Lancet "Clinical Obesity" Deep Dive Part 3 - Research Methodology

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Welcome to part 3 of a four-part deep dive into the attempt to further pathologize existing in a higher-weight body. In part 1 I looked at the stunning conflicts of interest among the group gathered to make a case for a new way to pathologize being higher-weight. In part 2 we analyzed the Executive Summary. For part 3, we’ll look at the methodology they used.

Content Note: This piece is super long because I want to get all the information out there for those who want/need it, but I also want to move on to other topics that people want/need to know about. Content note: The text in italics is from the original piece itself. I’ve kept it for the record, but you can also skip it completely and still understand the critique, save yourself some time reading, and save yourself the pain of reading the original work.

I want to acknowledge again that there are horrible things going on in the world, in many cases harming people for, what ultimately amounts to, profit. I’m spending so much time on this piece because this fits into that category, with the understanding that it may be more than you want to read right now and I encourage you to take care of yourself. I do want to be clear that if the ideas in this piece becomes accepted as part of standard medical thinking/practice, they will do untold harm to higher-weight people and create untold profit for those who seek to pathologize and eradicate fatness. As usual, those who are the most marginalized and vulnerable will be the most harm*.

Too long didn’t read

In the introduction and methodology they work hard to act like the only two opinions are the we should pathologize being higher-weight because it causes other health issues and (their preferred idea) that we should just go ahead and call being higher-weight a disease. They aggressively ignore the people and evidence that support the idea of simply not pathologizing being higher-weight. Not only are the authors of the piece massively conflicted, but I point out how the “special guests” they brought in to influence the authors are also conflicted.

They used a methodology called a Delphi Method that is supposed to be used to help a group of people with substantial disagreement come to consensus, but given that they were already pretty much in agreement (or taking money from companies that are) I would argue that they are using this method to manipulate readers into thinking that this is super solid science because they gained such high levels of agreement.

Alright, let’s get into it:

Introduction

ob*sity was first recognised as a disease by WHO in 1948, and more recently also by several medical societies and countries.1–9 The current WHO International Classification of Disease labels ob*sity as “a chronic complex disease”, and gives it a specific code (5B81).

A little context for this. The WHO didn’t decide to do this on their own. The entire process was driven by the International Ob*sity Task Force (IOTF), funded by the weight loss industry, paid for the WHO meeting at which this decision was made, then the IOTF produced a report claiming that ob*sity was a disease requiring medical treatment. Then Roche and BASF Knoll, two of IOTFs major funders, used that document to seek FDA approval for their weight loss drugs, claiming WHO authority.

The idea of ob*sity as a standalone disease entity, however, remains controversial, both within and beyond the medical community. Addressing the merit of this idea is a timely and consequential effort because defining ob*sity as a disease has profound ramifications for clinical practice, public health, and society.

And thus addressing the (extremely questionable) merit of this idea should come WAY before creating diagnostic criteria, no?

Those who support the recognition of ob*sity as a disease argue that even people with objective evidence of ill health face substantial barriers to access for health- care services, in addition to widespread weight-related social stigma.3–6,11 Formally recognising ob*sity as a standalone disease—according to those who support the idea—would probably provide stronger medical and cultural legitimacy to the condition, increase access to care for those in need, and might reduce societal stigma.

This is a convenient “argument” to make up, given that it ignores the distinct possibility that all of those “healthcare services” that the supporters of this study want higher-weight people to have access to, may be dangerous with very little risk of improved health (but have incredible profit potential for the weight loss industry.)

Again here, let’s all remember that all the claims in this piece are being made by a group of people who agree with this argument (and are financially and philosophically conflicted)

On the other side of the controversy, many assert that defining ob*sity as a disease could have negative ramifications on afflicted individuals and society overall.12 One argument is that portraying ob*sity as a disease could reduce attention to the role of individual responsibility,13 thereby encouraging unhealthy behaviours and undermining efforts to address the problem. In our opinion, this argument, to some extent, might reflect intrinsic weight bias and stigma in our society.

