Divide over weight: disease or lifestyle

National clinical treatment guidelines to be overhauled as highly effective weight-loss drugs usher in a ‘new paradigm’ in care.

The explosion in popularity of Ozempic, which has been widely prescribed for weight loss, has alarmed some doctors who are railing against a medicalised approach to weight.

The national clinical treatment guidelines for obesity are set to undergo an overhaul – shifting away from the notion weight control is “primarily the individual’s responsibility” ­– as the advent of highly effective weight-loss drugs ushers in a “new paradigm” in care.

The new guidelines are likely to acknowledge that the modern obesogenic society makes it ­extremely difficult for people to maintain a healthy weight and challenge the “eat less, move more” dogma as overly simplistic.

The federal government-­commissioned review will be led by researchers at Deakin University, who have signalled that the role of a suite of new weight-loss drugs will be central to deliberations around the new guidance. Demand for those drugs, such as diabetes medication Ozempic, has exploded in recent years.

In an exclusive interview outlining the direction of the updated advice, the project’s academic lead, professor of dietetics Judi Porter, said the advent of effective weight-loss drugs was an enormous development in obesity treatment and a scientific committee would examine the evidence of drugs’ benefits and risks amid a “massive overhaul of how we manage the issue of overweight and obesity”.

“It’s really exciting that we’re moving from really two paradigms of how to manage weight – behavioural or lifestyle approaches, and bariatric surgery – to now having this new approach with the pharmacotherapies,” Professor Porter said. “So that’s a massive change since the last guidelines were published in 2013.

“The traditional approaches were very much ‘go away and eat less and exercise more and it will be fixed’. The evidence has progressed a long way since that time. We now know that there are more ways to go about it, more support needed, and we can look to support people to manage their weight in a less stigmatising way.”

Two-thirds of Australians are overweight or obese, with roughly one-third overweight and one-third living with obesity. It’s one of the highest prevalences in the world. The explosion in popularity of Ozempic, which has been widely prescribed for weight loss, has alarmed some doctors who are railing against a medicalised approach to weight. There is currently a critical shortage of supply of Ozempic.

However, a new drug with the same active ingredient, Wegovy, has been approved for weight loss for those with severe obesity as an adjunct to diet and exercise and is expected to be available in coming months. The drugs can have side effects including, commonly, nausea and very rarely, kidney problems or vision changes.

Former Australian of the Year ophthalmologist James Muecke has been vocal in his criticism of what he says is a concerted push by Big Pharma to cash in on the positioning of obesity as a disease that requires a medical fix.

“You can imagine this will be an absolute coup for the pharmaceutical industry to have a potential quick fix, you know, people can keep on eating all their junk food and ultra processed food, and just take a tablet,” Dr Muecke says.

“The pharmaceutical industry is set to make a fortune out of weight loss drugs. They can see the dollar signs.”

The AMA has also called for caution, saying the focus should be on prevention. “There is no conceivable way human genetics have changed in any meaningful way over 30 or 40 years,” said AMA president Steve Robson. “So it has to be nurture. There is no other explanation.”

The guidelines, which will be reviewed by Deakin’s Institute for Health Transformation and Institute for Physical Activity and ­Nutrition, are used by GPs, primary healthcare nurses, primary healthcare professionals and allied health professionals.

It’s the first time in 10 years the guidelines have been reviewed. Professor Porter said researchers would extensively examine the scientific evidence around weight-loss drugs and dietary approaches, including intermittent fasting and low-carb diets, calorie restriction, and behavioural approaches. It would also include the impact of psychological supports and sleep.

Although Australia has had a national obesity strategy in place for more than a decade, there has been no improvement. A new national obesity policy was launched last year.

The clinical guidelines overhaul has been welcomed by obesity groups, who said for decades people struggling with their weight had been set up fail.

“Many healthcare professionals don’t really fully understand the complex drivers of obesity, the environmental drivers, which includes obesogenic food environments, but also biological drivers,” said the Obesity Collective’s Tiffany Petre.

“And with some people being more predisposed to obesity, simply telling someone to eat less and walk more is not only not effective, and not evidence-based, but in some circumstances would cause harm, because that person might feel stigmatised and not supported by their healthcare professional. The game has changed and the evidence has changed.”

Doctors at the front line of treating obesity say the new drugs, which act directly on the brain and control the drivers and hunger and satiety, are proving of enormous assistance for many patients. “There’s been such a demand for treatment because of effective therapies,” said Georgia Rigas, a Sydney GP who specialises in treating obesity. “Prior to that, people felt that there wasn’t anything that could help them to the degree that they needed. Now people are actively wanting to talk about it and seek treatment.”

Terri-Lynne South, medical director of Lifestyle Metabolic clinic in Brisbane and chair of the Royal Australian College of GPs Specific Interests Obesity Management group, said: “These drugs are actually affecting the biology of obesity, both in the gut and in the brain.

“We’re actually using the body’s physiology to help balance the hunger hormones versus the satiety hormones. It has been the best tool from a medication point of view that we’ve seen for some time.”

Despite the polarised views, most doctors agree that the “eat less, move more” message has fundamentally failed and is unhelpful. Professor Porter said the new guidelines would canvas approaches other than only calorie restriction, including low-carb diets and intermittent fasting.

The clinical guidelines are not intended to examine preventive approaches, but they will explore other dietary approaches, with a view that calorie restriction is not the only way to lose weight. The research will be examined throughout this year and a consultation paper will be published next January with public comments invited.