POPULATION

The growth monitoring recommendations apply to all children and youth 0–17 years of age who present to primary care. The prevention recommendations apply to all children and youth 0–17 years of age who have a healthy weight. They do not apply to children and youth with eating disorders, or who are underweight, overweight, or obese.

The management recommendations apply to children and youth 2–17 years of age who are overweight or obese. Children and youth with health conditions where weight management is inappropriate are excluded.

BURDEN OF ILLNESS

Estimates from 2009–2011 based on measured weight and height for children ages 5 to 17 years indicate that 32% are overweight (20%) or obese (12%), with the prevalence of obesity being almost twice as high in boys compared to girls.

INTERVENTIONS

Formal structured behavioural and lifestyle interventions, pharmacologic and surgical interventions.

RECOMMENDATIONS

• We recommend growth monitoring at all appropriate primary care visits using the 2014 WHO Growth Charts for Canada.
  (Strong recommendation, very low quality evidence)
• We recommend that primary care practitioners not routinely offer structured interventions aimed at preventing overweight and obesity in healthy weight children and youth.
  (Weak recommendation; very low quality evidence)
• For children and youth aged 2 to 17 years who are overweight or obese, we recommend that primary care practitioners offer or refer to structured behavioural interventions aimed at healthy weight management.
  (Weak recommendation, moderate quality evidence)
• For children and youth aged 2 to 11 years who are overweight or obese, we recommend that primary care practitioners not offer Orlistat aimed at healthy weight management.
  (Strong recommendation, very low quality evidence)
• For children and youth aged 12 to 17 years who are overweight or obese, we recommend that primary care practitioners not routinely offer Orlistat aimed at healthy weight management.
  (Weak recommendation, moderate quality evidence)
• For children and youth aged 2 to 17 years who are overweight or obese, we recommend that primary care practitioners not routinely refer for surgical interventions.
  (Strong recommendation, very low quality evidence)

BASIS OF RECOMMENDATIONS

• Growth monitoring is a long-standing, feasible, low- cost intervention that is unlikely to result in harms, and likely to be valued by parents and clinicians in identifying children and youth at risk of developing weight-related health conditions that may benefit from early identification.
• The quality of evidence for obesity prevention in primary care settings is weak, with interventions demonstrating only modest benefits on BMI in studies of mixed weight populations, with no evidence of long-term effectiveness.
• Behavioural interventions have demonstrated short-term effectiveness in reducing BMI in children and youth who are overweight or obese and are the preferred option, as the benefit-to-harm ratio appears more favourable than for pharmacologic interventions.
• Pharmacologic interventions in addition to a healthy nutrition and exercise intervention demonstrate modest short-term benefit for adolescents, but have frequent harms.
• We found no RCTs comparing surgical interventions to a control group in children and adolescents of any age.

DETAILS OF RECOMMENDED SERVICES

Growth monitoring consists of measurement of height or length, weight and BMI calculation or weight-for-length according to age.

Appropriate primary care visits include scheduled health supervision visits, visits for immunizations or medication renewal, episodic care or acute illness, and other visits where the primary care practitioner deems it appropriate. Primary care visits are completed at primary health care settings, including those outside of a physician’s office (e.g. public health nurses carrying out a well-child visit at a community setting).

Behavioural modification programs involve several sessions that take place over weeks to months, follow a comprehensive-approach delivered by a specialized inter-disciplinary team, involve group sessions, and incorporate family and parent involvement. Behaviourally-based interventions may focus on diet, increasing exercise, making lifestyle changes, or any combination of these. These can be delivered by a primary health care team in the office or through a referral to a formal program within or outside of primary care, such as hospital-based, school-based or community programs.

CONSIDERATIONS FOR IMPLEMENTATION

We sought but found no evidence that the benefits and harms of intervention varied in accordance to patient and parent characteristics, including age, sex, and socioeconomic status.

Provider skills and intervention formats varied widely. Therefore, only general aspects of the effective behavioural interventions could be identified.

Resources for offering the most effective interventions are more likely to be found in team-based primary health care settings. Emphasis should be placed on the delivery of comprehensive weight management programs by a specialized inter-disciplinary team. Primary care practitioners who wish to partake in the delivery of such programs should receive adequate training.