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Guideline

Obesity in adults: a clinical practice guideline

Sean Wharton, David C.W. Lau, Michael Vallis, Arya M. Sharma, Laurent Biertho, Denise Campbell-Scherer, Kristi Adamo, Angela Alberga, Rhonda Bell, Normand Boulé, Elaine Boyling, Jennifer Brown, Betty Calam, Carol Clarke, Lindsay Crowshoe, Dennis Divalentino, Mary Forhan, Yoni Freedhoff, Michel Gagner, Stephen Glazer, Cindy Grand, Michael Green, Margaret Hahn, Raed Hawa, Rita Henderson, Dennis Hong, Pam Hung, Ian Janssen, Kristen Jacklin, Carlene Johnson-Stoklossa, Amy Kemp, Sara Kirk, Jennifer Kuk, Marie-France Langlois, Scott Lear, Ashley McInnes, David Macklin, Leen Naji, Priya Manjoo, Marie-Philippe Morin, Kara Nerenberg, Ian Patton, Sue Pedersen, Leticia Pereira, Helena Piccinini-Vallis, Megha Poddar, Paul Poirier, Denis Prud’homme, Ximena Ramos Salas, Christian Rueda-Clausen, Shelly Russell-Mayhew, Judy Shiau, Diana Sherifali, John Sievenpiper, Sanjeev Sockalingam, Valerie Taylor, Ellen Toth, Laurie Twells, Richard Tytus, Shahebina Walji, Leah Walker and Sonja Wicklum
CMAJ August 04, 2020 192 (31) E875-E891; DOI: https://doi.org/10.1503/cmaj.191707
Sean Wharton
Departments of Medicine (Wharton), Endocrinology and Metabolism (Poddar, Sherifali), Family Medicine (Naji, Tytus) and Health Research Methods, Evidence and Impact Canada (Naji), McMaster University, Hamilton, Ont; The Wharton Medical Clinic (Wharton, Poddar), Hamilton, Ont.; Departments of Medicine (Lau, Nerenberg) and Family Medicine (Boyling, Henderson, McInnes, Walji, Wicklum), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Julia McFarlane Diabetes Research Centre and Libin Cardiovascular Institute of Alberta (Lau), Calgary, Alta.; Department of Family Medicine (Vallis, Piccinini-Vallis), Dalhousie University, Halifax, NS; Departments of Medicine (Sharma, Toth), Family Medicine (Campbell-Scherer, Kemp), Agricultural, Food and Nutritional Science (Bell, Pereira), Physical Education and Recreation (Boulé), and Occupational Therapy (Forhan), University of Alberta, Edmonton, Alta.; Adult Bariatric Specialty Clinic (Sharma), Royal Alexandra Hospital, Edmonton, Alta.; Obesity Canada (Sharma, Patton, Ramos Salas), Edmonton, Alta.; Department of Surgery (Biertho), Laval University, Quebec, Que.; School of Human Kinetics (Adamo, Prud’homme), University of Ottawa, Ottawa, Ont.; Department of Health, Kinesiology & Applied Physiology (Alberga), Concordia University, Montréal, Que.; Bariatric Centre of Excellence (Brown), The Ottawa Hospital, Ottawa, Ont.; Departments of Family Practice (Calam) and Endocrinology (Manjoo), University of British Columbia, Vancouver, BC; UBC Family Practice Residency Program (Calam) and Pfizer/Heart and Stroke Foundation Chair in Cardiovascular Prevention Research (Lear), St. Paul’s Hospital, Vancouver, BC; nutrition consultant (Clarke), Hamilton, Ont.; Indigenous Health Dialogue (Crowshoe), Health Sciences Centre, University of Calgary, Calgary, Alta.; Main East Medical Associates (Divalentino), Hamilton, Ont.; Bariatric Medical Institute (Freedhoff), Ottawa, Ont.; Department of Family Medicine (Freedhoff) and Division of Endocrinology and Metabolism (Shiau), Department of Medicine, University of Ottawa, Ottawa, Ont.; Herbert Wertheim School of Medicine (Gagner), Florida International University, Miami, Fla.; Hôpital du Sacre Coeur de Montréal (Gagner), Montréal, Que.; Humber River Hospital (Glazer), Toronto, Ont.; Division of Endocrinology and Metabolism (Glazer), Queen’s University, Kingston, Ont.; Departments of Internal Medicine (Glazer), Psychiatry (Hawa, Sockalingam), Family and Community Medicine (Macklin) and Nutritional Sciences (Sievenpiper), University of Toronto, Toronto, Ont.; Alberta Health Services (Grand, Hung, Johnson-Stoklossa), Edmonton, Alta.; Departments of Family Medicine and Public Health Sciences and Policy Studies (Green), Queen’s University, Kingston, Ont.; Kingston Health Sciences Centre (Green), Kingston, Ont.; Providence Care Hospital (Green), Kingston, Ont.; Centre for Addiction and Mental Health (Hahn, Sockalingam), Toronto, Ont.; University Health Network (Hawa, Sockalingam), Toronto, Ont.; Division of General Surgery (Hong), McMaster University, Hamilton, Ont.; Department of Family Medicine and Biobehavioral Health (Jacklin), University of Minnesota Medical School Duluth Campus, Duluth, Minn.; School of Kinesiology and Health Studies (Janssen), Queen’s University, Kingston, Ont.; School of Health and Human Performance (Kirk), Dalhousie University, Halifax, NS; School of Kinesiology and Health Science (Wharton, Kuk), York University, Toronto, Ont.; Division of Endocrinology (Langlois), Université de Sherbrooke, Sherbrooke, Que.; Centre intégré universitaire de santé et de services sociaux de l’Estrie - Centre hospitalier universitaire de Sherbrooke (Langlois), Sherbrooke, Que.; School of Kinesiology (Lear), Simon Fraser University, Vancouver, BC; Medcan Clinic (Macklin), Toronto, Ont.; Cardiometabolic Collaborative Clinic (Manjoo), Vancouver Island Health Authority, Victoria, BC; Institut universitaire de cardiologie et de pneumologie de Québec (Morin, Poirier), Laval University, Québec, Que.; Foothills Medical Centre (Nerenberg), Calgary, Alta.; C-ENDO Diabetes & Endocrinology Clinic (Pedersen), Calgary, Alta.; LMC Diabetes and Endocrinology ( Poddar), Toronto, Ont.; Department of Medicine (Rueda-Clausen), University of Saskatchewan, Regina, Sask.; Regina General Hospital (Rueda-Clausen), Regina, Sask.; Education Psychology (Russell-Mayhew), Werklund School of Education, University of Calgary, Calgary, Alta.; LEAF Weight Management Clinic (Shiau), Ottawa, Ont.; Heather M. Arthur Population Health Research Institute/Hamilton Health Sciences Chair in Interprofessional Health Research, School of Nursing (Sherifali), McMaster University, Hamilton, Ont.; Division of Endocrinology & Metabolism (Sievenpiper), St. Michael’s Hospital, Toronto, Ont.; Department of Psychiatry (Taylor), University of Calgary, Calgary, Alta.; School of Pharmacy (Twells), Memorial University, St. John’s, NL; Steelcity Medical Clinic (Tytus), Hamilton, Ont.; Calgary Weight Management Centre (Walji), Calgary, Alta.; School of Population and Public Health (Walker), University of British Columbia, Vancouver, BC; Centre for Excellence in Indigenous Health (Walker), University of British Columbia, Vancouver, BC.; O’Brien Institute of Public Health (Wicklum), University of Calgary, Calgary, Alta.
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David C.W. Lau
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Arya M. Sharma
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  • Highlighting obesity as a risk factor for endometrial cancer
    Andrea N Simpson [MD MSc FRCSC] and Genevieve Lennox [MD MSc FRCSC]
    Posted on: 04 November 2020
  • Clinicians need long-term support for the management of obesity
    Martin Hofmeister [PhD]
    Posted on: 28 September 2020
  • RE: Obesity in adults: a clinical practice guideline
    John M Sehmer [MD, M.Sc .]
    Posted on: 26 September 2020
  • RE: Obesity in adults: a clinical practice guideline.
    Tim Jordan [MD]
    Posted on: 25 September 2020
  • Nutrition advice for women with obesity – a collective responsibility
    Sarah Louise Killeen, Dr. Chandni Maria Jacob, Prof. Mark A. Hanson and Prof. Fionnuala M. McAuliffe
    Posted on: 22 September 2020
  • RE: Obesity in Adults
    Norman E,. Bottum [M.D. F.C.F.P. Dip Sport Med.]
    Posted on: 13 September 2020
  • RE: Obesity in adults: a clinical practice guideline
    James D. Douketis [MD]
    Posted on: 12 September 2020
  • RE: Permission for advice?
    Stephen R Workman [MD MSc]
    Posted on: 14 August 2020
  • RE: Obesity in adults: a clinical practice guideline
    Katherine Dulong
    Posted on: 11 August 2020
  • RE: Obesity in adults: a clinical practice guideline
    Antoine Hakim
    Posted on: 09 August 2020
  • RE: Further discussion of community and population-level strategies
    Daiva E Nielsen [PhD]
    Posted on: 07 August 2020
  • RE: Must implement a practical program
    william M. Goldberg [Md,DSc(hon) ,FRCP(C),FACP]
    Posted on: 05 August 2020
  • Posted on: (4 November 2020)
    Page navigation anchor for Highlighting obesity as a risk factor for endometrial cancer
    Highlighting obesity as a risk factor for endometrial cancer
    • Andrea N Simpson [MD MSc FRCSC], Obstetrician & Gynaecologist, Co-Chair, Community of Practice (CoP) in Obesity of the Society of Gynecologic Oncology of Canada (GOC)
    • Other Contributors:
      • Genevieve Lennox, Gynaecologic Oncologist

