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Practical tool aims to help GPs manage obesity


Filip Vukasin


8/09/2022 5:06:22 PM

Two decades’ worth of evidence has been collated into an algorithm GPs can use when managing patients with obesity.

Doctor consulting with patient.
The algorithm collates evidence from 2001–21 and provides a practical clinical tool to guide the implementation of existing worldwide guidelines.

The lead author of new Australian research into obesity is hopeful that the team’s algorithm will provide ‘useful guidance’ for all practitioners – but especially GPs – as they see the majority of the patient population.
 
Associate Professor Tania Markovic, Director of the Metabolism and Obesity Service at Royal Prince Alfred Hospital, told newsGP the ‘living document’ will be updated as treatments and evidence changes and that there is a need for more services to look after people with severe obesity.
 
‘Patients need greater access to treatments that are effective,’ she said.
 
‘Unlike other guidelines which are often very lengthy and do not always indicate the treatment pathway clearly, we have tried to prepare an algorithm that is evidence based, true to the approach of specialists looking after people with obesity, and easy to follow.’
 
Just released, the Australian algorithm for the management of obesity collates information from 2001–21 from PubMed and Medline, and provides a practical clinical tool to guide the implementation of existing worldwide guidelines.
 
Dr Gary Deed, Chair of RACGP Specific Interests Diabetes, told newsGP that the collation of worldwide evidence on its management into a simple algorithm will help GPs and patients.
 
‘[For GPs] to be able to utilise evidence consensus statements that support the need for targeted interventions to assist management of obesity in our patients,’ he said.
 
Treatment pathways are determined by a person’s body mass index (BMI) and waist circumference (WC), as well as the presence and severity of obesity-related complications.
 
A target of 10–15% weight loss is recommended for people with BMI 30–40 kg/m2 or abdominal obesity (WC >88 cm in females, WC >102 cm in males) without complications. The treatment focus should be supervised lifestyle interventions that may include a reduced or low energy diet, very low energy diet (VLED) or pharmacotherapy.
 
For people with BMI 30–40 kg/m2 or abdominal obesity and complications, or those with BMI >40 kg/m2, a weight loss target of 10–15% body weight is recommended, and management should include intensive interventions such as VLED, pharmacotherapy or bariatric surgery, which may be required in combination.
 
A weight loss target of >15% is recommended for those with BMI >40 kg/m2 and complications, and they should be referred to specialist care. Their treatment should include a VLED with or without pharmacotherapy and bariatric surgery.
 
Dr Georgia Rigas, co-author and former Chair of RACGP Specific Interests Obesity, told newsGP the algorithm has come at an opportune time.
 
‘Obesity is one of the most important health issues facing Australia and affects the health, wellbeing and productivity of many Australians,’ she said.
 
‘It has been an Australian National Health Priority Area since 2008. Currently, approximately two-thirds of Australian adults are living with pre-obesity [also known as overweight] or obesity.’
 
According to the 2020 National Obesity Prevention Strategy report, this trend is predicted to continue, leading to three quarters of the Australian population being overweight or obese by 2030.
 
Dr Rigas said creating the algorithm was collaborative, including GPs like herself and Dr Deed, with a view to support fellow GPs in proactively and effectively managing people living with obesity.
 
‘As GPs we are very experienced in chronic disease management, it is something we have been doing for years and doing it very well, with documented positive health outcomes for patients,’ she said.
 
‘With this updated algorithm, we now have a succinct framework specific to the Australian therapeutic landscape with which to work.’
 
The algorithm outlines measures for treatment including diet, exercise, and the use of multidisciplinary services such as exercise physiology, psychology, dietitians, coaches and bariatric surgery.
 
However, while the guidelines are clear, other factors can make access to surgery a ‘hit or miss process’ for some patients.
 
‘There is no nationally consistent policy governing quality services to people in need,’ Dr Deed said.
 
‘Access to public-funded metabolic surgery is very dependent on local- and state-based economic modelling, specialist skill availability and arbitrary criteria for referrals.’
 
The algorithm also outlines pharmacological approaches to obesity, such as phentermine, orlistat, liraglitude, naltrexone/bupropion, topiramate and semaglitude.
 
Semaglitude, an injectable diabetes medication marketed as Ozempic, was recently added to the Australian Register of Therapeutic Goods under the trade name Wegovy, but has been dogged by shortages due to unexpected global demand.
 
As a result, the Therapeutic Goods Administration (TGA) has asked practitioners to prioritise the supply of semaglutide for people with type 2 diabetes. The TGA, in consultation with key obesity and diabetes organisations, has also advised prescribers treating patients with either condition to ‘strongly consider alternatives’ due to the current intermittent supply situation.
 
Dr Deed says these supply issues will remain for the foreseeable future and GPs should investigate alternatives.
 
‘There are [other] on-label products that need to be considered – oral and injectable – that apply to a wide range of people presenting with overweight or obesity,’ he said.
 
‘Semaglutide is just one option … so GPs need to familiarise themselves with alternatives, which are well spelt out in the algorithm.’
 
Additional weight loss options are also likely to become available soon – a development described as ‘very exciting’ by Associate Professor Markovic.
 
‘There are other agents in the pipeline … and in 2023 we should have tirzepatide,’ she said
 
‘I have been prescribing semaglutide off label, as well as low-dose topiramate, which are also off label for weight loss, in combination with low-dose phentermine.
 
‘Of course, the fact that these medications are being used off label needs to be explained to patients along with the rationale for using them, results from clinical trials, side effects, etcetera, and patients need to be reviewed to ensure the medication is well tolerated and effective.’
 
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