RE: Obesity in adults: a clinical practice guideline
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.
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 Rather than adopting a guideline recommendation scheme that is rather outdated [2], there are newer and simpler schemes that provide a more practical approach to treatment recommendations: ‘do it’, or ‘OK to do it or not do it’ [3].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.