Perspectives on the new guideline for managing obesity in children

It’s been nearly two decades since the last Canadian clinical practice guideline on managing obesity in children. In that time, the science has advanced, treatment options have expanded, and the need for updated guidance has grown increasingly urgent. On this episode of the CMAJ Podcast, hosts Dr. Mojola Omole and Dr. Blair Bigham speak with three guests who contributed to or were impacted by the new guideline published in CMAJ. Together, they explore how the recommendations address the complexity of pediatric obesity and what it takes to implement them in real-world settings.

Dr. Geoff Ball, chair of the guideline steering committee, explains how the recommendations were shaped by evidence as well as the meaningful participation of parents and youth at every stage of development. He discusses how the panel weighed the benefits and risks of pharmacotherapy and bariatric surgery in the context of limited pediatric data and a rapidly evolving treatment landscape.

Dr. Michelle Jackman, a pediatrician and clinical lead at the Pediatric Centre for Wellness and Health in Calgary, shares how her team delivers multi-component behavioural interventions, often in the absence of system-wide supports. She reflects on how the new guideline has prompted her to reconsider referral pathways for bariatric surgery and advocate more strongly for patients.

Brenndon Goodman, a long-time patient advocate, offers his own experience navigating childhood obesity, including the emotional dimensions of eating, the impact of stigma, and the life-changing outcome of bariatric surgery. He calls for improved access to care and a stronger commitment to children and youth living with obesity.

This episode highlights both the progress and the persistent barriers in treating childhood obesity. The new guideline affirms that obesity is a complex chronic condition and provides much-needed support for physicians caring for children and youth living with it.

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Transcript

Dr. Mojola Omole

I'm Mojola Omole. 

Dr. Blair Bigham

And I'm Blair Bigham. This is the CMAJ podcast.

Dr. Mojola Omole

So Blair, today we are talking about a very new, exciting guideline that was published in the CMAJ about pediatric obesity.

Dr. Blair Bigham

It is robust, Jola. The authors, and there's many of them, have obviously put hundreds and hundreds of hours into this. The last pediatric obesity guideline was about 19 years ago.

And quite a few things have changed. Obviously, everyone who pays attention to the news knows that there's a lot of new medications out there. And of course, bariatric surgery that I guess was previously restricted to adults is now being offered more often to children.

Dr. Mojola Omole

Yeah, and in the paper, they outline recommendations ranging from behavioural exercise, nutrition, surgical intervention, and of course, what we've all been talking about in adult, pharmaceutical intervention.

Dr. Blair Bigham

So we're going to focus on this new clinical practice guideline in CMAJ and talk about obesity in children, which has been on the rise. So we have a panel with us today. We have a guideline expert, we have a frontline clinician, and we have a patient who has struggled himself with childhood obesity.

That's up next on the CMAJ podcast. Joining us to talk about the new guidelines are three guests who bring deep experience from clinical care, policy, and patient advocacy. Dr. Geoff Ball is the steering committee chair of the guideline. He's a professor and associate chair of research for the Department of Pediatrics and Alberta Health Services chair in obesity research at the University of Alberta in Edmonton. Dr. Michelle Jackman is a pediatrician and the clinical lead at the Pediatric Center for Wellness and Health at Alberta Children's Hospital, a role she's had since the center was established back in 2012. She's also a clinical assistant professor with the Cummings School of Medicine and the University of Calgary.

And last but not least, we have Brenndon Goodman, a longtime patient advocate who works closely with Obesity Canada, an advocacy group, and draws on his own experience in receiving treatment for obesity as a child and teenager. Geoff, Michelle, Brenndon, let's see if we can keep all of these voices straight. Welcome to the podcast.

All

Thanks very much.

Dr. Blair Bigham

So, let's start with a little bit of context for everybody on the other end of the airwaves. Geoff, why do we have these guidelines coming out now?

Dr. Geoff Ball

Well, Blair, it's been a long time coming to be honest with you. I remember way before COVID, I would see colleagues at conferences and we'd talk about the need to update the guidelines because some listeners may know the first Canadian guidelines came out in 2006, 2007. Lots has changed since then.

