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The GLP-1 Era in Pediatric Obesity Management · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

• 0:02
  I'm Holly Wehment, and this is Pediatrics Now, cases, updates,
• 0:07
  and discussions for the busy pediatric practitioner.
• 0:10
  One of the things that I think is so awesome about this podcast is we can bring
• 0:16
  you talks that you don't have time to attend.
• 0:19
  This talk is from our recent Pediatric Grand Rounds.
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  Pediatrics Now is brought to you by the Department of Pediatrics at UT Health
• 0:29
  San Antonio and University Health's new Women's and Children's Hospital.
• 0:35
  Let's listen in. Dr. Eskanameh, thank you very much for accepting our invitation.
• 0:39
  The floor is yours. Thank you so much for allowing me to talk about an area.
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  It's actually one of the reasons I entered endocrinology is the prevention of type 2 diabetes.
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  We are in a new era of a new option for obesity management and type 2 diabetes management.
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  So that's why I titled, and because I'm a Taylor Swift fan, in our GLP-1 era.
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  I think we have responses. So the correct answer is metformin.
• 1:09
  Metformin is not FDA approved for the treatment of obesity, even though it's used off-label.
• 1:14
  It's FDA approved for type 2 diabetes in children 10 or older.
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  All of the rest of them are.
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  Next question. Yeah, so the correct answer is all of the above.
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  Really, we should kind of be looking at all aspects and kind of stratifying
• 1:30
  where that patient or child sits in terms of their risk classification.
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  All right, last question. Which of the following are reported side effects of
• 1:42
  the GLP-1 receptor agonists?
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  Delayed gastric emptying, nausea, vomiting, bloating, pancreatitis,
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  some already entering in.
• 1:53
  Yeah, so that's the correct answer. All of the above.
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  All of those are reported side effects of the GLP-1. So I'm going to go ahead and start.
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  Now I can go back into...
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  There you go. All right. Thank you all for being patient with those QR codes.
• 2:14
  So I want to start off by kind of defining how we diagnose childhood obesity.
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  So we stratify kids depending on their BMI.
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  So the BMI category is determined by an age and sex specific percentile rather
• 2:31
  than specific cutoffs like the adults do.
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  So in terms of overweight, it's defined as a BMI at or above the 85th percentile
• 2:39
  and below the 95th percentile for age and sex.
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  Obesity is defined as at or above the 95th percentile.
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  And severe obesity is defined as a BMI equal to or more than 120th percent above the 95th percentile.
• 2:54
  So once you get into those kind of higher categories, we just kind of defined it as severe.
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  And then in older adolescent, the adult cutoff of a BMI equal to or greater
• 3:04
  than 30 can be used to define obesity if it is less than the 95th percentile BMI for age and sex.
• 3:11
  So the BMI itself really does have some limitations, right?
• 3:15
  So in looking at how we measure like body composition, the gold standard of
• 3:21
  determining fat mass and fat-free mass is really like the DEXA scan.
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  And we have other, you know, bioelectrical impedance in other ways.
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  So it's not really kind to take into consideration necessarily the body composition and fat content.
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  And so it may under or overestimate excess adiposity depending on,
• 3:41
  you know, certain races, ethnicities, age.
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  Part of my fellowship research project was doing body composition on infants
• 3:51
  and we know infants are just all balls of fat.
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  So, you know, it really kind of varies as in the trajectory of our age.
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  So this is a really busy slide, but I really kind of wanted to point out some
• 4:05
  kind of really important aspects.
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  So one is that pediatricians and primary health care providers should be assessing a BMI, right?
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  Their well-child visits and using the age and sex-specific CDC growth charts
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  to kind of classify, you know, if a child is obese and the severity of the obesity.
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  So if If the BMI is greater than the 85th percentile, then we look into kind
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  of stratifying into overweight, obese, or severe obesity categories.
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  And then if they fall into the obesity and severe obesity, well,
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  into any of those three categories, sorry, the next step would be doing comprehensive evaluation.
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  So depending on their age.
