Canadian Adult Obesity Clinical Practice Guideline

Obesity Canada, in collaboration with the Canadian Association for Bariatric Surgeons and Physicians, has developed the Canadian Adult Obesity Clinical Practice Guideline, recognized internationally as a leading resource in obesity management.

Healthcare providers gain practical, evidence-based strategies to better support patients living with obesity. Recognized internationally, this guideline is helping transform care standards and ensuring patients receive the respect and support they deserve.

Recommendations are summarized in the Canadian Medical Association Journal, with 19 detailed chapters available for download below. These open-source chapters will be updated as new evidence arises.

Quick reference: Recommendations & key messages by chapter

Reducing Weight Bias in Obesity Management, Practice, & Policy

Recommendations 

  1. Healthcare providers should assess their own attitudes and beliefs regarding obesity and consider how their attitudes and beliefs may influence care delivery (Level 1A; Grade A).
  2. Healthcare providers should recognize that internalized weight bias (bias towards oneself) in people living with obesity can affect behavioural and health outcomes (Level 2A; Grade B).
  3. Healthcare providers should avoid using judgmental words, (level 1A, grade A), images (Level 2B, Grade B) and practices (Level 2A, Grade B) when working with patients living with obesity.
  4. We recommend that healthcare providers avoid making assumptions that an ailment or complaint a patient presents with is related to their body weight (Level 3, Grade C).
Key Messages for People Living with Obesity 
 
  • Weight bias may affect quality of healthcare for individuals with obesity. For example, weight bias may negatively affect health professionals’ attitudes and behaviours toward individuals living with obesity.
  • Experiences of weight bias can harm your health and well-being. Experiencing unequal treatment because of your size or weight, for example, is not acceptable. Talk to your healthcare provider about your experiences with weight bias. Speak up and support action to stop weight-based discrimination.
  • Talk to your healthcare provider about addressing internalized weight bias. Bias can impact your behaviours and your health. Self-stigma and self-blame can be addressed through behavioural interventions, consistent with the principles of cognitive behaviour therapy and acceptance and commitment therapy. (See the “Effective Psychological and Behavioural Interventions for People Living with Obesity” chapter for more information on these therapies.)
  • Try focusing on improving healthy habits and quality of life rather than weight loss. Weight is not a behaviour and should not be a target for behaviour change.

Key Messages for Healthcare Policy Makers

  • Policy makers developing obesity policies should assess and reflect on their own attitudes and beliefs related to obesity.
  • Public health policy makers should avoid using stigmatizing language and images. It is well established that shaming does not change behaviours. In fact, shaming can increase the likelihood of individuals pursuing unhealthy behaviours and has no place in an evidence-based approach to obesity management.
  • Avoid making assumptions in population health policies that healthy behaviours will or should result in weight change. Weight is not a behaviour and should not be a target for behaviour change. Avoid evaluating healthy eating and physical activity policies, programs and campaigns in terms of population level weight or BMI outcomes. Instead, emphasize health and quality of life for people of all sizes. Because weight bias contributes to health and social inequalities, advocate for and support people living with obesity. This includes supporting policy action to prevent weight bias and weight-based discrimination.
  • Policy makers should know that most people living with obesity have experienced weight bias or some form of weight-based discrimination. Public health policy makers should consider weight bias and obesity stigma as added burdens on population health outcomes and develop interventions to address them. To avoid compounding the problem, we encourage policy makers to do no harm, and to develop people-centered policies that move beyond personal responsibility, recognize the complexity of obesity, and promote health, dignity and respect, regardless of body weight or shape.
  • Health care providers should ensure their clinical environment is accessible, safe and respectful to all patients regardless of their weight or size. Make efforts to improve health and quality of life rather than solely focusing on obesity management. Ask permission before weighing someone, and never weigh people in front of others; instead, place weighing scales in private areas. Health care providers should consider how their office’s physical space accommodates people of all sizes and ensure they have properly sized equipment (e.g., blood pressure cuffs, gowns, chairs, beds) ready in clinical rooms prior to patients arriving. Because weight bias impacts morbidity and mortality, advocate for and support people living with obesity. This includes action to create supportive healthcare environments and policies for people of all sizes.
 

Recommendations 

  1. Healthcare providers can recognize and treat obesity as a chronic disease, caused by abnormal or excess body fat accumulation (adiposity), that impairs health, with increased risk of premature morbidity and mortality (Level 2B, Grade B).1–6
  2. The development of evidence-informed strategies at the health system and policy level can be directed at the management of obesity in adults (Level 2B, Grade B).2–6
  3. Continued longitudinal national and regional surveillance of obesity that includes self-reported and measured data (i.e., heights, weights, waist circumference) may be collected on a regular basis (Level 2B, Grade B).2–6

Key Messages for Healthcare Policy Makers and Healthcare Professionals in Canada

  • Obesity is a chronic disease characterized by the presence of excessive and/or dysfunctional adipose tissue that impairs health and wellbeing.
  • Obesity increases the risk of serious chronic illnesses such as heart disease, cancer, stroke, diabetes and nonalcoholic fatty liver disease, among others.
  • Obesity impairs an individual’s health-related quality of life and reduces life expectancy.
  • In Canada, the prevalence of obesity in adults rose dramatically, increasing three-fold since 1985.
  • Obesity, defined as a BMI ≥ 30 kg/m2, affected 26.4% or 8.3 million Canadian adults in 2016.
  • Severe obesity (BMI ≥ 35 kg/m2), the fastest growing obesity subgroup, increased disproportionately over this same period. Since 1985, severe obesity increased 455% and affected an estimated 1.9 million Canadian adults in 2016.
  • Overweight, defined as a BMI between 25 and 29.9 kg/m2, affected an additional 34% of adults in Canada (10.6 million individuals).
  • Over the same 30-year time period, measures of abdominal obesity increased significantly, are more pronounced and are associated with significant increases in health risk.
  • As or more concerning: the increase in childhood obesity mirrors this adult trend.
  • One in three children and/or youths between six to 17 years have overweight or obesity, an increase from one in four in 1978/79.
  • The prevalence of obesity among boys, in particular adolescent boys 12-17 years, is significantly higher than for adolescent girls (16.2% versus 9.3%).
  • The causes of and contributors to obesity are complex and extend well beyond an individual’s choice over calories in and out. Established contributors to obesity include socioeconomic status, sex, ethnicity, access to healthcare, genetics, regional food and built environments.
  • Health professionals should not rely solely on BMI to predict an individual’s health risk but use it in conjunction with other screening and assessment tools.
  • Weight bias, stigma and discrimination are pervasive in the healthcare system and society and result in the unjust treatment of individuals living with obesity.
  • Obesity affects individuals, families and society. The economic burden is significant. In 2014, the global economic impact of obesity was estimated to be US $2.0 trillion or 2.8% of the global gross domestic product (GDP).
  • In Canada, obesity and its related illnesses result in a large cost to society due to increases in direct (i.e., physician, hospital, emergency room use) and indirect costs (i.e., lost productivity, absenteeism, disability), estimated to be $7.1 billion in 2010.
  • Successful management (i.e., prevention, management and treatment) of obesity requires collective effort at the policy, health system, community, and individual level.
  • There is a need for continued and focused investment in research funding to support the scientific understanding of obesity. This includes non-experimental research on the biopsychosocial and environmental causes and contributors, and experimental research to develop and test interventions to prevent, manage and treat obesity. Research on how best to implement evidence-based practice and policy is a priority.

Key Messages for Healthcare Professionals

  • Obesity is a heterogeneous disease that can develop via slow and steady weight gain over an extended period, or from rapid bursts of weight gain.
  • Regular assessments of body weight are needed to catch early weight gain. Use the Edmonton Obesity Staging System to evaluate if the patient has obesity.
  • Clinicians should initiate discussion around weight gain early and contemplate interventions that consider its com­plex causes, providing guidance beyond “eat less and move more.”
  • Many medications are associated with weight gain side effects that can contribute to long-term weight gain.
  • Excess pregnancy weight gain and post pregnancy weight retention are significantly reduced with behavioural interventions. Clinicians should counsel women attending prenatal care not to exceed pregnancy weight gain guide­lines, and also give pregnant women the necessary coun­selling, as well as dietary, physical activity and psychological interventions within prenatal visits.
  • Health benefits of smoking cessation outweigh the cardio­vascular consequences associated with smoking cessation related weight gain.
  • Short-term behavioural interventions (generally six months or less) aimed at preventing weight gain in young adult­hood, menopause, smoking cessation and breast cancer treatment have not yet been shown to be effective.
  • Longer interventions will likely be needed to properly examine strategies for preventing weight gain for many of these high-risk groups and in the general population.

Key Messages for People Living With Obesity

  • Preventing or delaying obesity is likely easier than long-term weight reduction.
  • Causes of and risk factors for weight gain are wide ranging, extending beyond personal lifestyle choices such as food intake and exercise, and include factors that you may or may not be able to control.
  • Obesity can develop with small gains in weight over a long period of time, or from rapid bursts of weight gain.
  • Average weight gain in Canada is 0.5kg – 1.0 kg per year.
  • People are prone to greater weight gain during certain life stag­es, including adolescence, young adulthood and pregnancy.
  • Raise your weight gain concerns with your primary care phy­sician, even if you have experienced modest weight gain.
  • Regular weighing by healthcare providers can help to identify patterns and factors contributing to weight gain early.