Other critics point to more objective issues, such as the fact that ob*sity is a highly heterogenous condition and that many people with excess adiposity have no signs of ongoing illness. Many argue that a risk factor is not a disease, and that BMI provides no information on the health of an individual. In this context, a blanket attribution of disease status to ob*sity (as currently defined and measured [ie, BMI >30 kg/m², or 27·5 kg/m² for Asian populations]) poses an objective risk of overdiagnosis, resulting in unwarranted use of drugs, technologies, and surgical procedures, with staggering costs for society, and negative ramifications at clinical, economic, and political levels.13–15

Do you know how I know that they are purposely co-opting actual weight-stigma work to peddle weight stigma and weight loss? Because they failed to even acknowledge, let alone address the evidence-based arguments of, those who are critical of the entire weight-centric/pathologization of higher-weight paradigm.

I mean, of course it’s much easier to win arguments when you are writing both sides of them and leaving out the arguments you aren’t able to adequately address, but I wouldn’t call it good science.

With such legitimate, and seemingly irreconcilable, arguments on both sides of the controversy, the debate remains unsettled. This dispute, however, reveals a crucial missing piece in the way ob*sity is conceptualised: because the illness directly caused by ob*sity is yet to be defined, ob*sity lacks a precise clinical identity.

Said another way, until it is proven that these illness are, in fact, caused by “ob*sity” (by whatever definition someone is using,) it’s inappropriate to assert diagnostic criteria for use with treatment.

This is like saying “given the high correlation between cis male pattern baldness and cardiac incidents, enough our group of experts (who all treat hair loss and/or take money from companies that do) have come to a consensus that baldness is a disease and everyone should immediately use the treatments that we either personally sell and/or that the companies that give us money sell.”

We must demand that the actual science come BEFORE the sales pitch.

Consistent with its original definition as a condition that poses a risk to health,1,4 ob*sity has been framed and extensively studied as a harbinger of other diseases. The manifestations of ob*sity as an illness, however, have not been adequately characterised. In fact, the phenotype of ob*sity is still only defined by corpulence, despite evidence that excess adiposity can also have clinical manifestations and cause illness by inducing dysfunction of various organs and tissues. Typically, scoring and staging systems and treatment algorithms for ob*sity are based on the presence of other diseases (often referred to as comorbidities), rather than clinical manifestations of ob*sity itself.16–18 Such narratives and practices have further cemented the notion of ob*sity as a condition of risk, but they do not explain the clinical identity of ob*sity per se.

That “original definition” was also constructed by the weight loss industry infiltrating and manipulating the healthcare industry. We don’t have to accept the patently false notion that being higher-weight has always been medicalized/pathologized.

Further, the studies they are relying on to make these claims have shared consistent methodological flaws including a failure to address possible confounders including weight stigma, weight cycling, and healthcare inequalities as well as a consistent lack of a mechanism by which to delineate the impacts of “ob*sity treatments” (which is their re-branding of “weight loss”) from the impacts of weight-neutral behavior changes that precede the weight changes.

A body of evidence that questions both the diagnosis and treament of “ob*sity” remains completely un-considered here. Either they know about this research and are ignoring it on purpose, in which case they lack the ethics needed to publish a paper such as this, or they don’t know about it, in which case they lack the requisite knowledge to publish a paper like this.

Disease states are fundamentally defined by their ability to cause illness, intended as both an objective and subjective human experience of ill health, secondary to ongoing alterations in the functioning of organs and tissues. With no explicit characterisation of the illness intrinsically induced by ob*sity, independent of comorbidities—in other words, without a clear subject for disease diagnosis—the question of whether ob*sity is a disease is objectively unanswerable.

Given this admission, maybe we don’t spend the next 40 pages defining and diagnosing it, what do you think?

The only reason they are considering it “objectively unanswerable” is because they unwilling to consider/admit the answer that “no, it’s not a disease.”

Furthermore, excess adiposity (as ob*sity is currently defined) can have quite different significance at the individual level, and even be a sign of other diseases (eg, Cushing’s syndrome or hypothyroidism). Thus, the current definition of ob*sity inherently lacks enough sensitivity and specificity for clinical use, justifying concerns about a blanket definition of ob*sity as a standalone disease state.

Without an operational definition of excess adiposity, and proof that it actually causes illness, ob*sity cannot be properly defined as a disease so until those things are settled, the rest of this is an exercise in (highly profitable) conjecture, PR, and marketing.