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  Looking at comprehensive history, so a review of system, like social determinants
• 4:53
  of health, so getting kind of really good social history, physical examination.
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  And when we're classifying kids, I think it's important to kind of recognize
• 5:02
  that when we discuss this with families, the language that we use is really
• 5:07
  important because it can be very uncomfortable and stigmatizing to,
• 5:11
  to bring this up with families.
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  And so using the kind of like person first language is really important.
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  So saying, you know, instead of saying an obese child, a child with obesity.
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  And so again, looking at once you, you know, diagnose them with either overweight,
• 5:30
  obese, or severe obesity, looking into the history, the mental and behavioral
• 5:35
  health screening, the social determinants of health, the physical exam.
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  And then depending on their age is doing these kind of annual checks,
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  blood pressure, fasting lipids, fasting plasma glucose, oral glucose tolerance
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  tests, chemoglobin A1C and ALT.
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  And then if any of these are abnormal, so referring to the AAP high blood pressure
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  clinical practice guidelines.
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  And then if not, then repeating at every visit.
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  And then the labs are abnormal, referring to the appendix index in the bright
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  future, which really kind of helps stratify like what the general pediatrician
• 6:13
  should do next or, you know,
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  primary healthcare provider in terms of, okay, if these labs are abnormal,
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  how frequently should we recheck?
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  So it really gives a good, the appendix is really nice in terms of kind of knowing
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  when to, you know, refer out or when to maybe repeat, you know,
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  kind of depending on where the levels fall.
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  And then in terms of the treatment, so I'm going to kind of go into more of
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  the treatment aspects of this, but really, you know.
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  What I kind of took away from these guidelines is that really we kind of want
• 6:49
  to start looking into even just like the weight loss pharmacotherapy or surgery
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  earlier on and not kind of delaying treatment if we know that the severity of
• 7:01
  the obesity is very high.
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  So I think that's kind of a practice change that I could have took from these guidelines.
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  So this is an example of a BMI percentile. So if you look at just the percentile
• 7:14
  itself, you know, it tells you that it's above the 95th percentile,
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  but it doesn't really kind of help you see the trajectory over time.
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  You just kind of see it in the sense that it's early been high.
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  So the BMI extended really is helpful, right? To kind of see the progression of the BMI over time.
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  So in this particular patient has always had really kind of severe obesity.
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  And if you look at the most recent point, you know, BMI is 223 percentile of the 95th percentile.
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  And so in our electronic medical record system, EPIC, it allows you to see the
• 7:52
  different kind of options of like the BMI extended or the BMI in terms of standard deviations.
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  So I think that's important to kind of to see. So the percentage of U.S.
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  Children and adolescents affected by obesity is actually 19%.
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  So that's 14.7 million between the years of 2017 to 2018.
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  That's pretty shocking.
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  And it's increasing among certain populations, so adolescents and non-Hispanic,
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  Black, and Mexican-American youth.
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  And it's estimated that at the current transcontinue, 57% of children ages 2
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  to 19 will have obesity by the time they are 35 years of age in 2050.
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  Looking at regionally, so in Texas, the prevalence 21% of youth ages 10 to 17
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  have obesity, giving Texas a ranking of 46 among the 50 states.
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  And then kind of looking at local trends. So this was taken from the WITI body
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  adventure data and in conjunction with our Metro Health Department and looking
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  at the prevalence by zip code.
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  And we've worked a lot with our metro department and adjudication of type one and type two.
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  So it's really kind of neat what their bioinformatics team can do.
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  But if you look at certain particular zip codes, particularly like the area
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  of town where we practice on the west side and certain school districts seem
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  to really have a high prevalence, kind of more of the central southern zip codes of the city.
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  So why is this important? Why does this matter? So we know that children and
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  adolescents with obesity often have a higher prevalence of comorbidities and
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  a greater risk of obesity in adulthood and morbidity and premature death.
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  And the risk of obesity-related comorbidities increases with the age and severity
• 9:44
  of obesity and varies by race and ethnicities.
