Professor Paolo Sbraccia is Professor of Internal Medicine in the
Department of Systems Medicine of the University of Rome Tor
Vergata, Rome, Italy, Chief of the Internal Medicine Unit and Obesity
Center (European Association for the Study of Obesity [EASO]-
accredited Collaborating Centre for Obesity Management) at the University Hospital Policlinico Tor Vergata, Rome, and Director of the Specialization School in Internal Medicine.
He is also currently serving as Treasurer and member of the Board of Trustees of the EASO, and President of the Italian Barometer Diabetes Observatory Foundation. In addition, Professor Sbraccia is Former President of the Italian Society of Obesity and of the Italian Federation of Endocrinology, Diabetology, Andrology, Metabolism and Obesity.
He was also a member of the Scientific Advisory Group for Diabetes
and Endocrinology of the European Medicines Agency (2008–2015).
In 2024, he was appointed to the Steering Committee of the Italian
Society of Obesity, for the development of new Obesity Guidelines under the auspices of the Italian NIH.
He is also a coauthor of the EASO new framework for the diagnosis, staging and management of obesity in adults. Prof Sbraccia published over 150 papers on peer-reviewed journals (H-index 42) and he is a member of the editorial boards and reviewer panels of various scientific journals; in particular, he is Section Editor for Diabetes and Endocrinology of Eating and Weight Disorders and Associate Editor for Internal and Emergency Medicine.
CURRENT CLINICAL GUIDELINES FOR OBESITY STAGING
WHAT ARE THE MAIN INDICATORS USED TO DETERMINE THE SEVERITY OF OBESITY ACCORDING TO THE NEW GUIDELINES?
Not really relevant since much attention has been given to the inclusion of people on the overweight range into the obesity definition if with high WtH (waist to height ratio). The severity remains based on the old BMI. The main indicators are therefore based on the severity of the clinical complications.
HOW DOES THE NEW STAGING MODEL INTEGRATE BOTH QUALITATIVE AND QUANTITATIVE MEASURES?
The EASO approach moves beyond traditional BMI- based classifications and incorporates clinical,
functional, and psychosocial factors. The EASO staging model bridges quantitative metrics (BMI,
biomarkers) with qualitative evaluations (psychosocial, functional status) to improve obesity classification and management. This aligns with modern precision medicine approaches, ensuring that treatment is tailored to individual needs. In fact, the new EASO framework proposes “to base the diagnosis of obesity on the recognition of abnormal and/or excessive fat accumulation (anthropometric component) and the analysis of its present and potential effects on health (clinical component)”. It is, therefore, of paramount importance to include a qualitative (thorough clinical evaluation and staging) to the quantitative anthropometric measures.
HOW IS THE STAGING SYSTEM ALIGNED WITH THE ASSESSMENT OF COMPLICATION RISK?
The EASO staging system aligns closely with complication risk assessment by categorizing obesity based on the presence, severity, and progression of obesity-related diseases – not just BMI. This approach ensures that staging reflects individual health risks and guides appropriate interventions. EASO directly links obesity severity to complication risk, enabling personalized, risk-stratified care. By integrating both clinical and functional outcomes, it ensures that high-risk patients receive timely, appropriate interventions.
WHICH MEASUREMENT AND ASSESSMENT METHODS ARE MOST APPROPRIATE FOR EVERYDAY CLINICAL PRACTICE?
In everyday clinical practice, the EASO staging model recommends a mix of simple, validated, and feasible measurement and assessment tools to evaluate obesity and its complications. The most appropriate methods for routine use, balancing accuracy and practicality, are: body composition and adiposity (percentage body fat) by dual-energy X-ray absorptiometry (DEXA) or, alternatively, bioelectric impedance when BMI and physical examination are ambiguous; BMI, WtH ratio.
WHAT SHOULD GENERAL PRACTITIONERS CONSIDER WHEN APPLYING THE NEW GUIDELINES?
When applying the new EASO obesity staging guidelines, general practitioners (GPs) should consider the following key practical aspects to ensure effective, patient-centered care:
- Move Beyond BMI Alone;
- Use waist circumference and calculate WtH ratio
(Keep a measuring tape in every consultation room.); - Perform a systematic evaluation of medical, functional
and psychological (mental health and eating behavior
pathology) status (clinical component) in any person
with obesity; - Evaluate the presence of medical complications and
metabolic risk factors according to a systematic and
cost-effective diagnostic assessment.
DIAGNOSTIC PHARMATHERAPEUTIC ALGORITHM AND PATHWAY (The new EASO algorithm should be published hopefully soon)
HOW DOES THE NEW THERAPEUTIC PATHWAY DIFFER FROM PREVIOUS APPROACHES TO OBESITY
MANAGEMENT?
The 2025 EASO algorithm shifts from a one-size-fits-all model to dynamic, personalized obesity care, leveraging advanced pharmacotherapy, and earlier interventions to improve outcomes. This reflects growing evidence that obesity is a heterogenous disease requiring precision medicine.
