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Prof. Rigas:

Yes, I was the lead author of the ACTION-Australia publication, which I should emphasize so we can put it into context, was conducted before the COVID-19 pandemic. At that point in time, we only had the earlier, 1st generation obesity management medications [OMMs] and at the other end of the therapeutic spectrum was metabolic bariatric surgery [MBS].

That study found that PwO were trying an average of 5 serious weight loss attempts with “lifestyle [LS] alone” interventions during the years leading up to that initial consultation with a HCP. This confirms what HCPs like myself hear in clinical practice: the majority of PwO are very motivated and proactively trying to manage their disease, albeit on their own. The same study also highlighted that most PwO blamed themselves for their disease and had past experiences of weight stigma by HCPs, providing some insights as to why they felt they should be able to “manage their weight” on their own.

There are many medical publications which have shown similar findings: that the majority of PwO report having felt stigmatized by HCPs and the wider community. As a result of this, such individuals are less likely to participate in preventative health screening initiatives and consequently present late, with more advanced disease.

Over the past two decades, significant changes have occurred on numerous fronts. First and foremost, our medical scientific understanding of obesity and the strong genetic determinants has expanded, as have the development of more effective therapies for HCPs like myself to choose from when managing PwO.

Secondly, and I am old enough to remember this, discriminating and shaming someone based on their body size was somehow “socially acceptable”. This is no longer the case. Infact, with the guidance and support of World Obesity Federation and other key stakeholders, there have been numerous public health awarenesscampaigns encouraging a change in the narrative by recognizing obesity as a disease and not a lifestyle choice. Such campaogns are also raising awareness in the community and encouraging PwO to have that initial conversation with their HCP. In recent times, PwO it appears seems more comfortable telling their friends/ family that they are on obesity management therapy, something which 20 years ago was unheard of, seemingly because of the stigmatizing, unsubstantiated belief, that the PwO is “cheating or taking the easy way out” by accepting treatment.

The proactive education of HCPs – in particular SCOPE accreditation has ensured that HCPs are well trained and regularly upskilled in managing PwO with the care and compassion they need and deserve. Concurrently, all forms of media and seemingly social media, has also played a role in raising awareness and encouraging PwO to have that initial conversation. International and National educational institutions, healthcare institutions/ bodies and patient advocacy organisations collectively continue to educate broader society about the science of obesity and the need to change the narrative.

Finally, pre-COVID, we only had the first-generation obesity management medications, which—when combined with lifestyle intervention—could help patients lose on average 8–10% of their starting weight, leading to meaningful health improvements.

However, the OMM landscape has shifted notably in the last five years with the regulatory approval of the newer, once- weekly subcutaneous GLP-1 receptor agonists based therapies for numerous multi-organ health gain benefits beyond weight loss alone. As a HCP, having a variety of effective, evidence-based therapies to choose from is very important and helpful. This marked a pivotal shift in obesity management, taking a more proactive approach rather than the traditional reactive approach.

Changing Attitudes: Proactive Engagement and Early Intervention

As you observed, there has been a noticeable shift, with more people living with obesity now proactively seeking medical advice and specifically inquiring about new medications. From a clinical perspective, this is an encouraging development. It aligns closely with the Australian Government's National Obesity Strategy, introduced in March 2023, which emphasizes earlier intervention in the progression of obesity.

It is important to acknowledge that not every person with obesity will want or require additional therapies, nor will every patient necessarily meet the eligibility criteria for such interventions. However, when patients take the initiative to seek advice and discuss these options, it opens a valuable dialogue. This consultative process enables healthcare professionals to assess each individual's suitability for different treatment approaches and provide tailored recommendations.

This positive change can be attributed to multiple factors, including ongoing education efforts directed at both healthcare professionals and the broader community. Increased awareness and understanding have empowered people with obesity to feel more comfortable seeking help and considering a wider range of therapeutic options.

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Prof. Rigas

The Australian Obesity Management Algorithm: Structure and Clinical Application

The Australian Obesity Management Algorithm integrates the latest medical and scientific evidence with a practical approach to patient care. Central to its framework is the Edmonton Obesity Staging System (EOSS), which is used to assess and stratify the severity of a patient's obesity-related health risks. By applying this system, clinicians can determine the most appropriate care pathway for each individual patient.

Patients with less complex or early-stage disease can often be managed effectively within primary care settings. These individuals, often require lifestyle optimization and add-on therapies according to their clinical profile and their response to previous therapies.

The algorithm also provides guidance for identifying patients who require specialist care such as those with advanced disease [high EOSS score], significant complexity [multi-organ multi-morbidity], and/or those who do not respond to previous therapeutic interventions are clearly indicated for referral to specialized units. This ensures that all patients receive care tailored to their individual healthcare needs, and that those with the greatest health risks can be directed to services which provide higher-level interventions and support.

The Role and Structure of the Australian Obesity Management Algorithm

Referral Criteria and Stratification Beyond BMI

Patients who present at Edmonton Obesity Staging System (EOSS) stage 3 or higher require timely referral to a specialist unit. The Australian Obesity Management Algorithm advances beyond the use of BMI as a sole metric, incorporating disease severity, related complications, and specific risk factors such as visceral adiposity, which is associated with considerable health risks. This comprehensive approach has established the algorithm as a practical clinical resource.

Practical Guidance: The Flowchart for Clinical Decision-Making

Although the full guidance document is detailed and thoroughly referenced, a concise and user-friendly single-page flowchart was developed for clinicians. Originally published as a paper, the content was condensed into this flowchart for ease of use. It enables healthcare providers to rapidly identify a patient’s stage and select appropriate, evidence-based interventions. These interventions usually include lifestyle optimization and add-on therapies such as: very-low-energy ?meal replacement diets [VLEDs], obesity management medications [OMMs], and/or referral for advanced therapies, including metabolic bariatric surgery [MBS] and possibly a combination of treatment modalities.