An adult guideline was published in 2020 and those of us who work in pediatrics have talked a lot about the need to update the guideline for children and for adolescents because not only has the science evolved about how guidelines are developed, but then of course we've learned more about obesity and obesity management in children and youth and families. And we thought this is an important time, important update to give to clinicians and to families. And yeah, so we've been working on it for the past four plus years and it's great to get at this point.

Dr. Blair Bigham

We're going to get into the nitty gritty of the guidelines. But first, tell us about how bringing patients and families into the guideline development process affected your work.

Dr. Geoff Ball

Yeah, that's a really good point. I should say from a science perspective, it's dispassionate. But then of course, when we have parents and we have patients and we have healthcare professionals on the front line, it's a very passionate issue, often an emotional issue for people who are on the front line.

So we do recognize that and certainly separate that when we need to. But then I hope that passion comes through in the recommendations and the work that we'll do communicating the guidelines and hopefully getting them used. But the input over the participation of parents and of youth along the way has been, I guess, fundamental.

Right from the beginning. And the group grew over time. I think that's the other part that I don't think it's recognized in the guideline, but we've certainly had an evolution as we went through to have parents involved, largely parents involved in helping to craft the research questions.

We had parents on our steering committee that we would talk about some of the procedural and sometimes the scientific things and then often be grounded by the real world things that families were experiencing. And so we had parents on our steering committee, we had parents on our guideline panel that actually helped to evaluate the evidence. We had parents contribute to the systematic reviews that we generated to help inform the guidelines.

So at every step along the way. And I know we've got parents who are involved in helping to communicate and get the guideline messages out into the public.

Dr. Blair Bigham

So let's jump into the first recommendation. Michelle, make this real for me. What is multi-component behavioral interventions?

What does that mean on the front lines?

Dr. Michelle Jackman

I work on a day-to-day basis with a dietician, an exercise specialist, a psychologist, a social worker, as well as we have access to psychiatry supports. Others have specialties within Alberta Children's Hospital, which we have really strong collaborations with, so including nephrology for helping us support those children with cardiometabolic and blood pressure requirements.

Dr. Blair Bigham

So you have a huge team and it sounds like you're very lucky and that's not necessarily commonplace. Tell us what that team does in terms of what a patient might experience.

Dr. Michelle Jackman

We tend to take an individualized approach, but all families attend an information session online and then they decide whether or not it's the right time for them. So then we ask of the family if they decide to go ahead with participating in the program. And we have two one-and-a-half-hour group parenting sessions where we deliver some basics in terms of parenting information around food, around some of our philosophies.

And many of the families when they come into the program have already felt stigmatized, judged. Many of the parents feel judged already. So we try to create a psychologically safe environment for them to be vulnerable and share what their barriers have been up to now and maybe what's been presented to them as being the concerns for their child's health.

Dr. Blair Bigham

Brenndon , you've been through a comprehensive program. Can you tell us a little bit about what tips or tricks or changes the program specifically helped you make?

Brenndon Goodman

Yeah, so I've had many experiences and many programs all over the GTA here where I've been throughout all my youth. And what I found was the best approach and the most useful was the programs that had multidisciplinary teams where the emphasis was on not just the physical and the overview of the life of the child, but especially psychological. They would have a full team of psychologists, social workers, and they spent a lot of time focusing on the psychological issues of childhood obesity just as much as the physical aspects.

Dr. Blair Bigham

Give me an example of a psychological aspect where you really found that social worker helped you move forward in your journey.

Brenndon Goodman

So I personally, like at home, I had a lot of issues with my parents, with my family. There's a lot of inter-family drama between my mom and my dad and my siblings. And so there were some issues there that needed to be resolved before I was going to start working on my obesity and the nature of food and why, not just what I ate, but why did I eat?

Why did I want to eat? What comfort did I draw from food? The emotional aspect of it, right?

When I was talking with the psychologists in the program and they're talking about these compulsions of eating or talking about it sort of even in the world of addiction, it opened my mind up to think about it differently. Because up until then, I was told it was a moral failing on my part. That was why I acted as I did.

Dr. Blair Bigham

As regions and provinces work to develop these type of multi-component offerings, one area of the guideline that's changed a lot in the last two decades is around the pharmacology for obesity. Geoff, how about I start with you here? How has this space changed since the last guidelines?

