Trending Topic: New Canadian Guidelines: Pediatric Obesity

What’s happening?

New Canadian clinical practice guidelines for the management of obesity in children and adolescents were released in April (1). The Practice-based Evidence in Nutrition: PEN^® team was asked: do these new guidelines change dietetic practice, and how will the PEN database be updated based on the recommendations?

The guidelines give recommendations for three major types of interventions: behavioural/ psychological; pharmacological; and surgical. As dietitians, our main focus is on behavioural interventions, and the recommendations from these new guidelines are consistent with the practice advice in the PEN System (see relevant Practice Questions). And while we will not be prescribing pharmacological or surgical interventions, clients may still ask us about them. In the spirit of keeping our readers informed, we’ve summarized the related recommendations that you may need to know below (1).

Obesity medications

Overall, these guidelines suggest that two types of obesity medications can be considered in children 12 years and older: GLP-1 agonists (e.g. exenatide, liraglutide, semaglutide) and biguanides (e.g. metformin). If used, these medications should be given in tandem with behavioural and/or psychological interventions. These medications were chosen because the benefits of their use outweighed the possible side-effects (most commonly nausea, diarrhea or vomiting), which rarely were bothersome enough to stop taking the medications.

Obesity medications are not recommended in children younger than 12 years due to a lack of evidence to guide their use.

Lipase inhibitors (e.g. orlistat) are not recommended in children or adolescents of any age. Their benefits were too trivial to justify their moderate adverse effects (especially gastrointestinal effects).

Bariatric or Metabolic Surgery

The new guidelines suggest that surgical interventions may be appropriate in adolescents (>13 years) who are identified as candidates based on a comprehensive, multidisciplinary health assessment by a team of specialists. If surgery is indicated, it should be provided along with behavioural and/or psychological interventions.

The two types of surgery recommended are laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. This is because little information is available to inform which pediatric candidates would benefit from other surgeries (e.g. gastric band, intragastric balloon).

No surgical interventions are recommended in children younger than 13 years old.

What are some benefits of pharmacological and surgical interventions?

Health-related quality of life, depression and anxiety were always listed as the most important (“critical”) outcomes, as were serious adverse events. Other outcomes included: weight, BMI, BMI z-score (i.e. change in BMI over time), biochemical measures (e.g. blood pressure, cholesterol, insulin resistance) and mild to moderate adverse events. All interventions that the guidelines recommended were associated with large enough benefits (according to the GRADE process) to outweigh any mild or moderate adverse events associated with treatment.

What about the evidence?

All of the above recommendations are based on low to moderate-certainty evidence according to GRADE criteria with the exception of GLP-1 agonists, which was based on very low to low-certainty evidence.

It should be noted that there is little long-term evidence examining pharmacological interventions; most of the studies examining these interventions were assessed under a 1-year period. Additionally, data that informed patient values and preferences were sparse, so the authors relied on the input of guideline panel members with lived obesity experience to supplement these findings. However, 10-year follow-up from surgical interventions is promising and suggests that weight and health benefits are maintained for up to 10 years in adolescents who have undergone bariatric surgery.

Bottom line

The new Canadian clinical practice guidelines for managing obesity in children and adolescents make recommendations for behavioural and psychological interventions that are consistent with the content provided in the PEN database. The following practice questions have been updated to include these new guidelines:

All management options should be assessed by a multidisciplinary team of specialists and considered in collaboration with patients and families based on “evidence, feasibility and availability” (1). There is no evidence to suggest that medications or surgery should only be considered where behavioural and psychological interventions are inadequate.

See related PEN content:

Reference

Ball GDC, Merdad R, Birken CS, Cohen TR, Goodman B, Hadjiyannakis S, et al. Managing obesity in children: a clinical practice guideline. CMAJ. 2025 Apr 13;197(14):E372-E389. doi: 10.1503/cmaj.241456. PMID: 40228835; PMCID: PMC12007946. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/40228835/