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  So some of the obesity-related comorbidities that we screen for are increased
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  intracranial hypertension, obstructive sleep, apnea, type 2 diabetes,
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  depression, anxiety, low self-esteem,
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  non-alcoholic fatty liver disease, dyslipidemia, PCOS, Blanc's disease,
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  SCFI, and hypertension.
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  So these are all things that we should be screening for as we do our review
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  of systems and our physical exam with our patients.
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  And our institution was very fortunate to be involved in the TODAY study.
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  And the TODAY study was a study done.
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  Many years ago, back in 2005. And there was a study of 10 to 17-year-olds with
• 10:31
  type 2 diabetes based on ADA criteria for less than two years.
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  They had a BMI of greater than 85% and a high C-peptide level is above 0.6.
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  And so they didn't have type 1 diabetes.
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  And out of this 699, you know, cohort of youth that were randomized to either
• 10:49
  metformin, metformin plus rosiglitazone or metformin plus intensive lifestyle intervention.
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  The majority of them fails metformin so
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  greater than 50 percent of the cohort and I think what we've
• 11:01
  learned now as we've followed so I became involved
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  you know as a you know young faculty in the in the pregnancy outcomes of these
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  now 30 year olds that were diagnosed as children with type 2 diabetes and it's
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  really kind of astonishing like the the results so there's a high rate of microalbuminuria,
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  greater than 60% with hypertension,
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  high rates of hyperlipidemia.
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  And then in pregnancies, 25% of the pregnancies were known outcomes resulted in a miscarriage.
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  24% resulted in preterm births. And 20% of the infants were born with major congenital anomalies.
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  So we really are recognizing that children that are diagnosed early with youth
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  onset type 2 diabetes really have a very aggressive form of diabetes and really kind of early of these,
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  comorbidities are seen or early onset comorbidities are seen.
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  So then we're talking about kind of like the comprehensive care of the prevention
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  of leading to that state, right?
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  So I'm not going to really focus on, you know, motivational interviewing or
• 12:13
  intensive health behavior and lifestyle changes or surgery, but really kind
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  of focus in on the pharmacotherapy aspect.
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  So what are the current FDA approved medications to treat obesity in children?
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  So actually we have these five medications that are actually FDA approved,
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  even though, like I mentioned, some medications like metformin are used off-label.
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  So the FDA approved ones include Orlistat, which is an intestinal lipase inhibitor
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  that blocks fat absorption from your diet. It's approved for ages 12 and older.
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  One of the real limitations of this is the side effect profile.
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  So statorrhea, fecal urgency, and flagellants. So most patients don't tolerate,
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  which is why a lot of people don't prescribe it.
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  We'll talk, we'll go into a little bit more of the GLP-1s.
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  So liraglutide and semaglutide are both subcutaneous injections.
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  They're GLP-1 receptor agonists, and they really help with satiety.
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  They're approved for ages 12 and up. Some of the side effects,
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  and I'll go into more detail about like the GI, but nausea, vomiting,
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  they're contraindicated in patients with MEN.
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  And because of the risk of medullary thyroid cancer or C-cell hyperplasia.
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  And then we have medications that are like combination and fentramine-tapiramate,
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  which is a central norepinephrine uptake inhibitor, but also non-selectively
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  inhibits serotonin and dopamine uptake.
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  And then tapiramate is a carbonic anhydrase inhibitor, and these kind of lessen
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  the hunger, and it can help manage cravings. Again, they're approved for ages 12 and older.
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  They can cause an elevated blood pressure, dizziness, headache,
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  tremor, dry mouth, stomach ache, and cognitive slowing.
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  And then setmelanotide is specifically for patients with genetic forms of obesity.
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  So for melanocorpion 4 receptor agonists, they are approved for children six
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  years and older with, you know, more specific causes of obesity that are genetic.
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  And so that is not something that usually the general practitioner would be
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  prescribing. Usually those are patients that we might see in our clinic.
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  So what is on formulary for Texas Medicaid?
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  Nothing. Texas Medicaid does not cover anti-obesity medications, unfortunately.