Recommendations 

  1. We recommend that health care providers ask patients living with obesity if they have concerns about managing self-care activities such as bathing, getting dressed, bowel and/or bladder management, skin and/or wound care, foot care. (Level 3, Grade C)
  2. We recommend that health care providers assess falls risk in people living with obesity as this could interfere with their ability and interest in participating in physical activity. (Level 3, Grade C)

Key Messages for Healthcare Professionals

  • Asking patients about their performance in daily activities including personal care, mobility and interactions with the built and social environment will provide valuable information about facilitators and barriers to engagement in daily activities, including treatment recommendations. This can help health care practitioners to tailor interventions for obesity treatment and management.
  • Places and spaces where health care service delivery occurs can be made physically accessible, equipped and respectful for use by persons living with obesity so that patients can access the full range of primary care services including assessment and treatment. Consideration of the accessible features surrounding the clinic space including access to parking, public transit, and door widths to accommodate mobility equipment are also needed.
  • Injury prevention, which includes falls risk reduction, is possible via the inclusion of exercises to improve postural control, balance, and lower extremity strength. The Falls Efficacy Scale is a psychometrically sound measure that determines an individual’s concern about their risk of falling while performing activities of daily living that involve walking or moving about.
  • Patients who report significant challenges with participation in activities of daily living may benefit from a referral for occupational therapy and/or physiotherapy.
  • Health care providers should look at the integrity of the patients’ skin and condition of any wounds in order to identify any areas of concern such as; pressure points, skin breakdown or signs of infection.

Key Messages for People Living with Obesity

  • The restricted range of motion, balance and mobility that some individuals living with obesity experience can impact the ability to complete self-care activities such as bathing, getting dressed, bowel and/or bladder management, skin and/or wound care, and foot care. Issues in this area may require adaptation of self-care activities and/or the use of assistive devices such as dressing aids, a long-handled reacher, long-handled sponges, bath benches, grab bars, and mobility aids.
  • Some individuals living with obesity experience issues with mobility and are at risk for slips, trips and/or falls. This could interfere with the ability and interest in participating in physical activity. Be sure to let your healthcare practitioner know if you have had a fall or are fearful of falling as you go about your day to day activities.
  • Obesity is associated with an increased risk of skin issues that can result in redness, blisters, rashes and open wounds that are resistant to healing. Individuals with obesity should routinely monitor the integrity of their skin and condition of any wounds in order to identify any areas of concern such as; pressure points, skin breakdown or signs of infection. Particular attention to be paid to areas in skin folds.
  • Your healthcare practitioners’ offices and clinical care spaces should be physically accessible and equipped so that all patients, including those living with obesity, can access the full range of primary care services including assessment and treatment. Let your healthcare practitioner know if there are barriers that prevent you from fully participating in and accessing care. This includes access to parking or public transit, elevators, stairs, seating, doorways, washroom accessibility, etc. Advocate to have barriers addressed and spaces modified.

Recommendations 

  1. We suggest that healthcare providers involved in screening, assessing and managing people living with obesity use the 5As framework to initiate the discussion by asking for their permission and assessing their readiness to initiate treatment (Level 4, Grade D, Consensus).
  2. Healthcare providers can measure height, weight and calculate Body Mass Index (BMI) in all adults (Level 2a, Grade B), and measure waist circumference in individuals with a BMI 25–35 kg/m2 (Level 2b, Grade B).
  3. We suggest a comprehensive history to identify root causes of weight gain as well as complications of obesity and potential barriers to treatment be included in the assessment (Level 4, Grade D).
  4. We recommend blood pressure measurement 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 (Level 3, Grade D).
  5. We suggest providers consider using the Edmonton Obesity Staging System to determine the severity of obesity and to guide clinical decision making (Level 4, Grade D).

Key Messages for Healthcare Professionals

  • Obesity is a chronic, progressive and relapsing disease, characterized by the presence of abnormal or excess adiposity that impairs health and social well-being.
  • Screening for obesity should be performed regularly by mea­suring body mass index (BMI) and waist circumference.
  • The clinical assessment of obesity should aim to establish the diagnosis and identify the causes and consequences of abnormal or excess adiposity on a patient’s physical, mental and functional health.
  • Providers participating in the assessment of obesity should focus on establishing values and goals of treatment, identi­fying which resources and tools may be needed and foster­ing self-efficacy with the patient in order to achieve long-term success.
  • A non-judgmental, stigma-free environment is necessary for an effective assessment of a patient living with obesity.

Key Messages for People Living with Obesity

  • Obesity is a chronic disease characterized by the accumu­lation of excess body fat that can have a negative impact on your physical and mental health, as well as your overall quality of life.
  • To guide you and your clinician on the best obesity treat­ment options, a clinical evaluation is needed to determine how your weight impacts your health and wellbeing. This may include both a mental health assessment and a physical exam.
  • Weight bias and stigma are common in the setting and can be detrimental to helping you achieve your health goals. Healthcare providers should conduct their obesity assessment in a sensitive and non-judgmental way.

 

Recommendations 

  1. We recommend regular monitoring of weight, glucose and lipid profile in people with a mental health diagnosis who are taking medications associated with weight gain (Level 3, Grade C).
  2. Healthcare providers can consider both efficacy and effects on body weight when choosing psychiatric medications (Level 2a, Grade B).
  3. Metformin and psychological treatment such as cognitive behavioural therapy should be considered for prevention of weight gain in people with severe mental illness who are treated with antipsychotic medications associated with weight gain (Level 1a, Grade A).
  4. Healthcare providers should consider lisdexamfetamine and topiramate as an adjunct to psychological treatment to re­duce eating pathology and weight in people with overweight or obesity and binge-eating disorder (Level 1a, Grade A).

