Cite this Chapter

Rueda-Clausen CF, Poddar M, Lear SA, Poirier P,

Assessment of People Sharma AM. Canadian Adult Obesity Clinical Practice
Guidelines: Assessment of People Living with Obesity.

Living with Obesity

Available from:
https://obesitycanada.ca/guidelines/assessment.
Accessed [date].
Christian F. Rueda-Clausen MD PhDi, Megha Poddar MDii, Scott
A. Lear PhDiii, Paul Poirier MD PhDiv, Arya M. Sharma MD PhDv Update History
Version 1, August 4, 2020. The Canadian Adult Obesity
i) Department of Medicine, University of Saskatchewan
Clinical Practice Guidelines are a living document,
ii) Department of Endocrinology and Metabolism, McMaster with only the latest chapters posted at
University obesitycanada.ca/guidelines.
iii) Faculty of Health Sciences, Simon Fraser University
iv) Quebec Heart and Lung Institute, Université Laval
v) Department of Medicine, University of Alberta

KEY MESSAGES FOR HEALTHCARE

PROVIDERS

• Obesity is a chronic, progressive and relapsing disease, • Providers participating in the assessment of obesity should
characterized by the presence of abnormal or excess adiposity focus on establishing values and goals of treatment, iden-
that impairs health and social wellbeing. tifying which resources and tools may be needed and fos-
tering self-efficacy with the patient in order to achieve
• Screening for obesity should be performed regularly by long-term success.
measuring body mass index (BMI) and waist circumference.
• A non-judgmental, stigma-free environment is necessary
• The clinical assessment of obesity should aim to establish for an effective assessment of a patient living with obesity.
the diagnosis and identify the causes and consequences of
abnormal or excess adiposity on a patient’s physical, mental
and functional health.

RECOMMENDATIONS

1. We suggest that healthcare providers involved in screening, barriers to treatment be included in the assessment (Level
assessing and managing people living with obesity use the 4, Grade D).13–15
5As framework to initiate the discussion by asking for their
permission and assessing their readiness to initiate treatment 4. We recommend blood pressure measurement in both arms,
(Level 4, Grade D, Consensus). fasting glucose or glycated hemoglobin and lipid profile to
determine cardiometabolic risk and, where appropriate,
2. Healthcare providers can measure height, weight and calculate ALT to screen for nonalcoholic fatty liver disease in people
body mass index (BMI) in all adults (Level 2a, Grade B),1–9 living with obesity (Level 3, Grade D).16,17
and measure waist circumference in individuals with a BMI
25–35 kg/m2 (Level 2b, Grade B).10–12 5. We suggest providers consider using the Edmonton Obesity
Staging System to determine the severity of obesity and to
3. We suggest a comprehensive history to identify root causes guide clinical decision making (Level 4, Grade D).18,19
of weight gain as well as complications of obesity and potential

Canadian Adult Obesity Clinical Practice Guidelines 1

 KEY MESSAGES FOR PEOPLE LIVING WITH
OBESITY

• Obesity is a chronic disease characterized by the accumu- your weight impacts your health and wellbeing. This may in-
lation of excess body fat that can have a negative impact clude both a mental health assessment and a physical exam.
on your physical and mental health, as well as your overall
quality of life. • Weight bias and stigma are common in clinical settings
and can be detrimental to helping you achieve your health
• To guide you and your clinician on the best obesity treatment goals. Healthcare providers should conduct their obesity
options, a clinical evaluation is needed to determine how assessment in a sensitive and non-judgmental way.

Introduction Many patients living with obesity have experienced some form
of weight bias in the primary care setting.30,31 This is due in part
Obesity is a chronic disease that requires a systematic and com- to professionals’ endorsement of negative attitudes and beliefs
prehensive diagnosis, assessment and treatment approach.20 The about obesity, misinformation about causality and perceptions
objective of an obesity assessment is to gather information to that patients with obesity may be unmotivated and non-compliant.
confirm the diagnosis, determine the severity of the disease and Many patients feel discriminated against and, as a result, will often
related comorbidities, identify triggers and drivers and to guide avoid seeking treatment and delay preventive care.32 This can affect
appropriate management discussions in a non-biased and stigma-free their health status, their relationship with professionals and their
clinical setting.21 Providers should initiate a discussion with the patient response to interventions.33
about their values and goals for treatment, facilitate reflection
and encourage accountability and self-directed management to We recommend that healthcare providers approach patients with
promote long-term improvements in health.15 empathy and sensitivity. In addition, it’s important to acknowl-
edge the complexity of the disease and the difficulty in sustaining
This chapter provides an evidence-based approach to assessing behavioural change as well as avoid stereotypes and oversimplifi-
obesity in the primary care setting through a structured history, cation of the disease.34 A supportive environment with appropri-
physical exam and clinically appropriate laboratory testing. The ate equipment (for example, appropriately sized blood pressure
authors also discuss clinical tools that allow for easy and efficient cuffs and gowns, armless chairs in waiting rooms, a private room
use in routine clinical practice. for weigh-ins) and asking for permission to weigh patients can
help foster patient comfort and dignity. Stigmatization of patients
leads to worsened outcomes and promotes disordered eating, in-
Definition of obesity creased rates of depression and lower rates of physical activity.35
This is reviewed in detail in the chapter Reducing Weight Bias in
Obesity is a complex chronic disease in which abnormal or excess Obesity Management, Practice and Policy.
body fat (adiposity) impairs health, increases the risk of long-term
medical complications and reduces lifespan.22–24 Obesity has tra- The use of structured interview formats (such as Obesity Canada’s
ditionally been viewed as a risk factor for a wide range of other 5As of Obesity ManagementTM) has been proposed to help facili-
health issues. The Canadian Medical Association,20 however, now tate discussions about obesity in primary care.36,37 An adaptation
considers obesity to be a chronic disease in its own right, similar to of the 5As’ template has been developed by Obesity Canada for
type 2 diabetes, hypertension and dyslipidemia (in line with other use in clinical practice. The main components of this framework
organizations including Obesity Canada, the American Medical include:
Association,25 the World Health Organization,24 the World Obesity
Federation and others).25–27 1. ASKING for permission to discuss weight and explore readiness;

2. ASSESSING obesity-related risks and root causes of obesity;

Initiating a discussion about obesity
management 3. ADVISING on health risks and treatment options;

Primary care providers play an important role in the management 4. AGREEING on health outcomes and behavioural goals; and
of most chronic diseases. However, due to the multitude of demands
in primary care and lack of comfort and training, the assessment and 5. ASSISTING in accessing appropriate resources and providers. 38,39
management of obesity is not easily undertaken. The initial ap-
proach, communication and attitude of the physician during an Finally, when conducting an obesity assessment and in order to
obesity assessment is a significant determinant to the patient’s achieve long-term success, it is important to assess each patient’s
success.28,29 readiness to change, intrinsic motivation and value and goals

Canadian Adult Obesity Clinical Practice Guidelines 2

when initiating a treatment plan.40 Personalizing the approach, may identify the higher-risk phenotype of obesity better than
recognizing patients’ strengths and reframing misconceptions either BMI or WC alone, particularly in those individuals with lower
about obesity are important key processes that can have a posi- BMI.58–60
tive impact on the patient’s ability to make long-term changes.15,24
These concepts are reviewed in detail in the Effective Psychological Regular assessment of BMI, WC and cardiometabolic risk factors
and Behavioural Interventions in Obesity Management chapter. can help identify people at greater risk of developing obesity. Regular
assessment should also inform care and allow for increased vigilance
avoiding obesogenic medications (see Table 8) and counselling on
Screening for obesity the avoidance of weight gain during high-risk time periods, such as
pregnancy or forced sedentariness due to injury (see Prevention and
Prior to initiating screening or assessment for obesity, it is important Harm Reduction of Obesity [Clinical Prevention]).
to ask patients’ permission to discuss the topic and/or to conduct
anthropometric measurements. Evaluation of anthropometric pa-
rameters is recommended as a practical screening tool to iden-
tify patients with increased adiposity in whom more intensive Box 1: Measuring Body Mass Index
assessments may be indicated.41 Moreover, performing regular
anthropometric screening can identify patients at risk of develop- • All anthropometric measurements should be conducted
ing obesity in whom awareness of their risk and implementation barefoot and in light clothing.
of preventive measures can have a significant positive long-term
effect on their health.42,43 Many anthropometric parameters have • Weight and height should be measured by trained
been recommended in the screening and assessment of obesity; professionals using standardized techniques and equip-
however, a calculated body mass index (BMI) and measured waist ment and recorded to the nearest 0.1 kg and 1 cm.
circumference (WC)44 are the most widely used.
• BMI should be calculated as weight (kg) divided by
Traditionally, BMI (weight [kg]/height2 [m]) has been used as a sur- the square of the body height in metres (kg/m2).
rogate measure of body fat, and thus an objective parameter to
define obesity, both in epidemiological and clinical studies.12,45–48
Large epidemiological studies have shown that Asian populations
may have increased adiposity and cardiometabolic risk at a lower
BMI, and alternative cut-off points have been proposed for this Table 1: Recommended Classification
patient population.49–54 Widely accepted classification of obesity of BMI45,53
based on specific BMI cut-offs are presented in Table 1.