    On behalf of the Community of Practice (CoP) in Obesity of the Society of Gynecologic Oncology of Canada (GOC), we would like to thank the authors of the recent guideline on the management of obesity in adults (1) for highlighting the elevated risk of endometrial cancer among women with obesity. Endometrial cancer is the fourth most common gynaecologic malignancy in women with 7,400 new diagnoses annually in Canada (2). Obesity is one of the most significant risk factors for this disease: the risk is tripled in women with a body mass index (BMI) above 30 kg/m2. (3)

    We advocate for increasing provider and public awareness of the association between obesity and endometrial cancer. In addition, we want to highlight that abnormal uterine bleeding or post-menopausal bleeding are red flags that require urgent assessment with an office endometrial biopsy. Endometrial biopsy is essential for diagnosis and cannot be replaced by imaging. Furthermore, young women with obesity and irregular menstrual cycles are at an increased risk for the development of endometrial hyperplasia and cancer. Management strategies for endometrial protection include: progestin-containing intrauterine devices (4) and the oral contraceptive pill (5).

    Aligning with the authors’ recommendation to focus on patient-centred health outcomes rather than weight loss alone,1 such risk-reducing interventions should routinely be offered to women with obesity, particularly in the setting of infrequent...

    Show More

    On behalf of the Community of Practice (CoP) in Obesity of the Society of Gynecologic Oncology of Canada (GOC), we would like to thank the authors of the recent guideline on the management of obesity in adults (1) for highlighting the elevated risk of endometrial cancer among women with obesity. Endometrial cancer is the fourth most common gynaecologic malignancy in women with 7,400 new diagnoses annually in Canada (2). Obesity is one of the most significant risk factors for this disease: the risk is tripled in women with a body mass index (BMI) above 30 kg/m2. (3)

    We advocate for increasing provider and public awareness of the association between obesity and endometrial cancer. In addition, we want to highlight that abnormal uterine bleeding or post-menopausal bleeding are red flags that require urgent assessment with an office endometrial biopsy. Endometrial biopsy is essential for diagnosis and cannot be replaced by imaging. Furthermore, young women with obesity and irregular menstrual cycles are at an increased risk for the development of endometrial hyperplasia and cancer. Management strategies for endometrial protection include: progestin-containing intrauterine devices (4) and the oral contraceptive pill (5).

    Aligning with the authors’ recommendation to focus on patient-centred health outcomes rather than weight loss alone,1 such risk-reducing interventions should routinely be offered to women with obesity, particularly in the setting of infrequent (anovulatory) menstrual cycles.

    About GOC
    The Society of Gynecologic Oncology of Canada is a non-profit organization consisting of physicians, nurses, scientists and other health care professionals specializing in gynecologic oncology. Its purpose is to improve the care of women with or at risk of gynecologic cancer by raising standards of practice, encouraging ongoing research, promoting innovation in prevention, care and discovery, and advancing awareness. GOC also seeks to disseminate knowledge to practitioners, patients and the general public on gynecologic cancer as well as cooperate with other organizations committed to women’s health care, oncology, and related fields.
    Website: www.g-o-c.org | Twitter: @Gyne_Oncology

    Show Less
    Competing Interests: None declared.

    References

    • Sean Wharton, David C.W. Lau, Michael Vallis, et al. Obesity in adults: a clinical practice guideline. CMAJ 2020;192:E875-E891.
    • Canadian Cancer Society. Canadian Cancer Statistics 2019. Accessed from: https://www.cancer.ca/~/media/cancer.ca/CW/cancer%20information/cancer%20101/Canadian%20cancer%20statistics/Canadian-Cancer-Statistics-2019-EN.pdf?la=en on September 30, 2020.
    • Amant F, Moerman P, Neven P, Timmerman D, Van Limbergen E, Vergote I. Endometrial cancer. Lancet. 2005;366(9484):491-505.
    • Jareid M, Thalabard JC, Aarflot M, Bovelstad HM, Lund E, Braaten T. Levonorgestrel-releasing intrauterine system use is associated with a decreased risk of ovarian and endometrial cancer, without increased risk of breast cancer. Results from the NOWAC Stu
    • Collaborative Group on Epidemiological Studies on Endometrial C. Endometrial cancer and oral contraceptives: an individual participant meta-analysis of 27 276 women with endometrial cancer from 36 epidemiological studies. Lancet Oncol. 2015;16(9):1061-107
  • Posted on: (28 September 2020)
    Page navigation anchor for Clinicians need long-term support for the management of obesity
    Clinicians need long-term support for the management of obesity
    • Martin Hofmeister [PhD], Nutrition Scientist, Department Food and Nutrition, Consumer Centre of the German Federal State of Bavaria, Munich, Germany

    Congratulations Wharton and colleagues for the comprehensive practice guideline on obesity management [1]. I agree that many multicausal and multidimensional interacting factors influencing obesity and their consequences. There are two 'physician' aspects worth mentioning.

    First, obesity affected 27.7% or 7.6 million Canadian adults in 2019. The authors are right with the regularly assessment step "Direct measurement of height, weight and waist circumference and calculation of body mass index (BMI) should be included in routine physical examination for all adults.“ [1] A current data analysis of the Canadian primary care electronic medical records with 707,819 patients aged 40 or older showed that 58.6% had at least one BMI recording but only 11.5% had at least one waist circumference (WC) documentation. However, in 81% of Canadian patients there was no simultaneous monitoring of BMI and WC by primary care clinicians [2].

    Second, obesity education currently has a very low priority in medical school curricula, with an average of just 10 hours over four years [3]. Medical students are by no means sufficiently prepared to manage patients with obesity - especially nutrition competencies are enormously deficient across the globe [4, 5]. In addition to this helpful practice guideline, primary care clinicians need urgent long-term support for the management of obese patients.

    Competing Interests: None declared.

    References

    • 1. Sean Wharton, David C.W. Lau, Michael Vallis, et al. Obesity in adults: a clinical practice guideline. CMAJ 2020;192:E875-E891.
    • 2. Lindeman C, et al. Body mass index and waist circumference documentation in Canadian primary care electronic medical records. Research Square 14 Jul, 2020. https://assets.researchsquare.com/files/rs-41280/v1/7fdfdc99-bc4a-4d9a-9046-661841aea57e.pdf
    • 3. Butsch WS, et al. Low priority of obesity education leads to lack of medical students' preparedness to effectively treat patients with obesity: results from the U.S. medical school obesity education curriculum benchmark study. BMC Med Educ 2020;20:23.
    • 4. Mastrocola MR, Roque SS, Benning LV, Stanford FC. Obesity education in medical schools, residencies, and fellowships throughout the world: a systematic review. Int J Obes (Lond) 2020;44:269-79.
    • 5. Crowley J, Ball L, Hiddink GJ. Nutrition in medical education: a systematic review. Lancet Planet Health 2019;3:e379-89.
  • Posted on: (26 September 2020)
    Page navigation anchor for RE: Obesity in adults: a clinical practice guideline
    RE: Obesity in adults: a clinical practice guideline
    • John M Sehmer [MD, M.Sc .], Physician, Clinical associate professor, UBC medical school

