Letter to Obesity Canada re: Canadian Pediatric Guidelines, November 2023

Obesity Canada

2-126 Li Ka Shing Centre for Health Research Innovation University of Alberta

Edmonton, AB T6G2E1

We represent Ontario Dietitians in Public Health (ODPH), the independent and official voice of Registered Dietitians working in Ontario’s public health system. We advocate for system approaches that mitigate harm while promoting health equity across all populations. One of our focuses is shifting the paradigm from a weight-centric approach to a weight-inclusive approach, which aims to address the systemic injustices that result from weight bias, stigma, and discrimination.

We are writing to express our deep concern with Obesity Canada’s public congratulatory blog post on January 10, 2023 regarding the release of the 2023 American Academy of Pediatrics Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity (AAP CPG). We urge Obesity Canada to not model the American recommendations when developing updated Canadian Clinical Practice Guidelines (CPG) for pediatric populations. The treatment recommendations in the AAP CPG are troubling, imposing possible mental, physical, and psychological harms to children and youth. We call on Obesity Canada to consider a weight-inclusive approach to care to better safeguard the children and families of our country.

We ask Obesity Canada’s Steering Committee to consider the following recommendations to inform upcoming guidelines:

1. Include studies that explore improvements to health independent of changes in weight status.

Healthcare interventions centered solely around weight neglect to acknowledge the decades of literature showing attempted weight loss results in weight regain 80-95% of the time, making long-term, sustained weight loss the exception, not the norm.^1,2 These weight-centric approaches also fail to acknowledge the emerging body of evidence demonstrating the harms of repeated weight-loss attempts, otherwise known as weight cycling. These harms include higher mortality of all causes including cardiovascular disease, poor cardiometabolic measures such as hypertension, dyslipidemia, and insulin resistance, increased risk of weight regain, and increased risk of disordered eating.^3,4 Further, growing evidence demonstrates successful improvements to health (i.e., blood pressure, cholesterol, cardiovascular fitness, mobility) can be achieved independent of changes to weight.⁴

Promoting health and well-being among children and youth should go beyond weight as an indicator. Instead, care should focus on fostering positive relationships with food, movement, body, and mind to encourage lifelong health behaviors regardless of how their growing bodies develop. The AAP CPG explicitly excluded studies that focused on health outcomes, rather than weight itself.⁵ We urge Obesity Canada’s Steering Committee to consider the benefits of including a wider range of evidence to promote healthy outcomes among children and youth,

avoiding what could be perceived as an unethical oversight.

2. Apply a comprehensive health equity lens, giving consideration to the social determinants of health.

Weight and body size are known to be complex and multifactorial, influenced by socio- ecological, genetic, and environmental factors. This includes, but is not limited to, genetics, racial or ethnic inequities, age, sex, living conditions, family history, trauma, income, culture, eating and physical activity habits, sleep, physical location, medical conditions, medications, and stress.⁶ Many of these are beyond individual control, and directly contribute to health inequities.⁷

Despite the established understanding of this complexity, clinical guidelines such as the recently released AAP CPG focus heavily on nutrition and physical activity behaviours as the primary means to address weight management.⁵ Writing guidelines that acknowledge the social determinants of health, but then go on to recommend solely individual solutions can worsen care outcomes and access.^6,8 Clinical practice guidelines should be created to support healthcare providers in doing comprehensive assessment that include addressing social challenges.⁹

We strongly urge Obesity Canada to adopt a health equity lens when formulating clinical practice guidelines, thereby better equipping health care professionals to assist individuals and families contending with systemic disparities. This holistic approach will not only lead to more inclusive and effective care but also contribute to the dismantling of inequities ingrained within our healthcare systems.

3. Endorse that all healthcare professionals participate in training and professional development in weight bias, stigma, and discrimination.

Frequently, practice guidelines maintain the notion of individual responsibility for health and weight control.⁹ This reinforces the cultural and societal preoccupations with weight, and places the blame and shame on individuals in larger bodies. As a result, people living in larger bodies often experience negative attitudes, assumptions, judgments, and even treatment as a result of these preconceived notions linked to their body weight, shape, or size. Increased childhood and adolescence experiences of weight bias, stigma and discrimination may lead to negative relationships with food and their body, deterring youth from enjoying and maintaining physical activity and healthy eating behaviors.¹⁰

Exploring how weight bias, stigma, and discrimination affects health care professionals, both consciously and subconsciously, is an essential step towards providing inclusive and equitable treatment to all. The AAP CPG provides surface level recommendations pertaining to weight bias, stigma, and discrimination, which disregards the impacts of these harms.⁵

We applaud Obesity Canada for their commendable effort by dedicating a chapter to address weight bias within the Clinical Practice Guidelines for Adults.¹¹ Our hope is that these insights and recommendations find their way into the forthcoming pediatric guidelines. Creating a healthcare system that is free of biases, stigma, and discrimination requires a multi-pronged approach where all players work together. We look forward to seeing further comprehensive projects that take a stance against weight bias, stigma and discrimination and that continue to include recommendations for practitioners to explore weight-inclusive evidence.