For most populations, the presence of overweight (BMI ≥ 25 kg/m2) Category BMI (kg/m2)
represents an increased risk and requires further evaluation of other Caucasian, Europid and North American ethnicity45
anthropometric, hemodynamic and biochemical parameters.4,55 A
BMI ≥ 30 kg/m2 is associated with an increase in cardiovascular risk Underweight < 18.5
factors and all-cause mortality and should be used as a screening Normal (healthy weight) 18.5–24.9
criterion to identify obesity in the general population.4,5 In adults
Overweight 25–29.9
with South-, Southeast- or East Asian ethnicity, the recommended
BMI cut-off for overweight should be ≥ 23 kg/m2. In special popu- Obesity Class I 30–34.9
lations such as the elderly, very muscular patients and those with Obesity Class 2 35–39.9
extreme tall or short stature, the BMI can be misleading and needs to
be interpreted with caution.9 Obesity Class 3 40–49.9
Obesity Class 4 50–59.9
Health Canada recommends the diagnosis of obesity not be based
Obesity Class 5 ≥ 60
on BMI alone.56 Nevertheless, given its simplicity, objectivity and
reproducibility, BMI continues to be an important measure in epi-
demiological and population-based surveillance studies. In a clinical South-, Southeast- or East Asian ethnicity53
setting, BMI at the recommended cut-offs should serve only as a Underweight < 18.5
simple screening measure. When used together with other clinical
indicators, such as WC and clinical evaluation of cardiometabolic and Normal range 18.5–22.9
other obesity-related complications, BMI can help identify individ- Overweight—At risk 23–24.9
uals who may benefit from obesity management. WC has been
Overweight—Moderate risk 25–29.9
independently associated to increase cardiovascular risk; however,
it is not a good predictor of visceral adipose tissue on an individual Overweight—Severe risk ≥ 30
basis.57 Integration of both BMI and WC in clinical assessment

Canadian Adult Obesity Clinical Practice Guidelines 3

Although BMI is a simple, objective and reproducible measure,
it has certain limitations that need to be recognized by clinicians Box 2: Measuring Waist Circumference
using these tools.36,37

• BMI is not a direct measure of body fat, cardiovascular risk or 1. Remove clothing from the waistline.
health.
2. Stand with feet shoulder width apart (25 to 30 cm or 10
• BMI does not indicate body fat distribution. to 12 inches) and a straight back.

• BMI does not account for muscle mass (it overestimates body 3. Palpate the abdomen to locate inferior margin of the
fat in muscular individuals). last rib at the level of the mid-axillary line.

• BMI can underestimate body fat in people who have lost muscle 4. Palpate and identify the crest of the ileum in both sides.
mass (sarcopenic obesity). Use the area between the thumb and index finger to
feel for the hip bone at the level of the mid-axillary line.
• BMI does not distinguish between men, women or ethnicity. This is the part of the hip bone at the side of the waist,
not at the front of the body.
• BMI is less accurate in certain populations (e.g., the elderly, people
with physical disability, people <18 years of age, people with 5. WC should be measured at the end of a normal expi-
severe obesity, during pregnancy and in patients with ascites or ration, midway between the inferior margin of the last
severe edema). rib and the crest of the ileum in a horizontal plane using
a stretch-resistant tape that provides a constant 100 g
• BMI over- or underestimates body fat in certain ethnic groups, tension and should be recorded to the nearest 1 cm.
such as Indigenous Peoples, South Asians, Chinese and other
populations. 6. Have the patient take two normal breaths, and on the
exhale of the second breath tighten the tape measure so
it is snug but not digging into the skin.
Waist circumference

Considering the limitation of BMI in determining fat composition and

distribution as well as the anatomical variations in fat deposition, • Varying cut-offs for ethnic populations.
the use of WC has been recommended as a surrogate measure of
abdominal or visceral fat.61 There is epidemiological evidence to • Less sensitive measure of visceral fat with increasing BMI.
suggest that WC can help identify individuals at increased risk for
cardiometabolic disease.57,62,63 A standardized method for accu- • WC requires further body exposure and can be perceived as an
rately measuring WC is outlined in Box 2. Current recommended intrusive measurement by some patients.
WC cut-offs are included in Table 2.
As with BMI, WC can be used as a simple and practical screening
In the United States and Canada, a WC ≥ 102 cm (in men) or ≥ tool to identify individuals at higher risk of cardiometabolic disease.
88 cm (in women) indicates an increased risk of visceral adiposity This may be particularly true for individuals who fall below the
and of developing cardiometabolic comorbidities. For adults with accepted BMI cut-offs for obesity. A variety of optimal cut-off values
a predominant South Asian, Southeast Asian or East Asian ethnicity, have been proposed, depending on ethnicity, measuring tech-
a lower cut-off for WC (≥ 85 cm in men and ≥ 75 cm in women) nique and outcomes of interest. Most cut-offs range from 65.5 to
is recommended. 101.2 cm for women and 72.5 to 103 cm for men.63–66 Patients
with an increased BMI (< 35 kg/m2) and an elevated WC are
Despite its low-tech appeal and significant statistical association associated with an increased risk of developing cardiometabolic
with cardiometabolic risk, there are important limitations to the risk factors, such as diabetes mellitus type 2 and hypertension.67
routine use of WC measurement in the clinical setting: Those with a BMI > 35 kg/m2 are likely to be at an increased risk
of cardiometabolic risk factors irrespective of their WC.
• WC is not a direct measure of visceral fat.

• Considerable training and standardization are required to ensure Integration of anthropometric measurements
inter- and intra-reader reproducibility.
Both BMI and WC provide valuable and complementary information
• WC is sensitive to abdominal distention due to food or fluid in the assessment of obesity and the estimation of cardiometabolic
intake, bloating, ascites, pregnancy, etc. risk. Among individuals with an elevated BMI (< 35 kg/m2), having
an increased WC may imply a greater risk of developing significant

Canadian Adult Obesity Clinical Practice Guidelines 4

 Table 2: Proposed Waist Circumference Cut-Off Points (cm) to Define Increased Abdominal
Adiposity by Predominant Ethnicity

Predominant Ethnicity Increased Abdominal Adiposity/ Significant Abdominal Adiposity/

Cardiovascular Risk Greater Cardiovascular Risk

Women Men Women Men

Caucasian Europid/United States/

Mid-East Mediterranean68 80 94 88 102

Latino Central/South American69 83 88 90 94

Sub-Saharan African68 80 94

African American 90 80 99 95

African 71.5 76.5 81.5 80.5

Asian 80 85

Chinese70 81 83

Korean71 75 80 85 90

Canadian Aboriginal72 80 94

cardiometabolic outcomes. Furthermore, among patients with a circumference.74,75 Despite the absence of concurrent cardiometa-
normal BMI, an increase in WC may imply intra-abdominal fat bolic risk factors, the so-called metabolically healthy patients with
deposition and an increased risk of cardiometabolic disease.73 obesity should not be considered to be fully medically healthy, as
These patients may benefit from early intervention to treat and these patients are at increased risk of mortality,75 and are more
prevent obesity-related complications. Finally, measuring WC in likely to suffer other non-metabolic conditions associated with
patients with a BMI > 35 kg/m2 may not change management, obesity, such as sleep apnea, depression and joint/back pain,
but it can provide patients with valuable information regarding among others. Information gathered in the obesity assessment and
the efficacy of their treatment during their long-term follow-up. analyzed using the Edmonton Obesity Staging System (EOSS) 18,19
Some patients can see changes in adipose distribution before a can help to understand the severity of the disease and guide the
significant change in body weight or BMI. intensity of treatment required.

