GUIDELINE CPD Obesity in adults: a clinical practice guideline

Sean Wharton MD, David C.W. Lau MD PhD, Michael Vallis PhD RPsych, Arya M. Sharma MD PhD, Laurent Biertho MD, Denise Campbell-Scherer MD PhD, Kristi Adamo PhD, Angela Alberga PhD, Rhonda Bell PhD, Normand Boulé PhD, Elaine Boyling PhD, Jennifer Brown RD MSc, Betty Calam MD, Carol Clarke RD MHSc, Lindsay Crowshoe MD, Dennis Divalentino MD, Mary Forhan OT PhD, Yoni Freedhoff MD, Michel Gagner MD, Stephen Glazer MD, Cindy Grand MPH, Michael Green MD MPH, Margaret Hahn MD PhD, Raed Hawa MD MSc, Rita Henderson PhD, Dennis Hong MD, Pam Hung MScOT BSc, Ian Janssen PhD, Kristen Jacklin PhD, Carlene Johnson-Stoklossa RD MSc, Amy Kemp BKin BA, Sara Kirk PhD, Jennifer Kuk PhD, Marie-France Langlois MD, Scott Lear PhD, Ashley McInnes PhD, David Macklin MD, Leen Naji MD, Priya Manjoo MD, Marie-Philippe Morin MD, Kara Nerenberg MD MSc, Ian Patton PhD, Sue Pedersen MD, Leticia Pereira PhD, Helena Piccinini-Vallis MD PhD, Megha Poddar MD, Paul Poirier MD, Denis Prud’homme MD MSc, Ximena Ramos Salas PhD, Christian Rueda-Clausen MD PhD, Shelly Russell-Mayhew PhD RPsych, Judy Shiau MD, Diana Sherifali RN PhD, John Sievenpiper MD PhD, Sanjeev Sockalingam MD MHPE, Valerie Taylor MD PhD, Ellen Toth MD, Laurie Twells PhD, Richard Tytus MD, Shahebina Walji MD, Leah Walker BA RCT, Sonja Wicklum MD n Cite as: CMAJ 2020 August 4;192:E875-91. doi: 10.1503/cmaj.191707

This article is available in French at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.191707/-/DC1 CMAJ Podcasts: author interview at https://www.cmaj.ca/lookup/doi/10.1503/cmaj.191707/tab-related-content

besity is a complex chronic disease in which abnormal or excess body fat (adiposity) impairs health, KEY POINTS increases the risk of long-term medical complications • Obesity is a prevalent, complex, progressive and relapsing Oand reduces lifespan.1 Epidemiologic studies define obesity chronic disease, characterized by abnormal or excessive body 2 using the body mass index (BMI; weight/height ), which can fat (adiposity), that impairs health. stratify obesity-related health risks at the population level. • People living with obesity face substantial bias and stigma, Obesity is operationally defined as a BMI exceeding 30 kg/m2 which contribute to increased morbidity and mortality and is subclassified into class 1 (30–34.9), class 2 (35–39.9) and independent of weight or body mass index. class 3 (≥ 40). At the population level, health complications • This guideline update reflects substantial advances in the from excess body fat increase as BMI increases.2 At the individ- epidemiology, determinants, pathophysiology, assessment, ual level, complications occur because of excess adiposity, prevention and treatment of obesity, and shifts the focus of obesity management toward improving patient-centred health location and distribution of adiposity and many other factors, outcomes, rather than weight loss alone. including environmental, genetic, biologic and socioeconomic Obesity care should be based on evidence-based principles of 11 • factors (Box 1). chronic disease management, must validate patients’ lived Over the past 3 decades, the prevalence of obesity has steadily experiences, move beyond simplistic approaches of “eat less, increased throughout the world,12 and in Canada, it has increased move more,” and address the root drivers of obesity. threefold since 1985.13 Importantly, severe obesity has increased • People living with obesity should have access to evidence-informed more than fourfold and, in 2016, affected an estimated 1.9 million interventions, including medical nutrition therapy, physical activity, Canadian adults.13 psychological interventions, pharmacotherapy and surgery. Obesity has become a major public health issue that increases health care costs14,15 and negatively affects physical and psychological health.16 People with obesity experience per- Obesity is caused by the complex interplay of multiple vasive weight bias and stigma, which contributes (independent genetic, metabolic, behavioural and environmental factors, with of weight or BMI) to increased morbidity and mortality.17 the latter thought to be the proximate cause of the substantial

© 2020 Joule Inc. or its licensors CMAJ | AUGUST 4, 2020 | VOLUME 192 | ISSUE 31 E875 GUIDELINE years. biological underpinningsofthisdiseasehasemergedinrecent E876 rise intheprevalenceofobesity. ference measurements alone. of all-cause mortality when compared with BMI or waist circum- In population studies, it has been shown to be a better predictor logical parameterstodetermine theoptimalobesitytreatment. obesity classificationconsiders metabolic,physicalandpsycho- tissue onanindividualbasis. diovascular risk,butitisnotagoodpredictorofvisceraladipose ence has been independently associated with an increase in car- will helptoidentifythosewhobenefitfromtreatment. ate physicalexaminationandrelevantlaboratoryinvestigations prehensive historytoidentifytherootcausesofobesity,appropri - addition toBMIandwaistcircumferencemeasurements,acom - ence alone, particularlyin those individualswith lower BMI. phenotype ofobesitybetterthaneitherBMIorwaistcircumfer - circumference inclinicalassessmentmayidentify the higher-risk for identifyingadiposity-relatedcomplications. to assessandclassifyobesity(adiposity),itisnotanaccuratetool suppl/doi:10.1503/cmaj.191707/-/DC2). BMI category(Appendix1,availableatwww.cmaj.ca/lookup/ guide clinicaldecisionsfromtheobesityassessmentandateach practice havebeenproposed. neurohormonal adaptivemechanisms. negative energybalanceandtriggeracascadeofmetabolic regulating foodintakeandenergyexpenditure(Box2). effective toolsinthelong-termmanagementofobesity. these alterationsinneurohormonalmechanismscanbecome increases theriskoffollowingcancers: The Edmontonobesitystagingsystemhasbeenproposedto Novel approachestodiagnoseandassessobesityinclinical Decreased foodintakeandincreasedphysicalactivityleadtoa • • • • • expectancy by6to14years. cancer risks,andtherebyreducingdisease-freedurationlife and fatmetabolism,leadingtoincreasedcardiometabolic adipocytokines andinflammatorymediatorsthatcanalterglucose Excess andectopicbodyfatareimportantsourcesof • • • • many medicalcomplications,suchas: dysfunctional andpredisposetheindividualtodevelopmentof homeostasis, butexcessiveadipositycanalsobecome Adipose tissuenotonlyinfluencesthecentralregulationofenergy Box 1:Complicationsofobesity cancers canbeattributedtoobesity,independentofdiet. Postmenopausal breast(women) Endometrium (women) Esophagus (bothsexes) Kidney (bothsexes) Colon (bothsexes) Gout Nonalcoholic fattyliverdisease Gallbladder disease Type 2diabetes 19 Thebrainplaysacentralroleinenergyhomeostasisby 6 3 4 1,7,8 29 33,34 11,18,19,28 It is estimated that 20% of all Itisestimatedthat20%ofall Integration of both BMI and waist IntegrationofbothBMIandwaist 18,19 5 A better understanding of the Abetterunderstandingofthe Although BMI is widely used AlthoughBMIiswidelyused 25,26 10 28 CMAJ This 5-stage system of Therapiesthattarget 19 | Waistcircumfer- AUGUST 4, 2020 9 Obesity Obesity 24 27 32 30,31 In In | VOLUME 192 support peoplelivingwithobesity. living withobesity. negatively influencesthelevelandqualityofcareforpeople upon peoplelivingwithobesity. irresponsibility andlackofwillpowercastsblameshame regarding obesityfuelsassumptionsaboutpersonal system. disease, it is not effectively managed within our current health patient-centred healthoutcomes,ratherthanweightlossalone. to shiftthefocusofobesitymanagementtowardimproving line areweight-losscentred.However,moreresearchisneeded weight-loss outcomes,severalrecommendationsinthisguide- of Canada. of, andaccessto,careforindividuals withobesityinallregions practice, buttheguidelineisintended toimprovethestandard ences maymakeitdifficultto puteveryrecommendationinto dations. Resourcelimitations andindividualpatientprefer- discretion shouldbeusedby all whoadopttheserecommen- intended toserveasaguideforhealthcareproviders;clinical line isfocusedonobesityinadults.Therecommendations are and peopleaffectedbyobesitytheirfamilies.Theguide - fessionals. Theguidelinemayalsobeusedbypolicy-makers The targetusersforthisguidelineareprimaryhealthcarepro - Scope is availableonline(http://obesitycanada.ca/guidelines/). researchers. Thisarticleisasummaryofthefullguideline,which care providerswith those ofexpertsonobesity management, and of people with lived experience and of interprofessional primary obesity. Importantly,thisguidelineincorporatestheperspectives informed optionsforassessingandtreatingpeoplelivingwith update istodisseminateprimarycarepractitionersevidence- patients withobesityreceive. obesity alsoaffectthelevelandqualityofhealthcarethat loss. about improvedhealthandwell-being,notjustweight the 2006Canadianclinicalpracticeguideline. approaches toassessandmanageobesity,itistimelyupdate Despite growing evidence that obesity is a serious chronic There is arecognition that obesity management should be • • • Box 2:Appetiteregulation With increasedknowledgeofthediseasestateandbetter 34–36 behaviour andhasbeenshowntobealteredinobesity. interconnectivity oftheseneuralnetworksdriveseating control onfoodchoicesandthedecisiontoeat.The Cognitive functionsintheprefrontalcortexexertexecutive and otherorgans. influenced bymediatorsfromadiposetissue,thepancreas,gut The crosstalkbetweenhomeostaticandhedoniceatingis and thefrontallobe(executivecontrol). (homeostatic control),themesolimbicsystem(hedoniccontrol) of thecentralneuralcircuitsincludinghypothalamus The controlofappetiteiscomplexandinvolvestheintegration 37,38 Becausethe existing literature is basedmainly on Canadianhealthprofessionalsfeelillequippedto | ISSUE 31 42 42 20–23 Thedominantculturalnarrative 41 Importantly,obesitystigma 39–41 Biasedbeliefsabout 43 Thegoalofthis Obesity-visual-nologos-print-E.pdf 1 2020-07-23 12:21 PM

Obesity complex disease in which abnormal or excess body fat impairs health OBESITY Effects: IN ADULTS ▼ health ▼ quality of life ▼ lifespan A clinical practice guideline People with obesity increased complications experience weight bias and mortality independent and stigma of weight or BMI BMI IS NOT AN ACCURATE TOOL FOR IDENTIFYING Weight bias thinking that people with Stigma acting OBESITY-RELATED obesity do not have enough willpower on weight-biased COMPLICATIONS or are not cooperative beliefs

THE PATIENT JOURNEY IN OBESITY MANAGEMENT

ASK ADVISE ON 1 PERMISSION 3 MANAGEMENT “Would it be all right Medical nutrition therapy if we discussed • Personalized counselling by a registered your weight?” dietitian with a focus on healthy food choices Asking permission and evidence-based nutrition therapy • Shows compassion and empathy Exercise

• Builds patient–provider trust • 30-60 min of moderate to vigorous activity most days

ASSESS THEIR STORY 2 Psychological Medications Bariatric • Goals that matter to the patient • Cognitive approach • For weight loss surgery • Obesity classification to behaviour change and to help • Surgeon–patient (BMI and waist circumference) • Manage sleep, maintain weight discussion • Disease severity time and stress loss (Edmonton Obesity Staging System) • Psychotherapy if appropriate 4M Treating the root causes of weight gain AGREE ON GOALS is the foundation of 4 Collaborate on a personalized, obesity management sustainable action plan

Focus on Mechanical Metabolic patient-centred health outcomes Mental Social milieu versus weight loss alone ASSIST WITH DRIVERS 5 AND BARRIERS GUIDELINE treatment canbegin. cuss obesity,andifthepatient permits,thenadiscussionon Health careprovidersshouldask thepatientpermissiontodis- ing withobesityareprepared toinitiateobesitymanagement. ity management,practiceandpolicy.” ca/guidelines/) in the chapter titled“Reducingweightbias in obes­ bias recommendationsareavailableonline(http://obesitycanada ​ E878 premature morbidityandmortality. lation (adiposity),whichimpairshealth,withincreasedriskof chronic disease,causedbyabnormalorexcessbodyfataccumu- Primary careprovidersshouldrecognizeandtreatobesityasa obtaining patientpermission Step 1:Recognitionofobesityasachronicdiseaseand 5. 4. 3. Discussionofthecoretreatmentoptions(medicalnutrition 2. 1. and adiscussionofsupportingevidence. lined belowwithhighlightsoftherelevantrecommendations vider inthecareofpeoplelivingwithobesity.Eachstepisout- determined asimportantforadvancingclinicalpracticeinCanada. cussion of the guiding principles that the executive committee (http://obesitycanada.ca/guidelines/). Thissynopsisoutlinesadis- ing evidenceareavailableinthe19chaptersoffullguideline ting. TheguidelinerecommendationsareshowninTable1. ney andclinicalmanagementapproachintheprimarycareset- This clinical practice guideline informs thearcofpatient jour- Recommendations individuals livingwithobesity. providers tobeawareoftheirownattitudesandbehaviourstoward stigma anddiscriminationinhealthcaresettingsisfor for patientslivingwithobesity. other complexchronicdisease. requires individualizedtreatmentandlong-termsupportlikeany does notpresentinthesamewayallpatientsandthat weight bias. ing aself-assessmenttool,liketheImplicitAssociationTest, for

