by Melinda Maryniuk, MEd, RDN, CDCES
The Canadian Adult Obesity Clinical Practice Guidelines (CPGs) provide a much-needed evidence and experience-based, patient-centered framework for healthcare professionals, patients and policy makers. They represent the first comprehensive update to Canadian obesity guidelines since 2007, and perhaps the most extensive review of published evidence conducted in obesity worldwide to date. Here’s our summary of what we think physicians will find most interesting / useful.
Key Takeaways from the Guidelines:
–Obesity is a complex disease caused by genetic, metabolic, behavioral and environmental factors.
-Obesity is chronic, progressive and relapsing.
–Weight bias describes the negative, weight-related attitudes, beliefs, assumptions and judgments in society that are held about people living in larger bodies. It is caused by an oversimplification of obesity. It is harmful and leads to increased risk for morbidity. All healthcare professionals should assess their own biases and create a safe environment for all patients.
-Regular monitoring can help catch early weight gain and HCPs should recognize the many life stages (including but not limited to, pregnancy, smoking cessation, cancer treatment, medication use, menopause, aging and young adulthood) that can be periods when weight gain is more common.
-BMI should only be used as a screening factor when it comes to diagnosing obesity. It should take special populations into consideration and be interpreted with extreme caution as it does not measure body fat or cardiovascular risk and/or health.
-HCPs should obtain an obesity-centered health history for all patients they are treating for obesity and excess weight.
-Healthy eating is for everyone, not just those who struggle with weight, and there is no “one size fits all” pattern when it comes to diet. HCPs should use a shared-decision making approach and/or collaborate with a dietitian when helping patients choose an eating style that works for them. Similarly, everyone should exercise, as physical activity provides a wide range of health benefits across all BMI categories.
Most Useful Checklists & Charts:
A stigma-free environment can help patients feel more comfortable and receptive to treatment. Use the checklist to ensure your office space is inclusive for bodies of all sizes
A handy chart outlining the key features (dosing, efficacy, side effects) of weight loss medications.
An algorithm to help choose the right medication.
Occupational therapy promotes health by facilitating engagement in activities of daily living. Ask patients about daily activity and consider the chart when deciding if patients will benefit from an OT referral.
Physiotherapy can help patients manage functional challenges. Ask patients about pain and functioning and consider the chart when deciding if patients will benefit from PT referral
A clinical tool such as the 4Ms (mental, mechanical, metabolic and monetary) can provide a practical approach for PCPs to explore major drivers, barriers and complications of obesity
When assessing patients with obesity, include the obesity centered questions in the chart.
Some medications are known to promote weight gain. Consider an alternative treatment option if the patient is gaining weight or already struggling with obesity.
Everyone can benefit from a healthy diet. Use this quick reference chart to assess patient readiness to change current eating habits and explore and collaborate care for new habits.
A list of nutrition interventions used in obesity management, their outcomes and impact, and their advantages and disadvantages.
Many patients with obesity experience micronutrient deficiency. This list contains the most common deficiencies, how to screen and drug and nutrient interactions.
*Tables from Canadian Adult Obesity Clinical Practice Guidelines
The 15 Most Relevant Recommendations – Selected for the Busy Family Physician
We recommend that primary care clinicians identify people with overweight and obesity, and initiate patient-centred, health-focused conversations with them.
Reducing Weight Bias
Healthcare providers should assess their own attitudes and beliefs regarding obesity and consider how their attitudes and beliefs may influence care delivery.
Reducing Weight Bias
We recommend that healthcare providers avoid making assumptions that an ailment or complaint a patient presents with is related to their body weight.
We suggest that healthcare providers involved in screening, assessing and managing people living with obesity use the 5As framework (See Appendix 2 of the guidelines) to initiate the discussion by asking for their permission and assessing their readiness to begin treatment.
We recommend measuring blood pressure in both arms, fasting glucose or glycated hemoglobin and lipid profile to determine cardiometabolic risk and, where appropriate, ALT to screen for nonalcoholic fatty liver disease in people living with obesity.
Medical Nutrition Therapy
Adults living with obesity should receive individualized medical nutrition therapy provided by a registered dietitian (when available) to improve weight outcomes (body weight, BMI), waist circumference, glycemic control, established lipid, and blood pressure targets.
Medical Nutrition Therapy
Adults living with obesity and type 2 diabetes should consider intensive lifestyle interventions that target a 7%–15% weight loss, to increase the remission of type 2 diabetes and reduce the incidence of nephropathy, obstructive sleep apnea and depression.
Aerobic physical activity (30 – 60 minutes of moderate to vigorous intensity, most days of the week) can be considered for adults who want to:
– Achieve small amounts of body weight and fat loss
– Achieve reduction in abdominal visceral fat and ectopic fat, such as liver and heart fat (level 1a, grade A), even in the absence of weight loss
– Favour weight maintenance after weight loss
– Favour the maintenance of fat-free mass during weight loss
– Increase cardiorespiratory fitness (level 2a, grade B) and mobility
Psychological and behavioral interventions
Multicomponent psychological interventions (combining behaviour modification [goal-setting, self-monitoring, problem-solving], cognitive therapy [reframing] and values-based strategies to alter diet and activity) should be incorporated into care plans for weight loss, and improved health status and quality of life (level 1a, grade A) in a manner that promotes adherence, confidence and intrinsic motivation
We recommend regular monitoring of weight, glucose and lipid profile in people with a mental health diagnosis and who are taking medications associated with weight gain.
Pharmacotherapy for weight loss can be used for persons with BMI ≥ 30 kg/m2 or BMI ≥ 27 kg/m2 with adiposity-related complications, in conjunction with medical nutrition therapy, physical activity and psychological interventions (liraglutide 3.0 mg, naltrexone-bupropion combination, orlistat).
Bariatric surgery can be considered for people with BMI ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 with at least 1 adiposity-related disease to:
- Reduce long-term overall mortality
- Induce significantly better long-term weight loss compared with medical management alone
- Induce control and remission of type 2 diabetes, in combination with best medical management, over best medical management alone
- Significantly improve quality of life Induce long-term remission of most adiposity-related diseases, including dyslipidemia, hypertension, liver steatosis and nonalcoholic steatohepatitis.
For adults living with overweight or obesity, the following commercial programs should achieve mild to moderate weight loss in the short or medium term, compared with usual care or education:
- WW (formerly Weight Watchers)
- Jenny Craig
Emerging Technologies and Virtual Medicine
The use of wearable activity tracking technology should be part of a comprehensive strategy for weight management.
Risk Reduction & Diabetes Prevention
Group-based diet and physical activity sessions informed by the Diabetes Prevention Program and the Look AHEAD (Action for Health in Diabetes) programs should be used as an effective management option for adults with overweight and obesity.
*All Recommendations from Canadian Adult Obesity Clinical Practice Guidelines
To learn more from the Canadian Adult Obesity Clinical Practice Guidelines, click here.
We help people living with obesity in Canada find a physician who specializes in obesity management near them… click here to see our physician locator tool.
Melinda Maryniuk is a registered dietitian, certified diabetes care and education specialist and serves as the Lead Clinical Consultant with My Weight What to Know. For over thirty years Melinda worked at Joslin Diabetes Center and served as Director of Clinical Education Programs in Joslin’s Innovation Division. She has authored over 100 publications and has lectured extensively on topics related to nutrition and diabetes around the world. Melinda has served on the Board of Directors of the American Diabetes Association (ADA) and the Association of Diabetes Care and Education Specialists and has received numerous national awards including the Outstanding Diabetes Educator Award from ADA and the Medallion Award from the Academy of Nutrition and Dietetics.