I’ve emerged from the isolation tank, prepared to dive back in to our final chapter on The Lancet’s PR piece. This is Part 4 of the series: click on the links to read Part 1, Part 2, and Part 3. It’s a long read, and full of truly awful fat phobia: please read with caution.
Lancet Commissioners Admit O*esity Is Not A Disease
Let’s begin with the hilariously awkward fact that 70% of Rubino’s hand-picked Commission disagreed with the ‘Pre-Delphi’ idea that o*esity was a disease.
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This was in stark contrast to Rubino’s 2021 marketing material research- funded by Novo Nordisk- which claimed that 90% of health professional agreed that o*esity was a disease, emphasising the shameless corruption of this field of ‘research’.
The Terminology Olympics
Disease classification is vital for Pharma companies in order to pressure governments to subsidise weight loss drugs. The Commissioner’s rejection must’ve come as a blow for Rubino. But in the pharma-infested swamp of o*esity ‘research,’ inconvenient facts often get suspiciously re-packaged.
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The Lancet’s work-around began by defining ‘disease’ and ‘illness’ in ways conveniently aligned with their ensuing argument. ‘Diseases,’ they claimed, have a ‘distinct pathophysiology,’ and can cause ‘illness.’ Because there’s no ‘distinct pathophysiology’ for larger bodied people, they couldn’t justify its classification as a ‘disease.’
The cunning bit was when they defined ‘illness’ as something which:
‘implies a deviation from the healthy functioning of organs and tissues or the whole individual. It is typically associated with specific clinical manifestations- physical and biochemical- that can be used as criteria for disease diagnosis.’ (emphasis added)
In other words, an illness can simultaneously ‘imply’ the existence of a disease, and provide ‘criteria’ for disease diagnosis. 5 references back up this interpretation- except they didn’t. 2- from the CDC & Scully– didn’t even mention ‘illness.’ Their Cambridge Dictionary reference simply defined illness as ‘a disease of the body or mind.’ References from Boyd and Farre & Rapley defined ‘illness’ as the patient’s subjective experience of ill health. None mentioned ‘illness’ as a way to legitimise criteria for disease diagnosis.
An exhausting 1200 word ramble on ‘alternative definitions’ of disease and illness followed, with diabetes, immune disease and mental health used to argue that an illness can ‘imply’ the presence of a disease, even without ‘distinct disease pathophysiology’.
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It’s Machiavellian: rather than accepting the Commissioners’ rejection of o*esity as a disease, Rubino reverse-engineered one by creating an ‘illness’. With this logic, if I wanted redheadedness declared a ‘disease,’ I’d be laughed out of the hairdressers, but after gathering a committee of gingerphobes to compile a list of ‘redhead-caused illnesses:’ freckles, fair skin, UV sensitivity, a high pain threshold…hey presto!- ‘clinical redheadedness!’
Name Games
After rejecting o*esity as a disease, 100% of Commissioners somehow agreed to define ‘clinical o*esity’ as a ‘chronic, systemic illness,’ and this definition was repeated multiple times within the Commission paper.
But sneakily, the accompanying Lancet Editorial called it a ‘chronic, systemic disease state.‘ A snazzy infographic of the Lancet’s key findings, provided as a convenient summary for health professionals, also defined it as ‘a chronic disease.’ And during their 4 hour live-streamed launch several speakers – many of whom were Co-authors- referred to ‘disease.’
Given that the Commissions’ mission was to settle the o*esity-as-a-disease drama- ‘one of the most controversial and polarising debates in modern medicine-‘ this bait-and-switch is inexcusable.
‘Distinct Pathophysiology’ of O*esity
The paper included a lazy attempt to describe the ‘pathophysiology’ of larger bodies. 7 brain regions allegedly involved in ‘o*esity’ were described- citing just one reference (9 times!)- which didn’t even mention 6 of the 7 brain regions.
