Obesity in Adults, A Clinical Practice Guideline

GUIDELINE CPD
Obesity in adults: a clinical practice guideline

Sean Wharton MD, David C.W. Lau MD PhD, Michael Vallis PhD RPsych, Arya M. Sharma MD PhD,
Laurent Biertho MD, Denise Campbell-Scherer MD PhD, Kristi Adamo PhD, Angela Alberga PhD,
Rhonda Bell PhD, Normand Boulé PhD, Elaine Boyling PhD, Jennifer Brown RD MSc, Betty Calam MD,
Carol Clarke RD MHSc, Lindsay Crowshoe MD, Dennis Divalentino MD, Mary Forhan OT PhD, Yoni Freedhoff MD,
Michel Gagner MD, Stephen Glazer MD, Cindy Grand MPH, Michael Green MD MPH, Margaret Hahn MD PhD,
Raed Hawa MD MSc, Rita Henderson PhD, Dennis Hong MD, Pam Hung MScOT BSc, Ian Janssen PhD,
Kristen Jacklin PhD, Carlene Johnson-Stoklossa RD MSc, Amy Kemp BKin BA, Sara Kirk PhD, Jennifer Kuk PhD,
Marie-France Langlois MD, Scott Lear PhD, Ashley McInnes PhD, David Macklin MD, Leen Naji MD,
Priya Manjoo MD, Marie-Philippe Morin MD, Kara Nerenberg MD MSc, Ian Patton PhD, Sue Pedersen MD,
Leticia Pereira PhD, Helena Piccinini-Vallis MD PhD, Megha Poddar MD, Paul Poirier MD, Denis Prud’homme MD MSc,
Ximena Ramos Salas PhD, Christian Rueda-Clausen MD PhD, Shelly Russell-Mayhew PhD RPsych, Judy Shiau MD,
Diana Sherifali RN PhD, John Sievenpiper MD PhD, Sanjeev Sockalingam MD MHPE, Valerie Taylor MD PhD,
Ellen Toth MD, Laurie Twells PhD, Richard Tytus MD, Shahebina Walji MD, Leah Walker BA RCT, Sonja Wicklum MD
n Cite as: CMAJ 2020 August 4;192:E875-91. doi: 10.1503/cmaj.191707
This article is available in French at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.191707/-/DC1
CMAJ Podcasts: author interview at https://www.cmaj.ca/lookup/doi/10.1503/cmaj.191707/tab-related-content
O
besity is a complex chronic disease in which abnormal
or excess body fat (adiposity) impairs health, KEY POINTS
increases the risk of long-term medical complications
and reduces lifespan.1 Epidemiologic studies define obesity
• Obesity is a prevalent, complex, progressive and relapsing
chronic disease, characterized by abnormal or excessive body
using the body mass index (BMI; weight/height2), which can fat (adiposity), that impairs health.
stratify obesity-related health risks at the population level. • People living with obesity face substantial bias and stigma,
Obesity is operationally defined as a BMI exceeding 30 kg/m2 which contribute to increased morbidity and mortality
and is subclassified into class 1 (30–34.9), class 2 (35–39.9) and independent of weight or body mass index.
class 3 (≥ 40). At the population level, health complications • This guideline update reflects substantial advances in the
from excess body fat increase as BMI increases.2 At the individ- epidemiology, determinants, pathophysiology, assessment,
ual level, complications occur because of excess adiposity, prevention and treatment of obesity, and shifts the focus of
obesity management toward improving patient-centred health
location and distribution of adiposity and many other factors, outcomes, rather than weight loss alone.
including environmental, genetic, biologic and socioeconomic
• Obesity care should be based on evidence-based principles of
factors (Box 1).11 chronic disease management, must validate patients’ lived
Over the past 3 decades, the prevalence of obesity has steadily experiences, move beyond simplistic approaches of “eat less,
increased throughout the world,12 and in Canada, it has increased move more,” and address the root drivers of obesity.
threefold since 1985.13 Importantly, severe obesity has increased • People living with obesity should have access to evidence-informed
more than fourfold and, in 2016, affected an estimated 1.9 million interventions, including medical nutrition therapy, physical activity,
Canadian adults.13 psychological interventions, pharmacotherapy and surgery.
Obesity has become a major public health issue that

increases health care costs14,15 and negatively affects physical
and psychological health.16 People with obesity experience per- Obesity is caused by the complex interplay of multiple
vasive weight bias and stigma, which contributes (independent genetic, metabolic, behavioural and environmental factors, with
of weight or BMI) to increased morbidity and mortality.17 the latter thought to be the proximate cause of the substantial
© 2020 Joule Inc. or its licensors CMAJ | AUGUST 4, 2020 | VOLUME 192 | ISSUE 31 E875
Box 1: Complications of obesity Box 2: Appetite regulation20–23
• The control of appetite is complex and involves the integration
GUIDELINE
Adipose tissue not only influences the central regulation of energy

homeostasis, but excessive adiposity can also become of the central neural circuits including the hypothalamus
dysfunctional and predispose the individual to the development of (homeostatic control), the mesolimbic system (hedonic control)
many medical complications, such as: and the frontal lobe (executive control).
• Type 2 diabetes 3
• The crosstalk between homeostatic and hedonic eating is
• Gallbladder disease 4 influenced by mediators from adipose tissue, the pancreas, gut
and other organs.
• Nonalcoholic fatty liver disease
5
• Cognitive functions in the prefrontal cortex exert executive

• Gout6
control on food choices and the decision to eat. The
Excess and ectopic body fat are important sources of interconnectivity of these neural networks drives eating
adipocytokines and inflammatory mediators that can alter glucose behaviour and has been shown to be altered in obesity.
and fat metabolism, leading to increased cardiometabolic and
cancer risks, and thereby reducing disease-free duration and life
expectancy by 6 to 14 years.1,7,8 It is estimated that 20% of all
cancers can be attributed to obesity, independent of diet.9 Obesity There is a recognition that obesity management should be
increases the risk of the following cancers:10 about improved health and well-being, and not just weight
• Colon (both sexes) loss. 34–36 Because the existing literature is based mainly on
• Kidney (both sexes) weight-loss outcomes, several recommendations in this guide-
line are weight-loss centred. However, more research is needed
• Esophagus (both sexes)
to shift the focus of obesity management toward improving
• Endometrium (women)
patient-centred health outcomes, rather than weight loss alone.
• Postmenopausal breast (women) Despite growing evidence that obesity is a serious chronic
disease, it is not effectively managed within our current health
system.37,38 Canadian health professionals feel ill equipped to
rise in the prevalence of obesity.18,19 A better understanding of the support people living with obesity. 39–41 Biased beliefs about
biological underpinnings of this disease has emerged in recent obesity also affect the level and quality of health care that
years.19 The brain plays a central role in energy homeostasis by patients with obesity receive.42 The dominant cultural narrative
regulating food intake and energy expenditure (Box 2).24 regarding obesity fuels assumptions about personal
Decreased food intake and increased physical activity lead to a irresponsibility and lack of willpower and casts blame and shame
negative energy balance and trigger a cascade of metabolic and upon people living with obesity.41 Importantly, obesity stigma
neurohormonal adaptive mechanisms.25,26 Therapies that target negatively influences the level and quality of care for people
these alterations in neurohormonal mechanisms can become living with obesity.42
effective tools in the long-term management of obesity.27 With increased knowledge of the disease state and better
Novel approaches to diagnose and assess obesity in clinical approaches to assess and manage obesity, it is timely to update
practice have been proposed.11,18,19,28 Although BMI is widely used the 2006 Canadian clinical practice guideline.43 The goal of this
to assess and classify obesity (adiposity), it is not an accurate tool update is to disseminate to primary care practitioners evidence-
for identifying adiposity-related complications.19 Waist circumfer- informed options for assessing and treating people living with
ence has been independently associated with an increase in car- obesity. Importantly, this guideline incorporates the perspectives
diovascular risk, but it is not a good predictor of visceral adipose of people with lived experience and of interprofessional primary
tissue on an individual basis.29 Integration of both BMI and waist care providers with those of experts on obesity management, and
circumference in clinical assessment may identify the higher-risk researchers. This article is a summary of the full guideline, which
phenotype of obesity better than either BMI or waist circumfer- is available online (http://obesitycanada.ca/guidelines/).
ence alone, particularly in those individuals with lower BMI.30,31 In
addition to BMI and waist circumference measurements, a com- Scope
prehensive history to identify the root causes of obesity, appropri-
ate physical examination and relevant laboratory investigations The target users for this guideline are primary health care pro-
will help to identify those who will benefit from treatment.32 fessionals. The guideline may also be used by policy-makers
The Edmonton obesity staging system has been proposed to and people affected by obesity and their families. The guide-
guide clinical decisions from the obesity assessment and at each line is focused on obesity in adults. The recommendations are
BMI category (Appendix 1, available at www.cmaj.ca/lookup/ intended to serve as a guide for health care providers; clinical
suppl/doi:10.1503/cmaj.191707/-/DC2).28 This 5-stage system of discretion should be used by all who adopt these recommen-
obesity classification considers metabolic, physical and psycho- dations. Resource limitations and individual patient prefer-
logical parameters to determine the optimal obesity treatment. ences may make it difficult to put every recommendation into
In population studies, it has been shown to be a better predictor practice, but the guideline is intended to improve the standard
of all-cause mortality when compared with BMI or waist circum- of, and access to, care for individuals with obesity in all regions
ference measurements alone.33,34 of Canada.
E876 CMAJ | AUGUST 4, 2020 | VOLUME 192 | ISSUE 31