Key Messages for Healthcare Professionals

  • Be aware of the links between mental illness and obesity, and ensure you manage the weight gain side-effects of medications used in the treatment of mental illness.
  • Be aware that mental illness can impact obesity manage­ment efforts, and screen patients for potential mental ill­nesses that need to be addressed.
  • Off-indication use of antipsychotics should be avoided, as significant metabolic adverse effects can occur even when these medications are prescribed at lower doses.
  • For patients with severe mental illness who gain weight on antipsychotic treatments, glucagon-like-1-peptides (GLP-1) have the most safety and efficacy evidence among medica­tions indicated for chronic obesity management in Canada. Cost may be a barrier for individuals trying to access this class of medications.
  • When initiating antipsychotic treatment for the first time, avoid medications with higher metabolic risk, as individuals in their first episode respond well regardless of which medi­cation is prescribed (and are at greatest risk for weight gain).
  • Consider switching strategies to a lower metabolic liability antipsychotic in individuals with severe mental illness who gain weight on an antipsychotic treatment.
  • For patients with severe mental illness who gain weight on antipsychotic treatments, metformin can be used in con­junction with behavioural obesity management interventions.
  • Behavioural obesity management therapy, ideally as part of a multi-modal treatment approach, can be effective in managing weight in individuals with co-occurring mental illness. The intensity of the behavioural intervention will need to increase for individuals with more severe psycho­pathology in the context of obesity.
  • Individuals undergoing bariatric surgery should undergo a pre-surgical mental health screen by a qualified bariatric clinician with experience in mental health to identify early risk factors for poor weight-loss outcomes or mental health deterioration.
  • Following pre-surgical screening, individuals should receive ongoing monitoring by a healthcare provider for psychiat­ric symptoms, eating psychopathology and substance use disorders, and for suicidal ideation or self-harm after bar­iatric surgery. For those individuals continuing psychiatric medications after surgery, monitoring of therapeutic effect is critical to maintaining psychiatric stability.
  • Be aware of the links between mental illness and obesity, and ensure you manage the weight gain side-effects of medications used in the treatment of mental illness.
  • Be aware that mental illness can impact obesity manage­ment efforts, and screen patients for potential mental ill­nesses that need to be addressed.
  • Off-indication use of antipsychotics should be avoided, as significant metabolic adverse effects can occur even when these medications are prescribed at lower doses.
  • For patients with severe mental illness who gain weight on antipsychotic treatments, glucagon-like-1-peptides (GLP-1) have the most safety and efficacy evidence among medica­tions indicated for chronic obesity management in Canada. Cost may be a barrier for individuals trying to access this class of medications.
  • When initiating antipsychotic treatment for the first time, avoid medications with higher metabolic risk, as individuals in their first episode respond well regardless of which medi­cation is prescribed (and are at greatest risk for weight gain).
  • Consider switching strategies to a lower metabolic liability antipsychotic in individuals with severe mental illness who gain weight on an antipsychotic treatment.
  • For patients with severe mental illness who gain weight on antipsychotic treatments, metformin can be used in con­junction with behavioural obesity management interventions.
  • Behavioural obesity management therapy, ideally as part of a multi-modal treatment approach, can be effective in managing weight in individuals with co-occurring mental illness. The intensity of the behavioural intervention will need to increase for individuals with more severe psycho­pathology in the context of obesity.
  • Individuals undergoing bariatric surgery should undergo a pre-surgical mental health screen by a qualified bariatric clinician with experience in mental health to identify early risk factors for poor weight-loss outcomes or mental health deterioration.
  • Following pre-surgical screening, individuals should receive ongoing monitoring by a healthcare provider for psychiat­ric symptoms, eating psychopathology and substance use disorders, and for suicidal ideation or self-harm after bar­iatric surgery. For those individuals continuing psychiatric medications after surgery, monitoring of therapeutic effect is critical to maintaining psychiatric stability.
  • For individuals regaining weight after bariatric surgery, psy­chosocial interventions should be used to address comor­bid psychiatric symptoms interfering with obesity manage­ment, such as depression and eating psychopathology, and to support behavioural change long-term.
  • For individuals with binge eating disorder and obesity or overweight, lisdexamfetamine is indicated to reduce eat­ing pathology. Off-label use of topiramate has also been shown to help.
  • Given the prevalence of mental health issues in individu­als with obesity, screening for mental illness (with a focus on depression, binge eating disorder and attention deficit hyperactivity disorder) is appropriate in all patients seeking obesity treatment.
  • Patients with obesity and a mental health diagnosis should be assessed for comorbidities.
  • Physicians should be aware of the weight gain and car­diometabolic risks associated with off-label antipsychotic use (absence of approval by regulatory bodies).
  • The current approved obesity medications can be helpful in patients with a mental illness and should be used based on clinical appropriateness.
  • In people living with overweight or obesity with Binge Eating Disorder, the following medications are effective to reduce eating pathology and weight: lisdexamfetamine, topiramate, and second-generation antidepressants SSRIs duloxetine and bupropion. These medications are effective in reducing eating pathology, but their effect on weight loss is less certain.
  • Patients with comorbid mental illness should be sup­ported with behavioural therapy, preferably as part of a multi-modal intervention, to manage weight.
  • Referral for more intense (i.e., long-term) and behavioural interventions, such as cognitive behavioural therapy, should be considered for individuals with significant binge eating and depressive symptoms in the context of obesity.
  • Patients seeking bariatric surgery should be screened for mental health comorbidities. The presence of an active psy­chiatric disorder does not exclude patients from bariatric surgery but warrants further assessment of potential im­pact on long-term weight loss.
  • Patients should be monitored for alcohol and substance use changes, as well as self-harm/suicidal ideation, after bariatric surgery. They should be informed about altered alcohol me­tabolism following Roux-en-Y gastric bypass surgery.
  • Post-bariatric surgery patients should be monitored for emergence of early postoperative psychiatric symptoms, self-harm and suicidal ideation and eating pathology (given their impact on weight loss outcomes.
  • Patients should undergo pre-bariatric surgery psychosocial assessment by an experienced bariatric clinician. Assessment should continue following surgery and can include the use of either clinician-administered or patient self-report measures.
  • We recommend psychiatric medication monitoring fol­lowing bariatric surgery due to potential changes in drug absorption and therapeutic effect, especially with malab­sorptive surgical procedures. For psychiatric medications with narrow therapeutic index, use of available protocols to manage perioperative levels is warranted.
  • Post-bariatric surgery behavioural and psychological inter­ventions to support maintenance of weight loss and to pre­vent significant weight regain may be useful.
  • Bariatric surgery teams should focus on strategies to im­prove patient engagement during the post-surgery follow-up period, specifically for high-risk patient groups.

Key Messages for People Living with Obesity

  • There are clear links between mental illness and weight. Please ensure your healthcare provider is aware of the treatments you are taking for your mental health issues.
  • Individuals with co-occurring mental illness should receive behavioural therapy in combination with a multi-modal treatment approach to manage obesity.
  • Early emergence of psychiatric symptoms and eating dif­ficulties after bariatric surgery could negatively influence post-surgical weight loss. Individuals should undergo men­tal health screening before bariatric surgery and have an interprofessional team identify and manage psychiatric symptoms and eating difficulties arising after surgery.
  • Given the potential risk for relapse of psychiatric symptoms, increased risk of substance use problems (such as alcohol) and potential risk of suicide, individuals undergoing bariat­ric surgery should be aware of changes in how alcohol can affect you, psychiatric medication absorption and the impor­tance of mental health monitoring after bariatric surgery.
  • Antipsychotics medications should not routinely be pre­scribed (especially on a long-term basis) for issues like sleep and anxiety.
  • If you are gaining or have gained weight when taking an antipsychotic medication and changes in behaviour have not been sufficient, metformin can be used to help prevent further weight gain and/or reduce weight.
  • Early studies suggest that, among medications approved for long-term obesity management in Canada, liraglutide has the most evidence to support its use to help reduce weight gained from antipsychotic medications.
  • If you have gained weight from an antipsychotic medica­tion, you can ask your physician if there might be another antipsychotic with a lower weight gain risk. This should be a decision made together with your doctor, taking into careful consideration other potential side effects/tolerabili­ty, and risk of mental health worsening.
  • If you have binge eating disorder, two medications (lis­dexamfetamine and topiramate) can be helpful to reduce both binge episodes and weight.

Recommendations 

  1. We suggest nutrition recommendations for adults of all body sizes should be personalized to meet individual values, preferences and treatment goals to support a dietary approach that is safe, effective, nutritionally adequate, culturally acceptable and affordable for long-term adherence. (Level 4, Grade D)
  2. 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 blood lipid targets, including LDL-C, triglycerides, and blood pressure. (Level 1a, Grade A)
  3. Adults living with obesity and impaired glucose tolerance (prediabetes) or type 2 diabetes may receive medical nutrition therapy provided by a registered dietitian to reduce body weight and waist circumference, and improve glycemic control and blood pressure. (Level 2a, Grade B)
  4. Adults living with obesity can consider any of the multiple medical nutrition therapies to improve health-related outcomes, choosing the dietary patterns and/or food-based approaches that support their best long-term adherence:
    • Calorie-restricted dietary patterns emphasizing variable macronutrient distribution ranges (lower, moderate, or higher carbohydrate with variable proportions of protein and fat) to achieve similar body weight reduction over 6-12 months. (Level 2a, Grade B)
    • Mediterranean dietary pattern to improve glycemic control, HDL-cholesterol and triglycerides (Level 2b, Grade C), reduce cardiovascular events (Level 2b, Grade C,), reduce risk of type 2 diabetes; (Level 2b, Grade C); and increase reversion of metabolic syndrome (Level 2b, Grade C) with little effect on body weight and waist circumference. (Level 2b, Grade C)
    • Vegetarian dietary pattern to improve glycemic control, established blood lipid targets, including LDL-C, and reduce body weight, (Level 2a, Grade B), risk of type 2 diabetes (Level 3, Grade C) and coronary heart disease incidence and mortality. (Level 3, Grade C)
    • Portfolio dietary pattern to improve established blood lipid targets, including LDL-C, apo B, and non-HDL-C (Level 1a, Grade B), CRP, blood pressure, and estimated 10-year coronary heart disease risk. (Level 2a, Grade B)
    • Low-glycemic index dietary pattern to reduce body weight (Level 2a, Grade B) glycemic control; (Level 2a, Grade B); established blood lipid targets, including LDL-C (Level 2a, Grade B), and blood pressure (Level 2a, Grade B)  and the risk of type 2 diabetes (Level 3, Grade C) and coronary heart disease. (Level 3, Grade C)
    • Dietary Approaches to Stop Hypertension (DASH) dietary pattern to reduce body weight and waist circumference; (Level 1a, Grade B); improve blood pressure (Level 2a, Grade B), established lipid targets, including LDL-C (Level 2a, Grade B), CRP (Level 2b, Grade B), glycemic control; (Level 2a, Grade B); and reduce the risk of diabetes, cardiovascular disease, coronary heart disease, and stroke. (Level 3, Grade C)
    • Nordic dietary pattern to reduce body weight (Level 2a, Grade B) and body weight regain; (Level 2b, Grade B) improve blood pressure (Level 2b, Grade B) and established blood lipid targets, including LDL-C, apo B, (Level 2a, Grade B), non-HDL-C (Level 2a, Grade B) and reduce the risk of cardiovascular and all-cause mortality. (Level 3, Grade C)
    • Partial meal replacements (replacing one to two meals/day as part of a calorie-restricted intervention) to reduce body weight, waist circumference, blood pressure and improve glycemic control. (Level 1a, Grade B)
    • intermittent or continuous calorie restriction achieved similar short-term body weight reduction. (Level 2a, Grade B)
    • Pulses (i.e. beans, peas, chickpeas, lentils) to improve body weight; (Level 2, Grade B)  improve glycemic control, (Level 2, Grade B), established lipid targets, including LDL-C, (Level 2, Grade B), systolic BP (Level 2, Grade C), and reduce the risk of coronary heart disease (Level 3, Grade C).
    • Vegetables and fruit to improve diastolic BP (Level 2, Grade B), glycemic control (Level 2, Grade B) and reduce the risk of type 2 diabetes (Level 3, Grade C) and cardiovascular mortality. (Level 3, Grade C)
    • Nuts to improve glycemic control, (Level 2, Grade B) established lipid targets, including LDL-C (Level 3, Grade C), and reduce the risk of cardiovascular disease. (Level 3, Grade C)
    • Whole grains (especially from oats and barley) to improve established lipid targets, including total cholesterol and LDL-C. (Level 2, Grade B)
    • Dairy foods to reduce body weight, waist circumference, body fat and increase lean mass in calorie-restricted diets but not in unrestricted diets (Level 3, Grade C) and reduce the risk of type 2 diabetes and cardiovascular disease. (Level 3, Grade C)

5. Adults living with obesity and impaired glucose tolerance (prediabetes) should consider intensive lifestyle interventions that target a 5% to 7% weight loss to improve glycemic control, blood pressure and blood lipids; (Level 1a, Grade A,)  reduce the incidence of type 2 diabetes, (Level 1a, Grade A,) microvascular complications (retinopathy, nephropathy, and neuropathy) (Level 1a, Grade B), cardiovascular mortality, and all-cause mortality (Level 1a, Grade B).