At a cellular level, they described how adipose (fat) cells expand ‘excessively,’ resulting in reduced blood flow, fibrosis, and cell death. This can cause an inflammatory process* and insulin resistance.
This was a simplified description of how metabolic dysfunction leads to insulin resistance, a process strongly influenced by genetic predisposition, age, and many other factors other than anthropomorphic body measurements. Body size alone is not a ‘smoking gun’ for insulin resistance: the genetic make-up of fat cells and their ability to increase in size (hypertrophy**) and multiply (hyperplasia**), has a huge influence on health. Smaller bodied people can develop metabolic syndrome – and many larger people don’t. The Lancets’ attempt to pass this off as ‘distinct’ to ‘o*esity’ is deceptive.
Dieting Causes Weight Gain
A ‘positive energy balance’ is when energy intake is greater than energy expenditure. The Lancet claimed:
‘A state of positive energy balance over a prolonged period- or energy burden – drives adipocyte hypertrophy and to a lesser extent hyperplasia, as well as weight gain.’
But the 2 references provided to support this actually described how calorie restriction from dieting slows metabolism.
‘Excessive adipose tissue expansion’ can occur as a biological response to restriction: via intentional dieting, illness, famine or food insecurity, fat cells shrink in size but not number. Shrunken fat cells upends our body’s homeostasis, triggering an array of changes designed to restore the fat cell’s previous size. These include slowing metabolism whilst increasing hunger hormones and fat storage efficiency. When normal eating resumes, the body rapidly stores energy, often leading to fat cell hypertrophy, as cells overcompensate for the energy threat. Over time, this cycle reinforces the body’s drive to regain and protect fat stores. The Lancet authors even admitted that:
‘equilibrium body weight is fiercely defended by the brain, regardless of whether this set point represents a so-called healthy weight or an excessive degree of body fat’.
It’s infuriating to see them admit the enormous physiological impact restriction has on human metabolic health, but still refuse to call out the weight loss industry as directly responsible for inflicting decades of weight cycling.
It’s in their interests to acknowledge set point in defending body weight, so they can argue that o*esity is a chronic, relapsing ‘disease,’ whilst steadfastly ignoring the harm done by repeated cycles of restriction inflicted by the weight loss industry. The lack of accountability is revolting.
‘Clinical O*esity’
Eventually, the paper provided 18 adult symptoms which constituted their manufactured ‘illness’ of clinical o*esity:*** These ‘symptoms’ were derived from discussions between the Commissioners. There’s no scientific basis for inclusion or exclusion- not even a literature review- they’re literally feelpinions:
- Central nervous system (CNS) – ‘raised intracranial pressure such as vision loss and/or recurrent headaches’,
- Upper airways (sleep apneas),
- Respiratory (hypoventilation or breathlessness),
- 6 cardiovascular conditions,
- A metabolic ‘cluster’ of hyperglycaemia, high triglycerides and low HDL cholesterol,
- NAFLD with hepatic fibrosis,
- Markers of kidney disease, ‘recurrent or chronic urinary tract infections,’
- Reproductive problems including PCOS or hypogonadism,
- Chronic, severe knee or hip pain,
- Lower limb lymphedema,
- ‘Significant age-adjusted limitations of mobility and/or other basic activities of daily living eg bathing, dressing, continence, eating).
- Sore throat from yelling at weight-centric health professionals****
The 13 child and adolescent criteria were similar, including 1 cardiovascular symptom (raised blood pressure) and 3 musculoskeletal (chronic pain or tripping due to leg malalignment, tibia vara, slipped femoral capital epiphysis).
These symptoms are not exclusive to larger bodied people. The Lancet told clinicians to ‘diagnose’ clinical o*esity only if they’re sure that the symptom was ’caused’ directly by o*esity, which is interesting because there’s no data given to demonstrate the ‘causal’ nature for any of them. Idiopathic intracranial hypertension is literally defined by ‘the absence of an identifiable casual factor.’ They even admitted that ‘the relationship between o*esity and cardiovascular disease is not well understood, due to the presence of multiple overlapping risk factors.’