Health careprovidersshouldnot assumethatallpatientsliv- derives fromhealth-basedinterventions. of therapy,focusingmainlyonthevalue that the person Agreement with theperson living with obesity regarding goals surgical interventions. may berequired, including psychological, pharmacologic and therapy andphysicalactivity)adjunctivetherapiesthat plications andbarrierstoobesitytreatment. priate measurements,andidentifyingtherootcauses,com- Assessment ofanindividuallivingwithobesity,usingappro- advice andhelptreatthisdiseaseinanunbiasedmanner. providers, whoshouldaskthepatientpermissiontooffer Recognition of obesity as a chronic disease by health care There are5stepsinthepatientarctoguideahealthcarepro- A completedescriptionoftherecommendationsandsupport- agement ofadvocacytoimprovecareforthischronicdisease. obesity incontinuedfollow-upandreassessments,encour- Engagement by health care providers with the person with Weight bias in health care settings can reduce the quality of care Weight biasinhealthcaresettingscanreducethequalityof Obesity is acomplexand heterogeneous chronic disease that 49 A full description and supporting evidence for weight Afulldescriptionandsupportingevidenceforweight 50,51 48 Thiscanbeachievedbycomplet- 42 Akeytoreducingweightbias, 1,2,18,44–47 CMAJ | AUGUST 4, 2020 . | VOLUME 192 screen fornonalcoholicfattyliverdisease. metabolic risk, and when indicated, alanine aminotransferase to cated hemoglobinvaluesandalipidpaneltodeterminecardio- blood pressureinbotharmsandobtainingfastingglucoseorgly- out basedonclinicaljudgment.Wealsorecommendmeasuring diagnostic imagingandotherinvestigationsshouldbecarried psychosocial barriers. Physical examination, laboratory, these rootcausesofweightgain,aswellphysical,mentaland and obesogenicmedications. addressing the root causes of obesity such as existing conditions disease follow-upofobesityandrelatedcomorbidities,including integrated intolong-termtherapeuticrelationshipswithchronic for thedevelopmentofpersonalizedplans.Theseplanscanbe their contextandculture,integraterootcauses,allows posity andadiposity-relatedhealthrisks. larly tion healthindices. remains a valuable tool for screening purposes and for popula ical examination for alladults. Although BMIhas its limitations, it ence andcalculation of BMIshould be includedin routine phys­ tizing andoverlysimplisticnarratives. address therootcausesofweightgainwithcaretoavoidstigma- health withafocusonbehavioursinallpatientsand Primary carecliniciansshouldpromoteaholisticapproachto Step 2:Assessment eters, andweightmaintenance afterweightloss. weight andfatloss,improvementincardiometabolicparam ­ onmostdaysoftheweekcanleadtoasmallamount of 60 min) and engaginginregularphysicalactivity.Aerobicactivity(30– benefit fromadoptingahealthy,well-balancedeatingpattern All individuals,regardlessofbodysizeorcomposition,would Nutrition andexercise pharmacologic andsurgicalinterventions. and adjunctivetherapies,whichmayincludepsychological, support forbehaviouralchange(e.g.,nutrition,physicalactivity) plans thataddresstheirrootcausesofobesityandprovide Adults livingwithobesityshouldreceiveindividualizedcare Step 3:Discussionoftreatmentoptions self-worth andidentity. binge-eating disorder,attention-deficit/hyperactivity experiences, andpsychologicalfactorssuchasmood,anxiety, en­ practices andbeliefs,socialdeterminantsofhealth,built chronic diseasesandobesogenicmedications,sociocultural genetics, epigenetics,neurohormonalmechanisms,associated goals, isanimportant elementofmanaginghealth andweight. preferences, whilefulfillingnutritional needsandtreatment eating patternthatispersonalized tomeetindividualvaluesand reduction incaloricintake.Long-term adherencetoahealthy 25 mg/m vironment, individuallifeexperienceslikeadversechildhood We recommendobtainingacomprehensivehistorytoidentify Direct measurementofheight,weightandwaistcircumfer- Root causes of obesity include biological factors such as Weight lossandweight-lossmaintenance requirealong-term measured to identify individuals with increased visceral adi- 2 and34.9mg/m | ISSUE 31 52 ForpersonswithincreasedBMI(between 50 2 ), waistcircumference should beregu- Workingwithpeopletounderstand 53 54 - GUIDELINE E879 The amount of of The amount (consensus) 56,59 60 Level 3, grade C 3, grade Level Level 3, grade C 3, grade Level Level 3, grade C 3, grade Level Level 3, grade C 3, grade Level Level 4, grade D 4, grade Level Level 3, grade D 3, grade Level Level 4, grade D 4, grade Level Level 4, grade D 4, grade Level and strength of of and strength Level 1a, grade A 1a, grade Level Level 1a, grade A 1a, grade Level A 1a, grade Level Level 2a, grade B 2a, grade Level Level 2a, grade B 2a, grade Level Level 2b, grade B grade 2b, Level Level 2b, grade B grade 2b, Level Level 2b, grade B grade 2b, Level recommendation† See recommendation See recommendation Category of evidence evidence of Category ISSUE 31 ISSUE | wound care, and foot care. and foot care, wound The weight loss achieved with health behavioural changes is is health behavioural changes loss achieved with The weight should be considered for prevention of weight prevention for should be considered weight loss varies substantially among individuals, depending depending among individuals, varies substantially weight loss - factors and not simply on indi on biological and psychosocial vidual effort. usually 3%–5% of body weight, which can result in meaningful meaningful which can result in of body weight, usually 3%–5% comorbidities. in obesity-related improvement pharmacologic, surgical), should be tailored to meet an individ ­ meet an tailored to should be surgical), pharmacologic, outcomes. or weight-related ual’s health-related VOLUME 192 VOLUME | - - (level 2b, grade B). grade (level 2b, 2 Recommendations However, med- However, AUGUST 4, 2020 AUGUST | 55,56 CMAJ Instead, medical nutrition ther nutrition medical Instead, 57,58 We recommend that health care providers avoid making assumptions that an ailment or complaint a patient presents presents a patient an ailment or complaint that making assumptions avoid providers care health that We recommend their body weight. to with is related Health care providers should assess their own attitudes and beliefs regarding obesity and consider how their attitudes their attitudes how obesity and consider regarding and beliefs attitudes their own should assess providers care Health delivery. care may influence and beliefs Health care providers may recognize that internalized weight bias (bias toward oneself) bias (bias toward weight with obesity in people living internalized that may recognize providers care Health outcomes. and health behavioural affect can B) and practices grade (level 2b, A), images (level 1a, grade words using judgmental should avoid providers care Health obesity. living with with patients B) when working (level 2a, grade We suggest that a comprehensive history to identify root causes of weight gain as well as complications of obesity and as complications as well gain of weight causes identify root to history a comprehensive that We suggest be included in the assessment. treatment to barriers potential Health care providers can recognize and treat obesity as a chronic disease, caused by abnormal or excess body fat body fat abnormal or excess by caused disease, as a chronic obesity treat and recognize can providers care Health morbidity and mortality. risk of premature with increased health, (adiposity), which impairs accumulation We recommend measuring blood pressure in both arms, fasting glucose or glycated hemoglobin and lipid profile to to hemoglobin and lipid profile or glycated glucose arms, fasting in both blood pressure measuring We recommend in people disease liver fatty nonalcoholic for screen to ALT appropriate, risk and, where cardiometabolic determine living with obesity. The development of evidence-informed strategies at the health system and policy levels can be directed at managing at be directed and policy levels can system the health at strategies The development of evidence-informed obesity in adults. We suggest that health care providers consider using the Edmonton Obesity Staging System (see Appendix 1)§ to System Obesity Staging the Edmonton using consider providers care health that We suggest decision-making. the severity of obesity and guide clinical determine Continued longitudinal national and regional surveillance of obesity that includes self-reported and measured data data and measured includes self-reported surveillance of obesity that and regional Continued longitudinal national basis. on a regular may be collected circumference) height, weight, waist (i.e., We recommend regular monitoring of weight, glucose and lipid profile in people with a mental health diagnosis and health in people with a mental and lipid profile of weight, glucose monitoring regular We recommend gain. with weight associated medications taking who are We recommend that health care providers ask people living with obesity if they have concerns about managing self-care about managing self-care if they ask people living with obesity concerns have providers care health that We recommend skin and and bladder management, bowel dressed, getting such as bathing, activities, therapy behavioural such as cognitive treatment and psychological Metformin gain. with weight associated medications with antipsychotic treated illness who are mental in people with severe gain Health care providers may consider both efficacy and effects on body weight when choosing psychiatric medications. weight when choosing psychiatric on body and effects efficacy both may consider providers care Health to treatment psychological to as an adjunct and topiramate lisdexamfetamine should consider providers care Health disorder. in people with overweight and weight or obesity and binge-eating pathology eating reduce We recommend that health care providers assess fall risk in people living with obesity, as this could interfere with their with interfere as this could risk in people living with obesity, assess fall providers care health that We recommend activity. in physical in participating ability and interest We suggest that health care providers involved in screening, assessing and managing people living with obesity use the assessing and managing people living in screening, involved providers care health that We suggest to their permission and assessing their readiness asking for the discussion by initiate 5As (see Appendix 2‡) to framework treatment. begin Health care providers can measure height, weight and calculate the BMI in all adults (level 2a, grade B), and measure B), and measure (level 2a, grade the BMI in all adults height, and calculate weight measure can providers care Health with a BMI 25–35 kg/m in individuals circumference waist Medical nutrition therapy is a foundation for chronic disease disease for chronic is a foundation therapy nutrition Medical 4 Reducing weight bias in obesity management, practice and policy practice obesity management, bias in weight Reducing 1 Table 1 (part 1 of 5): Recommendations on management of obesity in adults* obesity in adults* of on management Recommendations 5): 1 of 1 (part Table 2 3 12 Epidemiology of adult obesity Epidemiology of 5 13 6 14 7 The role of mental health in obesity management health mental of The role 15 Enabling participation in activities of daily living for people living with obesity people daily living for of in activities Enabling participation 8 17 16 18 9 Assessment people living with obesity of 10 11 management, including obesity management. including obesity management,