I mean, obviously, weight loss medications are in the news all the time these days.

Dr. Geoff Ball

Yeah, you can't watch a hockey game or a sporting event or anything on TV without some ad for obesity medications. It's omnipresent these days and it's been that way for a number of years now. I've been doing obesity research for over 20 years.

It's probably the most dynamic time in obesity management care since I've started. A lot of what we see in the news and a lot of what we read in the literature is based on adults. One of the limitations still with our guideline is even though we did a systematic review on pharmacotherapy, there's still not a great amount of evidence that we can rely on from children and youth.

That's essential because as Michelle can attest, a lot of the medications that are out in the market are based on evidence from adults. Then, they're used off-label for children and youth. We still have some ways to go.

I won't necessarily get into the details of all the recommendations that we have, but at least for pharmacotherapy, I can tell you when we had discussions as a guideline panel about GLP-1s. That's a new family of medications. It's relatively new.

Emerging evidence suggests that it's quite effective for the majority of people who take it, not for everybody, but there are side effects that come with it, adverse events. For some people, those adverse events might lead them to not take it and others might be able to tolerate it fine. There's still quite a ways to go to really understand the nature of the adverse events and the duration of it.

Because of course, like any therapy, if it's medication for high blood pressure, medication for dyslipidemia, you need to continue to take the medication. We don't know yet what years or decades of taking a medication like GLP-1 will have on growth and development and other health effects. They could be positive, they could be negative, but we don't know.

We had a lot of discussion within our guideline panel about what do we know now, what can we make recommendations on now and what do we have to wait for maybe five years, ten years when the guideline is updated and then we'll have more evidence. I can tell you there are a number of clinical trials that are going on in the pipeline, not just for GLP-1s, but for different combinations of drugs. Drugs plus surgery, drugs plus behavioral intervention.

It's a very dynamic time, like I said. We're still at the beginning, so the recommendation in five or ten years may be very different than what the recommendation is today.

Dr. Mojola Omole

Michelle, how often are you prescribing these treatments and what drives the decision to then put a pediatric patient on a GLP-1 or some other pharmacological intervention?

Dr. Michelle Jackman

Over the last year, my colleague and I have been prescribing these medications pretty well every day. I think there's been quite a shift towards that, but only in patients that we feel that they would individually benefit from it. It's a very individual choice.

Dr. Mojola Omole

What do you mean benefit? Sorry, just not to cut you off. I just want to have a better understanding of what does that mean to a patient, like to a pediatric patient, that there is a benefit.

Dr. Michelle Jackman

Right. I frame it for the families that the medication is not the treatment for the disease, but rather it's another tool. It's another tool in addition to the multimodal interventions that they're already receiving, hopefully at this point in time, by a number of our team members, the exercise, the intensive lifestyle, behavioral counseling around the dietitian that gives them around the diet, the lifestyle, as well as the psychology that Brenndon talked about, the emotional, addressing the emotional eating, addressing the underlying mental health components that we know are really the mainstay and the main foundation of having health and the sleep issues as well.

Dr. Geoff Ball

Sorry, just to add to what Michelle said, that's part of the recommendation that we have too from the guideline is that the medication, any medication, is not standalone medication, but it's in combination with behavioral and psychological intervention. So, what you just described, Michelle, is exactly the guideline, and I'm not even sure it's been released to you yet. So, I think what you're doing now is aligned with what we're doing.

Dr. Mojola Omole

Yeah. Brenndon , just a question for you. Like, when you were younger and you were going through this multidisciplinary team approach, if a medication like the semaglutides had been available, do you think you would have wanted to try them?

Brenndon Goodman

Oh, for sure. I definitely would have wanted to give them a shot and see. I had tried pretty much every different intervention that was available when I was a child, and I think a lot of these new interventions are promising. I think it would be very helpful to a lot of today's youth that are out there, and a lot of the options now coming out are seemingly more viable.

So, I think having these options is only a good thing, if anything.

Dr. Mojola Omole

What are some of the trade-offs, Geoff, do you think that families and clinicians have to think about if a pharmacological route is taken?