    The CMAJ and its peer reviewers concluded an article written by over 50 authors many sponsored by the pharmaceutical industry with over 80 recommendations would be of practical use to primary health care providers .
    Having a BMI over 25 or over is labelled as having the “disease” of obesity . Yet a 2013 study by Health Canada (1) found at age 20 the life expectancy for females[males] with BMI 18.5 to 24.9 (”normal” )was 62.9[57.2] years , who had a BMI 25 to 30 “overweight” was a further 66.5[ 61.0] years and for a BMI 30 to 35, otherwise known as Class 1 obesity, 64.6 [59.1] years . Both “overweight” males and females had a significantly longer life expectancy than those with normal weight . Those with Class 1 obesity still had a longer life expectancy than those with “normal” weight .
    A 2018 study (2) of populations in England, Finland, France and Finland between ages 50 and 75 found negligible if any differences in life expectancy between individuals with normal weight ( BMI 18.5- 24.9) overweight ( BMI 25-29.9 ) and class 1 obesity ( BMI 30 to 34.9)
    One of the CMAJ recommendations states pharmacotherapy should be considered for individuals with a BMI over over 30 . For the reasons above this would suggest the guideline recommendations for pharmacotherapy are based more on cosmetic considerations rather than health indications.
    Stigmatizing those who are “overweight” or have class 1 obesity by calling their condition a disease is not based...

    Show More

    The CMAJ and its peer reviewers concluded an article written by over 50 authors many sponsored by the pharmaceutical industry with over 80 recommendations would be of practical use to primary health care providers .
    Having a BMI over 25 or over is labelled as having the “disease” of obesity . Yet a 2013 study by Health Canada (1) found at age 20 the life expectancy for females[males] with BMI 18.5 to 24.9 (”normal” )was 62.9[57.2] years , who had a BMI 25 to 30 “overweight” was a further 66.5[ 61.0] years and for a BMI 30 to 35, otherwise known as Class 1 obesity, 64.6 [59.1] years . Both “overweight” males and females had a significantly longer life expectancy than those with normal weight . Those with Class 1 obesity still had a longer life expectancy than those with “normal” weight .
    A 2018 study (2) of populations in England, Finland, France and Finland between ages 50 and 75 found negligible if any differences in life expectancy between individuals with normal weight ( BMI 18.5- 24.9) overweight ( BMI 25-29.9 ) and class 1 obesity ( BMI 30 to 34.9)
    One of the CMAJ recommendations states pharmacotherapy should be considered for individuals with a BMI over over 30 . For the reasons above this would suggest the guideline recommendations for pharmacotherapy are based more on cosmetic considerations rather than health indications.
    Stigmatizing those who are “overweight” or have class 1 obesity by calling their condition a disease is not based on medical evidence . Perhaps it is no different than the American Psychiatrtic Association previously calling homosexuality a disease .

    Show Less
    Competing Interests: None declared.

    References

    • Sean Wharton, David C.W. Lau, Michael Vallis, et al. Obesity in adults: a clinical practice guideline. CMAJ 2020;192:E875-E891.
    • . Steensma C., Loukine L, Orpana H, Lo E, Choi B, Water C et l. Comparing life expectancy and health adjusted life expectancy by body mass index categoryin adult Canadians: a descriptive study . Popul Health Metr 2013 11; 11 :21
    • . Stenholm S, Head J , V Aalto et al. Body mass index as a predictor of healthy and disease free life expectancy between ages 50 qnd 75: a multicohort study. International Journal of Obesity . 2017; 41(5) : 769-775
  • Posted on: (25 September 2020)
    Page navigation anchor for RE: Obesity in adults: a clinical practice guideline.
    RE: Obesity in adults: a clinical practice guideline.
    • Tim Jordan [MD], Medical Doctor, Alberta Health Services

    As a family doctor in Alberta, I wanted to congratulate all those concerned, on the excellent job undertaken for the production of this CPG. Thank you and well done.

    Competing Interests: None declared.

    References

    • Sean Wharton, David C.W. Lau, Michael Vallis, et al. Obesity in adults: a clinical practice guideline. CMAJ 2020;192:E875-E891.
  • Posted on: (22 September 2020)
    Page navigation anchor for Nutrition advice for women with obesity – a collective responsibility
    Nutrition advice for women with obesity – a collective responsibility
    • Sarah Louise Killeen, PhD student (registered dietitian), UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
    • Other Contributors:
      • Dr. Chandni Maria Jacob, Senior Research Assistant, Postgraduate research student
      • Prof. Mark A. Hanson, Professor of Cardiovascular Science
      • Prof. Fionnuala M. McAuliffe, Professor and Obstetrician

    Wharton et al. provide a comprehensive resource for effective and ethical obesity management, across many populations and patient circumstances[1]. The specific focus on adult women living with obesity is welcomed, especially as pregnancy, preconception and postpartum are some of the most critical life-course timepoints for the prevention of non-communicable diseases across multiple generations[2]. The authors outline that where possible, adults living with obesity, which includes women of reproductive age, should have access to a registered dietitian for individualized medical nutrition therapy[1]. This is an excellent recommendation, and we also consider it important to advocate that all healthcare providers who see women with obesity, have an opportunity to promote healthy weight and nutrition[3,4]. Due to the growing prevalence of obesity and the associated demand on dietetic services, other healthcare professionals must capitalize on their contact with women and promote healthy behaviour change. It is important that nutrition is seen as a collective global responsibility and is embedded into multi-disciplinary health services, systems and policies[3,4]. The authors recommend that primary care physicians encourage and support pregnant women with obesity to consume a healthy dietary pattern[1]. Advice on how physicians can implement this into their practice, however, is lacking in this review. During pregnancy, women with obesity should be advised to follow a diet that...

