JOHN YANG: Tonight on PBS News Weekend, a new escalation in the Middle East as Israel's retaliatory attack on Iran fuels fears of a wider war, then for the third presidential election in a row, Michigan is playing a pivotal role and how doctors are using weight loss drugs to treat adolescents.

WOMAN: These medications work, and our children are really suffering from outcomes from excess weight ranging from mental health and bullying to type 2 diabetes.

(BREAK) JOHN YANG: Good evening.

I'm John Yang.

Tonight, Iran is saying that it might not respond in kind to Israel's first ever open attack on its soil if there's a cease fire in Gaza and Lebanon, more than 100 Israeli fighter jets and unmanned drones struck Iranian military targets.

Iran state run news agency said four members of its military were killed.

JOHN YANG (voice-over): The long anticipated retaliatory attack came early Saturday morning.

The Israeli Defense Forces said it struck targets where missiles are built and stored their answer to Iran's missile barrages on Israel in April and earlier this month, those followed the killings of Iranian and Hezbollah leaders, which Iran blamed on Israel.

On state TV, Iran's ruling regime played down the damage.

SAHAR EMAMI, State TV Anchor (through translator): Although the country's integrated air defense system successfully tracked and confronted the act of aggression, limited damage has been caused to some places.

The scope of the attack is being investigated.

JOHN YANG (voice-over): IDF spokesman Daniel Hagari indicated Israeli retaliation was done for now.

REAR ADM. DANIEL HAGARI, IDF Spokesperson (through translator): We are focused on the targets of the war in Gaza and Lebanon, Iran is the one that continues to push for a wider regional escalation.

We will know how to choose additional targets and attack them if necessary.

JOHN YANG (voice-over): International reaction was swift.

RECEP TAYIP ERDOGAN, Turkish President (through translator): I wish a speedy recovery to our neighbor, Iran and the Iranian government, which was the target of the Israeli aggression last night, the Zionist Israeli government wants to light the fuse on a regional conflict.

KEIR STARMER, United Kingdom Prime Minister: I am clear that Israel has the right to defend itself against Iranian aggression.

I'm equally clear that we need to avoid further regional escalation and urge all sides to show restraint.

Iran should not respond.

JOHN YANG (voice-over): This afternoon before flying to Pittsburgh for a campaign event, President Biden echoed that call.

JOE BIDEN, U.S. President: It looks like they didn't hit anything on the military targets.

My hope is this is the end.

JOHN YANG: A senior Administration official said efforts will soon resume to end the fighting in Lebanon, secure a ceasefire in Gaza and the return of Israeli hostages still held in Gaza.

Suzanne Maloney is director of the Foreign Policy Program at the Brookings Institution.

Suzanne, what do you make of this offer from or overture from Iran that they'll not retaliate if there's a ceasefire in Lebanon and Gaza?

SUZANNE MALONEY, The Brookings Institution: Well, I think this is consistent with the rhetoric that we've heard from Iran for some time.

They've tried to posture that they're actually defending the people of Gaza and the people of Lebanon, and that their hostile activity toward Israel will, in fact, stop if there is a cease fire.

I think it's also a face saving gesture, because they're unlikely to respond to what was a fairly complex and sophisticated attack by the Israelis yesterday against Iran.

JOHN YANG: Talk a little more about last night, the attack last night, was Israel able to accomplish its goals while at the same time heeding the international calls for restraint?

SUZANNE MALONEY: Well, I think it was a sort of Goldilocks approach on the part of the Israelis.

It was big enough to impose some costs, and I think to have some deterrent to impact on Iran's calculus.

But it was not so big as to create inevitable pressures for escalation and Iranian retaliation, which would put the region in a much wider and much more dangerous war.

That obviously was the goal of the United States that had been speaking with the Israeli counterparts about the nature of the attack.

There was a lot of discussion about whether nuclear sites would be targeted, whether Iran's oil and gas infrastructure might be targeted, but instead, they chose to target drone and missile production facilities as well as air defense and radar.

And I think that that was a very wise and appropriate choice.

JOHN YANG: Israel appears to have used the airspace of Jordan and Iraq to get to the targets in Iran.

What does that tell us about Iran standing among its Arab neighbors?

SUZANNE MALONEY: Well, the region's reaction has been quite interesting.

As you noted, two of Iran's neighboring states use permitted the Israelis to use their airspace to undertake these attacks.

It demonstrates how vulnerable Iran is because of the alignment of many of the rest countries in the rest of the region with Israel.

But of course, there are condemnations for many, many regional states as well, including Saudi Arabia, which I think speaks to the fact that no country in the region really wants to see this situation escalate further than it has.

JOHN YANG: There's been so for many years, Israel and Iran sort of fighting by proxy, Iranian sponsored groups like Hamas, Hezbollah and the Houthis attacking Israel.