Dr. Geoff Ball

Yeah, there's a number of positive effects that we've seen from the literature related to, if we would talk about GLP-1s specifically. So, for sure, there's improvements in weight and body mass index, however you define, in kids, we tend to use body mass index Z-scores.

Sometimes people use percentiles, but regardless, the evidence suggests that there are improvements to weight. There's some evidence to support the improvement of health-related quality of life, depression, anxiety. Those outcomes were really highly prioritized by our stakeholders.

When we asked families at the beginning of the guideline process, what outcomes matter to you? Weight was part of it, but the things that really mattered to them were things like health-related quality of life, other mental health outcomes, and then other improvements that have been demonstrated. Dyslipidemia improves, insulin resistance improves, blood pressure improves.

But the thing that a lot of us found interesting, so those people who were on our guideline panel, and it included parents who had taken GLP-1s. Well, this is anecdotal, right? This is just the experience we had on the panel.

But some of the parents had taken GLP-1s, and I think there were one or two children of the parents on the panel that had taken it as well. Those of us who hadn't taken it were at the beginning thinking, well, there's quite a few adverse events, and maybe this isn't going to be, it's not going to be as strong of a recommendation as we think it's going to be. But we were struck by the comments that people had made related to they would give it a try, and if even if the adverse events are gastrointestinal, and maybe they're quite severe, they would still tolerate it because the benefit, the payoff, the pros versus the cons was more pro than con for them.

So they would tolerate a higher level of adverse events to have treatment effects that were more beneficial.

Dr. Michelle Jackman

In practicality, when you mentioned trade-offs, again, I like to emphasize that it's not either medication or multimodal management. They have to work together. The two of them have to go together or you're not treating the disease.

And now that we have more research and understanding about the importance of brain neuroplasticity on the release of the interaction between the brain and the metabolism and insulin resistance, and with the GLP-1 agonists, they've helped us understand a little more into the biology of obesity. So when we talk about medications, it's really important that we frame it in this way, as well as also, I think that it helps them to feel, you know, that they're being supported and that they know, the families know that they're not going to be prescribed the medication and then dropped from the program. It's all part of the package.

So, and that in order, I mean, the research in the adults show that when they stop the medication, such as semaglutide, the weight gain comes back. And so I think that's further evidence to show that you can't just take a pill. This has to be the whole package, and the whole package has to continue.

Dr. Blair Bigham

Brenndon , a lot of these medications that the guideline mentions are somewhat novel, but one thing that's been around for a long time is bariatric surgery. And you were offered a sleeve gastrectomy when you were 17. Tell me, how did that conversation come to you?

How was that presented to you as a choice?

Brenndon Goodman

Well, how it had worked was, I was with the STOMP program here in Toronto, a childhood obesity program out of SickKids, and they had offered it to certain patients who cases merited it, so to speak. There's not enough surgical resources to go around in Canada, unfortunately. So I was offered it due to my morbid obesity, and I had expressed interest in it.

And given my history of failed interventions before, and long, many years struggling, it was decided to try out with the sleeve. And I can tell you personally, the surgery was a huge game changer for me. It basically changed my life.

I was able to go out, do more, go out with friends, keep up with them. And it showed me a side of my life I hadn't seen before. I've been overweight all my life.

So you don't realize the grass is greener sometimes until you actually get to touch it. So the surgery was a huge help for me, and I would recommend it for any other people or children dealing with obesity, especially if they've struggled with other interventions, not necessarily working. I would recommend it, yeah.

Dr. Blair Bigham

Well, that's a testimonial if I've ever heard one. Geoff, how has the evidence changed when it comes to bariatric surgery for kids and teenagers?

Dr. Geoff Ball

That's been an interesting one for us to review because the evidence is a bit different. There aren't very many. I think in the end, we had one randomized control trial to test different types of surgical interventions.

It's just not how research is done with surgery. So we had a lot of pre-post. We had a lot of, whether it's the sleeve gastrectomy or the Roux-en-Y, they're two procedures that are done in Canada by and large.

And those are the two that have the most evidence for us to make recommendations on. So the evidence is a bit weaker. It's more prone to bias just because the nature of the study designs are not RCTs.

But I think Brenndon 's testimonials is a good example. There can be dramatic weight loss that that intervention can elicit. And again, I'm sure Brenndon would attest to this as well.

