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Canadian Pediatric Obesity Clinical Practice Guideline

New guideline sets new standard for pediatric obesity management in Canada

With this first update in over 20 years, Managing Obesity in Children: A Clinical Practice Guideline gives healthcare professionals an evidence-based roadmap to support children and adolescents living with obesity.

Developed with input from families, youth, and 53 multidisciplinary experts, the guideline shifts the focus away from weight loss and toward improving overall health and quality of life.

Guideline recommendations & good practice statements

Recommendations

1. Behavioural and psychological interventions

1.1 Multicomponent interventions

We recommend using multicomponent interventions (i.e., at least 2 of physical activity, nutrition, psychology, and technology interventions) for managing obesity in children aged 18 years and younger.

Strength of recommendations; certainty of evidence: Strong; very moderate to low certainty

Rationale: For critically important and very important outcomes, compared with minimal interventions, multicomponent interventions had a small effect on depression, anxiety, and BMIz. Interventions had little to no effect on HRQoL. No serious AEs were reported in any multicomponent intervention studies. When mild to moderate AEs were reported, they were trivial.

1.2 Nutrition interventions

We suggest using nutritional interventions for managing obesity in children aged 18 years and younger.

Strength of recommendations; certainty of evidence: Conditional; very low to low certainty

Rationale: For critically important outcomes, no data were available, but for our very important outcome (BMIz), compared with minimal interventions, nutrition interventions had a small beneficial effect. No serious AEs were reported in any nutrition intervention studies. When mild to moderate AEs were reported, they were trivial. This recommendation relates to nutrition interventions exclusively, not in conjunction with other interventions.

1.3 Physical activity interventions

We suggest using physical activity interventions for managing obesity in children aged 18 years and younger.

Strength of recommendations; certainty of evidence: Conditional; very low to low certainty

Rationale: For critically important and very important outcomes, intervention effects were small for HRQoL and BMIz; for depression and anxiety, there were little to no effects. No serious AEs were reported in any physical activity intervention studies. On rare occasions when mild to moderate AEs were reported, they included musculoskeletal injuries (e.g., mild ankle sprain) or discomfort (e.g., postexertional malaise). This recommendation relates to physical activity interventions exclusively, not in conjunction with other interventions.

1.4 Psychological interventions

We suggest using psychological interventions for managing obesity in children aged 18 years and younger.

Strength of recommendations; certainty of evidence: Conditional; very low to moderate certainty

Rationale: For critically important outcomes, intervention effects for depression were moderate and small for HRQoL; no anxiety data were reported. For our very important outcome (BMIz), psychological interventions resulted in little to no effect. There was no evidence of serious AEs and very little evidence of mild to moderate AEs from psychological interventions. This recommendation relates to psychological interventions exclusively, not in conjunction with other interventions.

1.5 Technology interventions

We recommend neither for nor against using technology interventions for managing obesity in children aged 18 years and younger.

Strength of recommendations; certainty of evidence: Conditional; very low to low certainty

Rationale: For all critically important outcomes, there were little to no effects of technology interventions on HRQoL, depression, or anxiety. For our very important outcome, there was a small beneficial effect on BMIz. There was no evidence of serious (critically important outcome) or mild to moderate (important outcome) AEs. This recommendation relates to technology interventions exclusively, not in conjunction with other interventions.

2. Pharmacologic interventions

2.1 Glucagon-like peptide-1 receptor agonists

We suggest that glucagon-like peptide-1 receptor agonists be considered, in combination with behavioural and psychological interventions, for managing obesity in children aged 12 years and older.