    Show More

    Wharton et al. provide a comprehensive resource for effective and ethical obesity management, across many populations and patient circumstances[1]. The specific focus on adult women living with obesity is welcomed, especially as pregnancy, preconception and postpartum are some of the most critical life-course timepoints for the prevention of non-communicable diseases across multiple generations[2]. The authors outline that where possible, adults living with obesity, which includes women of reproductive age, should have access to a registered dietitian for individualized medical nutrition therapy[1]. This is an excellent recommendation, and we also consider it important to advocate that all healthcare providers who see women with obesity, have an opportunity to promote healthy weight and nutrition[3,4]. Due to the growing prevalence of obesity and the associated demand on dietetic services, other healthcare professionals must capitalize on their contact with women and promote healthy behaviour change. It is important that nutrition is seen as a collective global responsibility and is embedded into multi-disciplinary health services, systems and policies[3,4]. The authors recommend that primary care physicians encourage and support pregnant women with obesity to consume a healthy dietary pattern[1]. Advice on how physicians can implement this into their practice, however, is lacking in this review. During pregnancy, women with obesity should be advised to follow a diet that not only manages gestational weight gain but also meets their complex and dynamic nutritional needs for fetal growth and development[4]. The use of checklists in clinical practice has been encouraged by medical organisations[5]. The FIGO Nutrition Checklist is a purposively designed and brief nutritional questionnaire for women before or during pregnancy. It includes questions on personal dietary requirements or practices (e.g. vegan diet), body mass index, diet quality and micronutrients. It can therefore support clinicians who lack dietetic training to implement some of the recommendations outlined by the authors including the provision of dietary advice that is personalized, nutritionally adequate and culturally acceptable. To date, the FIGO Nutrition Checklist has been used in three separate countries in Europe and Asia and adapted to local requirements[2].

    We would welcome if Canada would consider use of the FIGO nutrition checklist in supporting healthcare professionals address nutrition and weight at each contact.

    Show Less
    Competing Interests: None declared.

    References

    • 1. Sean Wharton, David C.W. Lau, Michael Vallis, et al. Obesity in adults: a clinical practice guideline. CMAJ 2020;192:E875-E891.
    • Mark A. Hanson, Chandni Maria Jacob, Moshe Hod, et al. The FIGO pregnancy obesity and nutrition initiative (PONI). Int J Gynecol Obstet. 2019; 147: 131– 133.
    • Jacob CM, Killeen SL, McAuliffe FM et al. Prevention of noncommunicable diseases by interventions in the preconception period: A FIGO position paper for action by healthcare practitioners. Int J Gynecol Obstet. 2020; 151(Suppl 1): 6– 15.
    • McAuliffe FM, Killeen SL, Jacob CM, et al. Int J Gynecol Obstet. 020;151(Suppl 1):16–36.
    • ACOG Committee Opinion No. 680 Summary: The Use and Development of Checklists in Obstetrics and Gynecology. Obstet Gynecol. 2016; 128: 1200.
  • Posted on: (13 September 2020)
    Page navigation anchor for RE: Obesity in Adults
    RE: Obesity in Adults
    • Norman E,. Bottum [M.D. F.C.F.P. Dip Sport Med.], Family Physician, Haliburton Family Medical Centre

    I was initially pleased to see an update on obesity management presented to bring us up to date on the exciting changes in the weight management paradigm.(1)
    Unfortunately, as many consensus articles will do I found it lacked some of the not so new thoughts on the bodies hormonal response to macronutrients and presented the old, calories in, calories out statements. Several commercial products were noted but the words insulin, insulin resistance or hyper insulinemia were no where to be seen. The high insulin levels seen in Metabolic Syndrome is the driver of Type 2 Diabetes, hypertension, obesity, some cancers and dementia. It is time that we all become aware of the amazing results that we are getting treating this very easily diagnosed and clearly treatable metabolic issue.(2,3)

    Competing Interests: None declared.

    References

    • 1. Sean Wharton, David C.W. Lau, Michael Vallis, et al. Obesity in adults: a clinical practice guideline. CMAJ 2020;192:E875-E891.
    • 2. Fung J. The Obesity Code: Unlocking the Secrets of Weight Loss. 2016: Greystone Books.
    • 3. Barazzoni R, Cappellari G, Ragni M, et al. Insulin Resistance in obesity: an overview of fundamental alterations. Eat Weight Disord. 2018;23:149-157.
  • Posted on: (12 September 2020)
    Page navigation anchor for RE: Obesity in adults: a clinical practice guideline
    RE: Obesity in adults: a clinical practice guideline
    • James D. Douketis [MD], medical doctor, McMaster University and St. Joseph's Healthcare Hamilton

    I applaud the herculean effort of Wharton et al. to produce timely and comprehensive guidelines on the management of obesity [1], and offer the following comments:

    First, despite the wide array of topics covered I am surprised and disappointed that guidelines related to the prevention of obesity are conspicuously absent. With billions of dollars spent annually in Canada towards dietary, pharmacologic, surgical and psychological strategies to treat obesity and its many complications, it is unfortunate that so little attention and resources are dedicated to preventing obesity in children, adolescents and young adults. Perhaps a companion guideline focusing on primary prevention is in the works.

    Second, the guideline recommendation format, though well-intentioned, seems unwieldy and, at times, confusing [2]. For example, under pharmacotherapy in obesity management, there are three recommendations, all categorized as having the same level of evidence (Level 2a, Grade B), yet these separate recommendations state that pharmacotherapy “can be used”, “may be used”, and is “recommended”. For clinicians looking for guidance on ‘what to do’, these statements appear ambiguous and inconsistent with the evidence. Rather than adopting a guideline recommendation scheme that is rather outdated [2], there are newer and simpler schemes that provide a more practical approach to treatment recommendations: ‘do it’, or ‘OK to do it or not do it’ [3].

    As a third (minor) p...

