and significant side effects

Other medications: metformin — weight loss effects are modest and vary between individuals; it has not been shown to prevent β-cell decline in children with prediabetes, unlike in adults (RISE Consortium, 2018); tirzepatide — a combination GLP-1 and gastric inhibitory polypeptide (GIP) agonist, is approved for adults and has shown greater weight loss than semaglutide; another option in development is Triple G, a combination of GLP-1, GIP, and glucagon agonist, which offers promising weight reduction similar to bariatric surgery; setmelanotide — is approved for specific genetic forms of obesity; genetic obesity cases are rare, but they present with distinct features, such as early-onset obesity, hyperphagia, and possibly cognitive or behavioral challenges; identifying genetic causes of obesity is now more relevant, as it may guide treatment choices

Overcoming barriers: primary care providers play a vital role in obesity management by screening, providing behavioral interventions, and starting or referring patients for medications as needed; barriers include limited time, insurance coverage, and patient resistance to treatment; practical strategies for overcoming these barriers include leveraging electronic health record supports, motivational interviewing, and the ECHO model to bring specialized training to rural areas; practices may also benefit from having a dedicated champion trained in obesity management to support clinicians and patients between visits; advocating for community support, such as health coaches or community workers, and lobbying for insurance coverage are additional ways to ease the burden on primary care providers

Readings

Bays HE, Lazarus E, Primack C, et al. Obesity pillars roundtable: phentermine - past, present, and future. Obes Pillars. 2022;3:100024. doi:10.1016/j.obpill.2022.100024. PMID: 37990729; PMCID: PMC10661986; Bensignor MO, Arslanian S, Vajravelu ME. Semaglutide for management of obesity in adolescents: efficacy, safety, and considerations for clinical practice. Curr Opin Pediatr. 2024;36(4):449-455. doi:10.1097/MOP.0000000000001365. PMID: 38774967; PMCID: PMC11222026; Bomberg EM, Clark J, Rudser KD, et al. Clinical effectiveness and predictors of response to topiramate plus lifestyle modification in youth with obesity seen in a weight management clinical setting. Front Endocrinol (Lausanne). 2024;15:1369270. doi:10.3389/fendo.2024.1369270. PMID: 38800488; PMCID: PMC11116594; Bomberg EM, Clark J, Rudser KD, et al. Effectiveness and predictors of weight loss response to phentermine plus lifestyle modifications among youth in a paediatric weight management clinical setting. Pediatr Obes. 2024;19(8):e13143. doi:10.1111/ijpo.13143. PMID: 38886982; PMCID: PMC11239309; Chakhtoura M, Haber R, Ghezzawi M, et al. Pharmacotherapy of obesity: an update on the available medications and drugs under investigation. EClinicalMedicine. 2023;58:101882. doi:10.1016/j.eclinm.2023.101882. PMID: 36992862; PMCID: PMC10041469; Fox CK, Vock DM, Sherwood NE, et al. SMART use of medications for the treatment of adolescent severe obesity: a sequential multiple assignment randomized trial protocol. Contemp Clin Trials. 2024;138:107444. doi:10.1016/j.cct.2024.107444. PMID: 38219798; PMCID: PMC11037878; Hampl SE, Hassink SG, Skinner AC, et al. Clinical practice guideline for the evaluation and treatment of children and adolescents with obesity. Pediatrics. 2023;151(2):e2022060640. doi:10.1542/peds.2022-060640. Erratum in: Pediatrics. 2024;153(1):e2023064612. doi:10.1542/peds.2023-064612. PMID: 36622115; Hsia DS, Gosselin NH, Williams J, et al. A randomized, double-blind, placebo-controlled, pharmacokinetic and pharmacodynamic study of a fixed-dose combination of phentermine/topiramate in adolescents with obesity. Diabetes Obes Metab. 2020;22(4):480-491. doi:10.1111/dom.13910. PMID: 31696603; Inge TH, Courcoulas AP, Jenkins TM, et al; Teen–LABS Consortium. Five-year outcomes of gastric bypass in adolescents as compared with adults. N Engl J Med. 2019;380(22):2136-2145. doi:10.1056/NEJMoa1813909. PMID: 31116917; PMCID: PMC7345847; Ioannou G, Petrou I, Manou M, et al. Dietary and physical activity habits of children and adolescents before and after the implementation of a personalized, intervention program for the management of obesity. Nutrients. 2024;16(20):3477. doi:10.3390/nu16203477. PMID: 39458473; PMCID: PMC11510330; Jans A, Näslund I, Ottosson J, et al. Duration of type 2 diabetes and remission rates after bariatric surgery in Sweden 2007-2015: a registry-based cohort study. PLoS Med. 2019;16(11):e1002985. doi:10.1371/journal.pmed.1002985; Katole NT, Salankar HV, Khade AM, et al. The antiobesity effect and safety of GLP-1 receptor agonist in overweight/obese adolescents without diabetes mellitus: a systematic review and meta-analysis. Cureus. 2024;16(8):e66280. doi:10.7759/cureus.66280. PMID: 39238716; PMCID: PMC11376316; Liu L, Shi H, Shi Y, et al. Comparative efficacy and safety of glucagon-like peptide-1 receptor agonists in children and adolescents with obesity or overweight: a systematic review and network meta-analysis. Pharmaceuticals (Basel). 2024;17(7):828. doi:10.3390/ph17070828. PMID: 39065679; PMCID: PMC11279917; RISE Consortium. Impact of insulin and metformin versus metformin alone on β-cell function in youth with impaired glucose tolerance or recently diagnosed type 2 diabetes. Diabetes Care. 2018;41(8):1717-1725. doi:10.2337/dc18-0787. PMID: 29941500; PMCID: PMC6054504; van der Aa MP, Elst MA, van de Garde EM, et al. Long-term treatment with metformin in obese, insulin-resistant adolescents: results of a randomized double-blinded placebo-controlled trial. Nutr Diabetes. 2016;6(8):e228. doi:10.1038/nutd.2016.37. PMID: 27571249; PMCID: PMC5022149; Wagner BE, Cook S. Weight bias and stigma in pediatric obesity. Pediatr Clin North Am. 2024;71(5):819-830. doi:10.1016/j.pcl.2024.07.005. PMID: 39343495; Weghuber D, Barrett T, Barrientos-Pérez M, et al; STEP TEENS Investigators. Once-weekly semaglutide in adolescents with obesity. N Engl J Med. 2022;387(24):2245-2257. doi:10.1056/NEJMoa2208601. PMID: 36322838; PMCID: PMC9997064.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Kelsey receives grant/research support from Rhythm Pharmaceuticals. Members of the planning committee reported nothing relevant to disclose. Dr. Kelsey's lecture includes information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Kelsey was recorded at Pediatrics in the Islands: Clinical Pearls 2024, held on October 28, 2024, in Waikoloa, HI, and presented by Children’s Hospital Los Angeles Medical Group. For information about upcoming CME activities from this presenter, please visit https://www.chla.org/chla-medical-group/cme-conferences. Audio Digest thanks Dr. Kelsey and Children’s Hospital Los Angeles Medical Group for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 2.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 2.00 CE contact hours.

Lecture ID:

PD710101

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.