6. Adults living with obesity and type 2 diabetes should consider intensive lifestyle interventions that target a 7% to 15% weight loss to increase the remission of type 2 diabetes (Level 1a, Grade A) and reduce the incidence of nephropathy, (Level 1a, Grade A) obstructive sleep apnea (Level 1a, Grade A),  and depression (Level 1a, Grade A).

7. We recommend a non-dieting approach to improve quality of life and psychological outcomes (general well-being, body image perceptions), with mixed results for cardiovascular outcomes (blood lipids, blood pressure), body weight, physical activity, cognitive restraint and eating behaviours. (Level 3, Grade C)

Key Messages for Healthcare Professionals

  • Healthy eating is important for all Canadians, regardless of body size, weight or health condition. Key messages from Canada’s Food Guide for Healthy Eating can be used as a foundation for nutrition and food-related education (Figure 1). Use evidence-based nutrition resources to give your patients nutrition and behaviour change advice that aligns with their values, preferences and social determinants of health. (Figure 1)
  • There is no one-size-fits-all eating pattern for obesity management. Adults living with obesity may consider various nutrition intervention options that are client-centred and flexible. Evidence suggests this approach will better facilitate long-term adherence. (Table 1, Figure 2)
  • Nutrition interventions for obesity management should focus on achieving health outcomes for chronic disease risk reduction and quality of life improvements, not just weight changes. Table 2 outlines health-related outcomes to support patients/clients in obesity management.
  • Nutrition interventions for obesity management should emphasize individualized eating patterns, food quality and a healthy relationship with food. Including mindfulness-based eating practices that may help lower food cravings, reduce reward-driven eating, improve body satisfaction and improve awareness of hunger and satiety. 6–11
  • Caloric restriction can achieve short-term reductions in weight (i.e.< 12 months) but has not shown to be sustainable long-term (i.e. > 12 months). Caloric restriction may affect neurobiological pathways that control appetite, hunger, cravings and body weight regulation that may result in increased food intake and weight gain.64-66
  • People living with obesity are at increased risk for micronutrient deficiencies including but not limited to vitamin D, vitamin B12 and iron deficiencies. Restrictive eating patterns and obesity treatments (e.g. medications, bariatric surgery) may also result in micronutrient deficiencies and malnutrition. Assessment including biochemical values can help inform recommendations for food intake, vitamin/mineral supplements, and possible drug-nutrient interactions.
  • Collaborate care with a registered dietitian who has experience in obesity management and medical nutrition therapy. 12 Dietitians can support people living with obesity who also have other chronic diseases, malnutrition, food insecurity or disordered patterns of eating.
  • Future research should use nutrition-related outcomes and health behaviours in addition to weight and body composition outcomes. Characterization of population sample collections should use the updated definition of obesity as a chronic, progressive and relapsing disease characterized by the presence of adiposity that impairs health and social well-being rather than BMI exclusively. Qualitative data is needed to understand the lived experience of people with obesity.

Key Messages for People Living With Obesity

  • Nutrition is important for everyone, regardless of body size or health. Your health is not a number on a scale. When you are ready to make a change, choose behaviour-related goals to improve your nutrition status and health (medical, functional, emotional health) (Table 2).
  • There is no one-size-fits-all healthy eating pattern. Choose an eating pattern that supports your best health and can be maintained over time rather than a short-term diet. Talk to your health care provider to discuss the advantages and disadvantages of different eating patterns to help achieve your health-related goals.
  • How you eat is as important as what and how much you eat. Practice eating mindfully and promote a healthy relationship with food.
  • “Dieting” or severely restricting the amount you eat may cause changes to your body that can lead to weight regain over time.
  • See a registered dietitian for an individualized approach and on-going support for your nutrition and health-related needs.

Recommendations 

  1. Aerobic physical activity (30–60 minutes of moderate to vigorous intensity most days of the week) can be considered for adults who want to:
    1. Achieve small amounts of body weight and fat loss (Level 2a, Grade B);
    2. Achieve reductions in abdominal visceral fat (Level 1a, Grade A)2–4 and ectopic fat such as liver and heart fat (Level 1a, Grade A), even in the absence of weight loss;
    3. Favour weight maintenance after weight loss (Level 2a, Grade B);
    4. Favour the maintenance of fat-free mass during weight loss; (Level 2a, Grade B); and,
    5. Increase cardiorespiratory fitness (Level 2a, Grade B) and mobility (Level 2a, Grade B).
  2. For adults living with overweight or obesity, resistance training may promote weight maintenance or modest increases in muscle mass or fat-free mass and mobility (Level 2a, Grade B).
  3. Increasing exercise intensity, including high-intensity interval training, can achieve greater increases in cardiorespiratory fitness and reduce the amount of time required to achieve similar benefits as from moderate-intensity aerobic activity (Level 2a, Grade B).
  4. Regular physical activity, with and without weight loss, can improve many cardiometabolic risk factors in adults who have overweight or obesity, including:
    1. Hyperglycemia and insulin sensitivity (Level 2b, Grade B)
    2. High blood pressure (Level 1a, Grade B);
    3. Dyslipidemia (Level 2a, Grade B)
  5. Regular physical activity can improve health-related quality of life, mood disorders (i.e., depression, anxiety) and body im­age in adults with overweight or obesity (Level 2b, Grade B).

Key Messages for People Living with Obesity

  • Weight loss should not be the sole outcome by which the success of physical activity therapy is judged.
  • Increasing physical activity can be an integral component of all obesity management strategies.
 

Recommendations

  1. Multicomponent psychological interventions (combining behaviour modification [goal setting, self-monitoring, problem solving], cognitive therapy [reframing] and values-based strategies to alter nutrition 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 (Level 1B, Grade A).
  2. Healthcare providers should provide longitudinal care with consistent messaging to people living with obesity to support the development of confidence in overcoming barriers (self-efficacy) and intrinsic motivation (personal, meaningful reasons to change), to encourage the patient to set and sequence health goals that are realistic and achievable (Level 1A, Grade A,), to self-monitor behaviour (Level 1A, Grade A)  and to analyze setbacks using problem-solving and adaptive thinking (cognitive reframing), including clarifying and reflecting on values-based behaviours (Level 1A, Grade A).
  3. Healthcare providers should ask patients’ permission to educate them that success in obesity management is related to improved health, function and quality of life resulting from achievable behavioural goals, and not on the amount of weight loss. (Level 1A, Grade A).
  4. Healthcare providers should provide follow-up sessions consistent with repetition and relevance to support the development of self-efficacy and intrinsic motivation. Once an agreement to pursue a behavioural path has been established (health behaviour and/or medication and/or surgical pathways) follow-up sessions should repeat the above messages in a fashion consistent with repetition (the provider role) and relevance (the patient role) to support the development of self-efficacy and intrinsic motivation (Level 1A, Grade A).
Key Messages for Healthcare Professionals
 
  • All obesity management interventions involve behaviour on the part of the individual living with obesity (e.g., eating, activity, medication adherence), so behavioural change supports should be incorporated into all obesity management plans. This requires a shift in the patient-provider relationship from the provider as the expert (teach and tell) to that of the collaborator, sensitive to the psychology of the person.
  • Obesity management interventions should be evaluated based on how sustainable the behavioural components of the intervention are for the individual. Obesity management plans that are sustainable for the individual should be prioritized over clinician- or program-led management plans.
  • Individuals living with obesity should be encouraged to build self-esteem and self-efficacy (confidence to overcome barriers to the desired behaviour), based on results that are achievable from behavioural efforts and not on idealized ideas of body weight and
  • Nutrition, medical adherence and physical activities are outcomes of psychological and behavioural interventions and not interventions in themselves. Behaviour change strategies underlying dietary, medical and activity programs should be identified (i.e., what are the change strategies by which sustainable changes to eating, medical adherence and activity are achieved?)

