2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary]

David C.W. Lau; James D. Douketis; Katherine M. Morrison; Irene M. Hramiak; Arya M. Sharma; Ehud Ur

doi:10.1503/cmaj.061409

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Ethnic-specific waist circumference guidelines
David C.W. Lau

Posted on: 18 December 2007
Possible error in table 3 : re : waist circumf
Cleo Mavriplis

Posted on: 18 December 2007
Not all personal trainers are qualified to work with patients with obesity.
Dr. Darren E. R. Warburton

Posted on: 11 June 2007

Posted on: (18 December 2007)

Ethnic-specific waist circumference guidelines
David C.W. Lau
Excessive adiposity is associated with a myriad of medical complications and typically they escalate with increasing levels of adiposity. The evidence-based Canadian clinical practice guidelines recommend using the body mass index (BMI) in all adults and children as a first measure to determine health risk.1 In addition to BMI, the guidelines also recognize the importance of body fat distribution, namely central or ab...
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Excessive adiposity is associated with a myriad of medical complications and typically they escalate with increasing levels of adiposity. The evidence-based Canadian clinical practice guidelines recommend using the body mass index (BMI) in all adults and children as a first measure to determine health risk.1 In addition to BMI, the guidelines also recognize the importance of body fat distribution, namely central or abdominal obesity, as a strong predictor of the adiposity- related health risks, and recommend waist circumference (WC) measurement in all adults and adolescents as a new vital sign and an integral component of client assessment for global cardiometabolic risks. 1 In the 2003 Canadian body weight classification in adults, WC cutoff points of 102 cm and 88 cm were used to stratify health risks respectively for men and women. 2 The values were derived from studies in mainly Caucasian men and women with a BMI corresponding to the definition of obesity using a BMI of 30 kg/m2. 3 Data in different ethnic populations indicate that the risk for type 2 diabetes and other metabolic comorbidities occur at lower levels of adiposity and abdominal obesity. The Canadian guidelines adopted the ethnic specific cutoff points used by the International Diabetes Federation for the classification of metabolic syndrome. 4 The WC cutoff values for most men and women have been revised to 94 cm (37 in.) and 80 cm (31.5 in.) respectively. 1 However, different values are used for diverse ethnic populations, with specific cutoff points for South Asians, Chinese and Japanese. The WC cutoff points for Japanese men and women appear to be quite different, with a lower value of 85 cm for men and 90 cm for women. 1 Dr. Mavriplis queried if there was an error in these measurements. These WC values are extrapolated from visceral fat area determined by computerized tomography studies. 5 The Japan Society for the Study of Obesity observed in a study of 1193 Japanese adults (775 men and 418 women, average age 55 years), that a visceral fat area of 100 cm2 provides the best sensitivity and specificity for determining obesity as a disease associated with multiple risk factors. 5 The corresponding WC values for men and women with a visceral fat area of 100 cm2 are 85 cm and 90 cm respectively. 5 In view of how the WC values for Japanese adults are derived rather than by direct measurements, the Canadian guidelines recommend that the WC cutoff points for South Asians and Chinese be used for people of Japanese descent. It is evident in the future that the WC cutpoints will likely change as data from various ethnic populations are published.
1. Lau DCW, Douketis JD, Morrison K, et al; Obesity Canada Clinical Practice Guidelines Expert Panel. 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary]. CMAJ 2007;176(8 Suppl):S1-13. [For the complete set of guidelines, go to www.cmaj.ca/cgi/content /full/176/8/S1/DC1] 2. Canadian guidelines for body weight classification in adults. Ottawa, ON, Health Canada 2003. Cat. No. H49-179/2003E 3. Lean MEJ, Han TS, Seidell JC. Impairment of health and quality of life in people with large waist circumference. Lancet 1998;351:853-6. 4. Alberti KG, Zimmet P, Shaw J. The metabolic syndrome – a new worldwide definition. Lancet 2005;366:1059-62. 5. The Examination Committee of Criteria for ‘Obesity Disease’ in Japan. Japan Society for the Study of Obesity. New criteria for ‘obesity disease’ in Japan. Circ J 2002;66:987-92.
David C.W. Lau on behalf of the Obesity Canada Clinical Practice Guidelines Steering Committee and Expert Panel.
David C.W. Lau, MD, PhD, FRCPC, Professor of Medicine, Biochemistry and Molecular Biology University of Calgary
Conflict of Interest:
None declared
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Competing Interests: None declared.
Posted on: (18 December 2007)

Possible error in table 3 : re : waist circumf
Cleo Mavriplis
Dear Dr Lau, I was glad to see an ethnic-specific table of values for waist circumference in your article, since we see patients of many ethnic backgrounds. I was just wondering if there is an error in the measurement for Japanese women, since the value is larger than for Japanese men.I have tried to search the e-letters and snail mail letters in CMAJ to see if anyone reported this previously, and could not find any.If th...
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Dear Dr Lau, I was glad to see an ethnic-specific table of values for waist circumference in your article, since we see patients of many ethnic backgrounds. I was just wondering if there is an error in the measurement for Japanese women, since the value is larger than for Japanese men.I have tried to search the e-letters and snail mail letters in CMAJ to see if anyone reported this previously, and could not find any.If there has been a correction I would love to get it. Cleo Mavriplis MD, CCFP, FCFP
Conflict of Interest:
None declared
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Competing Interests: None declared.
Posted on: (11 June 2007)

