2013 Evidence Review on Overweight and Obesity â€å“managing Overweight and Obesity in Adultsã¢â‚¬â
Obesity in adults: a clinical practice guideline
KEY POINTS
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Obesity is a prevalent, complex, progressive and relapsing chronic illness, characterized by abnormal or excessive body fat (adiposity), that impairs health.
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People living with obesity face substantial bias and stigma, which contribute to increased morbidity and bloodshed independent of weight or body mass alphabetize.
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This guideline update reflects substantial advances in the epidemiology, determinants, pathophysiology, assessment, prevention and handling of obesity, and shifts the focus of obesity management toward improving patient-centred wellness outcomes, rather than weight loss alone.
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Obesity care should exist based on evidence-based principles of chronic disease management, must validate patients' lived experiences, movement beyond simplistic approaches of "eat less, move more," and accost the root drivers of obesity.
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People living with obesity should take admission to evidence-informed interventions, including medical nutrition therapy, physical action, psychological interventions, pharmacotherapy and surgery.
Obesity is a complex chronic disease in which abnormal or backlog body fat (adiposity) impairs health, increases the risk of long-term medical complications and reduces lifespan.i Epidemiologic studies define obesity using the body mass index (BMI; weight/meridianii), which can stratify obesity-related health risks at the population level. Obesity is operationally defined as a BMI exceeding xxx kg/yard2 and is subclassified into grade ane (xxx–34.ix), class 2 (35–39.9) and class iii (≥ forty). At the population level, health complications from excess body fat increase as BMI increases.ii At the private level, complications occur because of excess adiposity, location and distribution of adiposity and many other factors, including ecology, genetic, biologic and socioeconomic factors (Box 1).11
Box 1:
Complications of obesity
Adipose tissue not only influences the cardinal regulation of energy homeostasis, just excessive adiposity tin besides become dysfunctional and predispose the private to the evolution of many medical complications, such as:
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Type ii diabetes3
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Gallbladder disease4
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Nonalcoholic fat liver disease5
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Gout6
Excess and ectopic body fatty are important sources of adipocytokines and inflammatory mediators that can change glucose and fatty metabolism, leading to increased cardiometabolic and cancer risks, and thereby reducing affliction-free duration and life expectancy by half-dozen to 14 years.1,seven,8 It is estimated that 20% of all cancers can be attributed to obesity, independent of nutrition.nine Obesity increases the chance of the following cancers:ten
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Colon (both sexes)
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Kidney (both sexes)
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Esophagus (both sexes)
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Endometrium (women)
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Postmenopausal breast (women)
Over the past 3 decades, the prevalence of obesity has steadily increased throughout the world,12 and in Canada, it has increased threefold since 1985.13 Importantly, severe obesity has increased more than than fourfold and, in 2016, affected an estimated 1.9 1000000 Canadian adults.xiii
Obesity has become a major public health result that increases health intendance costs14,15 and negatively affects physical and psychological health.sixteen People with obesity experience pervasive weight bias and stigma, which contributes (independent of weight or BMI) to increased morbidity and mortality.17
Obesity is caused by the circuitous interplay of multiple genetic, metabolic, behavioural and environmental factors, with the latter idea to exist the proximate cause of the substantial ascent in the prevalence of obesity.18,xix A amend understanding of the biological underpinnings of this affliction has emerged in contempo years.nineteen The brain plays a central role in free energy homeostasis by regulating food intake and energy expenditure (Box 2).24
Box 2:
Ambition regulation20–23
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The control of ambition is complex and involves the integration of the key neural circuits including the hypothalamus (homeostatic command), the mesolimbic system (hedonic control) and the frontal lobe (executive command).
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The crosstalk between homeostatic and hedonic eating is influenced by mediators from adipose tissue, the pancreas, gut and other organs.
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Cerebral functions in the prefrontal cortex exert executive control on food choices and the decision to eat. The interconnectivity of these neural networks drives eating behaviour and has been shown to be altered in obesity.
Decreased food intake and increased physical activity lead to a negative energy rest and trigger a pour of metabolic and neurohormonal adaptive mechanisms.25,26 Therapies that target these alterations in neurohormonal mechanisms can go constructive tools in the long-term management of obesity.27
Novel approaches to diagnose and assess obesity in clinical do accept been proposed.11,18,19,28 Although BMI is widely used to assess and classify obesity (adiposity), it is not an authentic tool for identifying adiposity-related complications.19 Waist circumference has been independently associated with an increase in cardiovascular risk, merely it is not a good predictor of visceral adipose tissue on an individual footing.29 Integration of both BMI and waist circumference in clinical cess may identify the higher-hazard phenotype of obesity better than either BMI or waist circumference lone, peculiarly in those individuals with lower BMI.30,31 In add-on to BMI and waist circumference measurements, a comprehensive history to identify the root causes of obesity, advisable physical examination and relevant laboratory investigations will help to place those who will do good from treatment.32
The Edmonton obesity staging organization has been proposed to guide clinical decisions from the obesity assessment and at each BMI category (Appendix ane, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.191707/-/DC2).28 This 5-stage organization of obesity classification considers metabolic, physical and psychological parameters to determine the optimal obesity treatment. In population studies, it has been shown to be a ameliorate predictor of all-cause mortality when compared with BMI or waist circumference measurements solitary.33,34
There is a recognition that obesity management should be about improved health and well-being, and not only weight loss.34–36 Because the existing literature is based mainly on weight-loss outcomes, several recommendations in this guideline are weight-loss centred. Still, more than inquiry is needed to shift the focus of obesity management toward improving patient-centred health outcomes, rather than weight loss alone.
