New Paediatric Obesity Guidelines: What Parents Need to Know

Welcome to the Where Parents Talk podcast. We help grow better parents through science, evidence and the lived experience of other parents.

Learn how to better navigate the mental and physical health of your tween teen or young adult through proven expert advice. Here's your host, Lianne Castelino.

What do the latest national guidelines reveal about pediatric obesity and why could they change traditional approaches to helping kids stay healthy? Welcome to Where Parents Talk. My name is Lianne Castelino. Our guest today is a family physician who specializes in obesity medicine. Dr.

Tasneem Sajwani is medical director of the Edmonton Weight Management Center.

Thank you so much for having me. I'm honored. Thank you.

Lots to dive into on this topic. The new pediatric obesity care guidelines represent the first significant change in almost two decades.

Could you take us through that time lag a little bit and why, why were they released now?

So you're right.

It's been two decades since the last guidelines and one of the reasons, I believe, for the gap is that traditionally we used to approach pediatric obesity with just that notion of a lifestyle change.

And now we have a true understanding that obesity is a chronic, progressive, complex, multifactorial disease and it is something that deserves evidence based care.

And on top of that, there's been this tremendous data and information around the understanding of the biological, the psychosocial and the environmental drivers of obesity. So there is a lot of new information that needs to be brought forward.

And I think these guidelines are very timely, maybe a little too late even to even have that opportunity for our patients to access appropriate evidence based care. On top of that, there's this urgency. The Canadian government has stated that over the past 30 years, pediatric obesity has tripled.

That is a sense of urgency.

We know that one third of children who are of the ages of 4 to 11 have obesity and, sorry, one fourth of the children between 4, 4 to 11 have obesity and 1/3 of children between 12 to 17 have obesity. That is a tremendous number.

So if we don't get acting on that and have appropriate care measures for them, it's really going to be something that's going to grow even further.

We are going to dive into the science and unpack several of the elements that you just alluded to there. But I want to ask you first what was your specific role in developing these guidelines?

So I am a family physician and currently I do solely obesity medicine.

So my role was to be part of a panel that had other, other physicians, other healthcare providers, caregivers of children with obesity and patients with lived experience and being on this panel to help review the evidence and translate it in a way that would be useful for real world practice and be able to.

And part of my role, I feel was to take into account the language around stigma and bias and advocacy for our patients, people who don't have voices, to bring that forward into the language that is used in the guidelines themselves.

I'm actually really proud to be part of those guidelines because I feel that a novel approach was used where normally guidelines tend to speak just about the evidence and the outcomes tend to be, well, this is what we're trying to solve and this is how we measure success.

Whereas these guidelines were able to take the panelists lived experience and they placed a higher value on the quality of life, mental health and adverse effects of patients struggling with obesity or pediatric children. Obesity rather than the reduction in weight.

So the critical outcomes or the critically important outcomes were quality of life rather than reduction in weight, which yes, they are very important outcomes, but wasn't the first thing that was looked at. So for me that is incredibly novel and it puts the patients and the families in the center of this.

Speaking of patients and families, why do you believe that it is important for, for parents, Canadian parents, to be aware of these pediatric guidelines?

Well, I mean, we can't forget that obesity is a highly stigmatized disease and parents of children with obesity face this stigma from society in general, from health care providers and it brings a sense of shame and blame.

They can feel judged and I'm not going to discredit, of course what children feel, but because we're talking about parents, parents, especially parents with children that have obesity, should know that there is support, that there are resources, that there is science based care out there and that, that these guidelines may actually validate something that they've already known, that this is not a lifestyle, this is not a choice for these children and that we can access now evidence based, multimodal, compassionate, patient centered care. So they have help.

Now, as a family physician who sees this on the front lines of what you do every day, also as a physician who specializes in this area, what would you say concerns you the most as you look out at the landscape as it relates to pediatric obesity in Canada currently?

Well, a couple of things. One, we were just talking about that parents what they should know. I feel that access to that kind of care is still limited.

I'm hoping that these guidelines is going to change that. But for patients who struggle with obesity, whether they be adults or children, accessing that kind of care is still so limited. I do this all day.

So what I see is patients who've already been able to figure out how to get that specialized care, but that is such a small sliver of the population that needs that care. For me, I think I am concerned about how do we get that evidence based care to all of the patients that need it.

The second thing that worries me really is the prevalence of this weight bias and stigma. It truly is a barrier not only for patients and families, but it's a barrier from the other side, health caregivers.