Assessing the impact of excess or abnormal Edmonton Obesity Staging System

adiposity on health
Elements of the EOSS have been proposed to guide clinical decisions
The association between the diagnosis of obesity and the devel- from the obesity assessment and at each BMI category.19 Table 3
opment of obesity-related complications is strong but not always reviews the proposed clinical staging and its impact on manage-
linear; therefore, comparable levels of excess adiposity obesity can ment. EOSS is a measure of the mental, metabolic and physical
have different levels of impact on health and quality of life for impact that obesity has had on the patients’ health and uses these
different patients. Similarly, multiple reports have documented a factors to determine their stage of obesity (from stage 0–4). In
subgroup of “metabolically healthy” patients with obesity, char- population studies, EOSS has been shown to be a better predictor
acterized by the absence of any objective evidence of increased of all-cause mortality when compared to BMI or waist circumference
cardiometabolic risk despite having an elevated BMI and waist measurements alone.40

Canadian Adult Obesity Clinical Practice Guidelines 5

 Table 3: Edmonton Obesity Staging System

Stage Description Management

0 No apparent obesity-related risk factors (e.g., Identification of factors contributing to increased

blood pressure, serum lipids, fasting glucose, etc. body weight
within normal range), no physical symptoms, no
psychopathology, no functional limitations and/ Counselling to prevent further weight gain
or impairment of wellbeing through behavioural measures, including healthy
eating and increased physical activity

1 Presence of obesity-related subclinical risk factors Investigation for other (non-weight-related) risk
(e.g., borderline hypertension, impaired fasting factors
glucose, elevated liver enzymes, etc.), mild physical
symptoms (e.g., dyspnea on moderate exertion, More intense behavioural interventions, including
occasional aches and pains, fatigue, etc.), mild nutrition therapy, exercise and psychological
psychopathology, mild functional limitations treatments to prevent further weight gain
and/or mild impairment of wellbeing
Monitoring of risk factors and health status

2 Presence of established obesity-related chronic Initiation of obesity treatment, including

disease (e.g., hypertension, type 2 diabetes, considerations of all psychological interventions,
sleep apnea, osteoarthritis, reflux disease, poly- pharmacological and surgical treatment options
cystic ovary syndrome, anxiety disorder, etc.),
moderate limitations in activities of daily living Close monitoring and management of comorbidities
and/or wellbeing as indicated

3 Established end-organ damage such as myocardial More intensive obesity treatment including
infarction, heart failure, diabetic complications, consideration of all psychological interventions,
incapacitating osteoarthritis, significant psycho- pharmacological and surgical treatment options
pathology, significant functional limitations and/
or impairment of wellbeing Aggressive management of comorbidities as
indicated

4 Severe (potentially end-stage) disabilities from Aggressive obesity management as deemed

obesity-related chronic diseases, severe disabling feasible
psychopathology, severe functional limitations
and/or severe impairment of wellbeing Palliative measures including pain management,
occupational therapy and psychosocial support

Adapted from: Sharma AM, Kushner RF. A proposed clinical staging system for obesity. Int J Obes. 2009;33(3):289–295.19

Once the diagnosis has been established, the primary goal for the (Mental health, Mechanical, Metabolic, Monetary health / Milieu)
clinical assessment for obesity should be to identify the possible can provide a practical approach for primary care physicians to
causes leading to weight gain, determine the extent to which explore major drivers, barriers and complications of obesity (see
weight has affected the patients’ health and to systematically look Table 4).77 It can be used to provide a structure to perform an
for barriers in their management.76 Given that obesity is a complex efficient and complete obesity assessment, including the history,
and heterogeneous disease, this is often a daunting task for prima- physical exam and clinically indicated investigations.
ry care providers. Using a clinical tool such as the 4Ms framework

Canadian Adult Obesity Clinical Practice Guidelines 6

 Table 4: Components of the 4Ms Framework for
Assessment of Obesity77

Category Complications Frequency Investigations Treatment Notes

Mental Knowledge/cognition ++*

Health
Expectations ++*

Self-image + + * (F>M)

Internalized weight bias +++ This can be accomplished through sensitive Unresolved perception of weight bias
questioning/dialogue/motivational inter- can have an influence on obesity
viewing (e.g., “Can you share with me management.
if or how your weight affects your per-
ception of yourself?”) or by questionnaire Coping strategies to address internalized
(WBIS). See the chapter Reducing Weight weight bias should be incorporated into
Bias in Obesity Management, Practice behavioural interventions, consistent with
and Policy for details. the principles of cognitive behavioural
therapy and acceptance and commitment
therapy.

Mood/anxiety + + * (F>M) PHQ-9, GAD If starting pharmacotherapy, consider options

that do not increase weight (see the chapter
Prevention and Harm Reduction of Obesity
(Clinical Prevention)

Addiction ++* Yale Food Addiction Scale

Sleep ++*

Attention ++*

Personality ++*

Mechanical Osteoarthritis ++ History, X-ray

Gout +++ Uric acid level Avoid steroids if possible

Sleep apnea +++ STOP BANG sleep apnea questionnaire, CPAP therapy if indicated
Berlin Questionnaire, overnight sleep study

Plantar fasciitis ++*

Gastroesophageal reflux ++

Urinary incontinence ++*

Intertrigo ++*

Idiopathic intracranial +
hypertension
(Pseudotumour Cerebri)

Thrombosis +

Metabolic Type 2 diabetes +++ A1C, fasting glucose Consider medication options that are
weight neutral, promote weight loss

Hyperlipidemia +++ Total cholesterol, triglycerides, HDL-C

Nutritional deficiency +++ 25 hydroxy-vitamin D, iron studies, Vitamin D 1000-3000 units/day,

serum B12 level supplement as needed to achieve
therapeutic levels

Gout +++ Uric acid Avoid prednisone if possible

Hypertension ++ Ensure appropriate cuff size (bladder DASH diet, consider secondary causes
width 40% of arm circumference, length (e.g., sleep apnea, pain)
80–100% of arm circumference)54
Prioritize medications that affect the
renin-angiotensin system, avoid beta
blockers as first line

Canadian Adult Obesity Clinical Practice Guidelines 7

 Endocrine

PCOS/hypogonadism +

Infertility + Total testosterone, estradiol, prolactin, 17 Consider metformin if insulin resistant

hydroxyprogesterone, LH/FSH, DHEAS,
TSH if clinical suspicion of hypothyroidism

Cardiovascular disease ++ ECG, ECHO, treadmill/bicycle/nuclear

stress test if indicated and if patient able
Left ventricular hypertro-
phy, atrial fibrillation

Chronic venous stasis/

ulcers/thrombophlebitis

Stroke, DVT/PE

Neurological

Pseudotumor cerebri + Hx: Headache, pulsatile tinnitus,

papilledema

Gastrointestinal disease

Fatty liver ++/+++

Gallstones +++ Liver enzyme elevation, increased liver

stiffness (elastography) abdominal
ultrasound, FIB-4 score

Oncology + Routine cancer screening Patients with obesity are at high risk for
certain cancers and are less likely to be
Colorectal, gallbladder, screened due to technical issues with
pancreatic, breast, renal, diagnostic testing and delays in seeking
uterine, cervical, prostate medical attention.

Skin

Acanthosis, skin tags +++

Candida ++*

Intertrigo +*

Tinea +*

Folliculitis +*

Monetary Socioeconomic status +

Health/
”Milieu” Education

Access to food

Occupation

Disability

Clothing

Weight loss programs

Access to pharmacotherapy

Surgery

Vitamins

+ RR 1–2 (rare) but increased risk with obesity

++ RR 2–3 (uncommon) screen if appropriate

+++ RR >3 (common) screen most patients

PHQ-9: Patient Health Questionnaire-9; GAD: generalized anxiety disorder; CPAP: continuous positive airway pressure; PCOS: polycystic ovarian syndrome; LH/FSH:
luteinizing hormone/follicle stimulating hormone; DHEAS: dehydroepiandrosterone; TSH: thyroid stimulating hormone; ECG: electrocardiogram; ECHO: echocardiogram;
DVT/PE: deep venous thrombosis/pulmonary embolism; FIB-4 : Fibrosis-4, F: Female; M: Male; RR: Relative Risk; *Depending on patient population.