Key Messages for Healthcare Professionals Working in a Solo Practice

  • Adopt a collaborative relationship with the patient, using the principles of motivational interviewing, to encourage the patient to choose and commit to evidence-based, sustainable behaviours associated with obesity management.
  • Consider the use of a minimal intervention tool, such as Obesity Canada’s 5As of Obesity ManagementTM (Ask, Assess, Advise, Agree, Assist).
  • Healthcare providers should ask permission to educate the patient about obesity management success being related more to improved health, function and quality of life resulting from achievable behavioural and psychological goals, and not just on the amount of weight loss.
  • Education should be focused around biology, bias and behaviour. Ask permission to discuss evidence regarding biological and environmental factors, including genetics (family history, the instinctual drive for food), neuroendocrine functions that promote weight regain following weight loss, and physical and social environments (i.e. built environment, food availability/security, sociocultural factors).
  • Consider using the concept of “best weight” (i.e., the weight that a person can achieve and maintain while living their healthiest and happiest life). This education should be offered as a means of reducing self-bias and supporting appropriate outcome goals that acknowledge that weight is not a behaviour. This encourages body acceptance.
  • Educate the patient that success is related to setting achievable, sustainable goals to which they can adhere, while developing confidence to overcome barriers and fostering an intrinsic motivation to maintain the plan. Goals should positively impact health, function and quality of life.
  • Encourage the patient to:
    • Set, and sequence goals that are realistic and achievable.
    • Self-monitor behaviour.
    • Analyze setbacks using problem solving and cognitive reframing, including clarifying and reflecting on values-based behaviours. See Figure 1 for an illustration of how to support the patient in their obesity management journey.
    • For providers who function within teams (including obesity specialty programs), at least one member of the team should develop competency in behavioural interventions, including self-monitoring, goal setting and action planning, reinforcement management, social comparison, cognitive restructuring, motivational interviewing and values-based counselling. Psychological and behavioural interventions should focus on the impact of the intervention on adherence, self-efficacy and autonomous motivation.

Key Messages for People Living with Obesity

  • The main goal of psychological and behavioural interventions is to help people living with obesity make changes that are sustainable, that promote positive self-esteem and confidence, and that improve health, function and quality of life.
  • There is not one pathway to success. Goals should be individualized and be important to the individual and not just the clinician or program.
  • There are many psychological and behavioural strategies that can be helpful. Individuals living with obesity should seek out a clinician with expertise in behaviour change to help identify relevant strategies.
  • Given that healthier weights involve overcoming many challenges (cravings, habits, availability, social pressures) sustained behaviour change is more successful if the behaviours chosen by the individual are consistent with his/her core values.
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Recommendations

  1. Pharmacotherapy for obesity management can be used for individuals with BMI ≥ 30 kg/m2 or BMI ≥ 27 kg/m2 with adiposity-related complications, in conjunction with medi­cal nutrition therapy, physical activity and/or psychological interventions (semaglutide 2.4 mg weekly [Level 1a Grade A],1 liraglutide 3.0 mg daily [Level 2a, grade B],2-4 naltrexone/ bupropion 16 mg/180 mg BID [Level 2a, Grade B],5 orlistat 120 mg TID [Level 2a, Grade B]).6
  2. Pharmacotherapy may be used to maintain weight loss and to prevent weight regain (liraglutide 3.0 mg daily [Level 2a, Grade B],4 orlistat 120 mg TID [Level 2a, Grade B]).7
  3. Pharmacotherapy for obesity management in conjunction with health-behaviour changes for people living with predi­abetes and overweight or obesity (BMI ≥ 27 kg/m2) can be used to delay or prevent type 2 diabetes (T2DM) (liraglutide 3.0 mg daily [Level 2a, Grade B],3 orlistat 120 mg TID [Level 2a, Grade B]).8
  4. Obesity pharmacotherapy can be used in conjunction with health-behaviour changes in people living with T2DM and a BMI ≥ 27 kg/m2, for weight loss and improvement in gly­cemic control (semaglutide 2.4 mg weekly [Level 1a, Grade A],9 liraglutide 3.0 mg daily [Level 1b, Grade A],10 naltrex­one/bupropion 16 mg/180 mg BID [Level 2a, Grade B],11 or­listat 120 mg TID [Level 2a, Grade B]).12
  5. Pharmacotherapy can be considered in conjunction with health-behaviour changes in treating people with obstruc­tive sleep apnea and BMI ≥ 30 kg/m2, for weight loss and associated improvement in apnea-hypopnea index (liraglu­tide 3.0 mg daily [Level 2a, Grade B]).13
  6. Pharmacotherapy can be considered in conjunction with health-behaviour changes in treating people living with non-alcoholic steatohepatitis (NASH) and overweight or obesity, for weight loss and improvement of NASH param­eters (liraglutide 1.8 mg daily [Level 3; Grade C],14 semaglu­tide [Level 4 Grade D]).15
  7. Metformin and psychological treatment (such as cognitive behavioural therapy) should be considered for prevention of weight gain in people with severe mental illness who are treated with anti-psychotic medications associated with weight gain [Level 1a, Grade A].16*

* Please see Taylor VH, Sockalingam S, Hawa R, Hahn M. Canadian Adult Obesity Clinical Practice Guidelines: The Role of Mental Health in Obesity Management. 

  1. For people living with overweight or obesity who require pharmacotherapy for other health conditions, we suggest choosing medications that are not associated with weight gain [Level 4, Grade D, Consensus].
  2. We do not suggest the use of prescription or over-the-counter medications other than those approved in Canada for obesity management [Level 4, Grade D, Consensus].

Key Messages for Healthcare Professionals

  • Pharmacological treatments are an effective and scalable approach to treating obesity. As with any chronic disease, such as type 2 diabetes (T2DM) or hypertension, pharmacotherapy is an important pillar in the management of obesity.
  • The focus of obesity management should be the improvement of health parameters (metabolic, mechanical, mental, and/or quality of life [QoL]), not solely weight reduction, and should include outcomes that the patient identifies as important. Obesity is defined by body mass index (BMI) in clinical trials, which itself does not adequately reflect the burden of adiposity-related disease.
  • There are four medications indicated for long-term obesity management in Canada as adjuncts to health-behaviour changes: liraglutide (Saxenda®), naltrexone/bupropion (Contrave®) in a combination tablet, orlistat (Xenical®) and semaglutide (Wegovy®). All four medications are effective in producing clinically significant weight loss and health benefits greater than placebo over a duration of at least one year.
  • The individual response to pharmacotherapy for obesity management is heterogeneous. Efficacy (both for weight and management of obesity-related health issues), mechanism of action, safety, potential side effects/tolerability, contraindications, medication interactions, mode of administration and cost are important considerations in choosing the most appropriate obesity pharmacotherapy.
  • Obesity medications are intended as part of a long-term treatment strategy. Clinical trials of pharmacotherapy for obesity management consistently demonstrate regain of weight when treatment is stopped.
  • Medications that are not approved as pharmacotherapy for obesity management should not be used for this purpose.

Key Messages for People Living with Obesity

  • Obesity medications are effective for managing weight and weight-related health issues, often in combination with healthy behaviour changes and/or psychological interventions.
  • The goals in obesity management should include improve­ment in health and should include outcomes that are important to you.
  • There are four medications approved by Health Canada for long-term obesity management in Canada: liraglutide 3.0 mg (Saxenda®), naltrexone/bupropion in a combina­tion tablet (Contrave®), orlistat (Xenical®) and semaglutide 2.4 mg (Wegovy®). These medications can help you to achieve and maintain improvements in weight and health complications associated with excess weight. These medications have been proven to be safe and effective for obesity management.
  • Medications that are not approved for obesity treatment may not be safe or effective for obesity management and should be avoided.

Recommendations

  • We suggest a comprehensive medical and nutritional evaluation be completed and nutrient deficiencies corrected in candidates for bariatric surgery (Level 4, Grade D).
  • Preoperative smoking cessation can minimize postoperative complications (Level 2a, Grade B).
  • We suggest screening for and treatment of obstructive sleep apnea in people seeking bariatric surgery (Level 4, Grade D).

Key Messages for Healthcare Providers

  • Criteria for selection of appropriate candidates for bar­iatric surgery have been established to minimize surgical complications and to maximize the benefit of these important and limited procedures.
  • The preoperative workup should evaluate a patient’s medical, nutritional, mental and functional health status.
  • Special attention should be given to the care of patients living with type 2 diabetes (T2DM) who are considering bariatric surgery to minimize complications from uncon­trolled diabetes in the perioperative period.
  • Because of the risks of postoperative complications associated with tobacco use, cessation prior to bariatric surgery is mandatory and should be maintained lifelong.
  • In patients living with severe obesity, bariatric surgery, in combination with behavioral interventions, is a more effective option for long-term weight loss and control of chronic conditions, such as T2DM, hypertension, sleep apnea and dyslipidemia, as well as other conditions associated with increased adiposity.

