Consensus on Diagnosing Obesity in an Age of Cynicism

It would be hard to dispute that we are living in an age of cynicism. Distrust is all around – especially when the subject is health. Thus, it should not be a surprise that consensus about diagnosing obesity turns out to be quite a challenge.

And yet, we are surprised that a global consensus on the distinction between present illness and the risk of future illness in obesity has met with such a skeptical or perhaps even cynical response. We are, of course, talking about the report of Lancet Commission on Clinical Obesity.

Starting from a Place of Agreement

From the perspective of Robert Kushner, someone deeply respected in obesity care, this should not be hard. He writes that the commission has really only three basic messages:

1. It’s time to move beyond BMI for clinical assessment.

2. It’s time to better define the disease of obesity.

3. Clinicians should target and tailor treatment according to health status.

So as hard as consensus across many different countries can be, it is remarkable that 58 experts from all over the world, as well as 75 medical organizations, all endorsed this work. Even some of the folks finding fault with the commission report seem to agree on these principles. In a very skeptical post on LinkedIn, Arya Sharma writes that “there is really nothing new in this report.”

Bones of Contention

But clearly, Sharma is not happy with the Lancet report. He calls it “disingenuous and misleading” to suggest that the report offers something new. That leaves us scratching our heads. If the report is not terribly different from prior work he has done, but it has a broad embrace from global experts and organizations, is that a bad thing?

EASO has its own framework for defining obesity, which it clearly prefers. The organization does not like drawing a distinction between people living with excess adiposity but without active disease (preclinical obesity) and people with excess adiposity who have the active disease. It will “delay crucial early interventions,” they write. The Obesity Medicine Association raises similar concerns.

Managing Risk for Future Illness

Clearly, consensus about diagnosing obesity is not an easy thing to build. Everyone has a pride of authorship for their own frameworks. And people have really mixed feelings about relying on BMI. It is easy, but flawed. In Medscape, Francesco Rubino, who led the Lancet Commission, is adamant that “the Commission did not recommend excluding people with preclinical obesity from coverage of weight management treatments.” Rather, the recommendation is to tailor therapy to the needs and preferences of individual patients.

Honestly, this does not seem radical to us. But admittedly, more work will be needed to define how best to do that. Mistrust and talking past respected colleagues will get in the way. Overcoming it will require an effort.

Click here for the Lancet Commission report, here for the EASO response, here for the OMA response, and here for more of our perspective on it. For reporting from Medscape on differing views about it, click here. If you would like some food for thought about alternatives to cynicism and mistrust, click here.

Cynic Philosopher with His Dog, painting by Nicolas Gosse and Auguste Vinchon / Wikimedia Commons

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February 15, 2025