OBESITY Obesity complex disease in which abnormal or excess
body fat impairs health
IN ADULTS
Effects:
▼ health ▼ quality of life ▼ lifespan
A clinical practice guideline People with obesity increased complications

experience weight bias and mortality independent
and stigma of weight or BMI
BMI IS NOT AN ACCURATE
TOOL FOR IDENTIFYING
Weight bias thinking that people with Stigma acting
OBESITY-RELATED obesity do not have enough willpower on weight-biased
COMPLICATIONS or are not cooperative beliefs
THE PATIENT JOURNEY IN OBESITY MANAGEMENT
1 ASK
PERMISSION 3 ADVISE ON
MANAGEMENT
“Would it be all right Medical nutrition therapy
if we discussed
• Personalized counselling by a registered
your weight?”
dietitian with a focus on healthy food choices
Asking permission and evidence-based nutrition therapy
• Shows compassion and empathy Exercise
• Builds patient–provider trust • 30-60 min of moderate to vigorous activity
most days
2 ASSESS THEIR STORY

• Goals that matter to the patient
Psychological
• Cognitive approach
Medications
• For weight loss
Bariatric
surgery
• Obesity classification to behaviour change and to help • Surgeon–patient
(BMI and waist circumference) • Manage sleep, maintain weight discussion
• Disease severity time and stress loss
(Edmonton Obesity Staging System)
• Psychotherapy if
appropriate
4M
Treating the root
causes of weight gain
is the foundation of
obesity management
4 AGREE ON GOALS
Collaborate on a personalized,
sustainable action plan
Focus on Mechanical Metabolic
patient-centred
health outcomes Mental Social milieu
versus
weight loss alone
5 ASSIST WITH DRIVERS
AND BARRIERS
Recommendations Step 2: Assessment
Primary care clinicians should promote a holistic approach to
This clinical practice guideline informs the arc of the patient jour- health with a focus on health behaviours in all patients and
GUIDELINE
ney and clinical management approach in the primary care set- address the root causes of weight gain with care to avoid stigma-
ting. The guideline recommendations are shown in Table 1. tizing and overly simplistic narratives.
A complete description of the recommendations and support- Direct measurement of height, weight and waist circumfer-
ing evidence are available in the 19 chapters of the full guideline ence and calculation of BMI should be included in routine phys
(http://obesitycanada.ca/guidelines/). This synopsis outlines a dis- ical examination for all adults. Although BMI has its limitations, it
cussion of the guiding principles that the executive committee remains a valuable tool for screening purposes and for popula-
determined as important for advancing clinical practice in Canada. tion health indices.52 For persons with increased BMI (between
There are 5 steps in the patient arc to guide a health care pro- 25 mg/m2 and 34.9 mg/m2), waist circumference should be regu-
vider in the care of people living with obesity. Each step is out- larly measured to identify individuals with increased visceral adi-
lined below with highlights of the relevant recommendations posity and adiposity-related health risks.53
and a discussion of supporting evidence. Root causes of obesity include biological factors such as
1. Recognition of obesity as a chronic disease by health care genetics, epigenetics, neurohormonal mechanisms, associated
providers, who should ask the patient permission to offer chronic diseases and obesogenic medications, sociocultural
advice and help treat this disease in an unbiased manner. practices and beliefs, social determinants of health, built
2. Assessment of an individual living with obesity, using appro- environment, individual life experiences like adverse childhood
priate measurements, and identifying the root causes, com- experiences, and psychological factors such as mood, anxiety,
plications and barriers to obesity treatment. binge-eating disorder, attention-deficit/hyperactivity disorder,
3. Discussion of the core treatment options (medical nutrition self-worth and identity.50 Working with people to understand
therapy and physical activity) and adjunctive therapies that their context and culture, and integrate their root causes, allows
may be required, including psychological, pharmacologic and for the development of personalized plans. These plans can be
surgical interventions. integrated into long-term therapeutic relationships with chronic
4. Agreement with the person living with obesity regarding goals disease follow-up of obesity and related comorbidities, including
of therapy, focusing mainly on the value that the person addressing the root causes of obesity such as existing conditions
derives from health-based interventions. and obesogenic medications.
5. Engagement by health care providers with the person with We recommend obtaining a comprehensive history to identify
obesity in continued follow-up and reassessments, and encour- these root causes of weight gain, as well as physical, mental and
agement of advocacy to improve care for this chronic disease. psychosocial barriers. Physical examination, laboratory,
diagnostic imaging and other investigations should be carried
Step 1: Recognition of obesity as a chronic disease and out based on clinical judgment. We also recommend measuring
obtaining patient permission blood pressure in both arms and obtaining fasting glucose or gly-
Primary care providers should recognize and treat obesity as a cated hemoglobin values and a lipid panel to determine cardio-
chronic disease, caused by abnormal or excess body fat accumu- metabolic risk, and when indicated, alanine aminotransferase to
lation (adiposity), which impairs health, with increased risk of screen for nonalcoholic fatty liver disease.
premature morbidity and mortality.1,2,18,44–47
Obesity is a complex and heterogeneous chronic disease that Step 3: Discussion of treatment options
does not present in the same way in all patients and that Adults living with obesity should receive individualized care
requires individualized treatment and long-term support like any plans that address their root causes of obesity and that provide
other complex chronic disease. support for behavioural change (e.g., nutrition, physical activity)
Weight bias in health care settings can reduce the quality of care and adjunctive therapies, which may include psychological,
for patients living with obesity.42 A key to reducing weight bias, pharmacologic and surgical interventions.
stigma and discrimination in health care settings is for health care
providers to be aware of their own attitudes and behaviours toward Nutrition and exercise
individuals living with obesity.48 This can be achieved by complet- All individuals, regardless of body size or composition, would
ing a self-assessment tool, like the Implicit Association Test, for benefit from adopting a healthy, well-balanced eating pattern
weight bias.49 A full description and supporting evidence for weight and engaging in regular physical activity. Aerobic activity (30–
bias recommendations are available online (http://obesitycanada. 60 min) on most days of the week can lead to a small amount of
ca/guidelines/) in the chapter titled “Reducing weight bias in obes weight and fat loss, improvement in cardiometabolic param
ity management, practice and policy.” eters, and weight maintenance after weight loss.54
Health care providers should not assume that all patients liv- Weight loss and weight-loss maintenance require a long-term
ing with obesity are prepared to initiate obesity management. reduction in caloric intake. Long-term adherence to a healthy
Health care providers should ask the patient permission to dis- eating pattern that is personalized to meet individual values and
cuss obesity, and if the patient permits, then a discussion on preferences, while fulfilling nutritional needs and treatment
treatment can begin.50,51 goals, is an important element of managing health and weight.

Medical nutrition therapy is a foundation for chronic disease pharmacologic, surgical), should be tailored to meet an individ
management, including obesity management.55,56 However, med- ual’s health-related or weight-related outcomes.56,59
GUIDELINE
ical nutrition therapy should not be used in isolation in obesity The weight loss achieved with health behavioural changes is
management, as sustaining weight loss may be difficult long usually 3%–5% of body weight, which can result in meaningful
term because of compensatory mechanisms in the brain that improvement in obesity-related comorbidities.60 The amount of
promote positive caloric intake by increasing hunger and ulti- weight loss varies substantially among individuals, depending
mately causing weight gain.57,58 Instead, medical nutrition ther- on biological and psychosocial factors and not simply on indi-
apy, in combination with other interventions (psychological, vidual effort.
Table 1 (part 1 of 5): Recommendations on management of obesity in adults*
Category of evidence
and strength of
Recommendations recommendation†
Reducing weight bias in obesity management, practice and policy