Strength of recommendations; certainty of evidence: Conditional; very low to low certainty

Rationale: Overall, for critically important outcomes, GLP-1RAs had little to no effect on HRQoL; no data were available on depression and anxiety. For our very important outcome (BMIz), GLP-1RAs may result in a small reduction in BMIz. Subgroup analyses showed that semaglutide had more substantial effects on HRQoL (small effect) and BMIz (very large effect), along with effects on several other important outcomes, versus other GLP-1RAs. Evidence regarding an increased risk of serious AEs (a critically important outcome) with GLP-1RAs was uncertain. There may be a small increased risk in mild to moderate AEs with GLP-1RAs, but the risk appeared to vary. Most of the evidence supporting this recommendation was derived from children aged 12 years and older. The effectiveness and safety of GLP-1RAs for children younger than 12 years has not been evaluated. Studies that examined the effects of GLP-1RAs included concurrent behavioural and psychological interventions, which varied study to study.

2.2 Biguanides

We suggest that biguanides be considered, in combination with behavioural and psychological interventions, for managing obesity in children aged 12 years and older.

Strength of recommendations; certainty of evidence: Conditional; low to moderate certainty

Rationale: For critically important outcomes, biguanides (e.g., metformin) had little to no effect on HRQoL; no data were reported on anxiety and depression. For our very important outcome (BMIz), biguanides had a moderate effect. Biguanides resulted in no serious AEs (critically important outcome) but may result in more mild to moderate AEs than in controls. Most of the evidence supporting this recommendation was derived from children aged 12 years and older. Studies that examined the effects of biguanides included concurrent behavioural and psychological interventions, which varied study to study.

2.3 Lipase inhibitors

We suggest against using lipase inhibitors for managing obesity in children.

Strength of recommendations; certainty of evidence: Conditional; low certainty

Rationale: There was a lack of evidence for the effects of lipase inhibitors (e.g., orlistat) on critically important (HRQoL, anxiety, depression) and very important (BMIz) outcomes. Lipase inhibitor use may result in more cases of serious AEs (a critically important outcome) and more cases of mild to moderate AEs (e.g., gastrointestinal) than in controls. Most of the evidence supporting this recommendation was derived from children aged 12 years and older. Studies that examined the effects of lipase inhibitors included concurrent behavioural and psychological interventions, which varied study to study.

3. Surgical interventions

3.1 Laparoscopic sleeve gastrectomy

We suggest that laparoscopic sleeve gastrectomy be considered, in combination with behavioural and psychological interventions, for managing obesity in children aged 13 years and older who are deemed eligible candidates based on a comprehensive health assessment by a specialized, multidisciplinary team.

Strength of recommendations; certainty of evidence: Conditional; low to moderate certainty

Rationale: For critically important outcomes, LSG had a very large effect on HRQoL; no data were reported on anxiety and depression. For very important outcomes, weight and BMI decreased substantially. For undesirable effects, LSG may result in a higher incidence of serious AEs (a critically important outcome) and mild to moderate AEs (an important outcome). The effectiveness and safety of LSG were evaluated in individuals who were almost exclusively aged 13 years and older and in combination with behavioural and psychological interventions, which varied study to study.

3.2 Roux-en-Y gastric bypass

We suggest that Roux-en-Y gastric bypass be considered, in combination with behavioural and psychological interventions, for managing obesity in children aged 13 years and older who are deemed eligible candidates based on a comprehensive health assessment by a specialized, multidisciplinary team.

Strength of recommendations; certainty of evidence: Conditional; low to moderate certainty

Rationale: For critically important outcomes, RYGB had a large effect on HRQoL and small effects on anxiety and depression. For very important outcomes, RYGB led to substantial reductions in weight and BMI. For undesirable effects, RYGB may result in higher incidence of serious AEs (a critically important outcome) and mild to moderate AEs (an important outcome). The effectiveness and safety of RYGB were evaluated in individuals who were almost exclusively aged 13 years and older and in combination with behavioural and psychological interventions, which varied study to study.

Note: AE = adverse event, BMI = body mass index, BMIz = body mass index z score, GLP-1RA = glucagon-like peptide-1 receptor agonists, GRADE = Grading of Recommendations Assessment, Development and Evaluation, HRQoL = health-related quality of life, LSG = laparoscopic sleeve gastrectomy, RYGB = Roux-en-Y gastric bypass.

