The Australian Obesity Management Algorithm: A simple tool to guide the management of obesity in primary care ☆

Obesity is a complex and multifactorial chronic disease with genetic, environmental, physiological and behav- ioural determinants that requires long-term care. Obesity is associated with a broad range of complications including type 2 diabetes, cardiovascular disease, dyslipidaemia, metabolic associated fatty liver disease, reproductive hormonal abnormalities, sleep apnoea, depression, osteoarthritis and certain cancers.


The benefits of weight loss
In 2017-18, 67% of Australians aged 18 years and over were above a healthy weight, with 31% having obesity [1]. Obesity and its related complications place a considerable financial burden on Australia. In 2014-15, the direct and indirect costs of obesity were estimated at $8.65 billion [2]. Although the focus of this document is on weight loss interventions for the management of obesity, maintaining a healthy lifestyle and preventing weight gain in individuals whose weight is in the healthy or overweight range is an important and essential strategy to prevent a worsening of the current obesity epidemic.
Weight loss in people with obesity has proven medical benefits in reducing the risk of diabetes, other obesity-related complications and mortality [3]. The weight loss required to achieve some of these benefits is relatively small, with weight loss in the order of 5% showing reduction in diabetes risk [4]. However, some people with more severe obesity will require greater degrees of weight loss to improve their health, function and wellness.

The role of primary care
Primary care is critical to addressing Australia's obesity problem. It is essential that primary care practitioners identify and treat medical conditions that are largely driven by obesity as summarised in Appendix 2. Management of obesity in primary care requires a personalised approach, often in a shared care arrangement, with regular monitoring and the application of a variety of weight loss strategies, intensified over time if weight loss and health targets are not achieved.
Routine and regular consideration and assessment of weight are essential initial steps that allow identification of: • individuals whose weight is affecting their health and who may benefit from weight management interventions; and, • individuals who are gaining weight and require counselling and weight management interventions to prevent further weight gain.

Weight biasstigma -discrimination
Weight bias in obesity care is a common and important obstacle that can interfere with effective obesity treatment. Bias arises in part from the erroneous belief that obesity is caused by lifestyle choices alone. There is strong evidence that obesity is predominantly genetic [5,6] caused by classical genetic mutations [7][8][9] and epigenetic mechanisms [10,11]. Weight bias is common among healthcare providers with accumulating evidence that individuals with obesity are perceived as lacking self-control, unmotivated to improve health, noncompliant with treatment, and personally to blame for their weight [12]. Those who perceive bias from their healthcare providers have less trust in them, experience more difficulty losing weight and avoid preventive health services and medical appointments [13]. Conversely, provider weight bias may result in less willingness to help individuals with obesity compared to those with healthier weight. Healthcare professionals should reflect on their attitude towards individuals with obesity and the potential for weight bias as they can be major barriers to appropriate care.

A person-centred approach
Weight and weight loss can be sensitive issues. Most individuals with obesity have attempted multiple weight loss interventions and may not be ready to make another attempt. Poor body image, low self-esteem, psychological problems and eating disorders, such as binge eating and food addiction, are common and will influence the effectiveness of treatment. Even weight measurement may be upsetting for some people.
The objective of reducing weight and improving lifestyle behaviour should be discussed at the outset and differing expectations between medical and non-medical benefits reconciled. This discussion should be used to inform the setting of individual realistic and sustainable weight loss targets according to the treatment selected.

Lifestyle interventions
Supervised lifestyle interventions are an essential component of all weight loss strategies. Treatment goals focus on reducing energy intake, optimising diet quality and increasing energy expenditure. The consumption of a high energy diet does not necessarily equate to a nutritionally sound diet and consideration of the nutritional adequacy of an individual's diet needs to be considered [14]. On the other hand, improving diet quality and increasing physical activity improves health outcomes even without weight reduction. General advice on healthy eating is defined in the Australian Dietary Guidelines and the Australian Guide to Healthy Eating [15,16]. Similar weight loss can be achieved with diets of different macronutrient content [17,18]. Involving a multidisciplinary team, such as an accredited practicing dietitian, exercise physiologist, lifestyle coach or psychologist, should be considered. For some individuals, established commercial programmes may be appropriate [19].

