Degree in Medicine (Maximum) at the University of Padova, 1987. PhD in Experimental and Clinical Gerontology at the University of Padova, 1994. Post-degree in Geriatrics at the University of Padova, 1995. Full Professor of Nutrition and Dietetic Sciences – Department of Medicine – University of Padova. Director of the Clinical Nutrition Unit of the Padova University Hospital. Clinical Activity at the Center for the Study and the Integrated Management of Obesity – Padova University Hospital. Author of 218 publications in peer- reviewed international journals. H-INDEX Scopus: 59. Total citations: 12.911 Member of the editorial board of the following international scientific journals: Mediterranean Journal of Nutrition and Metabolism, Eating and Weight Disorders, Nutrients, Frontiers in Rehabilitation Sciences. Associate Editor in: Surgery for Obesity and Related Diseases, Obesity Surgery, Frontiers of Endocrinology. Vice President of the European Association for the Study of Obesity (EASO) for the Southern Region. Past President of the Italian Obesity Society (SIO). Actually involved in several international projects on the implementation of clinical guidelines for obesity more adherent to the vision of obesity as a non.communicable chronic disease and on the identificatgion of more precise targets for obesity management.
CURRENT CLINICAL GUIDELINES FOR OBESITY STAGING WHAT ARE THE KEY INDICATORS USED TO ASSESS OBESITY SEVERITY ACCORDING TO THE NEW EASO GUIDELINES?
According to the new framework for the diagnosis, staging and management of obesity in adults proposed by EASO, the diagnosis of obesity should be always based on the recognition of abnormal and/or excessive fat accumulation (anthropometric component) and on the analysis of its present and potential effects on health (clinical component).
HOW DOES THE UPDATED STAGING MODEL INCORPORATE BOTH QUALITATIVE AND QUANTITATIVE PARAMETERS?
The quantitative parameters (anthropometric component) include the BMI and the waist-to-height ratio. The qualitative parameters (clinical component) include a systematic evaluation of medical, functional and psychological (mental health and eating behavior pathology) status in any person with obesity.
IN WHAT WAY IS OBESITY STAGING LINKED TO THE EVALUATION OF COMPLICATION RISKS?
We stress the importance of measuring waist circumference and calculating the waist-to-height ratio in any person with a BMI <35 kg/m2 as a marker of visceral fat accumulation and increased cardiometabolic disease risk.
WHICH MEASUREMENT TOOLS AND ASSESSMENT METHODS ARE CONSIDERED MOST APPROPRIATE FOR DAILY CLINICAL PRACTICE?
BMI and the waist-to-height ratio are the cornerstone for anthropometric evaluation. We do not recommend a routine use of instrumental techniques of body composition assessment. However, we suggest to consider a determination of body composition and adiposity (% body fat) by dual-energy x-ray absorptiometry or, alternatively, bioelectric impedance when BMI and physical examination are ambiguous or in people presenting with clinical symptoms or risk factors for sarcopenic obesity.
WHAT SHOULD GENERAL PRACTITIONERS BE PARTICULARLY AWARE OF WHEN APPLYING THESE NEW RECOMMENDATIONS?
The assessment of waist circumference and the waist- to-height ratio is still underused by GPs. The framework strongly claims for a more regular determination of this important parameter.
DIAGNOSTIC ALGORITHM AND THERAPEUTIC PATHWAY HOW DOES THE NEWLY PROPOSED THERAPEUTIC PATHWAY DIFFER FROM PREVIOUS APPROACHES IN OBESITY MANAGEMENT?
An important novelty in our framework regards the anthropometric component of the diagnosis. The basis for this change is the recognition that BMI alone is insufficient as a diagnostic criterion, and that body fat distribution has a substantial impact on health. More specifically, abdominal fat accumulation is associated with an increased risk of developing cardiometabolic complications and is a stronger determinant of disease development than BMI, even in individuals with a BMI level below the standard cut-offs for obesity diagnosis. This is reflected by two novel and important statements. First, we make explicit that abdominal (visceral) fat accumulation is an important risk factor for health deterioration, also in people with low BMI and still free of overt clinical manifestations. Second, the new framework includes people with lower BMI (≥25-30 kg/ m2) but increased abdominal fat accumulation and the presence of any medical, functional or psychological impairments or complications in the definition of obesity, hence reducing the risk of undertreatment in this particular group of patients in comparison to the current BMI-based definition of obesity.