Have we reached a new phase now where these two countries, these two long time enemies, are going to be attacking each other directly?

SUZANNE MALONEY: Yes, I think that's exactly where we were.

As you noted, for about the past decade, there's been a gray zone war between Iran and Israel, often involving proxies or war in third countries such as Syria.

What we've seen since April is a willingness on the part of the Iranians to strike directly in an attributable fashion against Israel, and by Israel to respond directly with attacks on Iran -- on the Iranian homeland.

I think this is in much more dangerous phase of the war, although the actions of the past 24 hours may create some pause on the part of the Iranians to take the next step of escalation.

JOHN YANG: Much more dangerous phase.

Does this you think take us?

Are we step closer?

Are we closer to having a broader war in the Middle East?

SUZANNE MALONEY: We are absolutely on the precipice of a broader war, and the only thing that will really ensure that we don't get there is to see a ceasefire in Gaza, a reduction of tensions around the region, and a commitment on the part of Iran and other countries to stop trying to fuel the fire and trying to press their aggression against Israel.

I think the likelihood that we get there very quickly, unfortunately, is very low.

JOHN YANG: Suzanne Maloney, the Brookings Institution.

Thank you very much.

SUZANNE MALONEY: Thank you.

JOHN YANG: There are developments on Israel's other battlefronts.

The Lebanese health ministry says that more than 1 million people have been driven from their homes since fighting began there.

Israel says it's defending against Hezbollah rockets launched from Lebanon.

And in northern Gaza, Israeli troops withdrew from a hospital where the Palestinian health ministry says they held medical staff and patients without access to food or water.

In Ukraine, Russian drones struck Kyiv in an hours long nighttime barrage.

Ukrainian officials said one went into an apartment building, killing a 15-year-old girl and injuring five others.

And in central Ukraine, a missile struck a residential area in Dnipro.

Regional officials said a 14-year-old and four others were killed and at least 21 others injured.

Police in London were out in force today as anti-immigrant protesters and anti-discrimination demonstrators held competing rallies.

Thousands of opponents of immigration took to the streets in a march called Unite the Kingdom.

Nearby, anti-racism campaigners held a counter protest.

Immigration has been a flash point since July, when days of riots spread across the country targeting asylum seekers and mosques.

Still to come on PBS News Weekend, what the presidential candidates are saying to voters in the electoral battleground of Michigan, and how doctors are using weight loss drugs to tackle obesity in young people.

(BREAK) JOHN YANG: Today is the first day of statewide early voting in Michigan.

And both presidential candidates are in the state trying to energize their supporters.

Former President Donald Trump's in Novi, which is a suburb of Detroit.

DONALD TRUMP, U.S. Republican Presidential Nominee: Year after year, globalist politicians like Kamala Harris sold you out and let other countries loot and pillage and plunder your wealth.

JOHN YANG: Vice President Kamala Harris is on the other side of the state, pressing her message that reproductive rights are at stake in the election.

KAMALA HARRIS, U.S. Democratic Presidential Nominee: We are seeing the impact of these laws, causing clinics, health care clinics to shut down.

The physicians that I've been talking with are concerned about this myriad of issues that have highlighted the fact that because of Trump and what he did with the Supreme Court, we are looking at a health care crisis in America.

JOHN YANG: Tonight, she'll be in Kalamazoo with former First Lady Michelle Obama.

Earlier, I asked Chad Livengood, the Detroit News politics editor and columnist, to tell us about the race for Michigan's 15 electoral votes.

CHAD LIVENGOOD, The Detroit News: This race is neck and neck, and there is, there is no clear front runner in Michigan right now.

Kamala Harris is spending Saturday with first -- former First Lady Michelle Obama in Kalamazoo, a university town Western Michigan University.

She needs to do really well in these university towns in in Ann Arbor and Ypsilanti and Mount Pleasant and, of course, East Lansing as well, because this is where she's going to need to run the score up to counter some of Trump's advantages in working class cities in the state.

JOHN YANG: Former President Trump is today is in Oakland County, which is Detroit suburb.

What does that tell us about who he's trying to motivate?

CHAD LIVENGOOD: Yeah, he's trying to get the core Republican base of Oakland County that to get them out and get them to vote early.

This is, you know, his strategy has definitely turned towards trying to mirror the Democrat strategy in previous elections, to try to bank as many early votes, between absentee votes by mail and also early in person voting.

JOHN YANG: Michigan economy, of course, still built around the auto industry, the auto industry, internal combustion engines, this shift to electric vehicles.

How is each campaign dealing with that issue?

CHAD LIVENGOOD: Well, Donald Trump has honed in on this subject various with very tight specific issues going after EVs, essentially saying to people, your big three automakers should not be trying to compete with China.

I mean, he went into Flint vehicle city that had the birthplace of General Motors, and made this message about a month ago.