Reducing energy intake
The following are options for reducing energy intake and achieving an energy deficit:

Reduced energy diet (RED)
An RED aims to produce a modest energy deficit of 2000-4000 kJ/ day (480-960 kcal/day). This can be achieved by encouraging the intake of vegetables, fruit, wholegrains, legumes, nuts, seeds, lean meat, poultry, fish, eggs and low-fat milk, cheese and yogurt and minimising the intake of discretionary foods.

Low energy diet (LED)
An LED aims to reduce total daily energy intake to 4200-5000 kJ (1000-1200 kcal) for which a more prescriptive diet is needed. Specific meal plans can be provided, or prepared low energy meals can be obtained from commercial providers. LEDs can also be achieved by substituting one or two meals with one or two specially formulated meal replacements.

Very low energy diet (VLED)
For individuals who have not responded to a RED or LED, either a VLED or addition of weight reducing pharmacotherapy (see Section 2) should be advised. A VLED aims to reduce energy intake to less than 3300 kJ/day (800 kcal/day) by substituting meals with formulated meal replacements. VLEDs can be an initial weight loss strategy when supervised lifestyle interventions have been unsuccessful in reducing weight or when rapid weight loss is required (eg prior to bariatric or general surgery), particularly in patients with super-obesity (BMI > 50 kg/m 2 ). VLEDs are low in carbohydrate, inducing mild ketosis, which has an anorexic effect, after 2-3 days.

VLED in practice
VLEDs are often recommended for up to 12 weeks but can be continued for 6-12 months under careful supervision [20], depending on baseline and target weight. Recent studies [21][22][23] have demonstrated that these diets can be effectively prescribed in primary care with excellent outcomes. Participants achieved a mean weight loss of approximately 10-14.5% initial body weight after an eight-to-20 week VLED. At 12 months metabolic parameters improved in all the studies. In DiRECT [23], which enroled only subjects with type 2 diabetes (of up to six years' duration), 46% were in remission at 12 months and 36% were still in remission at two years [24].
Regular clinical review is essential and should occur at least monthly. Individuals may follow a partial or a complete VLED regimen. The partial regimen is more palatable and is based on two meal replacements per day (typically breakfast and lunch) and one serve of lean protein (usually for dinner) with vegetables (Appendix 3). A teaspoon of olive oil should be added to induce contraction of the gall bladder and reduce the risk of gallstone formation. The complete VLED regimen is based on three meal replacements per day plus vegetables. The choice of the programme (partial vs complete) depends on the target weight and the individual's ability to tolerate the VLED. Detailed instructions on how to prescribe a VLED are available here [25].

Contraindications to VLED.
• Pregnancy or lactation • Severe psychological condition (e.g. unstable anxiety disorders, major depression), alcoholism or drug dependence • Recent myocardial infarction, cerebrovascular event or unstable angina • Porphyria • Age > 65 years (use with caution as there are limited safety data)

Special groups.
• Diabetes treated with insulin or sulphonylurea: Doses of sulphonylurea or insulin should be reduced by 50% on commencement of the VLED. Subsequent dosage adjustments are based on frequent selfmonitoring of blood glucose. Treatment of hypoglycaemia with carbohydrate takes precedence over the diet.
• Taking Warfarin: Vegetable intake is often increased during a VLED and this may alter the international normalised ratio (INR). Individuals on warfarin should be instructed to test INR one week after commencing the VLED in case the warfarin dose requires adjustment. The absolute quantity of green vegetables is not the issue, rather the level of intake must be kept constant throughout the VLED.