Canadian Adult Obesity Clinical Practice Guidelines 8

Components of an obesity-centred history for all patients with obesity. The specific evaluations performed
should be based on the presenting symptoms, the patient’s risk
An obesity-centred history should include all parts of a routine factors and index of suspicion. Table 7 reviews some blood and di-
clinical interview, such as past medical and surgical history, med- agnostic testing for clinicians to consider when assessing a patient
ications, allergies and social and family history. However, an em- with obesity. Screening for metabolic syndrome with a HbA1c or
phasis should be placed on screening for underlying root causes fasting blood sugar, total cholesterol, serum triglycerides and HDL
and consequences of obesity (reviewed in Table 4). Key elements level is recommended in most patients.80 Patients who are at high
of the history include screening for sleep disorders; physical, sexual risk of fatty liver disease, including those with type 2 diabetes or
and psychological abuse; description of eating patterns; physical ac- metabolic syndrome, should be screened with an ALT level and an
tivity and screen time; internalized weight bias; mood and anxiety abdominal ultrasound. A referral to gastroenterology/hepatology
disorders; as well as substance abuse and addiction.13,14 A thor- may be appropriate in patients with persistently elevated liver enzymes
ough history of medications should screen for weight-promoting (greater than two times the upper limit of normal over six months
medications. Consider alternative options where possible. The most and/or high FIB-4 scores). The gold standard to diagnose non-alcoholic
common weight-promoting medications are outlined in Table 8. The fatty liver disease is a liver biopsy.81
clinician conducting the assessment should also identify and doc-
ument the patient’s values and goals around treatment and fos-
ter insight to help with long-term coping and self-management Evaluation of coronary artery disease
skills.15,24 Table 5 reviews some key components which are specific
to an obesity-focused interview. Key processes of a personalized Large prospective studies have documented obesity as being an
obesity assessment in primary care are highlighted in Table 5; independent predictor of coronary artery disease.82 This relationship
these have been shown to have a positive impact on the patient’s’ was stronger in younger individuals. Susceptibility to obesity-re-
ability to foster everyday change and facilitate improvements in lated cardiovascular complications is not only mediated by overall
their physical, mental and social health.15,24 body fat mass, but is largely dependent upon individual differences
in regional body fat distribution.73,83 Large cohort studies using im-
aging techniques have identified excess abdominal visceral adipose
Components of an obesity-centred physical tissue as a strong predictor in the development of cardiovascular
exam disease over time, independently of total body fat mass.84 Numerous
non-invasive tests can diagnose atherosclerosis or myocardial isch-
An obesity-centred physical exam should be focused on determining emia, or both. The correct choice depends on local expertise, the
the obesity phenotype, drivers of weight gain and treatment bar- relative strengths and weaknesses of each modality and individual
riers for all patients. The key components of an obesity-centred patient characteristics, as well as pretest likelihood of coronary
physical exam are outlined in Table 6. Routine anthropometric artery disease.
measurements should include height, weight, BMI and waist cir-
cumference. Blood pressure should be measured with an appro-
priately sized cuff according to the patient’s arm circumference. If Electrocardiogram
a large upper arm size is prohibitive, systolic blood pressure can be
measured in the forearm selecting the cuff size (small cuff [20.0– Obesity has the potential to impact the ECG in several ways, in-
26.0 cm], standard cuff [25.4–40.6 and 25.0–34.0 cm] and large cluding displacement of the heart by elevating the diaphragm
cuff [> 32.0 cm]) according to participant’s forearm circumfer- in the supine position, increasing the cardiac workload and in-
ence. For cuff installation in the forearm, position the distal edge creasing the distance between the heart and the recording elec-
of the cuff about 6 cm proximal to the styloid process of the ulna.78,79 trodes. Besides low QRS voltage and left-ward trend in the axis,
Neck circumference and airway patency are also helpful to estimate other alterations frequently seen are non-specific flattening of the
the risk of sleep apnea. In addition to a routine cardiorespiratory, a T-waves in the infero-lateral leads (attributed to the horizontal dis-
head, neck and gastrointestinal exam should be performed along placement of the heart) and voltage criteria for left atrial abnor-
with a general skin examination to rule out common skin findings mality. An increased incidence of false positive criteria for inferior
(see Table 6). A joint and gait examination is also recommended to myocardial infarction in individuals living with obesity, due to the
assess for barriers in mobility. A cursory endocrine exam includes elevation of the diaphragm has been reported.85 Left ventricular
palpating for an enlarged thyroid gland and screening for signs of hypertrophy is probably underdiagnosed based on the usual ECG
Cushing syndrome and polycystic ovarian syndrome. These signs, criteria in individuals with greater than Class II obesity. Since base-
if present, should prompt further biochemical screening. line ECG may be influenced by obesity (false positive for inferior
myocardial infarction, microvoltage, non-specific ST-T changes)
and patients with obesity may have impaired maximal exercise
Investigations to assess obesity testing capacity (dyspnea, mechanical limitations, left ventricular
diastolic dysfunction), other modalities may be of interest in the
Diagnostic testing is commonly ordered during the initial assess- evaluation of coronary artery disease in this population. Indeed,
ment of obesity to identify metabolic problems and to tailor therapy. due to impaired exercise tolerance because of mechanical and
There is no single blood test or diagnostic evaluation that is indicated physiological limitations related to stress testing in patients at very

Canadian Adult Obesity Clinical Practice Guidelines 9

 Table 5: Recommended Key Components of an Obesity-Centred Medical History

Interview Implication/Significance /Recommended

Details
Component Actions

Weight history Document age of onset of obesity and major weight trajectories Can help to understand patients weight journey, success/failures
over time of past attempts and causes of weight gain/loss in the past,
childhood vs. adult obesity
Previous weight loss attempts and response to interventions
(including behavioural interventions, medications, endoscopic Can help to establish realistic expectations
and surgical interventions)
Can help to prevent future weight gain and target behavioural
Highest and lowest weight and psychological treatment

Can help to make appropriate goals (e.g., weight stabilization

Major life event(s) associated with weight change if currently gaining weight)

Current phase of weight (e.g., gaining, losing, stable) Key Processes15,24

• Show compassion
• Real listening (paraphrase and summarize to ensure you
understand and validate the patient’s thoughts)
• Help patients make sense of their story (find root causes,
foster insight, find patterns/triggers, identify values/goals,
reflect on timeline to acknowledge impact on life in context
to weight)

Nutrition history Assess nutrition literacy Is there concern of physiological hunger, emotional eating,
mindless eating, knowledge deficit?86
Assess energy intake
See the chapter Medical Nutrition Therapy in Obesity Management
Identify current nutritional restrictions (Celiac disease, allergies) for details

Physical activity Current physical activity including time spent in sedentary Help patient to make self-directed activity goals
activities
Address limitations independently (e.g., pain management for
Limitations to activity (e.g., pain, time, motivation) joint pain, etc.)

Identify social limiting factor restricting access to increasing See the chapter Physical Activity in Obesity Management
physical activity
Key Processes15,24
• Recognize strengths
• Shift beliefs
• Reframe misconceptions
• Help establish whole-person value goals and functional
outcomes instead of weight-based goals

Depression and Screen for depression and anxiety Consider referral to psychiatry/psychology
anxiety screening

Other mental health Screen for attention deficit hyperactivity disorder, post-traumatic Consider referral to psychiatry/psychology
issues/drivers stress disorder, chronic grief
Review challenges with body image, self-esteem
Psychological impact of previous weight journey

Addiction/ Smoking status Consider referral to psychiatry/psychology

dependency
Alcohol intake

Use of cannabinoids and other psychoactive substances

Current or previous abuse of substance

Excessive use of caffeine-containing beverages (e.g., sugar

sweetened beverages)

Canadian Adult Obesity Clinical Practice Guidelines 10

 Abuse Screen for previous and current forms of physical, psychological Unresolved history of abuse and current abuse can be a barrier
and sexual abuse to obesity management and can have an impact on food
behaviours and relationship with food

Interdisciplinary approach may be required

Sleep history Number of hours of sleep per night Poor sleep quality and quantity can be a barrier to obesity
management.87
Use of pharmacologic sleeping aids
If positive screening (STOP BANG > 4), consider referral to rule
Sleep apnea-hypopnea screening (such as STOP BANG Sleep out sleep apnea
Apnea Questionnaire)

Medication history Review medications that can have a significant impact on See Table 8
weight.88
Key processes15,24
• Make sense of the story
• Help establish root causes

Social history Age, sex, ethnicity, marital status, Eating behaviours in shift workers may require additional
occupation/work schedule: number of hours per week, night consideration when deciding therapeutic options
shift work

Income support, medical coverage, access to exercise facilities Evaluate patients’ access to food options, nutritional educa-
tion, cooking skills

Consider involving a social worker/counsellor in cases where

income, medication coverage and resource access may be
limited

Level of functional independence In patients with decreased independence, consider involving

caregivers and decision makers

Family history History of first-degree relative with overweight/obesity or related Can help determine patients’ risk of obesity or related
complications complications

Overweight and obesity in other household members Group interventions are more challenging but more likely to be
feasible and sustainable in patients exposed to environments
where obesity is highly prevalent

Interpersonal Motivation See the chapter Effective Psychological and Behavioural

assessment Interventions in Obesity Management
Confidence
Key Processes15,24
Readiness to change • Recognize strengths
• Shift beliefs (help manage expectations, focus on the whole
Expectations health of the patient)
• Co-construct a new story (context integration, prioritizing
goals)
• Orient values and plan actions (help establish direction)
• Foster reflection (insight, motivation, accountability)
• Help internalize core messages (help establish coping skills)

Canadian Adult Obesity Clinical Practice Guidelines 11

 Table 6: Key Components of an Obesity-Centred Physical Exam

Vital signs: blood pressure (appropriately sized cuff), heart rate

Anthropometric measurement: weight, height, waist circumference, BMI

Head and neck

• Neck circumference, Mallampati score
• Thyroid exam
• Cushing’s (moon facies, prominent supraclavicular and dorsocervical fat pad)
• Polycystic ovary syndrome (acanthosis nigricans, hirsutism, acne)

Cardiorespiratory
• Heart rate and rhythm
• Signs of heart failure (added heart sounds, pedal edema, pulmonary rales)

Gastrointestinal
• Liver span
• Umbilical, incisional hernias
• Screening for stigmata of chronic liver disease (encephalopathy, ascites, jaundice, palmar erythema, etc.)

