Do pharmaceutical conflicts of interest compromise the AAP guideline on childhood obesity?

In January 2023, the American Academy of Pediatrics (AAP) published a clinical practice guideline on the evaluation and treatment of obesity in children and adolescents. Dr. Kathryn McKenna and I noted in an editorial in American Family Physician that the recommendation to consider prescribing weight loss drugs in adolescents 12 years and older was based primarily on short-term studies: “only 5 out of 27 randomized controlled trials [available to the AAP] included results beyond six months.” Although the percentage of US adolescents with obesity who were prescribed drugs rose modestly between 2018 and 2023, a recent study found that prescribing increased immediately after the guideline’s publication and every month thereafter through the end of 2024.

To be sure, the effects of nondrug interventions for obesity have been discouraging. A Cochrane review from 2020 found that combined dietary and physical activity interventions in adolescents 13 years and older did not lead to statistically significant changes to body mass index. Nonetheless, the US Preventive Services Task Force found insufficient evidence on the harms of long-term obesity medication use in children and decided to recommend only intensive behavioral interventions.

An analysis in the BMJ highlighted undisclosed financial conflicts of interest involving several authors of the AAP guideline and its accompanying technical report. Three guideline authors and one systematic review author received payments from pharmaceutical companies for consulting, travel, and other compensation between 2017 and 2023 ranging from $2,750 to $46,000; five other guideline authors received smaller amounts for meals and honoraria. From 2012 to 2024, 11 developers of glucagon-like peptide 1 (GLP-1) receptor agonist drugs made an estimated $1.9 to $2.6 million in corporate sponsorship payments to the AAP, including Novo Nordisk (semaglutide) and Eli Lilly (tirzepatide).

The AAP is hardly alone in permitting financial ties to drug companies. Other studies identified industry payments to the authors of the American Diabetes Association and the Infectious Diseases Society of America clinical practice guidelines, and 12 of 17 members of the 2023 board of directors and scientific committee of the Global Initiative for Asthma (GINA) received personal fees from AstraZeneca, which makes a brand-name inhaler used in the single maintenance and reliever therapy (SMART) treatment approach recommended by GINA guidelines.

Some would argue that the AAP guideline authors may have erred in not disclosing their pharmaceutical ties, but they would have likely come to the same conclusions about the effectiveness of GLP-1 receptor agonists and other weight loss drugs for adolescents. A counterpoint is that industry payments to individuals, regardless of amount, influence prescribing behavior and that those in a position to change the standard of care for children with obesity should refuse such payments. Finally, sound reasoning strongly supports that disclosing conflicts of interest is not enough to safeguard against bias in guidelines and other journal publications.

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This post first appeared on the AFP Community Blog.