4. Recommend that healthcare professionals screen all clients, regardless of body size, for signs and symptoms of disordered eating and eating disorders.

Disordered eating and eating disorders can have severe consequences to mental and physical health, including cardiovascular, endocrine, gastrointestinal, and skeletal disorders, osteoporosis, dental problems, nutritional deficiencies, psychiatric disorders, and substance use.⁶ Across Canada, youth are experiencing a mental health crisis and growing eating disorder rates. In Ontario, 46% of students in grades 7-12 reported being preoccupied about their weight or body shape.¹² Similar to weight and body size, the existence of eating disorders is highly stigmatized as well. Contrary to common assumptions, less than 6% of people with eating disorders are classified as “underweight,” whereas 37-41% of people presenting for eating disorder treatment fall within the “overweight” or “obese” BMI classifications.³ This reinforces the notion that weight, BMI, and body size are poor indicators to guide health assessments and treatment.

The AAP CPG failed to acknowledge the risk of eating disorders among youth, only recommending screening for depression over 12 years of age.⁵ Children and youth living in larger bodies have likely experienced weight bias, stigma, and discrimination at the time of assessment, and have possibly had weight loss attempts. There is also a high prevalence of disordered eating and eating disorders among individuals seeking bariatric surgery; lifetime binge eating disorder prevalence rates range from 13-50%, compared to only a 4.5% lifetime prevalence among the general population.¹³ Incorporating trauma-informed, client-centred practices, as well as comprehensive disordered eating screening tools can significantly reduce harms for pediatric clients (e.g., Ottawa Disordered Eating Screen for Youth).¹⁴

5. Exclude pharmaceutical and surgical intervention recommendations for the pediatric population until further long-term research on safety is established.

The AAP CPG recommendation to consider invasive and metabolically altering surgery among growing, developing children and youth is especially alarming. Not only are short- and long-term harms largely unknown, capacity to understand the full extent of bariatric surgery may be limited in youth.¹⁵ Complications observed in adults, including malnutrition, increased risk of alcohol use disorder, ulcers, hernias, and the potential need for subsequent surgeries, pose a greater risk among young, developing bodies.¹⁶ This physiologically-altering surgery has lifelong implications, and the “success” of surgery later in adulthood could be impacted by factors like trauma, socioeconomic status, and living conditions that are largely unpredictable in children.¹⁷

As described in a recent AMA Journal of Ethics commentary:

“Pharmaceuticals have been described as the prescription for fat people of what is diagnosed as disordered in thin people …skipping meals (anorectics), diet pills (pharmacotherapeutics themselves), laxatives (orlistat), and vomiting (a common glucagon-like peptide 1-related adverse effect).”³

Considering the lack of data to support long-term safety outcomes, and the risk of eating disorder onset during adolescence, we urge Obesity Canada to consider the risks that these interventions (both surgical and pharmaceutical) pose among youth.

Comprehensive, evidence-informed guidelines that are sensitive to existing weight bias, stigma, and discrimination can help promote equitable and weight-inclusive healthcare. As a community of concerned healthcare professionals, we recommend that Obesity Canada and the appointed Steering Committee consider the above discussion and recommendations in the upcoming Canadian Pediatric CPG. We welcome the opportunity to discuss these recommendations and look forward to reviewing the guidelines anticipated for release in 2023.

Sincerely,

Laura Abbasi, Co-Chair Year 1
Ontario Dietitians in Public Health

Amy MacDonald, Chair 
Body Diversity and Health Equity Working Group

References

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2. Chastain, R. (2021, November). Who Says Dieting Fails Most Of The Time? Weight and Healthcare. https://weightandhealthcare.substack.com/p/who-says-dieting-fails-the- majority
3. Floegel-Shetty, A. (2023). Should pharmaceuticals be used as weight loss interventions for adolescents classified as obese by BMI? AMA Journal of Ethics, 25(7), E478-495. https://journalofethics.ama-assn.org/article/should-pharmaceuticals-be-used-weight-loss- interventions-adolescents-classified-obese-bmi/2023-07
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14. Obeid, N., Norris, M., Buchholz, A., Hadjiyannakis, S., Spettigue, W., Flament, M., Henderson, K., & Goldfield, G. (2019). Development of the Ottawa Disordered Eating Screen for Youth: The ODES-Y. Journal of Pediatrics, 215, 209-215. https://www.jpeds.com/article/S0022-3476(19)31002-9/fulltext
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