Leading Pediatric Obesity Research with Justin Ryder, PhD

“We have several medications that have been FDA approved in adults and now a couple that are FDA approved in pediatrics that carry weight losses of 10, 15, 20 percent on average. It's an exciting time to be in this space because we actually have real treatments that really work, that treat the underlying biology and provide individuals with a tool to be successful on their weight loss journey.” — Justin Ryder, PhD

• Associate Professor of Surgery in the Division of Pediatric General Surgery and Pediatrics 
• Vice Chair of Research for the Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago 

Ryder shares insights from his latest research, including details from recent studies of anti-obesity medications in adolescents. He also discusses his advocacy work to ensure equal access to treatments for all.  

• Contrary to popular opinion, obesity is not a behavioral issue; it’s a disease, Ryder says. Obesity is perpetuated by susceptible genetics combined with toxic environmental factors.  
• Obesity is a chronic disease impacting approximately 15 million children in the U.S. alone. Obesity puts children at higher risk for comorbidities such as pre-diabetes, hypertension, dyslipidemia, hypertriglyceridemia, as well as mental health issues. 
• Obesity is also perpetuated by societal factors and race and ethnicity. For example, children who come from Hispanic and African American families are disproportionately impacted by obesity as well as some of the chronic diseases associated with obesity, especially hypertension and diabetes. 
• Instead of “watchful waiting” — or anticipating that a child will outgrow obesity — aggressive treatment should be considered including intensive behavioral modification, anti-obesity medications, and bariatric surgery.  
• While there are new medications to treat obesity in children, Wegovy, Zepbound and Saxenda, they are expensive and not always covered by insurance.  
• Ryder considers the financial obstacles to anti-obesity medications as a health equity issue, as only 16 states offer access to these medications through Medicaid. His advocacy has included helping to educate key stakeholders at Medicaid on the value of these drugs.  
• At Lurie Children’s, the majority of children in weight management clinics are on Medicaid and have had no access to medication.  
• Ryder would like to see more longitudinal research on anti-obesity medications to better understand long-term outcomes, both positive and negative, and why there is such biological variability in weight response to these drugs.  
• Ryder’s latest research projects include NIH-funded studies on biological and behavioral mechanisms driving weight gain as well as steatotic liver disease.    

Additional Reading 

• Find out more about the The Teen Longitudinal Assessment of Bariatric Surgery  study (Teen-LABS)  
• Read Ryder’s latest publications 
• Follow Ryder on X and LinkedIn 

Target Audience

Academic/Research, Multiple specialties

Learning Objectives

At the conclusion of this activity, participants will be able to:

1. Identify the research interests and initiatives of Feinberg faculty.
2. Discuss new updates in clinical and translational research.

Accreditation Statement

The Northwestern University Feinberg School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation Statement

The Northwestern University Feinberg School of Medicine designates this Enduring Material for a maximum of 0.50 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

American Board of Surgery Continuous Certification Program

Successful completion of this CME activity enables the learner to earn credit toward the CME requirement(s) of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

All the relevant financial relationships for these individuals have been mitigated.

Disclosure Statement

Justin Ryder, PhD, receives grant or research support from Boehringer Ingelheim Vetmedica GmbH. Course director, Robert Rosa, MD, has nothing to disclose. Planning committee member, Erin Spain, has nothing to disclose. FSM’s CME Leadership, Review Committee, and Staff have no relevant financial relationships with ineligible companies to disclose.

[00:00:00] Erin Spain, MS: This is Breakthroughs, a podcast from Northwestern University Feinberg School of Medicine. I'm Erin Spain, host of the show. The landscape of pediatric obesity treatment is evolving, and Northwestern Medicine scientists are at the forefront of this research into the most effective ways of treating obesity in children and teens and improving their access to care. My guest today, Dr. Justin Ryder, is a clinical and translational obesity scientist, working on several NIH funded projects focused on understanding how pediatric obesity impacts chronic disease risk and how biology drives weight regain. He's an associate professor of surgery and of pediatrics at Feinberg and serves as the vice chair of research for the Department of Surgery at Lurie Children's Hospital. He joins me today to talk about his recent work, which includes studies of anti-obesity medications in adolescents and advocacy work to ensure equal access of treatments to all. Welcome to the show. 

[00:01:12] Justin Ryder, PhD: Thanks for having me, Erin. 

