Deborah Howell (Host): This is the Peds Pod by Le Bonheur Children's Hospital. I'm Deborah Howell, and with me is Dr. Ying Weatherall, Le Bonheur pediatric surgeon and adolescent bariatric surgeon, as we talk about pediatric weight management, GLP-1 injections versus weight loss surgery, how these options work, when they're used, and what families need to know. Welcome to you, Dr. Weatherall.

Ying Weatherall, MD: Hello, Deborah. Thank you for having me today.

Host: Our pleasure. To get started, how has the approach to pediatric weight management shifted during your career?

Ying Weatherall, MD: One of the major shifts is that people are more willing to talk about it, and people are more willing to seek management for weight. I think when I started my practice about 10 years ago, this was sort of taboo and people didn't really know how to approach this topic with families. And so, they just simply didn't address it while the patient was in the clinic for, you know, various other reasons that may be obesity-related, like, obstructive sleep apnea, gallstones, things like that.

So, I think, most importantly, the pediatric community is more willing to talk about it. And I think that is really credible to the fact that there's been a lot of literature published about weight-related comorbidities as well as how to treat that, and then really how to treat weight in general, as kind of, you know, the first step to try to avoid long-term comorbidities associated with weight

Host: Yeah. And without the shame factor.

Ying Weatherall, MD: Correct. Yes.

Host: At what point does a pediatrician move from lifestyle and diet conversations to, you know, discussing medical interventions?

Ying Weatherall, MD: I think one of the critical changes is when the pediatrician starts to see obesity-related complications. And so, I always kind of tell my patients that we're very blessed that we get to intervene early in a patient's lifetime. And, you know, adult bariatric surgeons get the patients very late. And so, they are getting a more unhealthy patient, because they've been dealing with their weight for so long, their lifetime.

And so for us, our kids are younger, and so they actually are pretty healthy. However, there are early signs of weight-related complications such as kidney injury, and then also things like sleep apnea and then joint pain, and then insulin resistance. So, I think those obesity-related complications really is the turning point to stop having these conversations about lifestyle modifications and really trying to pursue a more, I guess, aggressive management for their weight.

Host: When we talk about weight loss surgery for minors, what are the most common procedures performed today?

Ying Weatherall, MD: The most common procedure performed is a gastric sleeve, otherwise called a sleeve gastrectomy. There are some adolescent bariatric surgeons that will still do gastric bypasses or otherwise known as Roux-en-Y gastric bypasses for weight. But most of the adolescent bariatric surgeons are doing gastric sleeves. And gastric sleeves is the most well-studied also in terms of complications, long-term outcomes. And so, at Le Bonheur, where we have a bariatric program for adolescents, this is the procedure that we exclusively perform.

Host: Got it. Are GLP-1 medications a bridge to healthier habits, or are they a long-term necessity once a teen starts them? And how do they work in a developing pediatric body?

Ying Weatherall, MD: So, GLP-1s are not very well-studied in pediatric patients. There is one very good paper on how GLP-1 changes a patient's weight in a peds population, and it's very, very good. It's a randomized double-blind controlled study for Wegovy or semaglutide versus lifestyle modifications. And it found that at one year, the weight loss with GLP-1 was 17% of starting weight, which is very good. However, compared to surgery, for example, surgery in the first year after having performed surgery, patients are losing about 27%. versus lifestyle modification, they're losing in the range of 3% to 4%. So, that's kind of what you're looking at.

And so, GLP-1s have been studied in pediatric population in the sense of how effective they are. However, it's not been studied in the sense of how does it change a pediatric patient as they're developing or growing. They are, in fact, only FDA-approved for 12-year-olds and over, which I think is a testament to the fact that they're not sure kind of what effects they would have on, for example, a patient who has not gone through puberty yet. And so, currently, in our clinic, we are able to provide GLP-1s for patients 12 years and over, as long as there's insurance coverage.

As far as GLP-1 being a long-term medication versus a bridge to surgery, I'm a surgeon. So, I think I'm a little bit biased. However, the literature for the adult populations are definitely showing that GLP-1s are a chronic sort of lifelong medication. Patients who go on it that come off regain the weight. And so, it really is considered more of a lifelong medication, which I think for our children, it is harder to tell the family that they have to do, for example, this injection for the rest of their life. And so, I really don't use GLP-1 as a lifelong kind of maintenance medication. It really is more of a bridge to surgery, and that's how we definitely use it in our clinic too.

Host: Interesting that there's only one paper so far.

Ying Weatherall, MD: That's right. I think more will come out. But right now, that's the only one. And it's a good paper. So, you know, because it's randomized, it's double-blind. And so, it's a very good paper. But I do think more data needs to come out about younger ages, how it affects their development. I think that's the big question too, because it's kind of unknown currently what that can do. And that's how surgery was too. You know, like 15 years ago, for example, I think the pediatricians were a little bit more reluctant to refer patients for surgery because they didn't have long-term data.

But surgery now, you know, gastric sleeves and gastric bypasses have 10-year, 15-year data. There are some small series of 30-year data. And so, these patients are alive, they're healthy, they've maintained their weight loss. And so, I think there's a lot more literature for surgery, so I think the pediatricians are more willing to refer patients for weight management at a comprehensive clinic where surgery is offered.

Host: Completely understandable. So, how do you help a family weigh the pros and cons of a daily or weekly injection versus a one-time permanent surgical change?

