Lancet "Clinical Obesity" Deep Dive Part 2 - Executive Summary

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In part 1 I looked at the massive conflicts of interest among the group gathered to make a case for a new way to pathologize being higher-weight. Today we’re going to go through the Executive Summary.

Content Notes:

The content in italics is directly quoted from the paper. You can skip it and still get the gist of the piece. As usual I’ve noted ob*sity with an asterisk (there is a full explanation at the bottom. Still, there is a ton of anti-fat language here so definitely take care of yourself. Finally, I want to note that a group of experts that I was part of had a zoom call to discuss this and we have agreed to credit each other in our individual writings since our discussion contributed to each other’s thoughts on this. I’m super grateful to the group and honored to be a part of it.

Too Long Didn’t Read

Despite being clear that “The idea of ob*sity as a disease remains highly controversial,” the commission just skipped over the controversy and brought together a panel who already agreed on the medicalization and pathologization of higher-weight people to make up definitions for “pre-clinical ob*sity” (which is just higher-weight people without health issues) and “clinical ob*sity” (which is higher-weight people who have health issues - that thinner people also get.) To “support” this, they make a lot of claims about the supposed effects of “excess adiposity” without anything approaching adequate evidence.

Bottom line - this piece represents the opinions of people who are all on the same side of, and stand to gain financially from, the controversial idea of “ob*sity” as a disease which has largely been architected by the weight loss industry who stand to benefit greatly, while endangering higher-weight people.

Alright, let’s take this bit by bit.

Current BMI-based measures of ob*sity can both underestimate and overestimate adiposity and provide inadequate information about health at the individual level, which undermines medically-sound approaches to health care and policy. This Commission sought to define clinical ob*sity as a condition of illness that, akin to the notion of chronic disease in other medical specialties, directly results from the effect of excess adiposity on the function of organs and tissues.

Let’s begin by being very clear about what they are doing. This is not a study that examined multiple sides of (what they admit is) the highly controversial idea that “ob*sity” is a disease. It’s not a group of experts that included weight-neutral providers or fat*-positive fat people. Instead, they mention the controversy and then ignore it, seeking instead to further pathologize being higher-weight. They didn’t create a study to come up with the idea of defining “clinical ob*sity.” They started out by deciding that they wanted to define “clinical ob*sity,” they got together a bunch of people who have careers and funding conflicts of interest rooted in pathologizing higher-weight bodies, and then they wrote this up.

Also, you can’t just get the band together and “define” the “effect of excess adiposity on the function of organs and tissues.” That requires actual science. You would have to have a clear, replicable operational definition of “excess adiposity” for a start. You would need to identify an actual causal mechanism for these supposed effects - the research it would have to control for variables like weight stigma and weight cycling and healthcare inequalities.

The reality here is that there is total overlap between the health issues that they are claiming “directly result” from excess adiposity and the health issues that people who are not “diagnosed” with “excess adiposity” have.

They would need identification/proof of a causal mechanism for the impacts of “excess adiposity” on those organ and tissue functions.

The idea that this is how “chronic disease in other medical specialties” is defined is nonsense. Imagine if we diagnosed asthma based on body size. I wrote about this in detail previously.

The specific aim of the Commission was to establish objective criteria for disease diagnosis, aiding clinical decision making and prioritisation of therapeutic interventions and public health strategies.

To this end, a group of 58 experts—representing multiple medical specialties and countries—discussed available evidence and participated in a consensus development process.

Holy jumping the gun Batman! Creating clinical decision making and therapeutic interventions should come AFTER there is agreement around whether or not this actually qualifies as a disease. Otherwise you run the risk of misleading providers and the public into believing that this is settled science and risk exposing patients to the risks of “therapeutic interventions” that they don’t need and that may create harm with no benefit.

Among these commissioners were people with lived experience of ob*sity to ensure consideration of patients’ perspectives.

When I first saw this I assumed they were some of the many patients that so-called “patient advocacy” groups brag about training to spout their weight loss industry funder’s message to the press.

I was wrong.

There are two people that the study claims have this identity. Except, as I discussed in detail previously, they aren’t just “patients” or people with “lived experience” nor are they patients trained by these organization. In fact, they are the LEADERS of two of these so-called “patient advocacy” groups (one is the Executive Director, the other is the President and CEO) that receive massive funding from the weight loss industry.