So it's one of those things that prevents patients from even coming in to see a healthcare provider and prevents health care providers from providing appropriate care. So that is also something that I'm hoping with these guidelines we'll settle a little bit.

But we experience this in adult obesity as well and hopefully we're moving the needle.

You alluded earlier in the conversation to the rising numbers of cases of pediatric obesity over the last three decades.

Certainly we can all attest to the seismic shifts in lifestyles, you know, the world at large society that could have impacted this research over the past 20 years. Since the last guidelines.

We're talking about sedentary behavior, devices, technology, the pandemic, cost of living, you know, access to whole fresh foods for, for many families. What are some of the key data points that were examined in the course.

Of crafting these guidelines exactly that we were looking into?

There were, I believe, five different systematic reviews that were, that were looked into and they did review those psychosocial interventions, medication use, behavioral interventions, and even surgical interventions.

And taking into account what was most effective or not effective at all, and, and I feel like in these guidelines there is clarity to how much effect just lifestyle or just behavioral inter interventions can make.

And quite frankly, it's a little bit more exciting than the adult population that if we do intervene at an earlier time and do apply some significant nutritional change, significant psychosocial behavior, we may actually be able to move our children out of the obesity realm. However, because of the new data that has come out now, we do have more tools.

We can pull out the medication tool for those who are needing it, or with of course, the conversation with the parents and the surgical tool. And these were tools that were not available before, and if they were, they were being used off label and it was very few.

One of the keys I guess for any parent or family to understand as a starting point is how do you define obesity and how does it differ from being overweight?

A good question.

I actually had this conversation very recently with some colleagues and from that conversation and something I felt all along, Obesity itself is a chronic disease. It is not a descriptive word.

It is something that exists as a chronic persistent multifactorial disorder that is characterized by excess fat mass or adiposity that causes harm that impacts health. And in children it isn't just about bmi. It isn't just about size either.

Just like it isn't in adults, it is about how that weight is affecting their health. Now, when it comes to overweight, overweight seems like a descriptive word to me, seems like a social construct.

Does someone who potentially have overweight, does that person have disease? Does that person have obesity? Maybe, maybe not. Could it be something that can trigger some assessment?

Potentially, but at the end of the day, overweight, if we medicalize that word, I really don't know where I would put doesn't mean that this person has disease. It means that this person has a different body shape, a different body size and that can be beautiful.

So then what would you say is the key metric that is used to measure obesity?

I wish I had a really concrete answer for that. I am going to have to say that BMI and BMI zeds are still the screening tool that we use to help diagnose obesity, at least in Canada.

A child that has a higher BMI or a higher BMI Z does that mean that they have obesity? No, that means that this should trigger some assessment into does this child have metabolic disease associated with their weight?

Does this child have a mechanical dysfunction, joint pain, sleep apnea that is associated with their weight? Is this child experiencing mental turmoil because of their weight? This is how we diagnose obesity.

There is a scale called the Edmonton Obesity Staging for Pediatrics that was developed here in Edmonton through Obesity Canada and it is recognized internationally as a more concise version of how to diagnose obesity as a disease. Yes, taking into account the BMI and BMI zs, but categorizing it on disease burden rather than just the number itself.

So when you talk about BMI or body mass index as a screening tool, what level of accuracy can we attribute to that BMI number as it relates to measuring potential obesity?

I don't know if there is an actual rate at which BMI is accurate or not.

It would be similar to if A person comes into my clinic and we check their blood pressure, which is a screening tool to see if someone has hypertension. Does it mean that that person, with that, with that current blood pressure is where I am going to diagnose that disease with? Absolutely not.

But it does trigger a list of investigations and a list of questions that will help me decide whether or not this is an accurate representation of how their disease state is.

If they have the disease state, it could just potentially be that they ran the clinic and sat down, didn't get a chance to breathe and their blood pressure was high. So I mean, I think, I don't know if there's any gold standard yet for a BMI of this magnitude to be considered absolute obesity.

If there is, it's likely more in the severer categories. But I don't think that there's been any particular decision made on where one side is obesity and one side is not.

You alluded to obesity as being a chronic progressive disease, especially when it comes to children. Dr. Sejuani, I wonder if you could paint a picture for us of what that looks like in practice.

What would you want parents to know about what chronic progressive disease like obesity can do to a child across the lifespan?

This, this is one of my worries.

It's when I look at the number of children that are even in elementary, elementary school age that now have obstruct, obstructive sleep apnea, that now have pre diabetes or diabetes, when we look at adults that develop chronic disease, chronic disease, meaning a disease that is going to persist for a very long time, that doesn't mean that we're not going to be able to manage it very well. We manage chronic disease relatively well, actually, but we never quite get rid of it, but we manage it well.