1 Health care providers should assess their own attitudes and beliefs regarding obesity and consider how their attitudes Level 1a, grade A
and beliefs may influence care delivery.
2 Health care providers may recognize that internalized weight bias (bias toward oneself) in people living with obesity Level 2a, grade B
can affect behavioural and health outcomes.
3 Health care providers should avoid using judgmental words (level 1a, grade A), images (level 2b, grade B) and practices See recommendation
(level 2a, grade B) when working with patients living with obesity.
4 We recommend that health care providers avoid making assumptions that an ailment or complaint a patient presents Level 3, grade C
with is related to their body weight.
Epidemiology of adult obesity
5 Health care providers can recognize and treat obesity as a chronic disease, caused by abnormal or excess body fat Level 2b, grade B
accumulation (adiposity), which impairs health, with increased risk of premature morbidity and mortality.
6 The development of evidence-informed strategies at the health system and policy levels can be directed at managing Level 2b, grade B
obesity in adults.
7 Continued longitudinal national and regional surveillance of obesity that includes self-reported and measured data Level 2b, grade B
(i.e., height, weight, waist circumference) may be collected on a regular basis.
Enabling participation in activities of daily living for people living with obesity
8 We recommend that health care providers ask people living with obesity if they have concerns about managing self-care Level 3, grade C
activities, such as bathing, getting dressed, bowel and bladder management, skin and wound care, and foot care.
9 We recommend that health care providers assess fall risk in people living with obesity, as this could interfere with their Level 3, grade C
ability and interest in participating in physical activity.
Assessment of people living with obesity
10 We suggest that health care providers involved in screening, assessing and managing people living with obesity use the Level 4, grade D
5As framework (see Appendix 2‡) to initiate the discussion by asking for their permission and assessing their readiness to (consensus)
begin treatment.
11 Health care providers can measure height, weight and calculate the BMI in all adults (level 2a, grade B), and measure See recommendation
waist circumference in individuals with a BMI 25–35 kg/m2 (level 2b, grade B).
12 We suggest that a comprehensive history to identify root causes of weight gain as well as complications of obesity and Level 4, grade D
potential barriers to treatment be included in the assessment.
13 We recommend measuring blood pressure in both arms, fasting glucose or glycated hemoglobin and lipid profile to Level 3, grade D
determine cardiometabolic risk and, where appropriate, ALT to screen for nonalcoholic fatty liver disease in people
living with obesity.
14 We suggest that health care providers consider using the Edmonton Obesity Staging System (see Appendix 1)§ to Level 4, grade D
determine the severity of obesity and guide clinical decision-making.
The role of mental health in obesity management
15 We recommend regular monitoring of weight, glucose and lipid profile in people with a mental health diagnosis and Level 3, grade C
who are taking medications associated with weight gain.
16 Health care providers may consider both efficacy and effects on body weight when choosing psychiatric medications. Level 2a, grade B
17 Metformin and psychological treatment such as cognitive behavioural therapy should be considered for prevention of weight Level 1a, grade A
gain in people with severe mental illness who are treated with antipsychotic medications associated with weight gain.
18 Health care providers should consider lisdexamfetamine and topiramate as an adjunct to psychological treatment to Level 1a, grade A
reduce eating pathology and weight in people with overweight or obesity and binge-eating disorder.
CMAJ | AUGUST 4, 2020 | VOLUME 192 | ISSUE 31 E879

GUIDELINE
and strength of
Medical nutrition therapy in obesity management

19 We suggest that nutrition recommendations for adults of all body sizes be personalized to meet individual values, Level 4, grade D
preferences and treatment goals to support a dietary approach that is safe, effective, nutritionally adequate, culturally
acceptable and affordable for long-term adherence.
20 Adults living with obesity should receive individualized medical nutrition therapy provided by a registered dietitian Level 1a, grade A
(when available) to improve weight outcomes (body weight, BMI), waist circumference, glycemic control, established
lipid, and blood pressure targets.
21 Adults living with obesity and impaired glucose tolerance (prediabetes) or type 2 diabetes may receive medical Level 2a, grade B
nutrition therapy provided by a registered dietitian (when available) to reduce body weight and waist circumference
and improve glycemic control and blood pressure.
22 Adults living with obesity can consider any of multiple medical nutrition therapies to improve health-related outcomes, choosing See recommendation
the dietary patterns and food-based approaches that support their best long-term adherence. (Full recommendation and
category and level of evidence available in the chapter titled “Medical nutrition therapy in obesity management.”)
23 Adults living with obesity and impaired glucose tolerance (prediabetes) should consider intensive behavioural interventions See recommendation
that target a 5%–7% weight loss, to improve glycemic control, blood pressure and blood lipid targets (level 1a, grade A) and
reduce the incidence of type 2 diabetes (level 1a, grade A), microvascular complications (retinopathy, nephropathy and
neuropathy) (level 1a, grade B), and cardiovascular and all-cause mortality (level 1a, grade B).
24 Adults living with obesity and type 2 diabetes should consider intensive lifestyle interventions that target a 7%–15% Level 1a, grade A
weight loss, to increase the remission of type 2 diabetes and reduce the incidence of nephropathy, obstructive sleep
apnea and depression.
25 We recommend a nondieting approach to improve quality of life, psychological outcomes (general well-being, body image Level 3, grade C
perceptions), cardiovascular outcomes, body weight, physical activity, cognitive restraint and eating behaviours.
Physical activity in obesity management
26 Aerobic physical activity (30–60 minutes of moderate to vigorous intensity most days of the week) can be considered for See recommendation
adults who want to:
• Achieve small amounts of body weight and fat loss (level 2a, grade B)
• Achieve reduction in abdominal visceral fat (level 1a, grade A) and ectopic fat, such as liver and heart fat (level 1a, grade A),
even in the absence of weight loss
• Favour weight maintenance after weight loss (level 2a, grade B)
• Favour the maintenance of fat-free mass during weight loss (level 2a, grade B)
• Increase cardiorespiratory fitness (level 2a, grade B) and mobility (level 2a, grade B).
27 For adults living with overweight or obesity, resistance training may promote weight maintenance or modest increases Level 2a, grade B
in muscle mass or fat-free mass and mobility.
28 Increasing exercise intensity, including high-intensity interval training, can achieve greater increases in cardiorespiratory fitness Level 2a, grade B
and reduce the amount of time required to achieve benefits similar to those from moderate-intensity aerobic activity.
29 Regular physical activity, with and without weight loss, can improve many cardiometabolic risk factors in adults who See recommendation
have overweight or obesity, including hyperglycemia and insulin sensitivity (level 2b, grade B), high blood pressure
(level 1a, grade B) and dyslipidemia (level 2a, grade B).
30 Regular physical activity can improve health-related quality of life, mood disorders (i.e., depression, anxiety) and body Level 2b, grade B
image in adults living with overweight or obesity.
Effective psychological and behavioural interventions in obesity management
31 Multicomponent psychological interventions (combining behaviour modification [goal-setting, self-monitoring, See recommendation
problem-solving], cognitive therapy [reframing] and values-based strategies to alter diet and activity) should be
incorporated into care plans for weight loss, and improved health status and quality of life (level 1a, grade A) in a manner
that promotes adherence, confidence and intrinsic motivation (level 1b, grade A).
32 Health care providers should provide longitudinal care with consistent messaging to people living with obesity in order to Level 1a, grade A
support the development of confidence in overcoming barriers (self-efficacy) and intrinsic motivation (personal, meaningful
reasons to change), to encourage the patient to set and sequence health goals that are realistic and achievable, to
self-monitor behaviour and to analyze setbacks using problem-solving and adaptive thinking (cognitive reframing),
including clarifying and reflecting on values-based behaviours.
33 Health care providers should ask people living with obesity for permission to educate them that success in obesity Level 1a, grade A
management is related to improved health, function and quality of life resulting from achievable behavioural goals and
not on the amount of weight loss.
34 Health care providers should provide follow-up sessions consistent with repetition and relevance to support the Level 1a, grade A
development of self-efficacy and intrinsic motivation. (Full recommendation is available in the chapter titled “Effective
psychological and behavioural interventions in obesity management.”)

GUIDELINE
and strength of
Pharmacotherapy in obesity management

35 Pharmacotherapy for weight loss can be used for persons with BMI ≥ 30 kg/m2 or BMI ≥ 27 kg/m2 with adiposity-related Level 2a, grade B
complications, in conjunction with medical nutrition therapy, physical activity and psychological interventions
(liraglutide 3.0 mg, naltrexone-bupropion combination, orlistat).
36 Pharmacotherapy may be used to maintain weight loss that has been achieved by health behaviour changes, and to Level 2a, grade B
prevent weight regain (liraglutide 3.0 mg or orlistat).
37 For people living with type 2 diabetes and a BMI ≥ 27 kg/m2, pharmacotherapy can be used in conjunction with health See recommendation
behaviour changes for weight loss and improvement in glycemic control: liraglutide 3.0 mg (level 1a, grade A),
naltrexone-bupropion combination (level 2a, grade B), orlistat (level 2a, grade B).
38 We recommend pharmacotherapy in conjunction with health behaviour changes for people living with prediabetes and Level 2a, grade B
overweight or obesity (BMI ≥ 27 kg/m2) to delay or prevent type 2 diabetes (liraglutide 3.0 mg; orlistat).
39 We do not suggest the use of prescription or over-the-counter medications other than those approved for weight management. Level 4, grade D
(consensus)
40 For people living with overweight or obesity who require pharmacotherapy for other health conditions, we suggest Level 4, grade D
choosing drugs that are not associated with weight gain. (consensus)
Bariatric surgery: selection and preoperative workup
41 We suggest that a comprehensive medical and nutritional evaluation be completed and nutrient deficiencies corrected Level 4, grade D
in candidates for bariatric surgery.
42 Preoperative smoking cessation can minimize perioperative and postoperative complications. Level 2a, grade B
43 We suggest screening for and treatment of obstructive sleep apnea in people seeking bariatric surgery. Level 4, grade D
Bariatric surgery: surgical options and outcomes
44 Bariatric surgery can be considered for people with BMI ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 with at least 1 adiposity-related See recommendation
disease (level 4, grade D, consensus) to:
• Reduce long-term overall mortality (level 2b, grade B)
• Induce significantly better long-term weight loss compared with medical management alone (level 1a, grade A)
• Induce control and remission of type 2 diabetes, in combination with best medical management, over best medical
management alone (level 2a, grade B)
• Significantly improve quality of life (level 3, grade C)
• Induce long-term remission of most adiposity-related diseases, including dyslipidemia (level 3, grade C), hypertension
(level 3, grade C), liver steatosis and nonalcoholic steatohepatitis (level 3, grade C).
45 Bariatric surgery should be considered in patients with poorly controlled type 2 diabetes and class I obesity (BMI Level 1a, grade A
between 30 and 35 kg/m2) despite optimal medical management.
46 Bariatric surgery may be considered for weight loss and/or to control adiposity-related diseases in persons with class 1 Level 2a, grade B
obesity, in whom optimal medical and behavioural management has been insufficient to produce significant weight loss.
47 We suggest that the choice of bariatric procedure (sleeve gastrectomy, gastric bypass or duodenal switch) be decided Level 4, grade D
according to the patient’s need, in collaboration with an experienced interprofessional team. (consensus)
48 We suggest that adjustable gastric banding not be offered owing to unacceptable complications and long-term failure. Level 4, grade D
49 We suggest that single anastomosis gastric bypass not be routinely offered, owing to long-term complications in Level 4, grade D
comparison with Roux-en-Y gastric bypass.
Bariatric surgery: postoperative management
50 Health care providers can encourage persons who have undergone bariatric surgery to participate in and maximize Level 2a, grade B
their access to behavioural interventions and allied health services at a bariatric surgical centre.
51 We suggest that bariatric surgical centres communicate a comprehensive care plan to primary care providers for patients Level 4, grade D
who are discharged, including bariatric procedure, emergency contact numbers, annual blood tests required, long-term (consensus)
vitamin and minerals supplements, medications and behavioural interventions, as well as when to refer back.
52 We suggest that after a patient has been discharged from the bariatric surgical centre, primary care providers conduct Level 4, grade D
annual review of the following: weight, nutritional intake, activity, adherence to multivitamin and mineral supplements, (consensus)
assessment of comorbidities and laboratory tests to assess and treat for nutritional deficiencies as required.
53 We suggest that primary care providers consider referral back to the bariatric surgical centre or to a local specialist for Level 4, grade D
technical or gastrointestinal symptoms, nutritional issues, pregnancy, psychological support, weight regain or other (consensus)
medical issues related to bariatric surgery, as described in the chapter titled “Bariatric surgery: postoperative management.
54 We suggest that bariatric surgical centres provide follow-up and appropriate laboratory tests at regular intervals Level 4, grade D
postsurgery with access to appropriate health care professionals (dietitian, nurse, social worker, bariatric physician, (consensus)
surgeon, psychologist or psychiatrist) until discharge is deemed appropriate for the patient.