    Show More

    I applaud the herculean effort of Wharton et al. to produce timely and comprehensive guidelines on the management of obesity [1], and offer the following comments:

    First, despite the wide array of topics covered I am surprised and disappointed that guidelines related to the prevention of obesity are conspicuously absent. With billions of dollars spent annually in Canada towards dietary, pharmacologic, surgical and psychological strategies to treat obesity and its many complications, it is unfortunate that so little attention and resources are dedicated to preventing obesity in children, adolescents and young adults. Perhaps a companion guideline focusing on primary prevention is in the works.

    Second, the guideline recommendation format, though well-intentioned, seems unwieldy and, at times, confusing [2]. For example, under pharmacotherapy in obesity management, there are three recommendations, all categorized as having the same level of evidence (Level 2a, Grade B), yet these separate recommendations state that pharmacotherapy “can be used”, “may be used”, and is “recommended”. For clinicians looking for guidance on ‘what to do’, these statements appear ambiguous and inconsistent with the evidence. Rather than adopting a guideline recommendation scheme that is rather outdated [2], there are newer and simpler schemes that provide a more practical approach to treatment recommendations: ‘do it’, or ‘OK to do it or not do it’ [3].

    As a third (minor) point, the authors refer to the “first evidence-based Canadian practice guideline on the prevention and treatment of obesity”, published in 2007 [4]. In fact, the Canadian Task Force for Preventive Health Care published such evidence-based guidelines in 1999 [5]; the Task Force has been for decades a highly-respected but under-funded vehicle of practice standards for clinicians in Canada and abroad.

    Show Less
    Competing Interests: None declared.

    References

    • 1. Sean Wharton, David C.W. Lau, Michael Vallis, et al. Obesity in adults: a clinical practice guideline. CMAJ 2020;192:E875-E891.
    • 2. Shekelle PG, Woolf SH, Eccles M, et al. Developing clinical guidelines. West J Med 1999;170:348-51.
    • 3. Neumann I, Santesso N, Akl EA, et al. A guide for health professionals to interpret and use recommendations in guidelines developed with the GRADE approach. J Clin Epidemiol 2016;72:45-55.
    • 4. Lau DCW, Douketis JD, Morrison KM, et al. 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary]. CMAJ 2007;10;176:S1-13.
    • 5. Douketis JD, Feightner JW, Attia J, Feldman WF. Periodic health examination, 1999 update: 1. Detection, prevention and treatment of obesity. Canadian Task Force on Preventive Health Care. CMAJ 1999;160:513-25.
  • Posted on: (14 August 2020)
    Page navigation anchor for RE: Permission for advice?
    RE: Permission for advice?
    • Stephen R Workman [MD MSc], Physician, Dalhousie University

    Patients frequently see physicians for obesity related diseases such as diabetes, hypertension or arthritis and joint pain. The guidelines seem, to me at least, to suggest that physicians should ask for permission before discussing weight and by inference weight loss. While this approach has merit it would be unnecessary if patients asked for help with weight loss. Many it seems do not.

    An alternative to asking permission to discuss 'weight' is to respectfully advise, when it is the case, that weight loss could help improve the illness which is causing suffering or for which patient is seeking assistance with managing. One can educate patients that weight loss is or could be beneficial with a reduced risk of fat shaming since improvement depends upon an individual patient and need not involve making or communicating a normative assessment such as BMI.

    I would go so far to state, and believe that physicians are in fact OBLIGATED to ensure that patients are aware of the beneficial effects of weight loss when suffering from obesity related conditions.

    I am sorry your diabetes has proven so difficult to manage. Have other physicians explained that weight loss and regular exercise could improve your diabetic control? I would like to talk to you about weight loss....(Pause)
    ."Sure great doc"
    No response?
    Is this alright with you?

    Competing Interests: None declared.

    References

    • Sean Wharton, David C.W. Lau, Michael Vallis, et al. Obesity in adults: a clinical practice guideline. CMAJ 2020;192:E875-E891.
  • Posted on: (11 August 2020)
    Page navigation anchor for RE: Obesity in adults: a clinical practice guideline
    RE: Obesity in adults: a clinical practice guideline
    • Katherine Dulong, Research Assistant, Macdonald Campus of McGill University

    Obesity, like the current COVID-19 pandemic, has long been treated as a public health crisis. However, obesity is not a simple contagious disease like COVID-19. It is a complex, multifaceted condition that has been medicalized to oblivion, to the point where it is commonly referred to as a chronic disease. Understanding the origin of BMI, the measure used to define obesity, provides valuable insight into obesity itself. BMI was first calculated by a Belgian astronomer and was never meant to be used in the health sciences.(2) It was a simple mathematical calculation, a statistical instrument, developed using only a White, European population.(3) The sample used for the discovery of the normal BMI range was composed of affluent white men, the most privileged class of society. The ranges that categorize BMI into “normal”, “overweight” and “obese” are thus rooted in racism, classism and misogyny. Public health messaging surrounding the obesity epidemic is grounded in fatphobia, which is itself deeply rooted in racism, classism and misogyny. Diet culture is pervasive, insidious and omnipresent. It ruins lives and stigmatizes individuals who live in larger bodies. The scientific community at large must fight against diet culture, weight stigma and fatphobia. Unlearning diet culture is the most crucial task to be done by healthcare professionals, today and tomorrow.

    Competing Interests: None declared.