But thinking about when an adult is diagnosed with a chronic disease, whether it be type 2 diabetes, whether it be hypertension, we automatically start thinking about how is their pancreas going to look like in 10 years? How is the neurovascular vasculature going to be in the next 10 years? How do I protect the kidney function and the vessels in the kidney?

How do I protect the vessels in the heart? And this is when an adult is diagnosed with a chronic disease, disease.

So when I think towards children now burdened with obesity and then their complications, including sleep apnea, including hypertension, including diabetes, I am now thinking about the disease burden that they are going to carry along with them.

If we do not intervene at the appropriate time because there are children, we don't have long term data so far as to if we intervene early enough, are we going to be able to reverse or remiss the disease?

And I think that these guidelines have brought that up very clearly that we do not have enough data to give us all of the answers and we need to move forward and do that. But yes, your question around what concerns me, it's the disease burden that these children carry.

Let's dive into those guidelines a little bit more. When you consider some of the key highlights of these guidelines, what would they be as it relates to pediatric obesity?

So to be honest, I mean, I'm not sure if you've taken a look, I'm sure you have, at the summary in the Canadian magazine. It is actually really readable and very understandable and I love that about them.

The 10 recommendations that were given, the nine good practice statements that was given, I would recommend anyone who is even remotely interested in obesity in general, specifically obesity and pediatrics, to actually go on into the life. But if I was to condense it even further, it is that obesity is first and foremost a chronic disease. It is not a lifestyle choice.

And not all people that carry extra weight have obesity. And when we are managing obesity, we are not trying to reduce weight itself. We are trying to optimize health and quality of life.

So that would be the, I would say the biggest takeaway point.

We also should understand that there is evidence based management out there that is multimodal, individualized to our patients and that takes into account the family and their decisions as well. That there are multiple tools in our toolbox.

Not just lifestyle intervention, not just nutrition, not just physical activity, but also medications and also if need be, surgery. That we have those tools, whether we use them or not, we should know about them and we should have access to them.

The guidelines place evidence or emphasis, I should say, on family centered care and a family centered model of care for parents. What does that look like? How can you illustrate it in layman's terms for the average family who may be battling obesity in their child?

It's hard. This is not easy.

I mean try to get, try to elicit any new behavior in our family that we are, that we might not be doing ourselves or that we weren't, we didn't grow up with. It's really, really hard. But the family has to be part of the solution.

Children rely on their families for their nutrition, for their activity, for their emotional support. So I feel like engaging with parents in that non judgmental way is the job of the healthcare providers. We need to do that.

We need to help them create a home environment that feels supportive, that feels like the main goal is health, not weight.

And that means involving parents in, in sleep training, involving parents and in screen time, understanding, involving parents and what whole foods and a healthy nutritious meal might look like.

So I feel like there is some onus on healthcare providers, whether they be dietitians, whether it be psychosocial specialists, physicians, to actually help our parents create those environments. Also maybe shifting the focus away from weight and shifting it to health. What is a healthy behavior?

Hey, maybe let's go for a walk, that'll be healthy, that'll give us some energy rather than you shouldn't sit on the couch all day because that's just going to make you gain weight. Moving away from those moralized, demoralized options.

Oh, this is a good food and this is a bad food and this is a good activity versus a bad activity. And I can go on and on about things that I have tried. I am not a behavioralist, I am not a dietitian to help with those minutiae.

But there are a lot of resources out there when it comes to children, psychosocial behaviors and dietitians. And I would say families that are struggling with this try to reach out to get that kind of care because it is so hard to do it on our own.

It is so hard not to say the wrong things thing.

And, and when we do, we worry about things like shaming, we worry about things reduce the like reduced self esteem, body dysmorphia and there's such a fine line sometimes. So I would say try to get.

The support, you know, when you break it down in those terms and, and you talk about how difficult it is, I mean it really does affect every single aspect or could of a family's life from you know, what you're doing at the grocery store, what you're doing at home, how you, what your relationship with food is as the parent, for example, and weight on and on and on.

So doctor, if you were to simplify in some way this topic for parents, in other words, you know, how could we make it more palatable for a parent to kind of wrap their heads around why this is an important, important area of focus in a family to perhaps proactively, potentially avoid going down this road of a chronic progressive disease like obesity?