Increasing energy expenditure
Regular physical activity is essential for well-being and to address obesity-related complications. All adults are recommended to follow the guidelines for physical activity [26,27]. Physical activity (particularly anaerobic-resistance exercise) can protect and improve muscle mass and strength and thus may prevent sarcopenia. Aerobic exercise improves cardiovascular fitness. People with musculoskeletal problems may need alternative forms of exercise, such as water-based activities. Individuals with cardiovascular or respiratory disease may need a gentler regimen. These people may benefit from seeing an exercise physiologist or engaging in community-based programmes. (Table 1) Anti-obesity pharmacotherapy may be useful in assisting with the initial weight loss and may be combined with a RED or LED if these approaches have not been successful. Pharmacotherapy can also help with weight loss maintenance after a VLED or the prevention of weight regain regardless of the approach for the initial weight loss. While weight loss pharmacotherapy will usually be required long-term, data on its long-term safety and effectiveness are limited. Only four medications have been approved by the Australian Therapeutic Goods Administration (TGA) for the treatment of obesity: phentermine, orlistat, liraglutide and naltrexone/bupropion. Phentermine is a centrally acting adrenergic agonist that suppresses appetite [28,29]. Duromine and Metermine are delivered in a slow release resin complex, while Phentermine Juno is in a hydrophobic wax matrix that contains hydrophylic release modifiers that are digested in the gastro-intestinal tract. Side effects include tachycardia, hypertension, insomnia and dry mouth. Phentermine should not be used with anti-depressant drugs or in individuals with coronary artery disease, arrhythmias or uncontrolled hypertension because of its cardiac stimulant actions. Phentermine is registered for short-term use (3 months) as an adjunct to lifestyle management of obesity. In conjunction with a hypocaloric diet, weight reduction of 5-10% is achieved with 12 weeks of treatment [28]. The longer-term safety of phentermine has been evaluated in the SEQUEL trial in which combined phentermine (maximum dose 15 mg) and topiramate (Qysmia) was continued for 2 years [30].

Orlistat (Xenical®)
Orlistat inhibits pancreatic and gastric lipase, reducing fat absorption by 30%. Side effects include steatorrhoea, oily spotting and flatulence if more than 30 g of fat is consumed daily. Potential complications of its long-term use are deficiencies of fat-soluble vitamins A, D, E and K and the development of oxalate kidney stones. In conjunction with lifestyle intervention, results from the XENDOS study reported a weight loss of 10.6 kg at 1 year and 5.8 kg at 4 years in the orlistat group compared to 6.2 kg and 3.0 kg weight loss in the placebo group, respectively. A 37% reduction in progression to type 2 diabetes was also reported in the orlistat group [31]. The safety of orlistat has been established over the 4 years of the XENDOS study.

Liraglutide 3 mg (Saxenda®)
Liraglutide is a once-daily glucagon-like peptide-1 receptor agonist (GLP1-RA) that slows gastric emptying and suppresses appetite. The starting dose is 0.6 mg daily by subcutaneous injection, with a weekly increment of 0.6 mg to minimise gastrointestinal side effects. While the recommended and maximal daily dose is 3.0 mg, some individuals may achieve good weight loss with lower doses. Since liraglutide is a blood glucose-lowering medication, other glucose-lowering medications may need adjustment in people with diabetes. Common adverse effects include nausea, vomiting, constipation and diarrhoea, which can be reduced by slowing the dose escalation schedule. There is an increased risk of gallstones and cholecystitis requiring cholecystectomy independent of weight loss. Early studies suggested a possible increased risk of pancreatitis but this has not been borne out in large meta-analyses [32]. Results from the SCALE trial, a 56-week placebo-controlled trial, demonstrated that treatment with 3 mg liraglutide in combination with lifestyle intervention, resulted in a mean weight loss of 8% compared to 2.6% in the placebo group [33]. While the LEADER Study showed that liraglutide 1.8 mg daily in people with type 2 diabetes improved cardiovascular outcomes compared with placebo [34], no differences in cardiovascular risk were shown in a post hoc analysis of data from 5 trials (n = 5908 participants) using the 3 mg daily dose compared to placebo [35].

