Obesity in Children—Clinician Recommendation Table

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The CTFPHC released the “Recommendations for growth monitoring, and prevention and management of overweight and obesity in children and youth in primary care” in 2015.

The task force recognizes that this guideline is currently out-of-date and has made a decision to “sunset” (archive) these recommendations. This was based on a review of the current evidence following the https://canadiantaskforce.ca/methods/updating-reaffirmation-and-sunsetting-clinical-practice-guidelines-methods-from-the-canadian-task-force-on-preventive-health-care/ methodology.

The decision to sunset the guideline was due to the following changes:

The evolving concept of obesity as a health issue (e.g., risk factor vs chronic disease or disorder) and resultant impact on selecting appropriate health outcomes
Substantial development in obesity management including pharmaceutical interventions that are beyond the scope of the Task Force mandate on preventive health care
Anticipated availability of an upcoming comprehensive Canadian guideline on obesity in children and youth

The task force acknowledges the importance of this topic to the health and wellbeing of Canadians. During future topic selection, we may re-evaluate aspects of this topic that are better suited to the Task Force mandate.

Prevention recommendations apply to healthy weight children and youth 0–17 years of age (i.e.maintain a healthy BMI trajectory according to the WHO Growth Charts for Canada ). They do not apply to children and youth with eating disorders, or who are underweight, overweight, or obese.

Management recommendations apply to children and youth 2–17 years of age who are overweight or obese. Children and youth with health conditions where weight loss is inappropriate are excluded.

Growth monitoring

Applies to all children and youth aged 0–17: we recommend growth monitoring at all appropriate primary care visitsⁱ using the WHO Growth Charts for Canada. Strong recommendation

Prevention

Structured behavioural interventions

Applies to children and youth of healthy weight aged 0–17: we recommend that primary care practitioners not routinely offer structured behavioural interventionsⁱⁱ (SBI) aimed at preventing overweight and obesity in healthy children. Weak recommendation

Management

Structured behavioural interventions

Applies to overweight or obese children and youth aged 2–17: we recommend that primary care practitioners offer or refer children and youth to structured behavioural interventions aimed at healthy weight management. Weak recommendation

Pharmacological interventions

Applies to children and youth aged 2–11 years: we recommend that primary care practitioners not offer Orlistat aimed at healthy weight management. Strong recommendation

Applies to children and youth aged 12–17 years: we recommend that primary care practitioners not offer Orlistat aimed at healthy weight management. Weak recommendation

Surgical interventions

Applies to overweight or obese children and youth aged 2–17: we recommend that primary care practitioners not routinely refer for surgical interventions. Strong recommendation

Additional information: general

Children naturally gain weight as they grow and their body mass index (BMI) increases with age. The goal of obesity prevention is to ensure that children who are following a healthy BMI trajectory maintain it. The goal of obesity management is to identify children who aren’t following a healthy BMI trajectory and help them return to one.

Additional information: growth monitoring
The strong recommendation implies that physicians should routinely monitor growth at all primary care visits for all children and youth.
Growth monitoring will be of value in early identification of weight-related health conditions in children and youth. These include hypertension, dyslipidemia, diabetes and non-alcoholic fatty liver disease.
For more information on growth monitoring, WHO Growth Charts, BMI, and how to approach the conversation about an abnormal growth pattern, please refer to the Dietitians of Canada’s tool.

Additional information: prevention

How do I implement this weak recommendation?

Clinicians should use their judgment in determining whether some families may benefit from being offered or referred to a program aimed at preventing overweight and obesity.
For example, if a family expresses concern about their child’s weight or is motivated to make lifestyle changes, clinicians should consider referring them to a program consistent with their values and preferences.
The CTFPHC did not evaluate the effectiveness of promoting other health behaviours in the primary care setting.

Additional information: management

How do I implement these weak recommendations?
- A weak recommendation in favour of referring children and youth to programs aimed at weight management implies that different choices may be appropriate for individual children (e.g., these interventions may be appropriate for most overweight and obese children and youth but not for those who don’t value the short-term benefits of these interventions). Clinicians should help each family reach a management decision consistent with their values and preferences.
- Similarly, pharmacological therapy may not be appropriate for most youth 12-17 years of age, but some youth and their families may choose to supplement programs with Orlistat (e.g., those who are less concerned about the harms of medication).
- Management decisions should be consistent with families’ values and preferences.
Which features should I look for when selecting a structured program?
- The most effective interventions vary substantially and availability of programs may change from province to province. Therefore, physicians should seek out local expertise to find reputable programs.
- The most effective weight management programs from our review included the following elements:
  - Focused on healthy nutrition, physical activity, making lifestyle changes, and were tailored to meet individual needs.
  - Included combinations of goal setting and/or active use of self-monitoring.
  - Were provided by a specialized interdisciplinary team and used multiple modes of delivery, such as a combination of group, individual and family sessions or individual sessions combined with technology-based components.
  - Ranged from 3 months to 3 years in duration.

Additional information: healthy living initiatives

The Canadian government is coordinating efforts with health services organizations across the country to provide information on healthy living programs in each province.
Please visit the Pan-Canadian Public Health Network’s list of resources to see recommended structured programs for healthy living.

For more information on the CTFPHC and its guidelines, download the CTFPHC mobile app for primary care practitioners on iTunes or Google Play. Or visit the CTFPHC mobile app page.

Footnotes

Appropriate primary care visits include well child visits, visits for immunizations or medication renewal, episodic care or acute illness, and other visits where the primary care practitioner deems it appropriate. Primary care visits are completed by primary care practitioners at primary health care settings, including those outside of a physician’s office (e.g. public health nurses carrying out a well-child visit at a community setting).
Structured behavioural interventions are intensive modification programs that involve several sessions. These take place over weeks to months, follow a comprehensive approach delivered by a specialized interdisciplinary team, include group sessions and incorporate family and parent involvement. Interventions examined include behavioural programs focused on healthy nutrition, increasing exercise, making lifestyle changes, or any combination of these. These can be delivered by a primary care team in the office or through a referral to a formal program within or outside of primary care, such as credible school-based or community programs.