However, the inability to recognise ob*sity as a direct cause of ill health could undermine effective treatment and medically sound policies from regulatory agencies and health insurers.

So we should skip the required science and just jump to the conclusion that is most profitable for the the weight loss industry (with which every author is somehow aligned/conflicted)? Students enrolled in their first research methods class are cringing all over the world.

It is common practice to require the presence of another disease (so-called ob*sity plus criteria) for indication to and coverage of ob*sity treatment. Such practices can effectively, and unfairly, deny access to care among many people who already have objectively ill health due to ob*sity alone.

Calm down. It’s hardly “unfair” to not treat a “disease” that doesn’t exist. First you would have to prove that the ill health was actually caused by ob*sity alone, otherwise the “treatment” you are offering exposes patients to risk without evidence of actual benefit.

These authors keep aggressively glossing over that part.

There is consequently an urgent need to define the illness that ob*sity specifically induces, intended as a distinct clinical entity in which the risk of ill health associated with excess adiposity has already materialised and can be objectively documented by specific signs and symptoms that reflect ongoing biological alterations of tissues and organs (we define this illness as clinical ob*sity).Such reframing can provide a crucial, missing piece in the way we conceptualise and approach ob*sity, with important ramifications for clinical practice, public health policies, and societal views of ob*sity.

False. There is an urgent need for high quality science that actually seeks to answer these questions and to see what the highest benefit, lowest risk options are for supporting the health of higher-weight people (rather than rushing to whatever makes the weight loss industry money.) Given that evidence of their claims above does not exist, this paper is far more an instrument of marketing and PR than science.

This Commission was established to identify clinical and biological criteria for the diagnosis of clinical ob*sity that, akin to diagnostic methods for chronic diseases in other medical specialties, reflect ongoing illness. The overarching aim is to help inform the decision making of clinicians and policy makers to facilitate identification of priorities for clinical interventions strategies (panels 1, 2).

Let’s translate this. The idea of pathologizing bodies based on size is controversial and lacks an evidentiary basis. This commission was established to gloss over all of that and move directly to influence peddling on behalf of messaging that supports the authors and the companies with which they have financial entanglements.

Keep it classy Lancet Commission.

Panel 1:

The problem the Commission sought to address Background

Despite evidence that some people with excess adiposity have objectively ill health due to ob*sity alone, ob*sity is generally considered a harbinger of other diseases, not a disease in itself.

The idea of ob*sity as a disease remains highly controversial. The clinical phenotype of ob*sity is still uniquely defined by BMI, which provides no information about health at the individual level. In this context, a blanket attribution of disease status to ob*sity (as currently defined and measured) poses an objective risk of overdiagnosis, with potentially negative ramifications at clinical, economic, and political levels.

What evidence? Can we get some kind of citation please? There are plenty of situations in which “I said what I said” doesn’t require additional proof. This paper is not among them.

I searched the document for “due to ob*sity alone” and found 5 occurrences, two with parenthetical explanations

“ie, clinical ob*sity” and “ie, severe symptoms or limitations of daily activities due to effects of ob*sity on pulmonary, cardiovascular, or musculoskeletal systems”)

but no citations to any evidence seem to exist.

I searched “objectively ill health” and found another instance in the paragraph

“However, there is ample evidence that excess adiposity itself can directly induce structural and functional alterations in multiple tissues and organs (eg, liver, heart, lungs, kidneys, and musculoskeletal system), causing objectively ill health, independent of the onset of other diseases. Thus, a more accurate definition of ob*sity—consistent with evidence that risk for other diseases and ongoing illness can both be associated with excess adiposity—is necessary to explain the full effect of ob*sity on health.” but, again there was no citation for any of this.

They seem to want us to take their word for it because a panel of people who were convened because they believe this is true…agree that it’s true.

Aim of the Commission

We sought to define clinical ob*sity and identify objective and pragmatic criteria for its diagnosis. As for the idea of illness in other medical specialties, clinical ob*sity is intended as

a substantial deviation from the normal functioning of tissues, organs, the organism as a whole, or any combination of these.

The objective of this Commission is to inform decision making of clinicians and policy makers and facilitate identification of priorities for clinical interventions and public health strategies.

Not to belabor the point, but this is a commission of people who all basically agree about a specific subject forwarding opinions from which they and their funders will benefit financially.