Table 1 (part 4 of 5: Recommendations on management of obesity in adults*
GUIDELINE
and strength of
Primary care and primary health care in obesity management

55 We recommend that primary care clinicians identify people with overweight and obesity, and initiate patient-centred, Level 3, grade C
health-focused conversations with them.
56 We recommend that health care providers ensure they ask people for their permission before discussing weight or Level 3, grade C
taking anthropometric measurements.
57 Primary care interventions should be used to increase health literacy in individuals’ knowledge and skill about weight Level 1a, grade A
management as an effective intervention to manage weight.
58 Primary care clinicians should refer persons with overweight or obesity to primary care multicomponent programs Level 1b, grade B
with personalized obesity management strategies as an effective way to support obesity management.
59 Primary care clinicians can use collaborative deliberation with motivational interviewing to tailor action plans to Level 2b, grade C
individuals’ life context in a way that is manageable and sustainable to support improved physical and emotional
health, and weight management.
60 Interventions that target a specific ethnic group should consider the diversity of psychological and social practices Level 1b, grade B
with regard to excess weight, food and physical activity, as well as socioeconomic circumstances, as they may differ
across and within different ethnic groups.
61 Longitudinal primary care interventions should focus on incremental, personalized, small behaviour changes (the Level 1b, grade B
“small change approach”) to be effective in supporting people to manage their weight.
62 Primary care multicomponent programs should consider personalized obesity management strategies as an effective Level 1b, grade B
way to support people living with obesity.
63 Primary care interventions that are behaviour based (nutrition, exercise, lifestyle), alone or in combination with Level 1a, grade A
pharmacotherapy, should be used to manage overweight and obesity.
64 Group-based diet and physical activity sessions informed by the Diabetes Prevention Program and the Look AHEAD Level 1b, grade A
(Action for Health in Diabetes) programs should be used as an effective management option for adults with
overweight and obesity.
65 Interventions that use technology to increase reach to larger numbers of people asynchronously should be a Level 1b, grade B
potentially viable lower cost intervention in a community-based setting.
66 Educators of undergraduate, graduate and continuing education programs for primary health care professionals Level 1a, grade A
should provide courses and clinical experiences to address the gaps in skills, knowledge of the evidence, and attitudes
necessary to confidently and effectively support people living with obesity.
Commercial products and programs in obesity management
67 For adults living with overweight or obesity, the following commercial programs should achieve mild to moderate See recommendation
weight loss in the short or medium term, compared with usual care or education:
• WW (formerly Weight Watchers) (level 1a, grade A)
• Optifast (level 1b, grade B)
• Jenny Craig (level 1b, grade B)
• Nutrisystem (level 1b, grade B)
68 Optifast, Jenny Craig, WW (formerly Weight Watchers) and Nutrisystem should achieve a mild reduction of glycated Level 1b, grade B
hemoglobin values over a short-term period compared with usual counselling in adults with obesity and type 2
diabetes.
69 We do not recommend the use of over-the-counter commercial weight-loss products for obesity management, owing Level 4, grade D
to lack of evidence.
70 We do not suggest that commercial weight-loss programs be used for improvement in blood pressure and lipid control Level 4, grade D
in adults living with obesity.
Emerging technologies and virtual medicine in obesity management
71 Implementation of management strategies can be delivered through Web-based platforms (e.g., online education on Level 2a, grade B
medical nutrition therapy and physical activity) or mobile devices (e.g., daily weight reporting through a smartphone
application) in the management of obesity.
72 We suggest that health care providers incorporate individualized feedback and follow-up (e.g., personalized Level 4, grade D
coaching or feedback via phone or email) into technology-based management strategies to improve weight-loss
outcomes.
73 The use of wearable activity tracking technology should be part of a comprehensive strategy for weight Level 1a, grade A
management.

GUIDELINE
and strength of
Weight management over the reproductive years for adult women living with obesity
74 We recommend that primary care providers discuss weight-management targets specific to the reproductive years See recommendation
with adult women with obesity: preconception weight loss (level 3, grade C); gestational weight gain of 5 kg to 9 kg
over the entire pregnancy (level 4, grade D); postpartum weight loss of — at minimum — gestational weight gain (level
3, grade C) to reduce the risk of adverse outcomes in the current or in a future pregnancy.
75 Primary care providers should offer behaviour change interventions including both nutrition and physical activity to See recommendation
adult women with obesity who are considering a pregnancy (level 3, grade C), who are pregnant (level 2a, grade B)
and who are postpartum (level 1a, grade A) in order to achieve weight targets.
76 We recommend that primary care providers encourage and support pregnant women with obesity to consume foods Level 3, grade C
consistent with a healthy dietary pattern in order to meet their target gestational weight gain.
77 We recommend that primary care providers encourage and support pregnant women with obesity who do not have Level 3, grade C
contraindications to exercise during pregnancy to engage in at least 150 minutes per week of moderate intensity
physical activity, to assist in the management of gestational weight gain.
78 Health care providers should not prescribe metformin for gestational weight gain in pregnant women with obesity See recommendation
(level 1b, grade A). We suggest that weight-management medications not be used during pregnancy or breastfeeding
(level 4, grade D).
79 We recommend that women with obesity be offered additional breastfeeding support because of decreased rates of Level 3, grade C
initiation and continuation.
Obesity management and Indigenous Peoples
80 We suggest that health care providers for Indigenous people living with obesity: Level 4, grade D
• Engage with the patient’s social realities. (consensus)
• Validate the patient’s experiences of stress and systemic disadvantage influencing poor health and obesity,
exploring elements of their environment where reduced stress could shift behaviours.
• Advocate for access to obesity-management resources within publicly funded health care systems, recognizing that
resources beyond may be unaffordable and unattainable for many.
• Help patients recognize that good health is attainable, and they are entitled to it.
• Negotiate small, attainable steps relevant to the patient’s context.
• Address resistance, seeming apathy and paralysis in patients and providers.
• Self-reflect on anti-Indigenous sentiment common within health care systems, exploring patient motivations and
mental health (e.g., trauma, grief) as alternative understandings of causes and solutions to their health problems.
Explore one’s own potential for bias influenced by systemic racism.
• Expect patient mistrust in health systems; reposition themselves as a helper to the patient instead of as an expert,
which may stir resistance and be a barrier to patients’ wellness.
• When resistance, seeming apathy and paralysis are encountered, explore patient mental and emotional health
needs, which have unique drivers and presentations in many Indigenous contexts.
• Build complex knowledge by healing relationships.
• Build patient knowledge and capacity for obesity self-management through longitudinal explorations of co-
occurring health, social, environmental and cultural factors. Strive to build relationships that incorporate healing
from multigenerational trauma that, owing to residential schools and child welfare system involvement, may more
frequently include sexual abuse.
• Build their own knowledge regarding the health legacy of colonization — including ongoing experiences of
anti-Indigenous discrimination within systems and wider society — to facilitate relationships built on mutual
understanding.
• Ensure knowledge provided is congruent with the patient’s perspectives and educational level, and is learner
centred, including potential for patient anticipation of racism or unequal treatment.
• Connect to behaviour, the body and Indigenous ways of knowing, doing and being.
• Elicit and incorporate the patient’s individual and community-based concepts of health and healthy behaviours in
relation to body size, activity and food preferences (e.g., preference for or scarce access to land-based foods and
activities).
• Deeply engage in learning of common values and principles regarding communication and knowledge-sharing in
Indigenous contexts (e.g., relationalism, noninterference).
Note: ALT = alanine aminotransferase, BMI = body mass index.