Despite growing evidence that obesity is a serious chronic disease, it is not effectively managed inside our electric current health system.37,38 Canadian health professionals feel ill equipped to support people living with obesity.39–41 Biased beliefs well-nigh obesity also touch on the level and quality of wellness care that patients with obesity receive.42 The dominant cultural narrative regarding obesity fuels assumptions about personal irresponsibility and lack of willpower and casts blame and shame upon people living with obesity.41 Chiefly, obesity stigma negatively influences the level and quality of care for people living with obesity.42
With increased knowledge of the affliction country and better approaches to assess and manage obesity, information technology is timely to update the 2006 Canadian clinical practice guideline.43 The goal of this update is to disseminate to main care practitioners evidence-informed options for assessing and treating people living with obesity. Importantly, this guideline incorporates the perspectives of people with lived experience and of interprofessional primary care providers with those of experts on obesity management, and researchers. This article is a summary of the full guideline, which is available online (http://obesitycanada.ca/guidelines/).
Scope
The target users for this guideline are primary health care professionals. The guideline may as well be used by policy-makers and people affected by obesity and their families. The guideline is focused on obesity in adults. The recommendations are intended to serve every bit a guide for health intendance providers; clinical discretion should exist used by all who prefer these recommendations. Resource limitations and individual patient preferences may make information technology hard to put every recommendation into practice, but the guideline is intended to improve the standard of, and access to, intendance for individuals with obesity in all regions of Canada.
Recommendations
This clinical practice guideline informs the arc of the patient journey and clinical management arroyo in the primary care setting. The guideline recommendations are shown in Table i.
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Table 1:
Recommendations on management of obesity in adults*
A consummate clarification of the recommendations and supporting testify are available in the xix chapters of the full guideline (http://obesitycanada.ca/guidelines/). This synopsis outlines a discussion of the guiding principles that the executive committee adamant as important for advancing clinical practice in Canada.
There are five steps in the patient arc to guide a health care provider in the care of people living with obesity. Each step is outlined beneath with highlights of the relevant recommendations and a discussion of supporting evidence.
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Recognition of obesity as a chronic disease by health care providers, who should ask the patient permission to offer communication and help treat this disease in an unbiased way.
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Assessment of an private living with obesity, using appropriate measurements, and identifying the root causes, complications and barriers to obesity treatment.
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Discussion of the cadre handling options (medical nutrition therapy and physical activity) and adjunctive therapies that may be required, including psychological, pharmacologic and surgical interventions.
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Agreement with the person living with obesity regarding goals of therapy, focusing mainly on the value that the person derives from health-based interventions.
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Engagement by health care providers with the person with obesity in continued follow-upward and reassessments, and encouragement of advocacy to meliorate intendance for this chronic affliction.
Pace 1: Recognition of obesity as a chronic disease and obtaining patient permission
Principal care providers should recognize and treat obesity as a chronic disease, caused past abnormal or excess body fatty accumulation (adiposity), which impairs wellness, with increased risk of premature morbidity and mortality.1,2,18,44–47
Obesity is a circuitous and heterogeneous chronic illness that does not present in the same style in all patients and that requires individualized handling and long-term support like any other complex chronic disease.
Weight bias in wellness intendance settings tin can reduce the quality of care for patients living with obesity.42 A key to reducing weight bias, stigma and discrimination in health care settings is for health intendance providers to be aware of their own attitudes and behaviours toward individuals living with obesity.48 This can exist achieved by completing a self-assessment tool, similar the Implicit Association Exam, for weight bias.49 A full clarification and supporting evidence for weight bias recommendations are available online (http://obesitycanada.ca/guidelines/) in the affiliate titled "Reducing weight bias in obesity management, practice and policy."
Wellness care providers should not assume that all patients living with obesity are prepared to initiate obesity management. Health care providers should ask the patient permission to discuss obesity, and if the patient permits, so a give-and-take on treatment can begin.l,51
Step 2: Assessment
Master care clinicians should promote a holistic arroyo to wellness with a focus on health behaviours in all patients and address the root causes of weight gain with care to avert stigmatizing and overly simplistic narratives.