apy, in combination with other interventions (psychological, with other interventions (psychological, apy, in combination ical nutrition therapy should not be used in isolation in obesity in obesity be used in isolation therapy should not ical nutrition difficult long loss may be as sustaining weight management, brain that mechanisms in the of compensatory term because ulti and hunger increasing by intake caloric positive promote mately causing weight gain. weight causing mately GUIDELINE E880 34 33 32 31 Effective psychological andbehavioural interventions inobesitymanagement 30 29 28 27 26 Physical activity inobesitymanagement 25 24 23 22 21 20 19 Medical nutritiontherapy inobesitymanagement Table 1(part 2of 5):Recommendations onmanagement of obesityinadults* psychological andbehavioural inobesitymanagement.”) interventions ofself-efficacydevelopment andintrinsicmotivation. (Full recommendation isavailable inthechapter titled“Effective Health care providers shouldprovide follow-up sessionsconsistent withrepetition andrelevance to supportthe not ontheamount ofweight loss. management isrelated to improved health, function andqualityoflife resulting from achievable behavioural goals and Health care providers shouldaskpeoplelivingwithobesity for permission to educate themthat success inobesity including clarifyingandreflecting onvalues-based behaviours. self-monitor behaviourandto analyze setbacks usingproblem-solving andadaptive thinking(cognitive reframing), reasons to change), to encourage thepatient to set andsequence health goals that are realistic andachievable, to ofconfidencesupport thedevelopment inovercoming barriers (self-efficacy) andintrinsicmotivation (personal, meaningful Health care providers shouldprovide longitudinalcare withconsistent messaging to peoplelivingwithobesityinorder to that promotes adherence, confidence andintrinsicmotivation 1b, (level grade A). incorporated into care plansfor weight loss,andimproved health status andqualityoflife 1a,grade (level A)inamanner cognitiveproblem-solving], therapy [reframing] andvalues-based strategies to alter diet andactivity) shouldbe Multicomponent psychological (combining interventions behaviourmodification [goal-setting, self-monitoring, image in adults orobesity. living with overweight Regular physical activity can improve health-related qualityoflife, mooddisorders (i.e., depression, anxiety) andbody 1a,grade(level 2a,grade B)anddyslipidemia(level B). orobesity,have overweight includinghyperglycemia 2b, andinsulinsensitivity(level grade B),highbloodpressure Regular physical activity, withandwithout weight loss,can improve manycardiometabolic riskfactors inadults who and reduce theamount oftimerequired to benefits achieve similarto thosefrom moderate-intensity aerobic activity. Increasing exercise intensity, includinghigh-intensity interval training, can greater achieve increases incardiorespiratory fitness in musclemassorfat-free massandmobility. For adults orobesity, livingwithoverweight resistance training maypromote weight maintenance ormodest increases • • • • • adults whowant to: Aerobic physical activity (30–60minutes ofmoderate to vigorous intensity most daysoftheweek) can beconsidered for perceptions), cardiovascular outcomes, physical bodyweight, activity, cognitive restraint andeating behaviours. We recommend anondieting approach to improve qualityoflife, psychological outcomes (general well-being, bodyimage apnea anddepression. weight loss,to increase theremission oftype2diabetes andreduce theincidence ofnephropathy, obstructive sleep Adults livingwith obesityandtype2diabetes shouldconsider intensive lifestyle that interventions target a7%–15% neuropathy) 1a,grade (level B),andcardiovascular andall-cause mortality 1a,grade (level B). reduce theincidence oftype2diabetes 1a,grade (level A),microvascular complications (retinopathy, nephropathy and that target a5%–7%weight loss,to improve glycemic control, bloodpressure andbloodlipidtargets 1a,grade (level A)and Adults livingwithobesityandimpaired glucose tolerance (prediabetes) shouldconsider intensive behavioural interventions category ofevidence andlevel available inthechapter titled“Medical nutritiontherapy inobesitymanagement.”) the dietary patterns andfood-based approaches that supporttheirbest long-term adherence. (Full recommendation and Adults livingwithobesitycan consider anyofmultiplemedical nutritiontherapies to improve health-related outcomes, choosing and improve glycemic control andbloodpressure. nutrition therapy provided by aregistered dietitian (whenavailable) to reduce bodyweight andwaist circumference Adults livingwithobesityandimpaired glucose tolerance (prediabetes) ortype2diabetes mayreceive medical lipid, andbloodpressure targets. (when available) to improve weight outcomes BMI),waist (bodyweight, circumference, glycemic control, established Adults livingwithobesityshouldreceive individualized medical nutritiontherapy provided by aregistered dietitian acceptable andaffordable for long-term adherence. preferences andtreatment goals to supportadietary approach that issafe, effective, nutritionallyadequate, culturally We suggest that nutritionrecommendations for adults ofallbodysizes bepersonalized to meet individualvalues, Increase cardiorespiratory 2a,grade fitness(level 2a,grade B)andmobility(level B). Favour themaintenance offat-free massduringweight 2a,grade loss(level B) Favour weight maintenance after 2a,gradeweight loss(level B) intheabsenceeven ofweight loss reductionAchieve inabdominalvisceral fat 1a,grade (level A)andectopic fat, suchasliver andheart fat 1a, grade (level A), smallamountsAchieve ofbodyweight andfat 2a,grade loss(level B) CMAJ | AUGUST 4, 2020 Recommendations | VOLUME 192 | ISSUE 31 Category of evidence See recommendation See recommendation See recommendation See recommendation See recommendation recommendation† Level 2b, grade B Level 2a,grade B Level 2a,grade B Level 2a,grade B Level 1a,grade A Level 1a,grade A Level 1a,grade A Level 1a,grade A Level 1a,grade A and strength of Level 4,grade D Level 3,grade C GUIDELINE E881 (consensus) (consensus) (consensus) (consensus) (consensus) (consensus) (consensus) Level 4, grade D 4, grade Level Level 4, grade D 4, grade Level Level 4, grade D 4, grade Level Level 4, grade D 4, grade Level Level 4, grade D 4, grade Level Level 4, grade D 4, grade Level Level 4, grade D 4, grade Level Level 4, grade D 4, grade Level Level 4, grade D 4, grade Level Level 4, grade D 4, grade Level Level 4, grade D 4, grade Level and strength of of and strength Level 1a, grade A 1a, grade Level Level 2a, grade B 2a, grade Level Level 2a, grade B 2a, grade Level Level 2a, grade B 2a, grade Level Level 2a, grade B 2a, grade Level Level 2a, grade B 2a, grade Level Level 2a, grade B 2a, grade Level recommendation† See recommendation See recommendation Category of evidence evidence of Category with adiposity-related with adiposity-related 2 ISSUE 31 ISSUE | with at least 1 adiposity-related 1 adiposity-related least with at 2 or BMI ≥ 27 kg/m 2 VOLUME 192 VOLUME | or BMI ≥ 35 kg/m 2 , pharmacotherapy can be used in conjunction with health with health be used in conjunction can , pharmacotherapy 2 Recommendations AUGUST 4, 2020 AUGUST | CMAJ ) to delay or prevent type 2 diabetes (liraglutide 3.0 mg; orlistat). 3.0 mg; (liraglutide type 2 diabetes delay or prevent ) to 2 ) despite optimal medical management. medical optimal ) despite 2 Reduce long-term overall mortality (level 2b, grade B) grade (level 2b, mortality overall long-term Reduce A) alone (level 1a, grade management with medical loss compared weight long-term better significantly Induce medical best over management, medical best with in combination of type 2 diabetes, and remission control Induce B) alone (level 2a, grade management C) (level 3, grade quality of life improve Significantly C), hypertension (level including dyslipidemia 3, grade diseases, adiposity-related of most remission long-term Induce C). (level 3, grade steatohepatitis and nonalcoholic steatosis C), liver (level 3, grade We suggest that the choice of bariatric procedure (sleeve gastrectomy, gastric bypass or duodenal switch) be decided or duodenal switch) bypass gastric (sleeve gastrectomy, procedure of bariatric the choice that We suggest team. interprofessional with an experienced need, in collaboration the patient’s to according Bariatric surgery may be considered for weight loss and/or to control adiposity-related diseases in persons with class 1 in persons diseases adiposity-related control to loss and/or weight for surgery may be considered Bariatric weight loss. significant to produce has been insufficient management and behavioural medical in whom optimal obesity, We suggest that bariatric surgical centres provide follow-up and appropriate laboratory tests at regular intervals intervals regular at tests laboratory and appropriate follow-up provide centres surgical bariatric that We suggest physician, bariatric social worker, nurse, (dietitian, professionals care health appropriate to with access postsurgery the patient. for is deemed appropriate until discharge or psychiatrist) psychologist surgeon, We do not suggest the use of prescription or over-the-counter medications other than those approved for weight management. weight for than those approved other medications or over-the-counter the use of prescription suggest We do not Pharmacotherapy for weight loss can be used for persons with BMI ≥ 30 kg/m persons be used for loss can weight for Pharmacotherapy We recommend pharmacotherapy in conjunction with health behaviour changes for people living with prediabetes and people living with prediabetes for behaviour changes with health in conjunction pharmacotherapy We recommend overweight or obesity (BMI ≥ 27 kg/m behaviour changes for weight loss and improvement in glycemic control: liraglutide 3.0 mg (level 1a, grade A), 3.0 mg (level 1a, grade liraglutide control: in glycemic loss and improvement weight for behaviour changes B). (level 2a, grade B), orlistat (level 2a, grade combination naltrexone-bupropion Bariatric surgery should be considered in patients with poorly controlled type 2 diabetes and class I obesity (BMI type 2 diabetes with poorly controlled in patients surgery should be considered Bariatric 30 and 35 kg/mbetween disease (level 4, grade D, consensus) to: D, consensus) (level 4, grade disease • • • • • For people living with type 2 diabetes and a BMI ≥ 27 kg/m people living with type 2 diabetes For Pharmacotherapy may be used to maintain weight loss that has been achieved by health behaviour changes, and to and to changes, behaviour health has been achieved by loss that weight maintain used to may be Pharmacotherapy 3.0 mg or orlistat). (liraglutide regain weight prevent complications, in conjunction with medical nutrition therapy, physical activity and psychological interventions and psychological activity physical nutrition therapy, with medical in conjunction complications, orlistat). combination, 3.0 mg, naltrexone-bupropion (liraglutide We suggest that adjustable gastric banding not be offered owing to unacceptable complications and long-term failure. and long-term complications unacceptable to owing be offered not banding gastric adjustable that We suggest For people living with overweight or obesity who require pharmacotherapy for other health conditions, we suggest suggest we conditions, health other for pharmacotherapy people living with overweight who require or obesity For gain. with weight associated not are choosing drugs that We suggest that single anastomosis gastric bypass not be routinely offered, owing to long-term complications in complications to long-term owing offered, be routinely not bypass gastric single anastomosis that We suggest bypass. gastric with Roux-en-Y comparison We suggest that a comprehensive medical and nutritional evaluation be completed and nutrient deficiencies corrected and nutrient deficiencies corrected be completed nutritional evaluation and medical a comprehensive that We suggest surgery. bariatric for in candidates We suggest that bariatric surgical centres communicate a comprehensive care plan to primary care providers for patients patients for primary providers plan to care care a comprehensive communicate centres surgical bariatric that We suggest long-term required, blood tests annual numbers, contact emergency procedure, including bariatric discharged, who are back. refer interventions, as when to as well and behavioural medications supplements, and minerals vitamin Health care providers can encourage persons who have undergone bariatric surgery to participate in and maximize in and maximize participate surgery to bariatric undergone who have persons encourage can providers care Health centre. surgical a bariatric services at interventions and allied health behavioural to their access We suggest screening for and treatment of obstructive sleep apnea in people seeking bariatric surgery. in people seeking bariatric sleep apnea of obstructive and treatment for screening We suggest Preoperative smoking cessation can minimize perioperative and postoperative complications. and postoperative perioperative minimize can smoking cessation Preoperative We suggest that after a patient has been discharged from the bariatric surgical centre, primary care providers conduct conduct primary providers centre, care surgical bariatric the from has been discharged patient a after that We suggest supplements, and mineral multivitamin to adherence activity, weight, nutritional intake, of the following: annual review nutritional deficiencies as required. for assess and treat to tests and laboratory assessment of comorbidities Bariatric surgery can be considered for people with BMI ≥ 40 kg/m for be considered surgery can Bariatric We suggest that primary care providers consider referral back to the bariatric surgical centre or to a local specialist for specialist a local or to centre surgical the bariatric to back referral consider primary providers that care We suggest or other support, regain weight psychological nutritional issues, pregnancy, symptoms, or gastrointestinal technical management. surgery: postoperative titled “Bariatric as described in the chapter surgery, bariatric to issues related medical 47 46 39 54 Pharmacotherapy in obesity management Pharmacotherapy 35 Table 1 (part 3 of 5): Recommendations on management of obesity in adults* obesity in adults* of on management 5): Recommendations 3 of 1 (part Table 38 45 37 36 48 40 49 Bariatric surgery: selection and preoperative workup and preoperative selection surgery: Bariatric 41 51 Bariatric surgery: postoperative management postoperative surgery: Bariatric 50 43 42 52 Bariatric surgery: surgical options and outcomes options surgical surgery: Bariatric 44 53

