The complexity of being overweight better reflected in refreshed Canadian obesity guidelines

People living with obesity have a powerful new tool to help them-and their doctors-better understand the condition, thanks to updated Canadian guidelines.

The Canadian Adult Obesity Clinical Practice Guidelines view the condition through a new lens that doesn't make stereotyped assumptions about being heavy, said project co-author Arya Sharma, past chair in obesity research and management at the University of Alberta.

Sharma and other U of A researchers from various faculties joined dozens of Canadian scientists to update the guidelines for defining and treating obesity.

It's the first update to the guidelines since they were released in 2006 by Obesity Canada.

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To shape a more relevant definition of obesity, Sharma, from the Faculty of Medicine & Dentistry, drew on work done on the Edmonton Obesity Staging System (EOSS), a measurement tool he helped develop in 2009. Rather than body mass index-a measure of weight-EOSS ranks obesity severity based on clinical assessment of weight-related health problems, mental health and quality of life.

"It changes the definition of obesity; in the old days the weigh scale would define whether someone had obesity, but now it's better defined as how it affects someone's health. So we're not labelling people who are healthy as having a disease," he said.

The refreshed guidelines better address the complexity of obesity, which isn't simply a matter of diet as reflected in the past, he added. "It's not as easy as saying eat less and move more. Different people have obesity for different reasons, so the idea that one diet, medication, or surgery will work for everyone is simply not true."

The guidelines also incorporate assessing root causes of obesity, including what Sharma deems the four Ms: metabolic problems, mental health drivers, mechanical issues (such as joint pain) and milieu--a person's social or cultural environment. U of A research also contributed to putting major emphasis on five principles health professionals can use in obesity management: ask, assess, advise, agree and assist the patient.

People can download the guidelines to have empowered conversations with their doctors, which is helpful in a landscape where most health professionals have very little training in obesity management, he added.

"By following these logical steps one after the other, there's a defined pathway to better managing people living with obesity," Sharma said.

Weight gain during pregnancy

U of A researchers also contributed to new chapters in the guidelines, including a much-needed one for pregnant women.

"Pregnancy is such a vulnerable time for excessive weight gain and for long-term health complications for both mother and baby, yet nothing had ever been written in the guidelines about pregnancy from an obesity perspective," said contributing nutrition scientist Rhonda Bell, based in the Faculty of Agricultural, Life and Environmental Sciences.

The guidelines now include a set of tools that doctors can use to support their patients for healthy weight gain during pregnancy, including women who were already heavy prior to conceiving--a group numbering about 13 per cent in Canada.

The guidelines fill an information gap for family doctors, who are usually the first medical professionals to see a pregnant patient, as opposed to a specialist.

"It helps inform and educate about best practices in promoting healthy weight gain and behaviours," Bell said. "It's a sound evidence-based approach to help women be as healthy as possible during and after pregnancy."

There's also guidance for dealing with weight gain well past pregnancy. "The medical community tends to step aside after the six-week post-partum checkup, and there's not a lot of discussion about mom's health and expectations for weight loss, but it's a time when women often move up in weight."

Experience a factor

The guidelines also include a new chapter reflecting the challenges individuals living with obesity experience as they go about their daily activities, with recommendations from occupational therapists and physical therapists.

"We felt we needed to raise awareness about some of those experiences learned from clients over the years," said contributing author Mary Forhan of the Faculty of Rehabilitation Medicine.

For instance, fatigue and fear of falling are two of the most common challenges faced by people living with obesity, yet there's little understanding of dilemmas posed by such barriers, she noted.

The guidelines offer opportunities for people to open up conversations with their doctors about the everyday strategies they use to get around and complete their day to day activities, and encourages health care professionals to ask necessary questions of their patients, "so they can get a better appreciation of the challenges their patient may experience everyday."

The strategies offered by occupational and physical therapists are readily applicable to people living with obesity, as with any other chronic condition, Forhan added.

"These updated guidelines come from a place of working with a patient and building on their strengths and abilities."

Exercise much more than weight loss

The benefits of physical activity get a boost in the guidelines, "painting a realistic picture of the best evidence on what exercise can do," said Normand Boulé, a professor in the Faculty of Kinesiology, Sport, and Recreation who helped update the information.

The update emphasizes a shift away from measuring the success of physical activity by weight loss or body mass index and more to other health outcomes, like lowering risk factors for heart disease and diabetes.

"If you just measure success on weight loss, the belief is that physical activity isn't important for obesity management, when in reality it offers an amazing range of benefits, even in the absence of weight loss," Boulé said.

The chapter also clarifies research findings on benefits of high-intensity interval and resistance exercises, which can have many of the same benefits as moderate-intensity, longer activity sessions. "We provide people with different options for exercise."

Overall, the revamped guidelines are being welcomed by the people they are designed to help, Sharma noted.

"A lot of people living with obesity were involved in writing and vetting the guidelines, and they're extremely excited and thankful that finally they'll be taken seriously when they go to family doctors with a health problem."