He's continued to talk about it and really rail against electric vehicles and Kamala Harris is trying to basically counter and say, hey, look, we want to compete with China.

And if we want to compete with China, on in the automotive industry, we have to make electric vehicles.

JOHN YANG: Another distinctive feature about Michigan politics is the large Arab American population, uh, sort of concentrated around Detroit.

Early on, when President Biden was still in the race, there was a lot of unhappiness among that community about his staunch support for Israel in the war in Gaza.

Now that Harris is in the race, how has that community approached her?

What are they thinking about Harris?

CHAD LIVENGOOD: That unhappiness has not eased, and it has maybe even grown more frustrated, as the war has in Gaza has dragged on, and now Israel has been bombing in Lebanon, and there's a large Lebanese population, particularly in Wayne County, Dearborn, Dearborn Heights, Hamtramck, that are furious, and so this is the real big jump ball, I think, for Democrats and maybe even the crisis, they don't really quite know how big it will be.

There are some leaders in the community, like the mayors of Hamtramck and Dearborn Heights, who have endorsed Trump.

And just yesterday, the mayor of Dearborn came out and said he can't vote for either one of them.

JOHN YANG: I mean, could that also affect the Senate race?

You've got the Democrats trying to hold on to the seat that Debbie Stabenow is stepping down from.

You have a current house member, Democratic House member, Alyssa Slotkin, running against a former Republican House member, Mike Rogers.

Could that affect that race as well?

CHAD LIVENGOOD: Oh, absolutely.

They are both pretty hawkish, pretty pro-Israel.

They are on paper, from a national security perspective, the exact same candidate in there.

He used to be an FBI agent.

She used to be a CIA agent.

She worked in the Obama Defense Department.

Now, whether she gets penalized by the Arab and Muslim voters of the state for it is kind of what is sort of the big unknown right now.

JOHN YANG: Democrats in Michigan are also trying to hold on to two open house seats, including the one that Slotkin is giving up, and both those races are toss ups are rated as toss ups.

Tell us about those races.

CHAD LIVENGOOD: This is a C race between Tom Barrett, the Republican who lost to Slotkin by three or 4.2 years ago, and Curtis Hertel Jr., who is a Democrat and long-time politician in Michigan.

And this is a racist neck and neck.

It's another race where the electric vehicle transition is definitely on the ballot.

Lansing is an auto town has two GM plants, and the future of boilers plants is pretty much in doubt right now.

Democrats are trying to use this as an issue to say, hey, look, if you elect to Tom Barrett or Donald Trump, this plant is -- this Cadillac plan is in serious danger of closing.

And then over to the east of there is the eighth congressional district, and that's the seat long held by Dan Kildee.

This is a seat where there's - - they've got a Democratic State Senator, Kristen McDonald Rivet running against a Republican entrepreneur, Paul Junge.

This is also see this neck and neck, and they're also out there battling over the EV transition.

And the messaging that you're seeing from Trump to Junge on down is, if we continue to transition to EVs, all these little plants that make components for gas engines and transmissions are going to go by the wayside, and so this, it's going to be a real big test about that messaging really motivates voters to go pull the lever for the Republicans.

JOHN YANG: A lot of reasons to watch in Michigan on election night, Chad Livengood of the Detroit News.

Thank you very much.

CHAD LIVENGOOD: Hey, thanks for having me, John.

JOHN YANG: You physicians are increasingly using weight loss drugs to treat obesity, diabetes and other chronic conditions in young people, including children.

In the last three years, the number of people aged between 12 and 25 using drugs like Wegovy and Ozempic has surged nearly 600 percent.

Ali Rogin looks at the high demand for these drugs and the concerns surrounding them.

ALI ROGIN: Approximately one in five children and adolescents in the U.S. is obese, but experts say early intensive treatment can prevent health issues down the line.

Early last year, the American Academy of Pediatrics recommended the use of medication to treat obesity in children's ages 12 and up.

We spoke to two young women who have been using these medications.

SOPHIE SIMMONS: I had been struggling with my weight, and I had never gotten my period before, and we weren't sure what was up with it, and I had taken some labs, and we found out that I had PCOS.

I think a lot of people think, especially PCOS, that they're stuck and there isn't options, and they're finding out that this is an option, because it has helped me lose almost 90 pounds, and I got my period, and it's helped with my confidence in so many other things.

And continuing it, I think, has just shown the effectiveness of it as well.

AUTUMN EKSTROM: I had tried, like, working out and stuff like that, but like, nothing was showing, like, helpful or like, there was no change at all in anything.

And so it was just kind of, like, hard and disappointing.

And the only thing that, like, actually helped with all that was the medication.

My appetite is, like -- has like, changed completely.

And like, it's been, like, suppressed like so much.