Naltrexone and bupropion (Contrave®)
Naltrexone 8 mg and bupropion 90 mg are available in an extended release (ER) tablet formulation. Although the precise mode of action of naltrexone and bupropion as anorectic agents is unknown, they are thought to act in both the hypothalamic hunger system and the mesolimbic reward centres of the brain [36]. The main side effects of this combination therapy are nausea and vomiting, hence the recommendation to gradually escalate the dose starting with one tablet daily and increasing the daily dose by one tablet per week to two tablets twice daily. The COR-I phase 3 clinical trial, in 1742 participants with BMI of 30-45 kg/m 2 or BMI 27-45 kg/m 2 with dyslipidaemia or hypertension, showed naltrexone 32 mg/bupropion 360 mg ER, when added to a hypocaloric diet and exercise, resulted in an average weight loss of 6.1% versus 1.3% with placebo (p < 0.001) at 56 weeks [37]. A study in people with type 2 diabetes and obesity found that naltrexone 32 mg/bupropion 360 mg ER treatment resulted in a 5% decrease in body weight from baseline (vs 1.8% placebo, p < 0.001) and a 0.6% reduction in HbA1c compared to 0.1% on placebo (p < 0.001) [38].

Off label pharmacotherapy
Other medications not approved by TGA for weight loss therapy are being used off label in Australia for the management of obesity by practitioners experienced in obesity care.

Topiramate
Topiramate is an anticonvulsant medication for difficult to control epilepsy and migraine. This medication has a powerful appetite suppressant effect, resulting in weight loss. A meta-analysis of 10 randomised controlled trials of at least 16 weeks duration concluded that the topiramate-treated group had additional weight loss of 5.3 kg compared with the placebo-treated group [39]. Effective doses are between 25 and 100 mg per day. Side effects include depression, difficulty concentrating, paraesthesia (common) and closed angle glaucoma (rare). Topiramate can be considered for use "off label" in people with obesity who have not responded to other weight loss medications or in whom other therapies are contraindicated.

Combined low dose phentermine and topiramate
The combination of these two monotherapies is useful for weight management. An Australian study investigating the safety, tolerability and efficacy of the combination showed that in about 40% of people the combination was not well tolerated, predominantly due to topiramate (25 mg mane) side effects. In those who tolerated the combination, the 10% weight loss achieved with a VLED was maintained over a mean duration of pharmacotherapy of 10 months. A group of people who continued phentermine-topiramate for 22 months had a further mean weight loss of 6.7 kg [40].

Semaglutide (Ozempic®)
Semaglutide is a once weekly GLP1-RA used in type 2 diabetes, at a maximum dose of 1 mg weekly, which results in substantial weight loss. The recommended starting dose is 0.25 mg once weekly with monthly increments to 1 mg weekly. A phase 2 trial suggests 1 mg once weekly is as effective for weight loss as liraglutide 3 mg daily [41]. A number of phase 3 trials have recently been published using doses of 2.4 mg once weekly. In a study in adults with obesity or BMI ≥ 27 kg/m 2 with at least one weight-related condition, participants achieved a mean weight loss of 14.9% body weight. Eighty-six percent of participants on active treatment had ≥ 5%, 69% ≥ 10% and 50% had ≥ 15% body weight loss [42]. The 2.4 mg once weekly dose has received US Federal Drug Administration and European Medicines Agency approval for weight loss. The side effects are similar to those of liraglutide apart from an additional adverse effect of worsening diabetic retinopathy in people with a pre-existing history of this condition. The mechanism of this is unknown. Patients with a history of diabetic retinopathy need close monitoring for progression of retinopathy.