Straight measurement of pinnacle, weight and waist circumference and adding of BMI should exist included in routine concrete examination for all adults. Although BMI has its limitations, information technology remains a valuable tool for screening purposes and for population health indices.52 For persons with increased BMI (between 25 mg/g2 and 34.9 mg/m2), waist circumference should be regularly measured to identify individuals with increased visceral adiposity and adiposity-related health risks.53
Root causes of obesity include biological factors such as genetics, epigenetics, neurohormonal mechanisms, associated chronic diseases and obesogenic medications, sociocultural practices and behavior, social determinants of health, congenital environment, private life experiences like agin childhood experiences, and psychological factors such equally mood, anxiety, binge-eating disorder, attending-deficit/hyperactivity disorder, cocky-worth and identity.50 Working with people to sympathize their context and civilisation, and integrate their root causes, allows for the development of personalized plans. These plans tin exist integrated into long-term therapeutic relationships with chronic illness follow-upwardly of obesity and related comorbidities, including addressing the root causes of obesity such equally existing conditions and obesogenic medications.
We recommend obtaining a comprehensive history to identify these root causes of weight gain, also every bit physical, mental and psychosocial barriers. Physical examination, laboratory, diagnostic imaging and other investigations should exist carried out based on clinical judgment. We as well recommend measuring claret pressure level in both artillery and obtaining fasting glucose or glycated hemoglobin values and a lipid console to determine cardiometabolic hazard, and when indicated, alanine aminotransferase to screen for nonalcoholic fatty liver disease.
Stride 3: Discussion of treatment options
Adults living with obesity should receive individualized care plans that address their root causes of obesity and that provide back up for behavioural alter (due east.yard., diet, physical activity) and adjunctive therapies, which may include psychological, pharmacologic and surgical interventions.
Nutrition and exercise
All individuals, regardless of trunk size or composition, would benefit from adopting a good for you, well-balanced eating pattern and engaging in regular physical activity. Aerobic activity (xxx–60 min) on most days of the week can lead to a pocket-size amount of weight and fat loss, improvement in cardiometabolic parameters, and weight maintenance later weight loss.54
Weight loss and weight-loss maintenance require a long-term reduction in caloric intake. Long-term adherence to a healthy eating design that is personalized to run into private values and preferences, while fulfilling nutritional needs and handling goals, is an important element of managing health and weight.
Medical nutrition therapy is a foundation for chronic illness management, including obesity management.55,56 However, medical diet therapy should not be used in isolation in obesity management, as sustaining weight loss may be difficult long term because of compensatory mechanisms in the brain that promote positive caloric intake by increasing hunger and ultimately causing weight gain.57,58 Instead, medical nutrition therapy, in combination with other interventions (psychological, pharmacologic, surgical), should exist tailored to meet an individual's health-related or weight-related outcomes.56,59
The weight loss achieved with wellness behavioural changes is usually 3%–5% of body weight, which can result in meaningful improvement in obesity-related comorbidities.60 The corporeality of weight loss varies essentially among individuals, depending on biological and psychosocial factors and not simply on individual effort.
The weight at which the body stabilizes when engaging in salubrious behaviours can be referred to as the "best weight"; this may not exist an "ideal" weight on the BMI scale. Achieving an "ideal" BMI may be very hard. If further weight loss is needed to meliorate wellness and well-being beyond what can be achieved with behavioural modification, then more intensive pharmacologic and surgical therapeutic options can be considered.
Psychological and behavioural interventions
All health interventions such equally good for you eating and physical action strategies, medication adherence or surgery preparation and adjustment approaches rest on behaviour modify.61 Psychological and behavioural interventions are the "how to" of modify. They empower the clinician to guide the patient toward recommended behaviours that tin be sustained over time.sixty A full clarification of psychological and behavioural interventions and supporting show are available online (http://obesitycanada.ca/guidelines/) in the chapter titled "Effective psychological and behavioural interventions in obesity management."
Pharmacotherapy
Nosotros recommend adjunctive pharmacotherapy for weight loss and weight-loss maintenance for individuals with BMI ≥ thirty kg/yard2 or BMI ≥ 27 kg/m2 with adiposity-related complications, to support medical diet therapy, physical activeness and psychological interventions. Options include liraglutide 3.0 mg, naltrexone-bupropion combination and orlistat. Pharmacotherapy augments the magnitude of weight loss across that which health behaviour changes tin achieve alone and is important in the prevention of weight regain.62–66 A full description and supporting evidence are bachelor online (http://obesitycanada.ca/guidelines/) in the chapter titled "Pharmacotherapy in obesity direction."
Bariatric surgery
Bariatric surgery may be considered for people with BMI ≥ 40 kg/thousand2 or BMI ≥ 35 kg/mii with at least 1 obesity-related disease. The decision regarding the type of surgery should be made in collaboration with a multidisciplinary squad, balancing the patient'due south expectations, medical condition, and expected benefits and risks of the surgery. A full description and supporting bear witness are available online (http://obesitycanada.ca/guidelines/) in the capacity titled "Bariatric surgery: pick and preoperative workup," "Bariatric surgery: options and outcomes" and "Bariatric surgery: postoperative management."