Musculoskeletal
• Osteoarthritis (Heberden’s/Bouchard’s nodes, weight-bearing joints)
• Gout
• Gait exam

Skin
• Candida, intertrigo, tinea, skin tags, psoriasis, acanthosis nigricans
• Nutritional deficiencies (pallor of conjunctiva, palmar crease rubor, atrophic glossitis, neuropathy)89
• Abdominal striae (violaceous striae wider than 1 cm)

Lower limbs
• Lymphedema (non-painful, pitting edema, typically arms/legs)
• Lipedema (often painful fat deposition, non-pitting edema, typically in arms and legs with sparing of the hands and feet)
• Venous insufficiency, ulcers, stasis, thrombophlebitis

high BMIs, a perfusion scan may be used instead of exercise testing experience mobility, joint and balance issues limiting their ability
for evaluating the presence of ischemic heart disease. to use a treadmill. In these patients, the use of a bike ergometer is
recommended. Higher systolic and diastolic blood pressures are typ-
ically found during the exercise stress test in patients with obesity.93
Exercise stress test

Standard stress test performance is limited in patients with obesity Nuclear imaging techniques
for a number of factors. ECG modification might limit accurate in-
terpretation. Aerobic capacity is diminished because of pulmonary Technetium sestamibi is the marker of choice in patients with obesity
dysfunction, orthopaedic limitations and left ventricular diastolic because of greater energy emission, which generates better im-
dysfunction. Many patients with obesity fail to achieve 80–85% ages.94–96 Weight-based limitations might occur in patients with a
of the age-predicted heart rate needed for diagnostically valid re- body weight above 350 pounds (~160 kg), which might require
sults.90,91 Standard Bruce and modified ramp protocols achieve valid planar imaging. Newer and more sensitive cameras might eliminate
results in most patients, with patients terminating the test because some of these issues, but their use still leads to challenges with
of fatigue, leg pain or dyspnea.92 Patients with obesity may also table weight and size, given that proper positioning of the patient

Canadian Adult Obesity Clinical Practice Guidelines 12

is required in order to use this system. Positron emission tomogra- including thyroid dysfunction, Cushing’s or acromegaly are not
phy (PET) computed tomography rubidium has a 91% sensibility routinely recommended unless clinically warranted. We encourage
and 89% specificity; is faster than sestamibi-SPECT; produces less age-appropriate cancer screening for patients with obesity as they
radiation exposure, better quality images and correction for at- are at an increased risk and often have poor outcomes due to lower
tenuation; and has a greater degree of diagnostic precision and rates of routine screening and delays in seeking treatment.
a reduced need for invasive examinations.97 The PET rubidium is
the nuclear imaging technique of choice for patients with obesity.
Can you have a high BMI and be healthy?

Stress echocardiography As with most health indicators (e.g., blood pressure, blood glu-
cose, cholesterol), there exists a curvilinear relationship between
Despite some limitations, exercise stress echocardiography is a valid the amount of body fat and its impact on health. In epidemiolog-
technique for patients with obesity.98 The feasibility of stress echo, us- ical studies the relationship between body fat (or BMI as a surro-
ing either physiological stress (treadmill exercise) or pharmacological gate) and health impacts follows a U-shaped curve with health
stress (dobutamine) is excellent in most cases. It is widely available, risks progressively increasing at both the lower and higher ends of
low cost, radiation free and has no weight limits. Stress echocardiog- the BMI spectrum.100 While there is a statistically significant rela-
raphy is highly operator-dependent and can be limited in the pres- tionship between increasing BMI and health risks, a given individ-
ence of poor acoustic windows related to pulmonary disease, obesity ual can present with virtually no relevant health issues over a wide
and respiratory motion. If severe limitations exist, transesophageal range of BMI levels.101,102 Although individuals with an elevated
echocardiography with dobutamine might be useful.99 BMI who appear healthy may have a modestly elevated health
risk (and a high likelihood of developing complications in the
long term),103 there is currently no evidence to support long-term
Evaluation of other conditions associated with benefits of intentional weight loss in these individuals. A prudent
obesity approach to individuals presenting with an elevated BMI without
the presence of overt impairment to health, would be to reinforce
Women with obesity and symptoms of polycystic ovary syndrome health behaviours aimed at preventing further weight gain and
should be screened for LH, FSH, total testosterone, DHEAS, prolactin, reducing the development of relevant complications.
TSH and 17 hydroxyprogesterone levels. Other endocrinopathies,

Table 7: Laboratory and Diagnostic Tests to Consider in the Assessment of Patients with Obesity

Consider for most patients

• HbA1c
• Electrolytes renal function tests (creatinine, eGFR)
• Total cholesterol, HDL- and LDL-cholesterol, triglycerides
• Alanine aminotransferase (ALT)
• Age-appropriate cancer screening

Consider only if clinically indicated

• Complete (full) blood count
• Thyroid stimulating hormone/thyroid function tests
• Uric acid
• Assessment of iron (TIBC, % saturation, serum ferritin, serum iron)
• Vitamins B12 and D levels
• Urinalysis
• Urine for micro-proteinuria

Women with obesity and symptoms of polycystic ovary syndrome

• LH, FSH, total testosterone, DHEAS, prolactin and 17 hydroxyprogesterone levels

LH: luteinizing hormone; FSH: follicle stimulating hormone; DHEAS: dehydroepiandrosterone; TIBC: total iron binding capacity.

Canadian Adult Obesity Clinical Practice Guidelines 13

 Table 8: Summary of Weight-Promoting Medications and Alternate Therapies

Category Class Name Weight gain Alternative therapy

Antihyperglycemics Insulins Insulin hh Biguanide (metformin)

DPP4i (alogliptin, linagliptin, sitagliptin,
Thiazolidinedione Pioglitazone hh saxagliptin)
GLP1 analogs (exenatide, liraglutide, dulaglutide,
semaglutide)
Sulfonylureas Glipizide h AGI (acarbose, miglitol)
SGLT2 inhibitors (canagliflozin, dapagliflozin,
empagliflozin)
Glyburide hh Pioglitazone/metformin*
Glipizide/metformin*
Glimepiride hh Glyburide/metformin*

Chlorpropamide hh
Tolbutamide hh
Gliclazide hh

Meglitinides Repaglinide h

Antidepressants Tricyclics Amitriptyline hhh Bupropion

Doxepin hhh Nefazodone
Imipramine hh Duloxetine
Nortriptyline hh Venlafaxine
Atypical Mirtazapine hh Desvenlafaxine
Trazodone
MAOIs Phenelzine hhh Levomilnacipran
Tranylcypromine hhh Vilazodone
Vortioxetine
Selegiline (topical MAOIs)
Selective Sertraline h
Serotonin Paroxetine hh
Reuptake Citalopram hhh Fluvoxamine (variable weight effect)
Inhibitors (SSRIs) Escitalopram hh
Fluoxetine hhh
Lithium Lithium hh

Haloperidol hh Ziprasidone
Antipsychotics Loxapine hh Lurasidone
Clozapine hh Aripiprazole
Chlorpromazine hh
Fluphenazine hh
Risperidone h
Olanzapine hh
Quetiapine hh
Iloperidone hh
Sertindole h

Anticonvulsants Valproic Acid hhh Topiramate

Carbamazepine hhh Zonisamide
Gabapentin hhh Lamotrigine

Corticosteroids Oral steroids Prednisone hhh Budesonide

Prednisolone hhh NSAIDs
Cortisone hhh

Inhaled steroids Ciclesonide h

Fluticasone h

Hormone Estrogens hh
replacement therapy Progestogens h

Antihistamines Diphenhydramine h Oxymetazoline

Beta blockers Propranolol h ACEi

ARBs
Metoprolol h CCBs (may cause fluid retention)
Atenolol hh Timolol

Antihypertensive Clonidine h Prazosin

ACEi
ARBs
Diuretics

DPP4i: Inhibitors of dipeptidyl peptidase 4; GLP-1: Glucagon-like peptide-1 receptor agonists; NSAIDs: Nonsteroidal anti-inflammatory drugs: SGLT-2: Sodium glucose co-transporter 2; AGI: Alpha-glucosidase
inhibitor; ACEi: Angiotensin converting inhibitors; ARBs: Angiotensin II receptors blockers; CCBs: Calcium channel blockers; MAOIs: Monoamine oxidase inhibitors; SSRIs: Selective serotonin reuptake
inhibitors;*Combination therapy is less likely to cause weight gain; h/h variable reported effect; h up to 5 kg weight gain; hh 5 to 10 kg weight gain; hhh more than 10 kg weight gain.

Canadian Adult Obesity Clinical Practice Guidelines 14

 Downloaded from: https://obesitycanada.ca/guidelines/assessment

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND 4.0)

The summary of the Canadian Adult Obesity Clinical Practice Guideline is published in the Canadian Medical Association Journal, and contains information on the full methodology,
management of authors’ competing interests, a brief overview of all recommendations and other details. More detailed guideline chapters are published on the Obesity Canada website at
www.obesitycanada.ca/guidelines.

