The Canadian Task Force on Preventive Health Care (CTFPHC) is composed of 14 experts who develop recommendations for clinical preventive services delivered by Canadian primary care practitioners.
The CTFPHC is responsible for prioritizing the topics that will be reviewed, and works with the Prevention Guidelines Division of the Public Health Agency of Canada to define the analytic framework and scope of each topic. In the preparation of evidence reviews and the development of recommendations for each topic, the CTFPHC collaborates with the Evidence Review and Synthesis Centre and the Prevention Guidelines Division.
The CTFPHC also leads knowledge translation activities, and assists key stakeholders in designing and implementing an evaluation strategy to assess the impact of the guidance documents.
Message from the Chair
Greetings! In this issue, I am pleased to announce the release of our newest clinical practice guideline. In March 2015, CMAJ published the CTFPHC’s Recommendations for growth monitoring, and prevention and management of overweight and obesity in children and youth primary care. For more information about the child obesity guideline, systematic reviews, and associated knowledge translation tools, please visit the CTFPHC child obesity guideline page.
As always, we appreciate your interest in the work of the CTFPHC and we encourage you to stay up to date on our work by visiting our website at www.canadiantaskforce.ca.
Marcello Tonelli, MD SM
Child Obesity Prevention and Management
CMAJ published the CTFPHC’s eighth guideline in March 2015. This latest guideline addressed childhood obesity and included six recommendations on growth monitoring, prevention, and management of overweight and obesity in primary care settings.
The prevalence of childhood obesity in Canada has nearly doubled since the 1970s, with current estimates from 2009–2011 indicating that nearly 32% of children aged 5 to 17 years are overweight or obese. Children who are overweight and obese are at greater risk for developing cardiovascular disease and diabetes in adolescence and adulthood, and excess weight in children often persists into adulthood.
The problem of obesity requires coordinated action from multiple sectors and levels of the health care system, including primary care. Primary care practitioners are well positioned to monitor the growth of infants, children, and adolescents (0–17 years) and ensure that children are following healthy growth trajectories. Thus, the CTFPHC strongly recommends that all primary care practitioners should measure height or length, and weight, and calculate body mass index (BMI) or weight-for-length, according to age using the World Health Organization Growth Charts for Canada at each appropriate primary care visit.
Given the limited evidence for obesity prevention programs in healthy-weight children in primary care settings, the CTFPHC does not recommend that practitioners routinely offer or refer healthy weight children to structured behavioural programs for the prevention of overweight or obesity. However, practitioners should consider the values and preferences of individual families, as some families may place a high value on the small potential benefits of these programs. The CTFPHC calls for more high quality research in this area.
Finally, primary care practitioners play a unique role in the management of obesity in children. The CTFPHC recommends that primary care practitioners offer or refer overweight or obese children and their families to structured behavioural programs aimed at healthy weight management. These programs should be delivered by an interdisciplinary team, involve group sessions, and incorporate parent and family involvement. It is not recommended that primary care practitioners offer pharmacological interventions (e.g., orlistat) to children who are overweight or obese or refer them for surgical interventions. For further details, visit the CTFPHC child obesity guideline page www.canadiantaskforce.ca.
Guidelines in Progress
Forthcoming guidelines developed by the CTFPHC will focus on the following topics:
- Screening for cognitive impairment
- Screening for colorectal cancer
- Screening for lung cancer
- Screening for developmental delay
- Screening for abdominal aortic aneurysm
- Screening for hepatitis C
- Tobacco prevention and cessation in children and adolescents
The CTFPHC always welcomes suggestions for guideline topics from members of the public and primary care practitioners. To submit a topic for consideration, please email firstname.lastname@example.org.
Patient Engagement in Guideline Development
The CTFPHC is conducting a project to engage patients in its guideline development process. Specifically, the CTFPHC is recruiting patients to provide input at up to two stages of the process: (1) when outcomes are selected for inclusion in the systematic review protocol that informs the guideline and (2) when the guideline recommendations are developed. The CTFPHC will use feedback provided by patients to guide the search for evidence on the harms and benefits of preventive health care interventions and to develop knowledge translation tools to accompany the guidelines. The CTFPHC is currently engaging patients in the process of developing two of its upcoming guidelines: lung cancer screening and hepatitis C screening.
The CTFPHC develops knowledge translation tools for primary care practitioners and members of the public to accompany each guideline. The purpose of the tools is to help clinicians and members of the public make decisions about preventive care.
Child Obesity Resources
To accompany its child obesity prevention and management guideline, the CTFPHC developed a double–sided quick reference clinical recommendation table. The clinical recommendation table helps practitioners identify which prevention and management actions are recommended and to whom these recommendations apply. Additional information on structured behavioural programs, resources, and how to best implement weak recommendations is provided on the back of the tool. Copies of the clinical recommendation table are available to download for free on the child obesity guideline page. As always, the CTFPHC encourages members of the public to discuss screening and management options with their primary care practitioner, who is aware of their health background and family history.
The CTFPHC’s mobile app helps physicians rapidly access CTFPHC guidelines and resources at the point of care and while on the go. The app contains guideline and recommendation summaries, knowledge translation tools, and links to additional resources. Key features include the ability to bookmark sections for easy access, display content in either English or French, and change the font size of text. The app is available on iTunes (for iPhones and iPads) and Google Play (for Android devices)
Understanding the GRADE Method
The Canadian Task Force on Preventive Health Care (CTFPHC) uses the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. This is an internationally recognized approach to evaluating systematic review evidence to develop clinical practice guidelines. GRADE recommendations are for clinicians, researchers, and policy makers.
The two key dimensions of the GRADE system are the quality of evidence (i.e., estimates of effect) and the strength of the recommendation. The quality of evidence (or estimates of effect) is based on the degree of confidence that the available evidence reviewed represents the true effect of the intervention or action for the primary outcomes of interest. This can be graded as high, moderate, low or very low.
There are four factors that form the basis of clinical practice guideline recommendations:
- Quality of evidence – estimates of the effect observed for outcomes
- Harms and benefits – evidence of the certainty about the balance between the benefits and harms of an action
- Values and preferences – evidence of the certainty or variability in the values and preferences of individuals
- Resources – evidence of whether the action is a wise use of resources These factors are weighed individually and in combination to form the strength of the recommendation.
The strength of recommendations can be strong or weak and the direction of a recommendation can be for or against a given action or intervention. Thus, there are four possible types of recommendations, each of which should be interpreted differently for implementation in clinical practice:
- A strong recommendation for an action or intervention
- this means that most patients would want to receive the action or intervention;
- A weak recommendation for an action or intervention
- this means that most patients would want to receive the action or intervention, but many patients may not;
- A weak recommendation against an action or intervention
- this means that most patients would not want to receive the action or intervention, but some patients may;
- A strong recommendation against an action or intervention
- this means most patients would not want to receive the action or intervention.
For more information on the CTFPHC’s use of the GRADE methodology, visit the website.