It's in combination with behavioral and psychological support. It's not a standalone. So I think the evidence is probably one of the things I'll mention, Blair, is it's a report that I saw not long ago.

Over the past several years, because of the increased availability and probably a little bit of marketing and the evidence behind GLP-1s, the pharmacological treatment has increased a lot. And there is some evidence to say that surgical interventions are becoming less common.

Dr. Blair Bigham

Because of the success of the medical treatment.

Dr. Geoff Ball

People may be opting out of surgery and trying pharmacotherapy maybe first, or maybe in lieu of surgical interventions because the perception, and maybe it's real, related to the invasiveness and the permanency of the intervention. We don't have any data on kids about that, but it's an interesting evolution.

Dr. Blair Bigham

With that said, I want to turn to Michelle. In practice, whether you're at your high-end wellness center or whether you're a family doctor in a clinic working solo without access to such a wonderful multi-D team, at what point does surgery come on the radar for you?

Dr. Michelle Jackman

Interestingly enough, in Alberta, we actually don't have access to bariatric surgery for pediatric population under 18.

Dr. Blair Bigham

Like it's just not funded, or there's no one who does it?

Dr. Michelle Jackman

It's currently not available. I have never referred a patient to it. I actually just sent out an email to some of my colleagues to see if any of them have referred or had special circumstance as exceptions made for any of their patients.

But to my knowledge, we've had to send patients out of province. And I think, like Brenndon  said, for him, it was a transformational life changer, potentially lifesaver, right? And if a medication has serious side effects, we can't use it.

It's not sustainable. So in that case, I have a number of patients that would benefit. And based on these guidelines, it's certainly making me question that my practice and that maybe I haven't advocated strongly enough for some certain individuals who would really benefit from bariatric surgery before the age of 18.

Dr. Blair Bigham

Brenndon , as an advocate working with a national profile, do you see people who struggle to find a surgeon when they feel that that's the choice they want to make?

Brenndon Goodman

Oh, for sure. It's become a huge problem people have spoken with across the country and in my experience, too. When I got the surgery at SickKids in 2012, it was very experimental.

STOMP was one of the first programs to offer it to people under 18. And it was, I think, they gave 10 or 20 a year. So it was very difficult.

And I know a lot of people in Canada who sought the surgery out aren't able to get it, or it's a three-year wait, or they have to go down to the States or other countries and pay thousands and thousands of dollars to get it. So it's very difficult to access here in Ontario, and it's even more difficult in many other provinces across Canada.

Dr. Mojola Omole

That's interesting to hear because as a surgeon who trained in general surgery, I feel like we have so many bariatric programs, especially in the GTA. So there seems to me to be literally around me, there's so many programs. And so there seems to be maybe a disconnect in terms of people being able to be connected to these programs in an effective manner.

Dr. Blair Bigham

Or Jola, do they only see adults? Are the programs excluding children?

Dr. Mojola Omole

Yeah, SickKids is the only place who does Peds. I would say probably in Ontario. I can't speak of Western. I think SickKids is the only one who has a program for pediatric population.

Dr. Blair Bigham

And Geoff or Michelle, where are you guys sending people from Alberta? Do they go to BC or do they have to come to Toronto?

Dr. Geoff Ball

I don't know what it's like in Calgary, Michelle, but in Edmonton, we wouldn't send them anywhere because we have nowhere to send them. 

Dr. Blair Bigham

Oh, they just don't get to have surgery.

Dr. Michelle Jackman

Yeah, we do have a few families that have gone to the US. And we have, I believe my colleague has referred one patient to SickKids.

Dr. Blair Bigham

I won't dwell too much more on this. I just find it very interesting that there's an access problem here for something that has appeared in the guidelines.

Dr. Michelle Jackman

Yeah. And it's interesting, Blair, because we had actually, and Jola, we have a surgeon who's very interested in doing it. But there's a number of system barriers.

Some of it includes the anesthetists, the pediatric anesthetists in terms of their experience with this population, because we aren't a large center. So it's just like cardiac, pediatric cardiac surgery, you want to have the center of excellence that performs a number of these procedures per year. So there's a number of system challenges that need to be really advocated for.

