DC endorsement decision on Canadian Adult Obesity CPGs

Date: April 27, 2021

Dietitians of Canada, along with other health organizations, was invited to endorse the new Canadian Adult Obesity Clinical Practice Guidelines (CPGs) released in August 2020 by Obesity Canada and the Canadian Association of Bariatric Physicians and Surgeons. After an extensive endorsement process which included a member survey and in-depth analysis by a group of volunteer member expert reviewers, DC does not have sufficient member support to endorse the CPGs.  
 
How did DC make this decision? 
 
Dietitians of Canada undertook a two-part endorsement process to inform our endorsement decision. For part one, a group of 11 volunteer member expert reviewers critically analyzed the CPGs and provided their feedback and endorsement recommendation to DC. Part two of the endorsement process was a member survey to provide all members the opportunity to voice their input about the new CPGs. A total of 159 members answered the question “Do you support DC endorsing the CPGs?”. When developing the endorsement process, DC established a target that a minimum of 75% of members who participated as expert reviewers and completed the member survey must agree to support DC’s endorsement of the CPGs. 
 
The final analysis showed that 58% of expert reviewers and survey respondents supported DC endorsing the CPGs, while 42% did not support the endorsement. The member survey and expert reviewer results contributed equally to the analysis. 
 
A significant amount of qualitative data was collected as part of the endorsement process. The positive aspects of the CPGs highlighted by members included:
 

• Acknowledgement of weight stigma and bias
• Shift from weight outcomes to health outcomes/quality of life
• Recommendation for health care providers to assess their own attitudes and beliefs and avoid making assumptions
• Person-centred approach/individualized, personalized care
• Recommendation to see a dietitian/recognition of the importance of medical nutrition therapy
• Recommendation of a non-dieting approach

 
Areas of concern highlighted by members included:

• Use of the term “obesity”/defining obesity as a chronic disease
• Contradictory statements throughout the guidelines about weight/weight loss. As an example, diet/calorie restriction is recommended, however it is then stated weight loss is not sustainable in the long term and may ultimately cause weight gain
• Strong focus on weight loss throughout the guidelines
• Strong focus on medication/pharmacotherapy and bariatric surgery 
• Lack of acknowledgement of the social determinants of health
• Adverse effects of weight loss treatment not fully examined

 
Supporting dietitians moving forward
 
The endorsement process reflected dietitians' diverse perspectives and varying reactions to these CPGs depending on their practice approach. This diversity of perspectives and dietetic practice is a strength and challenges dietitians to self-reflect, be mindful of biases, be open to learning about different approaches in dietetic practice and to engage in respectful conversations to further collaboration amongst dietitians and other health professionals.
 
As integral members of interdisciplinary health care teams, dietitians are the most qualified professionals to provide food and nutrition interventions. While not all dietitians fully agree with all recommendations in the CPGs, the CPGs are an evidence-based resource that can continue to be a useful tool dietitians use to guide their practice.

As we continue the dialogue as a profession, we can all agree there is no one-size-fits all approach to health and that our clients, patients and communities should be afforded respectful, non-stigmatizing care, independent of practice approach. Dietitians of Canada is committed to providing places for conversation and learning within the dietetic profession on the topic of weight, health and stigma and its effects on the health of Canadians.

Current DC tools and resources that are available include:

• PEN Backgrounder on Weight Stigma and Bias
• Learning on Demand session: The Effects of Internalized Weight Stigma 
• Learning on Demand session: Reducing Weight Stigma: How to Practice Weight-Inclusive Approaches in a Weight-Centric Society 
• Learning on Demand sessions: Nutrition Updates from the Canadian Adult Obesity Clinical Practice Guidelines (two-part series)

 
Coming Soon! 

• 2021 DC National Conference Session: Applying a Weight Inclusive Practice in Dietetics Using a Socioecological Framework
• PEN Backgrounder on Weight Inclusive / Health At Every Size® HAES Approach 
• PEN Background on Physiology of Body Weight, Weight Change and Adipose Tissue 

DC is also committed to reviewing and updating DC and PEN language to remove stigmatizing terms. 
 
Acknowledgements 
 
Thank you to DC members Jennifer Brown, lead author of the CPG Medical Nutrition Therapy Chapter and CPG Steering Committee member, and Carol Clarke, co-author of the Medical Nutrition Therapy Chapter, for their expert leadership in writing the Medical Nutrition Therapy Chapter and ensuring the dietitian voice was represented in the CPGs. 
 
Thank you to the following DC members who completed the expert member reviewer process: Lynette Amirault, Menna Ataya, Mun Cho, Lisa Galvez, Shannan Grant, Kristyn Hall, Anna Millman, Veronica Kacinik, Nooshin Alizadeh Pasdar, Sara Patenaude, and Carla Prado.