Correspondence: 15. Luig T, Anderson R, Sharma AM, Campbell-Scherer DL. Personalizing obesity
guidelines@obesitynetwork.ca assessment and care planning in primary care: patient experience and out-
comes in everyday life and health. Clin Obes. 2018;8(6):411-423. doi:10.1111/
cob.12283

References 16. Wildman RP. The obese without cardiometabolic risk factor clustering and the
normal weight with cardiometabolic risk factor clustering: prevalence and cor-
relates of 2 phenotypes among the US population (NHANES 1999-2004). Arch
1. Wormser D, Kaptoge S, Di Angelantonio E, et al.Separate and combined asso- Intern Med. 2008;168(15):1617-1624. doi:10.1001/archinte.168.15.1617
ciations of body-mass index and abdominal adiposity with cardiovascular dis-
ease : collaborative analysis of 58 prospective studies. Lancet. 377(9771):1085- 17. Campbell-scherer D, Ba JR, Mclsc DM, et al.Guideline harmonization and
1095. doi:10.1016/S0140-6736(11)60105-0 implementation plan for the BETTER trial : Building on Existing Tools to Im-
prove Chronic Disease Prevention and Screening in Family Practice. C Open.
2. Whitlock G, Lewington S, Sherliker P, Clarke R, Emberson J, Halsey J. Body-mass index 2014;2(1):E1-10. doi:10.9778/cmajo.20130040
and cause-specifi c mortality in 900 000 adults : collaborative analyses of 57 prospec-
tive. Lancet. 2009;373(9669):1083-1096. doi:10.1016/S0140-6736(09)60318-4 18. Grammatikopoulou MG, Chourdakis M, Gkiouras K, et al.Edmonton obesity stag-
ing system among pediatric patients: a validation and obesogenic risk factor analy-
3. Cornier M, Despre J, Lopez-jimenez F, Rao G. A Scientific Statement From sis. J Endocrinol Invest. 2018;41(8):947-957. doi:10.1007/s40618-017-0821-9
the American Heart Association. Circulation. 2011;124(18):1996-2019.
doi:10.1161/CIR.0b013e318233bc6a 19. Sharma AM, Kushner RF. A proposed clinical staging system for obesity. Int J
Obes. 2009;33(3):289-295. doi:10.1038/ijo.2009.2
4. Guh DP, Zhang W, Bansback N, Amarsi Z, Birmingham L, Anis AH. The incidence
of co-morbidities related to obesity and overweight : A systematic review and 20. Wisniewski AE. The weight of communication: The Canadian Medical Associ-
meta-analysis. BMC Public Health. 2009;9(1):88. doi:10.1186/1471-2458-9-88 ation Journal’s discourse on obesity. Public Underst Sci. 2013;22(3):351-364.
doi:10.1177/0963662511412861
5. Berrington de Gonzalez A, Hartge P, Cerhan JR, et al.Body-Mass Index and Mor-
tality among 1.46 Million White Adults. N Engl J Med. 2011;363(23):2211-2219. 21. Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, Ryn M Van.
Impact of weight bias and stigma on quality of care and outcomes for patients
6. Cerhan JR, Moore SC, Jacobs EJ, et al.A pooled analysis of waist circumfer- with obesity. Obes Rev. 2015;16(4):319-326. doi:10.1111/obr.12266
ence and mortality in 650,000 adults. Mayo Clin Proc. 2014;89(3):335-345.
doi:10.1016/j.mayocp.2013.11.011.A 22. Mechanick JI, Hurley DL, Garvey WT. Adiposity-based chronic disease as a
new diagnostic term: The American association of clinical endocrinologists
7. Lassale C, Tzoulaki I, Moons KGM, et al.Separate and combined associations of and American college of endocrinology position statement. Endocr Pract.
obesity and metabolic health with coronary heart disease : a pan-European case-co- 2017;23(3):372-378. doi:10.4158/EP161688.PS
hort analysis. Eur Heart J. 2018;39(5):397-406. doi:10.1093/eurheartj/ehx448
23. Garvey WT, Mechanick JI. Proposal for a Scientifically Correct and Medi-
8. WHO Expert Consultation. Appropriate body-mass index for Asian popu- cally Actionable Disease Classification System (ICD) for Obesity. Obesity.
lations and its implications for policy and intervention strategies. Lancet. 2020;28(3):484-492. doi:10.1002/oby.22727
2004;363(9403):157-163.
24. World Health Organization. Obesity: preventing and managing the global epidemic
9. Gavriilidou NN, Pihlsgård M, Elmståhl S. Anthropometric reference data for el- Report of a WHO Consultation (WHO Technical Report Series 894). 2000:252.
derly Swedes and its disease-related pattern. Eur J Clin Nutr. 2015;69(09):1066-
1075. doi:10.1038/ejcn.2015.73 25. Kyle T, Dhurandhar E, DB. A. Regarding Obesity as a Disease: Evolving Pol-
icies and Their Implications. Endocrinol Metab Clin. 2016;45(3):511-520.
10. Balkau B, Je D, Jp D, et al.International Day for the Evaluation of Abdominal doi:10.1016/j.ecl.2016.04.004.Regarding
Obesity ( IDEA ): a study of waist circumference, cardiovascular disease, and
diabetes mellitus in 168, 000 primary care patients in 63 countries. Circulation. 26. Vallgårda S, Nielsen MEJ, Hansen AKK, et al.Should Europe follow the US and
2007;116(17):1942-1951. declare obesity a disease ?: a discussion of the so-called utilitarian argument.
Eur J Clin Nutr. 2017;71(11):1263-1267. doi:10.1038/ejcn.2017.103
11. De Koning L, Merchant AT, Pogue J, Anand SS. Waist circumference and waist-to-
hip ratio as predictors of cardiovascular events: Meta-regression analysis of prospec- 27. Ortiz SE, Kawachi I, Boyce AM. The medicalization of obesity, bariatric sur-
tive studies. Eur Heart J. 2007;28(7):850-856. doi:10.1093/eurheartj/ehm026 gery, and population health. Health (Irvine Calif). 2017;21(5):498-518.
doi:10.1177/1363459316660858
12. Vazquez G, Duval S, Jacobs DR, Silventoinen K. Comparison of body mass index,
waist circumference, and waist/hip ratio in predicting incident diabetes: A me- 28. Welzel FD, Stein J, Pabst A, et al.Five A’s counseling in weight management of
ta-analysis. Epidemiol Rev. 2007;29(1):115-128. doi:10.1093/epirev/mxm008 obese patients in primary care: A cluster-randomized controlled trial (INTER-
ACT). BMC Fam Pract. 2018;19(1):97. doi:10.1186/s12875-018-0785-7
13. Luppino FS, de Wit LM, Bouvy PF, et al.Overweight, obesity, and depression: a
systematic review and meta-analysis of longitudinal studies. Arch Gen Psychia- 29. Retat L, Pimpin L, Webber L, et al.Screening and brief intervention for obesity in
try. 2010;67(3):220-229. primary care : cost- effectiveness analysis in the BWeL trial. Int J Obes. 2019;1.

14. Foster GD, Borradaile KE, Sanders MH, et al.A randomized study on the effect 30. Puhl RM, Luedicke J, Grilo CM. Obesity bias in training: Attitudes, beliefs, and
of weight loss on obstructive sleep apnea among obese patients with type 2 observations among advanced trainees in professional health disciplines. Obesity.
diabetes: The Sleep AHEAD study. Arch Intern Med. 2009;169(17):1619-1626. 2014;22(4):1008-1015. doi:10.1002/oby.20637

Canadian Adult Obesity Clinical Practice Guidelines 15

31. Smigelski-Theiss R, Gampong M, Kurasaki J. Weight bias and psychosocial 50. Herath HMM, Weerasinghe NP, Weerarathna TP, Amarathunga A. A Compar-
implications for acute care of patients with obesity. AACN Adv Crit Care. ison of the Prevalence of the Metabolic Syndrome among Sri Lankan Patients
2017;28(3):254-262. doi:10.4037/aacnacc2017446 with Type 2 Diabetes Mellitus Using WHO, NCEP-ATP III, and IDF Definitions. Int
J Chronic Dis. 2018:1-8. doi:10.1155/2018/7813537
32. Hunte HER, Williams DR. The association between perceived discrimination and
obesity in a population-based multiracial and multiethnic adult sample. Am J 51. James WPT, Chunming C, Inoue S. Appropriate Asian body mass indices? Obes
Public Health. 2009;99(7):1285-1292. doi:10.2105/AJPH.2007.128090 Rev. 2002;3(3):139-139. doi:10.1111/obr.12153

