Obesity on the CCFP exam

Approach

• Ask permission before you weigh the patient or raise weight.
• Adults: measure height and weight, then work out BMI. Obesity starts at 30 kg/m².
• Measure the waist when BMI is 25 to 35. A waist of 102 cm or more in men, or 88 cm or more in women, adds heart and diabetes risk.
• For South, Southeast or East Asian adults, overweight starts at a BMI of 23. Waist risk starts at 85 cm in men and 75 cm in women.
• BMI misleads in muscular people, older adults, pregnancy and anyone under 18. Do not apply adult cut-offs to a child or teen.
• Tell the patient the diagnosis plainly. Obesity is a chronic disease that can relapse, not a lack of effort.

Approach

• Every patient: blood pressure in both arms, A1c (average blood sugar) or fasting glucose, and a lipid profile.
• Use a cuff that fits. The cuff bladder should be about 40% of the arm's circumference wide, and 80 to 100% of the arm's circumference long.
• Add ALT, a liver enzyme, where fatty liver is likely. Electrolytes, creatinine and age-appropriate cancer screening suit most patients.
• Screen for sleep apnea with STOP-BANG, a short questionnaire. A score over 4 is a positive screen: consider referral to rule it out.
• Ask about joint pain and examine weight-bearing joints for osteoarthritis. Screen for depression and anxiety, for example with the PHQ-9 questionnaire.
• Ask about chest pain on effort. Many cannot reach the target heart rate on a treadmill, so pick a stress test that suits him.
• Stage the harm with the Edmonton Obesity Staging System (stage 0 to 4), not BMI alone.

Approach

• Order a TSH only for a clinical reason. It is not part of the routine obesity work-up.
• Other hormone causes, such as Cushing syndrome, are not tested routinely either. Test when the history or exam points to one.
• Look for clues on exam: an enlarged thyroid, a round moon face, or purple stretch marks wider than 1 cm.
• A woman with signs of polycystic ovary syndrome gets a TSH as part of that work-up.
• Do not screen adults without symptoms for thyroid disease. This advice does not cover pregnancy.
• Spend the visit on what helps: comorbidities, how weight affects life, and a plan.

Approach

• Open with a gentle question, such as how her weight affects how she sees herself.
• Ask about mood, worry, self-image, sleep and any weight bias she has met.
• Ask about abuse, past and present. It can shape a person's relationship with food.
• In adults, ask about work, money, access to food and daily function.
• Make the room free of judgment: right-sized gowns and cuffs, chairs without arms, a private place to weigh.
• Weight stigma makes things worse. It brings more disordered eating, more depression and less activity.

Approach

• Use the 5As: ask permission, assess, advise, agree on goals, and assist with resources.
• Ask about motivation, confidence, readiness and what she expects.
• Use motivational interviewing: she chooses the change and commits to it.
• Set small, realistic goals about health, function and quality of life, not only a target weight.
• Book follow-up and repeat the core messages. Readiness can change, so ask again.
• When she is ready for more, weigh medicine with her case by case, using the 2025 Obesity Canada update.

Approach

• Refer to a registered dietitian where one is available. No single eating pattern wins; pick one he can keep.
• Activity: 30 to 60 minutes of moderate to vigorous aerobic activity most days, plus resistance training. It helps health even without weight loss.
• Build behaviour support into every plan: goal setting, self-monitoring and problem solving.
• Behaviour change alone usually brings 3 to 5% weight loss, and it is often not kept off.
• Offer medicine with a BMI of 30 or more, or 27 or more with a weight-related complication. Use the lower ethnicity-specific cut-offs and waist size where they apply.
• Choose the medicine case by case: benefit for his complications, side effects, route, cost and his preference. Pair it with behaviour change.
• Keep an effective medicine going long term. Weight and health gains reverse when it stops.

Approach

• Give activity advice at well-child visits, before weight becomes a problem.
• Ask how much active play, screen time and sleep the child gets each day.
• Use Canada's movement targets for the child's exact age group. A preschooler's targets differ from a school-age child's.
• Count active play spread through the whole day, not one session.
• Suggest swaps the family can make together, such as active play in place of screen time.
• Praise effort and fun, not weight.

Approach

• Make the changes for everyone: the same meals, drinks and activity for the whole family.
• Ask parents to stop comments about her weight and eating. Stigma brings disordered eating, depression and less activity.
• No separate diet or calorie count for the child.
• Keep the scale out of daily family life. Track habits, not daily weight.
• Talk about health, fun and confidence, not a number.
• Watch for signs of an eating disorder at each visit.