*GRADE certainty of evidence(18) for behavioural and psychological, pharmacologic, and surgical interventions was based on critically important (HRQoL, depression, anxiety, and serious AEs) and very important outcomes (BMIz for behavioural and psychological and pharmacotherapy interventions; BMI and weight for surgery) only. Ranges were included for certainty of evidence ratings based on recommendations from the guideline panel and variability in the certainty of evidence across critically important and very important outcomes. Most panellists with lived experience placed higher value on improvements in HRQoL, depression, anxiety, serious AEs, and BMIz (or BMI and weight) than other outcomes.

Good practice statements for managing obesity in children

Health care providers should use person-first language and avoid using negative, stigmatizing language.

This good practice statement acknowledges that health care providers should establish trust, rapport, and a positive relationship with children and families, which begins with using appropriate language. Health care providers are in a good position to address the shame and guilt felt by some children and families, especially if they view obesity as a personal choice and moral failing. Some children with obesity and families have a history of negative interactions with health care providers, including feeling blamed and shamed. It is important to use encouraging, supportive words and language during clinical conversations. Health care providers should consider children’s age and maturity before initiating conversations about obesity, considering whether conversations should include caregivers exclusively, children exclusively, or caregivers and children together. Health care providers can plan and lead positive conversations using practical resources, including a casebook for health care providers and guide for caregivers.(19)

Health care providers should acknowledge that obesity is a complex, chronic, and relapsing disease that requires establishing a positive relationship with children and families, and includes providing longterm support for obesity management for children and families.

This good practice statement recognizes that misperceptions are common regarding the causes and consequences of obesity and weight gain. In their conversations with children and families, health care providers should acknowledge that genetic, physiologic, and environmental factors make it challenging to lose weight and maintain weight loss. The chronicity of obesity highlights the valuable role played by health care providers to help children and families transition from pediatric to adult care when that time comes.

Health care providers in Canada should assess children’s physical growth and development using the World Health Organization (WHO) growth charts for Canada(20) criteria and sex- and age-specific body mass index (BMI) data.

This good practice statement acknowledges the appropriateness of the WHO criteria for evaluating children’s growth and development, which is based on reference data relevant for Canadian children. This resource provides guidance for health care providers regarding weighing and measuring children as well as calculating and interpreting body mass index (BMI) and BMI z score. This statement is consistent with recommendations from leading Canadian health organizations. Health care providers should discuss growth and development using neutral words (e.g., BMI, weight, growth) that children and families may find less stigmatizing. They should also recognize that focusing solely on body weight can precipitate weight preoccupation, body image disturbances, and unhealthy eating behaviours in susceptible children and families.

Health care providers should consider the social determinants of health and how they may influence shared decision-making, intervention recommendations, and access to health care resources to support obesity management for children and families.

This good practice statement recognizes that obesity disproportionately affects some groups of children and families more than others based on social determinants of health, which may be a barrier to accessing culturally appropriate care to meet the social and material needs of children and families.

Health care providers should complete a comprehensive health assessment of children with obesity using a framework such as the 4Ms for Assessment of Obesity (Metabolic, Mechanical, Mental Health, Social Milieu) to help identify consequences of obesity and barriers to obesity management.

This good practice statement recognizes the complexity of obesity, extending beyond anthropometric outcomes such as BMI. It acknowledges the varied and dynamic genetic, physiologic, and societal influences on weight regulation. Attention should be paid to risk of eating disorders (e.g., binge-eating disorder, atypical anorexia), with referral to specialist care, when indicated. Interventions designed to manage obesity can have broad effects on health, so there is value in measuring a range of outcomes to monitor health status and changes over time. The 4Ms framework is based on the Edmonton Obesity Staging System for Pediatrics.(21)

Health care providers should take a nonjudgmental, nonstigmatizing approach that encourages children and families to participate in obesity management interventions, including talking with children and families about their expectations for improving health outcomes.