    References

    • 1. Sean Wharton, David C.W. Lau, Michael Vallis, et al. Obesity in adults: a clinical practice guideline. CMAJ 2020;192:E875-E891.
    • 2. Gonzalez, Maria, Correia, Maria & Heymsfield, Steven. (2017). A requiem for BMI in the clinical setting. Current Opinion in Clinical Nutrition & Metabolic Care, 20, 314-321. https://doi.org/10.1097/MCO.0000000000000395
    • 3. Harrison, C. (2019). Anti-diet: Reclaim your time, money, well-being, and happiness through intuitive eating. Hachette UK.
  • Posted on: (9 August 2020)
    Page navigation anchor for RE: Obesity in adults: a clinical practice guideline
    RE: Obesity in adults: a clinical practice guideline
    • Antoine Hakim, Neurologist, The Ottawa Hospital, and the University of Ottawa Brain and Mind Research Institute

    I am grateful for this publication which aims to shift the focus of obesity management from weight reduction toward improving patient-centered health outcomes. Having said that, I deeply regret the omission of dementia from the list of potential complications of obesity listed in this article. In a major study by Iturria-Medina et al (1) it was revealed that the first abnormal physiological event in the brain of individuals who will develop dementia is a reduction in cerebral blood flow, which occurs when they are still cognitively normal. Since then, multiple publications have confirmed that obesity results in a reduction of cerebral blood flow in many of the brain regions essential for cognitive activity, most recently confirmed by Amen and colleagues (2). The most likely reason for the association of obesity with brain hypo-perfusion is the inflammatory environment it promotes, which results in small vessel disease(3). It is therefore my contention that while dementia is not treatable, it is preventable (4), and emphasizing to patients the negative impact obesity has on cognitive function may provide them with a strong impetus to listen to the care provider's advice on how to manage obesity and follow it.

    Competing Interests: None declared.

    References

    • Sean Wharton, David C.W. Lau, Michael Vallis, et al. Obesity in adults: a clinical practice guideline. CMAJ 2020;192:E875-E891.
    • 1. Iturria-Medina Y, Sotero RC, Toussaint PJ, et al. Early role of vascular dysregulation on late-onset Alzheimer's disease based on multifatorial data-driven analysis. Nat Commun 7,11934 (2016)
    • 2. Amen DG, Wu J, Noble G, Newberg A. Patterns of regional cerebral blood flow as a function of obesity in adults. J Alzheimer's Disease 2020; DOI 10.3233.
    • 3. Hakim A. Small vessel disease. Front. Neurol. 10:1020. doi:10.3389/fneur.2019.01020
    • 4.Antoine Hakim. Save Your Mind. Seven Rules to Avoid Dementia. Barlow Books. 2017
  • Posted on: (7 August 2020)
    Page navigation anchor for RE: Further discussion of community and population-level strategies
    RE: Further discussion of community and population-level strategies
    • Daiva E Nielsen [PhD], Assistant Professor, McGill University, School of Human Nutrition

    Wharton et al. provide an excellent overview of the complexity of obesity and multiple biological, behavioural, and environmental contributors. While the resulting clinical practice guideline (CPG) provides a launching pad to abandon the flawed notion of obesity as a self-inflicted condition and redefine the clinical approach to obesity treatment and management in Canada, the critical role of retail food environments and affordability of healthy food was regrettably overlooked. While it is appreciated that CPG provide guidance for individual-level strategies, individual efforts without parallel efforts at a community or population-level may limit overall success in improving obesity-related outcomes among patients. Increasing evidence supports a role of retail food environments in body mass index (BMI) (1); however, inconsistent findings are likely due to variability in food environment measurements as well as lack of consideration of inter-individual differences in food cue reactivity. Indeed, recent research supports an argument for inter-individual differences in responsivity to food cues in the retail food environment, including advertising exposures such as in-store food displays (2). While additional research in this area is anticipated, the role of socio-economic status in obesity is more conclusive. Low socio-economic status is consistently associated with obesity, to an extent that an investigation of gene-obesogenic environment interactions in the UK Biobank conc...

    Show More

    Wharton et al. provide an excellent overview of the complexity of obesity and multiple biological, behavioural, and environmental contributors. While the resulting clinical practice guideline (CPG) provides a launching pad to abandon the flawed notion of obesity as a self-inflicted condition and redefine the clinical approach to obesity treatment and management in Canada, the critical role of retail food environments and affordability of healthy food was regrettably overlooked. While it is appreciated that CPG provide guidance for individual-level strategies, individual efforts without parallel efforts at a community or population-level may limit overall success in improving obesity-related outcomes among patients. Increasing evidence supports a role of retail food environments in body mass index (BMI) (1); however, inconsistent findings are likely due to variability in food environment measurements as well as lack of consideration of inter-individual differences in food cue reactivity. Indeed, recent research supports an argument for inter-individual differences in responsivity to food cues in the retail food environment, including advertising exposures such as in-store food displays (2). While additional research in this area is anticipated, the role of socio-economic status in obesity is more conclusive. Low socio-economic status is consistently associated with obesity, to an extent that an investigation of gene-obesogenic environment interactions in the UK Biobank concluded that low socio-economic position accentuated genetic susceptibility to obesity and best captured the relevant environmental factors (3). Indeed, affordability of healthy food is a recognized barrier to healthy eating and may be a particularly relevant target for obesity intervention. Given this relationship, additional efforts like Geisinger’s Fresh Food Farmacy, which is providing healthy food to people living with diabetes and facing food insecurity, are needed to demonstrate the possible benefit of community intervention at a potential root cause: food affordability. Participants in the Farmacy initiative are prescribed fresh food each week and fill the prescription (pick-up food) at the Farmacy clinic, alleviating financial barriers and retail exposures that pose challenges to healthy eating. Preliminary results from the Geisinger initiative have demonstrated a staggering 2-point reduction in HbA1c levels among participants, along with reductions in low-density lipoproteins, triglycerides, blood pressure, and BMI (4). Wharton et al. have illuminated the urgent need for access to appropriate and holistic obesity care in Canada and provide an excellent CPG to immediately improve the clinical approach. However, in order to more precisely address root causes and fully disrupt conventional approaches to obesity treatment and management, strategies for improving community and population-level factors need attention, investigation, and action.

    Show Less
    Competing Interests: None declared.

