Obesity remains, stubbornly, a major modern health problem.¹ Efforts to reduce it at both the population health and clinical levels have had little impact to date.² Although many individuals have had success in losing weight through various means, the standard diverse, multimodal treatment models for clinical practice are only marginally successful.³ Our experience indicates that, not surprisingly, many clinicians who have tried to develop a special understanding in the field have withdrawn in frustration. However, as stated in a recent review of the role of primary care in obesity: ‘…. given the influence and reach of primary care providers, we cannot afford for them to be sidelined in the treatment of obesity in larger populations.’⁴ 

There are several reasons for the lack of success in obesity management. Humans and other mammals have a genetic predisposition to gain excess fat under appropriate circumstances to help them survive the ‘feast and famine’ cycles of history. This has led to the selection of genes for energy storage, making weight gain the preferred process and weight loss a detrimental outcome. 

Changes in the modern environment mean that genetic predispositions are ­reinforced by environmental abundances e.g. energy-dense foods and effort-saving machinery. Obesity becomes a normal reaction to an abnormal environment, rather than an abnormal reaction to a ­normal environment.⁵ It has even been suggested that ‘…obesity is merely col­lateral damage in the battle for modernity.’⁶

Also, the variable interaction of genetics and environment guarantees a wide range of outcomes from any group of people on any single treatment program.⁷ This ­disparity in outcomes is far greater than the individual variation expected from most drug therapies, exacerbating clinical fatigue in managing the problem.

Obesity treatment guidelines provide a well-defined, if evolving, ­clinical model for treatment.³ Before triaging through such processes as the Edmonton Clinical Staging System⁸ to more intensive psychological, pharmaceutical and/or surgical procedures, it’s reasonable to ask if there are any ­experience-based practices, outside of formal government guidelines, that can help ­clinicians assist patients with weight loss.

Here, we provide practical recommendations for managing weight loss in ­primary care. These add value to, rather than replace, the standard guidelines for ­obesity management.⁹ They are discussed after a brief reconsideration of the rationale for weight loss and come from our combined 60 years’ experience of working at the clinical, epidemiological, research and academic levels in the area, plus a rating from health professionals at the recent conference of the Australasian Society of Lifestyle Medicine.¹⁰ Although the recommendations are targeted at clinical practice, specifically medical practitioners, it should be noted that neither author of this article is medical.

Rationale for weight loss 

Although obesity is associated with several chronic diseases, the exact nature of this relationship remains unclear.^1,11 In most cases, a molecular basis (i.e. ‘cause’) remains elusive, hence the more correct use of the term ‘determinants’ instead of ‘causes’. Recently a form of low-grade, ­systemic inflammation (‘metaflam­mation’),^12,13 which can lead to dysbiosis and allostasis with or without obesity,¹¹ has been found to be present in most forms of adiposity-based chronic diseases (ABCD).¹⁴ There are suggestions that obesity may thus be an element within a larger milieu of problems in society, rather than the unequivocal cause of all ill-health associated with ABCD.⁶