*A complete description of the recommendations and supporting evidence is available at http://obesitycanada.ca/guidelines/. Table 3 provides definitions for the actionable verbs
used in these recommendations.
†For the classification scheme for category of evidence and strength of evidence, see Box 3.
‡Appendix 2 is available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.191707/-/DC2.
§See Appendix 1.

The weight at which the body stabilizes when engaging in interventions to improve overall health; and redefining success
healthy behaviours can be referred to as the “best weight”; this as healthy behaviour change regardless of body size or weight.69
may not be an “ideal” weight on the BMI scale. Achieving an As this disease is chronic in nature, the treatment plan must
GUIDELINE
“ideal” BMI may be very difficult. If further weight loss is needed be long term. Health care providers and patients should design
to improve health and well-being beyond what can be achieved and agree on a personalized action plan that is practical and sus-
with behavioural modification, then more intensive pharmaco- tainable and addresses the drivers of weight gain.70
logic and surgical therapeutic options can be considered.
Step 5: Follow-up and advocacy
Psychological and behavioural interventions There is a need to advocate for more effective care for people liv-
All health interventions such as healthy eating and physical activ- ing with obesity. This includes improving the education and life-
ity strategies, medication adherence or surgery preparation and long learning of health care providers to be able to deliver effec-
adjustment approaches rest on behaviour change.61 Psycho tive, evidence-based obesity care. We also need to support
logical and behavioural interventions are the “how to” of change. allocation of health care resources to improve access to effective
They empower the clinician to guide the patient toward recom- behavioural, pharmacologic and surgical therapeutic options.
mended behaviours that can be sustained over time.60 A full There are substantial barriers affecting access to obesity care
description of psychological and behavioural interventions and in Canada, including a profound lack of interdisciplinary obesity
supporting evidence are available online (http://obesitycanada. management programs, a lack of adequate access to health care
ca/guidelines/) in the chapter titled “Effective psychological and providers with expertise in obesity, long wait times for referrals
behavioural interventions in obesity management.” and surgery, and the high costs of some treatments.,37,71–73 In gen-
eral, health care professionals are poorly prepared to treat obes
Pharmacotherapy ity.74 None of the anti-obesity medications available in Canada is
We recommend adjunctive pharmacotherapy for weight loss listed as a benefit on any provincial or territorial formulary and
and weight-loss maintenance for individuals with BMI ≥ 30 kg/m2 none is covered under any provincial public drug benefit or phar-
or BMI ≥ 27 kg/m2 with adiposity-related complications, to sup- macare program.71 Wait times for bariatric surgery in Canada are
port medical nutrition therapy, physical activity and psycho the longest of any surgically treatable condition.37,71 Although
logical interventions. Options include liraglutide 3.0 mg, access to bariatric surgery has increased in some parts of Canada,
naltrexone-bupropion combination and orlistat. Pharmacother- it is still limited in most provinces and nonexistent in the 3 terri
apy augments the magnitude of weight loss beyond that which tories.37,71,75 Patients referred to bariatric surgery can wait as long
health behaviour changes can achieve alone and is important in as 8 years before meeting a specialist or receiving the surgery.
the prevention of weight regain.62–66 A full description and sup- The lack of access to obesity treatments is contributing to rising
porting evidence are available online (http://obesitycanada.ca/ levels of severe obesity in Canada.46 Canadians affected by obesity
guidelines/) in the chapter titled “Pharmacotherapy in obesity are left to navigate a complex landscape of weight-loss products
management.” and services, many of which lack a scientific rationale and openly
promote unrealistic and unsustainable weight-loss goals.76
Bariatric surgery
Bariatric surgery may be considered for people with Methods
BMI ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 with at least 1 obesity-related
disease. The decision regarding the type of surgery should be Composition of participating groups
made in collaboration with a multidisciplinary team, balancing Obesity Canada and the Canadian Association of Bariatric Phys
the patient’s expectations, medical condition, and expected ben- icians and Surgeons assembled an executive committee and
efits and risks of the surgery. A full description and supporting evi- steering committee with broad expertise and geographic repre-
dence are available online (http://obesitycanada.ca/guidelines/) sentation. The executive committee (comprising 2 co-chairs
in the chapters titled “Bariatric surgery: selection and preopera- [S.W., D.C.W.L.], a primary care physician [D.C.-S.], a psychologist
tive workup,” “Bariatric surgery: options and outcomes” and [M.V.], a bariatric surgeon [L.B.] and a nephrologist [A.M.S.]) pro-
“Bariatric surgery: postoperative management.” vided overall vision and oversight for the guideline process.
The steering committee (n = 16) consisted of some lead
Step 4: Agreement regarding goals of therapy authors of each chapter and a person living with obesity; this
Because obesity is a chronic disease, managing it in the long committee identified additional researchers (chapter leads and
term involves patient–provider collaboration.67 Health care pro- authors) to write each chapter. The executive committee and
viders should talk with their patients and agree on realistic steering committee met in person in April 2017 and December
expectations, person-centred treatments and sustainable goals 2017 and at least monthly by phone.
for behaviour change and health outcomes.68 Chapter leads and chapter authors (n = 60) were selected
Helpful actions in primary care consultations to mitigate anti- based on their expertise in clinical practice and research in the
fat stigma include explicitly acknowledging the multiple determi- field of obesity medicine. The number of chapter authors per
nants of weight-disrupting stereotypes of personal failure or suc- chapter ranged from 2 to 4. Some chapter leads identified addi-
cess attached to body composition; focusing on behavioural tional authors to participate in writing each chapter.

Table 2: Summary of guideline development process
GUIDELINE
Activity Responsible group
• Mind-mapping exercise to identify the scope of the guideline and the broad sections and Executive committee
chapters (19 chapters)
• Develop research questions (PICO[T]) for each chapter Steering committee
• Conduct literature search77 MERST
• Load results of the literature search into the Distiller Systematic Review software program MERST
• Conduct critical appraisal of all papers77 Chapter leads
• Review results of critical appraisal and assign evidence grades to each paper using MERST
AGREE II tool78
• Develop reports with graded evidence MERST
• Develop recommendations based on the highest level of evidence and expert consensus Steering Committee with chapter leads and authors
• Review recommendations to ensure fidelity with the evidence (only for recommendations MERST
using grade A–C level evidence)
• Review recommendations to ensure fidelity with the evidence and relevance to primary Executive committee
care health care professionals
• Revise recommendations based on feedback from the executive committee and MERST Steering committee with chapter leads
• Review and approve final recommendations Executive committee
• External review of recommendations to assess relevance and feasibility Family physicians and people living with obesity
• External peer review of chapters Experts in each area
Note: AGREE = Appraisal of Guidelines for Research and Evaluation, MERST = McMaster Evidence Review and Synthesis Team; PICO(T) = Population, Intervention, Comparison,
Outcome, Time.
We engaged people living with obesity (n = 7) through partici- literature search. All clinical questions were developed with the
pation of the Public Engagement Committee of Obesity Canada. assistance of the McMaster Evidence Review and Synthesis Team
One member of the Public Engagement Committee (I.P.) was (MERST; previously the McMaster Evidence-Based Practice Cen-
assigned to the steering committee for this guideline. The Public tre) in the appropriate format (e.g., PICO [T] for therapeutics and
Engagement Committee met by phone once per month. We treatments, PEO for qualitative questions).
obtained contributions from committee members through
online surveys, focus groups and individual conversations. Literature review and quality assessment
We engaged Indigenous community members through a The McMaster Evidence Review and Synthesis Team supported
focus group (n = 14). Additionally, we obtained the insights of the guideline development through literature searches based
health care providers working with Indigenous communities via on the PI/PECOT questions for each chapter. A health sciences
a consensus-building process between these clinicians and chap- librarian, based at McMaster Health Sciences Library (Hamil-
ter authors, carried out over the spring of 2019, which further ton, Ont.), used this information to create search strategies for
grounded evidence in clinical practice. Details are available the MEDLINE and Embase databases. The searches were for
online (http://obesitycanada.ca/guidelines/) in the chapter titled peer-reviewed and published literature in the English lan-
“Obesity management with Indigenous Peoples.” guage; the search dates were January 2006 to June 2018.
Obesity Canada staff, consultants and volunteers (n = 15) pro- There were 14 searches that mapped directly to the chapters
vided administrative support and project coordination for the and another 7 searches that helped provide context for various
guideline development process. Table 2 outlines the guideline chapters. Search strategies are available on the obesity guide-
development process and the responsibilities of each group of line webpage (http://obesitycanada.ca/guidelines/). Once a
participants. search was conducted, the results were uploaded to EndNote,
where the duplicates were removed and the final set of cita-
Selection of priority topics tions was uploaded to DistillerSR software for selection and
The executive committee conducted a mind-mapping exercise to review.80 In addition to the electronic searches, the chapter
identify the scope of the guideline and the broad sections and authors identified additional citations and added them to the
chapters (April–June 2017).79 A total of 19 different sections and main search results.
chapters were prioritized. The steering committee developed PI/ Two reviewers completed screening of article titles and
PECOT (Population, Intervention or Exposure, Comparison, Out- abstracts and independently selected studies for possible inclu-
come, Time) questions for each chapter at an in-person meeting sion. Any citation that was selected for inclusion by either
on Dec. 15–16, 2017, resulting in 179 questions to guide the reviewer was moved to full-text review. One or more authors of

