Advances in Pediatric Endocrinology

Studies have shown that the rate of childhood obesity has more than tripled over the past 30 years, with obesity affecting one-fifth of children and adolescents ages 2 to 19 years in the United States. Indeed, pediatric overweight and obesity now affect more than 30 percent of children, making it the most common chronic disease of childhood. These alarming statistics underscore the importance of establishing an evidence-based approach for the management of children with obesity.

Dr. Marisa Censani

In the August 1, 2022, issue of Current Opinion in Pediatrics, Marisa Censani, MD, a pediatric endocrinologist and Director of the Pediatric Obesity Program in the Division of Pediatric Endocrinology at NewYork-Presbyterian Komansky Children’s Hospital, discusses the impact of COVID-19 on children and adolescents with obesity, new medical and surgical treatment options, and the availability of screening tests for rare genetic causes of obesity.

COVID-19 and Childhood Obesity

According to Dr. Censani, modeling studies predicted at least a 3 to 4 percent weight gain in children during the pandemic. In September 2021, a Centers for Disease Control and Prevention study projected that 22 percent of children and adolescents had obesity in August 2021, an increase from 19 percent in the previous year. “In our obesity practice, we are seeing children who had been making progress losing weight before the pandemic, return with an average weight gain of 10 to 20 pounds due to the lack of physical activity, sedentary remote learning, poor sleep, and poorly balanced dietary choices,” says Dr. Censani, who is also Associate Professor of Clinical Pediatrics at Weill Cornell Medicine. “Many of our families had lost consistent access to nutritious and adequate foods, such as fresh produce, and instead were eating more processed foods.”

Dr. Censani also cites a study conducted in New York reporting that obesity was the most frequent comorbidity in the 50 cases of children older than 2 years of age severely affected by COVID-19, noting that obesity was associated with severe disease necessitating mechanical ventilation.

Addressing the Clinical Challenges

Pediatric Obesity Algorithm: A Guide for Clinicians

“We know that children with obesity are at greater risk of becoming adults with obesity and associated health problems later in life, including type 2 diabetes, ischemic heart disease, and stroke,” says Dr. Censani. “We also know that children who have a BMI greater than the 95th percentile have a greater chance of maintaining that obesity into adulthood.”

To that end, Dr. Censani and practicing pediatricians and clinicians who treat obesity in infants, children, and adolescents have created the Pediatric Obesity Algorithm^®, an evidence-based clinical tool for the diagnosis and management of children with obesity. Produced by the Obesity Medicine Association, for which Dr. Censani serves on the Board of Trustees, the Pediatric Obesity Algorithm provides age-specific recommendations for use by clinicians with topics ranging from assessment to the diagnosis and treatment of obesity comorbidities. The guide combines scientific evidence, medical literature, and clinical experience into one document to educate clinicians and help them when making treatment recommendations or when referring their patients to childhood obesity specialists.

Dr. Censani emphasizes the importance of early diagnosis and intervention as children with obesity are at higher risk for metabolic syndrome, insulin resistance, high blood pressure, and hyperlipidemia.

“Earlier and more comprehensive management options will provide healthcare practitioners with an evidence-based approach for the diagnosis and treatment of children with obesity and give our patients the tools needed to prevent complications in adulthood.” — Dr. Marisa Censani

An Expanding Role for Pharmacotherapy

Diet and lifestyle interventions are primary treatments for childhood obesity, but pharmacotherapy can also play an important role. “Prior to 2020, there was only one FDA-approved medication for children 12 years or older – orlistat, an enteric lipase inhibitor that prevents the breakdown and absorption of fat,” says Dr. Censani. “However, it is very limited in clinical practice due to the side effects of abdominal distress, flatulence, diarrhea, and oily stools.”

Newer medications being offered today include:

• Phentermine – FDA-approved for weight loss in patients older than 16 years
• Metformin – commonly used in children and adolescents, although FDA-approved only in children 10 years or older with type 2 diabetes
  Metformin has been prescribed by obesity medicine specialists for polycystic ovary syndrome or severe insulin resistance with or without impaired glucose tolerance, with multiple trials showing a small amount of weight loss associated with metformin, particularly in the first few months of medication initiation.
• Phentermine and topiramate extended-release capsules – FDA-approved for the treatment of obesity in adolescents ages 12 to 17 years in July 2022.
• Liraglutide – a GLP-1 receptor agonist approved in 2019 to treat type 2 diabetes in children 10 years or older and approved by the FDA in December 2020 for adolescents aged 12 and older who have obesity, as defined by specific BMI cut-offs for age and sex that correspond to a BMI 30 kg/m2 or higher for adults, and who weigh more than 60 kg (132 pounds)
  A recent study reported a decrease in weight in patients who took liraglutide and underwent lifestyle therapy for 56 weeks.
• Setmelanotide – a melanocortin agonist developed for the treatment of obesity and approved by the FDA in November 2020 for patients 6 years or older who have obesity due to three rare genetic mutations: POMC deficiency, PCSK 1 deficiency, and LEP-R deficiency, and recently approved for Bardet-Biedl syndrome in June 2022.
  Setmelanotide is currently undergoing clinical trials related to additional rare genetic disorders associated with obesity.

Deciding on Surgery

Two studies have offered guidance for metabolic and bariatric surgery in youth 10 years of age and older outlining the criteria for surgery as a BMI ≥120 percentage of the 95th percentile with a major comorbidity or >140 percentage of the 95th percentile. The researchers maintain that previous barriers to undergoing surgery are not supported by evidence and that clinical decision-making should guide the decision for surgery. The most common surgery performed is the laparoscopic gastric sleeve, a safe and effective procedure in most youth with outcomes similar to those seen in adults.

Impact of Genetics on Obesity Medicine

Wider availability of genetic screening for rare genetic causes of obesity has impacted obesity medicine in youth. The majority of testing is based on mutations in genes involved in the MC4R pathway, which modulates regulation of appetite at the level of the paraventricular and arcuate nucleus of the hypothalamus. Some 10 laboratories offer genetic testing ranging from 2 to 79 different genetic mutations associated with individuals at risk for obesity. Indications for testing are broad, but clinical suspicion is particularly raised for children who present with obesity younger than age 5, defined as the criteria for early onset obesity.

Children with genetic causes of obesity frequently present with severe hyperphagia, defined as an obsession and almost complete preoccupation with food. Older children and adults who present with a history of childhood obesity may also meet criteria for screening.

Dr. Censani emphasizes that additional identification of genetic mutations is helping to reduce the stigma of obesity as a failure to maintain control over one’s food intake and may guide practitioners as to which patients are at particular risk.

“Earlier and more comprehensive management options will provide healthcare practitioners with an evidence-based approach for the diagnosis and treatment of children with obesity and give our patients the tools needed to prevent complications in adulthood,” adds Dr. Cesani. “Ultimately, as pediatricians we serve as advocates for the future health of our patients.”