New guidance reframes obesity as a chronic disease and outlines practical pathways for long-term cardiovascular care.
The National Heart Foundation has released Australia’s first clinical consensus statement on obesity and cardiovascular disease.
The 107-page document is an up-to-date evidence-based guideline for clinicians and includes how to define and diagnose overweight and obesity and interventions, including behavioural modifications, pharmacotherapy and surgery.
Roughly two thirds of Australian adults are living with overweight or obesity, with obesity projected to affect more than half the adult population by 2035.
“What we’ve found is that in this rapidly moving area where there have been new treatments become available – new hope really – for dealing with obesity management in the clinic, that health professionals need a very practical evidence-based guidance,” said Professor Garry Jennings, the Heart Foundation’s chief medical advisor.
“[The statement] considers weight stigma, it considers the needs of high priority populations, it considers what we’re now calling the cardiovascular kidney metabolic syndrome – recognising that older people, generally that are overweight, quite often have not just cardiovascular complications but also kidney complications, metabolic problems [and] problems with fatty liver, and that we shouldn’t just treat these things one by one.”
The statement places strong emphasis on tackling weight stigma and reframing obesity as a chronic disease rather than a matter of personal responsibility.
“For far too long, the public narrative has always been that obesity is an individualised problem; it’s an issue around willpower and motivation,” said Dr Mark Mellor, specialist GP in obesity and metabolic health.
“We know now that… it’s a chronic condition beyond the choice of the individual, and the determinants for obesity and, to some degree, cardiovascular disease as well, are complex and not within the direct control of the individual.
“Hopefully the statement goes some way to unpacking the issues around bias and stigma, particularly in the healthcare setting, but also in politics… [with] action on equitable access to effective treatment for people with obesity and cardiovascular disease.”
He highlighted several areas that were most significant for GPs.
“[The statement] offers really clear, practical clinical guidance for general practitioners [and] for healthcare practitioners more broadly, on how to assess and manage people with obesity and cardiovascular disease, or are at high risk of cardiovascular disease,” he explained.
“The statement underpins that obesity is a chronic, relapsing, lifelong condition, and that short term measures might not really be the way to go. We need to be thinking longitudinally and be patient-centred about it.
“The statement does highlight that practitioners need to think about escalating treatment, and it gives clear pathways for how to go about that. So, behaviour modification in terms of changes in nutrition and physical activity are always going to be core.
“But for some people, that might not work… and I think that the statement gives a really clear pathway about when we should be considering escalation to pharmacotherapies that are indicated for weight management and for cardiovascular disease and even surgical treatments.
“So hopefully this will go some way to combating treatment inertia among general practitioners and healthcare practitioners more widely.”
Behavioural modifications in the consensus statement centre around not just reducing weight but reducing the risk of cardiovascular consequences. It’s about a heart healthy, balanced eating pattern rather than solely reducing energy intake.
It highlights the evidence for the Mediterranean diet and the DASH diet, but with a focus on modifications that are sustainable in the long-term.
The recommendations around physical activity were in line with the daily 30 minutes of moderate to vigorous physical activity guideline, but Professor Jennings said it also recognised that any exercise was better than none.
“It really only recommends that people should do what they can. We also know that resistance exercise is very helpful in this situation too, and at the other end of the physical activity spectrum, limiting the time that people are sedentary,” he said.
Other recommendations focussed on the use of GLP-1 receptor agonists, such as semaglutide (Ozempic) and tirzepitide (Mounjaro). Professor Jennings described these medications as a “very important area of not just metabolic and weight control, but also reducing cardiovascular consequences”.
“Surgery has also been shown to have benefits as far as cardiovascular risk factors are concerned, and it has a place. It can be very effective in the long term,” he said.
Lifelong care and follow-up were highlighted, with a need to manage all factors rather than weight alone.
“Treatments with proven cardiovascular benefits should be prioritised and maintained for a long time. And this needs to happen in primary care, where we can get coordinated and lifelong cardiovascular risk management,” said Professor Jennings.
When discussing diagnosis, he explained that BMI still had an important place but should be considered alongside additional measurements.
“We know that body mass index has been around for a long time, and it’s served its purpose very well in terms of defining people that have a high body mass relative to their height. We also know it’s a little bit flawed,” he said.
“It also matters not just how much fat people have got in their body, but where it is located. And we know, for example, that waist circumference can add value in terms of identifying people that are at increased risk, and other measures that can be used include waist to height ratio and waist to hip ratio.
“What we’re suggesting is that we have to stick with body mass index, because all the clinical trials use that as the decision point for interventions, but we also are recommending for conditions that they keep an eye on these other factors which are associated with more fat in the body.”
The full consensus statement can be accessed here.