I love that question because I think that that question revolves around prevention, right? And there's so many levels that as a family we carry burdens of our own. One of those things being genetics.

And unfortunately until now There isn't a way to kind of switch the genetic gene. Right. So putting genetics aside, yes, all families.

And this should be a public, public drive, a public initiative to build healthier homes, to build in that physicality in our daily living, to build in those nutritional guidelines that may be a little bit more easier to approach.

I feel like even as a physician, I've looked at all of the food guidelines and I'm still confused as to what would be the right things to cook at home. Involve children in, in the decision making around what we should make. Involve children around decision making around what activities should we do.

Model the screen time behaviors that you want them to see. Model those behaviors for your children. So I, in terms of a general outlook, this has nothing to do with weight.

This has to do with general health in and out of self. And I feel like that baseline, even though it's written in the guidelines to achieve, is a baseline for all parents.

Absolutely. You talked about accessibility, the fact that it is an increasing challenge.

What advice would you give to a parent who feel like maybe they're trying to do their best not, you know, getting to where they need to be, can't access the kind of care that they need to be able to, you know, live Some of these guidelines.

I would say reach out.

I would, I would take the guidelines in hand, actually, the recommendations, I would take them to the healthcare providers and ask them to kind of go through them with them and see where they are able to implement some of these recommendations. Sometimes we have public services such as primary care networks where we have in Alberta that provide some of these supports.

We have YMCAs, we have community organizations that might be able to help families with physical activity.

We have food banks if there is underserved populations and try to work with the healthcare provider to see what we can take away from these guidelines and what we can realistically do. I mean, I can't say that these are easy to do. Go, take them, go everyone join a gym and everyone have a chef come home and cook for us.

That's not going to happen. We have to do what we can in the situation that we are in. And I would say reach out and talk to your healthcare providers about this.

See what available resources are out there and avail them.

In the course of your work and of your research, it just occurred to me as you were talking to ask you this question, is there any model country out there who has done this at a large scale, that it is in the public consciousness and where pediatric obesity perhaps is not such an issue that the numbers are going down or have stabilized. Is there, is there such a thing?

Not that I know of right now. And I feel that Canada is actually one of the jet setters in this.

I'm not saying there was recent guidelines that came out in the States as well that included medications and pharmacotherapy and surgical therapy. And they are ahead of us in actually performing these and having access to these surgeries for patients.

Of course this is in the private system, but when it comes to a publicly run system like ours, I feel like Canada is honestly a renegade in the way it's approaching things. And I think not only in adult obesity, but now in pediatric obesity and again with these particular guidelines.

Keeping the patients and their families at the center of this guideline, I feel is just so novel and just how all practice guidelines should be.

Truly, you alluded as well to early intervention that is only really possible if the conversation has been had at home, that there's been an identification, identification of needing to get support in the first place.

And all of that really does start with a conversation or communicating within the family or with the child that there is something that needs to be looked at here.

So is there a way that you could suggest, or what could you suggest to a parent about how to have that conversation with their child in a compassionate, non judgmental way?

I think that's really individual to the relationship between the parents and the child.

And I think sometimes, sometimes depending on the age of the child, it might be important for the parents or the caregivers themselves to have a conversation with their healthcare providers to potentially frame that conversation sometimes.

But if they are older children in their teenage years, again trying to remove focus from weight, the number on the scale as being what we are concerned about, because that is not what we are concerned about.

We are concerned about that child's health, their ability to do the things that they want to do but aren't able to do, about their metabolic health, about their mental health, and talk to them about what they would like to do to help manage these things. How would you like to move forward to manage those things?

Maybe, maybe we should see a doctor to see if we can help with the way you feel around friends when they bother you. Or maybe we could see a doctor to see if there's any help for you to sleep a little bit better because you're having trouble sleeping.

And maybe there's some healthier things that we can do to help with that and removing that notion of weight from the conversation, especially in that age group, and making it more about health and ability.

Dr. Sajwani, what would you say is the most important thing that you want parents to take away from these pediatric obesity guidelines.

That there is now help out there? That we are not alone as parents with children that struggle with weight.

There is safe evidence based tools that we have in our toolbox and that care should be centered around you and your child and it should be individualized and you are deserving of that. There's no if, ands and buts about that.

Is there anything that I did not ask you that you'd like to add?

No. I think that that was a really great conversation.

Dr.

Tasneem Sejwani, medical director of the edmonton management weight management center, family physician, thank you so much for your time and for your perspective today.

Thank you.

To learn more about today's podcast guest and topic as well as other parenting themes, visit where parents.