Adaptability and Ongoing Revision

The document is both practical and firmly grounded in evidence, while remaining adaptable to evolving scientific knowledge. The intention is to revise the algorithm every one to two years, ensuring it reflects advances in science and newly approved therapies. As new treatments become available and understanding of obesity deepens, this approach ensures that clinical guidance remains current, relevant, and fluid for practitioners.

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Prof. Rigas:

Barriers to Access and Managing Patient Expectations in Obesity Treatment

Financial Barriers to Obesity Treatment

In Australia, patients seeking obesity management medication face a significant access barrier as not a single obesity medication is subsidized by the government. Furthermore, less than 5% of potentially eligible PwO access metabolic bariatric surgery. Consequently, PwO must self-fund these treatments, which creates a substantial obstacle for many. This challenge is particularly acute for those living with higher BMI and EOSS scores, who are often the sickest, more medically complex to manage and often come from lower socioeconomic backgrounds. Ironically, those most in need of advanced therapies—whether OMMs or MBS—are the least able to afford them. Addressing this inequity remains a priority, and ongoing advocacy focuses on encouraging government policy review to improve access for these vulnerable populations.

Addressing Unrealistic Weight-Loss Expectations

Beyond the issue of access, many patients present with unrealistic expectations regarding weight loss. Insights from the Australian ACTION study have revealed a disconnect between patient goals, what is clinically achievable, and the amount of “weight loss” actually necessary to improve specific health conditions. To address this gap, a structured approach is utilized during patient consultations.

The process begins with a thorough review of the patient’s medical, mental health, and metabolic history, which is then summarized within the EOSS framework. Patients are asked about their motivation for weight loss, with the most common response being a desire "to be healthier." This is further explored by asking what "being healthier" means to that particular individual, recognizing that answers vary widely. Next, patients are asked how much weight they believe they need to lose to achieve their health goals. If their expectations are unrealistic, a gentle discussion follows to explore the origins of these beliefs, which may stem from healthcare professionals or social media.

Setting Evidence-Based, Shared Goals

To guide patients toward realistic and clinically meaningful goals, a visual slide is presented that organizes weight-loss percentages into columns (5–10%, 10-15%, 15-20%, >20% “total weight loss”) and lists the comorbidities that tend to improve within each range. Together, the patient and clinician identify which category best relates to the patient’s individual health conditions. For example, meaningful improvement in type 2 diabetes management typically requires a minimum of 10–15% weight loss, which then becomes the shared, evidence-based target. Throughout this process, it is emphasized that the data serves as an impartial guide, shifting the focus toward health improvement and ensuring that weight loss is of “quality”—primarily by reducing visceral adiposity (referred to by the media as “belly fat”, while preserving fat-free mass namely muscle, and bone health.

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Prof. Rigas:

You are correct, however whilst a standard GP consultation lasts approximately15 minutes, there are provisions to schedule longer appointments where necessary- especially for PwO whose health profile appears complex with multi-morbidity and/or multi-organ pathology. Prior to an initial new patient appointment with myself, I review the referral letter and the patient’s responses to screening questionnaires and other required information, to ensure adequate time is allocatedfor initial visits.

Personally, a few senior Australian GP colleagues and I published an article [Forgione N et al (2018)] for primary care doctors, explaining that a HCP is not required to address in detail every component of care at the initial consultation, and that a piece-meal approach is preferred. Personally, I usually draw a mind map with the patient, placing their name in the center and surrounding it with identified health issues. I then ask the PwO to prioritize the most important health issue for them at that particular point in time. This allows for a patient centric approach to patient care. We may start with one or two focus areas, and address the others over the ensuing weeks - months. Firstly, this approach empowers the pate=ient whilst concurrently reaffirming to them that they have been listended to, and that their journey thus far has been acknowledged. Secondly, it provides a clear roadmap – a sense of direction for the PwO, reemphasizing that obesity is a chronic condition requiring ?long-term management. Personally, this strategy has proven highly effective for my patients with complex multi-morbidity and/or multi-organ system involvement.

Multidisciplinary Coordination for Continuity of Care

Coordinated Multidisciplinary Care in Obesity Management

Effective management of obesity hinges on the coordinated involvement of multiple healthcare professionals (HCPs). This team-based approach typically includes, but is not limited to, dietitians, exercise activists, psychologists, single-organ specialists such as cardiologists or hepatologists, and bariatric surgical teams. Each professional brings unique expertise to address the complex needs of people with obesity [PwO] throughout their care journey.

The primary responsibility for managing most PwO rests with their usual general practitioner (GP). The GP serves as the central coordinator, overseeing the patient’s overall health and aligning treatment strategies among the various HCPs involved. Only when more intensive therapies are required—such as specialist obesity management or bariatric surgery—should the GP refer the patient to such intensive service providers. Following such intensive interventions, the patient should ideally be transitioned back to their GP’s care through a “shared care” model. This model mirrors approaches used for other chronic diseases, such as type 2 diabetes and cardiovascular disease, ensuring continuity and consistency in long-term management.

Obesity is recognized as a chronic, progressive disease. As such, PwO will likely require support from different HCPs at various stages of their life journey. The GP, in their role as care provider and care coordinator, is best positioned to ensure that the patient receives the right treatment and support from the appropriate professionals at the right time. By aligning key health goals and facilitating communication among the multidisciplinary team, the GP helps to optimize outcomes and provide comprehensive, patient-centered care.