Ying Weatherall, MD: I think, you know, it's a shared decision-making. And so, every family is at a different place in terms of how ready they are for both of those options. I've had patients come to clinic and say, "I want surgery. I don't want to do injections every week." And it's very clear to them that they want one solution. Whereas other families say, "Oh, this injection weekly seems very innocuous, and the surgery seems very scary." And so, everyone's just different on where they are. And so, our job is to really make it clear kind of what the pros and cons for both options, and then help the family come to the decision that is the best for them and for their patient for their child.

And I think it depends on resources. A lot of it depends on family members or friends that have had surgery. It'd be interesting to see how many patients who have surgery have somebody in their life that have had bariatric surgery that's kind of influenced them and made it less scary to them.

So, a lot of our patients actually have like an aunt or an uncle or a parent or a teacher who have had surgery. And so, they're much more willing to go through it because they've witnessed one of their close person kind of go through it safely and with great results.

Host: And yeah, and they're thriving. So, why would you not want to replicate that in your own life?

Ying Weatherall, MD: Exactly. Exactly.

Host: There specific situations where surgery is clearly the better choice over medication for the patient or maybe vice versa?

Ying Weatherall, MD: I think it depends on their weight. As the kids age, when they're in their early kind of preteen years, if their weight is not so severe that they don't have a lot of comorbidities, then I think medication is a very good option. However, as the weight is high, the body will express weight-related complications. And when you start to have those, those patients do better with surgery. And for the simple reason that surgery is more effective overall for weight loss, and then also some of the reactions that occur in the body after a gastric sleeve, for example, GLP-1 levels just naturally increase, ghrelin levels decrease. And so, some of those natural changes are not achieved with medication, and they are better achieved with surgery.

And so in my opinion, a patient with an obesity-related complication should be a patient who needs to lose more weight to be able to revert that comorbidity. And timing is of the essence also, you know, because surgical weight loss, really maximal surgical weight loss can occur in the first nine months. And then, for GLP-1s, around the same time, however, it's way less like I said, 17% versus 27%. So, it really just depends on kind of what metabolic state that patient is in to see if whether or not they would benefit more from surgery versus medication.

Host: I'm sure our listeners are wondering, okay, so you said a lot of weight needs to be lost. Is there a definition for adolescent obesity?

Ying Weatherall, MD: Yes, there is a definition for adolescent obesity. It's based on growth curves. So, the pediatric weight has different kinds of growth curves. And ideally, everybody is close to the 50th percentile. And so, malnutrition, for example, is measured as a percent of the growth curve, and then same for obesity. And so, anything over 85% is considered overweight. And then, obesity is a percentage of the 99th percentile. And so, class 1, 2, and 3 are defined differently. And so, for example, class 3 obesity is 140% of the 99th percentile, and these are the patients that we offer surgery to.

Host: Got it. If a parent is concerned about their child's weight, what's the very first step they should take with their primary care doctor?

Ying Weatherall, MD: The very first step is to talk about it. Everyone still thinks that obesity is a hard conversation to talk about. And it is true, it isn't as easy to talk about weight as it is to talk about weight-related complications such as pre-diabetes or blood pressure. Because I think providers or pediatricians don't want to come across as judgmental, for example. They want to have the family feel like their clinic is a safe place for the patient, and that's very, very important.

So, I think from the parent's perspective, it would be great to start that conversation because, for lack of a better word, that is sort of the elephant in the room. The provider does want to talk about it. And so when we provide provider training in terms of, you know, how to broach the topic of obesity with families to pediatricians, the same concept works for families.

And so, I think the first thing is to talk about it with the pediatricians, and they'd be surprised how much the pediatrician knows about weight management and how much they can do actually in the pediatrician's office. So, I think that is the first step.

Host: Is there anything else you want to add to our conversation before we wrap up?

Ying Weatherall, MD: Well, I just wanted to make a plug for Le Bonheur Children's Hospital. We've been committed to weight management for as long as I've been there. I'm finishing up my 11th year. And I think, like I said, years and years ago, obesity really wasn't a topic that people addressed, but we now know that obesity really is the cause for a lot of comorbidities. It makes everything worse. Even in an asthmatic, it makes their asthma worse.

So, I just want to make sure that everybody knows that we at Le Bonheur have a healthy lifestyle clinic, which is a comprehensive weight management clinic for patients of all ages. We see toddlers up until 17, 18-year-olds. And we offer different things to those patients. The toddlers, we start with, you know, lifestyle modification, which is diet, exercise. And then, for the preteens, we offer them different types of medications, including GLP-1s. And then, for the teenagers that are 14, 15 years and over, we start talking about bariatric surgery.

And so, that clinic is extremely, extremely well-funded. And there's a lot of really smart people and very passionate people working in that clinic, myself included. And so, I just want everyone to know that the resource is there and that all they would have to do is, you know, reach out and refer, and we would be able to help that family and that patient.

Host: That's a great comfort to families. Dr. Weatherall, we thank you so much for talking to us today about pediatric weight management and helping us to understand how to treat it.

Ying Weatherall, MD: Thank you, Deborah.

Host: That was Dr. Ying Weatherall. For more information, go to lebonheur.org. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. I'm Deborah Howell. This is The Peds Pod by Le Bonheur Children's Hospital. Thanks for listening