The Commission defines ob*sity as a condition characterised by excess adiposity, with or without abnormal distribution or function of adipose tissue, and with causes that are multifactorial and still incompletely understood.

We define clinical ob*sity as a chronic, systemic illness characterised by alterations in the function of tissues, organs, the entire individual, or a combination thereof, due to excess adiposity.

These are definitions only the weight loss industry could love.

“Excess adiposity” is an incredibly vague concept, highly susceptible to manipulation to create the largest possible market for weight loss “treatments.”

They would need to provide definitive proof that this “excess adiposity” actually causes the alterations and, again, “alterations in the function of tissues, organs, the entire individual, or a combination thereof, due to excess adiposity” is remarkably imprecise.

Clinical ob*sity can lead to severe end-organ damage, causing life-altering and potentially life-threatening complications (eg, heart attack, stroke, and renal failure).

Based on what evidence? How do they account for confounders including weight stigma, weight cycling, and healthcare inequalities? Just saying stuff does not make it true. (In the next part we’ll dig into the claims they make later in the paper.)

We define preclinical ob*sity as a state of excess adiposity with preserved function of other tissues and organs and a varying, but generally increased, risk of developing clinical ob*sity and several other non-communicable diseases (eg, type 2 diabetes, cardiovascular disease, certain types of cancer, and mental disorders). Although the risk of mortality and ob*sity-associated diseases can rise as a continuum across increasing levels of fat mass, we differentiate between preclinical and clinical ob*sity (ie, health vs illness) for clinical and policy-related purposes.

This still relies on a “diagnosis” based on body size. Also the use of “pre-clinical” is a nice trick that suggests, without proof, an expected progression to “clinical” that must be “interrupted” with treatment. What they’ve done here is to keep all of the people they can manage to diagnose based on their vague criteria as either “preclinical” or “clinical” as customers to the weight loss industry.

I also want to repeat here that this isn’t new - it’s just a reboot of the Edmonton Staging System and the ABCD (Adipose-Based Chronic Disease), previous failed attempts to claim taht “ob*sity is a “disease.”

We recommend that BMI should be used only as a surrogate measurement of body fat, where available, or at least one anthropometric criterion (eg, waist circumference, waist-to-hip ratio, or waist-to-height ratio) in addition to BMI, using validated methods and cutoff points appropriate to age, gender, and ethnicity. In people with very high BMI (ie, >40 kg/m²), however, excess adiposity can pragmatically be assumed, and no further confirmation is required.

Wait - so BMI should only be used as a surrogate unless BMI is over 40 at which point BMI is all you need? There seems to be no limit to the number of ways they could “diagnose” this - by what method are all of these other anthropomorphic measures being validated? And only one measure is required beyond BMI? So a healthcare provider can just keep trying different measurements until a patient qualifies? Why no discussion of the massive controversy about BMI?

And they are still pathologizing size/body composition despite the complete overlap between the health conditions that those who are “diagnosed” have and health conditions that those who are not “diagnosed” have.

This is proven by the fact that they are, again, still using BMI at the highest ends - predicating treatment risk on size.

We also recommend that people with confirmed ob*sity status (ie, excess adiposity with or without abnormal organ or tissue function) should be assessed for clinical ob*sity. The diagnosis of clinical ob*sity requires one or both of the following main criteria: evidence of reduced organ or tissue function due to ob*sity (ie, signs, symptoms, or diagnostic tests showing abnormalities in the function of one or more tissue or organ system); or substantial, age-adjusted limitations of daily activities reflecting the specific effect of ob*sity on mobility, other basic activities of daily living (eg, bathing, dressing, toileting, continence, and eating), or both.

So, there’s this thing called surveillance bias. Very simply put, it refers to differences in disease incidence between two groups that are due to the fact that one group is tested earlier/more often/differently. This recommendation is tailor made to create surveillance bias. This is especially dangerous if the health issues that they are incredibly quick to blame on weight are actually due to confounding issues like weight cycling, weight stigma, or healthcare inequalities.