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  And Texas state employees, so within our own institution, they drop the coverage
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  for anti-obesity medication. So it's really hard to get the care that we need for our patients.
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  And this is just an example of the path it takes to get a GLP-1 receptor agonist
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  for a patient with type 2 diabetes.
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  So for type 2 diabetes, they are approved, they're on Medicaid formulary,
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  but the patient has to be 18 or older.
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  And so if they don't, they medically deny the request.
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  And so there's, there are other options that you can kind of pathways around it.
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  But this is just to kind of illustrate some of the challenges that we have to
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  really get these medications approved.
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  So what is a GLP-1? So the incretins are hormones released from endocrine cells
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  in the epithelium of the small intactins, so the L-cells,
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  in response to food that act on the pancreatic beta cells to regulate insulin secretion.
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  So really in response to food, they release insulin.
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  There's two primary incretin hormones in humans.
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  So there's a glucose-dependent insulinotropic polypeptide, GIP,
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  also known as gastric inhibitory peptide and glucagon-like peptide one. So the GLP one.
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  And interestingly, they're not the only good thing that came out of the eighties,
• 16:01
  including myself, but they were discovered in the 1980s.
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  And the, the way that they kind of progressed into.
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  Into commercial use is that they were able to isolate the DNA of the lizard, the,
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  the venom of the lizard so
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  they produce a hormone called exanidide 4 and has
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  a lot of structural similarities to glp1 but unlike
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  glp1 it doesn't break down quickly so
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  it remains active in the body for an extended period of time so it was the perfect
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  candidate for a diabetes drug so here are some of the incretin and logs that
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  are used in type 2 diabetes and so we have you know the the world now world known Ozembek, right?
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  So it's a once weekly injection for type 2 diabetes.
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  And actually it's not FDA approved currently in children.
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  It's adults that are at the type of. Bogowi is approved for weight loss.
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  We have Trulicity though.
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  Trulicity is approved for type 2 diabetes for kids 10 and older.
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  Victosa also is approved for
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  type 2 diabetes. Bayeda, so some of the older GLP-1s that are once daily.
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  Mongero, which is trisepatide, which is kind of a combination drug,
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  is not currently approved for kids less than 18.
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  Same thing for Rebelsis, that oral medication that's a GLP-1.
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  It's not approved for less than 18.
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  So to kind of give an overview, so GLP-1s really kind of work at several target
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  organs. So at the level of the brain and hypothalamus, it helps promote the feeling of satiety.
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  At the level of the gut, it delays gastric emptying.
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  It also helps decrease blood pressure and it can increase thermogenesis and
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  lipolysis and adipose tissue.
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  And then as I mentioned, it helps in the secretion of insulin from the pancreas.
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  So these are two really kind of pivotal studies that were done in adults.
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  So the first one is the SCALE trial.
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  So this was a 56-week randomized placebo-controlled trial
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  aimed to evaluate the efficacy and safety of three milligrams of liraglutide
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  injected sub-Q as an adjunct to a reduced calorie diet and increased physical
• 18:25
  activity for weight management in overweight or obese adults who didn't have diabetes at baseline.
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  And then the second kind of pivotal study was a phase three double-blind randomized
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  control trial comparing semiglutide with placebo plus lifestyle changes in overweight
• 18:41
  or obese adults without diabetes.
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  And these patients were assigned to receive 2.4 milligrams of semiglutide.
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  And so sorry the resolution
• 18:53
  of this is a little blurry but basically panel so this chart shows that the
• 18:58
  proportion of patients who lost at least five percent more than 10 percent and
• 19:04
  greater than 15 percent of their baseline body weight so in the lara glutate
• 19:09
  group this was 63 percent,
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  compared to 27% lost greater than 5% of their body weight.
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  33% versus 10% lost greater than 10% of their body weight.
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  And 14% versus 3% lost greater than 15% of their body weight.
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  So these are pretty impressive.
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  And lariglutide is a once-weekly injection.
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  The most frequently reported side effects of the lariglutide were mild to moderate nausea and diarrhea.