This good practice statement recognizes the important role played by health care providers to support children and families in accessing and participating in obesity management interventions. This can include applying motivational interviewing and cognitive behavioural therapy to help support and sustain healthy behaviours, as well as discussing expected outcomes from different intervention strategies. Obesity management success can be defined in different ways (e.g., enhanced health-related quality of life, reduced blood pressure, improved mobility and participation in physical activities) by health care providers, children, and families. Changes in health outcomes can vary between individuals for a variety of reasons, and some outcomes may be more responsive than others to intervention-related changes.

Health care providers should use resources such as the 5As for Pediatric Obesity Management(22) (Ask, Assess, Advise, Agree, Assist) to enable screening and caring for children with obesity and families in a respectful, participatory manner.

This good practice statement acknowledges that health care providers need resources and tools that can provide structure to guide assessment and obesity management with children and families. As an example, the 5As of Pediatric Obesity Management serves as a tool kit for health care providers, and includes whiteboard videos as companion resources with background on obesity and how to incorporate the 5As into clinical practice.

Health care providers should present children and families with intervention options for managing obesity based on evidence, feasibility, and availability.

This good practice statement acknowledges that behavioural and psychological, pharmacologic, and surgical interventions can improve health outcomes in pediatric obesity management. There is no evidence to support a stepwise approach whereby pharmacologic and surgical interventions should be offered only if behavioural and psychological interventions prove ineffective. Using shared decision-making with families, health care providers should consider all intervention options. Centres that offer bariatric surgery for adolescents with obesity are limited in Canada, but health care providers should apply established screening and assessment criteria when considering surgery as an option.(23)

Health care providers should ideally offer services for managing pediatric obesity in a multidisciplinary team environment, where available.

This good practice statement acknowledges the complexity of obesity, which often requires health care providers with diverse and complementary expertise (e.g., dietitian, family physician, kinesiologist, nurse, pediatrician, psychologist, social worker) to assess and manage obesity, its causes, and its consequences, using behavioural and psychological, pharmacologic, and surgical interventions. In Canada, health services for managing pediatric obesity are limited, especially in rural and remote communities. Many health care providers do not work in multidisciplinary teams, so partnering with colleagues who possess complementary knowledge and skills will require proactive communication and coordination.

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Appendix 3: Considerations for implementating recommendations for managing pediatric obesity

Information from three systematic reviews with meta-analyses (SRMAs) (1–3) and other supplementary sources of evidence (4) were used to populate GRADE Evidence-to-Decision (EtD) tables, which our Guideline Panel used to evaluate the best available evidence and determine recommendations for our clinical practice guideline. In our EtD tables, several domains were considered, including the Problem, Desirable Effects, Undesirable Effects, Certainty of Evidence, Values, and Balance of Effects. Issues related to intervention Acceptability (including treatment burden (5)) and Feasibility also informed our conversations with panelists; these latter elements are essential for making ‘societal’ recommendations, but were not required for our ‘individualized’ recommendations. For this reason, and because of their length, they were not included in our manuscript. Information that panelists considered regarding Acceptability and Feasibility are provided below, acknowledging a range of factors that are needed when regions, provinces or countries are considering health care services. These issues can inform clinical conversations and decision-making between patients, caregivers, and healthcare providers when making therapeutic decisions about managing pediatric obesity.

