doi:10.1111/imj.

13474

CLINICAL PERSPECTIVES

Approaches to obesity management

Arianne N. Sweeting1,2 and Ian D. Caterson1,2
1
Department of Endocrinology, Royal Prince Alfred Hospital, and 2Boden Institute, Charles Perkins Centre, University of Sydney, Sydney, New South
Wales, Australia

Key words This review will provide an overview of the currently available approaches to obesity
obesity, lifestyle, VLED, pharmacotherapy, management available in Australia, including the various approaches to lifestyle inter-
bariatric surgery. vention, in addition to evaluating the safety and efficacy of adjuvant therapies, includ-
ing pharmacotherapy and bariatric surgery.
Correspondence
Arianne N. Sweeting, Department of
Endocrinology, Royal Prince Alfred Hospital,
Camperdown, Sydney, NSW 2050, Australia.
Email: arianne.sweeting@sydney.edu.au

Received 27 September 2016; accepted

23 November 2016.

Introduction bariatric surgery can prevent cardiovascular morbidity

and mortality,8 presumably because of the significantly
The global obesity epidemic has led to more than tripling
greater (10–40 kg) and sustained weight loss achieved
in the prevalence of obesity since 1980, with 63.4% of
compared to lifestyle intervention alone.9
the Australian adult population now overweight and
Accordingly, although lifestyle intervention remains
obese.1 Obesity is associated with multiple comorbidities,
the foundation for obesity management, adjuvant thera-
with cardio-metabolic complications predominantly
pies, including very low-energy diets (VLED), pharmaco-
accounting for the observed increased risk of morbidity
therapy and bariatric surgery, are increasingly
and mortality and major costs in managing the associ-
recognised as important components of obesity manage-
ated osteoarthritis and musculoskeletal disorders.
ment. In general, these therapies are indicated where
It is well established that a 5–10% weight reduction
lifestyle intervention has failed to achieve sufficient
from baseline reduces this cardio-metabolic risk and
weight reduction in obese or overweight individuals to
improves quality of life,2,3 even if individuals remain in
improve associated disease or quality of life or sufficient
the overweight or obese category, and this should be the
improvement in obesity-related comorbidities.10,11
primary goal of obesity management. However,
This review will provide an overview of the currently
although short-term weight loss is readily achievable,
available approaches to obesity management available in
weight maintenance is difficult because of both evolu-
Australia, evaluating the safety and efficacy of adjuvant
tionary counter-regulatory neuroendocrine mechanisms,
therapies, including pharmacotherapy and bariatric
which promote weight regain,4 and environmental fac-
surgery.
tors such as inappropriate food intake and increased sed-
entary lifestyle as physical activity appears particularly
important for weight maintenance.5 Lifestyle
Despite this, there is growing evidence that a ‘serious’
weight loss attempt, which results in reduced weight The hierarchical approach to obesity management
even if that weight is subsequently regained, produces a emphasises the importance of sustained lifestyle inter-
lasting benefit with improvement in cardiovascular risk vention, specifically diet (caloric/energy restriction,
and decreased cardiovascular and overall mortality.6,7 including use of VLED) and increased physical activity.
Moreover, the Swedish Obesity study demonstrated that The National Health and Medical Research Council
(NHMRC) clinical practice guidelines for the manage-
ment of overweight and obesity provide a recommended
Funding: None. framework, particularly useful at the primary care level,
Conflict of interest: None. based on the 5As approach (Ask, Assess, Advise, Assist