I think the end goal is, like, ultimately, to, like, get me off of it.

Because, like, I don't want to be, like, taking it forever.

And like, if we can, like, we've been lowering the dosages.

So, like, if we can slowly get me off of it and like, everything, like, kind of like stays, like, normal or like, or if anything, like, things get better and not worse, then, like, that's good.

ALI ROGIN: Despite the effectiveness of these drugs, some doctors are concerned about the lack of data available for children using them long term.

Dr. Melanie Cree is a pediatric endocrinologist at Children's Hospital Colorado, and she treated both Sophie and autumn.

Dr. Cree, thank you so much for joining us.

First of all, why are we seeing this increase of children using these medications?

DR. MELANIE CREE, Pediatric Endocrinologist, Children's Hospital Colorado: The reason we're seeing such an increase is that these medications work, and our children are really suffering from outcomes from excess weight, ranging from mental health and bullying to the development of serious metabolic disease such as type 2 diabetes.

ALI ROGIN: When you're treating patients, what sort of options do you consider before looking at medication?

MELANIE CREE: So we always look at lifestyle in terms of trying to help a child who's struggling with weight achieve better health, and we can look at different aspects of food.

Are they getting enough fruits and vegetables, cutting down on simple carbohydrates, really cutting liquid calories?

What can they do to increase their activity?

Is there neighborhood safe to exercise in?

Do they have access to facilities or sports?

Sleep is very important.

Do they have somewhere quiet to sleep?

Do they get enough sleep and then, obviously, mental health is very important, and are they stressed, or are they living in a difficult social environment, and helping align all of these to optimize children's health is something that we do prior to trying any medication.

ALI ROGIN: What are some of the misconceptions that you've encountered about prescribing these medications and the children who are on them?

MELANIE CREE: I think the number one misconception is that the individual is failing somehow, that somebody has to do these medications if they don't have a strong enough willpower, and that they're weak and can't do this on their own.

And that's just absolutely not true.

These are chemicals, and when you take chemicals and they help you lose weight, that means that you've got a problem with the chemicals in your brain that are helping you to regulate how you sense appetite and how you sense fullness, and so you take these medications, and they actually change the way that your brain senses food.

ALI ROGIN: Like we talked about earlier.

There are concerns about the lack of long term information on the use of these in children.

What are your concerns?

MELANIE CREE: Many.

There's a very, very low risk of increased thyroid cancer for the duration of time that we've studied these medications, and for animals entire lives, but humans live much longer.

So, I think that's one of the biggest things that we're automatically watching for.

Something that one of my research partners is interested in, is how do these medications affect the brain differently when we're an adolescent within a developing brain, compared to an adult who doesn't have a developing brain, and brain that's changing so much.

If you use this medication all through your teens, does that permanently change how your brain senses food?

ALI ROGIN: In the patients that you've been seeing as they get older, do you recommend for them to stay on these medications over the long term, well into adulthood.

What does that tend to look like?

MELANIE CREE: You know, we've got patients that have come down 80, 90 pounds.

We're now at ideal goal weight.

And what do we do?

We've done a really good job of figuring out how to start it, how to keep people healthy, on it increase protein and really increase activity.

And then we get to go wait.

The data in adults show that if you don't lose at least 15 percent of your weight on semaglutide, when you stop, a year later, you're back up to your starting weight.

I've been trying with a couple patients to switch them from the injectables when they get to target weight to pills that we have a little bit more safety data on, but right now, this is exactly what we're doing, trial and error with my patients and all of us in the woods together.

ALI ROGIN: And what about the insurance question?

There are concerns that companies won't want to support the long term usage of these drugs in children as they get older.

I know that this is uncharted territory in many ways, but what are the possible issues there?

MELANIE CREE: Well, what we're having a problem with is when they get to their goal weight, then the insurance companies are renewing their approvals and saying, well, this individual isn't obese.

We're not going to pay for the medication anymore, and they're that way because we were using the medication.

So that is exactly the hurdle that we're facing right now.

You know, if we can prevent Type 2 Diabetes in kids, the economic effect is going to be dramatic within the next 15 years.

It's very hard, and our health care system is not set up around prevention, but we really need to come up with pediatric models to model and say, okay, well, what is the cost if a patient develops type 2 diabetes as a teenager.

What are you looking at in the next 20 years?

Pregnancy complications for youth who have excess weight and then have babies in their 20s are much higher.

So there are a lot of costs that are much higher.

But putting all of that together to make the drug company right now pay for it is a little bit challenging.

ALI ROGIN: Dr. Melanie Cree with Children's Hospital Colorado.

Thank you so much.

MELANIE CREE: Thank you.

JOHN YANG: And that is PBS News Weekend for this Saturday.

I'm John Yang, for all of my colleagues, thanks for joining us.

See you tomorrow.