Behavioural and psychological interventions: Acceptability

Behavioural and psychological interventions are likely to be acceptable for most children and families, although they can place demands on families related to making and maintaining changes to improve health outcomes. Not all family members will be ready, willing, or able to implement changes, so individualized, tailored interventions are likely to be most acceptable; practical issues (e.g., time commitments, competing work/school/recreational activities), perceptions, and experiences with healthcare providers and within the healthcare system, both positive and negative, can also influence acceptability. Most children referred for obesity management do not initiate care (6,7) and a relatively high proportion (i.e., 30 to 40%) of children and caregivers discontinue care or drop out prematurely, which limits potential health benefits (8). The SRMA that informed our recommendations did not examine intervention intensity (i.e., type, frequency, and duration); however, evidence suggests that children who receive ≥26 hours of clinical contact in behavioural and psychological interventions provided over 6 to 12 months can derive modest improvements in anthropometry (i.e., 2 to 3 kg/m2 decrease in absolute body mass index; (9)). Less intensive interventions may also be effective at improving health outcomes, including changes to outcomes beyond anthropometry (10), which may be acceptable to families. Many behavioural and psychological interventions offered in clinical settings are delivered using principles and techniques that align with Motivational Interviewing (MI); however, there is little evidence from the included RCTs to suggest that MI is superior to other approaches. Research is needed to assess the characteristics that determine the impact of MI on treatment outcomes, including provider training, intervention fidelity, and child/family characteristics (11). MI-based interventions are patient-centred, engaging, and driven by curiosity and a non-judgemental approach by health care providers, so families typically rate MI-based interventions favourably (12,13).

Behavioural and psychological interventions: Feasibility

Behavioural and psychological interventions provided in clinical settings like many included in our SRMA (2) are not always feasible. These types of interventions are usually offered by multidisciplinary teams of healthcare providers in urban/suburban centres, with limited services in rural/remote communities (14). They tend to be resource-intensive for both healthcare providers and families. In Canada, the availability and accessibility of these interventions vary geographically. Some provincial health care systems support numerous multidisciplinary clinics for managing pediatric obesity; others provide no specialized care. Many services are available through the public health care system, but private services also exist, paid for by families as an out-of-pocket expense or through enhanced healthcare plans and/or employment benefits. Post-COVID-19 pandemic, health services are more accessible to families given the increased use and acceptance of virtual care, such as video conferencing, which can reduce barriers to care, especially for families living in rural/remote communities. Evidence-based approaches should be used while acknowledging the need for practical solutions in resource-limited settings. Healthcare providers should consider applying a variety of resource, including virtual care platforms, structured tools (e.g., 5As for Pediatric Obesity Management), resources for self-directed behavioural changes, partnering with local community centre and services, and connecting with specialized centres, when indicated. Other uses of technology offer potential benefits. For example, interventions that use text messaging to deliver general or tailored MI messages to families is likely to be more feasible to deliver versus interventions that include proprietary or commercial web-based platforms and/or technological tools or devices designed to improve behaviours; however, RCTs are needed to better evaluate the efficacy of various delivery modes. For optimal delivery, psychological interventions require training, skills, and expertise. Workshops, certification programs, and formal educational training are widely available for healthcare providers to acquire and maintain proficiency in delivering these types of interventions, including resources offered by Obesity Canada. Of note, some interventions are offered by providers with limited training and support, which can have a negative impact on intervention fidelity and treatment impact (15) as well as adherence and attrition.

Pharmacological interventions: Acceptability

Although metformin is used frequently for managing type 2 diabetes, RCTs included in our review included participants without diabetes (3). Through discussions with our lived experience panelists, several mentioned that taking a medication for obesity management would need to be worthwhile (i.e., lead to an improvement in critically important desirable outcomes without or with minimal undesirable adverse effects). Acceptability may vary depending on medication dose. The acceptability of metformin may vary among individuals, so an individualized approach is needed. Factors such as age, comorbidities, risks, benefits, costs, availability, outcomes that the family considers most important, and the willingness of the child and their family to adhere to treatment plans are crucial to consider, all of which highlight the important role healthcare providers should play in offering individualized approaches to patients and families. Currently, most evidence from pediatric studies is derived from studies that included medication delivery by injection (weekly), although other delivery modes (e.g., oral) are likely to influence acceptability as well as intervention efficacy and adverse events (16,17). Since GLP1RAs are relatively new medications for managing pediatric obesity, the long-term effects (desirable and undesirable) remain largely unknown.