    References

    • Sean Wharton, David C.W. Lau, Michael Vallis, et al. Obesity in adults: a clinical practice guideline. CMAJ 2020;192:E875-E891.
    • 1. Stevenson AC, Brazeau A-S, Dasgupta K, Ross NA (2019). Evidence synthesis – Neighbourhood retail food outlet access, diet and body mass index in Canada: a systematic review. Health Promot Chronic Dis Prev Can. 39(10):261-280.
    • 2. Nielsen DE, Han Y, Paquet C, Portella AK, Ma Y, Dube L. Interaction of DRD2/ANKK1 Taq1A Genotype with in-Store Retail Food Environment Exposures on Diet Quality in a Cohort of Quebec Adults. Lifestyle Genom. 2020;13(2):74-83.
    • 3. Hess A, Passaretti M, Coolbaugh S (2019). Fresh Food Farmacy. Am J Health Promotion. 33(5):830-832.
    • 4. Tyrrell J, Wood AR, Ames RM, Yaghootkar H, Beaumont RN, Jones SE et al. Gene-obesogenic environment interactions in the UK Biobank study. 46(2):559-575.
  • Posted on: (5 August 2020)
    Page navigation anchor for RE: Must implement a practical program
    RE: Must implement a practical program
    • william M. Goldberg [Md,DSc(hon) ,FRCP(C),FACP], Retired internist, Clinical Professor McMaster Faculty of Medicine

    This is a detailed out line of the obesity problem and potential solutions,however there must be developed a clear protocol that could be applied at the present time to the individual patient.This can only be accomplished by developing pilot multi disciplinary teams across the country to apply the appropriate cognitive behaviour methodology to the problem as well as the pharmacological and other therapeutic modalities mentioned.These teams must arrive at current best approach,thenapply and evaluate it on a continual basis,willing to change whenever the course of action dictates.The most difficult and time consuming portion ,which to my mind is the most important,is the cognitive behavioural aspect.In my experience(1) a team approach is the only way to go,but it requires leadership that directs the way to reach the defined goals of the protocol .These pilot programs could then be able to teach the community of family doctors and community of citizens ,as a whole what beliefs and behaviours they must change to bring the scourge of obesity under control.It will no be done by research and publication but only by clear example of how a workable protocol of action can be applied.The medical profession has ignored the last 40 years of proven benefit of cognitive behavioural principles combined with best evidence medicine(1)

    Competing Interests: None declared.

    References

    • Sean Wharton, David C.W. Lau, Michael Vallis, et al. Obesity in adults: a clinical practice guideline. CMAJ 2020;192:E875-E891.
    • 1:An Internist Journey with Behavioural Mediciine,CJGIM,vol10,Issue 6,2015
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Canadian Medical Association Journal: 192 (31)
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Obesity in adults: a clinical practice guideline
Sean Wharton, David C.W. Lau, Michael Vallis, Arya M. Sharma, Laurent Biertho, Denise Campbell-Scherer, Kristi Adamo, Angela Alberga, Rhonda Bell, Normand Boulé, Elaine Boyling, Jennifer Brown, Betty Calam, Carol Clarke, Lindsay Crowshoe, Dennis Divalentino, Mary Forhan, Yoni Freedhoff, Michel Gagner, Stephen Glazer, Cindy Grand, Michael Green, Margaret Hahn, Raed Hawa, Rita Henderson, Dennis Hong, Pam Hung, Ian Janssen, Kristen Jacklin, Carlene Johnson-Stoklossa, Amy Kemp, Sara Kirk, Jennifer Kuk, Marie-France Langlois, Scott Lear, Ashley McInnes, David Macklin, Leen Naji, Priya Manjoo, Marie-Philippe Morin, Kara Nerenberg, Ian Patton, Sue Pedersen, Leticia Pereira, Helena Piccinini-Vallis, Megha Poddar, Paul Poirier, Denis Prud’homme, Ximena Ramos Salas, Christian Rueda-Clausen, Shelly Russell-Mayhew, Judy Shiau, Diana Sherifali, John Sievenpiper, Sanjeev Sockalingam, Valerie Taylor, Ellen Toth, Laurie Twells, Richard Tytus, Shahebina Walji, Leah Walker, Sonja Wicklum
CMAJ Aug 2020, 192 (31) E875-E891; DOI: 10.1503/cmaj.191707

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Obesity in adults: a clinical practice guideline
Sean Wharton, David C.W. Lau, Michael Vallis, Arya M. Sharma, Laurent Biertho, Denise Campbell-Scherer, Kristi Adamo, Angela Alberga, Rhonda Bell, Normand Boulé, Elaine Boyling, Jennifer Brown, Betty Calam, Carol Clarke, Lindsay Crowshoe, Dennis Divalentino, Mary Forhan, Yoni Freedhoff, Michel Gagner, Stephen Glazer, Cindy Grand, Michael Green, Margaret Hahn, Raed Hawa, Rita Henderson, Dennis Hong, Pam Hung, Ian Janssen, Kristen Jacklin, Carlene Johnson-Stoklossa, Amy Kemp, Sara Kirk, Jennifer Kuk, Marie-France Langlois, Scott Lear, Ashley McInnes, David Macklin, Leen Naji, Priya Manjoo, Marie-Philippe Morin, Kara Nerenberg, Ian Patton, Sue Pedersen, Leticia Pereira, Helena Piccinini-Vallis, Megha Poddar, Paul Poirier, Denis Prud’homme, Ximena Ramos Salas, Christian Rueda-Clausen, Shelly Russell-Mayhew, Judy Shiau, Diana Sherifali, John Sievenpiper, Sanjeev Sockalingam, Valerie Taylor, Ellen Toth, Laurie Twells, Richard Tytus, Shahebina Walji, Leah Walker, Sonja Wicklum
CMAJ Aug 2020, 192 (31) E875-E891; DOI: 10.1503/cmaj.191707
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