Box 3: Classification schemes77 Table 3: Definitions of actionable verbs used in the
recommendations82–84
GUIDELINE
• Level 1a: Evidence from meta-analysis of randomized Grade level Suggested terms
controlled trials (RCTs)
Level 1, grade A recommendations Use the term “should”
• Level 1b: Evidence from at least 1 RCT
Level 2, grade B recommendations Use the terms “may” or “can”
• Level 2a: Evidence from at least 1 controlled study without
randomization Level 3, grade C recommendations Use the term “recommend”
• Level 3: Evidence from nonexperimental descriptive studies, Level 4, grade D and consensus Use the term “suggest”
such as comparative studies, correlation studies and case– recommendations
control studies
• Level 4: Evidence from expert committee reports or opinions or Chapter authors used a standardized terminology to make
clinical experience of respected authorities, or both
the recommendation more specific. The actionable verbs used
Strength of recommendation for each of the recommendations were informed by the literature
• Grade A: Directly based on level 1 evidence (Table 3).82–84
• Grade B: Directly based on level 2 evidence or extrapolated We used an iterative process to finalize the recommenda-
recommendation from category 1 evidence tions. Methodologists from MERST provided an independent
• Grade C: Directly based on level 3 evidence or extrapolated review of recommendations that had a grade between A and C,
recommendation from level 1 or 2 evidence for which they examined the clarity of wording and the fidelity of
• Grade D: Directly based on level 4 evidence or extrapolated the recommendations with the evidence. Two methodologists (a
recommendation from level 1, 2 or 3 evidence
primary and secondary reviewer) reviewed each recommenda-
Adapted with permission from BMJ Publishing Group Limited. Shekelle PG, Woolf tion, using checklists as a guide for assigning levels of evidence
SH, Eccles M, et al. Developing clinical guidelines. West J Med 1999;170:348-51.
to each citation. The methodologists met, discussed and reached
consensus on grading the recommendations, and reported their
suggestions regarding revisions to the wording or grading to the
the relevant chapter conducted reviews of full-text articles for executive committee. Chapter leads edited the recommenda-
relevancy. Selected citations were then assessed for their meth- tions based on the MERST review process.
odological quality using the Shekelle approach.77,81 Each citation The executive committee voted on each recommendation, to
was categorized into prevention, treatment, evaluation of diag- ensure consensus. If a recommendation did not reach 100%
nostic properties or prognosis. Once that selection was made, agreement, the executive committee discussed the recommen-
the appropriate methods worksheet was displayed in the dation in depth until consensus was achieved. The chapter leads
DistillerSR platform, from which the methodological questions subsequently modified the wording of this recommendation, as
were answered and a level of evidence generated based on the required, and the executive committee approved the newly
type and quality of the study. The levels of evidence informed the worded recommendation. The executive committee provided
strength of the recommendations and were generated from the final approval of all the recommendations. All the recommenda-
methods worksheets (Box 3).77 tions included in this guideline achieved 100% agreement.
Development of recommendations External review

Recommendations were formulated by the steering committee, External reviewers (primary care health care professionals and
chapter leads and chapter authors based on the highest level of people living with obesity [n = 7]) reviewed the recommenda-
evidence available (Box 3).77 Chapter leads and authors reviewed tions for relevance and feasibility. We made some modifica-
the type and strength of the available evidence (level) and added tions to reflect language and the context of the primary care
the study reference that provided the highest level of evidence setting. A separate external peer review was conducted for each
for the specific recommendation. chapter.
Recognizing the importance of qualitative research in
addressing questions pertinent to the care of people living with Management of competing interests
obesity, content experts in qualitative research (S.K., X.R.S., Funding came from the Canadian Institutes of Health Research
D.C.S., L.C., S.R.M.) were involved in the review of all materials Strategic Patient-Oriented Research initiative, Obesity Canada’s
informing these recommendations. Consensus appraisal of evi- Fund for Obesity Collaboration and Unified Strategies (FOCUS)
dence quality by reviewers with expertise in qualitative methods initiative, the Canadian Association of Bariatric Physicians and
informed the level of evidence in these recommendations. Surgeons, and in-kind support from the scientific and profes-
Some grade D recommendations were formulated based on sional volunteers engaged in the process. The views of the fund-
expert committee reports, opinions or clinical experience of ing body have not influenced the content of the guideline. All
respected authorities, and referenced accordingly; other grade D committee members (executive and steering committees), chap-
recommendations formulated by chapter authors were noted ter leads and chapter authors were volunteers and not remuner-
with “Consensus” after the grade D. ated for their services.

The executive committee developed and managed the com- policies approach obesity.88 This guideline will be used to assist
peting interest policy and procedures for mitigating bias. The in advocacy efforts to federal and provincial governments to
GUIDELINE
policy and disclosures of competing interest are available on the improve the care of individuals with obesity.
guideline website. All participants were required to disclose
potential competing interests. We maintained detailed compet- Other guidelines
ing interest declarations throughout the process for all members
of the steering and executive committees, as well as the partici- In 2006, the first evidence-based Canadian clinical practice guide-
pating methodologists from MERST. We used the International line on the prevention and management of obesity in adults and
Committee of Medical Journal Editors’ disclosure form, with the children was released.43 In 2015, the Canadian Task Force on Pre-
addition of government funding sources. ventive Health Care, in collaboration with scientific staff of the
Individuals with relevant disclosures were not excluded from Public Health Agency of Canada and the McMaster Evidence
conducting the critical appraisals or voting on recommenda- Review and Synthesis Centre, released a set of recommendations
tions. However, the executive committee asked individuals with for prevention of weight gain and use of behavioural and pharma-
direct competing interests to abstain from voting in the areas in cologic interventions to manage overweight and obesity in adults
which they had the conflict. Any discussion regarding off-label in primary care.89 This guideline was not designed to “apply to
use of drugs included the caveat that the use was off label. people with BMI of 40 or greater, who may benefit from special-
As mentioned earlier, methodologists from MERST who had no ized bariatric programs” and reviewed only intervention trials
competing interests reviewed and graded78 each included study to conducted in settings generalizable to Canadian primary care.
ensure the evidence had been appropriately assessed. They also The guideline also did not include surgical treatments.
reviewed the recommendations (graded between A and C) to ensure
that recommendations were aligned with the evidence. Finally, we Gaps in knowledge
conducted an external review process to assess the feasibility of the
recommendations and evaluate for the presence of bias. The recommendations in this guideline are informed by the best
level of evidence available in 2020. We acknowledge that ongo-
Implementation ing research will continue to inform and advance obesity
management.90,91
Obesity Canada and the Canadian Association of Bariatric Sur- Current treatment options, apart from surgical intervention,
geons and Physicians have created a joint guideline website rarely yield sustained weight loss beyond 20%, and for some
(http://obesitycanada.ca/guidelines) that hosts the full guideline; people living with obesity, this level of weight loss may be inade-
interim updates; a quick reference guide; key messages; health quate for the resolution or improvement of many adiposity-
care provider tools, slide kits, videos and webinars; and resources related medical complications. There is a need for more treat-
for people living with obesity and their support systems, in English ment options to meet the needs of people with obesity. Weight
and French. The guideline will be hosted on the website as a living regain continues to be a challenge for many patients who have
document. Each chapter lead will monitor evidence related to this received treatment.92
guideline and will collaborate with the executive committee to
update the recommendations if new evidence becomes available Conclusion
that could influence the recommendations. A framework for
implementation (5As Framework) is available in Appendix 2. Obesity is a prevalent, complex chronic disease that affects a
More than 10 years after the release of the first Canadian large number of adults in Canada and globally, and yet only a
obesity guideline in 2006, access to obesity care remains an issue small fraction of people living with obesity who could benefit
in Canada.37,71 Obesity is not officially recognized as a chronic dis- from treatment have access to care. This updated evidence-
ease by the federal, provincial and territorial, and municipal gov- informed guideline is an attempt to enhance access and care by
ernments, despite declarations by the Canadian Medical Associa- people living with obesity through recognition among health care
tion 85 and the World Health Organization. 86 The lack of providers that obesity requires long-term treatment. The newer
recognition of obesity as a chronic disease by public and private insights into appetite regulation and the pathophysiology of
payers, health systems, the public and media has a trickle-down obesity have opened new avenues for treating this chronic
effect on access to treatment.72 Obesity continues to be treated disease. Reducing weight bias and stigma, understanding the root
as a self-inflicted condition, which affects the type of interven- causes of obesity, and promoting and supporting patient-centred
tions and approaches that are implemented by governments or behavioural interventions and appropriate treatment by health
covered by health benefit plans.87 care providers — preferably with the support of interdisciplinary
Implementation of this guideline will require targeted policy care teams — will raise the standards of care and improve the
action, as well as advocacy efforts and engagement from people well-being of people living with obesity. Dissemination and
living with obesity, their families and health care providers. implementation of this guideline are integral components of our
Canadian organizations have come together to change the narra- goals to address this prevalent chronic disease. Much more effort
tive regarding obesity in Canada, to eliminate weight bias and is needed to close the gaps in knowledge through obesity
obesity stigma, and to change the way health care systems and research, education, prevention and treatment.