GUIDELINE E882 57 56 55 carePrimary health andprimary care inobesitymanagement Table 1(part 4of 5:Recommendations onmanagement of obesityinadults* 59 58 63 62 61 60 66 65 64 71 Emerging technologies andvirtualmedicineinobesitymanagement 70 69 68 67 Commercial products andprograms inobesitymanagement 73 72 management asaneffective intervention to manage weight. care shouldbeusedto interventions Primary increase health literacy inindividuals’ knowledge andskillaboutweight taking anthropometric measurements. We recommend that health care providers ensure askpeoplefor they theirpermissionbefore discussingweight or health-focused conversations withthem. We recommend care that andobesity, cliniciansidentifypeoplewithoverweight primary andinitiate patient-centred, health, andweight management. individuals’ life context inaway that ismanageable andsustainable to supportimproved physical andemotional care clinicianscanPrimary usecollaborative deliberation withmotivational to tailor interviewing action plansto with personalized obesitymanagement strategies asaneffective way to supportobesitymanagement. care cliniciansshouldreferPrimary care orobesityto persons withoverweight multicomponent primary programs pharmacotherapy, shouldbeusedto manage andobesity. overweight care that interventions Primary are behaviourbased (nutrition,exercise, lifestyle), aloneorincombination with way to supportpeoplelivingwithobesity. care multicomponentPrimary programs shouldconsider personalized obesitymanagement strategies asaneffective “small change approach”) to beeffective insupportingpeople to manage their weight. careLongitudinal shouldfocus interventions onincremental, primary personalized, smallbehaviourchanges (the across andwithindifferent ethnic groups. with regard to excess food weight, andphysical activity, aswell associoeconomic circumstances, maydiffer asthey thatInterventions target aspecificethnic group shouldconsider thediversity ofpsychological andsocialpractices necessary tonecessary confidently andeffectively supportpeoplelivingwithobesity. should provide courses andclinical experiences to address thegaps inskills,knowledge oftheevidence, andattitudes Educators ofundergraduate, graduate andcontinuing education programs health care for primary professionals potentially viablelower cost inacommunity-based intervention setting. thatInterventions to usetechnology increase reach to larger numbers ofpeopleasynchronously shouldbea overweight andobesity.overweight (Action for Health inDiabetes) programs shouldbeusedasaneffective management option for adults with Group-based diet andphysical activity sessionsinformed by theDiabetes Prevention Program andtheLook AHEAD application) inthemanagement ofobesity. medical nutritiontherapy andphysical activity) ormobiledevices (e.g.,dailyweight reporting through asmartphone Implementation ofmanagement strategies can bedelivered through Web-based platforms (e.g.,onlineeducation on in adults livingwithobesity. We donot suggest that commercial weight-loss programs beusedfor improvement inbloodpressure andlipid control to lackofevidence. We donot recommend theuseofover-the-counter commercial weight-loss products for obesitymanagement, owing diabetes. hemoglobin values over ashort-term periodcompared withusualcounselling inadults withobesityandtype 2 Optifast, JennyCraig, WW(formerly WeightWatchers) andNutrisystem amildreduction shouldachieve ofglycated • • • • weight lossintheshortormediumterm, compared withusualcare oreducation: For adults orobesity, livingwithoverweight thefollowing commercial programs mildto should achieve moderate management. The useofwearable activity tracking shouldbepart technology ofacomprehensive strategy for weight outcomes. coaching orfeedback via phoneoremail)into technology-based management strategies to improve weight-loss We suggest that health care providers incorporate individualized feedback andfollow-up (e.g.,personalized Nutrisystem 1b, (level grade B) Jenny Craig 1b, (level grade B) Optifast 1b, (level grade B) WW (formerly WeightWatchers) 1a,grade (level A) CMAJ | AUGUST 4, 2020 Recommendations | VOLUME 192 | ISSUE 31 Category of evidence See recommendation recommendation† Level 1b, grade B Level 1b, grade B Level 1b, grade B Level 1b, grade B Level 1b, grade B Level 1b, grade B Level 2b, grade C Level 2a,grade B Level 1b, grade A Level 1a,grade A Level 1a,grade A Level 1a,grade A Level 1a,grade A and strength of Level 4,grade D Level 4,grade D Level 4,grade D Level 3,grade C Level 3,grade C GUIDELINE E883 (consensus) Level 3, grade C 3, grade Level Level 3, grade C 3, grade Level C 3, grade Level Level 4, grade D 4, grade Level and strength of of and strength recommendation† See recommendation See recommendation See recommendation Category of evidence evidence of Category ISSUE 31 ISSUE | VOLUME 192 VOLUME | Recommendations AUGUST 4, 2020 AUGUST | CMAJ Engage with the patient’s social realities. with the patient’s Engage and obesity, influencing poor health disadvantage and systemic of stress experiences the patient’s Validate shift behaviours. could stress reduced where of their environment elements exploring that recognizing systems, care within publicly funded health resources obesity-management to access for Advocate for many. and unattainable beyond may be unaffordable resources it. entitled to and they are is attainable, health good that recognize Help patients context. the patient’s to relevant steps small, attainable Negotiate and providers. in patients and paralysis seeming apathy resistance, Address and motivations patient exploring systems, care within health sentiment common on anti-Indigenous Self-reflect problems. their health and solutions to of causes grief) understandings (e.g., trauma, health as alternative mental racism. systemic by bias influenced for potential own one’s Explore of as an expert, instead the patient as a helper to themselves reposition systems; in health mistrust patient Expect wellness. patients’ to and be a barrier resistance which may stir health and emotional mental patient explore encountered, are and paralysis seeming apathy When resistance, contexts. in many Indigenous and presentations unique drivers needs, which have relationships. healing by knowledge Build complex of co- longitudinal explorations through obesity self-management for and capacity knowledge Build patient healing incorporate that build relationships to Strive factors. and cultural social, environmental health, occurring may more involvement, system and child welfare schools residential to owing that, trauma multigenerational from abuse. sexual include frequently of experiences — including ongoing colonization of legacy the health regarding knowledge Build their own built on mutual relationships facilitate — to and wider society within systems discrimination anti-Indigenous understanding. level, and is learner and educational perspectives with the patient’s is congruent provided knowledge Ensure or unequal treatment. of racism anticipation patient for including potential centred, doing and being. of knowing, ways the body and Indigenous behaviour, to Connect in behaviours and healthy of health concepts individual and community-based the patient’s Elicit and incorporate and foods land-based to access or scarce for (e.g., preference preferences and food activity body size, to relation activities). in and knowledge-sharing communication and principles regarding values of common in learning Deeply engage noninterference). (e.g., relationalism, contexts Indigenous We suggest that health care providers for Indigenous people living with obesity: Indigenous for providers care health that We suggest • • • • • • • • • • • • • • • • We recommend that women with obesity be offered additional breastfeeding support because of decreased rates of rates of decreased support because additional breastfeeding with obesity be offered women that We recommend and continuation. initiation We recommend that primary care providers encourage and support pregnant women with obesity who do not have have with obesity who do not women and support pregnant encourage primary providers that care We recommend intensity of moderate per week 150 minutes least in at engage to during pregnancy exercise to contraindications gain. weight of gestational in the management assist to activity, physical with obesity women in pregnant gain weight gestational for metformin prescribe should not providers care Health or breastfeeding be used during pregnancy not medications weight-management that A). We suggest grade (level 1b, D). (level 4, grade We recommend that primary care providers encourage and support pregnant women with obesity to consume foods foods consume with obesity to women and support pregnant encourage primary providers that care We recommend gain. weight gestational their target meet to in order pattern dietary with a healthy consistent Primary care providers should offer behaviour change interventions including both nutrition and physical activity to activity nutrition and physical interventions including both behaviour change should offer Primary providers care B) (level 2a, grade pregnant are C), who (level 3, grade a pregnancy considering with obesity who are adult women targets. achieve weight to A) in order (level 1a, grade postpartum and who are We recommend that primary care providers discuss weight-management targets specific to the reproductive years years the reproductive specific to targets discuss weight-management primary providers that care We recommend 9 kg to of 5 kg gain weight C); gestational loss (level 3, grade weight obesity: preconception with with adult women (level gain weight minimum — gestational loss of — at weight D); postpartum (level 4, grade pregnancy the entire over pregnancy. or in a future in the current outcomes the risk of adverse reduce C) to 3, grade Obesity management and Indigenous Peoples and Indigenous Obesity management 80 79 77 78 76 75 Note: ALT = alanine aminotransferase, BMI = body mass index. = alanine aminotransferase, ALT Note: verbs the actionable definitions for 3 provides Table http://obesitycanada.ca/guidelines/. at available is and supporting evidence of the recommendations description *A complete used in these recommendations. 3. see Box of evidence, and strength of evidence category for scheme the classification †For www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.191707/-/DC2. at ‡Appendix 2 is available §See Appendix 1. Weight management over the reproductive years for adult women living with obesity adult women for years the reproductive over Weight management 74 Table 1 (part 5 of 5): Recommendations on management of obesity in adults* obesity in adults* of on management 5): Recommendations 5 of 1 (part Table

GUIDELINE “Bariatric surgery:postoperativemanagement.” tive workup,”“Bariatricsurgery:optionsandoutcomes” in thechapterstitled“Bariatricsurgery:selectionandpreopera - dence areavailable online (http://obesitycanada.ca/guidelines/) efits andrisksofthesurgery.Afulldescriptionsupportingevi - the patient’sexpectations,medicalcondition,andexpectedben - made incollaborationwithamultidisciplinaryteam,balancing disease. Thedecisionregardingthetypeofsurgeryshouldbe for behaviourchangeandhealth outcomes. expectations, person-centred treatments and sustainable goals viders shouldtalkwiththeirpatientsandagreeonrealistic or BMI≥ E884 term involves patient–provider collaboration. Because obesityisachronicdisease,managingitinthelong Step 4:Agreementregardinggoalsoftherapy the preventionofweightregain. health behaviourchangescanachievealoneandisimportantin apy augmentsthemagnitudeofweightlossbeyondthatwhich ­naltrexone-bupropion combinationandorlistat.Pharmacother- logical interventions.Optionsincludeliraglutide3.0mg, port medicalnutritiontherapy,physicalactivityandpsycho­ mended behavioursthatcanbesustainedovertime. They empowerthecliniciantoguidepatienttowardrecom- logical andbehaviouralinterventionsarethe“howto”ofchange. and weight-lossmaintenanceforindividualswithBMI≥ We recommendadjunctivepharmacotherapyforweightloss Pharmacotherapy behavioural interventionsinobesitymanagement.” ca/guidelines/) inthechaptertitled“Effectivepsychologicaland supporting evidenceareavailableonline description ofpsychologicalandbehaviouralinterventions cess attached to bodycomposition;focusing onbehavioural nants ofweight-disruptingstereotypes ofpersonalfailureorsuc- fat stigmaincludeexplicitlyacknowledging themultipledetermi- adjustment approachesrestonbehaviourchange. ity strategies,medicationadherenceorsurgerypreparationand All health interventions such as healthy eating and physical activ- Psychological andbehaviouralinterventions logic andsurgicaltherapeuticoptionscanbeconsidered. with behaviouralmodification,thenmoreintensivepharmaco- to improvehealthandwell-being beyond whatcanbeachieved “ideal” BMImaybeverydifficult.Iffurtherweightlossisneeded may notbean“ideal”weightontheBMIscale.Achieving healthy behaviourscanbereferredtoasthe“bestweight”;this BMI Bariatric surgerymaybeconsideredforpeoplewith Bariatric surgery management.” guidelines/) in the chapter titled “Pharmacotherapy in obesity porting evidence are available online (http://obesitycanada.ca Helpful actionsinprimarycare consultationstomitigateanti- The weight at which the body stabilizes when engaging in ≥ 40 kg/m 27kg/m 2 orBMI≥ 2 withadiposity-relatedcomplications,tosup- 35kg/m 62–66 2 with at least 1 obesity-related withatleast1obesity-related Afulldescriptionandsup- CMAJ (http://obesitycanada. 68 67 Health care pro- | AUGUST 4, 2020 61 30kg/m Psycho­ 60 Afull ​ / 2

| VOLUME 192 tional authorsto participateinwritingeachchapter. chapter rangedfrom2to4.Some chapterleadsidentifiedaddi- field ofobesitymedicine.The numberofchapterauthorsper based ontheirexpertiseinclinical practiceandresearchinthe 2017 andatleastmonthlybyphone. steering committeemetinpersonApril2017andDecember authors) towriteeachchapter.Theexecutivecommitteeand committee identifiedadditionalresearchers(chapterleadsand authors ofeachchapterandapersonlivingwithobesity;this the longestofanysurgicallytreatablecondition. tories. ­ it isstilllimitedinmostprovincesandnonexistentthe3 terri access tobariatricsurgeryhasincreasedinsomepartsofCanada, ity. eral, healthcareprofessionalsarepoorlypreparedtotreatobes­ levels ofsevereobesityinCanada. as 8 yearsbeforemeetingaspecialistorreceivingthesurgery. promote unrealisticandunsustainableweight-lossgoals. and services,manyofwhichlackascientificrationaleopenly are left to navigate a complex landscape of weight-loss products and surgery,thehighcostsofsometreatments. providers with expertise in obesity, longwait times for referrals management programs,alackofadequateaccesstohealthcare in Canada,includingaprofoundlackofinterdisciplinaryobesity behavioural, pharmacologicandsurgicaltherapeuticoptions. allocation of healthcare resources to improve access to effective tive, evidence-basedobesitycare.Wealsoneedtosupport long learning of health care providers to be able to deliver effec- ing withobesity.Thisincludesimprovingtheeducationandlife- There isaneedtoadvocateformoreeffectivecarepeopleliv- Step 5:Follow-upandadvocacy as healthybehaviourchangeregardlessofbodysizeorweight. interventions toimproveoverallhealth;andredefiningsuccess vided overallvisionandoversightfortheguidelineprocess. [M.V.], abariatricsurgeon[L.B.]andnephrologist[A.M.S.])pro - [S.W., D.C.W.L.],aprimarycarephysician[D.C.-S.],psychologist sentation. Theexecutivecommittee(comprising2co-chairs steering committeewithbroadexpertiseandgeographicrepre - icians andSurgeonsassembledanexecutivecommittee Obesity CanadaandtheCanadianAssociationofBariatric Phys­ Composition ofparticipatinggroups Methods tainable andaddressesthedriversofweightgain. and agreeonapersonalizedactionplanthatispracticalsus- be longterm.Healthcareprovidersandpatientsshoulddesign macare program. none iscoveredunderanyprovincialpublicdrugbenefitorphar- listed asabenefitonanyprovincialorterritorialformularyand 74 Chapter leadsandchapterauthors (n The lack of access to obesity treatments is contributing to rising The lackofaccesstoobesitytreatmentsiscontributingrising There are substantial barriers affecting access to obesity care There aresubstantial barriers affectingaccesstoobesitycare The steeringcommittee(n As this disease is chronic in nature, the treatment plan must None of the anti-obesity medications available in Canada is Noneoftheanti-obesitymedicationsavailableinCanadais 37,71,75 Patients referred to bariatric surgery can wait as long Patients referred to bariatric surgery can wait as long | ISSUE 31 71 Wait times for bariatric surgery in Canada are WaittimesforbariatricsurgeryinCanadaare =16)consistedofsomelead 46 Canadians affected by obesity Canadiansaffectedbyobesity =60)wereselected 70 37,71 ,37,71–73 Although 76 Ingen- 69 GUIDELINE E885 Responsible group Responsible Executive committee Executive committee Steering MERST MERST leads Chapter MERST MERST and authors leads with chapter Committee Steering MERST committee Executive leads with chapter committee Steering committee Executive with obesity physicians and people living Family area in each Experts ISSUE 31 ISSUE | In addition to the electronic searches, the chapter In addition to the electronic searches, the chapter 80 Two reviewers completed screening of article titles and Two reviewers completed screening of article titles and Literature review and quality assessment Team supported The McMaster Evidence Review and Synthesis searches based the guideline development through literature A health sciences on the PI/PECOT questions for each chapter. Library (Hamil- librarian, based at McMaster Health Sciences ton, 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 lan- guage; the search dates were January 2006 to June 2018. 14 searcheswere There chapters the to directly mapped that and another 7 searches that helped provide context for various chapters. Search strategies are available on the obesity guide- line 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 of cita- tions was uploaded to DistillerSR software for selection and review. authors identified additional citations and added them to the the to them added and citations additional identified authors main search results. abstracts and independently selected studies for possible inclu- sion. Any citation that was selected for inclusion by either reviewer was moved to full-text review. One or more authors of literature search. All clinical questions were developed with the literature search. All clinical questions were and Synthesis Team assistance of the McMaster Evidence Review Practice Cen- (MERST; previously the McMaster Evidence-Based and therapeutics for [T] PICO (e.g., format the appropriate in tre) treatments, PEO for qualitative questions). VOLUME 192 VOLUME | AUGUST 4, 2020 AUGUST | CMAJ 77 A total of 19 different sections and 79 77 = 14). Additionally, we obtained the insights of of insights the obtained we Additionally, 14). = 78 n Obesity Canada staff, consultants and volunteers (n = 15) pro- = 7) through partici- We engaged people living with obesity (n through a We engaged Indigenous community members Mind-mapping exercise to identify the scope of the guideline and the broad sections and and sections and the broad of the guideline the scope identify to exercise Mind-mapping (19 chapters) chapters chapter each for (PICO[T]) questions Develop research search literature Conduct Load results of the literature search into the Distiller Systematic Review software program software Review Systematic the Distiller into search of the literature results Load all papers of appraisal critical Conduct using paper each to grades and assign evidence appraisal critical of Review results II tool AGREE evidence with graded Develop reports consensus and expert level of evidence on the highest based Develop recommendations recommendations for (only evidence fidelity with the ensure to recommendations Review A–C level evidence) using grade primary to and relevance fidelity with the evidence ensure to recommendations Review professionals care health care and MERST committee the executive from on feedback based recommendations Revise final recommendations and approve Review and feasibility relevance assess to of recommendations review External of chapters peer review External Note: AGREE = Appraisal of Guidelines for Research and Evaluation, MERST = McMaster Evidence Review and Synthesis Team; PICO(T) = Population, Intervention, Comparison, Intervention, Comparison, = Population, PICO(T) and Synthesis Team; Review Evidence = McMaster MERST and Evaluation, Research of Guidelines for = Appraisal AGREE Note: Time. Outcome, • • • Table 2: Summary of guideline development process 2: Summary development guideline of Table Activity • • • • • • • • • • • health care providers working with Indigenous communities via health care providers working with Indigenous clinicians and chap- a consensus-building process between these ter authors, carried out over the spring of 2019, which further available are Details practice. clinical in evidence grounded online (http://obesitycanada.ca/guidelines/) in the chapter titled “Obesity management with Indigenous Peoples.” the for coordination project and support administrative vided guideline development process. Table 2 outlines the guideline development process and the responsibilities of each group of participants. pation of the Public Engagement Committee of Obesity Canada. pation of the Public Engagement Committee was (I.P.) Committee Engagement Public the of member One guideline. The Public assigned to the steering committee for this We month. per once phone by met Committee Engagement members through obtained contributions from committee conversations. online surveys, focus groups and individual ( group focus