33. Pearl RL, Hopkins CH, Berkowitz RI, Wadden TA. Group cognitive-behavioral 52. Altschuler EL. Prescient description of frontal lobe syndrome in an Edgar Allan
treatment for internalized weight stigma: a pilot study. Eat Weight Disord - Stud Poe tale. Lancet. 2004;363(9412):902.
Anorexia, Bulim Obes. 2018;23(3):357-362. doi:10.1007/s40519-016-0336-y
53. Pan W-H, Yeh W-T. How to define obesity? Evidence-based multiple ac-
34. Fruh SM, Nadglowski J, Hall HR, Davis SL, Crook ED, Zlomke K. Obesity Stigma tion points for public awareness, screening, and treatment: an extension of
and Bias. J Nurse Pract. 2016;12(7):425-432. doi:10.1016/j.nurpra.2016.05.013 Asian-Pacific recommendations. Asia Pac J Clin Nutr. 2008;17(3):370-374.
doi:10.6133/apjcn.2008.17.3.02
35. Puhl RM, Heuer CA. The stigma of obesity: A review and update. Obesity.
2009;17(5):941-964. doi:10.1038/oby.2008.636 54. Pan WH, Yeh WT, Weng LC. Epidemiology of metabolic syndrome in Asia. Asia
Pac J Clin Nutr. 2008;17:37-42. doi:10.1002/9780470779750.ch4
36. Akpinar E, Bashan I, Bozdemir N, Saatci E. Which is the best anthropometric
technique to identify obesity: Body mass index, waist circumference or waist- 55. Hartemink N, Boshuizen HC, Nagelkerke NJD, Jacobs MAM, Van Houwelingen
hip ratio? Coll Antropol. 2007;31(2):387-393. HC. Combining risk estimates from observational studies with different expo-
sure cutpoints: A meta-analysis on body mass index and diabetes type 2. Am J
37. Feldstein CA, Akopian M, Olivieri AO, Kramer AP, Nasi M, Garrido D. A compar- Epidemiol. 2006;163(11):1042-1052. doi:10.1093/aje/kwj141
ison of body mass index and waist-to-hip ratio as indicators of hypertension risk
in an urban Argentine population: A hospital-based study. Nutr Metab Cardio- 56. Health Canada. Canadian Guidelines for Body Weight Classification in Adults :
vasc Dis. 2005;15(4):310-315. doi:10.1016/j.numecd.2005.03.001 Quick Reference Tool for Professionals.; 2016. http://www.hc-sc.gc.ca/fn-an/
nutrition/weights-poids/guide-ld-adult/cg_quick_ref-ldc_rapide_ref-eng.php.
38. Rueda-Clausen CF, Benterud E, Bond T, Olszowka R, Vallis MT, Sharma AM.
Effect of implementing the 5As of Obesity Management framework on 57. Yusuf S, Hawken S, Ôunpuu S, et al.Obesity and the risk of myocardial infarc-
provider-patient interactions in primary care. Clin Obes. 2014;4(1):39-44. tion in 27 000 participants from 52 countries: A case-control study. Lancet.
doi:10.1111/cob.12038 2005;366(9497):1640-1649. doi:10.1016/S0140-6736(05)67663-5

39. Jay M, Gillespie C, Schlair S, Sherman S, Kalet A. Physicians’ use of the 5As in 58. Thu Tran NT, Blizzard CL, Luong KN, et al.The importance of waist circumference and
counseling obese patients: Is the quality of counseling associated with patients’ body mass index in cross-sectional relationships with risk of cardiovascular disease in
motivation and intention to lose weight? BMC Health Serv Res. 2010;10(1):159. Vietnam. PLoS One. 2018;13(5):e0198202. doi:10.1371/journal.pone.0198202
doi:10.1186/1472-6963-10-159
59. Du SM, Ma GS, Li YP, et al.Relationship of body mass index, waist circum-
40. Sharma AM, Campbell-Scherer DL. Redefining obesity: Beyond the numbers. ference and cardiovascular risk factors in Chinese adult. Biomed Environ Sci.
Obesity. 2017;25(4):660-661. doi:10.1002/oby.21801 2010;23(2):92-101. doi:10.1016/S0895-3988(10)60037-2

41. Douketis JD, Macie C, Thabane L, Williamson DF. Systematic review of long-term 60. Janssen I, Heymsfield SB, Allison DB, Kotler DP, Ross R. Body mass index and
weight loss studies in obese adults: Clinical significance and applicability to clini- waist circumference independently contribute to the prediction of nonabdomi-
cal practice. Int J Obes. 2005;29(10):1153-1167. doi:10.1038/sj.ijo.0802982 nal, abdominal subcutaneous, and visceral fat. Am J Clin Nutr. 2002;75(4):683-
688. doi:10.1093/ajcn/75.4.683
42. Littman AJ, Damschroder LJ, Verchinina L, et al.National evaluation of obe-
sity screening and treatment among veterans with and without mental 61. Pinho CPS, Diniz A da S, Arruda IKG, Leite APDL, Petribu M de MV, Rodrigues
health disorders. Gen Hosp Psychiatry. 2015;37(1):7-13. doi:10.1016/j.gen- IG. Waist circumference measurement sites and their association with visceral
hosppsych.2014.11.005 and subcutaneous fat and cardiometabolic abnormalities. Arch Endocrinol Me-
tab. 2018;62(4):416-423. doi:10.20945/2359-3997000000055
43. Lau DCW, Douketis DJ, Morrison KM, Hramiak IM, Sharma AM, Ur E. 2006
Canadian clinical practice guidelines on the management and prevention of 62. Csongová M, Volkovová K, Gajdoš M, et al.Gender-associated differences in
obesity in adults and children [summary]. Can Med Assoc J. 2007;176(8):S1- the prevalence of central obesity using waist circumference and waist-to-height
S13. www.cmaj.ca/cgi/content/full/176/8/S1/DC1. ratio, and that of general obesity, in Slovak adults. Cent Eur J Public Health.
2018;26(3):228-233. doi:10.21101/cejph.a4719
44. Ortega FB, Sui X, Lavie CJ, Blair SN. Body mass index, the most widely used but
also widely criticized index: would a criterion standard measure of total body 63. Wang Z, Ma J, Si D. Optimal cut-off values and population means of waist
fat be a better predictor of cardiovascular disease mortality? Mayo Clin Proc. circumference in different populations. Nutr Res Rev. 2010;23(2):191-199.
2016;91(4):443-455. doi:10.1016/j.physbeh.2017.03.040 doi:10.1017/S0954422410000120

45. World Health Organization. Physical status: The use and interpretation of an- 64. Lear SA, James PT, Ko GT, Kumanyika S. Appropriateness of waist circumfer-
thropometry. 1995;854. ence and waist-to-hip ratio cutoffs for different ethnic groups. Eur J Clin Nutr.
2010;64(1):42-61. doi:10.1038/ejcn.2009.70
46. Seidell JC, Kahn HS, Williamson DF, Lissner L, Valdez R. Report from a centers
for disease control and prevention workshop on use of adult anthropometry 65. Cardinal TR, Vigo A, Duncan BB, et al.Optimal cut-off points for waist circum-
for public health and primary health care. Am J Clin Nutr. 2001;73(1):123-126. ference in the definition of metabolic syndrome in Brazilian adults: Baseline
doi:10.1093/ajcn/73.1.123 analyses of the Longitudinal Study of Adult Health (ELSA-Brasil). Diabetol Me-
tab Syndr. 2018;10(1):49. doi:10.1186/s13098-018-0347-0
47. Pi-Sunyer FX. Obesity: criteria and classification. Proc Nutr Soc. 2000;59(4):505-
509. doi:10.1017/s0029665100000732 66. Zaher Z, Zambari R, Pheng C, Muruga V, Ng B, Appannah G. Optimal cut-off levels
to define obesity: Body mass index and waist circumference, and their relationship
48. Javed A, Jumean M, Murad MH, et al.Diagnostic performance of body mass index to to cardiovascular disease, dyslipidaemia, hypertension and diabetes in Malaysia.
identify obesity as defined by body adiposity in children and adolescents: A systematic Asia Pac J Clin Nutr. 2009;18(2):209-216. doi:10.6133/apjcn.2009.18.2.09
review and meta-analysis. Pediatr Obes. 2015;10(3):234-244. doi:10.1111/ijpo.242
67. Douketis JB, Paradis G, Keller H, Martineau C. Canadian guidelines for body
49. Misra A, Khurana L. The metabolic syndrome in South Asians: Epidemiology, weight classification in adults: Application in clinical practice to screen for over-
determinants, and prevention. Metab Syndr Relat Disord. 2009;7(6):497-514. weight and obesity and to assess disease risk. CMAJ. 2005;172(8):995-998.
doi:10.1089/met.2009.0024 doi:10.1503/cmaj.045170

