Defining Obesity and Reflecting on the Lancet Consensus
The Lancet Diabetes and Endocrinology Commission recently released an article with a new definition and diagnosis of obesity, and I’m excited to dive right in. This topic has been on my mind for a while, and when I saw this article drop, it felt like the perfect moment to discuss it.
I've spent some quality time reading through the article and reflecting on its findings, but truth be told, I was already planning to address obesity on this podcast. I’ve been thinking through how I would explain it and what insights I wanted to share with all of you. So now, after seeing the article, I’m even more eager to explore this topic, give my perspective, and discuss where we go from here
What is obesity?
First off, let’s talk about what obesity really is. It’s often misunderstood, whether in everyday conversations or even in medical settings. The Obesity Medicine Association (OMA) defines it as a chronic, relapsing condition that’s treatable but influenced by multiple factors, including behavior and biology. Basically, it’s when too much body fat causes issues in how the body works, leading to health problems—whether hormonal, physical, or even mental.
To keep things simple, you can think of obesity as weight that’s causing—or is likely to cause—a medical issue. This straightforward definition makes it easier for both healthcare providers and patients to figure out if weight loss could really help improve overall health.
The Language of Obesity in Clinical Practice
In clinical settings, the language used to discuss obesity matters. Despite being an expert in obesity medicine and holding leadership roles in the field, I rarely use the term "obesity" when speaking with patients. Instead, I opt for the term "weight"—a neutral and universally applicable word. Studies suggest that patients prefer this terminology, as it feels less stigmatizing and more approachable.
While technical terms like "obesity" are necessary in certain contexts, such as insurance coverage or qualifying for medications, they are not always the best choice for patient interactions. For example, a patient once asked me, "Do I have obesity?" after their pharmacy mentioned the term in connection with their prescription for Wegovy or Zepbound. It struck me that, in my effort to create a comfortable and supportive environment, I had not explicitly discussed the diagnosis in those terms.
This scenario underscores the balance clinicians must strike:
Medical Accuracy: Clearly communicating diagnoses when needed, especially for treatment plans and insurance requirements.
Empathy and Understanding: Using language that resonates with patients and respects their preferences.
As a physician, my primary goal is to help patients address their health challenges—whether that involves sinus congestion, headaches, depression, or weight. The specific labels we use often do not change the course of treatment or the solutions we provide. For patients prescribed medications like Wegovy or Zepbound, the diagnosis of obesity is implicit. However, the term itself may not always resonate, and that is something clinicians must navigate thoughtfully.
The terminology surrounding obesity may evolve as definitions improve and societal attitudes shift. For now, the focus remains on addressing patients’ health concerns in a way that is both effective and sensitive. By prioritizing understanding and problem-solving, healthcare providers can better support patients on their health journeys.
Obesity Consensus Statement: Insights for Personalized Care
When looking at the recent consensus statement on obesity, it’s important to know what it’s all about. Unlike guidelines that spell out specific recommendations, this is more of a big-picture effort—a group of experts coming together to agree on key ideas and principles.
This statement was put together by 58 experts from all over the world, bringing in a variety of perspectives. Some were well-known names in the field, while others were newer voices, which is always refreshing. Here’s an interesting twist: at the start of the process, only about a third of them agreed that obesity is a disease. Surprising, right? It shows just how much diversity of opinion exists, even among specialists. In smaller, more focused groups, you’d likely see more agreement on calling obesity a disease, but this broader mix brought out different viewpoints.
The whole process involved surveys and discussions to nail down areas of agreement. The final document includes those agreed-upon statements, backed by explanations and science. Sounds thorough, but there’s a trade-off—it’s not always easy to keep the finer details intact when you’re trying to get everyone on the same page. Consensus-building is more about finding common ground than having everyone 100% on board with every detail, so some of the complexity can get lost along the way.
At the end of the day, though, as a clinician, it all comes down to the patient in front of you. Consensus statements give a helpful framework, but they won’t always fit neatly with every individual’s situation. That’s where nuance comes in—these statements are a guide, not a rulebook.
For practitioners, it’s a good reminder: these documents are tools, not something set in stone. They give useful context for understanding obesity, but they shouldn’t dictate every decision. The main focus should always be on the individual—on their unique needs and challenges—even if that means stepping outside the broader definitions or recommendations from the consensus.
Rethinking Obesity Assessment: Moving Beyond BMI
A key takeaway from the consensus statement is the move away from using BMI as the sole measure for diagnosing obesity. While BMI or weight can still serve as initial screening tools, the consensus recommends confirming a diagnosis of obesity with additional measures such as waist circumference, waist-to-hip ratio, DEXA scans, or bioelectrical impedance. These tools provide a more comprehensive understanding of an individual’s health and body composition.
The statement introduces a nuanced perspective, suggesting that a BMI over 40 likely indicates clinical obesity. However, for BMIs below 40, further evaluation is necessary to determine whether obesity is present. This approach shifts the threshold for what might traditionally be labeled as obesity. Previously, a BMI of 30 or higher was the standard marker, but the updated framework emphasizes a broader, more detailed assessment.
Initially, this adjustment might seem like a departure from established practices. However, it closely aligns with how many clinicians already approach weight management in practice. For example, when a patient with a BMI between 25 and 35 seeks support, the focus shifts to evaluating their individual needs. The goal is to determine if medically supported weight loss would offer tangible health benefits, rather than relying solely on BMI as a definitive measure.