Stride 4: Agreement regarding goals of therapy
Because obesity is a chronic disease, managing information technology in the long term involves patient–provider collaboration.67 Health care providers should talk with their patients and concord on realistic expectations, person-centred treatments and sustainable goals for behaviour modify and wellness outcomes.68
Helpful deportment in principal intendance consultations to mitigate antifat stigma include explicitly acknowledging the multiple determinants of weight-disrupting stereotypes of personal failure or success attached to torso limerick; focusing on behavioural interventions to amend overall health; and redefining success as healthy behaviour change regardless of torso size or weight.69
As this disease is chronic in nature, the treatment plan must exist long term. Health care providers and patients should pattern and concord on a personalized action program that is applied and sustainable and addresses the drivers of weight gain.seventy
Step 5: Follow-upwards and advocacy
There is a need to advocate for more effective care for people living with obesity. This includes improving the educational activity and lifelong learning of health care providers to be able to deliver effective, testify-based obesity care. We also need to support allocation of health care resource to amend admission to constructive behavioural, pharmacologic and surgical therapeutic options.
At that place are substantial barriers affecting admission to obesity intendance in Canada, including a profound lack of interdisciplinary obesity management programs, a lack of adequate admission to wellness care providers with expertise in obesity, long wait times for referrals and surgery, and the high costs of some treatments.,37,71–73 In general, health care professionals are poorly prepared to treat obesity. 74 None of the anti-obesity medications available in Canada is listed equally a benefit on whatsoever provincial or territorial formulary and none is covered under any provincial public drug benefit or pharmacare program.71 Expect times for bariatric surgery in Canada are the longest of whatever surgically treatable condition.37,71 Although access to bariatric surgery has increased in some parts of Canada, it is all the same express in most provinces and nonexistent in the 3 territories. 37,71,75 Patients referred to bariatric surgery can await as long equally eight years before coming together a specialist or receiving the surgery.
The lack of admission to obesity treatments is contributing to rising levels of severe obesity in Canada.46 Canadians afflicted by obesity are left to navigate a circuitous landscape of weight-loss products and services, many of which lack a scientific rationale and openly promote unrealistic and unsustainable weight-loss goals.76
Methods
Composition of participating groups
Obesity Canada and the Canadian Clan of Bariatric Physicians and Surgeons assembled an executive commission and steering commission with broad expertise and geographic representation. The executive committee (comprising 2 co-chairs [South.Due west., D.C.W.L.], a master care physician [D.C.-Southward.], a psychologist [M.V.], a bariatric surgeon [L.B.] and a nephrologist [A.M.S.]) provided overall vision and oversight for the guideline process.
The steering commission (n = 16) consisted of some lead authors of each chapter and a person living with obesity; this committee identified additional researchers (chapter leads and authors) to write each chapter. The executive committee and steering committee met in person in April 2017 and December 2017 and at to the lowest degree monthly past phone.
Chapter leads and chapter authors (northward = sixty) were selected based on their expertise in clinical practice and research in the field of obesity medicine. The number of affiliate authors per chapter ranged from 2 to 4. Some chapter leads identified additional authors to participate in writing each chapter.
We engaged people living with obesity (n = 7) through participation of the Public Engagement Committee of Obesity Canada. One member of the Public Engagement Committee (I.P.) was assigned to the steering committee for this guideline. The Public Engagement Committee met by phone one time per month. Nosotros obtained contributions from commission members through online surveys, focus groups and individual conversations.
We engaged Ethnic community members through a focus group (n = 14). Additionally, we obtained the insights of health care providers working with Ethnic communities via a consensus-building process between these clinicians and chapter authors, carried out over the spring of 2019, which further grounded prove in clinical practice. Details are available online (http://obesitycanada.ca/guidelines/) in the chapter titled "Obesity management with Indigenous Peoples."
Obesity Canada staff, consultants and volunteers (n = 15) provided administrative back up and project coordination for the guideline evolution process. Table ii outlines the guideline development procedure and the responsibilities of each group of participants.
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Tabular array ii:
Summary of guideline evolution process
Pick of priority topics
The executive committee conducted a listen-mapping exercise to identify the scope of the guideline and the broad sections and chapters (April–June 2017).79 A total of nineteen dissimilar sections and chapters were prioritized. The steering committee adult PI/PECOT (Population, Intervention or Exposure, Comparison, Result, Fourth dimension) questions for each chapter at an in-person coming together on December. 15–16, 2017, resulting in 179 questions to guide the literature search. All clinical questions were developed with the assistance of the McMaster Show Review and Synthesis Squad (MERST; previously the McMaster Evidence-Based Practice Center) in the appropriate format (due east.g., PICO [T] for therapeutics and treatments, PEO for qualitative questions).
Literature review and quality assessment
The McMaster Evidence Review and Synthesis Squad supported the guideline development through literature searches based on the PI/PECOT questions for each chapter. A health sciences librarian, based at McMaster Health Sciences Library (Hamilton, Ont.), used this information to create search strategies for the MEDLINE and Embase databases. The searches were for peer-reviewed and published literature in the English language; the search dates were January 2006 to June 2018. There were 14 searches that mapped directly to the chapters and another 7 searches that helped provide context for various chapters. Search strategies are available on the obesity guideline webpage (http://obesitycanada.ca/guidelines/). Once a search was conducted, the results were uploaded to EndNote, where the duplicates were removed and the final set up of citations was uploaded to DistillerSR software for selection and review.80 In add-on to the electronic searches, the affiliate authors identified additional citations and added them to the main search results.
