What Is Clinical Obesity?

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I’ve now had eleven different doctors ask me about this article, so let’s talk about it! Here is one of the emails:

“I’m an MD and I just read this article in Medscape about “clinical ob*sity.” Should I be worried? I feel like I should be worried. I understand it hasn’t happened yet, but it seems like one of those things that will happen all at once without any chance to pushback. Any ideas on how to handle this?” 

The article from Medscape is called “Coming Soon: A New Disease Definition, ‘Clinical Ob*sity’

It begins: (the indented sections are from the article)

An upcoming document will entirely reframe ob*sity as a “condition of excess adiposity” that constitutes a disease called “clinical ob*sity” when related tissue and organ abnormalities are present.

To be clear, we don’t yet have the document in question, though I’ve certainly made a note on my calendar to be on the lookout for it. In the meantime, here are my thoughts on what we do know.

The article explains that it will be launched in mid January 2025  One (of many) immediate issues that I foresee is the operational definition of “excess adiposity.” If you have the same idea of “fun” as I do, you can google “adiposity” and see how many different definitions are floating around. From “being ob*se” to “the amount of fat in the body” to “overall expansion of body fat” Will that be defined as a certain percentage of body fat? Something else? If I were a betting woman, I would bet that they’ll try something like “when adipose tissue begins to impact health” which is a nonsense non-definition that I wrote about here. That said, we don’t have the document yet so of course I’ll reserve judgment until I can read it and break it down. 

What I will say is that from my perspective the ambiguity is the point. When the weight loss industry is creating definitions, they are always focused on a definition that sounds “scientific” but in practice can be interpreted as broadly as possible in order to “qualify” as many people as possible for their products. 

I’m also wondering if this is an attempted reboot of “Adiposity-Based Chronic Disease” which the weight loss industry made up a few years ago as yet another attempt to pathologize bodies based on size, but this time with a sequential alphabetical acronym (ABCD - see what they did there?) To borrow a phrase from Regina George: stop trying to make ABCD happen.

I think some clues to the purpose lie in the fact that the information was premiered at “Ob*sity Week” which is a marketing/PR event by and for those who profit from selling weight loss and weight loss accessories. 

Francesco Rubino, MD is the lead author. He has pinned his career to selling weight loss as a weight loss surgeon and now Chair of Metabolic and Bariatric Surgery at Kings College in London. He has pushed for weight loss surgeries to be performed on progressively thinner patients. Since he is not in the US, he is not listed in Open Payments, but a 2023 bio from EASD E-learning listed that he has received “research support / grants from Medtronic, Ethicon Endosurg. and Novo Nordisk and speaker’s honorarium / fees from Medtronic, Ethicon Endosurg. and Novo Nordisk. He has also received board member / advisor panel payments from GT Metabolic Solution together with consultancy fees from Medtronic, Ethicon Endosurg. and GI dynamics. Professor Rubino is the president of the Metabolic Health Institute.”

Interestingly, I searched pretty hard and couldn’t find the Metabolic Health Institute, so I don’t know what that’s about.  

The article goes on:

“The idea of ob*sity as a disease remains highly controversial,” Rubino noted, adding that the current body mass index (BMI)–based definition contributes to this because it doesn’t distinguish between people whose excess adiposity place them at excess risk for disease but they’re currently healthy vs those who already have undergone bodily harm from that adiposity.

Here it is. The goal, again, is to “diagnose” as many people as possible as potential customers for the weight loss industry. This argument allows for interventions for “prevention” and interventions for “treatment” (though I image there will be significant overlap and weight/fat loss will be a part of both.) As always, attempts to blame disease risk on being higher-weight or having higher body fat ignore (sometimes strenuously ignore) significant confounding variables including weight stigma, weight cycling, and healthcare inequalities (including those which stem from treating higher-weight people with health issues differently than thin people with the same health issues.)  

“Having a framework that distinguishes at an individual level when you are in a condition of risk and when you have a condition of disease is fundamentally important. You don’t want to blur the picture in either direction, because obviously the consequence would be quite significant… So, the commission focused exactly on that point,” he said.

This is starting to sound like a repeat of the “Edmonton Ob*sity Staging System” which was also concerningly unscientific and rooted in weight stigma. 

The new paper will propose a two-part clinical approach: First, assess whether the patient has excess adiposity, with methods that will be outlined. Next, assess on an organ-by-organ basis for the presence of abnormalities related to excess adiposity, or “clinical ob*sity.” The document will also provide those specific criteria, Rubino said, noting that those details are under embargo until January.

