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My name's Doctor Patrice Forner. I am an endocrinologist in Sydney and today I'm presenting on the Australian obesity guidelines. These are my disclosures. So the brief I was given for today's talk was to discuss the. Australian obesity guidelines. In 2010, the NHMRC developed the clinical Practice guidelines for the management of overweight and obesity in Australia, and these guidelines were published in 2013 but are now rescinded. The 2024 draft guidelines were released for public consultation in November last year, so what I'm presenting today will be a combination of the draft guidelines, but also the Australian uh obesity algorithm, which is an excellent document written by one of my colleagues and endorsed as a clinical guideline, uh, by the Australian Diabetes Society. So the objectives for today are to discuss practical evidence-based treatment plans, uh, including lifestyle, pharmacotherapy and referrals, and to explain when to reassess or adjust treatment, uh, and to touch on how to have bias-aware, supportive conversations about obesity that account for the local culture in Australia. So I'll just start with a poll. Now which of the following is correct? A. In 2017 to 2018, 68% of Australians aged 18 years and over were above a healthy weight. B. Obesity is associated with a broad range of complications, type 2 diabetes, cardiovascular disease, dyslipidemia, metabolic associated fatty liver disease, sleep apnea, depression, osteoarthritis, and certain cancers. C. Treatment pathways for overweight and obesity should be determined by a person's anthropometry, that is BMI and waist circumference, and the presence and severity of obesity-related complications. D, weight loss in people with obesity has proven medical benefits in reducing the risk of diabetes and other obesity-related complications and mortality, or E, all of the above. Great. Those of you who chose E, you are correct. Uh, obesity is a significant problem in Australia and worldwide, and it is associated with a number of obesity-related complications. And by treating obesity as a chronic disease, we have the potential to improve these complications and reduce mortality. I'm going to introduce you to our first case, this is Claire. She's a 52 year old female. Her past medical history is significant for obstructive sleep apnea, dyslipidemia, hypertension, and metabolic associated fatty liver disease, and she's currently taking Perindopril 5 mg and rosuvastatin 20 mg daily. On examination, she weighs 102 kg with a height of 156 centimeters, giving her a BMI of 41.9. Her waist circumference is 118 centimeters and she has a waist to height ratio of 0.75. I'm just going to pause there for one second to discuss waist to height ratio. Now this is a measure of distribution of body fat, and it's used as a proxy for central adipocity, and that's because it correlates really well with abdominal adipocity on CT scans. And there's been a very recent paradigm shift in obesity diagnosis with the new Lancet Commission on Obesity. And the European Association for the Study of Obesity recommending that obesity is no longer diagnosed based on BMI but is confirmed by surrogate measures such as the waist to height ratio. Now the cut-off for increased risk is greater than 0.5, so this value of 0.75 is well above the threshold and indicates a very high cardio metabolic risk. And later on I'll go on to talk about, about BMI and waist circumference, and that's because our management algorithms are still heavily centered around the use of BMI and it's certainly still helpful when determining eligibility for treatment, but I'd encourage you to calculate a waist to height ratio in clinical practice. But getting back to Claire, her HbA1c is 6.2%, so she has pre-diabetes. You can see that her triglycerides are very mildly elevated at 2.2 with the upper limit of normal being 2.0. So another poll. What is the most appropriate initial weight management strategy for Claire in addition to lifestyle intervention? Is it A, reduced energy diet in the primary care setting, B, very low energy diet in the primary care setting, C, VLED, so very low energy diet, plus or minus pharmacotherapy under specialist care, or D, bariatric surgery? Excellent, so a lot of you picked C, and that is the correct answer, uh, very low energy diet, plus or minus phar pharmacotherapy under specialist care. Next poll, what is the weight loss target for Claire? Is it 55 to 1010 to 15, or greater than 15%? And the correct answer is D, greater than 15%. So this takes us to the Australian Obesity Management algorithm, and I'm presenting this because it's a really great resource, but because our national guidelines are still open for public consultation, and this document was written by Associate Professor Tanya Markovic and colleagues, and the aim of this document is to assist GPs in treatment decisions for non-pregnant adults with obesity. And to provide a practical clinical tool to guide the implementation of existing guidelines in the primary care setting. Now the treatment pathways are determined by a person's BMI and waist circumference and the presence or absence and severity of obesity-related complications. And the algorithm considers two BMI categories. So you can see in red on the left, a BMI of 30 to 39.9 and on the right, a BMI of greater than 40. Now if you look at the very left side of the algorithm, those without obesity related complications can be managed in the primary care setting with supervised lifestyle intervention. But for those with complications, and by complications I mean medical complications like diabetes, cardio metabolic disease, metabolic associated fatty liver disease, or polycystic ovarian syndrome, but also psychological complications and physical complications like osteoarthritis. For anyone with these types of complications, more intensive intervention is recommended, whether that's very low energy diet, pharmacotherapy, or bariatric surgery, and I'll go into this in further detail in the upcoming slides. The supervised lifestyle intervention is an essential component of all weight loss strategies, and involving a multidisciplinary team such as an accredited practicing dietitian, an exercise physiologist or psychologist should be considered quite early on. Uh, the treatment goals overall focus on reducing energy intake and optimizing diet quality and whether that's in the form of a reduced energy diet or a low energy diet or very low energy diet in the form of meal replacement therapy. And of course we also want to increase energy expenditure, we all know that regular physical activity is essential for wellbeing, but physical activity, particularly in the form of anaerobic resistance exercise can protect and improve muscle mass and strength and can prevent sarcopenia. Now this is particularly important in those using pharmacotherapy or those proceeding to metabolic bariatric surgery. If we follow the algorithm, for individuals who haven't responded to a reduced energy diet, you can consider either using a very low energy diet or the addition of pharmacotherapy. Now VLED or VLCD um uh it's, It refers to commercially available packaged diets um that provide daily requirements of protein, vitamins and minerals, and it works by restricting carbohydrate to about 60 to 70 g per day, and that results in a state of nutritional ketosis, which is a potent appetite suppressant. It's very effective, we expect about 15% total body weight loss within 3 months with strict adherence, and by strict adherence I mean 3 meal replacements a day. Some individuals may prefer to follow a partial VLED which is 2 meal replacements per day, and you can use this, it's recommended for use for up to 12 weeks, but really you can continue it for 6 to 12 months under careful supervision. Obviously there are contraindications, ketosis is a big no no in pregnancy, so we're certainly not using it in women who are pregnant, you can use it in the lead up to pregnancy, but as soon as there's a positive pregnancy test, we stop the VLED. There are some special groups that we need to think about, patients with type 2 diabetes who are on insulin or.