Two reviewers completed screening of article titles and abstracts and independently selected studies for possible inclusion. Any commendation that was selected for inclusion by either reviewer was moved to total-text review. One or more authors of the relevant chapter conducted reviews of full-text articles for relevancy. Selected citations were so assessed for their methodological quality using the Shekelle approach.77,81 Each citation was categorized into prevention, treatment, evaluation of diagnostic properties or prognosis. Once that selection was fabricated, the advisable methods worksheet was displayed in the DistillerSR platform, from which the methodological questions were answered and a level of prove generated based on the type and quality of the study. The levels of evidence informed the forcefulness of the recommendations and were generated from the methods worksheets (Box iii).77
Box three:
Classification schemes77
Category of evidence
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Level 1a: Bear witness from meta-analysis of randomized controlled trials (RCTs)
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Level 1b: Evidence from at least 1 RCT
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Level 2a: Testify from at least ane controlled study without randomization
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Level 3: Show from nonexperimental descriptive studies, such as comparative studies, correlation studies and case–command studies
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Level 4: Evidence from expert committee reports or opinions or clinical experience of respected government, or both
Force of recommendation
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Grade A: Direct based on level 1 prove
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Grade B: Straight based on level two evidence or extrapolated recommendation from category i evidence
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Grade C: Directly based on level 3 evidence or extrapolated recommendation from level 1 or 2 bear witness
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Class D: Directly based on level 4 evidence or extrapolated recommendation from level 1, 2 or 3 testify
Adapted with permission from BMJ Publishing Group Limited. Shekelle PG, Woolf SH, Eccles M, et al. Developing clinical guidelines. West J Med 1999;170:348-51.
Development of recommendations
Recommendations were formulated by the steering committee, chapter leads and affiliate authors based on the highest level of evidence available (Box 3).77 Chapter leads and authors reviewed the type and strength of the bachelor evidence (level) and added the report reference that provided the highest level of evidence for the specific recommendation.
Recognizing the importance of qualitative research in addressing questions pertinent to the care of people living with obesity, content experts in qualitative enquiry (S.Thousand., X.R.S., D.C.South., 50.C., S.R.M.) were involved in the review of all materials informing these recommendations. Consensus appraisal of show quality by reviewers with expertise in qualitative methods informed the level of bear witness in these recommendations.
Some class D recommendations were formulated based on good committee reports, opinions or clinical experience of respected government, and referenced accordingly; other grade D recommendations formulated by affiliate authors were noted with "Consensus" after the grade D.
Chapter authors used a standardized terminology to make the recommendation more specific. The actionable verbs used for each of the recommendations were informed by the literature (Table 3).82–84
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Table 3:
Definitions of actionable verbs used in the recommendations82–84
Nosotros used an iterative procedure to finalize the recommendations. Methodologists from MERST provided an contained review of recommendations that had a form between A and C, for which they examined the clarity of wording and the fidelity of the recommendations with the show. Two methodologists (a principal and secondary reviewer) reviewed each recommendation, using checklists equally a guide for assigning levels of evidence to each citation. The methodologists met, discussed and reached consensus on grading the recommendations, and reported their suggestions regarding revisions to the wording or grading to the executive commission. Chapter leads edited the recommendations based on the MERST review procedure.
The executive committee voted on each recommendation, to ensure consensus. If a recommendation did not reach 100% agreement, the executive commission discussed the recommendation in depth until consensus was achieved. The chapter leads afterward modified the wording of this recommendation, as required, and the executive committee approved the newly worded recommendation. The executive commission provided final approving of all the recommendations. All the recommendations included in this guideline achieved 100% agreement.
External review
External reviewers (master care health care professionals and people living with obesity [northward = 7]) reviewed the recommendations for relevance and feasibility. We made some modifications to reverberate linguistic communication and the context of the master care setting. A separate external peer review was conducted for each affiliate.
Direction of competing interests
Funding came from the Canadian Institutes of Health Research Strategic Patient-Oriented Enquiry initiative, Obesity Canada's Fund for Obesity Collaboration and Unified Strategies (FOCUS) initiative, the Canadian Clan of Bariatric Physicians and Surgeons, and in-kind support from the scientific and professional person volunteers engaged in the process. The views of the funding body have not influenced the content of the guideline. All commission members (executive and steering committees), chapter leads and chapter authors were volunteers and not remunerated for their services.
The executive commission developed and managed the competing involvement policy and procedures for mitigating bias. The policy and disclosures of competing interest are bachelor on the guideline website. All participants were required to disclose potential competing interests. We maintained detailed competing interest declarations throughout the procedure for all members of the steering and executive committees, likewise as the participating methodologists from MERST. We used the International Committee of Medical Journal Editors' disclosure class, with the improver of government funding sources.
Individuals with relevant disclosures were not excluded from conducting the critical appraisals or voting on recommendations. However, the executive committee asked individuals with directly competing interests to abstain from voting in the areas in which they had the conflict. Any discussion regarding off-label use of drugs included the caveat that the use was off label.