Bariatric surgery
Bariatric surgery remains the most efficacious weight loss intervention for the treatment of obesity. Bariatric surgery should be considered as part of a comprehensive treatment delivered by a multidisciplinary team including primary care practitioners, physicians, surgeons, dietitians and psychologists. The potential benefits of surgery need to be assessed for each individual by suitably trained and experienced practitioners and balanced against the individual risk profile. Components of successful bariatric surgery care include an informed patient, tailored operation, optimisation of health prior to surgery, committed multiprofessional team care and long-term follow up. All individuals considered for bariatric surgery need a careful risk to benefit assessment and optimisation of health prior to surgery. Not all individuals in whom surgery is a potential treatment option will be suitable for surgery, especially if they have multiple and advanced complications. These people should be referred for multidisciplinary at a tertiary institution for ongoing care. A detailed description of available bariatric surgical procedures is discussed in the 2013 National Health and Medical Research Council (NHMRC) Guidelines [4].
The NHMRC clinical practice guidelines for the management of overweight and obesity [4] state that, taking into account the individual situation, bariatric surgery may be considered for adults with: • BMI > 40 kg/m 2 ; • BMI > 35.0-39.9 kg/m 2 and comorbidities that may improve with weight loss; or • BMI > 30.0 -34.9 kg/m 2 who have poorly controlled type 2 diabetes and are at increased risk of cardiovascular disease.
The Australian Diabetes Society endorsed the 2nd Diabetes Surgery Summit meeting guidelines [43] on bariatric surgery as a treatment option for individuals with type 2 diabetes, which state that metabolic bariatric surgery is recommended for individuals with: • BMI ≥ 40 kg/m 2 regardless of the level of glycaemic control or complexity of glucose lowering regimens; or • BMI 35.0-39.9 kg/m 2 with inadequate glycaemic control despite lifestyle and optimal medical therapy.
Bariatric surgery should be considered in individuals with BMI 30.0-34.9 kg/m 2 with inadequately controlled hyperglycaemia despite optimal medical treatment by either oral or injectable medications (including insulin).

Categorise the obesity
The algorithm considers two categories of BMI: BMI 30-40 kg/m 2 and BMI > 40 kg/m 2 and the presence of abdominal obesity. While BMI has some limitations, it remains a useful measure for guiding management decisions. The association between BMI and fat distribution varies according to a number of factors including race such that South Asian, South Eastern Asian, Eastern Asian and Australian Aboriginal & Torres Strait Islander populations are characterised by higher adiposity for a given BMI [44,45], and for these populations the equivalent categories are BMI 27.5-37.5 and BMI > 37.5 kg/m 2 (Table 2). Similarly, there are racial differences for the cut offs for abdominal obesity, but the categories also differ according to sex (Table 2). Although abdominal obesity tends to increase with BMI it is important to be aware that some people with a BMI in the normal or overweight range may have abdominal obesity. This occurs particularly in the elderly in association with sarcopenia. While the gold standard for measurement of abdominal fat is with computed tomography or magnetic resonance imaging, measurement of the waist circumference provides a very good estimate of metabolic disease risk. Currently there is no consensus on the optimal protocol for this measure with data supporting its measurement either at the midpoint between the lowest rib and the iliac crest; the level of the iliac crest; or, the narrowest point of the torso. Consistency of the method used is important as values differ with each technique [46].

Assess for obesity-related complications
Assessment of obesity-related complications (Appendix 2) provides additional guidance for the treatment pathway. Complications are grouped under medical, psychological and those resulting in physical limitations. The majority of individuals with a BMI > 40 kg/m 2 will have obesity-related complications. Some complications are more responsive to weight loss including type 2 diabetes, metabolic associated fatty liver disease (MAFLD), polycystic ovary syndrome (PCOS), hypogonadism and hypertension and will benefit most from weight loss treatments [47]. Although there are various systems to stage obesity, this algorithm adopts a simplified approach to obesity staging. Given the chronic progressive nature of obesity, assessment of obesity-related complications needs to be ongoing and repeated at regular intervals.