734 Internal Medicine Journal 47 (2017) 734–746

© 2017 Royal Australasian College of Physicians

and Arrange follow up).12 A multidisciplinary approach
is generally required given the multifactorial aetiology of
obesity, associated comorbidities and its generally
chronic relapsing and remitting course.
Dietary intervention should aim for an energy deficit
of 2–4 MJ per day (i.e. ~ 500–1000 kcal) to achieve a
steady rate of weight loss of 0.5–1 kg per week, although
weight plateau generally occurs by 6 months.13 The
Australian Guide to Healthy Eating guidelines, devel-
oped by the NHMRC, recommends a daily number of
serves based on the lowest energy requirements within
each age and gender group, and thus, following the
guidelines should lead to an appropriate energy deficit
for an overweight or obese individual (http://www.
eatforhealth.gov.au). Furthermore, online dynamic
models that predict how alterations to diet and physical
activity impact weight loss over time (i.e. http://
bwsimulator.niddk.nih.gov and http://www.pbrc.edu/
research-and-faculty/calculators/weight-loss-predictor/)
may be useful in establishing a target energy intake for
an individual based on their desired weight loss and
requirements for ongoing weight maintenance.
Long-term observational data from the National
Weight Control Registry in the United States have identi-
fied specific lifestyle factors associated with improved
maintenance of weight reduction.10,11 These include
engaging in high levels of physical activity (approxi-
mately 1 h per day); adhering to a low-calorie, low-fat
diet; consuming breakfast regularly; self-monitoring
weight and maintaining a consistent eating pattern
throughout the week.10 Larger initial weight losses and
longer durations of maintenance are also associated with
better long-term outcomes.11 It is also apparent that if
maintenance of weight reduction is achieved for 2–5
years, the likelihood of longer-term success, even after
10 years, significantly increases.10
Given that lifestyle intervention does not often result in
maintained weight reduction, adjunctive therapies should
be considered when lifestyle strategies have not achieved
5–10% baseline weight reduction or improvement in
obesity-related comorbidities after a minimum of 3 months
or to prevent weight regain after a lifestyle programme.12
Very low-energy diets
VLED are the most intensive dietary intervention for obe-
sity management. They aim to replace (completely or par-
tially) usual dietary intake with nutritionally complete
commercial products fortified with the recommended
daily allowances of micronutrients, providing a total of
450–800 kcal (1855–3297 kJ) per day.14 Rapid initial
weight loss is achieved, and there is associated ketosis-
mediated appetite suppression, which helps patients
Internal Medicine Journal 47 (2017) 734–746
© 2017 Royal Australasian College of Physicians
Obesity management
persevere on the VLED regimen, with weight loss of
~1.5–2.0 kg for women and 2.0–2.5 kg for men per week,
although this subsequently plateaus.15 Most commercial
VLED preparations recommend replacing three meals per
day and provide approximately 70 g of protein; however,
a minimum protein intake of 0.8 g/kg/day of bodyweight
is generally recommended to attenuate the loss of lean
body mass.15,16 Larger individuals may need four or five
meal replacements a day to help reduce appetite on the
VLED regimen. It is also worth noting that not all com-
mercially available meal replacements are nutritionally
complete and thus intended/appropriate for use as a VLED
regimen.
VLED should be used under medical supervision
even in the absence of obesity comorbidities, and reg-
ular medical review is required to manage the effect
of VLED on obesity comorbidities. For example, anti-
hypertensive agents may need to be decreased, while
significant dose reduction of diabetic agents are
required to avoid hypoglycaemia in the setting of rapid
weight loss and the carbohydrate restriction provided
by the VLED.14 Those with type 1 diabetes can be
managed with this therapy but under close specialist
supervision.
Pharmacotherapy
Obesity pharmacotherapy has experienced a recent
revival with the Federal Drug Administration’s (FDA)
approval of four new agents for chronic obesity therapy
since 2012. These include phentermine/topiramate
extended release (ER) (Qsymia), lorcaserin (Belviq), nal-
trexone HCl/bupropion HCl ER (Contrave) and higher-
dose liraglutide (Saxenda). Of these, only higher dose lir-
aglutide has been TGA approved in Australia, joining
orlistat (Xenical) (approved for chronic obesity manage-
ment) and phentermine (Duromine) (approved for
short-term obesity management).
In general, pharmacotherapy achieves weight reduc-
tion intermediate to that of lifestyle intervention and
bariatric surgery. Newer pharmacotherapies frequently
target peripheral and central homeostatic pathways
and utilise combination therapy to counteract better
the multiple counter-regulatory neuroendocrine
mechanisms that promote weight regain. This also
allows the use of lower doses of the constituent
monotherapy agents, theoretically improving the risk–
benefit ratio of pharmacotherapy.17 Nevertheless, the
poor history of obesity pharmacotherapy demonstrates
the importance of long-term cardiovascular and neuro-
cognitive data in evaluating the ultimate safety of
these therapies.
735