• 19:42
  And then for the semiglutide trial in adults, so again, they was comparing semiglutide
• 19:48
  with placebo and lifestyle changes in overweight and obese adults with diabetes.
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  There were 1,961 participants assigned to receive 2.4 milligrams of semiglutide.
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  And the primary endpoints were the percent change in body weight and a reduction
• 20:04
  of greater than 5% of the body weight.
• 20:07
  So by week 68.
• 20:10
  The weight declined more in semaglutide than the placebo group,
• 20:14
  so 14.9% versus 2.4% in the placebo group.
• 20:19
  So you see the percent of weight loss from baseline was clinically said in that case.
• 20:25
  And again, the side effects were similar in terms of mainly just kind of GI side effects.
• 20:31
  Some of the more serious side effects were related to hepatobiliary events that
• 20:37
  were reported more often in the semaglutide group.
• 20:40
  And then kind of moving into the pediatric trials. So again,
• 20:45
  very similar trials that were done in kids.
• 20:48
  So with liraglutide, this was a 56-week trial and a 26-week follow-up period.
• 20:55
  And these were adolescents that were 12 to less than 18 years of age with obesity
• 21:00
  and a poor response to lifestyle alone.
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  They were assigned to receive either liraglutide or placebo in addition to lifestyle
• 21:08
  therapy. And the primary endpoint was a change from baseline in the body mass index.
• 21:14
  And also they were looking at the standard deviation score at week 56.
• 21:18
  So they had 125 kids in the lara glutee group, 126 in the placebo group.
• 21:26
  And the percent change in BMI in terms of standard deviation was minus 0.23%.
• 21:34
  So it was clinically significant.
• 21:37
  And if you looked at it, you know, in certain groups, there was a reduction
• 21:42
  in BMI of at least 5% in 51 of the 113 participants.
• 21:48
  And again, the side effects were very similar in terms of the adult study.
• 21:52
  So a lot of GI side effects were reported. And then after discontinuation,
• 21:58
  there wasn't an increase in the BMI standard deviation score from the lyridlutite
• 22:03
  group compared to the placebo.
• 22:04
  So the kids essentially started to regain the weight once they came off.
• 22:09
  And then similar to the adult study, so we've now done, and some of my colleagues
• 22:15
  have been involved in some of these trials.
• 22:17
  So the once weekly semiglutide in adolescents with obesity is called the STEP-teens trial.
• 22:24
  And so it's a phase three multinational double-blind parallel group randomized
• 22:29
  placebo-controlled trial to assess the efficacy and safety of semiglutide plus
• 22:34
  lifestyle intervention compared to just lifestyle intervention alone.
• 22:37
  And so they recruited 201 adolescents ages 12 to less than 18 with a body mass
• 22:44
  index in the greater than or equal to the 95th percentile or in the 80,
• 22:49
  greater than or equal to the 85th percentile with at least one related coexisting condition.
• 22:54
  So some of these kids, if they had like diabetes or high blood pressure,
• 22:57
  they were still able to be assigned into the semi-cutite group.
• 23:01
  All the participants and their parents received counseling and nutrition on
• 23:07
  physical activity for the weight loss throughout the trial.
• 23:10
  And the primary endpoint was a percentage change in BMI from baseline to week 68.
• 23:16
  So the results showed a reduction in the percent change in the semiglutate group
• 23:23
  of 16.1 compared to placebo.
• 23:26
  And then a reduction of body weight of greater than 5% and 73% of the participants.
• 23:33
  So again, really clinically significant.
• 23:37
  And actually the placebo group had a modest increase in the percent change of
• 23:41
  their BMI compared to the semiglutide group.
• 23:44
  So, and then again, the side effects were very similar in terms of the adult
• 23:50
  trials and also in the lyrugutides.
• 23:53
  So in kind of a head-to-head comparison, I mean, they both have a very similar
• 23:58
  profile. So the brand names of these FDA-approved medications are Saxenda for
• 24:03
  the lyroglutide and Wagovi for the semiglutide.
