Last week, new guidelines for the prevention and management of obesity in primary care in Canada were published by the Canadian Task Force on Preventive Health Care in the Canadian Medical Association Journal.
Unfortunately, it is not exactly a ‘solutions based’ document. The main recommendations are as follows:
1. Body mass index (BMI) should be calculated by family doctors to help prevent and manage obesity.
2. Structured programs should not be offered to adults of normal weight, to prevent weight gain.
3. For adults with overweight or obesity, structured programs should be offered to help with weight loss.
4. Medications should not be used to treat obesity.
While I could pick apart their focus on BMI, or that not offering preventive programs was (in their words) a weak recommendation based on very low quality evidence, I want to focus on their recommendation not to use medications to treat obesity.
Advising us against using medications to treat obesity may be short sighted. While Canada currently has very little in terms of medications to treat obesity, several medications have been approved in the last three years by the FDA in the United States to treat obesity, some of which may become approved for use by Health Canada as well. Will the guidelines be hastily rewritten if/when these medications become available to us? Advising against medications to treat obesity leaves us with lifestyle measures on one end of the spectrum, and bariatric surgery on the other end. While the US and Europe move forward in accepting obesity as a medical problem with medication options to treat it, is Canada going to stay in the dark ages on this? Note that while our Task Force is telling us not to use medications to treat obesity, that the Endocrine Society in USA simultaneously released their Clinical Practice Guideline about how to treat obesity with medications. While I agree that the current singular medication available to treat obesity in Canada (orlistat) is not very useful, a note that options may change in the near future may have given this section a little more balance.
Another concern I have with these guidelines: Discussion of bariatric surgery was conspicuous in its complete absence. While bariatric surgery is an extreme treatment measure for obesity, it is a valuable one, and of great benefit for some patients. It is stated that these guidelines are not intended for patients with a BMI over 40 (bariatric surgery is considered an option if BMI is >40, or >35 with complications of obesity), but I feel that at least a head nod to the existence of bariatric surgery should have been given in this document.
And – how does one exclude people with BMI >40 from the guidelines, when one in eight Canadian adults who struggle with obesity fall into this category?
The procedure that leads to creation of guidelines is a rigorous review of evidence, and I get that this is why these guidelines look the way they do – lifestyle intervention studies and evidence are poor, medication options in Canada are currently limited, and availability of bariatric surgery is minimal compared to the number of people who could benefit from these procedures.
However, as an advocate (warrior?) for my patients who struggle with excess weight, I will continue to remain optimistic that more options and accessibility will ultimately become available to Canadians to treat this condition.