WHAT TOOLS AND STEPS ARE RECOMMENDED FOR PERSONALIZING TREATMENT?
Obesity is a multifactorial, chronic, relapsing, non communicable disease marked by an abnormal and/or
excessive accumulation of body fat. Obesity has direct negative effects on the functioning of individual organs, the whole body, or both, and serves as a gateway to a wide range of obesity-related complications, that can be broadly classified into two categories: those resulting from altered and pathological mechanical forces, referred to as fat mass diseases, and those associated with dysregulated endocrine, inflammatory, or immune responses, known as sick fat diseases.
No specific tools are recommended, rather a complications-oriented flow chart is provided that guides clinicians based on the current body of knowledge, This approach aligns with the concept of obesity as an adiposopathy, distinguishing between factors primarily associated with fat mass and those linked to dysfunctional or “sick” fat.
THE ROLE OF THE MULTIDISCIPLINARY APPROACH
WHAT DEFINES AN OPTIMALLY FUNCTIONING MULTIDISCIPLINARY TEAM IN THE CONTEXT OF OBESITY TREATMENT?
An optimally functioning multidisciplinary team (MDT) for obesity treatment is characterized by coordinated, patient-centered care that addresses the complex physiological, psychological, and social aspects of obesity. Key defining features include: Physicians (endocrinologists, bariatric surgeons, primary care), Dietitians/Nutritionists, Psychologists/Psychiatrists, Exercise Physiologists-Physical Therapists, Nurses/Care Coordinators.
WHAT STRATEGIES PROMOTE EFFECTIVE COMMUNICATION AMONG TEAM MEMBERS?
It is very important to organize regular team meetings to discuss patient progress and adjust treatment plans. Shared decision-making with input from all disciplines. Unified treatment goals aligned with patient preferences (e.g., weight loss, metabolic health, mobility improvement).
WHAT BARRIERS EXIST TO IMPLEMENTING THIS APPROACH ACROSS DIFFERENT HEALTHCARE SYSTEMS?
Implementing a multidisciplinary team approach for obesity treatment faces several systemic, financial, cultural, and logistical barriers across healthcare systems. These challenges vary depending on the setting (e.g., high- vs. low-income countries, public vs. private healthcare), but common obstacles include: siloed specialties, primary care physicians may lack pathways to refer patients to obesity specialists, shortage of obesity specialists, bias among providers, socioeconomic barriers, focus on acute over chronic care, reimbursement barriers for the new pharmacotherapies. Successful implementation requires system-level changes, including payment reform, provider education, and anti-stigma efforts. Some examples in well-structured NHS show promise but highlight the need for tailored solutions based on regional resources.
WHAT IS YOUR OPINION ON INCLUDING THE GUT MICROBIOME AS PART OF A PERSONALIZED THERAPEUTIC APPROACH WHEN EVALUATING PATIENTS WITH OBESITY OR METABOLIC SYNDROME?
The gut microbiome is undoubtedly a promising area of scientific research, yet it remains far from being integrated into routine clinical practice. This is due to insufficient robust human data and the lack of proven effective treatments – such as probiotics and prebiotics – that demonstrate significant benefits over placebo in managing obesity and metabolic disorders.
PHARMACOGENETICS AND PRECISION MEDICINE IN THE TREATMENT OF OBESITY AND DIABETES
SOME PATIENTS WITH OBESITY AND/OR TYPE 2 DIABETES DO NOT RESPOND WELL TO STANDARD PHARMACOLOGICAL THERAPY. HAVE YOU REFERRED SUCH PATIENTS FOR PHARMACOGENETIC ANALYSIS? WHAT ARE YOUR IMPRESSIONS? HAVE YOU ENCOUNTERED CASES WHERE THE RESULTS OF SUCH TESTING HAVE SIGNIFICANTLY CHANGED YOUR TREATMENT APPROACH?
On the horizon, we see immense potential for precision medicine – leveraging genome sequencing, pharmacogenetics, pharmacogenomics, AI, and digital health technologies. However, this remains a vision for the future; for now, clinical practice continues to rely on empirical approache.
WHAT IS YOUR VIEW ON THE USE OF WHOLE EXOME OR GENOME SEQUENCING AS A TOOL FOR PRECISION DIAGNOSIS IN PATIENTS WITH COMPLEX METABOLIC PROFILES OR A STRONG FAMILY HISTORY? DO YOU HAVE EXPERIENCE IN WHICH THIS TYPE OF MOLECULAR DIAGNOSTICS HELPED UNCOVER THE CAUSE OF A CLINICAL
PRESENTATION? DO YOU SEE A GROWING ROLE FOR THESE TECHNOLOGIES IN AN INDIVIDUALIZED APPROACH TO METABOLIC DISORDERS?
In our center, we conduct whole exome sequencing for all cases of early-onset obesity characterized by severe hyperphagia. Beyond its diagnostic value, this approach aims to identify genetic mutations eligible for treatment with setmelanotide, an MC4 receptor agonist that exemplifies precision medicine in action.