Set weight loss targets
The algorithm provides a weight loss target of 10-15% in individuals Mane, in the morning; tds, 3 times per day; bd, twice a day; MAO, monoamine oxidase; SSRI, selective serotonin reuptake inhibitor. TGA, Therapeutic Goods Administration. *Available through the veteran system. 1 Estimated price from pharmacy websites. The estimates of price per month are calculated by dividing the cost by the number of tablets per script, multiplied by the dose/day. Prices listed as Aug 2021.
with BMI 30-40 kg/m 2 and > 15% in those with BMI > 40 kg/m 2 . These targets are indicative only and personalised weight loss targets should be set between the clinician and the person with obesity. Lesser degrees of weight loss can still have medical benefits, especially in the prevention of diabetes.

Using health services
The management of obesity requires a multidisciplinary team and a long-term chronic disease approach. The algorithm suggests that primary care is ideally placed to manage the care of people with BMI 30-40 kg/m 2 without obesity-related complications. Shared care arrangements between primary care physicians and specialist services should be considered for people with BMI 30-40 kg/m 2 with complications or BMI > 40 kg/m 2 without complications. Individuals with BMI > 40 kg/m 2 with complications should be considered for referral to specialist care. (Fig. 1). (Fig. 1)

Management of individuals with BMI 30-40 kg/m 2 without complications
Supervised lifestyle intervention is the mainstay of management for individuals with BMI 30-40 kg/m 2 without established complications. Initially this includes a reduced energy diet or a low energy diet, combined with a programme to increase regular physical activity. Referral to multidisciplinary care such as an accredited practicing dietitian, exercise specialist (ie exercise physiologist, physical educator, sports physician or physiotherapist), lifestyle coach or an established commercial weight loss programme can be considered. If weight loss is insufficient or weight regain is experienced, a VLED can be considered or a RED, LED or VLED can be combined with pharmacotherapy.

Management of individuals with BMI 30-40 kg/m 2 with obesityrelated complications or BMI > 40 kg/m 2 without complications
This group of individuals requires more intensive interventions. Three main options are available and the choice of therapies should be guided by previous weight loss interventions and response.
1. VLED may be an initial option for individuals who have not tried this previously and are willing to use meal replacements. If effective in achieving adequate weight loss, the meal replacements can be reduced, and the diet can be replaced with a weight maintenance diet. If weight is regained the VLED can be reintroduced. A VLED can also be used in the short-term to reduce liver volume prior to abdominal surgery and to reduce surgical complications. 2. Pharmacotherapy can be used in combination with a RED or LED, or considered in individuals who do not have an adequate initial response to the VLED, are unwilling to follow a VLED or regain weight once the VLED is relaxed. 3. Bariatric surgery is an option for individuals who do not respond to the VLED plus pharmacotherapy or have previously tried this approach without satisfactory weight loss, or who have type 2 diabetes.

Management of individuals with BMI > 40 kg/m 2 with obesityrelated complication
These individuals should be considered for intensive medical interventions and are best managed in specialist care. The combination of a VLED and pharmacotherapy should be considered as initial treatment. Subsequent management is guided by response. Bariatric surgery should be recommended, especially in the presence of weight responsive complications or when previous interventions have not resulted in sustainable weight loss or health improvements.

Age
The nadir for lowest mortality associated with weight is not constant and varies with age, ethnicity and the presence of other disease. Obesity defined by BMI ≥ 30 kg/m 2 does not appear to carry the same mortality risk in older adults (> 65 years). With ageing, lowest mortality is associated with a BMI higher than the normal range [48]. The mortality risk associated with weight loss (including intentional) increases with age, generating an altered risk to benefit ratio. Healthy ageing should therefore focus on lifestyle, quality nutrition and physical activity to improve cardiovascular fitness, optimise functional independence and quality of life.

Young adults (18-35 years)
Adolescence and early adulthood are often associated with a decrease in physical activity and rapid weight gain. Particular attention should be given to early detection and management of individuals on a positive weight trajectory and with high cardio-metabolic risk. Interventions should be initiated early to prevent weight gain, complications and end-organ damage.