To the knowledge of our Guideline Panel members, lipase inhibitors are not covered by any provincial healthcare system in Canada and prescribed very infrequently in adults, and probably close to never in adolescents. Through discussions with our panelists, physician members described reluctance to prescribe lipase inhibitors for obesity management, especially considering recent beneficial evidence with newer medications as well as low effectiveness and undesirable side effects.

Pharmacological interventions: Feasibility

Metformin is covered by provincial health care plans in Canada, so expenses related to use may not be a barrier for most families. In addition, we are not aware of any issues regarding limited availability of the medication, so it should also be easily accessible. Currently, metformin is prescribed ‘off label’ since weight loss is not listed as an indication. Coverage and cost of obesity medications vary between provinces in Canada. Access to GLP1RAs is variable with private insurers. Coverage for semaglutide varies across provinces. This medication is not covered for obesity management by either the Ontario (OHIP+) or Quebec (RAMQ) health insurance boards. Private insurance companies may consider covering medication costs, but coverage appears dynamic and variable across jurisdictions. For example, one GLP1RA (semaglutide) costs ~$400 CDN/month. Based on the experience of some guideline panelists with lived experience, some insurance companies have denied coverage for obesity management but considered prescribing the medication for diabetes management. Semaglutide is approved for use in Canada for individuals ≥12 years old to manage obesity, although limited availability and supply constraints have limited accessibility in the recent past. Overall, the feasibility of GLP1RAs likely varies by province and type of insurance and availability of resources for families. It may also vary by physician beliefs and values, prescribing behaviours, benefits to cardiometabolic health outcomes, cost, and weight gain rebound if the medication is discontinued.

Surgical interventions: Acceptability

Acceptance of bariatric surgery will likely be affected by adolescents’ and caregivers’ perceptions about the potential benefits and harms as well as the lifelong requirements for nutritional supplements and medical follow-up (18). Evidence suggests that parental acceptance of bariatric surgery varies and is positively influenced by counseling from pediatric healthcare providers (19). Several additional reports highlighted moderate to high levels of acceptability of bariatric surgery in pediatrics, which includes primarily individuals ≥13 years of age. For instance, in a randomized, open-label, two-year, multicentre trial in Sweden (20) that included 50 13- to 16-year olds with a BMI ≥35 kg/m2 underwent bariatric surgery (Roux-en-Y Gastric Bypass [RYGB] or Laparoscopic Sleeve Gastrectomy [LSG]) or intensive non-surgical treatment, no participants in the surgical group reported regretting study participation. In the non-surgical group, two participants reported regretting study participation at the 1-year follow-up, and one at the 2-year follow-up, due to feeling helpless and not achieving weight loss. In a qualitative study of 18 adolescent bariatric surgery patients from Ontario, Canada, investigators reported that adolescents were mostly positive or ambivalent about their personal and social experiences up to two years post-surgery (21). Finally, in a diverse (32% Black; 18% Hispanic) US-based group of 20 adolescents that underwent bariatric surgery, at ~10 years post-surgery, participants continued to weigh less than their pre-surgical weight, but continued to struggle with issues related to body image and food attachment. Their ongoing challenges led them to require or prefer continuing mental health support and monitoring their health over time (22).

Healthcare providers of our Guideline Panel tended to view bariatric surgery as an acceptable intervention for managing pediatric obesity in those who experienced limited success with behavioral and psychological interventions alone and underwent evaluation by a multidisciplinary team in a specialized centre, determining them to be good surgical candidates. One member of our Guideline Panel who had lived experience with obesity reported that, in his conversations with numerous adults who underwent bariatric surgery and despite the occurrence of some undesirable adverse effects, none expressed regret in having undergone surgery, suggesting a high level of acceptability for surgical interventions.

Surgical interventions: Feasibility

In Canada, the availability of and access to pediatric bariatric surgery varies by province affecting feasibility of implementation. Currently, there are only two centres that offer bariatric surgery to adolescents (one in Quebec; one in Ontario). Overall, services are very limited for bariatric surgery in Canada.

References

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Systematic reviews that informed this guideline

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