Not all personal trainers are qualified to work with patients with obesity.
Dr. Darren E. R. Warburton
We would like to respond to the “2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children,” and specifically to the references to “exercise professionals” contained therein (1). We are in full agreement that exercise professionals play an essential role in the management and treatment of obesity, and welcome the fundamental and novel recommendation regarding the impor...
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We would like to respond to the “2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children,” and specifically to the references to “exercise professionals” contained therein (1). We are in full agreement that exercise professionals play an essential role in the management and treatment of obesity, and welcome the fundamental and novel recommendation regarding the important role of the exercise professional (particularly by Dent et al. in Chapter 9). This represents a truly progressive step forward in thinking surrounding the prevention and treatment of obesity. However, we also believe that some of the statements by Dr. Dent and colleagues may inadvertently place patients with obesity at increased risk. As identified throughout the clinical practice guidelines, many overweight and obese individuals are at an increased risk of various co-morbidities, including cardiovascular disease. It is therefore imperative that exercise professionals involved in treating such individuals have a clear knowledge of the absolute and relative contraindications to exercise for patients with obesity. We strongly believe that such knowledge can only be developed through formal and rigorous post-secondary academic training within a faculty of exercise science. Dent et al. list some personal training designations provided by for-profit organizations that do not require advanced college or university education in health and exercise science. We are greatly concerned with the implications that this statement will have for the safety and well-being of patients with obesity and indeed for Canadians in general. The lack of formal and rigorous academic training in health and fitness will inevitably compromise the ability of such practitioners to work safely and effectively with patients having chronic disease (2).
We would never advocate patients working with medical practitioners, psychologists or dieticians that had not passed a national examination process having completed formal post-secondary training in their field. Similarly, we (physicians specializing in exercise science and other allied health professionals) cannot endorse for this purpose personal training designations that do not require post-secondary training and certification. We feel it is important to distinguish clearly between the competencies inherent in different training/certification programmes.
In Canada, individuals with advanced academic and practical preparation are recognized through the comprehensive and rigorous certifications provided by the Canadian Society for Exercise Physiology (CSEP); qualifications include the CSEP-Certified Personal Trainer (CSEP- CPT) and the CSEP-Certified Exercise Physiologist (CSEP-CEP) (2). The CSEP -CPT is trained in exercise and weight reduction strategies for asymptomatic individuals and/or individuals who have been cleared for unrestricted physical activity by a physician. The CSEP-CEP is the most advanced exercise prescription and assessment certification, authorizing involvement with both healthy and clinical populations. In the US, the ACSM-Exercise Specialist and ACSM-Registered Clinical Exercise Physiologist are somewhat analogous qualifications, again offering the academic and practical preparation required to work with clinical populations; these advanced ACSM certifications are recognized nationally as the definitive certification(s) by the medical community - and/or allied health professionals. The certifications provided by CSEP are at a similar level, and as such should receive the same degree of recognition in Canada.
Together, both health and allied health professionals (including qualified exercise professionals) have the knowledge and experience to provide information based on sound physiological principles, a clear understanding of absolute and relative contraindications to exercise, and an extensive background of research and practical application. A strengthening of the current positive relationship will greatly enhance the common battle against the global crisis of obesity, while minimizing the risk to individual patients.
References:
1. Lau DC, Douketis JD, Morrison KM, Hramiak IM, Sharma AM, and Ur E. 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary]. Can Med Assoc J 176: S1-13, 2007.
2. Warburton DE, Nicol C, and Bredin SS. Health benefits of physical activity: the evidence. Can Med Assoc J 174: 801-809, 2006.
Authors (Affiliations):
Dr. Darren E. R. Warburton PhD (1,2)
Dr. Shannon S. D. Bredin PhD (2)
Dr. Philip Chilibeck PhD (3)
Dr. Jonathon Fowles PhD (4)
Alex Game MSc, CSEP-CEP (5)
Dr. Norman Gledhill PhD (6)
Dr. Mark Haykowsky PhD (7)
Karyn Humber CSEP-CEP, CSEP-CPT ME (8)
Veronica Jamnik MSc, PhD Cand, CSEP-CEP, CSEP-CPT ME (6)
Dr. Peter T. Katzmarzyk PhD (9)
Dr. Michael Koehle MD, PhD (2,10)
Douglas Lafreniere MSc, CSEP-CEP, CSEP-CPT ME (11)
Dr. Don C. McKenzie MD PhD (2,10)
Rosie Neil MSc, CSEP-CEP, CSEP-CPT ME (12)
Nancy Payne MSc, CSEP-CEP (13)
Dr. Art Quinney PhD (14)
Dr. Robert Ross PhD (9)
Dr. Roy Shephard MD PhD (15)
Dr. Jack Taunton MD (2,10,16)
Dr. Scott Thomas PhD (17)
Lori Zehr MSc, CSEP-CEP, ACSM-ES (18)
1. Cardiovascular Physiology and Rehabilitation Laboratory, Experimental Medicine Program, Faculty of Medicine, University of British Columbia 2. School of Human Kinetics, University of British Columbia 3. College of Kinesiology, University of Saskatchewan 4. School of Recreation Management and Kinesiology, Acadia University 5. Faculty of Physical Education and Recreation, University of Alberta 6. Kinesiology and Health Science, York University 7. Faculty of Rehabilitation Sciences, University of Alberta 8. Fitness and Health Promotion Program, Humber College 9. School of Kinesiology and Health Studies, Queen’s University 10. Division of Sports Medicine, Faculty of Medicine, University of British Columbia 11. Fitness and Health Promotion Program, School of Health Sciences, Loyalist College 12. Kinesiology, University of Calgary 13. Co-Chair, CSEP Certified Exercise Physiologist Technical Committee 14. Deputy Provost, University of Alberta 15. Professor Emeritus, University of Toronto 16. Chief Medical Officer, Vancouver 2010 Olympic and Paralympic Winter Games 17. Faculty of Physical Education and Health, University of Toronto 18. Exercise and Wellness Program, Centre for Sport and Exercise Education, Camosun College
Conflict of Interest:
None declared
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Competing Interests: None declared.