Sweeting & Caterson
Phentermine
The noradrenergic sympathomimetic agent phentermine
is approved as a short-duration (<3 months) adjunct to
lifestyle modification, although it should be noted that
combination phentermine/topiramate ER is indicated for
long-term treatment in the United States. The exact
mechanism of action of phentermine is unknown, but it
appears to act within the hypothalamus to upregulate
noradrenaline, resulting in the stimulation of β2-
adrenergic receptors to induce appetite suppression; it
also appears to inhibit monoamine oxidase, potentiating
the effect of serotonin and possibly increasing basal met-
abolic rate.18–20 Phentermine is associated with a 3.6 kg
(95% confidence interval (CI), 0.6–6.0 kg) greater
weight loss compared with placebo in studies.21
Adverse effects related to phentermine are attributable
to its stimulant properties and include dry mouth, agita-
tion, insomnia and decreased concentration.18–20 Signifi-
cant cardiovascular and neurocognitive complications
were also historically attributed to this therapy; however,
a recent meta-analysis of phentermine monotherapy stud-
ies concluded that phentermine is not associated with any
serious adverse events.22 It may be used, after medical
reassessment, for later/succeeding periods of 3 months.
Orlistat
The triacylglycerol lipase inhibitor orlistat reduces the
breakdown, and thus absorption, of some dietary fats by
binding to lipase, inhibiting hydrolysis of triglycerides
into fatty acids and monoglycerides and increasing faecal
fat excretion by 30%.23 It is approved for long-term obe-
sity management and remains the only obesity pharma-
cotherapy with long-term safety and efficacy data.
Orlistat is modestly effective when combined with life-
style intervention, associated with a 2.89-kg (95% CI,
2.27–3.51 kg) or 2.9% (95% CI, 2.5–3.4%) placebo-
subtracted weight reduction.24,25 Nevertheless, this is of
sufficient magnitude to improve cardio-metabolic para-
meters, with a 37.3% reduced incidence of new onset
type 2 diabetes, improved blood glucose levels in those
with existing type 2 diabetes and lowered low-density lip-
oprotein-cholesterol (because of its mechanism of action)
and blood pressure observed in intervention studies.24,25
Despite this, the high frequency of gastrointestinal side-
effects limits its utility, although these symptoms are gen-
erally mild and significantly reduced on a low-fat diet.
Liraglutide
Liraglutide is a GLP-1 receptor (GLP-1R) agonist that is
TGA- and PBS-approved for the treatment of type
736
2 diabetes at a dose of 1.8 mg daily. In December 2015,
higher-dose liraglutide (3 mg) was also TGA-approved
for the long-term treatment of obesity, although there
are currently limited long-term safety and efficacy data
on this dose. Importantly, liraglutide 1.8 mg was
recently shown to reduce cardiovascular morbidity and
mortality in individuals with type 2 diabetes over a
median follow-up 3.8 years.26 Peripherally, GLP-1R ago-
nists slow gastric emptying, causing early satiety,27 while
associated gastrointestinal adverse effects also contribute
to reduced appetite.28,29 However, weight loss associated
with GLP-1R agonists can occur independent of delayed
gastric emptying and the associated gastrointestinal
sequelae.30 Liraglutide-induced appetite suppression
may therefore be predominantly centrally mediated as
liraglutide crosses the blood–brain barrier.31,32
Modest weight reduction has been consistently
observed with liraglutide treatment for type 2 diabetes,
leading to several large recent trials that confirmed dose-
dependent weight reduction in obese and overweight
patients without diabetes33–36 of up to a mean of 8.4 kg
for liraglutide 3 mg in conjunction with lifestyle inter-
vention, compared to 2.8 kg for placebo (i.e. 5.6 kg
mean-subtracted weight loss with liraglutide).36 Liraglu-
tide was also associated with improvement in several
cardio-metabolic parameters.26,33–36
Liraglutide is commonly associated with generally self-
limiting gastrointestinal sequelae, including nausea,
vomiting, diarrhoea and constipation in addition to head-
ache and hypoglycaemia in individuals with type 2 diabe-
tes on concurrent anti-diabetic therapy.33–36 Rare adverse
effects include acute pancreatitis and other gastrointesti-
nal effects, such as dyspepsia, reflux and gastroenteritis.
Renal impairment because of severe dehydration from
nausea and vomiting and urinary tract infections has also
been reported.37 Liraglutide may be associated with neu-
rocognitive symptoms, including fatigue, dizziness,
insomnia, suicidal ideation and anxiety. It is contraindi-
cated in those with a personal or family history of medul-
lary thyroid cancer or multiple endocrine neoplasia
(MEN) syndrome type 2 because of an increased inci-
dence of thyroid C-cell tumours in rodents. It should be
noted, however, that GLP-1R expression is higher in
rodents compared to human thyroid C-cells.37
Bariatric surgery
Bariatric surgery remains the most effective management
approach to obesity, with reported beneficial effects on
appetite-mediating hormones, cardio-metabolic para-
meters and improved survival.38–40 Indeed, the
Australian Diabetes Society (ADS) has recently endorsed
international guidelines recommending bariatric surgery
Internal Medicine Journal 47 (2017) 734–746
© 2017 Royal Australasian College of Physicians
 Obesity management