Key Messages for People Living with Obesity

  • Bariatric surgery is the beginning of a life-long journey. You should educate yourself about the necessary changes required to optimize your long-term outcomes for a healthier life.
  • Before surgery you will be asked to perform several investi­gations such as blood work, cardiac or pulmonary testing, to ensure that you are ready and safe for surgery.
  • If you are at high risk for obstructive sleep apnea, you may be asked to undergo a sleep study to determine if you have significant sleep apnea.
  • A current or recent history of smoking or nicotine con­sumption puts you at risk of complications after bariatric surgery. Smoking is cessation is required before surgery, and must be maintained for life.
  • You may be given a low-calorie diet two to three weeks before surgery in order to shrink your liver size and make your surgery easier.
  • If you are living with diabetes, you will have to follow your blood sugars very closely and obtain instructions on how to adjust your diabetes medications while on the low-calorie diet prior to bariatric surgery.
  • Because changes in the absorption of some medications may occur with certain bariatric surgical procedures, you may be asked to change either the type or preparation of the medication you are currently taking.

Recommendations

  1. Bariatric surgery can be considered for people with BMI ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 with at least one adiposity-related disease to (Level 4, Grade D, Consensus) to:
    1. Reduce long-term overall mortality (Level 2b, Grade B);
    2. Induce significantly better long-term weight loss com­pared to medical management alone (Level 1a, Grade A);
    3. Induce control and remission of type 2 diabetes, in com­bination with best medical management, over best med­ical management alone (Level 2a, Grade B);
    4. Significantly improve quality of life (Level 3, Grade C);
    5. Induce long-term remission of most obesity-related diseases, including dyslipidemia (Level 3, Grade C),7 hypertension (Level 3, Grade C), liver steatosis and nonalcoholic ste­atohepatitis (Level 3, Grade C).
  2. Bariatric surgery should be considered in patients with poorly controlled type 2 diabetes and Class I obesity (BMI between 30 and 35 kg/m2) (Level 1a; Grade A) despite optimal medical management.
  3. Bariatric surgery may be considered for weight loss and/or to control adiposity-related diseases in persons with Class 1 obesity, in whom optimal medical and behavioural management have been insufficient to produce significant weight loss (Level 2a, Grade B).
  4. We suggest the choice of bariatric procedure (sleeve gas­trectomy, gastric bypass or duodenal switch) be decided according to the patient’s need, in collaboration with an expe­rienced interprofessional team (Level 4, Grade D, Consensus).
  5. We suggest that adjustable gastric banding not be offered due to unacceptable complications and long-term failure (Level 4, Grade D).
  6. We suggest that single-anastomosis gastric bypass not be rou­tinely offered, due to long-term complications in comparison with standard Roux-en-Y gastric bypass (Level 4, Grade D).

Key Messages for Healthcare Professionals

  • Bariatric surgery should be considered for patients with severe obesity (body mass index (BMI) ≥ 35 kg/m2) and obesity-related diseases, or BMI ≥ 40 kg/m2 without obesity-related diseases.
  • Bariatric surgery could be considered for patients with obesity (BMI ≥ 30 kg/m2) with severe obesity-related diseases not responding to medical management.
  • The choice of bariatric procedure should be tailored to pa­tients’ needs, in collaboration with a multidisciplinary team and based on the discussion of risks, benefits and side-effects.
  • Several procedures are currently performed in Canada (ad­justable gastric banding, sleeve gastrectomy, gastric bypass, duodenal switch and others) but variations exist.
  • For patients with severe obesity, surgery offers superior out­comes compared to best medical management, in terms of quality of life, long-term weight loss and resolution of obesity-related diseases, especially type 2 diabetes, sleep apnea, fatty liver disease and hypertension.
  • Laparoscopic approach should be standard and is associated, for most patients, with a low mortality rate (< 0.1%) and low serious complication rate (< 5%).
  • Bariatric surgery improves life expectancy.
  • Novel surgical and endoscopic approaches are being used and developed and can represent an option for specific patients.

Key Messages for People Living with Obesity

  • If you are suffering from severe obesity, you should enquire about bariatric surgery. In your situation, behavioural inter­ventions and medical therapies are important but usually not effective enough to obtain significant long-term weight loss and remission of obesity-related diseases.
  • Bariatric surgery in combination with modifications to health behaviours can result in significant long-term weight loss (20% to 40% of your body weight) and control, or, in some cases, complete remission, of obesity-related diseases, including type 2 diabetes, sleep apnea, fatty liver disease and hypertension.
  • Different surgical options exist (e.g., sleeve gastrectomy, gastric bypass and duodenal switch), with different levels of effectiveness. You should have an extensive discussion with the surgical team before deciding which surgical option seems to be the best for you.
  • All surgeries have some adverse effects and potential risks, and require lifelong management to follow-up, mineral and vitamin supplementations, and behavioural changes.

Recommendations

  1. Healthcare providers can encourage people who have un­dergone bariatric surgery to participate and maximize their access to behavioural interventions and allied health services at a bariatric surgical centre (Level 2a, Grade B).
  2. We suggest that bariatric surgical centres communicate a comprehensive care plan to primary care providers on pa­tients who are discharged, including: bariatric procedure, emergency contact numbers, annual blood tests required, long-term vitamin and mineral supplements, medications, behavioural interventions and when to refer back (Level 4, Grade D, consensus).
  3. We suggest that after a patient has been discharged from the bariatric surgical centre, primary care providers should annually review: nutritional intake, activity, compliance with multivitamin and mineral supplements, and weight, as well as assess comorbidities, order laboratory tests to assess for nutritional deficiencies and investigate abnormal results and treat as required (Level 4, Grade D, consensus).
  4. We suggest that primary care providers consider referral back to the bariatric surgical centre or to a local specialist for technical or gastrointestinal symptoms, nutritional issues, pregnancy, psychological support, weight regain or other medical issues as described in this chapter related to bariatric surgery (Level 4, Grade D, consensus).
  5. We suggest that bariatric surgical centres provide follow-up and appropriate laboratory tests at regular intervals post-sur­gery with access to appropriate healthcare professionals (dietitian, nurse, social worker, surgeon, bariatric physician, psychologist/psychiatrist) until discharge is deemed appro­priate for the patient (Level 4, Grade D, consensus).

Key Messages for Healthcare Professionals

  • Adherence to consistent post-operative behavioural changes (behaviour modification for nutrition plans, physical activity and vitamin intake) can optimize obesity management and health while minimizing post-operative complications.
  • Working in partnership, the bariatric surgical centre, the local bariatric medicine specialist, the primary care provider and the patient living with obesity need to establish and commit to a shared care model of chronic disease manage­ment for long-term follow-up.
  • The primary care provider should refer patients with post-bariatric surgery complications back to the bariatric surgical centre, or to a local bariatric medicine specialist.

Key Messages for People Living with Obesity Who Have Had Bariatric Surgery

  1. If you have had bariatric surgery, it is important for you to take your nutritional supplements lifelong and to continue to follow the post-bariatric surgical nutrition plan, exercise and any other recommendations given by your original specialist team. By doing this, you will increase your chances of staying healthy and reduce complications that can arise from bariatric surgery.
  2. Attend all scheduled appointments and programming offered by your bariatric surgical site. Once you are dis­charged from the bariatric surgical site, schedule annual appointments with your primary care provider to check your blood work, reassess your medications and address any issues related to changes in your weight.
  3. After bariatric surgery, it is possible that there can be a negative impact on mood, relationships, body image, de­velopment of addictions and reduced ability to cope with stress. If you are struggling, discuss this with your original specialist team or, if you have been discharged, with your primary care provider.
  4. Remember that your lowest weight post-surgery will occur between 12 to 18 months. After this, there is a natural increase in weight that occurs. If you are gaining excessive amounts of weight, discuss this with your bariatric team or primary care provider.
  5. If you are 12 to 18 months post-bariatric surgery and are planning a pregnancy, discuss this with your bariatric team, primary care provider and obstetrician.

Recommendations

For clinicians:

  1. We recommend primary care clinicians identify people with overweight and obesity, and initiate patient-centred, health focused conversations with them (Level 3, Grade C).
  2. We recommend healthcare providers ensure they ask people for their permission prior to discussing weight or taking anthropometric measurements (Level 3, Grade C).
  3. Primary care interventions should be used to increase health literacy in individuals’ knowledge and skill about weight management as an effective intervention to manage weight (Level 1a, Grade A).
  4. Primary care clinicians should refer persons with overweight or obesity to primary care multicomponent programs with personalized obesity management strategies as an effective way to support obesity management (Level 1b, Grade B).
  5. Primary care clinicians can use collaborative deliberation with motivational interviewing to tailor action plans to individuals’ life context in a way that is manageable and sustainable to support improved physical and emotional health, and weight management (Level 2b, Grade C).