And again, these guidelines bring up an exciting opportunity. They've identified some significant gaps. And at the same time, it's exciting how many more opportunities we do have now to offer patients.

Dr. Geoff Ball

Just one thing to add to that, Jola. We had discussions in Edmonton a number of years ago about developing a surgical program. And there was interest from an adult surgeon to come and train a pediatric surgeon.

There was interest from everybody involved, except hospital leadership, because it was an issue of space and it was an issue of money. It wasn't an issue of whether it's effective or whether we should offer it. So the barriers are system barriers.

I would say they're not evidence barriers, and they're not patient-centered barriers. They're above that, and that's problematic.

Dr. Blair Bigham

Brenndon, I want to give you the last word here. Listening to this conversation, having gone through this your teenage years, your adult years, what do you think our audience needs to hear right now?

Brenndon Goodman

I think what they need to hear is that, unfortunately, obesity is a growing issue. Childhood obesity is a growing issue, and there needs to be more focus in political will, in the medical system, funding towards obesity. It's an issue that is not getting, I believe, the attention it needs.

It's only getting worse, and we need to be very proactive to tackle it. I can tell you myself, I had experienced that as a child, having many tumultuous interactions with people in the medical system that simply didn't understand obesity or how it worked, or just saw it as a simple calculation of eat less, move more. That created a very difficult childhood for me.

So there needs to be more attention. There needs to be more research, more funding to help people living with obesity. We need to do better to create better outcomes for adults and especially children.

Dr. Blair Bigham

Thank you so much to all of you for participating in our conversation. This has been amazing.

Dr. Geoff Ball

Thanks very much.

Dr. Michelle Jackman

Yeah, thanks.

Dr. Blair Bigham

Dr. Geoff Ball was the Steering Committee Chair for the new Pediatric Obesity Guidelines published in CMAJ. Dr. Michelle Jackman is a Clinical Lead at the Pediatric Center for Wellness and Health at Alberta Children's Hospital. And Brenndon Goodman is a long-time patient advocate who works closely with obese patients in Canada.

Dr. Mojola Omole

Thank you guys very much for joining us. This has really been great. Thank you.

Dr. Michelle Jackman

Thank you. Thanks for inviting us.

Dr. Mojola Omole

So Blair, one area that I wanted to explore, and it would be interesting to explore that the guidelines doesn't talk about, is the durability of the various interventions, right? Oftentimes, we do not view obesity as a chronic disease, that it's not something that you quote unquote cure. And it would have been, I would like the next iterations to talk a little bit of durability, right?

And so to kind of frame it that for physicians to understand that it's progression. And as Brenndon  said, you know, the sleeve when he was 17 was like a massive game changer in his life and the importance of that.

Dr. Blair Bigham

Yeah. And I also think this is where guidelines sometimes do a disservice when they assess for indirectness. So let's say they're using adult literature and they're saying, well, the adult literature is indirect when we talk about teen obesity.

I don't know that that's necessarily true. Like I don't know that a paper that focuses on 18 to 40 year olds doesn't apply or is somehow less valuable than a paper that focuses only on people aged 14 to 17. For me, whether you're talking about indirectness or bias or kind of these wonky guideline terms, the real shocker for me is that if a patient and a clinician decide that they do want to move forward with meds or surgery, sometimes that's really hard to implement.

It might not be covered. You might not even have access to a surgeon. You might have to pay out a pocket for certain medications. That's where I think the real disservice is happening, is my take. 

Dr. Mojola Omole

Understandable. I think for me, my final takeaway is that something that I've always believed strongly and I think as all physicians is that we should not equate weight with health and also understanding the same compassion that we show patients who have type 1 diabetes, we should show to people who have obesity.

Dr. Blair Bigham

100%.

Dr. Mojola Omole

This is it for this episode of CMAJ Podcast. The link to the study is in the show notes. Thanks so much for listening.

Please rate, review and share the podcast and please give us five stars. The podcast is produced for CMAJ by Neil Morrison at PodCraft Productions. Catherine Varner is our Associate Editor of CMAJ and Senior Editor on the podcast.

I'm Mojola Omole. 

Dr. Blair Bigham

I'm Blair Bigham. Until next time, be well.