as a management strategy for type 2 diabetes in those
with class III (body mass index (BMI) ≥40 kg/m2) obesity
or those with class II (BMI 35.0–39.9 kg/m2) obesity who
have had inadequate glycaemic control with lifestyle and
pharmacotherapy intervention.41 However, bariatric sur-
gery has the most adverse safety profile of the adjuvant
obesity interventions, primarily related to perioperative
morbidity and mortality. The major limitations of bariat-
ric surgery in Australia are its lack of accessibility in the
public hospital system and lack of long-term follow-up
systems/programmes.
The most commonly performed types of bariatric sur-
gery in Australia include laparoscopic-adjustable gastric
banding (LAGB), laparoscopic sleeve gastrectomy (LSG)
and laparoscopic Roux-en-Y gastric bypass (LRYGB).
LSG is frequently performed as it is less invasive and
complicated than LRYGB.42 Increasing evidence suggests
that the efficacy of LSG and LRYGB relate not only to
their mechanical restrictive and malabsorptive sequelae
but also to significant effects on gastrointestinal hor-
mones, beneficially altering neuroendocrine pathways
and regulating energy homeostasis.43,44 In general,
malabsorptive procedures, such as LRYGB, produce
greater weight loss and improvement of obesity-related
comorbidities.39,40 Although head-to-head comparisons
of bariatric surgery efficacy are limited, a UK observa-
tional study reported weight loss of 38 kg for LRYGB,
31 kg for LSG and 20 kg for LAGB over 4 years.45 An
Australian study demonstrated that individuals who
underwent LAGB maintained 47% excess weight loss
(i.e. the proportion of weight above BMI 25 kg/m2 that
is lost) at 10 years.46 Similar to other obesity manage-
ment approaches, however, the majority of weight loss
generally occurs in the first year post-surgery, with sub-
sequent weight plateau or increase.38–40
Ongoing lifestyle intervention post-bariatric surgery,
therefore, remains crucial for long-term weight mainte-
nance. Other important considerations for bariatric sur-
gery relate to the lack of long-term data and appropriate
choice of surgery, including associated complications
and revision rates. Acute perioperative complications,
such as haemorrhage, obstruction, anastomotic leak,
infection and pulmonary emboli, can occur in up to
10% of individuals.47 Long-term involvement of a mul-
tidisciplinary team and medical follow up is also essen-
tial given associated bone and nutritional issues,
including increased risk of osteoporosis, often exacer-
bated by long-term vitamin D deficiency and potentially
also mediated by alterations in circulating adipokines
and gastrointestinal hormones48; ‘dumping syndrome’,
which occurs in up to 76% of individuals and micronu-
trient deficiencies, with vitamin B12 deficiency evident
in up to 30% of individuals after LRYGB. Fat-soluble
vitamin deficiencies can also occur.42 Long-term surgical
follow-up is also important for subsequent band adjust-
ment for LAGB.
Conclusions
Lifestyle intervention remains the foundation of obesity
management; however, its effectiveness is frequently
limited by weight regain in the longer term. Accordingly,
adjunctive therapies, including pharmacotherapy and
bariatric surgery, have an increasingly important role to
play in obesity management. Bariatric surgery, and to a
lesser extent pharmacotherapy, appear promising long-
term intervention strategies both to maintain weight
reduction and improve associated cardio-metabolic risk;
however, longer-term safety and efficacy data are still
required. The cost-effectiveness of these strategies must
also be considered given the global obesity epidemic and
the fact that obesity is an increasingly chronic disease
requiring long-term management. Ultimately, obesity,
which should be considered a disease and has in fact
been formally classified as such in several countries, is
best managed with a multidisciplinary approach, and
therapy, perforce, is lifelong.