[00:01:13] Erin Spain, MS: So let's start off this episode by you sort of setting the record straight for everyone and defining obesity. What is obesity? 

[00:01:21] Justin Ryder, PhD: Obesity, in my opinion, and in the opinion of about 35 medical organizations, it's a disease. It's not a behavior. I think of it as a complex gene environment interaction. And when you have susceptible genetics and a toxic environment, like we all live in, it perpetuates obesity. And there's tremendous biological underpinning and etiology of obesity and it's tremendously impacted by our behaviors, but behaviors do not drive weight. It's really the biology. 

[00:01:58] Erin Spain, MS: And this is something that you are passionate about sharing with your providers at Lurie Children's and also fellow investigators. Is that right? 

[00:02:06] Justin Ryder, PhD: Absolutely, I think, you know, from an educational standpoint obesity curriculum and medical training over the past several years has caught on to this, but most pediatricians and adult medical providers were not trained that obesity was a disease. They were trained that it was a behavior and that you could learn how to treat obesity by exercising more and dieting and eating better. That's been our approach, our public health approach, certainly for the last 40 plus years. I don't think it's really worked very well. 

[00:02:37] Erin Spain, MS: So you mentioned obesity. It's a chronic disease that's very common in the pediatric population, impacting approximately 15 million children in the U. S. alone. What are some of the health risks that are associated with childhood obesity? 

[00:02:53] Justin Ryder, PhD: So obesity places children at higher risks for developing a whole host of comorbidities: pre-diabetes, diabetes on the cardiovascular side of things, hypertension, dyslipidemia, hypertriglyceridemia, but also has a strong connection with non-biologically based things like mental health disorders, some of which are biologically based and some of which are not, depression, anxiety, increased suicidal ideation, lower quality of life, and then also musculoskeletal limitations, big bodies are hard on joints. And so, there are a lot of short-term challenges of obesity, but some of these become long term problems as well. 

[00:03:33] Erin Spain, MS: So you mentioned these biological things, these non-biological aspects. Are there specific cultural or societal factors that also contribute to childhood obesity? 

[00:03:44] Justin Ryder, PhD: Yeah, absolutely. Structural racism has definitely contributed to childhood obesity. There is a strong genetic component in certain families and, racial and ethnic groups, so children that come from Hispanic Latino families and Black and African American families are disproportionately impacted by the disease of obesity as well as some of the chronic diseases associated with obesity, especially hypertension and diabetes. And so there's definitely a social and ethnic component to obesity. 

[00:04:19] Erin Spain, MS: What are some of the effective treatments for childhood obesity? 

[00:04:24] Justin Ryder, PhD: The American Academy of Pediatrics put out new clinical practice guidelines last year. It came out in January. They said some things very clearly in there, so I'll distill the 135 plus page document down really clearly. One, obesity is a disease. Two, watchful waiting is a practice that we should not endorse anymore. And what that means is children are not going to grow out of this. Once you develop obesity, the likelihood of you growing out of it is very, very low. And so what we need to do is treat it and treat it aggressively. Anybody who has a BMI above the 85th percentile, which is overweight should be considered for some form of obesity prevention or treatment. And those really fall into three categories. So there's intensive behavioral modification and lifestyle modification. The recommendation is 26 contact hours within a given year. It's very, very challenging for providers to deliver in tertiary care settings like we have at Lurie Children's Hospital, but also in the community and local pediatricians, nobody can really do that. It's really, really hard. Then we have a number of anti-obesity medications, so medications that treat the underlying pathophysiology of the disease of obesity. There's a number of them that are FDA approved for ages 12 and up, as well as several that are approved in adults that they're in the pipeline and being studied in pediatrics. And then we also have Bariatric surgery, and bariatric surgery is also an extraordinarily effective treatment for obesity, but also the underlying other comorbidities that are associated with obesity, bariatric surgery also treats very effectively. 

[00:06:04] Erin Spain, MS: I want to talk more about the weight loss medications, especially the new ones on the market. Tell me about this new class of weight loss drugs and how they work in children. 