Older adults (>65 years)
Research in the elderly is scant. There is no clear BMI target in this age group. With aging there is a reduction in muscle mass, height loss and an increase in abdominal obesity, none of which are accounted for in the BMI. The main goal in older adults with obesity is to improve physical function and minimise the impact of obesity-related complications. In individuals with BMI 30-40 kg/m 2 and BMI ≥ 40 kg/m 2 without complications, the aims of treatment are to maintain health and physical function, prevent weight gain and generate a more moderate intentional weight loss. In individuals with a BMI ≥ 40 kg/m 2 with obesity-related complications, more intensive therapies are indicated, but maintaining physical function, favourable body composition and quality nutrition may require specific lifestyle programmes. When engaging older adults in intensive therapies, cardiovascular fitness should be considered.

Pregnancy
Obesity during pregnancy is associated with an increased risk of obstetric complications, hypertension, gestational diabetes, foetal macrosomia, birth defects and increased risk of obesity in the offspring. In women with BMI > 30 kg/m 2 , a total weight gain not exceeding 9 kg is recommended [49,50]. Gestational weight gain (GWG) should be closely monitored in women with obesity, as well as in women with a  healthy pre-pregnancy weight, as excessive GWG is associated with poorer maternal and neonatal outcomes. In women with excessive weight gain, weight management strategies should be implemented. If indicated, bariatric surgery should be performed at least 12-18 months prior to pregnancy. All medications available for weight loss in Australia are category B for use in pregnancy.

Implementation in primary care and linkage with specialist care
Obesity is a chronic disease that requires lifelong management. Primary care physicians play a key role in identifying individuals with obesity and implementing appropriate interventions to support weight loss and prevent weight regain. Primary care should assist individuals to access obesity support services that address the complexity surrounding obesity. General practices can strategically improve services for these individuals and carers through personal education, education of practice staff, development of obesity focused practice resources (e.g. weighing scales to monitor individuals across the obesity ranges as a matter of routine) and development of a referral network of specialist services or multidisciplinary teams able to manage obesity and weight-related complications. Practice systems that exist for chronic disease management can be used for weight management such as recall systems and reviews focusing on high risk individuals with complications and those who have had bariatric surgery [27,[51][52][53][54].

CRediT authorship contribution statement
All authors contributed to the writing of this document. Nathalie Kirzirian collated the first draft based on input from all authors. Erica Bessell prepared the table entitled "Summary of current guidelines for management of overweight and obesity" based on literature review and re-configured the algorithm by amalgamating several pathways into one pictorial. All authors reviewed and approved this version (October, 2021) of the guidelines.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Competing interest statement
TPM has received support from Novo Nordisk for seminar presentations at conferences and Eli Lilly for participation in an advisory board. She serves on the Nestle Health Science VLCD Advisory Board. JP is on Advisory Boards for Novo Nordisk and iNOVA and has given lectures on obesity management for Novo Nordisk and iNova. JBD has received support from I-Nova as a consultant, advisory board and speaker fees; Nestle Health Science Consultant, advisory board and speaker fees; Novo Nordisk: Advisory board and speaker fees. GR has received consulting and speaking honoraria from NovoNordisk, iNova, Ethicon (Johnson & Johnson), Reshape HelathSciences and Nestle HealthScience. GD has received payments from Novo Nordisk, Inova pharmaceuticals for participation in advisory boards and seminar presentations at conferences. SC has received payments from Novo Nordisk and iNOVA pharmaceuticals for participation in advisory boards.

Acknowledgements
All persons who have made substantial contributions to the work reported in the manuscript (e.g., technical help, writing and editing assistance, general support), but who do not meet the criteria for authorship, are named in the Acknowledgements and have given us their written permission to be named. If we have not included an Acknowledgements, then that indicates that we have not received substantial contributions from non-authors.