• 24:07
  They are contract-indicated in pregnancy, family history of medullary thyroid
• 24:11
  cancer, and MEN2 because of the risk of concern of growth in the C-cells.
• 24:17
  And really, this has been mostly in rat studies, so we really haven't seen it much.
• 24:23
  In like the adult, in the pediatric studies.
• 24:27
  But that is something to kind of keep in mind if there's any family history
• 24:31
  of MTC that's a contraindication to its use.
• 24:34
  And then warnings in any history of acute pancreatitis, gallbladder disease,
• 24:39
  issues with hypoglycemia. So if they're used concurrently with insulin or any
• 24:45
  other medication that can increase their risk of hypoglycemia.
• 24:49
  And then in kids with acute kidney injury and in terms of adverse drug reactions.
• 24:55
  So things that really the general pediatrician should be looking out for is a lot of the GI stuff.
• 25:00
  So nausea, diarrhea, vomiting, injection site reactions.
• 25:06
  And I'm not gonna go into like the titration, but again, there are some recommendations
• 25:11
  in terms of when to discontinue if we're not seeing a clinical response,
• 25:16
  but really kind of getting kids to a maintenance dose is key.
• 25:21
  And then a little bit more on the potential side effects. So we talked about
• 25:23
  pancreatitis, gallbladder disease, hypoglycemia, and the kidney failure.
• 25:30
  A lot of times there's concerns because the kids are not really eating as much.
• 25:34
  They have early satiety.
• 25:35
  So if they're not drinking as much, they can get dehydrated.
• 25:39
  So that's really important, you know, to counsel patients in terms of making
• 25:42
  sure they're staying really well hydrated.
• 25:46
  Retinopathy is really starting to come out and studied a little bit more
• 25:49
  in adults with type 2 diabetes in terms
• 25:52
  of like the rapid progression of retinopathy and
• 25:57
  then also potential side effects that are listed on both of
• 25:59
  the medications depression that's a suicide and then the delayed gastric emptying
• 26:04
  and risk for aspiration i highlighted that because there's actually a new consensus
• 26:10
  guidelines for adults and children that was put out by the American Society
• 26:15
  of Anesthesiologists with the GLP-1s to really,
• 26:19
  for patients that are on the once-daily GLP-1s to hold it on the day of the procedure.
• 26:25
  And for patients that are on weekly dosing, you know, to hold or to consider
• 26:29
  holding a week prior to the procedure.
• 26:32
  And this is irrespective if they're using it for type 2 diabetes or for weight loss.
• 26:38
  So that kind of poses a challenge for us as endocrinologists too in terms of
• 26:42
  management of blood sugars, you know, while these medications are not being used.
• 26:47
  But it is really important because of the risk for aspiration.
• 26:51
  So that's kind of where it might start to get a little bit tricky in terms of
• 26:56
  procedures, but it is really important to counsel the patients about these potential side effects.
• 27:01
  And then this is a recent article.
• 27:06
  It's more of a review by Dr.
• 27:11
  Drucker, who is really kind of instrumental and helped isolate the exenitide
• 27:17
  from the lizard, from the ajila monster.
• 27:20
  So one of the things that, you know, the ones that are in gray are kind of the
• 27:25
  things that we know, right?
• 27:26
  So nausea, diarrhea, constipation, vomiting, reduced bowel motility,
• 27:31
  and, you know, the question of potential like ileus, retained gastric content, aspiration,
• 27:38
  AKI, again, these patients can get dehydrated because if they're not eating
• 27:43
  because of the satiety, they might also not be drinking as much.
• 27:46
  And so that can lead to dehydration and AKI. And then this kind of risk of gallbladder disease,
• 27:53
  and those are obviously more serious that were reported in both,
• 28:00
  in a lot of the adult studies.
• 28:02
  And then here, I mean, I think this, the retinopathy, increased risk for pancreatitis
• 28:07
  and cancers really kind of need to be explored and studied more.
• 28:11
  And there's a lot of ongoing trials in adults that are really looking into this a lot more closely.