Canadian Adult Obesity Clinical Practice Guidelines 16

68. Alberti KGMM, Eckel RH, Grundy SM, et al.Harmonizing the metabolic syn- 87. Van Cauter E, Knutson KL. Sleep and the epidemic of obesity in children and
drome: A joint interim statement of the international diabetes federation task adults. Eur J Endocrinol. 2008;159(SUPPL_1):S59-S66. doi:10.1530/EJE-08-0298
force on epidemiology and prevention; National heart, lung, and blood insti-
tute; American heart association; World heart federation; International . Circu- 88. Domecq JP, Prutsky G, Leppin A, et al.Drugs commonly associated with weight
lation. 2009;120(16):1640-1645. doi:10.1161/CIRCULATIONAHA.109.192644 change: A systematic review and meta-analysis. J Clin Endocrinol Metab.
2015;100(2):363-370. doi:10.1210/jc.2014-3421
69. Herrera VM, Casas JP, Miranda JJ, et al.Interethnic differences in the accuracy of
anthropometric indicators of obesity in screening for high risk of coronary heart 89. Aasheim ET, Aylwin SJB, Radhakrishnan ST, et al.Assessment of obesity beyond
disease. Int J Obes. 2009;33(5):568-576. doi:10.1038/ijo.2009.35 body mass index to determine benefit of treatment. Clin Obes. 2011;1(2-3):77-
84. doi:10.1111/j.1758-8111.2011.00017.x
70. Pan J, Wang M, Ye Z, et al.Optimal cut-off levels of obesity indices by different
de fi nitions of metabolic syndrome in a southeast rural Chinese population. J 90. Gondoni LA, Titon AM, Nibbio F, Augello G, Caetani G, Liuzzi A. Heart rate
Diabetes Investig. 2016;7(4):594-600. doi:10.1111/jdi.12440 behavior during an exercise stress test in obese patients. Nutr Metab Cardiovasc
Dis. 2009;19(3):170-176. doi:10.1016/j.numecd.2008.07.001
71. Cho GJ, Yoo HJ, Hwang SY, et al.Differential relationship between waist circumfer-
ence and mortality according to age, sex, and body mass index in Koreans with age 91. Lear S, Brozic A, Myers J, A I. Exercise stress testing. An overview of current guidelines.
of 30 – 90 years ; a nationwide health insurance database study. 2018;16(1):131. Sport Med. 1999;27(5):285-312. doi:10.1016/B978-1-4557-4815-0.00006-4
72. Manjoo P, Dannenbaum D, Joseph L, Torrie J. Utility of current obesity thresh-
olds in signaling diabetes risk in the James Bay Cree of Eeyou Istchee. BMJ Open 92. Bires, A M, Lawson D, Wasser TE, Raber-Baer D. Comparison of bruce treadmill
Diabetes Res Care. 2015;3(1):e000114. doi:10.1136/bmjdrc-2015-000114 exercise test protocols: Is ramped bruce equal or superior to standard bruce in
producing clinically valid studies for patients presenting for evaluation of cardi-
73. Yusuf PS, Hawken S, Ôunpuu S, et al.Investigators IS. Effect of potentially ac ischemia or arrhythmia with body mass index equal to or grea. J Nucl Med
modifiable risk factors associated with myocardial infarction in 52 countries Technol. 2013;41(4):274-278. doi:10.2967/jnmt.113.124727
(the INTERHEART study): case-control study. Lancet. 2004;364(9438):937-952.
doi:10.1016/S0140-6736(04)17018-9 93. Chrysohoou C, Skoumas J, Georgiopoulos G, et al.Exercise capacity and hae-
modynamic response among 12,327 individuals with cardio-metabolic risk fac-
74. Li H, He D, Zheng D, et al.Metabolically healthy obese phenotype and risk of car- tors undergoing treadmill exercise. Eur J Prev Cardiol. 2017;24(15):1627-1636.
diovascular disease: Results from the China Health and Retirement Longitudinal
Study. Arch Gerontol Geriatr. 2019;82:1-7. doi:10.1016/j.archger.2019.01.004 94. Korbee R, Boiten H, Ottenhof M, Valkema R, van Domburg R, Schinkel A. What is the
value of stress (99m)Tc-tetrofosmin myocardial perfusion imaging for the assessment
75. Neeland IJ, Poirier P, Després JP. Cardiovascular and Metabolic Heterogeneity of very long-term outcome in obese patients? J Nucl Cardiol. 2013;20(2):227-233.
of Obesity: Clinical Challenges and Implications for Management. Circulation.
2018;137(13):1391-1406. doi:10.1161/CIRCULATIONAHA.117.029617 95. Ferraro S, Perrone-Filardi P, Desiderio A, et al.Left ventricular systolic and diastol-
ic function in severe obesity: A radionuclide study. Cardiology. 1996;87(4):347-
76. Aronne LJ. Classification of obesity and assessment of obesity-related health 353. doi:10.1159/000177118
risks. Obes Res. 2002;10(SUPPL. 2):105-115. doi:10.1038/oby.2002.203
96. Freedman N, Schechter D, Klein M, Marciano R, Rozenman Y, Chisin R. SPECT
77. Sharma AM. M, M, M & M: a mnemonic for assessing obesity. Obes Rev. attenuation artifacts in normal and overweight persons: Insights from a ret-
2010;11(11):808-809. doi:10.1111/j.1467-789X.2010.00766.x rospective comparison of Rb-82 positron emission tomography and TI-201
SPECT myocardial perfusion imaging. Clin Nucl Med. 2000;25(12):1019-1023.
78. Leblanc MÈ, Auclair A, Leclerc J, et al.Blood Pressure Measurement in Severely doi:10.1097/00003072-200012000-00014
Obese Patients: Validation of the Forearm Approach in Different Arm Positions.
Am J Hypertens. 2019;32(2):175-185. doi:10.1093/ajh/hpy152 97. Yoshinaga K, Chow BJW, Williams K, et al.What is the Prognostic Value of Myo-
cardial Perfusion Imaging Using Rubidium-82 Positron Emission Tomography? J
79. Leblanc MÉ, Croteau S, Ferland A, et al.Blood pressure assessment in severe Am Coll Cardiol. 2006;48(5):1029-1039. doi:10.1016/j.jacc.2006.06.025
obesity: Validation of a forearm approach. Obesity. 2013;21(12):533-541.
doi:10.1002/oby.20458 98. Supariwala A, Makani H, Kahan J, et al.Feasibility and prognostic value of stress
echocardiography in obese, morbidly obese, and super obese patients referred for
80. Canadian Cardiovascular Society. The Canadian Cardiovascular Society’s DYS- bariatric surgery. Echocardiography. 2014;31(7):879-885. doi:10.1111/echo.12481
LIPIDEMIA Guidelines.; 2016. http://search.jamas.or.jp/link/ui/2016153831.
99. Madu E. Transesophageal dobutamine stress echocardiography in the evaluation
81. Chalasani N, Younossi Z, Lavine JE, et al.The diagnosis and management of nonal- of myocardial ischemia in morbidly obese subjects. Chest. 2000;117(3):657-
coholic fatty liver disease: Practice guidance from the American Association for the 661. doi:10.1378/chest.117.3.657
Study of Liver Diseases. Hepatology. 2018;67(1):328-357. doi:10.1002/hep.29367
100. Bhaskaran K, dos-Santos-Silva I, Leon DA, Douglas IJ, Smeeth L. Association of
82. Poirier P, Giles TD, Bray GA, et al.Obesity and cardiovascular disease: Patho- BMI with overall and cause-specific mortality: a population-based cohort study
physiology, evaluation, and effect of weight loss: An update of the 1997 of 3·6 million adults in the UK. Lancet Diabetes Endocrinol. 2018;6(12):944-
American Heart Association Scientific Statement on obesity and heart disease 953. doi:10.1016/S2213-8587(18)30288-2
from the Obesity Committee of the Council on Nutrition, Physical. Circulation.
2006;113(6):898-918. doi:10.1161/CIRCULATIONAHA.106.171016 101. Xu Y, Li H, Wang A, et al.Association between the metabolically healthy obese
phenotype and the risk of myocardial infarction: Results from the Kailuan study.
83. Kragelund C, Hassager C, Hildebrandt P, Torp-Pedersen C, Køber L. Impact of Eur J Endocrinol. 2018;179(6):343-352. doi:10.1530/EJE-18-0356
obesity on long-term prognosis following acute myocardial infarction. Int J Car-
diol. 2005;98(1):123-131. doi:10.1016/j.ijcard.2004.03.042 102. Lee SJ, Arslanian S. Body Composition and Cardiorespiratory Fitness Be-
tween Metabolically Healthy Versus Metabolically Unhealthy Obese Black
84. Abraham TM, Pedley A, Massaro JM, Hoffmann U, Fox CS. Association be- and White Adolescents. J Adolesc Heal. 2019;64(3):327-332. doi:10.1016/j.
tween visceral and subcutaneous adipose depots and incident cardiovascular jadohealth.2018.08.024
disease risk factors. Circulation. 2015;132(17):1639-1647. doi:10.1161/CIRCU-
LATIONAHA.114.015000 103. Lin H, Zhang L, Zheng R, Zheng Y. The prevalence, metabolic risk and effects of
lifestyle intervention for metabolically healthy obesity: a systematic review and
85. Fuster V, Alexander R, O’Rourke R. Hurst’s The Heart, 10th Edition.; 2000. meta-analysis A PRISMA-compliant article. Med (United States). 2017;96(47).
doi:10.1097/MD.0000000000008838
86. Sharma AM, Padwal R. Obesity is a sign - Over-eating is a symptom: An aetio-
logical framework for the assessment and management of obesity. Obes Rev.
2010;11(5):362-370. doi:10.1111/j.1467-789X.2009.00689.x

Canadian Adult Obesity Clinical Practice Guidelines 17