Features of primary care and primary healthcare community-based interventions for clinicians and developers:

  1. Interventions that target a specific ethnic group should consider the diversity of psychological and social practices with regards to excess weight, food, physical activity as well as socio-economic circumstances, as they may differ across and within different ethnic groups (Level 1B, Grade B).
  2. Longitudinal primary care interventions should focus on incremental, personalized, small behaviour changes (the “small change approach”) to be effective in supporting people to manage their weight (Level 1B, Grade B).
  3. Primary care multicomponent programs should consider personalized obesity management strategies as an effective way to support people living with obesity (Level 1B, Grade B).
  4. Primary care interventions that are behaviour-based (nutrition, exercise, lifestyle), alone or in combination with pharmacotherapy, should be utilized to manage overweight and obesity (Level 1a, Grade A).
  5. Group-based nutrition and physical activity sessions informed by the Diabetes Prevention Program (DPP) and the Look AHEAD (Action for Health in Diabetes) program should be used as an effective management option for adults with overweight and obesity (Level 1b, Grade A).
  6. Interventions that use technology to increase reach to larger numbers of people asynchronously should be a potentially viable lower-cost intervention in a community-based setting (Level 1b, Grade B).

Educational recommendations to support development of obesity management skills in primary healthcare clinical workforce:

  1. Educators of undergraduate, graduate and continuing education programs for primary healthcare professionals should provide courses and clinical experiences to address the gaps in skills, knowledge of the evidence and attitudes necessary to confidently and effectively support people living with obesity (Level 1a, Grade A).

Key Messages for Primary Care Providers

  • Primary care clinicians should initiate patient-centred conversations with their patients about overweight or obesity. The 5As of Obesity ManagementTM (Ask-Assess-Advise-Agree-Assist) approach, starting with asking permission to discuss weight, is an appropriate format to use.
  • Primary care clinicians should promote a holistic approach to weight and health focusing on health behaviours and addressing root causes of weight gain, with care to avoid stigmatizing and using overly simplistic narratives like “eat less and move more.”
  • Prescribing clinicians must be aware of obesogenic medications and consider alternatives for people living with overweight and obesity. When obesogenic medications must be used, physicians should discuss the risks with patients and institute monitoring for weight gain.
  • Providers and patients need to be aware of the risks of weight cycling and adopt strategies that focus on sustained changes to maintain healthy habits over time.

Key Messages for People Living with Obesity

  • Prevention of weight gain is crucial and realistic; weight loss is potentially very difficult depending on an individual’s weight drivers. Setting a value-based functional goal shifts the focus from weight to health and quality of life and may help with sustainable changes.
  • Individualized nutrition counselling can result in modest reductions of weight and waist circumference.
  • Mindfulness, acceptance and commitment therapies, added to multicomponent behavioural interventions, may be considered in developing a personal weight management strategy.
  • Many medical issues such as disrupted sleep, pain, mechanical problems, metabolic conditions and psychiatric conditions can contribute to challenges with weight management. People should seek medical help if they are struggling with weight maintenance or gain.
  • When prescribed a new medication to treat a medical condition, particularly if the medication is intended for long-term use, patients living with obesity should inquire about the potential associated weight effects.

Recommendations

  1. For adults living with overweight or obesity, the following commercial programs should achieve mild to moderate weight loss over the short or medium-term, compared to usual care or education:
    1. WW® (Weight Watchers): (Level 1A, Grade A)
    2. Optifast®: (Level 1B, Grade B)
    3. Jenny Craig® (Level 1B, Grade B)
    4. Nutrisystem Inc. (Level 1B, Grade B)
  2. Optifast®, Jenny Craig®, WW® (formerly Weight Watchers) and Nutrisystem Inc. should achieve a mild reduction of gly­cated hemoglobin values over a short-term period compared to usual counselling in adults with obesity and type 2 diabetes (Level 1B, Grade B).
  3. We do not recommend the use of over-the-counter com­mercial weight loss products for obesity management, owing to lack of evidence (Level 4, Grade D).
  4. We do not suggest that commercial weight-loss programs be used for improvement in blood pressure and lipid control in adults living with obesity (Level 4, Grade D).

Key Messages for Healthcare Professionals

  • The commercial weight loss industry is enormous. Clini­cians should familiarize themselves with the commercial obesity management offerings in their vicinity. Criteria have been published to evaluate whether a commercial program is safe and potentially successful (i.e., offering a combination of nutrition, physical activity and behaviour change support; with realistic weight loss goals of 0.5–1.0 kg per week, a long-term weight maintenance approach; a good safety profile and reasonable costs).
  • None of the weight loss products from the commercial industry that were studied in randomized control trials of more than 12 weeks duration were shown to produce clin­ically meaningful weight loss.
  • Some commercial programs that combine nutrition, physical activity and support (Jenny Craig®, Nutrisystem®, Optifast®, WW® (formerly Weight Watchers) can be used to induce modest weight loss. Some programs have also shown im­provement in glycemic control in patients with obesity and diabetes but no effect on lipids or blood pressure have been demonstrated.

Key Messages for People Living with Obesity

  • The commercial weight loss industry is flourishing and is often characterized by unrealistic advertising. Before ad­hering to a commercial program or using a commercial weight loss product, people with obesity should ensure that the approach is safe and potentially effective (a combi­nation of nutrition, physical activity and behaviour change support, realistic weight loss goals of 0.5–1.0 kg per week, a long-term weight maintenance approach; a good safety profile and reasonable costs).
  • People living with obesity should be leery of weight loss programs that: i) promise weight loss with­out diet or exercise; ii) promise weight loss while eating as much food as you want; iii) Promise reduction of weight from particular locations on the body; iv) promise overly rapid loss (for example: losing 30 pounds in 30 days); or v) Include before and after photos and personal endorsements that seem too good to be true).
  • Many natural weight loss products are available without a prescription but none of these have been proven to provide clinically meaningful weight loss in high-quality scientific studies.
  • Some commercial programs (WW® [formerly Weight Watchers], Optifast®, Jenny Craig®, Nutrisystem Inc.) have been shown to be effective to produce modest weight loss. These are not successful in all people but are generally con­sidered safe.

Recommendations

  1. Implementation of management strategies can be delivered through web-based platforms (e.g., online education on medical nutrition therapy and physical activity) or mobile devices (e.g., daily weight reporting through a smartphone phone application) in the management of obesity (Level 2a, Grade B).
  2. We suggest that healthcare providers incorporate individu­alized feedback and follow-up (e.g., personalized coaching or feedback via phone or email) into technology-based man­agement strategies to improve weight loss outcomes (Level 4, Grade D).
  3. The use of wearable activity tracking technology should be used as part of a comprehensive strategy for weight loss (Level 1a, Grade A).

Key Messages for Healthcare Professionals

  • The management of obesity through technological means has shown benefits in recent years. These include treatment and follow-up strategies delivered through portable devices (e.g., mobile phones), web-based platforms (e.g., websites) and wearable tracking devices (e.g., pedometers).
  • Technology-based interventions provide cost-effective, time-efficient and flexible options for the management of patients with obesity, either on their own or as an adjunct to conventional (face-to-face) care.
  • The weight-loss benefits of technology-based interventions in the management of obesity have repeatedly been proven in the literature. However, there is insufficient data comparing these interventions to conventional (face-to-face) management. This prohibits us from forming firm conclusions about their comparative benefits in the management of patients living with obesity.

Key Messages for People Living with Obesity

  • Technology-based strategies can help you manage your health, both when used alone or when combined with con­ventional (face-to-face) obesity management approaches.
  • There are multiple options for incorporating technology into your obesity management program, including through your portable device (e.g., mobile phone), a web-based platform (e.g., website) and/or a wearable tracking device (e.g., pedometer).
  • In many cases, you may find technology-based strategies more convenient and time-efficient than face-to-face en­counters with your health care provider. We suggest you discuss with your healthcare provider which options might work best for you.

Recommendations

These recommendations pertain to the management of weight over the reproductive years for adult women with obesity (i.e., body mass index [BMI] ≥30 kg/m2) with a singleton pregnancy, who are ≥ 18 years of age and do not have pre-existing diabetes or gestational diabetes.

  1. General advice: We recommend primary care providers should discuss weight management targets specific to the reproductive years with adult women with obesity: precon­ception weight loss (Level 3, Grade C), gestational weight gain of 5 kg–9 kg over the entire pregnancy (Level 4, Grade D); postpartum weight loss of – at minimum – gestational weight gain (Level 3, Grade C) to reduce the risk of adverse outcomes in the current or in a future pregnancy.
  2. Combined behaviour change interventions: Primary care providers should offer behaviour change interventions, including both nutrition and physical activity, to adult women with obesity who are considering a pregnancy (Level 3, Grade C), who are pregnant (Level 2a, Grade B) and who are postpartum (Level 1a, Grade A) in order to achieve weight targets.
  3. Nutrition counselling alone: We recommend primary care providers encourage and support pregnant women with obesity to consume foods consistent with a healthy dietary pattern in order to meet their target gestational weight gain (Level 3, Grade C).
  4. Physical activity counselling alone: We recommend pri­mary care providers encourage and support pregnant women with obesity who do not have contraindications to exercise during pregnancy to engage in at least 150 minutes per week of moderate intensity physical activity to assist in the manage­ment of gestational weight gain (Level 3, Grade C).
  5. Pharmacotherapy: Healthcare providers should not pre­scribe metformin for managing gestational weight gain in women with obesity (Level 1b, Grade A). We suggest no weight management medications during pregnancy or breast­feeding (Level 4, Grade D).
  6. Breastfeeding: We recommend women with obesity be offered additional breastfeeding support due to decreased rates of initiation and continuation (Level 3, Grade C).

