A New Clinical Practice Guideline for Managing Obesity in Children

To fill gaps in knowledge and management of pediatric obesity, a panel of healthcare professionals, caregivers, and people living with obesity, in partnership with Obesity Canada, collaborated on a clinical practice guideline for the management of pediatric obesity, published in CMAJ.

The objective, according to the healthcare professionals who compiled the guideline, is to “support children, families, and health care providers to have informed discussions about the balance of benefits and harms for available obesity management interventions to support value- and preference-sensitive decision-making.”

The guideline focuses on an individualized approach to managing obesity in children aged 18 years and younger using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) evidence-to-decision framework and includes 10 recommendations for behavioral, psychologic, pharmacologic, and surgical interventions and 9 good practice statements for management of pediatric obesity. The recommended interventions are listed according to category below.

Behavioral and Psychologic Interventions

• Multicomponent intervention: Use of at least 2 of the behavioral and psychologic interventions listed. This recommendation was derived from a meta-analysis of 22 randomized controlled trials (RCTs) (2,184 participants; 55% female; ages 3-5 years, 17.4%; 6-12 years, 43.5%; 13-18 years, 21.7%).
• Nutritional guidance: This recommendation was derived from a meta-analysis of 8 RCTs (447 participants; 56% female; ages 6-12 years, 37.5%; 13-18 years, 62.5%). A nutritional intervention consists of nutritional counselling and nutritional education that includes goal-setting, problem-solving, and self-monitoring techniques.
• Physical activity: This recommendation was derived from 23 RCTs (1,437 participants; 51% female; ages 6-12 years, 39.1%; 13-18 years, 56.5%) wherein aerobic or resistance training interventions were the most common methods of physical activity. Combined training seems to be more effective than either exercise modality alone.
• Psychologic support: This recommendation was derived from 9 RCTs (1,336 participants; 53% female; ages 3-5 years, 11.1%; 6-12 years, 22.2%; 13-18 years, 66.7%) that investigated different modes of counselling, including group-based education for families, cognitive behavioral therapy, and group therapy sessions.
• Technology intervention: The guideline does not recommend for or against the use of a technological intervention in management of pediatric obesity. Thirteen RCTs (901 participants; 51% female; ages 6-12 years, 30.8%; 13-18 years, 53.8%) were considered for this recommendation, but the guideline collaborators were unable to determine whether interventions such as websites, smartphone applications, or wearable devices positively affected children aged 18 years and younger with obesity.

Pharmacologic Interventions

• Glucagon-like peptide 1 receptor agonists (GLP-1 RAs): These should be used in conjunction with behavioral and psychologic interventions for children aged 12 years and older only. The recommendation for use of exenatide, liraglutide, and semaglutide was derived from meta-analysis of 7 RCTs (684 participants; 56% female; aged 3-12 years, 12.5%; 13-18 years, 87.5%).
• Biguanides: This recommendation was derived from a meta-analysis of 26 RCTs (2,218 participants; 58% female; ages 3-12 years, 27.6%; 13-18 years, 55.2%) that all included metformin. Metformin can be considered in combination with behavioral and psychologic interventions for children aged 12 years and older only.
• Lipase inhibitors: This recommendation was based on meta-analysis of 2 RCTs (579 participants; 68% female; all aged 13-18 years) that included orlistat. The guideline recommends against using lipase inhibitors to treat pediatric obesity.

Surgical Interventions

• Laparoscopic sleeve gastrectomy: This intervention can be considered in addition to behavioral and psychologic interventions in obesity management for children aged 13 years and older who are eligible candidates based on assessment by a multidisciplinary team.
• Roux-en-Y gastric bypass: This intervention can also be considered in addition to behavioral and psychologic interventions for children aged 13 years or older who are deemed eligible candidates by a multidisciplinary team.

The 9 good practice recommendations include:

• Use first-person language with patients and avoid negative and stigmatizing terms.
• Acknowledge that obesity is a disease with a complex, chronic, and relapsing nature and establish a positive relationship with pediatric patients and their families to provide long-term support for obesity management.
• Assess childhood growth and development using the WHO growth charts for sex-specific and age-specific BMI data.
• Consider social determinants of health and how they might affect shared decision-making, recommendations for interventions, access to resources, and management of obesity for different families.
• Complete a comprehensive health assessment of children with obesity using a framework such as the 4Ms for Assessment of Obesity (Metabolic, Mechanical, Mental health, social Milieu) to identify consequences of obesity and barriers to obesity management.
• Take a nonjudgmental and non-stigmatizing approach to encourage participation in management interventions, including discussion of expectations for improving health outcomes with both children and families.
• Implement resources such as the 5As for Pediatric Obesity Management (Ask, Assess, Advise, Agree, Assist) to better screen and care for patients with respect and to encourage participation.
• Present options for obesity interventions that are based on evidence, feasibility, and availability.
• Offer services of a multidisciplinary team, when possible, to maximize benefits of assessment and management.

“To support value- and preference-sensitive decision-making, we encourage health care providers and the systems they work in to apply and share our guideline so children with obesity and their families can have informed discussions about the balance of benefits and harms for available, acceptable, and feasible obesity management interventions,” the panel concluded.

Reference

Ball GCD, Merdad R, Birken CS, et al. Managing obesity in children: a clinical practice guideline. CMAJ. 2025;197(14):E372-E389. Published online April 14, 2025. DOI:https://doi.org/10.1503/cmaj.241456