Where Is Diabetes?
The Commissioners claimed that their diagnostic criteria for clinical o*esity only included ‘individual alterations of organ function, not diseases in their own right.’ This is allegedly why they chose to exclude Type 2 diabetes as a criterion for clinical o*esity:
‘Using a disease state as a diagnostic criteria for another disease would be contradictory on logical grounds.’
But this makes no sense, as many of the criteria – lymphoedema, idiopathic intracranial hypertension, sleep apnea, non-alcoholic fatty liver disease (NAFLD)- are diseases in their own right.
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The only way this can make sense is via the Commission’s agenda to get more weight loss drug subsidies: Pharma don’t need to include diabetes because they’ve already secured subsidies for it.
Diagnosing Clinical O*esity:
In order to be diagnosed with ‘clinical o*esity,’ people need to have ‘excessive adiposity’ (using the laborious extra measures we discussed in Part 3), plus one criterion from their illness list.
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One is an insanely low bar: diagnostic criteria in mental health (which they used as an example to justify their ‘illness’ definition) requires several ‘symptoms’ to meet diagnostic criteria- and these are based on evidence based clusters of symptoms.
The Lancet cowboys simply cobbled together an array of wildly different ‘signs’ – including breathlessness (!) and urinary incontinence- without a coherent underpinning, and experiencing a single one of these common human experiences can earn the label of ‘clinical o*esity.’ It’s the easiest club in the world to join!
How Common is ‘Clinical O*esity?’
During a 4-hour livestream ‘launch event,’ Commission co-author Eric Ravussin presented unpublished data on the ‘prevalence of clinical o*esity.’ He used BMI plus waist/hip ratio plus 11 ‘criteria’ from the Lancet list (including diabetes- even though they excluded it). 31% of their sample of 239 000 met criteria. Of these, 35% had no ‘organ dysfunction’ and 65% had ‘organ dysfunction.’
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Visibly incredulous, Ravussin admitted that people without ‘o*esity’ can also experience ‘organ dysfunction’ but suspiciously didn’t present the data, stating that he is ‘looking at correcting these numbers.’ #Dodgy.
Commission co-author Jose Manuel Fernandez-Real also presented information from a Spanish medical database. This used BMI plus 12 signs of ‘clinical o*esity’ (once again including type 2 diabetes), finding 35% of non-o*ese and 57% of o*ese people with at least 1 condition.
These two datasets revealed about one third of smaller bodied people have health issues typically attributed to larger people, and roughly one third of larger people have no signs of illness- numbers eerily similar to BMI based NHANES data.
After going to all the extra effort of diagnosing ‘clinical o*esity,’ we’re back to where we started: anthropomorphic measures don’t tell us much about health, and the issues impacting larger bodied people also happen in smaller ones. It’s almost like weight-centric focus is stopping science from seeing the big picture!
‘Pre-Clinical O*esity’
In an awful take on ‘actually healthy,’ the Lancet authors labelled everyone with ‘excess adiposity’ as suffering ‘pre-clinical o*esity:’
‘a condition of excess body fat associated with variable level of health risk, but no ongoing illness.’
Providing no references, they claimed that people ‘living with preclinical o*esity are generally at higher risk of developing diseases, such as: clinical o*esity, cardiovascular disease, some cancers, and Type 2 diabetes’.
Whilst also admitting that:
‘The likelihood and rate of progression from preclinical o*esity to clinical o*esity is unknown and requires investigation.’
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Preserving their future customer base, they recommend that those with preclinical o*esity should have ‘equitable access to health care when needed to reduce an individual’s risk of developing clinical o*esity‘, and ‘monitoring with or without prophylactic intervention.‘ This leaves the door open to push weight loss drugs and even surgery on people with no health conditions.