Key Messages for Healthcare Professionals

This chapter addresses the management of weight related to three phases of a woman’s reproductive years – precon­ception, during pregnancy and postpartum – for adult wom­en with obesity. Although these reproductive periods are addressed separately, it is important to consider that these phases represent the continuum of weight management over the reproductive years in women with obesity. During these time periods, women frequently access the healthcare system, thus providing clinicians with health promotion opportunities which may have positive impacts on the short- and long-term health of both the woman and her children. Discussion of the obstetric and anesthetic management for women with obesity during pregnancy is beyond the scope of this clinical practice guideline.

Key Messages for People Living with Obesity

The reproductive years, including before, during and after pregnancy, bring many additional challenges for women with obesity in maintaining a healthy weight beyond eating well and being physically active. It is important for women with obesity to seek advice and support from their healthcare pro­viders on strategies to optimize their own health outcomes, as well as those of their children, over both the short and long-term.

The strategies described in this chapter include:

  1. Entering pregnancy at a lower BMI;
  2. Targeting weight gain during the entire pregnancy to 5 kg– 9 kg; and
  3. Returning to at least the pre-pregnancy BMI in the year after delivery.

Recommendations

We suggest that healthcare providers for Indigenous people living with obesity:

  • Engage with patient social realities.
  • Validate the patient’s experiences of stress and systemic disadvantage influencing poor health and obesity, explor­ing elements of their environment where reduced stress could shift behaviours (Level 4, Grade D, Consensus).
  • Advocate for access to obesity management resources within publicly funded healthcare systems, recognizing that resources beyond may be unaffordable and unattain­able for many (Level 4, Grade D, Consensus).
  • Help patients recognize that good health is attainable, and they are entitled to it (Level 4, Grade D, Consensus).
  • Negotiate small attainable steps relevant to the patient’s context (Level 4, Grade D, Consensus).
  • Address resistance, seeming apathy and paralysis in patients and providers (Level 4, Grade D (Consensus).
  • Self-reflect on anti-Indigenous sentiment common with­in healthcare systems, exploring patient motivations and mental health (e.g., trauma, grief) as alternative understandings of causes and solutions to their health problems. Explore one’s own potential for bias influenced by systemic racism (Level 4, Grade D, Consensus).
  • Expect patient mistrust in health systems; reposition your­self as a helper to the patient instead of as an expert, which may stir resistance and be a barrier to their wellness(Level 4, Grade D, Consensus).
  • When resistance, seeming apathy and paralysis are en­countered, explore patient mental and emotional health needs, which have unique drivers and presentations in many Indigenous contexts (Level 4, Grade D, Consensus).
  • Build complex knowledge by healing relationships (Level 4, Grade D, Consensus).
  • Build patient knowledge and capacity for obesity self-man­agement through longitudinal explorations of co-occurring health, social, environmental and cultural factors. Strive to build relationships that incorporate healing from multi-gen­erational trauma, which due to residential schools and child welfare system involvement may more frequently include sexual abuse (Level 4, Grade D, Consensus).
  • Build your own knowledge regarding the health legacy of colonization—including ongoing experiences of anti-Indig­enous discrimination within systems and wider society—to facilitate relationships built on mutual understanding (Level 4, Grade D, Consensus).
  • Ensure knowledge provided is congruent with the patient’s perspectives and educational level, and is learner-centred, including potential for patient anticipation of racism or unequal treatment (Level 4, Grade D, Consensus).
  • Connect to behaviour, the body and Indigenous ways of knowing, doing and being (Level 4, Grade D, Consensus).
  • Elicit and incorporate the patient’s individual and commu­nity-based concepts of health and healthy behaviours in re­lationship to body size, activity and food preferences (e.g., preference for and/or scarce access to land-based foods and activities) (Level 4, Grade D, Consensus).
  • Deeply engage in learning of common values and princi­ples around communication and knowledge sharing in Indig­enous contexts (e.g., relationalism, non-interference) (Level 4, Grade D, Consensus).

Key Messages for Healthcare Professionals

Exploring obesity within the context of multiple co-occurring health, socioeconomic, environmental and cultural factors, and situating these within policy/jurisdictional structures specific to Indigenous populations (e.g., federal versus provincial health funding), can facilitate emerging opportunities for obesity management. These contexts highlight a tension that providers must navigate, between drivers of obesity embedded in social- and system-level inequities and protective factors that promote healing through relationships and culturally contextualized approaches to care. Healthcare professionals should consider the following contextual factors when providing obesity care for Indigenous peoples:

  • Structural inequities (i.e., social and systemic in origin) are embedded in health, education, social services and other systems, and they maintain social disadvantage for a large segment of the Indigenous population. These inequities influence food security, for example, through lower wages perpetuated by inaccessible education and high food costs in urban and remote areas, or through limited access to activity-based resources at individual and community levels. Indigenous people have experienced systemic disadvantage throughout their lifespan and those of their family members, producing a cumulative effect on obesity. In Indigenous contexts, obesity is therefore deeply affected by responses to pervasive stressors, as individuals navigate social and systemic barriers to meeting their goals.
  • Overwhelming stress from social (e.g., discrimination) and systemic exclusion (e.g., poor or absent primary healthcare) can disempower Indigenous people in maintaining healthy behaviours. Patients may appear to be resistant to healthcare recommendations, where together with healthcare providers they may come to feel fatalistic toward their capacity to address obesity. Healthcare professionals often interpret such patient incongruity with recommendations in a deficit lens, labeling it as patient non-compliance or non-adherence. This non-concordance, or seeming apathy, may actually be a sense of paralysis in the face of overwhelming stress.
  • Exploration of the patient’s social reality can open opportunities for contextualized approaches to obesity management.
  • Reflection on assumptions about seeming apathy may contextualize patient motivations, where deep exploration of one’s own perceptions, attitudes and behaviours toward Indigenous patients may uncover anti-Indigenous sentiment implicit in healthcare practices or systems.
  • Validation of a patient’s experiences of inequity can empower both patients and providers to identify steps to address social factors that influence health behaviours.
  • Culture and relationships facilitate learning of complex knowledge. The interaction of obesity with co-occurring structural factors represents complex knowledge that is critical for patients to gain deep understanding of their health. Non-Indigenous healthcare providers may have ways of knowing and doing that are inconsistent with Indigenous patient perspectives on health knowledge and how it should be exchanged. Obesity management in this context requires a longitudinal, relationship-centred approach that engages and explores interactions with co-existing factors to build both knowledge and trust, in a manner aligned with Indigenous principles for communication.
    • Connection: When patients connect with healthcare providers around their co-occurring health needs, there are complex linkages between wider structures and their health. The therapeutic relationship may be critically supportive when knowledge is delivered in a relevant way and makes sense to the patient.
    • Trust-building: Healing of the therapeutic relationship is itself fundamental to engaging and supporting patients within contexts of multi-generational trauma to explore complex intersections in relation to health and health behaviour change.
    • Differing worldviews: Western concepts of healthy behaviours related to obesity management, including preferences for body size, activity and food, may be dis­cordant with Indigenous perspectives. Patients may not identify with provider perspectives, and providers must not assume that patients share provider worldviews or principles around how to communicate health knowl­edge. Discordant perspectives may involve a distinct sense of locus of control, self-efficacy and modes for speaking about the pathways into and out of obesity. An Indigenous approach to knowledge exchange in­cludes contextualizing knowledge within the world of the patient and employing a narrative-based and indi­rect approach to sharing knowledge.

Key Messages for People Living with Obesity

There is a strong relationship between stress, health, and obesity. Addressing stressors is an important part of being healthy.

  • The causes of obesity are complex, with unique personal and historical factors that include colonization and residen­tial school experiences affecting Indigenous people. Look for opportunities to speak with your healthcare providers, family, and wider community to build understanding of its causes and to reveal pathways to your health and wellness.
  • Addressing stress and other emotional pain in your life can be protective of obesity. It is important for you to explore, identify, and address causes of stress in your life, at personal, social, and wider system levels. Seek out support from people you trust, including your healthcare providers. Doctors, nurses, dietitians, and social workers can be important re­sources for healing and accessing knowledge.
  • Part of healing from the past is working on small, attainable steps that may best influence positive health and promote a healthier body weight.
  • Community resources are important in this journey. Seek to connect with community activities that promote healthy be­haviours (e.g., activity groups, traditional food preparation, community gardens).
  • Due to colonization and social exclusion, Indigenous people experience significant stress that discourages overall mental and emotional wellness. Cultural and community disruption caused by colonization complicate the already-complex causes of obesity for Indigenous people. Learning about the causes and possible solutions to stressors at personal, social, and systemic levels is important to preventing and managing obesity, as this can allow you to connect to opportunities for support.

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