Updating the Canadian clinical practice guideline for managing pediatric obesity: a protocol

Effectiveness of pharmacological interventions for managing obesity in children and adolescents: A systematic review and meta-analysis framed using minimal important difference estimates based on GRADE guidance to inform a clinical practice guideline

OBJECTIVE

To summarize the literature on pharmacotherapy for managing paediatric obesity.

METHODS

A systematic review and meta-analysis were conducted of randomized controlled trials (RCTs) with <18-year-olds of pharmacotherapeutic agents published up to November 2022. Estimates of effect for outcomes were presented relative to minimal important differences and GRADE certainty of evidence. We examined data on patient/proxy-reported outcome measures (PROMs), cardiometabolic risk factors, anthropometry and adverse events (AEs).

RESULTS

Overall, 35 RCTs were included. Trials examined metformin (n = 26), glucagon-like peptide-1 receptor agonists (GLP1RAs) (n = 7) and a lipase inhibitor (orlistat; n = 2). Intervention duration varied (3-24 months). Metformin had little to no benefit on PROMs (e.g., health-related quality of life [HRQoL]; 6 RCTs), moderate reductions in triglycerides, a moderate decline in insulin resistance, a small to moderate decline in BMI z-score (BMIz) and a moderate increase in mild to moderate gastrointestinal AEs. Response to GLP1RAs was heterogeneous and results of subgroup analysis demonstrated variability of impact. Liraglutide (2 RCTs) resulted in a small reduction in HOMA-IR and BMIz, but little to no benefit on other outcomes. Exenatide (4 RCTs) had a moderate reduction on blood pressure and a small decrease in BMIz with little to no benefit on other outcomes. Semaglutide (1 RCT) had a small benefit on HRQoL, a small reduction on SBP, a moderate reduction on total cholesterol and LDL-cholesterol, a large reduction on triglyceride, and a very large decline in BMIz accompanied by a small increase in mild to moderate gastrointestinal AEs. Orlistat had a moderate reduction in DBP and little to no benefit in other outcomes measured, but had a very large increased risk of mild to moderate gastrointestinal AEs. Serious AEs were rare and for interventions with sufficent AE reporting, were considered not likely attributable to the interventions.

CONCLUSION

Few studies examined the impact of pharmacotherapy on PROMs. There is evidence that metformin and GLP1RAs lead to important improvements in cardiometabolic and anthropometric outcomes while accompanied by mild to moderate AEs. Long-term effectiveness and safety of GLP1RAs remain to be evaluated.

Assessing the state of obesity care: Quality, access, guidelines, and standards

Background

An international panel of obesity medicine experts from multiple professional organizations examined patterns of obesity care and current obesity treatment guidelines to identify areas requiring updating in response to emerging science and clinical evidence.

Aims

The panel focused on multiple medical health and societal issues influencing effective treatment of obesity and identified several unmet needs in the definition, assessment, and care of obesity.

Methods

The panel was held in Leesburg, Virginia in September 2019.

Results

The panelists recommended addressing these unmet needs in obesity medicine through research, education, evaluation of delivery and payment of care, and updating clinical practice guidelines (CPG) to better reflect obesity's pathophysiological basis and heterogeneity, as well as the disease's health, sociocultural, and economic complications; effects on quality of life; need for standards for quantitative comparison of treatment benefits, risks, and costs; and the need to more effectively integrate obesity treatment guidelines into routine clinical practice and to facilitate more direct clinician participation to improve public understanding of obesity as a disease with a pathophysiological basis. The panel also recommended that professional organizations working to improve the care of people with obesity collaborate via a working group to develop an updated, patient-focused, comprehensive CPG establishing standards of care, addressing identified needs, and providing for routine, periodic review and updating.

Conclusions

Unmet needs in the definition, assessment and treatment of obesity were identified and a blueprint to address these needs developed via a clinical practice guideline that can be utilized worldwide to respond to the increasing prevalence of obesity.

Putting weight-related conversations into practice: Lessons learned from implementing a knowledge translation casebook in a disability context

BACKGROUND

Due to reported challenges experienced by healthcare providers (HCPs) when having weight-related conversations with children with disabilities and their families, a knowledge translation (KT) casebook was developed, providing key communication principles with supportive resources. Our aim was to explore how the KT casebook could be implemented into a disability context. Study objectives were to develop and integrate needs-based implementation supports to help foster the uptake of the KT casebook communication principles.

