Delivering joined-up care for people living with obesity and diabetes remains one of the most important and challenging aspects of metabolic medicine. Many patients transition between diabetes, weight-management, psychological and cardiovascular services, yet their needs often do not align with existing pathways.
‘Ultimately, effective metabolic care extends beyond weight reduction: it encompasses improved health, function, confidence and overall quality of life.’
As an Advanced Clinical Practitioner (ACP) within a busy endocrine and metabolic clinic, these service gaps are evident on a daily basis. Drawing on training through the World Obesity Federation’s SCOPE Certification programme and postgraduate study in diabetes and endocrinology, my practice is grounded in evidence-based obesity management and guided by current international standards.1,2
MY BACKGROUND
My professional journey spans over 25 years, combining a foundation in applied biomedical science with extensive clinical experience across acute medicine, surgery, emergency care and critical care. This has provided deep insight into complex metabolic and systemic conditions, reinforcing the importance of multidisciplinary collaboration. These experiences underpin my specialisation in endocrinology, diabetes and metabolism, where clinical practice and research closely overlap. Integrating scientific understanding with frontline clinical expertise continues to shape my holistic, person-centred approach to metabolic care.
CLINICAL EXPERIENCE AND INCRETIN-BASED THERAPIES
My experience as lead nurse on multiple clinical trials involving glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptor analogues has provided insight into patient experiences across all phases of therapy. These include initiation, titration, long-term use, follow up and the effects of discontinuation. These observations align with major trial findings on incretin-based therapies, including semaglutide and tirzepatide.3,4,5 While these agents have transformed therapeutic options, access and implementation across NHS services remain complex.6
ELIGIBILITY AND ACCESS
A persistent challenge is the narrowness of current commissioning criteria. GLP‑1 receptor agonists are usually approved for people with type 2 diabetes or for those referred to specialist weight‑management services, often requiring additional co-morbidities such as hypertension, dyslipidaemia or sleep apnoea.2,6 In practice, referrals also come from cardiology, renal, respiratory and orthopaedic teams, where excess weight contributes to disease progression or delays essential procedures. For some, weight reduction is a prerequisite for surgery or transplantation, making timely pharmacological support clinically important.
For individuals with severe obesity, whose functional limitations significantly affect daily life, a multidisciplinary review within specialist services allows discussion of whether GLP‑1 therapy may be appropriate under exceptional circumstances. Such multidisciplinary team decisions, supported by consultant oversight and clear documentation, help ensure equitable, evidence‑based care.
OPERATIONAL AND PATIENT FACTORS
‘Demand for incretin-based therapies continues to rise, accompanied by longer waiting lists and a need for close follow up during dose escalation.’
Demand for incretin-based therapies continues to rise, accompanied by longer waiting lists and a need for close follow up during dose escalation.7 Variation in local interpretation of guidance can create inequities, while intermittent supply issues disrupt continuity of care.
Structured education and realistic expectations are vital. Glycaemic improvement often precedes measurable weight loss, which typically evolves over months.3,8 Discontinuation is most often related to gastrointestinal effects or difficulties accessing medication rather than lack of efficacy.9 Consistent follow up, dietetic and psychological input, and reinforcement of non‑scale outcomes (energy, glycaemic stability, cardiometabolic risk reduction) support long-term engagement.1,2
THE EVOLVING ROLE OF THE ACP
Obesity pathways have historically centred on dietetic, psychological and surgical interventions, and the role of advanced nursing practice in pharmacological management is still emerging. With clear governance structures and close consultant collaboration, ACPs provide continuity, safety monitoring and holistic care that enhance patient experience and outcomes.10
Within our GLP‑1/GIP clinic, each patient undergoes a comprehensive baseline assessment, including anthropometry, metabolic and safety markers, and structured education on injection technique, side‑effect management and lifestyle strategies.6,11 Prescribing and titration of GLP‑1 and GIP/GLP‑1 receptor agonists are undertaken within my Trust‑approved ACP prescribing scope, aligned with departmental governance and national guidance. Pharmacotherapy is positioned as an adjunct to sustained behaviour change, with gradual titration guided by clinical response and tolerability.9
Continuing professional development remains central to my role. The SCOPE Certification programme1 provides an internationally recognised framework, while postgraduate training and ongoing clinical updates ensure alignment with evolving evidence and standards.
INFORMED AND SAFE PRESCRIBING
Patient understanding and safety‑netting are fundamental. Before initiation, medications are reviewed, adjustments agreed upon and, where relevant, plans for insulin titration established. Enhanced retinal monitoring is arranged for patients with retinopathy due to the potential for early worsening with rapid glycaemic improvement.9 ‘SADMAN’ sick‑day rules (embedded within national acute‑illness guidance) are reinforced, and GLP‑1 therapy is aligned safely with SGLT2 (sodium–glucose co-transporter-2) inhibitor use when appropriate.11
LOOKING AHEAD
Demand for integrated pathways addressing diabetes and obesity continues to grow. Establishing consistent national criteria, clearer referral routes for people without diabetes and greater recognition of ACP‑led contributions would support equitable and sustainable care.6 Patient feedback and peer‑support initiatives are equally important in ensuring that service design remains responsive to real-world needs.
Ultimately, effective metabolic care extends beyond weight reduction: it encompasses improved health, function, confidence and overall quality of life. Continued collaboration across clinical, commissioning, research and patient networks will be essential to sustain progress in this evolving field.
ALLAN DAVASGAIUM
Advanced Clinical Practitioner in Endocrinology, Diabetes and Metabolism, University Hospitals Coventry and Warwickshire NHS Trust
Disclaimer: the views expressed are those of the author and do not necessarily represent those of the NHS or any affiliated institutions.
REFERENCES
1. World Obesity Federation 2025 SCOPE Certification Programme https://www.worldobesity.org/training-and-events/scope/ certification.
2. NICE 2025 Overweight and Obesity Management NG246 https://www.nice.org.uk/guidance/ng246.
3. Wilding JPH et al. 2021 New England Journal of Medicine https://doi.org/10.1056/NEJMoa2032183.
4. Jastreboff AM et al. 2022 New England Journal of Medicine https://doi.org/10.1056/NEJMoa2206038.
5. Frías JP et al. 2021 New England Journal of Medicine https://doi.org/10.1056/NEJMoa2107519.
6. NHS England 2025 Interim Commissioning Guidance for NICE TA1026. https://bit.ly/489Y4gi.
7. Aroda VR et al. 2022 Diabetes Obesity and Metabolism https://doi.org/10.1111/dom.14710.
8. Busetto L et al. 2024 Nature Medicine https://doi.org/10.1038/s41591-024-03095-3.
9. American Diabetes Association 2024 Diabetes Care https://doi.org/10.2337/dc25-SINT.
10. NHS England 2025 Multi-Professional Framework for Advanced Clinical Practice 2025 http://bit.ly/3LX8kkI.
11. NICE 2022 Type 2 Diabetes in Adults: Management NG28 https://www.nice.org.uk/guidance/ng28.