Regardless of the “methods that will be outlined” this is still diagnosing bodies based on size/body composition rather than shared symptomatology. Remember that any organ “abnormalities” (by whatever definition) that occur in higher weight people or people with higher percentages of body fat also occur in lower weight people and people with lower percentages of body fat. The thing that should be avoided is a “diagnosis” that is simply “having health issues while existing in a higher-weight/higher body fat body.” Remember that what are often referred to as “ob*sity related” or “weight related” health issues are just health issues that happen to people of all sizes that get called “ob*sity related” or “weight related” when higher-weight people have them.

However, he did say that “We are going to propose a pragmatic approach to say that BMI alone is not enough in the clinic. It’s okay as a screening tool, but when somebody potentially has ob*sity, then you have to add additional measures of adiposity that makes sure you decrease the level of risk… Once you have ob*sity, then you need to establish if it’s clinical or nonclinical.”

My first concern here (which is one of many) is that routine clinical weigh-ins and the myopic focus on body size they support are already known to drive patient disengagement including delaying and avoiding appointments. How much worse will this get with “additional measures” to obsess about patient size? And, again, I would be that when the methodology is published it will be created to “diagnose” the broadest possible group of people as we saw last year with the AMA.

Asked to comment, session moderator John D. Clark, MD, PhD, Chief Population Health Officer at Sharp Rees-Stealy Medical Group, San Diego, California, told Medscape Medical News, “I think it'll help explain and move medicine as a whole in a direction to a greater understanding of ob*sity actually being a disease, how to define it, and how to identify it. And will, I think, lead to a greater understanding of the underlying disease.”

I think it is likely to make it even more difficult for higher-weight people to get the same ethical, evidence-based care that thin patients get, and more difficult for patients who want to focus on supporting their health and not have their size blamed and “treated” for health issues that thinner people also get.

And, Clark said, it should also help target individuals with preventive vs therapeutic approaches. “I would describe it as matching the right tool to the right patient. If a person has clinical ob*sity, they likely can and would benefit from either different or additional tools, as opposed to otherwise healthy ob*sity.”

I will be interested to see the difference between “preventative” vs “therapeutic” approaches. Again, were I a betting woman, I would guess is that those who are higher-weight and have actual health issues will be targeted for more dangerous and expensive diet drugs and surgeries while those who don’t have actual health issues will be prescribed the same behavior-based interventions that have been failing and harming people for the past century. But again, that’s just a guess.

Rubino told Medscape Medical News he hopes the new framework will prompt improvements in reimbursement and public policy. “Policymakers scratch their heads when they have limited resources and you need to prioritize things. Having an ob*sity definition that is blurry doesn't allow you to have a fair, human, and meaningful prioritization… Now that we have drugs that cannot be given to 100% of people, how do you decide who gets them first?” I hope this will make it easier for people to access treatment. At the moment, it is not only difficult, but it's also unfair. It's random. Somebody gets access, while somebody else who is very, very sick has no access. I don't think that's what we want.”

To me this seems like it tips the hat to what’s really happening here. This appears to me to be about one (or all) of three things:

1. Broadening the definition of who is eligible for weight loss treatment under the guise of “defining” ob*sity

2. Pushing for insurance coverage of these drugs (by shoring up their claim that they are a “disease” treatment) 

3. Pushing back against concerns around the risks of these drugs and other “treatments” (by saying that since people are “very, very sick” the risks are worth it) ignoring that thin people who are “very, very sick” are often provided with ethical, evidence-based care rather than body size manipulation

I’ve said before, and I’ll say again, GLP-1 drugs are solid type 2 diabetes drugs and they may have other health benefits. Maybe other interventions that are targeted at “ob*sity” or “clinical ob*sity” or whatever they are trying to call it today have actual health benefits as well. To find out if they do, they should be researched for that specific health issue and they should be prescribed as interventions for those actual health issues and not for the “treatment” of so-called “ob*sity” - “clinical” or otherwise. It should be unacceptable that higher-weight people are subjected to different/more dangerous interventions than thin people who have the same health issues so that the weight loss industry can make even more billions of dollars.

In terms of what we can do, until the paper is out we can talk about the issues that we do know about. Once it launches we can push back against the using these “diagnoses” and diagnostic measures wherever we have power/privilege/leverage. I’m sure I’ll have more ideas once the paper and all of its methodology are published.

In the meantime, I’ll keep an eye out for this paper in January and get an analysis out as soon as I can.

UPCOMING EVENT

An Introduction to Weight Inclusive Care: The Next Frontier of Health Equity

The Association for Weight and Size Inclusive Medicine (AWSIM) is an incredible international medical organization working to advance weight-inclusive care. The event will feature an introduction to weight inclusive medicine and to AWSIM, followed by a multispecialty Q&A panel with practicing physicians from their Board. 1.5 AMA PRA Category 1 Credits Offered

When: 12/4/24 at 5pm Pacific/8 Eastern
Details and Registration

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*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 Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.