METHODS

A sample of nurses, physicians, occupational therapists and physical therapists were recruited from a Canadian paediatric rehabilitation hospital. Informed by the Theoretical Domains Framework, group interviews were conducted with participants to understand barriers to having weight-related conversations in their context. Implementation strategies were developed to deliver the KT casebook content that addressed these identified barriers, which included an education workshop, simulations, printed materials, and a huddle and email strategy. Participant experiences with the implementation supports were captured through workshop evaluations, pre-post surveys and qualitative interviews. Post-implementation interviews were analysed using descriptive content analysis.

RESULTS

Ten HCPs implemented the KT casebook principles over 6 months. Participants reported that the workshop provided a clear understanding of the KT casebook content. While HCPs appreciated the breadth of the KT casebook, they found the abbreviated printed educational materials more convenient. Strategies developed to address participants' need for a sense of community and opportunities to learn from each other did not achieve their aim. Increased confidence in integrating the KT casebook principles into practice was not demonstrated, due, in part, to having few opportunities to practice. This was partly because of the increase in competing clinical demands at the onset of the COVID-19 pandemic.

CONCLUSIONS

Despite positive feedback on the product itself, changes in the organisational and environmental context limited the success of the implementation plan. Monitoring and adapting implementation processes in response to unanticipated changes is critical to the success of implementation efforts.

Systematic Development of National Guidelines for Obesity Care: The Swedish Approach

INTRODUCTION

With the rapid development of treatment modalities for obesity management, there is an increasing demand for guidance to facilitate the prioritization of interventions. In 2020, the Swedish National Board of Health and Welfare started the process of producing the first national guidelines for obesity care directed to decision makers who allocate resources to the best knowledge-based care. The main aim of this paper was to describe the systematic development of these guidelines, designed to guarantee uniformly high standards of care throughout the whole country.

METHODS

The standardized procedures of the National Board of Health and Welfare were applied to construct guidelines in a systematic and transparent way, including priority setting of recommendations and quality indicators to evaluate the progress of implementation. The process involved independent expert committees including professionals and patient representatives, and the guidelines were reviewed through an open public consultation.

RESULTS

National guidelines were issued in 2023, encompassing a broad scope, from identification and diagnosis to multiple treatment modalities, embedded in a life-course perspective from pregnancy to the elderly, as well as highlighting the need for improved knowledge and competence of health care providers.

CONCLUSIONS

National guidelines for improved standard care and evidence-based and efficient use of health care resources for obesity treatment can be developed in a systematic way with professionals and patient representatives.

Impact of Physical Activity Counselling on Children with Medical Conditions and Disabilities and Their Families

Physical activity counselling can target cognitive-affective participation barriers, but counselling benefits for children with medical conditions/disabilities were unknown. This study investigated successes, challenges, and the impact of physical activity counselling on children and their families. One-on-one semi-structured interviews were completed with 7 patients (2 male/5 female, aged 13-17) and 4 parents who participated in 2-8 weekly counselling sessions (2015-2020). Interviews were recorded and transcribed verbatim for inductive thematic analyses. Counselling encouraged positive mindset changes (viewing physical activity more holistically, making it "more fun and manageable", helping them to "learn how to love moving and doing sports"). Participants felt strong support (feeling heard, validated, and provided with "hope… that we can still achieve things… even though it may seem like there's limitations"). Counselling was viewed positively. The intent to improve active lifestyle attitudes and confidence was reflected in positive, primarily cognitive-affective (motivation for activity, "more general skills of having a positive attitude towards physical activity and the willingness to try new things") outcomes. More sessions, additional resources to keep, and follow-up after counselling completion were recommended to support behaviour change. Future research should evaluate enhanced counselling services and comparing children who have and have not received such counselling.

Incorporation of patient and family values and preferences for health-related outcomes in paediatric obesity management: A systematic review

OBJECTIVE

A systematic review of value and preference studies conducted in children and their caregivers related to the estimated benefits and harms of interventions for managing paediatric obesity.