• 28:18
  So I wanted to provide the audience with some of the resources.
• 28:22
  We have a really great multidisciplinary team in our clinic.
• 28:26
  We have an amazing social worker and nutritionist.
• 28:30
  And so, but sometimes, you know, it's, it might seem out of our capacity to
• 28:34
  provide the lifestyle interventions that we need for our patients. So it takes a village.
• 28:40
  So really kind of knowing what resources we have in our community.
• 28:44
  So I, so the HEB or sorry, the healthy corner stores actually are just like
• 28:50
  convenience stores, gas stations that have produce and non-processed foods that accept SNAP.
• 28:55
  The HEB nutrition services, I thought it was really amazing to actually go shopping
• 29:00
  with you to provide kind of good, good, healthy choices.
• 29:04
  And some of the other counseling services that accept a lot of the insurances
• 29:09
  that we see. And then in terms of just food safety, so I just wanted to kind
• 29:14
  of provide a list of resources that our wonderful staff got together for me and shared.
• 29:20
  And then some of the exercise resources, because really, you know,
• 29:23
  it's not just about using the pharmacological, you know, intervention.
• 29:26
  It's also to be able to provide the resources so that patients can also continue
• 29:32
  to exercise to build up muscle mass.
• 29:34
  One of the concerns that's also kind of come up is that in patients with like
• 29:39
  sarcopenic obesity, in other words, kind of what you see in a more adult population
• 29:45
  is that, you know, with age, muscle mass declines.
• 29:49
  And so when they have these rapid weight loss, they're also losing additional muscle mass.
• 29:56
  So it's really important to counsel patients. They still need to,
• 30:00
  you know, follow a good, healthy exercise regimen, build that muscle mass.
• 30:05
  So when we're thinking about things like body composition, they're also incorporating
• 30:11
  that really important aspect. And so here are some of the resources that we have for our patients.
• 30:17
  And then also the mental health aspect, right?
• 30:20
  We talked about how stigmatizing obesity and just addressing it can be,
• 30:24
  but then also with the weight loss, what does that mean?
• 30:27
  You know, is that some kids get really disappointed if they're not seeing the change in their weight.
• 30:35
  So just being able to kind of provide some support in a really kind of comprehensive
• 30:40
  way. So this is my other baby.
• 30:44
  So Dr. Reyes and one of our previous research coordinators really were instrumental
• 30:51
  in developing what we now call as object power.
• 30:55
  It was previously called camp power up. And so this is a camp.
• 31:00
  This was a vision that they saw in terms of really trying to prevent.
• 31:05
  The development of type 2 diabetes in youth and really kind of targeting high-risk
• 31:09
  individuals that were already kind of meeting the BMI criteria,
• 31:13
  but also had a first-degree relative with type 2 diabetes and other comorbidities.
• 31:19
  And so this kind of lifestyle intervention, in addition to nutritional education,
• 31:24
  has been an ongoing project. And it actually has kind of exceeded our expectations
• 31:30
  and now been taken by the ADA as a national model.
• 31:33
  And so if you go on the ADA website, you will see now Project Power for Adults.
• 31:38
  And so it all, it all was grassroots from our endocrine team.
• 31:43
  So I'm really proud of it. I'm proud that we've been able to do really fun things.
• 31:47
  We take the kids to the Witty.
• 31:49
  We, last year we gave them bikes that were all donated by community partners.
• 31:55
  We've had, you know, the local soccer organizations come in and teach,
• 32:00
  you know, the kids different things just to kind of make, you know,
• 32:04
  it not so stigmatizing in a group with a lot of peers that are kind of going through the same thing.
• 32:09
  So I want to thank everyone for your attention.
• 32:14
  My son, my other baby is in his dino era right now.
• 32:19
  Thank you, Dr. Eskanam for that wonderful overview of obesity management,
• 32:24
  especially the GLP-1 receptor agonist.
• 32:28
  There are already three questions in the chat box. The first one is,
• 32:31
  what is the rate of obesity recurrence when GLP-1 receptor agonist is discontinued?