As mentioned earlier, methodologists from MERST who had no competing interests reviewed and graded78 each included report to ensure the evidence had been appropriately assessed. They likewise reviewed the recommendations (graded between A and C) to ensure that recommendations were aligned with the evidence. Finally, we conducted an external review process to assess the feasibility of the recommendations and evaluate for the presence of bias.
Implementation
Obesity Canada and the Canadian Association of Bariatric Surgeons and Physicians have created a joint guideline website (http://obesitycanada.ca/guidelines) that hosts the full guideline; acting updates; a quick reference guide; central letters; wellness care provider tools, slide kits, videos and webinars; and resource for people living with obesity and their back up systems, in English language and French. The guideline will be hosted on the website as a living document. Each chapter lead will monitor testify related to this guideline and will collaborate with the executive committee to update the recommendations if new evidence becomes available that could influence the recommendations. A framework for implementation (5As Framework) is available in Appendix 2.
More than than ten years after the release of the first Canadian obesity guideline in 2006, admission to obesity care remains an issue in Canada.37,71 Obesity is not officially recognized as a chronic affliction by the federal, provincial and territorial, and municipal governments, despite declarations past the Canadian Medical Association85 and the World Health Organization.86 The lack of recognition of obesity every bit a chronic disease by public and private payers, wellness systems, the public and media has a trickle-downwardly outcome on admission to treatment.72 Obesity continues to exist treated as a self-inflicted condition, which affects the type of interventions and approaches that are implemented past governments or covered by health do good plans.87
Implementation of this guideline volition require targeted policy activeness, equally well as advancement efforts and date from people living with obesity, their families and wellness care providers. Canadian organizations have come together to change the narrative regarding obesity in Canada, to eliminate weight bias and obesity stigma, and to change the way health care systems and policies approach obesity.88 This guideline volition be used to assist in advancement efforts to federal and provincial governments to improve the care of individuals with obesity.
Other guidelines
In 2006, the first evidence-based Canadian clinical practice guideline on the prevention and management of obesity in adults and children was released.43 In 2015, the Canadian Task Force on Preventive Health Intendance, in collaboration with scientific staff of the Public Health Agency of Canada and the McMaster Evidence Review and Synthesis Centre, released a set of recommendations for prevention of weight proceeds and utilise of behavioural and pharmacologic interventions to manage overweight and obesity in adults in principal care.89 This guideline was not designed to "employ to people with BMI of 40 or greater, who may benefit from specialized bariatric programs" and reviewed only intervention trials conducted in settings generalizable to Canadian chief intendance. The guideline also did not include surgical treatments.
Gaps in knowledge
The recommendations in this guideline are informed by the best level of evidence available in 2020. We admit that ongoing research will keep to inform and advance obesity management.90,91
Current treatment options, apart from surgical intervention, rarely yield sustained weight loss across 20%, and for some people living with obesity, this level of weight loss may be inadequate for the resolution or improvement of many adiposity-related medical complications. At that place is a demand for more than handling options to meet the needs of people with obesity. Weight regain continues to exist a challenge for many patients who have received handling.92
Conclusion
Obesity is a prevalent, complex chronic illness that affects a large number of adults in Canada and globally, and yet only a small-scale fraction of people living with obesity who could benefit from treatment accept admission to care. This updated evidence-informed guideline is an attempt to raise access and care past people living with obesity through recognition among health care providers that obesity requires long-term handling. The newer insights into appetite regulation and the pathophysiology of obesity take opened new avenues for treating this chronic disease. Reducing weight bias and stigma, understanding the root causes of obesity, and promoting and supporting patient-centred behavioural interventions and appropriate handling by wellness intendance providers — preferably with the support of interdisciplinary intendance teams — will raise the standards of intendance and improve the well-being of people living with obesity. Dissemination and implementation of this guideline are integral components of our goals to address this prevalent chronic illness. Much more effort is needed to shut the gaps in knowledge through obesity research, education, prevention and treatment.
Acknowledgements
The authors give thanks Obesity Canada staff members Dawn Hatanaka, Nicole Pearce, Brad Hussey, Robert Fullerton and Patti Whitefoot-Bobier for their coordinating back up as well as their contributions for the development of the Obesity Guidelines website, online resources, tables and figures. The authors too thank members of the Obesity Canada Public Engagement Committee (Lisa Schaffer, Candace Vilhan, Kelly Moen, Doug Earle, Brenndon Goodman), who contributed to the creation of the research questions and reviewed fundamental messages for individuals living with obesity and recommendations for wellness care providers. The authors also thank McMaster Show Review and Synthesis Team (MERST) member Donna Fitzpatrick, who played a critical role in developing the methods needed for the guideline; and thank the reviewers whose comments helped to ameliorate the chapters and this manuscript. The authors thank Barbara Kermode-Scott and Brad Hussey for editing the guidelines, Elham Kamran and Rubin Pooni for enquiry aid, and Hashemite kingdom of jordan Tate from the Physician Learning Program at the University of Alberta for designing the 5As framework for the guideline.