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Competing interests: Sean Wharton reports receiving honoraria and receiving speaker honoraria from Novo Nordisk, Bausch Health, Eli Lilly,
travel expenses and has participated in academic advisory boards for Boehringer Ingelheim, Nestlé Health Science, Janssen and AstraZeneca;
GUIDELINE
Novo Nordisk, Bausch Health, Eli Lilly and Janssen. Sean Wharton is also research subvention from Novo Nordisk and Sanofi; and consultation
the medical director of a medical clinic specializing in weight manage- honoraria from Novo Nordisk, Bausch Health, Eli Lilly, Boehringer Ingel-
ment and diabetes. David Lau reports receiving grants and research heim, Janssen and AstraZeneca. Sue Pedersen reports receiving
support from AstraZeneca, Novo Nordisk and the Canadian Institutes of personal fees from Novo Nordisk, Bausch Health, Janssen, Eli Lilly,
Health Research (CIHR); speaker bureau fees from AstraZeneca, Bausch Merck, AstraZeneca, Boehringer Ingelheim, Sanofi, Pfizer; grants from
Health, Boehringer Ingelheim, Diabetes Canada, Eli Lilly, Merck and Eli Lilly, AstraZeneca, Boehringer Ingelheim and Sanofi; and nonfinan-
Novo Nordisk; and consulting fees from Amgen, AstraZeneca, Bausch cial support from Novo Nordisk, Bausch Health, Janssen, Eli Lilly,
Health, Boehringer Ingelheim, Gilead, HLS Therapeutics, Janssen, Eli AstraZeneca, Boehringer Ingelheim and Sanofi, outside the submitted
Lilly and Novo Nordisk. Michael Vallis is a member of advisory boards for work. Megha Poddar reports receiving honoraria for continuing medical
Novo Nordisk, Bausch Health and LifeScan. Michael Vallis has also re- education (CME) from Novo Nordisk, Bausch Health, Boehringer
ceived consulting fees from Bausch Health, LifeScan, Novo Nordisk and Ingelheim, Eli Lilly, Jenssen, Merck, the Canadian Collaborative Re-
Sanofi, and speaking fees from Novo Nordisk, Sanofi, Bausch Health, search Network and the Antibody Network; education grants from Novo
Abbott and AbbVie. Arya Sharma reports receiving speaker’s bureau and Nordisk and Bausch Health; fees for mentorship from Novo Nordisk;
consulting fees from Novo Nordisk, Bausch Pharmaceuticals and Astra- fees for membership of advisory boards from Novo Nordisk and Bausch
Zeneca. Laurent Biertho reports receiving grants from Johnson and Health; and a quality improvement project grant from Boehringer
Johnson and Medtronic, and is a member of advisory boards for Novo Ingelheim. Paul Poirier reports receiving fees for consulting and con-
Nordisk and Bausch Health, outside the submitted work. Denise tinuing medical education from AstraZeneca, Boehringer Ingelheim,
Campbell-Scherer has no personal financial relationships, but reports Janssen, Eli Lilly, Novo Nordisk, Valeant and Bausch Health, outside the
receiving research funding from the following sources in the past submitted work. Judy Shiau reports receiving personal fees from Novo
3 years: Novo Nordisk Alberta Diabetes Fund (NOVAD), a peer-reviewed Nordisk and Bausch Health, outside the submitted work. Diana Sherifali
grant that is a partnership between the University Hospital Foundation, reports receiving consulting fees for advice regarding chronic disease
Novo Nordisk and Alberta Innovates joint funders; Alberta Innovates and diabetes management from Merck, and a grant from Obesity Can-
Health Solutions (Cancer Prevention Research Opportunity and Collab- ada to support the literature review process, during the conduct of the
orative Research and Innovation Opportunities competitions), CIHR study. John Sievenpiper reports receiving grants from CIHR, the Nutri-
(Strategy for Patient-Oriented Research and Knowledge-to-Action com- tion Trialists Fund at the University of Toronto, the International Nut
petitions); Northern Alberta Family Medicine Fund; and the Alberta and Dried Fruit Council Foundation, the Tate & Lyle Nutritional Research
Cancer Prevention and Legacy Fund. She also reports receiving know Fund at the University of Toronto, the American Society for Nutrition,
ledge transfer funding from the following sources in the past 3 years: an the Glycemic Control and Cardiovascular Disease in Type 2 Diabetes
unrestricted education grant from Obesity Canada, funded by Novo Fund at the University of Toronto, the National Dried Fruit Trade Associ-
Nordisk Global; a Worldwide University Network Meeting Grant; an ation, PSI Graham Farquharson Knowledge Translation Fellowship, the
Agency for Healthcare Research and Quality R13 grant for a Healthcare Diabetes Canada Clinician Scientist award, the Banting & Best Diabetes
Effectiveness and Outcomes Research; and a Physician Learning Pro- Centre Sun Life Financial New Investigator Award, the Canada Founda-
gram grant from Alberta Health and the Alberta Medical Association. tion for Innovation, and the Ministry of Research and Innovation’s
Angela Alberga reports receiving the following grants: the Santé Award Ontario Research Fund. Dr. Sievenpiper has received personal fees from
from Fonds de Recherche du Quebec, the Mitacs Accelerate Grant, and Perkins Coie LLP, Tate & Lyle, Dairy Farmers of Canada, PepsiCo, Food-
the Concordia University Start-up Team Grant, outside the submitted Minds LLC, European Fruit Juice Association, International Sweeteners
work. Jennifer Brown reports receiving nonfinancial support from Novo Association, Nestlé Health Science, Canadian Society for Endocrinology
Nordisk, and personal fees from Bausch Health, Dietitians of Canada, and Metabolism, GI Foundation, Pulse Canada, Wirtschaftliche Vereini-
Obesity Canada and the Canadian Association of Bariatric Physicians & gung Zucker e.V., Abbott, Biofortis, the European Food Safety Authority,
Surgeons. Yoni Freedhoff is the co-owner of the Bariatric Medical Insti- the Physicians Committee for Responsible Medicine, the Soy Nutrition
tute and Constant Health, which provide weight management services; Institute and the Comité Européen des Fabricants de Sucre.
Constant Health has received a grant from Novo Nordisk. Yoni Freedhoff Dr. Sievenpiper has received nonfinancial support from Tate & Lyle,
is also the author of The Diet Fix: Why Diets Fail and How to Make Yours PepsiCo, FoodMinds LLC, European Fruit Juice Association, Interna-
Work published by Crown Publishing Group, and receives royalties for tional Sweeteners Association, Nestlé Health Science, Wirtschaftliche
the book. In addition, he is the sole author of the Weighty Matters blog Vereinigung Zucker e.V., Abbott, Biofortis, the European Food Safety Au-
and a column for Medscape and many other op-eds and articles in thority and the Physicians Committee for Responsible Medicine,
which he has publicly expressed opinions about the treatment, manage- Kellogg Canada, American Peanut Council, Barilla, Unilever, Unico
ment and prevention of obesity. Yoni Freedhoff also regularly speaks on Primo, Loblaw Companies, WhiteWave Foods, Quaker, California Walnut
topics related to obesity and receives honoraria and travel costs and ex- Commission, Almond Board of California, outside the submitted work.
penses for same. Michel Gagner reports receiving speaker honoraria Dr. Sievenpiper is a member of the International Carbohydrate Quality
from Ethicon, WL Gore and Medtronic; consulting fees from Novo Nord- Consortium and the Clinical Practice Guidelines Expert Committees of
isk, Bausch Health and Lexington Medical; and holds stock options with Diabetes Canada, European Association for the Study of Diabetes, Can
Lexington Medical. Margaret Hahn reports receiving consulting fees adian Cardiovascular Society, and Obesity Canada, and holds
from Alkermes. Marie-France Langlois reports receiving personal fees appointments as an Executive Board Member of the Diabetes and Nutri-
from Novo Nordisk, Valeant, Merck Canada, Sanofi, Eli Lilly and tion Study Group of the European Association for the Study of Diabetes,
Boehringer Ingelheim; a grant from Merck Canada; and other fees from and as Director of the Toronto 3D Knowledge Synthesis and Clinical Trials
AstraZeneca and from TIMI (Thrombolysis in Myocardial Infarction) Foundation. He is also an unpaid scientific adviser for the Program in
Study Group for diabetes clinical research as a principal investigator, all Food Safety, Nutrition and Regulatory Affairs and the Carbohydrates
outside the submitted work. David Macklin reports receiving personal Committee of the International Life Science Institute North America. He
fees from Novo Nordisk and Bausch Health, outside the submitted work. has a spousal relationship with an employee of Anheuser-Busch InBev.
Priya Manjoo reports receiving personal fees from Novo Nordisk, Bausch Sanjeev Sockalingam reports receiving honoraria from Bausch Health
Health and Sanofi; and grants from Boehringer Ingelheim, Sanofi and Canada within the last 36 months. Valerie Taylor reports receiving
AstraZeneca, outside the submitted work. Marie-Philippe Morin reports speaker fees from Sunovion. Shahebina Walji reports receiving consulting

