Brenndon Goodman was nine years old when a doctor told him he would be dead by 30 if he couldn’t get his weight under control.
“You’re going through all the issues a normal nine-year-old goes through. On top of that, also being told you’re overweight, you’re an aberration. For me, I felt like I was a failure,” said Goodman, 30, who lives in Thornhill, Ont.
He said he remembers endless — and unhelpful — appointments at weight-loss programs that amounted to cookie-cutter diet plans and shame. What finally worked was when a team of doctors, dietitians, specialists and psychologists at Toronto’s Hospital for Sick Children started telling him about the psychological and genetic aspects of obesity.
That kind of collaborative and inclusive approach should be what all doctors and nurses take when treating children struggling with obesity, say the authors of new Canadian clinical practice guidelines published on Monday in the Canadian Medical Association Journal.
The authors say doctors should make sure patients and families are well informed and included in any decision-making.
They also say that health-care workers should provide psychological treatments like counselling for behavioural change, along with such strategies as improving nutrition and physical activity.
“In terms of, you know, the ‘eat less, move more’ movement, we know that alone, as a treatment for obesity, does not provide sustained success,” said Dr. Sanjeev Sockalingam, a professor in the psychiatry department at the University of Toronto and scientific director at the non-profit Obesity Canada, which co-developed the new guidelines.
In some cases, the authors say, families should also be given a chance to consider medications, like GLP-1s — sold under brand names like Ozempic or Mounjaro — which mimic the naturally occurring hormone to help regulate appetite and blood sugar levels, and are widely used for Type 2 diabetes or weight loss. The guidelines also say some children struggling with weight management could be considered for weight loss surgery, under certain conditions.
It’s the first time the guidelines have been updated since 2007 — and they are long overdue, say some experts.
“A lot has changed in how we manage children, and there’s a lot of new literature as well,” said Dr. Jill Hamilton, head of the endocrinology division at the Hospital for Sick Children and one of the co-authors of the guidelines.
“For so long, we focused on just weight or [body mass index] as an outcome,” she said.
“Other outcomes are as important, or more important, than that to families. Things like improving health-related quality of life,” such as high blood pressure, musculoskeletal pain, anxiety or bullying.
New guidelines target stigma
The new guidelines also talk about the stigma associated with obesity.
It’s a huge change from the guidelines published in 2007, where the word “stigma” isn’t mentioned.
“We’ve had a long-standing history in obesity care and management, where people have attributed it as something to do with willpower,” Sockalingam said.
“All that stigma just perpetuates all the negative experiences, especially children and youth experience day to day.”
The new guidelines instead define childhood obesity as a chronic, stigmatized and progressive disease, characterized by the presence of excess body fat that could impact a patient’s health or well-being.
“It is a complex chronic disease, and like other chronic diseases, we need more tools in the toolbox to treat it,” Sockalingam said.
Encouraging health-care providers to recognize obesity as such, he said, might encourage more research that could help scientists nail down the best markers to define and treat the condition.
But others say the new guidelines don’t go far enough in breaking down the stigma associated with childhood obesity.
Vincci Tsui, a registered dietitian based in Calgary and the founder of Weight-Inclusive Dietitians in Canada, said while it’s good that the guidelines emphasize the importance of addressing weight stigma, a higher body weight shouldn’t be treated as a disease in and of itself.
“The problem is when you pathologize a body size, or pathologize this idea of ‘excess body fat,’ that in and of itself also increases stigma,” she said.
Major medical groups are proposing a change to how doctors diagnose obesity, moving away from the body mass index or BMI. The new definition intends to move away from weight stigma and instead focus on treatment.
Medication and bariatric surgery
Tsui said health-care providers should keep in mind that the guidelines recommend stronger interventions, like taking GLP-1 drugs or undergoing bariatric surgery, only in certain conditions, such as after a risk-benefit analysis.
She also cautioned that there’s not a huge amount of evidence about the side effects of drugs like GLP-1s for children — something also noted by Hamilton, one of the co-authors.
“Currently it’s only recommended for ages 12 and up, and obviously further research is needed because these are relatively new medications,” Hamilton said.
“More work is needed in this area in all age groups, but also especially in pediatrics.”
Ultimately, Hamilton said, health-care providers should respect the families’ views and wishes, including when it comes to more invasive interventions like surgery — especially for children who have significant health conditions associated with obesity, such as obstructive sleep apnea or insulin resistance.
For some kids, like Brenndon Goodman, weight-loss surgery can really make a positive difference.
“It’s a choice I would make again a hundred times,” he said, because he was able to think about it carefully and felt supported by a good team long after the procedure.
Goodman said he’s hoping that young people and families also get a chance to make that decision, if that’s what they want and need.
As Canada prepares to release new guidelines for treating childhood obesity, some experts are criticizing new guidelines in the United States that recommend more aggressive treatments like medication and surgery for children as young as 12 and 13 years old.