Footnotes
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This commodity is available in French at www.cmaj.ca/lookup/suppl/doi:ten.1503/cmaj.191707/-/DC1
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CMAJ Podcasts: author interview at https://www.cmaj.ca/lookup/doi/ten.1503/cmaj.191707/tab-related-content
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Competing interests: Sean Wharton reports receiving honoraria and travel expenses and has participated in bookish advisory boards for Novo Nordisk, Bausch Health, Eli Lilly and Janssen. Sean Wharton is too the medical director of a medical clinic specializing in weight management and diabetes. David Lau reports receiving grants and research support from AstraZeneca, Novo Nordisk and the Canadian Institutes of Wellness Inquiry (CIHR); speaker bureau fees from AstraZeneca, Bausch Wellness, Boehringer Ingelheim, Diabetes Canada, Eli Lilly, Merck and Novo Nordisk; and consulting fees from Amgen, AstraZeneca, Bausch Health, Boehringer Ingelheim, Gilead, HLS Therapeutics, Janssen, Eli Lilly and Novo Nordisk. Michael Vallis is a member of advisory boards for Novo Nordisk, Bausch Health and LifeScan. Michael Vallis has also received consulting fees from Bausch Health, LifeScan, Novo Nordisk and Sanofi, and speaking fees from Novo Nordisk, Sanofi, Bausch Health, Abbott and AbbVie. Arya Sharma reports receiving speaker's bureau and consulting fees from Novo Nordisk, Bausch Pharmaceuticals and Astra-Zeneca. Laurent Biertho reports receiving grants from Johnson and Johnson and Medtronic, and is a member of advisory boards for Novo Nordisk and Bausch Health, outside the submitted piece of work. Denise Campbell-Scherer has no personal financial relationships, but reports receiving inquiry funding from the following sources in the past 3 years: Novo Nordisk Alberta Diabetes Fund (NOVAD), a peer-reviewed grant that is a partnership between the University Hospital Foundation, Novo Nordisk and Alberta Innovates articulation funders; Alberta Innovates Health Solutions (Cancer Prevention Enquiry Opportunity and Collaborative Research and Innovation Opportunities competitions), CIHR (Strategy for Patient-Oriented Research and Knowledge-to-Action competitions); Northern Alberta Family Medicine Fund; and the Alberta Cancer Prevention and Legacy Fund. She too reports receiving cognition transfer funding from the following sources in the by 3 years: an unrestricted pedagogy grant from Obesity Canada, funded by Novo Nordisk Global; a Worldwide Academy Network Meeting Grant; an Agency for Healthcare Research and Quality R13 grant for a Healthcare Effectiveness and Outcomes Research; and a Physician Learning Program grant from Alberta Health and the Alberta Medical Association. Angela Alberga reports receiving the following grants: the Santé Award from Fonds de Recherche du Quebec, the Mitacs Accelerate Grant, and the Concordia University Start-upward Team Grant, exterior the submitted work. Jennifer Brown reports receiving nonfinancial back up from Novo Nordisk, and personal fees from Bausch Health, Dietitians of Canada, Obesity Canada and the Canadian Clan of Bariatric Physicians & Surgeons. Yoni Freedhoff is the co-owner of the Bariatric Medical Plant and Constant Health, which provide weight management services; Abiding Health has received a grant from Novo Nordisk. Yoni Freedhoff is too the author of The Diet Fix: Why Diets Fail and How to Make Yours Work published by Crown Publishing Grouping, and receives royalties for the book. In improver, he is the sole author of the Weighty Matters blog and a column for Medscape and many other op-eds and articles in which he has publicly expressed opinions most the treatment, management and prevention of obesity. Yoni Freedhoff also regularly speaks on topics related to obesity and receives honoraria and travel costs and expenses for aforementioned. Michel Gagner reports receiving speaker honoraria from Ethicon, WL Gore and Medtronic; consulting fees from Novo Nordisk, Bausch Health and Lexington Medical; and holds stock options with Lexington Medical. Margaret Hahn reports receiving consulting fees from Alkermes. Marie-French republic Langlois reports receiving personal fees from Novo Nordisk, Valeant, Merck Canada, Sanofi, Eli Lilly and Boehringer Ingelheim; a grant from Merck Canada; and other fees from AstraZeneca and from TIMI (Thrombolysis in Myocardial Infarction) Report Group for diabetes clinical research as a chief investigator, all outside the submitted work. David Macklin reports receiving personal fees from Novo Nordisk and Bausch Wellness, outside the submitted work. Priya Manjoo reports receiving personal fees from Novo Nordisk, Bausch Health and Sanofi; and grants from Boehringer Ingelheim, Sanofi and AstraZeneca, outside the submitted work. Marie-Philippe Morin reports receiving speaker honoraria from Novo Nordisk, Bausch Health, Eli Lilly, Boehringer Ingelheim, Nestlé Wellness Science, Janssen and AstraZeneca; research subvention from Novo Nordisk and Sanofi; and consultation honoraria from Novo Nordisk, Bausch Health, Eli Lilly, Boehringer Ingelheim, Janssen and AstraZeneca. Sue Pedersen reports receiving personal fees from Novo Nordisk, Bausch Health, Janssen, Eli Lilly, Merck, AstraZeneca, Boehringer Ingelheim, Sanofi, Pfizer; grants from Eli Lilly, AstraZeneca, Boehringer Ingelheim and Sanofi; and nonfinancial