METHODS

We searched Ovid Medline (1946-2022), Ovid Embase (1974-2022), EBSCO CINAHL (inception to 2022), Elsevier Scopus (inception to 2022), and ProQuest Dissertations & Theses (inception to 2022). Reports were eligible if they included: behavioural and psychological, pharmacological, or surgical interventions; participants between (or had a mean age within) 0-18 years old with overweight or obesity; systematic reviews, primary quantitative, qualitative, or mixed/multiple methods studies; and values and preferences as main study outcomes. At least two team members independently screened studies, abstracted data, and appraised study quality.

RESULTS

Our search yielded 11 010 reports; eight met the inclusion criteria. One study directly assessed values and preferences based on hypothetical pharmacological treatment for hyperphagia in individuals with Prader-Willi Syndrome. Although not having reported on values and preferences using our a priori definitions, the remaining seven qualitative studies (n = 6 surgical; n = 1 pharmacological) explored general beliefs, attitudes, and perceptions about surgical and pharmacological interventions. No studies pertained to behavioural and psychological interventions.

CONCLUSION

Future research is needed to elicit the values and preferences of children and caregivers using the best available estimates of the benefits and harms for pharmacological, surgical, and behavioural and psychological interventions.

A survey of stakeholders' perceived importance of health indicators and subgroup analyses to inform the Canadian clinical practice guideline for managing paediatric obesity

OBJECTIVE

To assess stakeholder ratings of health indicators and subgroup analyses in systematic reviews used to update the Canadian Clinical Practice Guideline for Managing Paediatric Obesity.

METHODS

Stakeholders (caregivers of children with obesity and Clinical Practice Guideline Steering Committee members) completed an online survey between April 2020 and March 2021. Participants rated importance of health indicators and subgroup analyses for behavioural and psychological, pharmacotherapeutic, and surgical interventions for managing paediatric obesity from not important to critically important using Grading, Recommendations, Assessment, Development and Evaluation criteria.

RESULTS

No health indicators or subgroup analyses were rated not important by the 30 caregivers and 17 Steering Committee members. Across intervention types, stakeholders rated anxiety, depression, health-related quality of life, serious adverse events, plus age and weight status subgroups as critically important.

CONCLUSION

Stakeholder ratings will inform data reporting and interpretation to update Canada's Clinical Practice Guideline for Managing Paediatric Obesity.

Risk Factors of Recurrent Stroke in Young and Middle-Aged Stroke Patients after Interventional Therapy

Objective

To explore the risk factors of recurrent stroke in young and middle-aged stroke patients after interventional therapy.

Methods

Retrospective analysis was conducted on the data of 300 young and middle-aged stroke patients treated in our hospital (February 2015–February 2017). All patients received interventional therapy. They were followed up continuously after the interventional therapy, with recurrent stroke as the only endpoint event, and those who did not have the endpoint events were followed up for 5 years. Then, the patients were divided into the occurrence group and the nonoccurrence group according to whether there was a stroke. The social demographic data and clinical examination data of all patients were collected to analyze the differences between the groups. Logistic regression analysis was performed on the factors with statistically significant differences to verify the factors affecting recurrent stroke in young and middle-aged stroke patients after interventional therapy.

Results

Among the 300 patients, 69 (23.0%) had recurrent stroke and 231 (77.0%) had no recurrent stroke. The occurrence group (n = 69) had 12 cases (17.4%) of massive cerebral infarction, 18 cases (26.1%) of cerebral watershed infarction, 5 cases (7.2%) of multiple cerebral infarction, 25 cases (36.2%) of lacunar infarction, and 9 cases (13.0%) of TIA. Notable differences were observed in age, drinking history, marital status, body weight, diastolic pressure, systolic pressure, fasting blood glucose, glycosylated hemoglobin, cholesterol, and fibrinogen between the occurrence group and the nonoccurrence group (P < 0.05). The binary logistic regression analysis showed that age, drinking history, diastolic pressure, fasting blood glucose, glycosylated hemoglobin, cholesterol, and fibrinogen were the influencing factors of recurrent stroke in young and middle-aged stroke patients after interventional therapy.

Conclusion

Blood glucose, blood lipid, blood pressure, age, and living habits have an impact on recurrent stroke in young and middle-aged patients after interventional therapy. Therefore, while strictly controlling blood glucose, blood lipid, and blood pressure, patients should improve their living habits and enhance the awareness of prevention after interventional therapy.