The executive committee conducted a mind-mapping exercise to identify the scope of the guideline and the broad sections and chapters (April–June 2017). Selection of priority topics chapters were prioritized. The steering committee developed PI/ PECOT (Population, Intervention or Exposure, Comparison, Out- meeting in-person an at chapter each for questions Time) come, on Dec. 15–16, 2017, resulting in 179 questions to guide the GUIDELINE methods worksheets(Box3). strength oftherecommendationsandweregeneratedfrom type andqualityofthestudy.Thelevelsevidenceinformed were answeredandalevelofevidencegeneratedbasedonthe Distiller­ the appropriatemethodsworksheetwasdisplayedin nostic propertiesorprognosis.Oncethatselectionwasmade, was categorizedintoprevention,treatment,evaluationofdiag- E886 evidence available(Box3). chapter leads and chapterauthors Recommendations were formulated by the steering committee, Development ofrecommendations odological qualityusingtheShekelleapproach. relevancy. Selectedcitationswerethenassessedfortheirmeth- the relevantchapterconductedreviewsoffull-textarticlesfor with “Consensus ” afterthegrade D. recommendations formulated bychapterauthorswerenoted respected authorities,andreferenced accordingly;othergrade D expert committeereports,opinions orclinicalexperienceof informed thelevelofevidencein theserecommendations. dence qualitybyreviewerswithexpertiseinqualitativemethods informing theserecommendations.Consensusappraisalofevi - D.C.S., L.C.,S.R.M.)wereinvolvedinthereviewofallmaterials obesity, contentexpertsinqualitativeresearch(S.K.,X.R.S., addressing questionspertinenttothecareofpeoplelivingwith for thespecificrecommendation. the studyreferencethatprovidedhighestlevelofevidence the typeandstrengthofavailableevidence(level)added Some gradeDrecommendations wereformulatedbasedon Recognizing theimportanceofqualitativeresearchin SH, EcclesM,etal.Developingclinicalguidelines.WestJMed1999;170:348-51. Adapted withpermissionfromBMJPublishingGroupLimited.ShekellePG,Woolf • • • • Strength ofrecommendation • • • • • Category ofevidence Box 3:Classificationschemes recommendation fromlevel1,2or3evidence Grade D:Directlybasedonlevel4evidenceorextrapolated recommendation fromlevel1or2evidence Grade C:Directlybasedonlevel3evidenceorextrapolated recommendation fromcategory1evidence Grade B:Directlybasedonlevel2evidenceorextrapolated Grade A:Directlybasedonlevel1evidence clinical experienceofrespectedauthorities,orboth Level 4:Evidencefromexpertcommitteereportsoropinions control studies such ascomparativestudies,correlationstudiesandcase– Level 3:Evidencefromnonexperimentaldescriptivestudies, randomization Level 2a:Evidencefromatleast1controlledstudywithout Level 1b:Evidencefromatleast1RCT controlled trials(RCTs) Level 1a:Evidencefrommeta-analysisofrandomized SR platform,fromwhichthemethodologicalquestions 77 Chapterleadsandauthorsreviewed 77 77 based onthehighest level of

CMAJ | 77,81 AUGUST 4, 2020 Eachcitation | VOLUME 192 ated fortheirservices. ter leadsandchapterauthorswere volunteersandnotremuner- committee members(executive andsteeringcommittees),chap- ing bodyhavenotinfluenced the contentofguideline.All sional volunteersengagedinthe process.Theviewsofthefund- Surgeons, andin-kindsupport fromthescientificandprofes- initiative, theCanadianAssociationofBariatricPhysiciansand Fund for Obesity Collaboration and Unified Strategies (FOCUS) Strategic Patient-OrientedResearchinitiative,ObesityCanada’s Funding camefromtheCanadianInstitutesofHealthResearch Management ofcompetinginterests chapter. setting. Aseparateexternalpeerreviewwasconductedforeach tions toreflectlanguageandthecontextofprimarycare tions forrelevanceandfeasibility.Wemadesomemodifica - people living with obesity [ External reviewers (primary care health care professionals and External review tions includedinthisguidelineachieved100%agreement. final approvalofalltherecommendations.Allrecommenda- worded recommendation.Theexecutivecommitteeprovided required, andtheexecutivecommitteeapprovednewly subsequently modifiedthewordingofthisrecommendation,as dation indepthuntilconsensuswasachieved.Thechapterleads agreement, theexecutivecommitteediscussedrecommen- ensure consensus.Ifarecommendationdidnotreach100% tions basedontheMERSTreviewprocess. executive committee.Chapterleadseditedtherecommenda- suggestions regardingrevisionstothewordingorgrading consensus ongradingtherecommendations,andreportedtheir to eachcitation.Themethodologistsmet,discussedandreached tion, usingchecklistsasaguideforassigninglevelsofevidence primary andsecondaryreviewer)reviewedeachrecommenda- the recommendationswithevidence.Twomethodologists(a for whichtheyexaminedtheclarityofwordingandfidelity review ofrecommendationsthathadagradebetweenAandC, tions. MethodologistsfromMERSTprovidedanindependent (Table 3). for eachoftherecommendationswereinformedbyliterature the recommendationmorespecific.Theactionableverbsused recommendations Level 4,grade Dandconsensus Level 3,grade Crecommendations Level 2,grade Brecommendations Level 1,grade Arecommendations Grade level recommendations Table 3:Definitions of actionable verbs usedinthe The executivecommitteevotedoneachrecommendation,to We usedaniterativeprocesstofinalizetherecommenda- Chapter authorsusedastandardizedterminologytomake 82–84 | ISSUE 31 82–84 n = 7]) reviewed the recommenda- Use theterm “suggest” Use theterm “recommend” Use theterms “may”or“can” Use theterm “should” Suggested terms GUIDELINE - E887 This guideline will be used to assist to assist be used will guideline This 88 In 2015, the Canadian Task Force on Pre- In 2015, the Canadian 43 92 This guideline was not designed to “apply to designed to “apply to This guideline was not 89 90,91 ISSUE 31 ISSUE | Current treatment options, apart from surgical intervention, intervention, Current treatment options, apart from surgical in advocacy efforts to federal and provincial governments to to and provincial governments efforts to federal in advocacy with obesity. care of individuals improve the rarely yield sustained weight loss beyond 20%, and for some 20%, and for some rarely yield sustained weight loss beyond loss may be inade- people living with obesity, this level of weight of many adiposity- quate for the resolution or improvement a need for more treat- related medical complications. There is Weight obesity. with people of needs the meet to options ment patients who have regain continues to be a challenge for many received treatment. The recommendations in this guideline are informed by the best by are informed this guideline in recommendations The that ongo- level of evidence available in 2020. We acknowledge obesity to inform and advance ing research will continue management. Conclusion disease that affects a Obesity is a prevalent, complex chronic large number of adults in Canada and globally, and yet only a small fraction of people living with obesity who could benefit evidence- updated This care. to access have treatment from informed guideline is an attempt to enhance access and care by people living with obesity through recognition among health care providers that obesity requires long-term treatment. The newer insights into appetite regulation and the pathophysiology of obesity have 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 treatment by health care providers — preferably with the support of interdisciplinary care teams — will raise the standards of care 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 disease. Much more effort obesity through knowledge in gaps the close to needed is research, education, prevention and treatment. Other guidelines - guide practice clinical Canadian evidence-based first the 2006, In and management of obesity in adults andline on the prevention children was released. Gaps in knowledge policies approach obesity. approach policies ventive Health Care, in collaboration with scientific staff of the the in collaboration with scientific staff of ventive Health Care, of Canada and the McMaster Evidence Public Health Agency Centre, released a set of recommendationsReview and Synthesis - gain and use of behavioural and pharma for prevention of weight adultsin obesity and overweight manage to interventions cologic in primary care. ized bariatric programs” and reviewed only intervention trials trials intervention only reviewed and programs” bariatric ized primary care. conducted in settings generalizable to Canadian treatments. The guideline also did not include surgical people with BMI of 40 or greater, who may benefit from special from benefit may who greater, or 40 of BMI with people VOLUME 192 VOLUME | The lack of The lack of 86 AUGUST 4, 2020 AUGUST | each included study to CMAJ 78 87 Obesity continues to be treated 72 Obesity is not officially recognized as a chronic dis- chronic a as recognized officially not is Obesity 37,71 and the World Health Organization. ity guideline in 2006, access to obesity care remains an issue 85 Implementation of this guideline will require targeted policy Implementation of this guideline will require targeted policy The executive committee developed and managed the com- the and managed developed committee The executive disclosures were not excluded from Individuals with relevant methodologists from MERST who had noAs mentioned earlier, More than 10 years after the release of the first Canadian More than 10 years after the release of the first Canadian action, as well as advocacy efforts and engagement from people living with obesity, their families and health care providers. Canadian organizations have come together to change the narra- tive regarding obesity in Canada, to eliminate weight bias and and health care systems and to change the way obesity stigma, peting interest policy and procedures for mitigating bias. The bias. The for mitigating policy and procedures peting interest on the interest are available disclosures of competing policy and to disclose were required website. All participants guideline compet- We maintained detailed interests. potential competing all members the process for declarations throughout ing interest - committees, as well as the partici of the steering and executive from MERST. We used the International pating methodologists with the Journal Editors’ disclosure form, Committee of Medical funding sources. addition of government - appraisals or voting on recommenda conducting the critical with individuals committee asked executive However, the tions. in to abstain from voting in the areas direct competing interests conflict. Any discussion regarding off-label which they had the the caveat that the use was off label. use of drugs included competing interests reviewed and graded ensure the evidence had been appropriately assessed. They alsoensure the evidence had been appropriately A and C) to ensurereviewed the recommendations (graded between evidence. Finally, wethat recommendations were aligned with the the feasibility of theconducted an external review process to assess of bias. recommendations and evaluate for the presence

in Canada. in Implementation of Bariatric Sur- Obesity Canada and the Canadian Association website guideline joint a created have Physicians and geons hosts the full guideline;(http://obesitycanada.ca/guidelines) that health messages; key guide; reference quick a updates; interim and resourcescare provider tools, slide kits, videos and webinars; systems, in Englishfor people living with obesity and their support the website as a livingand French. The guideline will be hosted on thisto related evidence monitor will lead chapter Each document. committee to guideline and will collaborate with the executive becomes availableupdate the recommendations if new evidence A framework for that could influence the recommendations. in Appendix 2. implementation (5As Framework) is available obes­ recognition of obesity as a chronic disease by public and private payers, health systems, the public and media has a trickle-down effect on access to treatment. as a self-inflicted condition, which affects the type of interven- tions and approaches that are implemented by governments or covered by health benefit plans. ease by the federal, provincial and territorial, and municipal gov- ease by the federal, provincial and territorial, ernments, despite declarations by the Canadian Medical Associa- tion GUIDELINE 17. E888 References 19. 18.

