Sally Howlett is a GP Leadership Fellow in Sussex and Kent from 2025 to 2026 and an NHS Salaried GP in Hove. She has a postgraduate diploma in obesity and weight management. She is on LinkedIN.
Obesity now affects more than a quarter of adults in the United Kingdom and continues to rise across Europe. As its management becomes increasingly complex—with new pharmacological therapies, evolving diagnostic frameworks, and persistent stigma—primary care clinicians are firmly at the centre of care. Attending the European Association for the Study of Obesity (EASO) Primary Care Obesity Masterclass in Vienna offered a timely opportunity to reflect on how we translate this rapidly evolving evidence into everyday practice.
One of the clearest messages from the meeting was the need to move beyond body mass index (BMI) as the sole tool for assessing obesity. While BMI remains useful for population-level screening, it fails to distinguish between fat and lean mass or account for fat distribution. Increasingly, waist-to-height ratio (WHtR) is being advocated as a practical adjunct. The principle is simple: waist circumference should be less than half of height. A ratio above 0.5 is associated with increased cardiometabolic risk and may identify patients who would otherwise be overlooked using BMI alone.1 In primary care, incorporating this measure would require minimal additional time yet offer more nuanced risk stratification.
Despite the prevalence of obesity, both clinicians and patients often hesitate to raise the topic.
Equally important was the discussion around how we initiate conversations about weight. Despite the prevalence of obesity, both clinicians and patients often hesitate to raise the topic. The 5As framework—Ask, Assess, Advise, Agree, Assist—provides a structured, patient-centred approach that helps reduce discomfort on both sides. Evidence suggests that many patients would welcome support with weight management, yet mutual hesitation creates a barrier.2 Recognising this shared reluctance is key. In practice, these conversations are rarely resolved in a single consultation; instead, they require continuity, trust, and careful pacing within the realities of primary care.
The issue of stigma remains a significant barrier to effective care. Weight bias—both implicit and explicit—continues to exist within healthcare settings and can undermine patient engagement. Reframing obesity as a chronic, relapsing disease rather than a simple lifestyle choice is therefore essential. This shift reflects a growing understanding of the complex interplay between genetics, environment, psychology, and physiology. Weight loss triggers adaptive biological responses, including increased appetite and reduced energy expenditure, which make long-term maintenance challenging.3 Recognising these mechanisms helps move the conversation away from blame and towards long-term support.
The emergence of incretin-based therapies marks a major shift in obesity management. Glucagon-like peptide-1 (GLP-1) receptor agonists and newer dual incretin agents are demonstrating substantial and sustained weight loss in clinical trials. Patients frequently describe a reduction in “food noise,” enabling behavioural changes that were previously difficult to sustain. However, discussions at the masterclass highlighted a critical issue: weight regain following treatment discontinuation. Evidence suggests that a significant proportion of lost weight is regained when therapy stops, reinforcing the concept of obesity as a condition requiring ongoing management rather than short-term intervention.4 For primary care, this raises important questions around long-term prescribing, maintenance strategies, and equitable access.
Debates around nutritional advice also revealed the ongoing uncertainty in public health messaging. While the recommendation to consume five portions of fruit and vegetables daily remains widely endorsed, concerns were raised about excessive fructose intake from high fruit consumption. A pragmatic consensus emerged: prioritising vegetables while limiting fruit to around two portions daily may balance nutritional benefit with metabolic considerations. Although not definitive, such discussions reflect the need for more nuanced dietary guidance tailored to metabolic health rather than broad population messaging.
Another area of interest was the cardiovascular impact of metabolic therapies. Rather than viewing sodium–glucose cotransporter-2 (SGLT2) inhibitors and GLP-1 receptor agonists as competing options, they are increasingly seen as complementary. SGLT2 inhibitors show strong benefits in heart failure and renal outcomes, while GLP-1 receptor agonists reduce atherosclerotic cardiovascular events.5 This reinforces the need for individualised treatment strategies based on patient risk profiles.
Clinicians from across Europe described the real-world challenges of changing dietary patterns, cultural attitudes to exercise, and the importance of family and community dynamics.
Case-based discussions brought these themes into sharp focus. Clinicians from across Europe described the real-world challenges of changing dietary patterns, cultural attitudes to exercise, and the importance of family and community dynamics. Particularly striking was the role of peer support in overcoming stigma and the importance of involving families in managing adolescent obesity. These examples served as a reminder that effective obesity care extends beyond prescriptions—it requires a multidisciplinary and socially informed approach.
For primary care clinicians, several practical lessons emerge. Firstly, simple additions such as waist-to-height ratio can enhance risk assessment. Second, structured yet empathetic communication frameworks like the 5As can facilitate more effective consultations. Finally, as pharmacological options expand, clinicians will need to adapt to a model of long-term obesity management, similar to other chronic diseases.
Ultimately, the masterclass reinforced the notion that progress in obesity care is not solely about new treatments, but about changing how we think, speak, and act. If we are to meet the scale of this challenge, primary care must lead not only in prescribing therapies, but in shaping conversations—grounded in evidence, empathy, and sustained partnership with our patients. I would like to thank EASO for delivering the obesity masterclass and leading the way for primary care based obesity management .
References
- Ashwell M, Gibson S. Waist-to-height ratio as an indicator of early health risk. BMJ Open. 2016;6:e010159. DOI: 10.1136/bmjopen-2015-010159
- Aveyard P, Lewis A, Tearne S, et al. Screening and brief intervention for obesity in primary care. Lancet. 2016;388:2492–500. DOI: 10.1016/S0140-6736(16)31893-1
- Hall KD, Kahan S. Maintenance of lost weight and long-term management of obesity. Med Clin North Am. 2018;102(1):183–97. DOI: 10.1016/j.mcna.2017.08.01
- Wilding JPH, Batterham RL, Calanna S, et al. Once-weekly semaglutide in adults with overweight or obesity. N Engl J Med. 2021;384:989–1002. DOI: 10.1056/NEJMoa2032183
- Neuen, B. L., Fletcher, et al, Cardiovascular, Kidney, and Safety Outcomes With GLP-1 Receptor Agonists Alone and in Combination With SGLT2 Inhibitors in Type 2 Diabetes: A Systematic Review and Meta-Analysis. Circulation, 2024;150(22), 1781–1790. DOI: 10.1161/CIRCULATIONAHA.124.071689
Featured Photo by Jacek Dylag on Unsplash