[00:06:15] Justin Ryder, PhD: So we're really at an extraordinary time where for about 30 years, we didn't have very many medications that were safe and effective for treating obesity. And if they were effective, the efficacy was rather small, on average 5 percent weight loss. Over the past several years now, we have several medications that have been FDA approved in adults and now a couple that are FDA approved in pediatrics that carry weight losses of 10, 15, 20 percent on average. It's an exciting time to be in the space because we actually have real treatments that really work, that treat the underlying biology and provide individuals with a tool to be successful on their weight loss journey. One of the challenges we have, though, is those medications are extraordinarily expensive. And not a lot of insurances are covering them, and if they are covering them, it's still a burden on patients and families because the out of pocket costs, even with coverage, can be high. Nevertheless it's not to say that those drugs won't come down in cost as more are added to the pipeline. And we have more tools in our toolbox, but it's really shifting and changing the landscape of obesity treatment in both children and in adults. 

[00:07:32] Erin Spain, MS:  And the brand names of those drugs are Wegovy and ZepBound. Is there another one as well? 

[00:07:38] Justin Ryder, PhD:  Yeah. Wegovy, ZepBound, and Saxenda. 

[00:07:41] Erin Spain, MS: But states have been clamping down on coverage of any sort for a lot of these medications. I think just 16 states offer access to anti-obesity medications through Medicaid. Tell me about how big of a barrier this is for patients who want to try these new drugs. 

[00:07:58] Justin Ryder, PhD: Right, and so I think of that as a health equity issue more so than anything else. For instance, at Lurie Children's Hospital, the kids with obesity, 60 percent are covered by Medicaid. And right now, until hopefully next month Medicaid does not allow access to any anti-obesity medications. I mean, 60 percent of the kids that probably reside in Illinois, if we extrapolate and think that, you know, that's a comparable number, have limited access to care. And nationally, there's a number of states, 35 or so, that have no coverage for anti-obesity medication. So any kid that's on Medicaid or an adult that's on Medicaid would not have access to any anti-obesity medications. But there are states that have it approved. It's really unfortunate that they are scaling this back as well. So North Carolina and Texas just announced that they are going to scale back their coverage of anti-obesity medications because it was costing them too much. And so it's really this delicate balance of doing the right thing from a health equity perspective and for treating people with a real disease as effectively as possible and cost. 

[00:09:06] Erin Spain, MS: And you've been involved in advocating for Illinois Medicaid to cover these anti-obesity medications for children and adults. And this has been effective. Tell me about this work. 

[00:09:16] Justin Ryder, PhD: Yeah, so I joined Northwestern and Lurie Children's Hospital in January of 2023. One of the first things I did was use our extraordinarily impactful government affairs office here at Lurie Children's Hospital to help connect me with the right people at Medicaid and within the state to start to have these important conversations about why they should be covering anti-obesity medications, to educate them about the disease of obesity and how having access to these tools and medications is a health equity issue, but also could be cost savings for the state but also the right thing to do to cover these medications. So we've been successful in those efforts and the new class of medications, the GLP-1 receptor agonists will be covered by Illinois Medicaid, hopefully in March of this year. 

[00:10:07] Erin Spain, MS: So once these are covered by Medicaid coverage, what impact do you foresee this is going to have on treatment of obesity in Illinois? 

[00:10:16] Justin Ryder, PhD: Well, right now at Lurie Children's, the majority of kids that are in our weight management clinics are on Medicaid. They have no access to any medications at all, so it could totally change their treatment course and path, because right now it's two buckets. It's lifestyle or it's surgery, and we add a third treatment option, which is going to be very, very powerful. In adults it's going to be the same thing or people that may have been trying to pay for some of these medications out of pocket now will have a pathway to do so that's less financially burdensome to them. 

[00:10:48] Erin Spain, MS: Can you talk a little bit more about why it's important to address this cost issue with the obesity drugs? And there have been some studies that have been published that were looking at the cost effectiveness of this drug, and you wrote some commentary to respond to one of these studies. And you were quite passionate to point out that these drugs are working in teens and that, yes, the cost is something that we need to take into consideration, but tell me some of your perspective on this. 