21. 20.

22.

16. 10. 15. 14. 13. 12. 11. 8 1. 4. 3. 7. 9. 2 6 5. . . .

Sutin Health 2009;9:88. obesity andoverweight:asystematicreviewmeta-analysis. Prospective StudiesCollaboration; Garvey 372- American CollegeOfEndocrinologypositionstatement. diagnostic term:theAmericanAssociationofClinicalEndocrinologistsand Mechanick Psychol Sci prospective cohortstudies.DiabetesResClinPract2010;89:309-19. between overweightandobesitytheriskofdiabetes:ameta-analysis 776- meta-analysis of239prospectivestudiesinfourcontinents. D analyses of57prospectivestudies.Lancet2009;373:1083-96. Body-mass indexandcause-specificmortalityin900 Aune Abdullah Global BMIMortalityCollaboration; 4473-88. receptor agonistliraglutide-dependent weightloss. Fasshauer 1078- control ofhungerandmetabolismwithin theAgRPneuron. Cedernaes 2020; actionable diseaseclassificationsystem(ICD)forobesity. Longo gallbladder disease.EurJEpidemiol2015;30:1009-19. Secher 2015;36:461-70. nant of obesity-associated metabolic complications. a modellingstudy. lost fromdiabetesandcardiovasculardiseaseinoverweightobesepeople: Grover 2003;289:187-93. Fontaine 2014; review anddose–responsemeta-analysisofprospectivestudies. Aune E2358. Guh updated cost-of-illnessstudy.ObesRev2010;11:31-40. Ackerman Wolin KY,CarsonKColditzGA.Obesityandcancer.Oncologist2010;15:556-65 Anis obesity-canada-snapshot.html (accessed2020May22). Available: Obesity inCanada—Snapshot.Ottawa:PublicHealthAgencyofCanada;2009. dren, adolescents,andadults.Lancet2017;390:2627-42. analy­ index, underweight,overweight,andobesityfrom1975to2016:apooled NCD RiskFactorCollaboration(NCD-RisC). - /public​-health/services/health-promotion/healthy-living/obesity-canada/health Health AgencyofCanada;modified2011June23.Available:www.canada.ca/en Obesity in Canada — Health and economic implications. Ottawa: Public 808- Sharma obesity andcancer.CurrObesRep2017;6:195-203. economic​ , et al. 86. 8 9 DP, AH, 28: 53: . . 91.e5. sis of2416population-basedmeasurementstudiesin128·9millionchil- D, D AR,

M , SA, A WT, 484- 1591- Norat AM. Norat Zhang Body-mass index and all-cause mortality: Individual-participant-data Body-mass indexandall-causemortality:Individual-participant-data , , Zhang Stephan KR, Zatterale A Jelsing SE, -implications.html (accessed2020May22). M, Kaouache www.canada.ca/en/public-health/services/reports-publications/ 2015; JI, J , Mechanick 92. M, M&M:amnemonicforassessingobesity. , Peeters 601. Blüher Redden Huang Hurley Blackburn T, T W, , W 26: Vatten Vatten , Bansback Y J Lancet DiabetesEndocrinol 1803- , , Bansback F M. Terracciano Baquero , DL, W M A DT, Naderi ,

, , Adipokines inhealthanddisease. LJ. JI. LJ. Rempel de Courten Ramsey 11. OA, Garvey Wang Proposal for a scientifically correct and medically Body massindex,abdominalfatnessandtheriskof Body mass index and the risk of gout: A systematic Body massindexandtheriskofgout:Asystematic N, Marchildon J N AF, et al. , , C, P et al. WT. A et al. KM, Di Angelantonio , . et al. et al. et al. Weight discriminationandriskofmortality. Whitlock The incidenceofco-morbiditiesrelatedto Adiposity-based chronic disease as a new Adiposity-based chronicdiseaseasanew M et al. Adipose tissue dysfunctionasdetermi- , Obesity andoverweightinCanada:an The arcuatenucleusmediatesGLP-1 et al. Years oflifelostduetoobesity. Years of life lost and healthy life-years Years of life lostand healthy life-years F, et al. Transcriptional basisforrhythmic G, Worldwide trendsinbody-mass 2015; The magnitudeofassociation Lewington CMAJ Insights intothelinkbetween E , 3 Bhupathiraju : 114- 000 adults:collaborative J ClinInvest

| Int JMolSci 22. Endocr Pract AUGUST 4, 2020 Obesity (SilverSpring) Trends Pharmacol Sci S, Cell Metab Obes Rev Sherliker Lancet ShN, BMC Public Eur JNutr 2014; 2016;388:​ Wormser 2019 2017; 2019; 2010; P, JAMA et al. 124:​ ; 20 23:​ 29:​ 11:​ :​ ​

​ | VOLUME 192 45. 44. 38. 37. 43. 40. 33. 35. 28. 39. 32. 36. 34. 29. 27. 41. 42. 24. 23. 26. 25. 30. 31.

2020 May22). www.who.int/news-room/fact-sheets/detail/obesity-and-overweight (accessed Obesity andoverweight.Geneva:World HealthOrganization;2020.Available: CMAJ 2007;176(Suppl):S1-13. management andpreventionofobesity inadultsandchildren Guidelines ExpertPanel. adult, agegroups(18 yearsandolder).Ottawa:StatisticsCanada. Table 13-10-0096-20:Bodymassindex, overweightorobese,self-reported, Block Obesity Canada;2017. Report cardonaccesstoobesitytreatmentforadultsinCanada2017.Edmonton: [published erratuminBMCResNotes2016;9:164].2015;8:810. the knowledgegapinobesitymanagementamongprimarycarepractitioners Lau ing review. Greener Prim HealthCareResDev management inprimarycare:aqualitativestudyofcomorbidpainandobesity. Padwal 2015; Kuk based obesityclinic.JObes2015;:619734. prevalence andassociationwithweightlossinapubliclyfundedreferral- Sharma 2015; glucagon-like peptide-1receptoractivationinhumans. tion inresponsetoanticipationandconsumptionofpalatablefoodisalteredby sionals andpolicymakers. of obesitycausationandinterventionamongstoverweightpeople,healthprofes- Janke 2003; epidemic? Knowledgeandattitudesofinternalmedicineresidents. Hruby Ogunleye 570- ation withweighthistoryandmortalityrisk. Canning with overweightandobesity.CMAJ2011;183:E1059-66. system topredictmortalityinapopulation-representativecohortofpeople statement. Grundy Obes (Lond)2009;33:289-95. van Bloemendaal integration inthedevelopmentofobesity.FrontPhysiol2018;9:900. Kirk Visceral and ectopic fat, atherosclerosis, and cardiometabolic disease: a position Visceral andectopicfat,atherosclerosis,cardiometabolicdisease:aposition International ChaironCardiometabolicRiskWorkingGroupVisceralObesity. Alberga level studyonobesitymanagement.QualHealthRes2014;24:790-800. Hill Rev Physiol2017;79:401-23. Sternson Bliss Eur JNeurosci hedonic feedingandsuppressesdopamineconcentrationviaincreasedreuptake. Mebel perspective. Ross abdominal fatcompartments.JObes2013;:454285. Neeland on VisceralObesity.NatRevEndocrinol2020;16:177-89. clinical practice:aConsensusStatementfromtheIASandICCRWorkingGroup JO. 6 JL, DCW, SFL, 17: 36: 33: ES, R . JP, DM, EA, A , Understanding and addressing the epidemic of obesity: an energy balance Understanding andaddressingtheepidemicofobesity:anenergybalance

AS, , Ardern RS, 878- 669- Neeland J 673- SM

AM, Hu Whiteside KL, IJ Price , DeSalvo

SM, Ramirez A, Douglas Prim HealthCareResDev Douketis Wong Edache , Lancet DiabetesEndocrinol | , Pajewski ISSUE 31 Endocr Rev FB. Ross 86. 75. 89. Neeland Osunlana Kushner Brown 2012; Eiselt SL, CI, The epidemiologyofobesity:abigpicture. JC,

IJ, L R KB, Penney IY, Church F , ML, 36: , E. Veltman , A-K. JD, Dong Després Yamashita RE, Forhan van Teijlingen NM,

Fisher 2336- RF. IJ The gut-brainaxis,thehumangutmicrobiotaandtheir

Haltzman 2006; A, , Morrison Wharton 2016; Three pillarsfortheneuralcontrolofappetite. Turer Allison Asselin A proposedclinicalstagingsystemforobesity. Soc SciMed YJ, TS, TL, 2006 Canadianclinicalpracticeguidelinesonthe 46. M 27: WP. DJ,

J-P et al. , et al. et al. 17: et al. 750-

S AT Ten Kulve Are physicians equipped to address the obesity Are physiciansequippedtoaddresstheobesity , DB,

B , 33- J, 2019; et al. S KM, , et al. , Insulin in the ventral tegmental area reduces Insulin intheventraltegmentalareareduces E 61. Blame, shame,andlackofsupport:amulti- , Edmonton ObesityStagingSystem:associ- et al. Weight bias and health care utilization: a scop- et al. et al. . 41. et al. et al. More of the same? Conflicting perspectives More ofthesame?Conflictingperspectives 2010; 2019; et al.; 20: ; Waist circumferenceasavitalsignin International Atherosclerosis Society Patient’s experience with comorbidity Patient’s experiencewithcomorbidity

e116. doi:10.1017/S1463423619000227 The 5As team intervention: bridging Waist circumference as measure of Using theEdmontonobesitystaging JS, 70: Edmonton ObesityStagingSystem 7 : 715- Obesity CanadaClinicalPractice 1042- Appl PhysiolNutrMetab et al. 25. 9 Brain reward-systemactiva- . Diabetes ObesMetab Pharmacoeconomics [summary]. Prev Med 2011; Annu Int J 36:​ ;

GUIDELINE

96. CMAJ E889 89- West J West J : Obesity Obesity 7 33. 62. : 7 2018; N Engl J Med 2521- Cardiovascular Otolaryngol Head 2012; 385: 31S. et al. . 9 . - 2015; 9 FL, 608. 7 27: Curr Obes Rep 205- e598- Lancet 37: Suppl):123S- Implement Sci Medical therapy for pulmonary Medical therapy for pulmonary 2019; Brancati AGREE Next Steps Consortium. 108: , Weight loss strategies for obese for obese Weight loss strategies P 133( 2013; Grades of recommendation for anti- A critical analysis of obesity prevention et al. 2018; Developing clinical guidelines. Developing clinical practice guidelines: et al.; , et al. Bolin Obesity as a disease: the Obesity Society G , 2008; R et al. et al. GP, , The orbitofrontal cortex functionally links The orbitofrontal cortex functionally links RR, et al. et al. , T et al. , R , Chest Working minds: a practitioner’s guide to cognitive M Management of obesity: improvement of health- Management of obesity: improvement S JM, Canadian Task Force on Preventive Health Care. Wing et al. Obesity prevention and management strategies inObesity prevention and management Clinical practice guideline development manual: a Can J Diabetes RR. E; . X 42. et al. Simonneau Inequities in healthcare: a review of bias and discrimi- Inequities in healthcare: a review “Lose 40 pounds in 4 weeks”: regulating commercial “Lose 40 pounds in 4 weeks”: Obesity (Silver Spring) Caulfield , MJ, . Browman Laukkanen RN. Eccles , Kahan X K Jaeschke Can J Public Health M SH, Shaw AM. 28. JD, E839- Lee Grimshaw SH, ME, CM,