Methods

Conception of the Commission

The idea and general plan to convene a global

Expert group for the definition of diagnostic criteria of chronic

illness in ob*sity (clinical ob*sity) was conceived by FR, and discussed with editors of The Lancet Diabetes & Endocrinology journal for consideration as a Lancet Commission. The Commission on clinical ob*sity was organised in partnership with the Institute of Diabetes, Endocrinology and ob*sity at Kings Health Partners. Additional scientific input about the programme of the Commission was sought from other ob*sity experts who served as members of the steering committee (RLB, DEC, ISF, NJF-L, EG, CWlR, and GM).

Again, they are freely admitting that this group was convened to bypass the science needed to gain adequate understanding of a controversial issue and, instead, to make a case for one side of the controversy by finding agreement among a group that were all in agreement.

Selection of Commissioners

Members of the Commission were selected to ensure a balanced representation of relevant medical disciplines and different world regions. Academic clinicians and scientists with important contributions and work in the clinical management of ob*sity, in the understanding of mechanisms underlying clinical manifestations of the condition, or both, were selected dependent on eligibility in regard to conflicts of interest per the journal’s policies for Lancet Commissions. 58 international experts were ultimately recruited as commissioners, representing multiple geographic regions and the following medical specialties: ob*sity medicine, endocrinology, internal medicine, bariatric and metabolic surgery, paediatrics, nutrition, psychology, primary care, gastroenterology, cardiovascular medicine, molecular biology, and public health. The Commission also included people with lived experience of ob*sity (VMM and JN) as commissioners to ensure consideration of the perspectives of people living with ob*sity.

Commissioners were required to attend monthly online meetings and offline activities, and participate in mandatory surveys (pre-Delphi) and formal Delphi rounds to generate consensus.

They wanted a balance of disciplines and areas of the world, but absolutely no balance in approach? I’ll get into this in the next (and final) installment about this - but there is really no point in using the Delphi method they chose when the study population were all selected because they agree (or they have financial entanglements with organizations and companies that do.)

Subcommittees

The steering committee provided general oversight and scientific direction for the programme (eg, subject selection, agenda, and inclusion of external experts) of this Commission. Additional subcommittees were formed to coordinate specific aspects of the work of the Commission (ie, genetics and pathophysiology, clinical signs and symptoms, effects of ob*sity on health, ob*sity in children and adolescents, perspectives of people with lived experience, Delphi questionnaire, ethnic-specific cutoffs for BMI and waist circumference, writing group, and communication). Several commissioners participated in one or more subcommittee (each subgroup included five to ten experts). Inclusion in subcommittees was on the basis of voluntary participation and specialised expertise.

Subcommittees were tasked with various additional activities, including further discussion of evidence, analysis of results from online surveys, preparation of pre-Delphi surveys and Delphi questionnaires, initial manuscript drafting, and planning communication. Proposals made by the subcommittees were then discussed with the whole group of commissioners during regular monthly meetings.

Translation: Subcommittees were made up of people with career and financial conflicts of interest and their proposals were discussed with a larger group of people with career and financial conflicts of interest. This does not have the ring of sound science.

Monthly, online, whole group meetings

Between June 20, 2022 and Dec 16, 2024, meetings were held monthly online with the whole group of commissioners to discuss scientific evidence, define a framework for the definition of clinical ob*sity, identify general principles for the selection of diagnostic criteria, test support for potential conclusions, and facilitate planning of the Commission’s manuscript and related communications. Such meetings had a structured agenda including one or more presentations, a group discussion, and real-time voting sessions for pre-Delphi assessment of evidence and identification of suitable subjects for consensus development.

Wow y’all, that's a lot of “methodology” for a foregone conclusion. It’s almost as if they are trying to dazzle us with scientific language so that we don’t notice the lack of the actual science they would need to support their claims.

Review and discussion of evidence

Evidence appraised by the commissioners related to a broad range of topics, such as definitions of disease and diagnostic criteria in other medical specialties, biological mechanisms of ob*sity, effects of ob*sity on the structure and function of tissues and organs, and effects of ob*sity on daily activities. Evidence about the outcomes of treatments was not formally reviewed by the group because making recommendations for specific treatments is beyond the remit of this Commission.

