As with any chronic treatable disease, as affirmed by the AMA in 2013 and most related professional medical organizations, access to the most effective treatments for obesity should not be made more difficult to access; rather, it should be made easier. Those proposed stipulations that are specifically problematic are as follows:

1. The requirement to have failed a diet and exercise regimen utilizes decade old recommendations from The Obesity Society that do not take into account new evidence and development of new therapies. Even one of the authors of the recommendations (Dr. Donna Ryan, Pennington Biomedical Research Center) strongly disagrees with the appeal to these recommendations in dictating the care of patients with obesity in 2023.
2. The "life threatening" requirement is superfluous, as obesity, being a progressive chronic disease, is ALWAYS life-threatening. It is the primary driver of cardiovascular disease (the #1 killer in the US) and underlies up to 40% of all adult cancer diagnoses in the US. 
3. Limiting the prescribing of Imcivree to endocrinologists or geneticists for those who meet the criteria for the rare obesity gene variants is a wholly inappropriate roadblock to this FDA-approved therapy. I am a board-certified bariatrician. I work with two endocrinologists who have never prescribed this medication and have no experience in its use. Being an endocrinologist, on its own, in no way makes a physician competent in the current practice of obesity medicine. the prescriber of Imcivree is irrelevant if the patient has a rare obesity gene disorder proven by genetic testing. At a minimum this requirement, if used at all, must include board-certified obesity medicine specialists. However, given the lack of access to endocrinologists, geneticists, and obesity specialists, even this would unnecessarily overly restrict access to this treatment for these individuals. 
4. The requirement that Saxenda and Wegovy only be available to those who meet bariatric surgery criteria (BMI >35 with comorbidity or BMI >40) not only violates the clear FDA indication of BMI >27 with comorbidity or BMI >30, it will make it more difficult to help prevent worsening of obesity in those with BMI <35. Should we delay adequate treatment and simply refer all of these patients for bariatric surgery (many of which will also end up on appropriate medical therapy in addition as we are discussing a chronic disease)?
5. Finally, there are several reasons why the "registered dietician"(sic) requirement is inappropriate. First, there are not enough dietitians adequately trained in obesity to make this feasible. it will only hinder appropriate care, not foster it. Secondly, any board-certified obesity specialist can and will counsel regarding nutrition as it indeed necessarily needs to be part and parcel of an overall obesity treatment plan.

Thank you for the opportunity to opine on this very important topic that is up for discussion.