Hoffman , DJ, , Hall , S SC, K G 182: LA, Kho 1917- Forhan Shiffman Kotz Inequalities in access to bariatric surgery in Canada. Inequalities in access to , Abman Woolf 54. Sharma X Ramos Salas ISSUE 31 ISSUE Cooke Behavioural interventions for preventing and treating obesity in in treating obesity and for preventing interventions Behavioural Woolf Meerkin | Klein 131: 2010; AM, MC, RM, . Y, , Byeon , Baur Gorber PG, DB, , Ramos Salas 145- AM. P M B AM, M GH, P, NM, 2007; WH, B-y, CMAJ 369: effects of intensive lifestyle intervention in type 2 diabetes. 2013; obesity and white matter hyperintensities. Sci Rep 2020;10:2930. Look AHEAD Research Group; Park 2018 position statement. Recommendations for prevention of weight gain and use of behavioural and Recommendations for prevention of weight gain and use of behavioural and in adults in obesity and overweight manage to interventions pharmacologic primary care. CMAJ 2015;187:184-95. Jastreboff Canadian Obesity Advocacy Network (COAN). Edmonton: Obesity Canada. Canadian Obesity Advocacy Network (COAN). Edmonton: Obesity Canada. Available: https://obesitycanada.ca/coan (accessed 2020 May 22). Brauer Badesch policies and strategies. Dietz Sharma 2009;180:367-8. weight-loss programs. CMAJ Shekelle Guyatt Evidence-Based Clinicalthrombotic agents: American College of Chest Physicians Practice Guidelines (8th Edition). arterial hypertension: updated ACCP evidence-based clinical practice guidelines. arterial hypertension: updated ACCP evidence-based clinical Chest Rosenfeld action. quality-driven approach for translating evidence into Neck Surg 2009;140(Suppl 1):S1-43. Canadian Medical Asso- Obesity as a chronic medical disease [policy]. Ottawa: ciation; 2015, reviewed 2019 Mar. 3. Available: https://policybase.cma.ca/en/ permalink/policy11700 (accessed 2020 May 22). Obesity: preventing and managing the global epidemic — Report of a WHO Con- sultation (WHO Technical Report Series 894). Geneva: World Health Organiza- tion; 2000. Ramos Salas nation in obesity treatment. care training and systems for prevention and care. care training and systems for 2016;188:317-8. Freedhoff reviewing, reporting, and publishing guidelines; updating guidelines; and the reviewing, reporting, and publishing guidelines; updating and accounting for emerging issues of enhancing guideline implementability comorbid conditions in guideline development. Forhan DistillerSR enterprise plan. Ottawa: Evidence Partners: Available: www. DistillerSR enterprise plan. Ottawa: Evidence Partners: (accessedevidencepartners.com/products/distillersr-systematic-review-software/ 2020 May 22). Shekelle task analysis. Cambridge (MA): MIT Press; 2006. Canada: shifting paradigms and putting people first. Canada: shifting paradigms program vs. standard care. weight management adults: personalized 2006;14:1777-88. (Silver Spring) . Edmonton: for adults in Canada 2019 access to obesity treatment Report card on 2019. Obesity Canada; Sharma AGREE II: advancing guideline development, reporting and evaluation in health evaluation in reporting and development, advancing guideline AGREE II: care. Crandall Sharma 2007;8:441-9. adults. Obes Rev Byrne Med 1999;170:348-51. Brouwers

92. 91. 90. 89. 88. 83. 74. 75. 77. 82. 84. 85. 86. 87. 76. 73. 81. 80. 71. 72. 79. 69. 70. 78. VOLUME 192 VOLUME |

. 9 Am J 2013;​

251- . Weight Weight 4 11: Int J Obes Int J Obes

J Acad Nutr 604. 330- Effect of nal- Diabetes Care 2014; 39: 10. 1597- - 6 : 2015; 4 365: AUGUST 4, 2020 AUGUST | 407. Can Fam Physician Fam Can 2008; Body Image Long-term persistence of of persistence Long-term 2011;

389- CMAJ 14: 22. Addressing obesity via diabetes diabetes via obesity Addressing COR-I Study Group. et al. et . . , , Long-term persistence of adaptive 11- E Can J Diabetes

Energy balance and its components: Energy balance NN8022-1923 Investigators. 2017; Current and predicted prevalence of prevalence predicted and Current Clinical review: modified 5 As: minimalClinical review: modified 5 As: Medical nutrition therapy and weight Effect of orlistat on weight regain and et al.; Personalizing obesity assessment and and Personalizing obesity assessment 373: The relationship of waist circumferencewaist of relationship The N Engl J Med et al. SCALE Obesity and Prediabetes NN8022- Unrealistic weight loss expectations in Unrealistic weight loss expectations in et al. et al. [published erratum in BMJ 2007;335:0-a]. Defining the optimal dietary approach for RA, et al. et et al.; Redefining obesity: beyond the numbers. the beyond obesity: Redefining . et al. et al. DA, 2015; , 8 . . J, , et al. Long term pharmacotherapy for obesity and et al. et S AM, Surg Obes Relat Dis JW, D S H, et al.; Delbridge , (accessed https://implicit.harvard.edu/implicit/ et al.

, Eight-year weight losses with an intensive life- et al. , , C , 402- K AM, T Position of the Academy of Nutrition and Dietetics: LA M, Malleability of weight-biased attitudes and beliefs: a weight-biased attitudes and Malleability of et al. The influence of age, sex and body mass index on the

19: Klein Burns J Phys Act Health , Sharma Gallagher Plodkowski P CM. Rossner Kemnitz , Reddigan MT. SK, , H et al. J, Fujioka PG, K, 2011; N Engl J Med S , Li , Sharma 51. Bouchard Torrella SB, L Spinou A randomized, controlled trial of 3.0 mg of liraglutide in in liraglutide of mg 3.0 of trial controlled randomized, A A , DM, , R, R 47. S T, Liu GA, , Hirsch 1443- Prendergast R Brannick Fujioka 129- Campbell-Scherer , , Hollander Tonstad M, Astrup 37: Davidson , , P Champagne , , Bray 32.

Gregory FL, RN, Padwal X B Spinos 116: Are behavioural interventions doomed to fail? Challenges to self- Are behavioural interventions doomed to fail? Challenges Mani TA, AM Heymsfield , 27- Piccinini-Vallis .

Orellana HA, Anderson D, HA, C, L , LK, SM, Ata 2013; , , M 31. , M 30: P T KD, 2016; M 27- Rosenbaum Healthcare (Basel) 2018;6:E73. Look AHEAD Research Group. safe, effective and sustainable weight loss in overweight and obese adults. safe, effective and sustainable weight loss in overweight 2014;22:5-13. style intervention: the look AHEAD study. Obesity (Silver Spring) Vallis hormonal adaptations to weight loss. Clin Nutr 2008;88:906-12. Koliaki thermogenesis in subjects who have maintained a reduced body weight. thermogenesis in subjects who have maintained a reduced trexone plus bupropion on weight loss in overweight and obese adults (COR-I): adults and obese in overweight loss on weight bupropion plus trexone a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial. Lancet 2010;376:595-605. Pi-Sunyer maintenance and additional weight loss with liraglutide after low-calorie-diet- after liraglutide with loss and additional weight maintenance study. randomized Maintenance SCALE the loss : weight induced intervention for obesity counseling in primary care. intervention for obesity counseling 59: Sharma loss questions for the evidence analysis library prevention of type 2 diabetes 2 type of prevention library analysis evidence the for questions loss :1578-611. project: systematic reviews. J Acad Nutr Diet 2017;117 Raynor in adults. interventions for the treatment of overweight and obesity Diet Sumithran (Lond) Wadden Greenway Twells ;25:660-1. Obesity (Silver Spring) 2017 Camhi Richelsen . . Group Study 1839 weight management. candidates for bariatric surgery. management support in chronic Diseases. care planning in primary care: patient experience and health outcomes in care: patient experience and health outcomes in care planning in primary 2018;8:411-23. everyday life and health. Clin Obes Vallis and total body fat: sex and race differences. and BMI to visceral, subcutaneous, Obesity (Silver Spring) Mabire Raynor BMJ 2007;335:1194-9. Educators Diabetes of Association American self-management education and training. Diabetes Educ 2012;38:151-4. Kaly overweight: updated meta-analysis 2020 May 22). Luig Project Implicit. 2011. Available: 2011. Implicit. Project 2014;2:E18-26. a trend analysis. CMAJ Open obesity in Canada: Hall effectiveness of brisk walking for obesity management in adults: a systematic systematic a adults: in management obesity for walking brisk of effectiveness review and meta-analysis. cardiovascular risk factors following a very-low-energy diet in abdominally cardiovascular risk factors following a very-low-energy diet in abdominally obese patients:a 3-year randomized, placebo-controlled study. 2007; Rucker of weight bias reduction interventions. meta-analysis -94. Am J Clin Nutr 2012;95:989 body weight regulation. implications for Lee 58. 60. 61. 59. 64. 52. 56. 57. 62. 63.