Evidence on each topic was summarised by individual commissioners or subcommittees and presented to the whole group during monthly online meetings. Additional guest experts who were not involved in the Commission (see Acknowledgments) were occasionally invited to provide further input during these meetings by presenting reviews of evidence on specific topics. However, these experts did not participate in the development of the conclusions for the Commission.

Attendance at online meetings was a mandatory requirement for commissioners, however, when unable to attend, commissioners were asked to review recordings of online meetings and provide feedback or further input as necessary. Written summaries of presentations and discussions, online chats, and copies of presentations of evidence were circulated among the whole group after each online meeting.

Through reviews of subcommittee summaries of evidence, the commissioners sought to define diagnostic criteria on the basis of the effect of ob*sity on tissues and organs; the clinical manifestations and proposed diagnostic criteria are included in this Commission on clinical ob*sity.

Not sure a group who doesn’t understand the definition of “mandatory” should be in charge of defining disease but let’s move on from that and talk about these “guest experts” who were in a position to exert influence over the panel but were not required to list their conflicts of interest. So let me help with that. (Content Note - many of these links contain weight stigma, I’ve removed the hyperlink for the site. If the links contain any form of the word “ob*se” you’ll need to replace the asterisk with the “e”). Finally, this is not a complete list of conflicts.)

Donna Ryan

Has taken over $760,000 from the pharmaceutical and medical device industries including over 630,000 from Novo Nordisk alone between 2017 and 2023 https://openpaymentsdata.cms.gov/physician/869765

Past president of The Ob*sity Society (TOS) which is a weight loss industry trade group that takes massive funding from the weight loss industry and which I wrote about in detail previously.

She currently serves at TOS’s Publications Committee Chair

She was a research on Novo Nordis’s weight loss meds

She “remains an active consultant and advisor to companies developing drugs, devices, lifestyle programs and medical approaches to ob*sity management”
https://www.worldob*sity.org/training-and-events/scope/fellowship/dr-donna-ryan

Arya Sharma

Has a speaker biography on Novo Nordisk's website:
https://sciencehub.novonordisk.com/speakers/arya-sharma-easd2024.html

Founder and Past-Scientific Director of Ob*sity Canada whose funders include Boehringer ingelheim, Lilly, Desjardins Insurance, Novo Nordisk, Optifast, Pfizer, TOPS club, Weight Watchers, and My Viva and goodself

https://ob*sitycanada.ca/partners/

Co-author of the Edmonton Ob*sity Staging Sytem which is a previous failed attempt to do something very similar to what these people are doing by classifying higher-weight people with health issues differently than thinner people with the same health issues (I wrote about it in detail in the past.)

Sophia Steer

Did some research linking being higher-weight to rheumatoid arthritis. From what I could find, she is the closes of anyone involved to not having any conflicts of interest.

Khalida Ismail

Study disclosure:has received honoraria for educational lectures from Sanofi, Novo Nordisk, Janssen and Eli Lilly
https://pmc.ncbi.nlm.nih.gov/articles/PMC7057797/

In another: has been paid honorarium by Eli Lilly and Company, Janssen Pharmaceutica, Sanofi S.A. (Paris, France) and Novo Nordisk A/S (Bagsværd, Denmark) for educational lectures.

https://discovery.ucl.ac.uk/id/eprint/10093130/1/Bookshelf_NBK553250.pdf

Richard Barnes

He patented a technology to use a cell phone and AI to guess someone’s body composition. He is marketing it as a replacement for Body Mass Index and is selling it (I have this on my list to write about, but it keeps being pushed back for the sake of bigger nonsense https://www.bodyvolume.com/plans-and-pricing )

William Alazawi

Study disclosures: Advisory and speaker fees from GlaxoSmithKline, Novo Nordisk, Intercept, Thriva, Janssen, Gilead Sciences, Metadeq and UCB; competitive grant funding from GlaxoSmithKline, MSD and Gilead Sciences; director at Kudu Spectrum
https://onlinelibrary.wiley.com/doi/10.1111/liv.16224

Consensus development process

Pre-Delphi phase

This phase sought to investigate prevailing opinions about crucial questions (eg, is ob*sity a disease?), find agreement regarding which areas and issues should be deliberated, assess strengths and gaps of scientific evidence, and generally serve as a guide for preparation of the Delphi questionnaires.