• 32:39
  So how often does it recur after you discontinue the medication?
• 32:44
  I don't think we really fully know yet. Dr.
• 32:48
  Lynch, you're on the call and I know you're kind of doing some of these extension studies.
• 32:52
  I don't know if you could speak to that.
• 32:55
  I don't know if we have enough literature right now to kind of see how many
• 32:59
  kids once they come off will go uh.
• 33:02
  So by the time Dr. Lynch comes on, there is a second half. Yeah,
• 33:06
  I don't think we know. I think that's the answer.
• 33:09
  We're doing the step team. Actually, we're part of, Dr.
• 33:12
  Lynch is one of the PIs for the extension to the step teams.
• 33:16
  And so we're kind of looking at the long-term outcomes of the original cohort,
• 33:23
  but also enrolling new patients on it.
• 33:25
  And so I think that's going to provide us more information of how many kids
• 33:29
  are regaining the weight once they come off. And is this going to be a long-term
• 33:33
  medication that they're not going to need to continue on?
• 33:35
  The second half of the question, reasons for discontinuing these medications.
• 33:39
  What are the indications for discontinuing these medications?
• 33:43
  Yeah, so some of the indications, and I kind of touched on this a little bit
• 33:48
  on one of the slides, was a failure to see a change in the BMI.
• 33:52
  So if there hasn't decreased by greater than 1% from baseline after you're already
• 33:57
  on a maintenance dose. So you really have to get to the, you know,
• 34:01
  the escalation of the dose.
• 34:03
  And that can be challenging. That poses a challenge for us because,
• 34:06
  you know, we have limited availability sometimes with our appointments.
• 34:10
  And so we can't be bringing patients in necessarily every month.
• 34:14
  And so we had, and if we see this expanding, it would be kind of having to be
• 34:18
  a dedicated way to do that, to make sure that there, you know,
• 34:22
  we're seeing the change from baseline. Yeah.
• 34:25
  If they're not kind of achieving that, you know, reduction in BMI.
• 34:29
  The other question, sort of request from Dr.
• 34:33
  Cortez, can these resources, the links
• 34:35
  you provided for exercise and other resources emailed to the faculty?
• 34:41
  And the other one is, this would be useful for AVS in EPIC.
• 34:46
  And I don't know what AVS stands for, but I think if you provide these links
• 34:50
  on EPIC, this would be helpful.
• 34:54
  Yeah, I can definitely do that. in the after visits, I mean,
• 34:57
  like in the patient instruction.
• 34:59
  There's a question, a comment from Dr. Williams. Those not specialists were
• 35:03
  supposed to code excessive weight gain instead of obesity and then code the BMI.
• 35:09
  Now that it is not an option, so is it correct and sufficient for non-ENDO to
• 35:16
  code the three categories, like over 120%, et cetera?
• 35:20
  Yeah, they do. And the AAP actually has some really nice guidelines in terms
• 35:25
  of coding obesity for the general practitioner.
• 35:29
  So, I mean, I think there, I didn't dive into that and I'm not as familiar.
• 35:35
  I think that's one of the things that we really can work to improve within our
• 35:39
  own division, how we code this.
• 35:41
  But the AAP actually has some really nice guidelines in how to code for the general practitioner.
• 35:47
  Thank you so much for listening to that fascinating talk. Don't forget to click
• 35:52
  on the link in this podcast for free credit.
• 35:55
  Our website is pediatricsnowpodcast.com. My email address is on there.
• 36:01
  Please email me with questions or episode ideas.
• 36:05
  Pediatrics Now is also sponsored by CPAN, no call too small.
• 36:11
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• 36:15
  Also, wherever you get your podcasts,
• 36:18
  it's meant to be one less thing you have to say in the exam room.
• 36:23
  That's Pediatrics Now for Parents, wherever you get your podcasts,
• 36:27
  or pediatricsnowforparents.com.
• 36:30
  Thank you so much for listening.
• 36:32
  I'm Holly Wehment, and I'll see you soon.