Also note that they pathologize disabilities that exist in people of all sizes, but are being used to prop up this weight-loss-industry-friendly definitions for higher-weight people. This is one of many intersections of weight stigma and ableism. It will result in dangerous “treatments” (that are the stock and trade of the companies that form the many conflicts of interests that the authors have) for things which may not be solved by the “interventions” they are recommending for higher-weight people and/or may be more safely and effectively addressable with mobility aids, increased flexibility, strength, stamina etc.

Just like the open-ended definition they’ve given themselves for “anthropomorphic measures” to “diagnose” that I pointed out earlier, these ideas of “basic activities of daily living” can be endlessly expanded by the weight loss industry to increase their market by increasing diagnosis.

The ultimate result in this kind of thinking is that patients and providers end up assuming that body size is to blame for anything and everything perceived as negative that might be happening to a higher-weight person is because of their weight. These assumptions can delay the actual care the patients need (that a thinner patient would be much more likely to get) sometimes forever.

People with clinical ob*sity should receive timely, evidence-based treatment, with the aim to induce improvement (or remission, when possible) of clinical manifestations of ob*sity and prevent progression to end-organ damage.

What is the definition of “evidence-based treatment” here? Even if they could prove the progression to end-organ damage, where is the proof that these “treatments” will prevent progression to end-organ damage?

Why are thin people with the same health issues being given different treatment? How is it scientific to assume that these issues are due to “excess fat” in people who they claim have it but due to…something else…for people who don’t?

People with preclinical ob*sity should undergo evidence-based health counselling, monitoring of their health status over time, and, when applicable, appropriate inter- vention to reduce risk of developing clinical ob*sity and other ob*sity-related diseases, as appropriate for the level of individual health risk.

So people who would be defined as healthy if their bodies were a different size must spend time/money/energy on “counselling and monitoring” and may be subjected to “interventions” to prevent health issues that thin people get even though those people are not exposed to the risks of these “interventions” (And let’s not forget that all of this “counseling and monitoring” is going to be blamed on higher-weight people and added into the “cost of ob*sity”.) Finally, what is the evidence basis for the counselling, monitoring, and interventions.

Policy makers and health authorities should ensure adequate and equitable access to available evidence-based treatments for individuals with clinical ob*sity, as appropriate for people with a chronic and potentially life-threatening illness.

Wait - now it’s not just “chronic” it’s “potentially life-threatening”? And not a citation in site. This is a talking point from the weight loss industry, including their handcrafted “bill of rights.” One has to wonder - what is a weight loss industry marketing statement doing in a definition and diagnostic criteria guideline?

Public health strategies to reduce the incidence and prevalence of ob*sity at population levels must be based on current scientific evidence, rather than unproven assumptions that blame individual responsibility for the development of ob*sity.

Ah yes, now that they have more profitable treatment options, the weight loss industry has been falling all over itself to walk back decades of messaging blaming fat people for being fat. Now they don’t want to blame us, but the absolutely want to eradicate us from the earth and prevent any more of us from existing. Charming.

How are they defining scientific evidence? What is the requirement of evidence that public health strategies should be using?

Once again, this falls into the category of “just saying stuff” which is not the same as science.

Weight- based bias and stigma are major obstacles in efforts to effectively prevent and treat ob*sity; health-care professionals and policy makers should receive proper training to address this important issue of ob*sity.

You gotta love it when they give lip service to anti-stigma efforts while completely (and conveniently) ignoring that fact that this approach may increase stigma. Suggesting that the people qualified to train about this “stigma” are from this same group of people who are on the side of this “controversial issue” who ascribe to a medicalization and eradication standpoint.

I cannot recommend Rachel Fox’s work on this strongly enough! and Medical Students for Size Inclusivity have created a lecture analysis tool based on that work.

All recommendations presented in this Commission have been agreed with the highest level of consensus among the commissioners (grade of agreement 90–100%) and have been endorsed by 76 organisations worldwide, including scientific societies and patient advocacy groups.

Let’s stay I put together a group of 56 people who like pineapple on their pizza. 46 of them actually take payments from companies that sell pineapple pizza. I ask them how much they agree that pineapple pizza is delicious. I publish a paper saying that pineapple is, objectively, delicious on pizza.

Similar agreement could be reached in any commission who were selected for their agreement on an issue, especially when the vast majority of whom receive funding from organizations whose policies the agreements support.

In part 3 we’ll further breakdown the methodology and statistics.

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.