[00:11:17] Justin Ryder, PhD: Any cost effectiveness study that's done in pediatrics on anti-obesity medications, in my opinion, is premature. Because we only have one year data on these medications, and to really look at effectiveness and cost, you need five, ten year studies because you need a duration of the effects, duration of the costs, and right now we're studying medications that are brand new. They're really expensive, because guess what? The drug companies put hundreds of millions, if not billions of dollars to develop these medications and they need to recoup their costs. We wouldn't criticize somebody for having a high price of a new cancer drug that treats cancer. Yet these new anti-obesity medications, everybody's up in arms about the cost of the medications. If insurance would cover them better, maybe we would be having less of this conversation. And then the other challenge is, is when you do a cost effectiveness analysis, they take into account the wholesale cost of the medication, not actually what the consumer direct price is. So you and I, if our insurance covers Wegovy, it's not costing us $1,300 a month, it's costing maybe $100 a month, right? But so if you do a cost effectiveness analysis of a drug that's 1,300 versus Phentermine, for instance, which has been FDA approved since 1958 and costs $5, whether insurance covers it or not, of course, that drug's going to be more cost effective because it's dirt cheap. But it doesn't mean that it's better medication, right? And so any conversation along those lines needs to be balanced with the current environment. Of course, new drugs to market are going to be very expensive, but it doesn't mean that they're not worth using. 

[00:12:59] Erin Spain, MS: It's important to note that longitudinal research is critical for understanding the long-term effects of anti-obesity medications. What gaps in research do you believe need to be filled? 

[00:13:10] Justin Ryder, PhD: Yeah, it's a critical gap in pediatrics and one thing we get criticized for all the time. So the longest duration studies we have in pediatrics for anti-obesity medications are a little over a year. So we definitely need to continue to study these medications long term and we're not talking about one or two years, but five, ten year effects of being on anti-obesity medications. Study real world outcomes of these medications, working with our pharmaceutical company partners to really study the long-term implications both good and bad. So we know what the risks are of being on these medications and do we have a beneficial you know, risk benefit ratio? I fully believe that it'll show just like we've shown with bariatric surgery, that the long-term implications of being on these anti-obesity medications is favorable but we need to understand the risks so that we can educate families, patients, and ourselves on what the implications of being on these medications long term is. 

[00:14:12] Erin Spain, MS: One of the truths about these medications is that this is a lifetime medication, what we know right now. Can you talk to me a little bit about that? And that's a concern that maybe some folks have about starting a child on a medication that may last for life. 

[00:14:27] Justin Ryder, PhD: it's a real conundrum. I think as a medical community, we don't know. We don't know if you need to be on the medication lifelong. There's actually a great study that just came out on Wegovy on what happens if you've been on it for a year and then what happens the next year when you're off of it. And so it was a study that was done from 12, 000 people. So it's a real world outcome study of people that were on Wegovy for a year and then off of it for a year. And what happened was, I think, pretty remarkable. I'm not going to give the exact percentages, but it was 20 percent stayed right about where their weight was. Okay, so they kept everything off. Twenty percent gained a little or 20 percent lost a little. So 60 percent were within sort of a range of where they should be. And then 20 percent were right back to where they started. But then there was also 20 percent who had lost more weight than they had lost. All over the board. We call this heterogeneity or biological variability. And so from a treatment perspective, it's actually kind of nice because what that shows is that there's some people that actually don't need to be on the medication long term or for the rest of their life. There's some people that actually give them that boost, give them that success, allow them to reset maybe their physiology a little bit. And they might be able to keep it off. Maybe that's 40 percent of people. Then there might be another 40 percent of people who, maybe we could down titrate the medication. Maybe they don't need to be on the maximal dose of that medication. Maybe they could be on half the dose that they were on. But then there might be 20 percent that they might need to stay on it for the rest of their life. But we don't really know who those people are, what proportion they are, and with which medications we might be able to do this. So it's a ripe area for study, there's a lot of people that are pursuing that sort of question. It really brings home sort of some precision medicine aspects. And we're just getting to the point where we can start to study that with these new obesity medications. 

[00:16:28] Erin Spain, MS: Well, one area of obesity treatment where we do have a lot of data and information is bariatric surgery. And on a previous episode of this podcast, we had your longtime collaborator, Dr. Thomas Inge, who's a professor of surgery at Feinberg and surgeon in chief in the Department of Surgery at Lurie Children's, he came on and was talking about the teen longitudinal assessment of bariatric surgery study or Teen Labs. Tell me about your collaborations with Dr. Inge on looking at bariatric surgery outcomes in teens. 