support from Novo Nordisk, Bausch Health, Janssen, Eli Lilly, AstraZeneca, Boehringer Ingelheim and Sanofi, exterior the submitted piece of work. Megha Poddar reports receiving honoraria for continuing medical educational activity (CME) from Novo Nordisk, Bausch Wellness, Boehringer Ingelheim, Eli Lilly, Jenssen, Merck, the Canadian Collaborative Research Network and the Antibody Network; education grants from Novo Nordisk and Bausch Health; fees for mentorship from Novo Nordisk; fees for membership of informational boards from Novo Nordisk and Bausch Wellness; and a quality improvement project grant from Boehringer Ingelheim. Paul Poirier reports receiving fees for consulting and continuing medical instruction from AstraZeneca, Boehringer Ingelheim, Janssen, Eli Lilly, Novo Nordisk, Valeant and Bausch Health, outside the submitted piece of work. Judy Shiau reports receiving personal fees from Novo Nordisk and Bausch Health, exterior the submitted work. Diana Sherifali reports receiving consulting fees for advice regarding chronic illness and diabetes management from Merck, and a grant from Obesity Canada to support the literature review process, during the conduct of the study. John Sievenpiper reports receiving grants from CIHR, the Nutrition Trialists Fund at the Academy of Toronto, the International Nut and Stale Fruit Council Foundation, the Tate & Lyle Nutritional Research Fund at the University of Toronto, the American Society for Diet, the Glycemic Command and Cardiovascular Disease in Blazon 2 Diabetes Fund at the University of Toronto, the National Dried Fruit Trade Association, PSI Graham Farquharson Noesis Translation Fellowship, the Diabetes Canada Clinician Scientist award, the Banting & Best Diabetes Center Dominicus Life Financial New Investigator Award, the Canada Foundation for Innovation, and the Ministry of Inquiry and Innovation'due south Ontario Research Fund. Dr. Sievenpiper has received personal fees from Perkins Coie LLP, Tate & Lyle, Dairy Farmers of Canada, PepsiCo, Nutrient-Minds LLC, European Fruit Juice Clan, International Sweeteners Association, Nestlé Health Scientific discipline, Canadian Society for Endocrinology and Metabolism, GI Foundation, Pulse Canada, Wirtschaftliche Vereinigung Zucker due east.Five., Abbott, Biofortis, the European Food Prophylactic Authority, the Physicians Committee for Responsible Medicine, the Soy Nutrition Institute and the Comité Européen des Fabricants de Sucre. Dr. Sievenpiper has received nonfinancial support from Tate & Lyle, PepsiCo, FoodMinds LLC, European Fruit Juice Association, International Sweeteners Association, Nestlé Health Scientific discipline, Wirtschaftliche Vereinigung Zucker e.5., Abbott, Biofortis, the European Nutrient Safe Authorization and the Physicians Commission for Responsible Medicine, Kellogg Canada, American Peanut Council, Barilla, Unilever, Unico Primo, Loblaw Companies, WhiteWave Foods, Quaker, California Walnut Commission, Almond Board of California, outside the submitted piece of work. Dr. Sievenpiper is a fellow member of the International Saccharide Quality Consortium and the Clinical Practise Guidelines Expert Committees of Diabetes Canada, European Clan for the Written report of Diabetes, Canadian Cardiovascular Society, and Obesity Canada, and holds appointments as an Executive Board Fellow member of the Diabetes and Nutrition Report Group of the European Association for the Study of Diabetes, and as Managing director of the Toronto 3D Noesis Synthesis and Clinical Trials Foundation. He is also an unpaid scientific adviser for the Program in Nutrient Prophylactic, Nutrition and Regulatory Affairs and the Carbohydrates Committee of the International Life Scientific discipline Institute N America. He has a spousal relationship with an employee of Anheuser-Busch InBev. Sanjeev Sockalingam reports receiving honoraria from Bausch Health Canada inside the last 36 months. Valerie Taylor reports receiving speaker fees from Sunovion. Shahebina Walji reports receiving consulting or advisory lath fees from Novo Nordisk, Bausch Health and Takeda and speaker's bureau fees from Novo Nordisk and Bausch Wellness. Shahebina Walji also reports selling Optifast Meal replacements through a weight management centre Optifast is a production produced and sold by Nestlé. No other competing interests were declared.
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This article has been peer reviewed.
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Contributors: All of the authors contributed to the formulation and design of the work and the acquisition, assay, and interpretation of data. All of the authors drafted the manuscript, revised it critically for important intellectual content, gave final approval of the version to be published and agreed to exist accountable for all aspects of the work.
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Funding: Funding for this initiative was provided past Obesity Canada, the Canadian Association of Bariatric Physicians and Surgeons, and the Canadian Institutes of Health Research through a Strategy for Patient-Oriented Research grant, with no participants or authors receiving whatever personal funding for their creation.
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Source: https://www.cmaj.ca/content/192/31/E875
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