Lancet Opinion Piece on "Clinical Obesity"

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In November I responded to readers’ questions about a paper that was being teased to the media suggesting a new definition for “ob*sity.” The paper is now out, and it’s even worse than I thought. I’ve had a lot of requests to write about it and there is a ton of media on it right now (though, sadly, not a ton of any kind of critical/investigative journalism.)

As regular readers know, I am in the middle of a four-part series with Dr. Zed Zha about weight and inflammation. I’m pausing that today to give an overview of the issues with this article from the initial analysis that I’ve completed. After the final two pieces of the inflammation series are published, I’ll have a deep dive into the massive conflicts of interest and methodological issues with this paper. I also 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.

I think the three most important things to understand are that:

1. I cannot stress enough that this is much more an opinion piece than anything even resembling a scientific article.

2. The conflicts of interest are many, with authors working in and/or having significant financial ties to the weight loss industry.

3. While they are claiming that this is a “new definition,” it is anything but. This is just a rehashing of old ideas, putting a new name on previous failed attempts at defining existing in a higher-weight body as a a disease, including the Edmonton Staging System (the many issues of which I wrote about previously,) and so-called ABCD (Adiposity-Based Chronic Disease). The basic idea is that if a thin person gets diagnosed with a health condition - they simply have that health condition. But if a higher-weight person gets diagnosed with that same health condition - even with the exact same symptoms and presentation - they now have two health conditions. The actual condition they have and so-called “clinical ob*sity.” “Clinical ob*sity” is just “having health issues while fat*.”

Note: I want to point out that this may have been a very purposeful attempt to make it sound like there is far wider agreement on this issue than actually exists, or it may simply be the result of paradigm entrenchment, but the result is the same in either case.

Let’s get into this:

I know it’s common advice to start with where you agree with a paper, so I’ll do that.

I agree with them that the idea of "ob*sity" as a disease is highly controversial “both within and beyond the medical community.” In fact, they admit that the idea of ob*sity as a disease is “one of the most controversial and polarising debates in modern medicine.”

I think it’s crucial to note that this paper cannot be construed to address hat controversy. Rather, they’ve gathered a bunch of people who were philosophically and/or financially on the same side of that controversy. In the deep dive I’ll cover their extremely questionable claims otherwise.

The disclosure of conflicts of interest of the 56 authors takes almost two full pages and doesn’t include things like those authors whose careers selling weight loss will benefit financially if these opinions are taken seriously. Even the two supposed “patients” who were part of the group are heavily involved with pharma-funded astroturf organizations.

In the conflict of interest disclosures for 56 authors, Novo Nordisk appears 62 times (Novo Nordisk is the manufacturer and marketer of weight loss drug Wegovy and has been repeatedly caught in shady marketing practices including influence peddling.) Eli Lilly (maker and marketer of weight loss drug Zepbound) appears 42 times. One of the authors actually left the writing team to become a senior Vice President (and shareholder) for Eli Lilly.

This article is not settled science or an appropriate standard of care.

There is one other thing I agree with. In their attempts to find a definition of disease that they can use for their purpose, they cite a 2001 paper by Stanley Heshka and David Allison called “Is ob*sity a disease".” I actually checked out that paper and, while Heshka and Allison are certainly rooted in weight stigma and a weight-centric model, they make some very astute (and, given this new paper, one might say prescient) observations in their findings about the idea of calling ob*sity” a disease:

”While it might nevertheless be possible to achieve a social consensus that [ob*sity] is a disease despite its failure to fit traditional models of disease, the merits of such a goal are questionable… and it may be interpreted as self-serving advocacy without a sound scientific basis.” (emphasis mine)

Well, I certainly agree with that.

So what we have here is a paper that represents the opinions of a group of people whose philosophies, careers, and in most cases financial entanglements are rooted in the "ob*sity" as a disease model and this piece merely clarifies and extends those opinions and is, again, not actionable advice for healthcare providers or patients.

The opinions outlined in this piece rest on a series of unproven assumptions that must be rigorously tested scientifically. Until they are, enacting these opinions across healthcare is, again, unscientific and risks serious harm to patients.

Those assumptions include:

The most problematic unproven assumption (because it destroys their entire case if scrutinized) is that "ob*sity," however it might be defined, is actually causing the health issues that these authors are happy to assume it does. They repeatedly claim a causal mechanism without citing any thing at all.

Unless research methods have changed drastically since Monday, you’re not allowed to just say stuff that would be financially beneficial to you if it were true - you actually have to have solid evidence to make these kinds of claims. Just one of the issues here is that this article does not address (or even mention) that these assumptions of causality fail to account for the impact of confounding variables including weight stigma and weight cycling, both of which have been shown to be linked to negative health outcomes commonly blamed on "ob*sity."

Without clarity on this matter, those who are identified as "ob*se" by the incredibly broad criteria suggested in this opinion piece will be subjected to treatments that have been shown to result in additional weight cycling as well as additional risks, up to and including death.

As someone who is both higher-weight and queer, I can’t help but notice that if (like those healthcare experts who lobbied for the pathologization of "homosexualiaty,") those who now lobby for the pathologization of being higher-weight are, in fact, fomenting stigma through their stance, then they risk increasing patients' risk of the very health issues they are trying to prevent or "treat.”

I’m going to say it again, because it’s extremely important. While those who are firmly on the side of pathologizing bodies based on size and/or weight have a right to their shared opinion, for the sake of patient safety and good science we must keep repeating and being clear that this article does not represent settled science (or, really, much science at all) let alone an evidence-based standard of care for higher-weight people.

On Wednesday we’ll be back to the series on inflammation and after that I’ll have a deep dive into this potentially dangerous paper including everything from conflicts of interest to sketchy science.

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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.