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doi:10.1111/imj.13471

ETHICS IN MEDICINE

Conflicts of interest in medicine: taking diversity seriously

Jane Williams ,1 Christopher Mayes,1 Paul Komesaroff,2 Ian Kerridge1 and Wendy Lipworth1
1
Centre for Values, Ethics and the Law in Medicine (VELiM), University of Sydney, Sydney, New South Wales, and 2Faculty of Medicine, Nursing and
Health Sciences, Monash University, Melbourne, Victoria, Australia

Key words
conflicts of interest, attitudes, qualitative
research.
Correspondence
Jane Williams, Centre for Values, Ethics and the
Law in Medicine (VELiM), K25, University of
Sydney, Sydney, NSW 2006, Australia.
Email: jane.h.williams@sydney.edu.au
Received 19 February 2017; accepted
5 March 2017.
Conflicts of interest (COI) are considered ubiquitous in many healthcare
arrangements,1 but there is disagreement on how COI should be defined, whether
non-financial conflicts deserve attention and the relationship between COI and harm.
We conducted a study of Australian healthcare professionals and students to gain a bet-
ter understanding of the way that COI are understood in practice. In this paper, we out-
line an empirically derived taxonomy of the understanding of, and attitudes towards,
COI. We carried out 25 semistructured interviews with clinicians working in several
fields across Australia and held six focus group discussions with medical students in
New South Wales. Interviewees and focus groups followed similar question routes
investigating participants’ understanding of COI and views of management. All data
were compared and analysed using a matrix of pre-determined questions. There were,
broadly, two views of COI: that COI were potentially harmful and morally compromis-
ing and another that saw COI as less serious and easily managed through existing struc-
tures. Definitions of COI varied widely and were both financial and non-financial.
Causes of COI were, variously, systemic, individual and/or relational. Some participants
associated COI with moral wrongdoing, and a variety of potential harms was identified.
Views on how COI should be managed were similarly varied. We found considerable
heterogeneity in how COI are understood in practice. This has implications for manage-
ment systems that are currently in place, and we suggest a more sophisticated system
for considering and mitigating COI.

Internal Medicine Journal 47 (2017) 734–746 739

© 2017 Royal Australasian College of Physicians