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Welcome to the Quick Consult podcast, brought to you by Metall. Before starting this podcast, please review the faculty information, disclosure statements, and learning objectives using the link in the episode description. To claim your CME credit, complete the evaluation using the link in the episode description. This podcast is a continuing education activity managed and accredited by Affinity CE in collaboration with Metal. This activity is supported by an independent medical education grant from Lily. Welcome to the Global Obesity Academy Insights podcast series, where we translate international clinical guidelines into practical, patient-centered strategies for managing obesity. Over 4 episodes will cover initiating treatment, adjusting therapy when goals aren't met, establishing effective follow-up, and fostering bias-aware communication to enhance patient engagement. Welcome to episode one. In this episode, we will focus on initiating guideline-based obesity treatment. We'll explore how to overcome treatment challenges to help patients start on long-term evidence-based plans. I'm joined by our expert, Doctor Patrice Forner, a leading specialist in endocrinology in Australia. Welcome. Let's begin with the foundational approach. International obesity standards recommend a five-step framework. As, assess, advise, agree, assist as a starting point. For busy clinicians, the assess step seems crucial. What are the essential quick components of the assessment that identify a patient's personalized drivers, barriers, and readiness for change? Absolutely, the five A's framework is central to obesity management, and while every step matters, assesses where we gather the information that shapes everything that follows. When I'm assessing someone, I'm really trying to understand three things, why this person is living with obesity, how it's affecting their life, and what factors will help or hinder change. We always start with an obesity-centered history, and that means looking at the weight journey, when the weight changes began, what life events may have contributed, and what they've tried before, and how those experiences have shaped their confidence and expectations. I also ask about day to day nutrition and activity patterns and any barriers they regularly run into. Mental health screening is also essential. Depression, anxiety, internalized weight bias, chronic stress and poor sleep can all be major drivers of weight gain. I always ask about sleep apnea because it's common, underdiagnosed, and tightly linked to weight. Medication history is another key piece, especially drugs that can contribute to weight gain like certain antidepressants, antipsychotics, insulin, or steroids. And then we need to consider the social context, support systems, work patterns, and importantly, the patient's ability to access and afford treatment. From there we move on to an obesity-focused physical exam, and essentially we're looking for complications or contributors like hypertension, osteoarthritis, insulin resistance, or sleep apnea. Now the four M's frameworks, that's metabolic, mechanical, mental health, and monetary or or social factors, is a great way to summarize what we find. And importantly, we're not just relying on BMI. Measures like waist circumference and waist to height ratio give us a much clearer sense of central adipocity and cardio metabolic risk. And all of this information comes together to form a personalized picture that tells us what's driving weight gain, what conditions we need to manage in parallel, and how ready that person is to take the next steps. Once we have this picture, treatment often moves beyond just lifestyle. Pharmacotherapy can be utilized to decrease weight, optimize health, and support health behavior changes. When initiating treatment, especially for patients with specific comorbidities, how does the evidence on specific health benefits of each medication influence your choice of a first line agent? For example, if a patient has pre-diabetes, osteoarthritis, or obstructive sleep apnea and obesity, what does the evidence indicate about effective drug classes? So once we understand the individual drivers and the comorbidities, pharmacotherapy becomes a, a really powerful tool, not just for weight loss, but for improving overall health and treating obesity-related complications. And you're absolutely right, some medications have particularly strong evidence in specific subpopulations, but the evidence base is evolving quickly, so it's really important that we can stay aligned with current guidelines. I'm going to refer to the Canadian obesity guidelines today that were updated in August 2025, and that's because the Australian guidelines are still in development, but the key message is you should always follow your local guidance because approvals, indications and access can vary. So for clinicians in Europe, that means the ESO practical guidelines for obesity management in adults. The real art of treatment is matching the right medication to the right patient based on their comorbidities, their personal goals, and what's actually available and accessible to them. You mentioned pre-diabetes, and if we look purely at the published literature and the guidelines, loralatide, orlistat, and tezepetide have level 2A evidence for reducing progression to diabetes. So maglatide has level 1A evidence, so that's very high certainty for pre-diabetes and for achieving normal glycemia in type 2 diabetes. When it comes to obstructive sleep apnea, we have data for loralatide helping to reduce the hypopnea, sorry, the apnea hypopnea index severity, and that's backed by level 2A evidence. There is level 1A evidence for tezepetide at higher doses, so that's your 10 or 15 mg dose. So for someone struggling with uh with obstructive sleep apnea, these choices can provide a real functional benefit. With regard to osteoarthritis, we, we often underestimate how much even modest weight loss can improve pain and mobility.immaglatide has level 1A evidence for reducing osteoarthritis symptoms, particularly knee osteoarthritis, and tezepetide is currently under investigation. Ultimately it comes back to tailoring treatment to the individual. We're not just treating weight, we're considering their social and financial circumstances and the obesity related complications that may be present. That clearly demonstrates how we personalize the advised step. International guidelines emphasize the three pillars of obesity management, medical nutrition therapy, physical activity, and psychological interventions in conjunction with pharmacotherapy or bariatric surgery. Since health behavior changes alone are most often insufficient for sustained weight loss, how should clinicians frame this combination approach to set the stage for long-term success and prevent the cycle of weight regain? This is such an important point because clinicians really need to frame the three pillars as the foundation of long-term chronic disease management, not as short-term lifestyle advice or time-limited programs. One of the core messages that we want to reinforce is that obesity behaves just like any other chronic relapsing condition. And it needs the same sustained multimodal approach. We never stop someone's anti-hypertensive after 3 months and expect their BP to stay controlled, and obesity is no different. As you mentioned earlier, relying on behavior change alone is rarely enough to maintain weight loss over time, and we know that when treatment, especially pharmacotherapy, is stopped, weight tends to return and metabolic improvements fade. So the way we frame this for patients is that the three pillars, so nutrition therapy, physical activity, and psychological support work best together, and they work best when paired with effective medical therapy or bariatric surgery when indicated. It's the combination that prevents weight cycling and supports long-term stability. The big takeaway we want patients to hear is that this isn't about willpower or short-term fixes, it's about sustainable long-term treatment that integrates the pillars with the right medical support so we can achieve results at last. When initiating treatment, how do you structure the initial conversation to make it clear that this will be a longitudinal, multi-component plan and that the ultimate goal is achieving their best weight? One thing I always try to make absolutely clear from the start is that pharmacotherapy isn't the whole answer. It's an important tool, a very effective tool, but it's only one part of a much larger long-term strategy. And what really drives success is the plan that we build together. So I'll say to the patient, Let's design something that's actually feasible for you, something that fits your life, your routines, your challenges, and your goals, and that's where we move into co-creating a personalized, sustainable action plan. So this is not a generic checklist, it's not a prescriptive diet, it's a plan that integrates medical therapy with the behavioral pillars in a way that feels doable and empowering. Then we talk about what success really means, so we discuss their best weight. Now best weight is the weight that they can achieve and maintain while living their healthiest and happiest life. That shifts the focus away from perfection and helps patients feel they don't need to chase unrealistic weight targets. And finally, I stress that regular timely follow-up is not optional. That's where we fine tune medications, we support behavior change, troubleshoot barriers, and importantly, celebrate progress. It's the ongoing contact that keeps patients engaged and prevents that familiar cycle of doing well for a while and then slipping away.