Out of the clash of ideas comes truth

Out of the clash of ideas comes truth—a phrase that aptly captures the discussions at the launch event of the Lancet Commission on Clinical Obesity. The event brought together diverse perspectives from leading experts, sparking vigorous debate not only at the venue but also across social and mass media. I recognized the need to add to my previous post https://www.dhirubhai.net/posts/yulia-lurye-md-80a49765_definition-and-diagnostic-criteria-of-clinical-activity-7286172899659448320-EYFL?utm_source=share&utm_medium=member_desktop

more expanded key opinions expressed during panel discussion, highlighting the challenges and opportunities surrounding the new concept of clinical obesity.

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Prevalence and medicalization of obesity

“A while ago, we would be told, ‘Don’t you dare medicalize 28% of our English population,’ or, if you include overweight individuals, ‘Don’t you dare medicalize 68% of our adult population.’ Clearly, the prevalence of clinical obesity will be lower. An attempt to estimate the prevalence of clinical obesity in England was hampered because not enough people have other measurements of adiposity besides BMI. This is the beginning of an important and long journey. But we have defined the categorical divide of disease status for individuals. The real challenge is implementation across populations. It is generalists who will have to apply what we’ve described as preclinical and clinical obesity. It will require massive resource allocation—healthcare professionals, funding for blood tests, and other tests to categorize people.” Jonathan Valabhji

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Moving beyond BMI

“It is a very positive step forward in helping people who suffer from the consequences of chronic overnutrition. However, a couple of questions come up. The first is pragmatic: What is the next step from BMI? Is it to have two parameters or bioimpedance, because this is an affordable tool that might be usable in practice? Then there is a more conceptual question. The logical step would be that BMI should be followed by an assessment of the amount of body fat, because it is the amount of body fat that leads to pathology. However, it is more complicated than that, because actually, it is an amount of body fat that is inadequate for the energy intake. This is what leads to metabolic rather than mechanical pathological consequences. We need more sophisticated thinking about how obesity and/or overnutrition leads to its adverse consequences.” Edward Gregg

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Defining obesity as a disease

“Let’s talk about the elephant in the room. We have this unusual situation where new therapies have taken over the whole field of obesity too fast. It is now critical to define a diagnosis and answer the question: What is a disease, and what is not a disease? Often, we see patients in our clinics who are not actually patients but seek these new medications. Therefore, it is important to take a step back and redefine what constitutes a disease. Those with clinical obesity will need immediate help. However, those with preclinical obesity might still be candidates for novel weight management treatments if they have additional indications.” Stefan Bornstein

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Complexities of excessive adiposity

“It is essential to address the problem of excessive adiposity. What constitutes excessive fat for one individual may differ for another. Therefore, we need a clear definition. The new framework aims to identify pathogenic clinical conditions or comorbidities that develop due to obesity, but it is also important to consider genetics and the vulnerability of organs to disease. Symptomatology of organ dysfunction could be due to a combination of obesity, genetics, and overnutrition. What may be missing in the proposed definition of clinical obesity is the dynamic nature of the condition and the granularity of phenotypes, both of which are crucial for developing effective treatment algorithms.” Toni Vidal-Puig MD PhD FRCP FMedSci MBA

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Waist circumference and practical tools

“To the point that we haven’t defined clear criteria for excessive adiposity—those criteria already exist. For example, waist circumference and waist-to-height ratio are included in many sets of guidance, including the recently published NICE guidelines in the UK.”

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“How much is a tape measure? Patients can measure waist circumference, and GPs can do it either. It doesn’t require additional resources.”

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Obesity and the global burden of disease

“This commission presents a remarkable opportunity. From a global health perspective, defining obesity as a distinct illness, rather than a simple health risk, could be transformative. The Global Burden of Disease (GBD) study defines the causes of death and disability for every condition, in every country in the world. The GBD sets the agenda for policy and political priorities in health. Where is obesity in the GBD? It is not included as a cause of death or disability—only BMI is referenced as part of a risk factor analysis, which often receives less attention. By introducing clinical obesity into these analyses, we could properly estimate the burden of this disease and elevate it as a political priority.”

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Population differences and patient communication

“In people of Indian subcontinent and East Asian backgrounds, we may find a higher prevalence of clinical obesity due to central fat distribution at relatively lower BMIs and potentially untreated health issues.”

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“How do we translate these definitions into language patients can understand? I often say, ‘You have too much fat for you,’ because personal fat pressure varies between individuals. Unfortunately, we cannot currently measure personal fat pressure. Unlike LDL cholesterol, which is easily measurable, insulin resistance—a key early physiological abnormality from excessive nutrition—is difficult to quantify. Measuring insulin requires fasting, and it is not a reliable analyte. If we could measure it easily, it might serve as a biomarker for clinical obesity. The real challenge is developing a biomarker to identify when nutrition exceeds the body’s safe capacity to store fat and begins manifesting as hyperinsulinemia.”

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Reconciliation across existing frameworks

“Very recently, the EOSO (European Association for the Study of Obesity) introduced a framework proposing a different diagnostic approach for obesity management. While the EOSO supports the Lancet Commission, these approaches differ significantly. How should we manage these differences? It is critical to have consensus.”

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“We should not pit these two frameworks against each other. They address different purposes. The Lancet Commission offers a useful tool for assessing the patient as a whole.”

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The event has sparked vigorous discussion that continues to unfold across social media and other platforms. Links to other impactful opinions are included below:

EASO has raised significant concerns about the recent Lancet Commission report on Obesity Diagnosis and Management, and insists on defining Obesity as an adiposity-based chronic disease (ABCD) https://www.dhirubhai.net/posts/european-association-for-the-study-of-obesity_easo-has-raised-significant-concerns-about-activity-7288515141472534528-e-Fm?utm_source=share&utm_medium=member_desktop

Obesity Canada endorses the Lancet report, being proud to see many established by Obesity Canada principles and priorities reflected?in the report. The Canadian guideline defines obesity as a “complex chronic disease in which abnormal or excess body fat (adiposity) impairs health, increases the risk of long-term medical complications, and reduces lifespan.” https://www.dhirubhai.net/pulse/endorsing-change-obesity-canadas-take-2025-lancet-commission-n2dhc/?trackingId=kNqeRUVzQZOPAYhYpumjZg%3D%3D

Prof. Arya M. Sharma finds the report a major setback. Read here to know why: https://www.dhirubhai.net/feed/update/urn:li:activity:7287354495531937792?updateEntityUrn=urn%3Ali%3Afs_updateV2%3A%28urn%3Ali%3Aactivity%3A7287354495531937792%2CFEED_DETAIL%2CEMPTY%2CDEFAULT%2Cfalse%29

Dr. Courtney Younglove raises a question: ?'If we collectively adopt the distinction between clinical obesity and preclinical obesity, will we improve care and outcomes for those who want treatment - or will we make access to treatment even harder?'https://www.dhirubhai.net/feed/update/urn:li:activity:7286019473340342275?updateEntityUrn=urn%3Ali%3Afs_updateV2%3A%28urn%3Ali%3Aactivity%3A7286019473340342275%2CFEED_DETAIL%2CEMPTY%2CDEFAULT%2Cfalse%29

The debates reflect the complexity of the issue and the need for collaboration and consensus.