By considering additional factors and measurements, clinicians can make more informed decisions about whether weight loss interventions are appropriate and beneficial for their patients.
Clinical and Preclinical Obesity
The consensus introduces a new way to classify obesity, splitting it into two categories: clinical obesity and preclinical obesity. The idea behind this is to clarify things, but it might also raise some questions. For example, preclinical obesity isn’t the same as metabolically healthy obesity. It’s all about preserved organ function, meaning the weight is elevated but hasn’t yet caused major health problems.
This approach is trying to make a distinction between fat mass—the actual weight—and the potential metabolic issues that can come with it. So, preclinical obesity is essentially weight that’s not yet messing with someone’s health. But here’s where it gets tricky: there’s a gray area when it comes to determining who might actually benefit from treatment.
When someone has a BMI over 40, the connection between their weight and medical issues is usually pretty clear, so the need for treatment is obvious. But for those in the middle range, now called preclinical obesity, it’s not so straightforward. This is where the finer details of the consensus really come into play.
The consensus does a good job of listing medical conditions and challenges that would justify treatment, like cardiovascular disease, fatty liver disease with fibrosis, sleep apnea, high blood pressure, joint pain, and more. They even mention practical struggles, like difficulty doing everyday tasks like bathing or using the toilet, which can definitely be reasons to step in with treatment.
Some of these conditions, like severe health impacts or mobility issues, make it clear that treatment is needed. But the gray zone of preclinical obesity still leaves a lot of room for interpretation. It’s a good reminder that weight management needs to be personalized—focused on whether someone’s weight is really causing health problems or making life more difficult.
Addressing the Gray Areas in Obesity Risk and Treatment
One of the key aspects that seems overlooked in the consensus is a critical question: Is an individual’s weight likely to cause a problem? This question sits in a gray area that calls for personalized discussions between clinicians and their patients, underscoring the need for clinical expertise to navigate these complexities.
Take, for instance, the relationship between weight and cancer. While research shows a clear epidemiological link between the two, there isn’t a precise way to measure this risk for an individual. For someone with a BMI of 35, it’s challenging to determine whether their weight will directly increase their cancer risk. Statistically, the correlation exists, but it becomes difficult to translate that into actionable guidance for an individual patient.
This gray zone is particularly significant for certain groups, such as breast cancer survivors who want to lose weight to reduce their risk of recurrence. Similarly, individuals with a strong family history of cancer often seek weight management as a preventative measure. These nuanced situations highlight areas that a broad classification system like preclinical obesity might miss.
The consensus suggests that preclinical obesity should initially be managed through lifestyle changes, with more intensive interventions determined by a collaborative discussion between the patient and clinician. However, this approach raises questions: At what point does obesity become a risk factor that necessitates active treatment? This decision often depends on the unique circumstances of each patient, including their medical history, current health concerns, and personal goals.
Clinicians must weigh individual risks and benefits, ensuring that treatment plans align with each patient's needs and concerns. This level of personalization is vital in addressing the nuanced and often complex relationship between weight and health outcomes.
Overlooked Factors in Weight Management
The recent consensus seems to have missed some critical aspects of weight management, particularly weight velocity—the rate at which weight is being gained. Rapid weight gain often signals a need for early intervention. For example, if someone starts gaining weight quickly due to a new medication, life change, menopause, or an injury, waiting until they gain 50 pounds and experience health problems makes little sense. Addressing this early could prevent future complications.
Another overlooked issue is the psychological distress associated with weight, which can be compounded by weight bias and stigma. While the consensus was developed by an international group, weight stigma may vary across regions. However, for many patients, this distress is a significant challenge. It’s particularly frustrating for individuals who are highly active—running marathons, doing CrossFit, or biking through difficult terrain—and eating balanced diets yet still struggling with weight.
Newer weight-loss medications often make a significant difference for these patients, alleviating the frustration of hard work not yielding results. These treatments help align their efforts with meaningful outcomes, which is an essential component of comprehensive care.
A pressing concern in the United States is insurance coverage for weight-loss medications. These treatments are expensive, and insurers frequently look for reasons to deny coverage. The new definitions of obesity might make it even harder for patients to qualify for these medications. For instance, medications like Wegovy and Qsymia have removed BMI from their labels, stating only “overweight” or “obesity.” Without clear criteria tied to BMI, patients might face additional barriers to accessing effective treatment.
For those who have benefited from these medications, the potential for reduced access is troubling. Patients whose lives have been transformed by these treatments may struggle to maintain their progress under these new guidelines.
These concerns highlight the need for practical solutions that ensure equitable access to care while addressing the nuances of weight management. It's clear that further refinement and discussion are necessary to better support patients in achieving lasting health outcomes.
Obesity stands out as a complex and unique condition. It is not only a disease in its own right but also a risk factor for other diseases. This duality presents challenges in determining how to treat and address both aspects effectively.
What defines obesity often depends on the harm it causes or is likely to cause. This perspective highlights the importance of individualized care in addressing weight-related health issues. While the Lancet Commission's report offers extensive insights, after reflecting on its 35-plus pages, one guiding principle remains clear: obesity is best understood as weight that causes or is likely to cause harm to an individual.
Want to dive deeper into the topic? Listen to the full episode to get more insights on obesity and its treatment.
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