A series of questionnaires for real-time (during online meetings) and offline surveys were prepared by members of the steering group and other sub- committees. These questionnaires included open-ended questions, agree or disagree options, and multiple choice queries designed to capture the initial orientations of the expert group about various topics relevant to the Commission.

A specific aim of the pre-Delphi phase was to discuss general definitions of disease in medicine and existing criteria for the diagnosis of chronic diseases in other disciplines. The goal of such discussion was to define a suitable model for the definition of illness in ob*sity, principles to guide the definition of clinical ob*sity, and identification of its diagnostic criteria. Results from pre- Delphi questionnaires were used by members of the Delphi subcommittee to draft the Delphi questionnaire. These preparatory questionnaires were not a formal part of the Delphi process, and as such are not included here or in the appendices.

Let’s talk about the Delphi technique. (In addition to having learned about this technique, I was a participant in a Delphi study last year that has been accepted for publication.)

This is a study design that was originally created with the goal of bringing together experts with disparate opinions and offering them a systematic, anonymous method by which to move toward consensus.

The technique includes a series of “rounds.” The findings of each round form part of the basis for the next round which creates a gradual evolution of the findings. The results of each round are viewable by participants. This makes participants privy to the thoughts/answers of others and creates an opportunity for people to change their thinking in response to ideas they hadn’t previously considered.

How many rounds there will be and what threshold for “consensus” will be used is different from one study to another. Often, especially if it’s believed that the experts have widely differing opinions, round one questions will be open-ended. The ideas generated here are then used for subsequent rounds in which a rating scale is used to determine agreement or disagreement of each expert with the salient ideas.

They authors admit:

“The idea of ob*sity as a standalone disease entity, however, remains controversial, both within and beyond the medical community"

“On the other side of the controversy, many assert that defining ob*sity as a disease could have negative ramifications on afflicted individuals and society overall”

“With such legitimate, and seemingly irreconcilable, arguments on both sides of the controversy, the debate remains unsettled”

“The idea of ob*sity as a disease remains highly controversial”

“The idea of ob*sity as a disease is at the centre of one of the most controversial and polarising debates in modern medicine”

So they…checks notes…got a group of people who are all basically one side of the controversy and designed a study to prove that they agreed? Where’s the science?

As they, themselves, explain “A specific aim of the pre-Delphi phase was to discuss general definitions of disease in medicine and existing criteria for the diagnosis of chronic diseases in other disciplines. The goal of such discussion was to define a suitable model for the definition of illness in ob*sity, principles to guide the definition of clinical ob*sity, and identification of its diagnostic criteria”

So they admit - they were not trying to see if there was a consensus among a broad group of experts on the idea of pathologizing higher-weight bodies.

Instead they created a group of experts and a study design wherein the pathologization of being higher-weight was a forgone conclusion - the only questions would be around how to pathologize it.

I feel like they are using a Delphi method here to suggest scientific rigor in creating a consensus around a complex, controversial question when what they’ve done is the exact opposite - simplifying a complex question by ignoring/dismissing the complexity/controversy and then gaining agreement among a panel who were selected for their preexisting agreement by modifying a study design to their purpose.

Delphi-like process

After analysis of the results of pre-Delphi surveys and review of recorded proceedings from online meetings, a subcommittee of eight commissioners prepared a Delphi questionnaire that was comprised of a set of statements that were believed to reflect available evidence and capture the consensus of the largest majority among the group.

Believed by whom to reflect available evidence and capture consensus of the largest majority of the group?

Approximately 3 weeks before the questionnaire was first administered to the commissioners, they were instructed in rules of the Delphi process and the timing of each Delphi round. Commissioners were assured that responses were confidential, with individual responses known only to an impartial, non-voting survey moderator.

The moderator was Isabel Rockingham. She is the Programme Manager - Diabetes, Endocrinology & Ob*sity at King’s Health Partners/Guy’s & St Thomas’ NHS Foundation Trust per her Twitter bio (which I’m not linking to.) So her career is vested in the medicalization of higher-weight bodies.

The moderator administered the Delphi questionnaire to all 58 commissioners, using an online survey platform (Microsoft Teams Survey) throughout a total of three Delphi rounds. The original Delphi method was adapted to the scopes and nature of this Commission; unlike other Delphi studies, in which the first round consists mainly of open-ended questions, we used agree or disagree questions designed by the Delphi subcommittee for the first round, that were based on outcomes from the pre-Delphi phase.