WHAT TOOLS AND PROCEDURAL STEPS ARE RECOMMENDED FOR TAILORING TREATMENT TO INDIVIDUAL PATIENT NEEDS?
We propose that the choice of the appropriate initial level of intervention (behavioral modifications alone, psychological therapy, obesity medications, metabolic/ bariatric procedures) should be based on the individual therapeutic goals, the clinical severity of obesity and the previous obesity treatments, rather than on anthropometric parameters only.
WHAT IS THE ROLE OF BOTH NON-SURGICAL AND SURGICAL INTERVENTIONS IN THE NEW ALGORITHM?
Pillars of treatment for obesity management in adults are behavioral modifications (including nutritional therapy, physical activity, stress reduction, sleep improvement), psychological therapy, obesity medications, and metabolic/bariatric (surgical and endoscopic) procedures. Behavioural modifications should be recommended for all persons with obesity. Obesity management medications should be prescribed, according to official labelling, as an adjunct to behavioural modifications, in patients with a BMI ≥30 kg/m2 or a BMI ≥7 kg/m2 with an obesity-related disease or complications. We raise the possibility to consider the use of obesity management medications in adults of Caucasian ethnicity with BMI ≥25 kg/m2 and a waist-to-height ratio ≥0.5 and the presence of medical, functional or psychological impairments or complications. Metabolic/bariatric procedures should be considered in patients with BMI ≥40 kg/m2 or with BMI ≥35 kg/m2 with an obesity-related disease or complications or with BMI ≥30 kg/m2 and poorly controlled type 2 diabetes despite optimal medical therapy.
HOW IS THE PATIENT’S PSYCHOSOCIAL PROFILE TAKEN INTO ACCOUNT IN THERAPEUTIC DECISION MAKING?
Therapeutic goals should be set at the beginning of the treatment, according to the severity and stage of obesity, taking into account available therapeutic options, possible side effects and risks, and patient preferences. The individual drivers of obesity and possible barriers to treatment (psychological/mental, mechanical/functional, metabolic, and SES–related drivers/barriers) should be clearly discussed with the patient.
WHAT SUCCESS INDICATORS ARE HIGHLIGHTED IN THE NEW CLINICAL RECOMMENDATIONS?
We stress the fact that the management and treatment of obesity have wider objectives than weight loss alone and include the prevention, resolution or improvement of obesity-related complications, better quality of life and mental well-being, and improvement of physical/ social functioning and fitness. In defining personalized therapeutic goals for obesity management in adults we should consider prevention of further weight gain and obesity-related complications and the achievement and maintenance of weight loss sufficient to prevent, resolve or improve obesity-related complications and/or improve quality of life and/or mental well-being and/ or improve physical/social functioning and fitness.
THE ROLE OF THE MULTIDISCIPLINARY APPROACH
WHAT ARE THE KEY CHARACTERISTICS OF AN EFFECTIVELY FUNCTIONING MULTIDISCIPLINARY TEAM IN OBESITY CARE?
Considering obesity as a multifactorial, chronic, relapsing disease a long-term multidisciplinary management should be organised in every patient. The ideal network of care should involve the general practitioner, obesity specialist, nutritionist (dietician), exercise physiologist (physiatrist), behavioural therapist (psychologist/psychiatrist).
WHICH STRATEGIES ARE MOST EFFECTIVE IN PROMOTING COMMUNICATION AND COLLABORATION WITHIN THE TEAM?
A clear sharing of therapeutic goals and mutual respect for the individual professional skills and roles are the keys.
WHAT CHALLENGES HINDER THE IMPLEMENTATION OF THIS APPROACH IN DIFFERENT HEALTHCARE SYSTEMS?
No health-care system can provide multidisciplinary specialised management pathways for all those who live with obesity and overweight. However, prioritarisation for treatments should be based on the individual therapeutic goals, the clinical severity of obesity and the previous obesity treatments, rather than on anthropometric parameters only.
HOW CAN CONTINUITY OF CARE BE MAINTAINED WHEN TRANSITIONS BETWEEN SPECIALISTS OCCUR?
Implementation of digital communication technologies and continuing medical education are probably the most important factors.
COULD YOU PROVIDE CONCRETE EXAMPLES OF SUCCESSFUL MULTIDISCIPLINARY COLLABORATION IN CLINICAL PRACTICE?
Multidisciplinary patient evaluation and follow-up has been implemented and used as a routine practice in bariatric surgeries. This approach has facilitated access to surgery, reduced complications and improved long-term results.
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