With the Lancet Commission’s definition and criteria for diagnosing clinical obesity, Stat News says the Commission has sparked “a global debate among experts.” The latest flare-up comes from a clinical practice guideline communication the Endocrine Society published last week. In this guidance, the authors explain that the society chose to pause before fully endorsing the Lancet Commission framework because of practical considerations:

“The Commission’s reframing represents a meaningful conceptual advance. Broader adoption will require practical and equitable implementation.”

A Sticking Point on Diabetes

One of the sticking points the Endocrine Society identified was the consideration of diabetes. The society’s guidance says:

“A clinician who sees a patient with obesity and new-onset T2DM instinctively recognizes an adiposity-driven disease process that merits intensive intervention. The Commission, however, excludes T2DM from its list of obesity-induced organ dysfunctions.”

The Lancet Commision regards obesity with type 2 diabetes as “preclinical.” Most clinicians would regard it as a clinically important manifestation of obesity. Endocrinologist Amy Rothberg, senior author of the new guidance, was blunt about this discrepancy:

“Really, it makes zero sense, particularly for the patients. And for the provider, it will undoubtedly complicate clinical decision making.”

The lead author of the Lancet Commision report, Francesco Rubino, sees this perspective as erroneous. He told Stat News:

“The suggestion that diabetes should be a criterion for diagnosing clinical obesity may be the paper’s most telling mistake. Diseases are defined to identify discrete entities – they do not incorporate other independent diseases as their own diagnostic criteria.”

Most telling mistake? Clearly, Rubino begs to differ.

Seeking a Harmonized Framework

The Endocrine Society, like many other experts in the field, sees merit in the work of the Lancet Commission. But they see unfinished business for bringing pragmatic clarity to the diagnosis of clinical obesity. Their guidance tells us:

“The Lancet Commission framework represents a constructive shift toward diagnosing obesity by assessing whether excess adiposity is contributing to clinically meaningful illness. However, its dependence on detailed causal adjudication, the conceptual ambiguity of the preclinical obesity category, and the extensive diagnostic requirements limit its feasibility and carry a risk of exacerbating existing inequities.”

They call for “harmonization with established staging systems (EOSS, EASO)” to produce guidance that is more pragmatic. Rubino seems to agree with the need for greater clarity:

“The critics of the Lancet Commission owe patients – and everyone else – a clear answer to that question.”

Without a doubt, there is more work to do.

Click here for the new Endocrine Society guidance, here, here, and here for further perspective.

Unfinished Landscape, painting by Werner Holmberg / Wikimedia Commons