or advisory board fees from Novo Nordisk, Bausch Health and Takeda and sion of Endocrinology (Langlois), Université de Sherbrooke, Sherbrooke,
speaker’s bureau fees from Novo Nordisk and Bausch Health. Shahebina Que.; Centre intégré universitaire de santé et de services sociaux de
GUIDELINE
Walji also reports selling Optifast Meal replacements through a weight l’Estrie - Centre hospitalier universitaire de Sherbrooke (Langlois), Sher-
management centre Optifast is a product produced and sold by Nestlé. brooke, Que.; School of Kinesiology (Lear), Simon Fraser University,
No other competing interests were declared. Vancouver, BC; Medcan Clinic (Macklin), Toronto, Ont.; Cardiometabolic
Collaborative Clinic (Manjoo), Vancouver Island Health Authority, Victo-
This article has been peer reviewed.
ria, BC; Institut universitaire de cardiologie et de pneumologie de Qué-
Affiliations: Departments of Medicine (Wharton), Endocrinology and bec (Morin, Poirier), Laval University, Québec, Que.; Foothills Medical
Metabolism (Poddar, Sherifali), Family Medicine (Naji, Tytus) and Health Centre (Nerenberg), Calgary, Alta.; C-ENDO Diabetes & Endocrinology
Research Methods, Evidence and Impact Canada (Naji), McMaster Uni- Clinic (Pedersen), Calgary, Alta.; LMC Diabetes and Endocrinology
versity, Hamilton, Ont; The Wharton Medical Clinic (Wharton, Poddar), (Poddar), Toronto, Ont.; Department of Medicine (Rueda-Clausen), Uni-
Hamilton, Ont.; Departments of Medicine (Lau, Nerenberg) and Family versity of Saskatchewan, Regina, Sask.; Regina General Hospital (Rueda-
Medicine (Boyling, Henderson, McInnes, Walji, Wicklum), Cumming Clausen), Regina, Sask.; Education Psychology (Russell-Mayhew), Werk-
School of Medicine, University of Calgary, Calgary, Alta.; Julia McFarlane lund School of Education, University of Calgary, Calgary, Alta.; LEAF
Diabetes Research Centre and Libin Cardiovascular Institute of Alberta Weight Management Clinic (Shiau), Ottawa, Ont.; Heather M. Arthur
(Lau), Calgary, Alta.; Department of Family Medicine (Vallis, Piccinini- Population Health Research Institute/Hamilton Health Sciences Chair in
Vallis), Dalhousie University, Halifax, NS; Departments of Medicine Interprofessional Health Research, School of Nursing (Sherifali), McMas-
(Sharma, Toth), Family Medicine (Campbell-Scherer, Kemp), Agricul- ter University, Hamilton, Ont.; Division of Endocrinology & Metabolism
tural, Food and Nutritional Science (Bell, Pereira), Physical Education (Sievenpiper), St. Michael’s Hospital, Toronto, Ont.; Department of
and Recreation (Boulé), and Occupational Therapy (Forhan), University Psychiatry (Taylor), University of Calgary, Calgary, Alta.; School of Phar-
of Alberta, Edmonton, Alta.; Adult Bariatric Specialty Clinic (Sharma), macy (Twells), Memorial University, St. John’s, NL; Steelcity Medical
Royal Alexandra Hospital, Edmonton, Alta.; Obesity Canada (Sharma, Clinic (Tytus), Hamilton, Ont.; Calgary Weight Management Centre
Patton, Ramos Salas), Edmonton, Alta.; Department of Surgery (Walji), Calgary, Alta.; School of Population and Public Health (Walker),
(Biertho), Laval University, Quebec, Que.; School of Human Kinetics University of British Columbia, Vancouver, BC; Centre for Excellence in
(Adamo, Prud’homme), University of Ottawa, Ottawa, Ont.; Department Indigenous Health (Walker), University of British Columbia, Vancouver,
of Health, Kinesiology & Applied Physiology (Alberga), Concordia Uni- BC.; O’Brien Institute of Public Health (Wicklum), University of Calgary,
versity, Montréal, Que.; Bariatric Centre of Excellence (Brown), The Calgary, Alta.
Ottawa Hospital, Ottawa, Ont.; Departments of Family Practice (Calam)
Contributors: All of the authors contributed to the conception and
and Endocrinology (Manjoo), University of British Columbia, Vancouver,
design of the work and the acquisition, analysis, and interpretation of
BC; UBC Family Practice Residency Program (Calam) and Pfizer/Heart
data. All of the authors drafted the manuscript, revised it critically for
and Stroke Foundation Chair in Cardiovascular Prevention Research
important intellectual content, gave final approval of the version to be
(Lear), St. Paul’s Hospital, Vancouver, BC; nutrition consultant (Clarke),
published and agreed to be accountable for all aspects of the work.
Hamilton, Ont.; Indigenous Health Dialogue (Crowshoe), Health Sci-
ences Centre, University of Calgary, Calgary, Alta.; Main East Medical Funding: Funding for this initiative was provided by Obesity Canada,
Associates (Divalentino), Hamilton, Ont.; Bariatric Medical Institute the Canadian Association of Bariatric Physicians and Surgeons, and the
(Freedhoff), Ottawa, Ont.; Department of Family Medicine (Freedhoff) Canadian Institutes of Health Research through a Strategy for Patient-
and Division of Endocrinology and Metabolism (Shiau), Department of Oriented Research grant, with no participants or authors receiving any
Medicine, University of Ottawa, Ottawa, Ont.; Herbert Wertheim School personal funding for their creation.
of Medicine (Gagner), Florida International University, Miami, Fla.; Hôpi-
Acknowledgements: The authors thank Obesity Canada staff members
tal du Sacre Coeur de Montréal (Gagner), Montréal, Que.; Humber River
Dawn Hatanaka, Nicole Pearce, Brad Hussey, Robert Fullerton and Patti
Hospital (Glazer), Toronto, Ont.; Division of Endocrinology and Metab
Whitefoot-Bobier for their coordinating support as well as their contri-
olism (Glazer), Queen’s University, Kingston, Ont.; Departments of Inter-
butions for the development of the Obesity Guidelines website, online
nal Medicine (Glazer), Psychiatry (Hawa, Sockalingam), Family and
resources, tables and figures. The authors also thank members of the
Community Medicine (Macklin) and Nutritional Sciences (Sievenpiper),
Obesity Canada Public Engagement Committee (Lisa Schaffer, Candace
University of Toronto, Toronto, Ont.; Alberta Health Services (Grand,
Vilhan, Kelly Moen, Doug Earle, Brenndon Goodman), who contributed
Hung, Johnson-Stoklossa), Edmonton, Alta.; Departments of Family
to the creation of the research questions and reviewed key messages for
Medicine and Public Health Sciences and Policy Studies (Green),
individuals living with obesity and recommendations for health care
Queen’s University, Kingston, Ont.; Kingston Health Sciences Centre
providers. The authors also thank McMaster Evidence Review and Syn-
(Green), Kingston, Ont.; Providence Care Hospital (Green), Kingston,
thesis Team (MERST) member Donna Fitzpatrick, who played a critical
Ont.; Centre for Addiction and Mental Health (Hahn, Sockalingam),
role in developing the methods needed for the guideline; and thank the
Toronto, Ont.; University Health Network (Hawa, Sockalingam),
reviewers whose comments helped to improve the chapters and this
Toronto, Ont.; Division of General Surgery (Hong), McMaster University,
manuscript. The authors thank Barbara Kermode-Scott and Brad
Hamilton, Ont.; Department of Family Medicine and Biobehavioral
Hussey for editing the guidelines, Elham Kamran and Rubin Pooni for
Health (Jacklin), University of Minnesota Medical School Duluth Cam-
research assistance, and Jordan Tate from the Physician Learning Pro-
pus, Duluth, Minn.; School of Kinesiology and Health Studies (Janssen),
gram at the University of Alberta for designing the 5As framework for
Queen’s University, Kingston, Ont.; School of Health and Human Perfor-
the guideline.
mance (Kirk), Dalhousie University, Halifax, NS; School of Kinesiology
and Health Science (Wharton, Kuk), York University, Toronto, Ont.; Divi- Correspondence to: Sean Wharton, [email protected]

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GUIDELINE CPD

Obesity in adults: a clinical practice guideline

n Cite as: CMAJ 2020 August 4;192:E875-91. doi: 10.1503/cmaj.191707

This article is available in French at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.191707/-/DC1

CMAJ Podcasts: author interview at https://www.cmaj.ca/lookup/doi/10.1503/cmaj.191707/tab-related-content

Obesity has become a major public health issue that

Adipose tissue not only influences the central regulation of energy

• Cognitive functions in the prefrontal cortex exert executive

E876 CMAJ | AUGUST 4, 2020 | VOLUME 192 | ISSUE 31

▼ health ▼ quality of life ▼ lifespan

A clinical practice guideline People with obesity increased complications

THE PATIENT JOURNEY IN OBESITY MANAGEMENT

2 ASSESS THEIR STORY

E878 CMAJ | AUGUST 4, 2020 | VOLUME 192 | ISSUE 31

Table 1 (part 1 of 5): Recommendations on management of obesity in adults*

Reducing weight bias in obesity management, practice and policy

CMAJ | AUGUST 4, 2020 | VOLUME 192 | ISSUE 31 E879

Medical nutrition therapy in obesity management

E880 CMAJ | AUGUST 4, 2020 | VOLUME 192 | ISSUE 31

Pharmacotherapy in obesity management

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Primary care and primary health care in obesity management

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Note: ALT = alanine aminotransferase, BMI = body mass index.

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Development of recommendations External review

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analyses of 57 prospective studies. Lancet 2009;373:1083-96. perspective. Endocr Rev 2006;27:750-61.

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