46. 53. 65. 51. 54. 55. 67. 68. 50. 49. 47. 66. 48. GUIDELINE E890 AstraZeneca, outside the submitted work. Marie-Philippe Morin reports AstraZeneca, outsidethesubmitted work.Marie-PhilippeMorinreports Health andSanofi;grantsfrom BoehringerIngelheim,Sanofiand Priya Manjooreportsreceivingpersonal feesfromNovoNordisk,Bausch fees fromNovoNordiskandBausch Health, outsidethesubmittedwork. outside thesubmittedwork.David Macklin reportsreceivingpersonal Study Groupfor diabetes clinical research asaprincipalinvestigator,all AstraZeneca andfromTIMI(ThrombolysisinMyocardialInfarction) Boehringer Ingelheim; a grant from Merck Canada; and other fees from from NovoNordisk,Valeant,MerckCanada,Sanofi,EliLilly from Alkermes.Marie-FranceLangloisreportsreceivingpersonalfees Lexington Medical.MargaretHahnreportsreceivingconsultingfees isk, BauschHealthandLexingtonMedical;holdsstockoptionswith from Ethicon,WLGoreandMedtronic;consultingfeesNovoNord - penses forsame.MichelGagnerreportsreceivingspeakerhonoraria topics relatedtoobesityandreceiveshonorariatravelcostsex - ment andpreventionofobesity.YoniFreedhoffalsoregularlyspeakson which hehaspubliclyexpressedopinionsaboutthetreatment,manage - and acolumnforMedscapemanyotherop-edsarticlesin the book.Inaddition,heissoleauthorofWeighty Matters Work is alsotheauthorofThe Diet Fix: Why DietsFailandHow to MakeYours Constant HealthhasreceivedagrantfromNovoNordisk.YoniFreedhoff tute andConstantHealth,whichprovideweightmanagementservices; Surgeons. YoniFreedhoffistheco-ownerofBariatricMedicalInsti- Obesity CanadaandtheCanadianAssociationofBariatricPhysicians& Nordisk, and personal fees from Bausch Health, Dietitians of Canada, work. JenniferBrownreportsreceivingnonfinancialsupportfromNovo the ConcordiaUniversityStart-upTeamGrant,outsidesubmitted from FondsdeRechercheduQuebec,theMitacsAccelerateGrant,and Angela Albergareportsreceivingthefollowinggrants:SantéAward gram grant from Alberta Health and the Alberta Medical Association. Effectiveness and Outcomes Research; and a Physician Learning Pro Agency forHealthcareResearchandQualityR13granta Nordisk Global;aWorldwideUniversityNetworkMeetingGrant;an unrestricted educationgrantfromObesityCanada,fundedbyNovo ledge transferfundingfromthefollowingsourcesinpast3years:an Cancer PreventionandLegacyFund.Shealsoreportsreceivingknow­ petitions); Northern Alberta Family Medicine Fund; and the Alberta (Strategy forPatient-OrientedResearchandKnowledge-to-Action orative ResearchandInnovationOpportunitiescompetitions),CIHR Health Solutions(CancerPreventionResearchOpportunityandCollab- Novo Nordisk and Alberta Innovates joint funders; Alberta Innovates grant thatisapartnershipbetweentheUniversityHospitalFoundation, NovoNordiskAlbertaDiabetesFund(NOVAD),apeer-reviewed 3 years: receiving researchfundingfromthefollowingsourcesinpast Campbell-­ Nordisk and Bausch Health, outside the submitted work. Denise Johnson andMedtronic,isamemberofadvisoryboardsforNovo Zeneca. LaurentBierthoreportsreceivinggrantsfromJohnsonand consulting feesfromNovoNordisk,BauschPharmaceuticalsandAstra- Abbott andAbbVie.AryaSharmareportsreceivingspeaker’sbureau Sanofi, and speaking fees from Novo Nordisk, Sanofi, Bausch Health, ceived consultingfeesfromBauschHealth,LifeScan,NovoNordiskand Novo Nordisk,BauschHealthandLifeScan.MichaelVallishasalsore- Lilly andNovoNordisk.MichaelVallisisamemberofadvisoryboardsfor Health, BoehringerIngelheim,Gilead,HLSTherapeutics,Janssen,Eli Novo Nordisk;andconsultingfeesfromAmgen,AstraZeneca,Bausch Health, BoehringerIngelheim,DiabetesCanada,EliLilly,Merckand Health Research(CIHR);speakerbureaufeesfromAstraZeneca,Bausch support fromAstraZeneca,NovoNordiskandtheCanadianInstitutesof ment and diabetes. David Lau reports receiving grants and research the medicaldirectorofaclinicspecializinginweightmanage- Novo Nordisk, Bausch Health, Eli Lilly and Janssen. Sean Wharton is also travel expensesandhasparticipatedinacademicadvisoryboardsfor Competing interests:SeanWhartonreportsreceivinghonorariaand published by Crown Publishing Group, and receives royalties for publishedbyCrownPublishingGroup,andreceivesroyaltiesfor Scherer has no personal financial relationships, but reports Scherer hasnopersonalfinancialrelationships,butreports CMAJ | AUGUST 4, 2020 com- blog blog and - | VOLUME 192 speaker fees from Sunovion. Shahebina Walji reports receiving consulting speaker fees from Sunovion. Shahebina Walji reports receiving consulting ValerieTaylorreportsreceiving Canada withinthelast36 months. Sanjeev Sockalingamreportsreceiving honorariafromBauschHealth has aspousalrelationshipwithanemployee ofAnheuser-BuschInBev. He Committee oftheInternationalLife ScienceInstituteNorthAmerica. Food Safety,NutritionandRegulatory AffairsandtheCarbohydrates Foundation. HeisalsoanunpaidscientificadviserfortheProgramin and asDirectoroftheToronto3DKnowledgeSynthesisClinical­ tion StudyGroupoftheEuropeanAssociationforDiabetes, appointments asanExecutiveBoardMemberoftheDiabetesandNutri - adian CardiovascularSociety,andObesityCanada,holds Diabetes Canada,EuropeanAssociationfortheStudyofDiabetes,Can ­ Consortium andtheClinicalPracticeGuidelinesExpertCommitteesof Dr. Sievenpiper is a member of the International Carbohydrate Quality Commission, AlmondBoardofCalifornia,outsidethesubmittedwork. Primo, LoblawCompanies,WhiteWaveFoods,Quaker,CaliforniaWalnut Kellogg Canada,AmericanPeanutCouncil,Barilla,Unilever,Unico thority andthePhysiciansCommitteeforResponsibleMedicine, Vereinigung Zuckere.V.,Abbott,Biofortis,theEuropeanFoodSafetyAu - tional SweetenersAssociation,NestléHealthScience,Wirtschaftliche PepsiCo, FoodMinds LLC, European Fruit Juice Association, Interna Dr. SievenpiperhasreceivednonfinancialsupportfromTate&Lyle, Institute andtheComitéEuropéendesFabricantsdeSucre. the PhysiciansCommitteeforResponsibleMedicine,SoyNutrition gung Zuckere.V.,Abbott,Biofortis,theEuropeanFoodSafetyAuthority, and Metabolism,GIFoundation,PulseCanada,WirtschaftlicheVereini- Association, NestléHealthScience,CanadianSocietyforEndocrinology Minds LLC,EuropeanFruitJuiceAssociation,InternationalSweeteners Perkins CoieLLP,Tate&Lyle,DairyFarmersofCanada,Pepsi­ Ontario ResearchFund.Dr.Sievenpiperhasreceivedpersonalfeesfrom tion forInnovation,andtheMinistryofResearchInnovation’s Centre SunLifeFinancialNewInvestigatorAward,theCanadaFounda- Diabetes CanadaClinicianScientistaward,theBanting&Best ation, PSIGrahamFarquharsonKnowledgeTranslationFellowship,the Fund attheUniversityofToronto,NationalDriedFruitTradeAssoci- the GlycemicControlandCardiovascularDiseaseinType2Diabetes Fund attheUniversityofToronto,AmericanSocietyforNutrition, and DriedFruitCouncilFoundation,theTate&LyleNutritionalResearch tion TrialistsFundattheUniversityofToronto,InternationalNut study. JohnSievenpiperreportsreceivinggrantsfromCIHR,theNutri- ada to support the literature review process, during the conduct of the and diabetesmanagementfromMerck,agrantObesityCan- reports receivingconsultingfeesforadviceregardingchronicdisease Nordisk andBauschHealth,outsidethesubmittedwork.DianaSherifali submitted work. Judy Shiau reports receiving personal fees from Novo Janssen, Eli Lilly, Novo Nordisk, Valeant and Bausch Health, outside the tinuing medicaleducationfromAstraZeneca,BoehringerIngelheim, Ingelheim. PaulPoirierreportsreceivingfeesforconsultingandcon- Health; andaqualityimprovementprojectgrantfromBoehringer fees formembershipofadvisoryboardsfromNovoNordiskandBausch Nordisk andBauschHealth;feesformentorshipfromNovoNordisk; search NetworkandtheAntibodyNetwork;educationgrantsfromNovo Ingelheim, EliLilly,Jenssen,Merck,theCanadianCollaborativeRe- education (CME) from Novo Nordisk, Bausch Health, Boehringer work. MeghaPoddarreportsreceivinghonorariaforcontinuingmedical AstraZeneca, Boehringer IngelheimandSanofi,outsidethe submitted cial supportfromNovoNordisk,BauschHealth, Janssen, EliLilly, Eli Lilly,AstraZeneca,BoehringerIngelheimandSanofi;nonfinan- Merck, AstraZeneca,BoehringerIngelheim,Sanofi,Pfizer;grantsfrom personal feesfromNovoNordisk,BauschHealth,Janssen,EliLilly, heim, JanssenandAstraZeneca.SuePedersenreportsreceiving honoraria fromNovoNordisk,BauschHealth,EliLilly,BoehringerIngel- research subventionfromNovoNordiskandSanofi;consultation Boehringer Ingelheim, Nestlé Health Science, Janssen and AstraZeneca; receiving speakerhonorariafromNovoNordisk,BauschHealth,EliLilly, | ISSUE 31 Co, Food- Trials Trials - GUIDELINE E891 ISSUE 31 ISSUE | iatry (Taylor), University of Calgary, Calgary, Alta.; School of Phar- iatry (Taylor), University of Calgary, Calgary, Alta.; sion of Endocrinology (Langlois), Université de Sherbrooke, Sherbrooke, de Sherbrooke, (Langlois), Université sion of Endocrinology sociaux de de santé et de services intégré universitaire Que.; Centre (Langlois), Sher- de Sherbrooke hospitalier universitaire Centre l’Estrie - University, (Lear), Simon Fraser School of Kinesiology brooke, Que.; Toronto, Ont.; Cardiometabolic Medcan Clinic (Macklin), Vancouver, BC; Victo- Island Health Authority, Clinic (Manjoo), Vancouver Collaborative Qué- de pneumologie de et cardiologie de universitaire Institut BC; ria, University, Québec, Que.; Foothills Medicalbec (Morin, Poirier), Laval Endocrinology & Diabetes C-ENDO Alta.; Calgary, (Nerenberg), Centre Endocrinology and Diabetes LMC Alta.; Calgary, (Pedersen), Clinic - Department of Medicine (Rueda-Clausen), Uni ­(Poddar), Toronto, Ont.; Regina, Sask.; Regina General Hospital (Rueda- versity of Saskatchewan, - Education Psychology (Russell-Mayhew), Werk Clausen), Regina, Sask.; LEAF Alta.; Calgary, Calgary, of University of Education, School lund (Shiau), Ottawa, Ont.; Heather M. Arthur Weight Management Clinic Institute/Hamilton Health Sciences Chair inPopulation Health Research - Research, School of Nursing (Sherifali), McMas Interprofessional Health Ont.; Division of Endocrinology & Metabolismter University, Hamilton, Hospital, Toronto, Ont.; Department of (Sievenpiper), St. Michael’s Psych­ Medical Steelcity NL; John’s, St. University, Memorial (Twells), macy Centre Management Weight Calgary Ont.; Hamilton, (Tytus), Clinic Public Health (Walker),(Walji), Calgary, Alta.; School of Population and Centre for Excellence inUniversity of British Columbia, Vancouver, BC; Vancouver, Columbia, British of University (Walker), Health Indigenous University of Calgary,BC.; O’Brien Institute of Public Health (Wicklum), Calgary, Alta. and Contributors: All of the authors contributed to the conception of and interpretation analysis, acquisition, and the of the work design revised it critically fordata. All of the authors drafted the manuscript, of the version to beimportant intellectual content, gave final approval of the work. published and agreed to be accountable for all aspects Canada,Funding: Funding for this initiative was provided by Obesity and Surgeons, and thethe Canadian Association of Bariatric Physicians a Strategy for Patient- Canadian Institutes of Health Research through authors receiving anyOriented Research grant, with no participants or personal funding for their creation. membersstaff Canada Obesity thank authors The Acknowledgements: Fullerton and PattiDawn Hatanaka, Nicole Pearce, Brad Hussey, Robert as well as their contri- Whitefoot-Bobier for their coordinating support website, onlinebutions for the development of the Obesity Guidelines thank members of theresources, tables and figures. The authors also (Lisa Schaffer, CandaceObesity Canada Public Engagement Committee Vilhan, Kelly Moen, Doug Earle, Brenndon Goodman), who contributed to the creation of the research questions and reviewed key messages for individuals living with obesity and recommendations for health care providers. The authors also thank McMaster Evidence Review and Syn- thesis 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 improve the chapters and this manuscript. The authors thank Barbara Kermode-Scott and Brad Hussey for editing the guidelines, Elham Kamran and Rubin Pooni for research assistance, and Jordan Tate from the Physician Learning Pro- gram at the University of Alberta for designing the 5As framework for the guideline. Correspondence to: Sean Wharton, [email protected] VOLUME 192 VOLUME | - Heart AUGUST 4, 2020 AUGUST | CMAJ or advisory board fees from Novo Nordisk, Bausch Health and Takeda and Bausch Health and fees from Novo Nordisk, or advisory board Shahebina and Bausch Health. fees from Novo Nordisk speaker’s bureau a weight replacements through selling Optifast Meal Walji also reports Nestlé. by sold and produced product a is Optifast centre management interests were declared.No other competing been peer reviewed. This article has (Wharton), Endocrinology and Affiliations: Departments of Medicine Family Medicine (Naji, Tytus) and HealthMetabolism (Poddar, Sherifali), - and Impact Canada (Naji), McMaster Uni Research Methods, Evidence The Wharton Medical Clinic (Wharton, Poddar),versity, Hamilton, Ont; of Medicine (Lau, Nerenberg) and FamilyHamilton, Ont.; Departments McInnes, Walji, Wicklum), Cumming Medicine (Boyling, Henderson, of Calgary, Calgary, Alta.; Julia McFarlaneSchool of Medicine, University and Libin Cardiovascular Institute of AlbertaDiabetes Research Centre Piccinini- (Vallis, Medicine of Family Department Alta.; Calgary, (Lau), Halifax, NS; Departments of Medicine Vallis), Dalhousie University, - Medicine (Campbell-Scherer, Kemp), Agricul (Sharma, Toth), Family Science (Bell, Pereira), Physical Educationtural, Food and Nutritional (Forhan), Universityand Recreation (Boulé), and Occupational Therapy Clinic (Sharma),of Alberta, Edmonton, Alta.; Adult Bariatric Specialty Canada (Sharma, Royal Alexandra Hospital, Edmonton, Alta.; Obesity of Surgery Patton, Ramos Salas), Edmonton, Alta.; Department Kinetics Human of School Que.; Quebec, University, Laval (Biertho), DepartmentOnt.; Ottawa, Ottawa, University of Prud’homme), (Adamo, Concordia Uni- of Health, Kinesiology & Applied Physiology (Alberga), (Brown), The versity, Montréal, Que.; Bariatric Centre of Excellence Practice (Calam)Family Departments of Ont.; Ottawa Hospital, Ottawa, Columbia, Vancouver,and Endocrinology (Manjoo), University of British and Pfizer/­ BC; UBC Family Practice Residency Program (Calam) and Stroke Foundation Chair in Cardiovascular Prevention Research Prevention Research and Stroke Foundation Chair in Cardiovascular consultant (Clarke),(Lear), St. Paul’s Hospital, Vancouver, BC; nutrition Health Sci- Hamilton, Ont.; Indigenous Health Dialogue (Crowshoe), Medical East Main Alta.; Calgary, Calgary, of University Centre, ences Medical Institute Associates (Divalentino), Hamilton, Ont.; Bariatric Medicine (Freedhoff)(Freedhoff), Ottawa, Ont.; Department of Family (Shiau), Department ofand Division of Endocrinology and Metabolism Wertheim School Ont.; Herbert Ottawa, Ottawa, Medicine, University of Miami, Fla.; Hôpi- of Medicine (Gagner), Florida International University, Que.; Humber Rivertal du Sacre Coeur de Montréal (Gagner), Montréal, and Metab­ Hospital (Glazer), Toronto, Ont.; Division of Endocrinology Departments of Inter- olism (Glazer), Queen’s University, Kingston, Ont.; Family and nal Medicine (Glazer), Psychiatry (Hawa, Sockalingam), Sciences (Sievenpiper),Community Medicine (Macklin) and Nutritional Health Services (Grand, University of Toronto, Toronto, Ont.; Alberta Hung, Johnson-Stoklossa), Edmonton, Alta.; Departments of Family (Green), Policy Studies and Sciences and Public Health Medicine Queen’s University, Kingston, Ont.; Kingston Health Sciences Centre (Green), Kingston, Ont.; Providence Care Hospital (Green), Kingston, Ont.; Centre for Addiction and Mental Health (Hahn, Sockalingam), Toronto, Ont.; University Health Network (Hawa, Sockalingam), Toronto, Ont.; Division of General Surgery (Hong), McMaster University, Hamilton, Ont.; Department of Family Medicine and Biobehavioral Cam Duluth School Medical Minnesota of University (Jacklin), Health pus, Duluth, Minn.; School of Kinesiology and Health Studies (Janssen), Queen’s University, Kingston, Ont.; School of Health and Human Perfor- mance (Kirk), Dalhousie University, Halifax, NS; School of Kinesiology Divi- Ont.; Toronto, University, York Kuk), (Wharton, Science Health and