[00:16:57] Justin Ryder, PhD: So I've been really grateful for the opportunity and collaboration with Dr. Inge to work on Teen Labs for almost 10 years now, and we're about ready to actually publish our 10-year findings. But what we've shown is that adolescent bariatric surgery is safe and it's effective at treating not just obesity where mean weight loss at a year with both Roux-en-Y gastric bypass and sleeve gastrectomy is around 30 to 35 percent weight loss. But also is effective at treating many of the comorbid conditions such as diabetes, pre diabetes, hypertension. It's associated with obesity at about a 70 percent success rate across the board of all comorbidities. And then it's also durable. So out to 10 years, weight loss on average is still 20 percent from where they were to begin with. So better than most of the anti-obesity medications get in one year. And we're showing that from one surgical procedure out to 10 years is quite remarkable. And we still have quite durable resolution of a lot of those comorbid conditions. But there are some risks. So with any study, we need to look at what's good and what's bad. And so there are some risks. So there are some nutritional deficiencies and Teen Labs really help set some of the guidelines on how surgeons should be prescribing vitamins and multivitamins in the post-surgical setting. We're also really interested in bone health, because we don't want to set kids up for early osteoporosis because that's been shown in adults, and we're not necessarily seeing the same signal in adolescents, but we have to continue to study this, and it's really important that we do this work. 

[00:18:34] Erin Spain, MS: Are we going to be able to borrow some of the methods and some of the ways that you've studied bariatric surgery and apply that to these weight loss drugs and the outcomes in kids? 

[00:18:45] Justin Ryder, PhD: I certainly hope so. I hope that the NIH funds us to do a 10, 15 year study of anti-obesity medication to understand the good and the bad so that we can inform guidelines, inform care in an appropriate way with appropriately designed study. Whether or not it's NIH or industry funding, a study of that nature, it's absolutely vital that we study long term outcomes. Both good and bad, so that we can inform clinical practice, but inform also the people that are going to be taking these potential medications for a number of years. 

[00:19:21] Erin Spain, MS: Tell me about some of the projects that you're currently working on that fall into these categories. 

[00:19:27] Justin Ryder, PhD: Yeah, so right now we're really fortunate to have some good support for some of our ongoing research. So we have one NIH funded study that's looking at this question of why is it so hard to keep weight off in kids? So after kids have successfully lost weight, what's the biology and behavioral mechanisms that are driving weight regain. So we have funding to study that in a cohort of adolescents that are in puberty, which is a really strange time period for the kid going through it, for their families, but also from a biological perspective, there's a whole lot going on. We have funding from the NIH to do a study looking at a diabetes medication and seeing if it can treat obesity and what we call steatotic liver disease. So when you have a lot of fat that's infiltrated the liver it's sort of a very difficult area for treatment. And there's a lot of adult studies that are focused on treating NASH or, or, or steatotic liver disease, but there's not a lot of pediatric studies. So we're we have a study going on and we're trying to get funding and actively pursuing a study where we would love to do the first randomized trial of some of the newer anti-obesity medications versus bariatric surgery, because the question always comes up, should I try the new medications that cause maybe 15, 20, 25 percent weight loss, or should I have surgery? We don't know the answer to that question, and we need to have a rigorously designed study to, to be able to provide that evidence base for clinicians, but also patients and families, which therapies might be best, what are the, what's the risk and benefit of those two, and you can't do that until you have a rigorous, randomized clinical trial, and so we're actively trying to get that funded. 

[00:21:15] Erin Spain, MS: What would your hope be for the generation of kids who are being born right now? And they're being born into this environment where obesity rates are high, but new treatments are on the horizon. What's your hope for them? 

[00:21:27] Justin Ryder, PhD: Yeah, so right now about 20 percent of kids in the U.S. have obesity, and we've seen an increase in prevalence from 5 percent in the 1980s to now where it's 20 percent in the 2020s, if you will. I'd like to see in the next 40 years us cut that in half and go back down to 10 percent. If we did that, I would be so happy, I would love to put myself out of a job. How about that? 

[00:21:52] Erin Spain, MS: Well, thank you so much, Dr. Justin Ryder, for being on the show and for sharing all this exciting work that you're doing. We appreciate your time. 

[00:22:00] Justin Ryder, PhD: Thank you. 

[00:22:01] Erin Spain, MS: You can listen to shows from the Northwestern Medicine Podcast Network to hear more about the latest developments in medical research, health care, and medical education. Leaders from across specialties speak to topics ranging from basic science to global health to simulation education. Learn more at feinberg.northwestern.edu/podcasts.