So it sounds like they used the “pre-Delphi” phase to stack the deck further and make sure that they went into this “Delphi-like” process already primed for the desired outcomes.

For the first two rounds of the Delphi process, all questions contained a box for optional supplementary comments; commissioners who did not agree with the proposed statements were invited to state their reasons and propose amendments. Each round was conducted over 2 weeks: 1 week for response acquisition (including email reminders before the closing date), plus another week for data analysis and preparation of the subsequent round. A personalised email message was sent by the moderator to any respondent who had disagreed with specific statements or had proposed amendments.

A personalised email saying what, exactly?

The Delphi subcommittee was consulted by the moderator to assist with matters that required medical expertise, while retaining confidentiality of the identity of commissioners who raised questions or who had initially disagreed on proposed statements. Consensus was defined as agreement by a supermajority (ie, >67%), consistent with other medical consensus conferences. After the first two rounds, statements that had unanimous or near-unanimous consensus were considered approved. A third round of Delphi was used to further discuss statements with lower levels of consensus to verify the possibility of increasing support via appropriate amendments to the statements. All commissioners reviewed the results and signed a statement to confirm their agreement with the final recommendations.

As the work of this Commission—including the Delphi process—did not expose commissioners to risk as the activities and questions in the Delphi questionnaires referred to matters that are part of the participants’ normal, daily experience, professional experience, or both, ethics approval was not deemed necessary.

I’d like to point out that being repeatedly asked questions about the pathologization and “treatment” of existing in a higher-weight body is only so much a “part of the participants’ normal, daily experience, professional experience, or both” that they could skip ethics approval can only be true because they didn’t include weight-inclusive providers or patients in the group. They don’t need ethics approval, they need ethics in general.

To me this is just a weird use of Delphi - the anonymity doesn’t seem important when these people know that they share opinions. Jumping right to the “aree/disagree” questions suggests that they knew they did, as is born out by the high rates of agreement. I honestly think they did this because people who didn’t read/analyze their work, but know what a Delphi Study is would think “Wow, that’s super high agreement, these conclusions must be solid!”

Descriptors of grade of consensus Consistent with previous studies consensus was considered to have been reached when a super majority (>67%) of the expert group agreed on a given statement. However, language was iteratively modified to maximise agreement, and the degree of consensus for each statement was graded according to the following scale: grade U, 100% agreement (unanimous): grade A, 90–99% agreement; grade B, 78–89% agreement; grade C, 67–77% agreement. This grading scale indicates statements that reflect unanimous or near-unanimous opinions (grades U or A), strong agreement with little variance (grade B), or a consensus statement that reflects an averaging of more and possibly extremely diverse opinions (grade C). We report both the level of consensus and the percentage grade of agreement for each statement (tables 1–3; appendix 2 pp 2–3).

We’ll check out this table in part 4.

Delphi results

All three rounds of Delphi were accomplished with 100% response rate (58 of 58 commissioners). A total of 82 statements (including definitions and diagnostic criteria) had consensus, of which 49 (60%) were unanimous consensus and 33 (40%) near-unanimous. We defined 18 criteria for the diagnosis of clinical ob*sity in adults (range of consensus 90–100%; table 2), plus 13 criteria in children and adolescents (range of consensus 96–100%; table 2).

I would love to understand more about how they modified language to maximize agreement. It very much seems to me like they are trying to exaggerate the importance of their findings (ie: we were ok with 67% but look at how much higher it was!)

The organ, tissue, or body system part of the results table certainly line up very well with the additional uses that are currently being studied for the GLP-1s.

Interesting choices on the rounding (ie: they claim that 98% of 58 people agreed so… 56.84 people?)

Also, the “lack of agreement” seems almost manufactured

For example, 5% (2.9 people?) disagree with “Future clinical studies should further define criteria for remission of clinical ob*sity and cure of ob*sity” So they all agree that it’s a potentially deadly disease but 3-ish of them DON’T think research should be dedicated to remission and cure?

My head hurts.

In part 4 (the final part!) we’ll break down the “results” of the “study”.

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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.