O*esity Outrage
Not everyone was overjoyed by the Lancet paper. The Novo Nordisk funded EASO released a statement insisting that o*esity is a chronic disease and plugging their own ABCD model. Their biggest gripe was ‘pre-clinical o*esity,’ which they said was ‘risky’ and may delay ‘crucial early intervention’. The Obesity Medicine Association (OMA) also released a hand-wringing statement, recommending Dr Sharma’s EOSS staging system instead.
Dr Sharma, stand-up-o*esity-comedian turned Indie-folk-blues singer was greatly outraged with Rubino’s Commission, calling the clinical o*esity criteria an ‘incoherent laundry list of problems,‘ but neglected to mention that he was paid to present to the Commission.
This self-serving push back from rival o*esity disease mongers ignored the massive conflicts of interest evident in the Lancet crew, which was raised in a BMJ editorial calling for a separation of industry influence from the creation of medical diagnostic criteria.
Apart from deep dives from wonderful folks in the weight-inclusive community, such as Ragen Chastain, I haven’t seen critiques of the lazy science and dubiously low bars of this paper. We’ve submitted a letter to the Editor of The Lancet to protest on the grounds of conflicts of interest, but haven’t heard back as yet.
This Is All About Selling Drugs
During the live-streamed launch event co-author John Kirwan told the audience that influencing health policy was ‘a big part of what this Commission is trying to do.’
This was followed by a touching video message from US Senator Bill Cassidy, Chair of the Senate Health committee and leader of the Treat and Reduce Obesity Act: he’s spent years lobbying to have weight loss drugs covered by Medicare. Bill said:
‘The Lancet Commission’s crucial work will help this immensely. It’ll help us to better understand o*esity and that will in turn inform policy making in Washington DC.’
The Lancet PR piece was about political lobbying, not health. It even included a section titled ‘Implications for Policy’ — something that should have no place in a supposedly medical discussion. The real issue faced by Pharma companies is finding a ‘more appropriate and cost-effective allocation of resources’ — a fancy way of admitting that no health system on earth can afford to subsidise weight loss drugs for a third of its population. The heat is on: Danish regulators have cracked down on subsidies for weight loss drugs, and multiple insurers in the USA have stopped paying. Citing crippling costs and insufficient evidence of any long term health benefits, the Australian PBAC has repeatedly rejected Novo Nordisk’s overtures to fund their weight loss drug price gouging.
The Lancet Commission’s bizarrely complex diagnostic criteria provides the veneer of a ‘clinical assessment process’ to trim the herd — not enough to kill the market, but enough to placate payers. It’s still a goldmine for Pharma, but by offering the illusion of selectivity, they’ll improve their chances of getting coverage approved.
Bill said he was looking forward to working with the Trump administration on this. But in early April 2025 the administration, hell bent on slashing government spending, rejected a push for weight loss drugs to be added to Medicare and Medicaid: not surprising given the projected cost of $US40 billion!
But this happened before Dr. Oz, cardiologist & spruiker of green coffee beans for weight loss, was sworn in as the new head of the CMS, the federal agency responsible for Medicare. Ever the optimists, Novo Nordisk responded by saying they hope that:
‘with the confirmation of the new CMS director, the Trump Administration will move forward to finalize the definition of obesity.‘ (emphasis added)
No prizes for guessing which ‘definition’ they’ll be pushing for.
If you’ve read through to the end of this, thank you! The Lancet’s ‘clinical o*esity’ is outrageous propaganda posing as ‘evidence,’ and it’s important that we fully understand the BS at play here. Please feel free to share this series widely!
Time for a well-deserved cocktail, stay strong diet culture drop outs!
Louise
If you’re a health professional looking for help with providing weight-inclusive care in the age of the GLP1’s, I provide clinical supervision, and my books are currently open. If you’re struggling with GLP1 pressure, food, your body, exercise, or an eating disorder, I can help. My office is Flourish Kirribilli in Sydney, and I’m happy to see people from all over the world for online appointments.
* For an excellent discussion about ‘inflammation’ and weight, check out Ragen Chastain’s series with Dr Zed Zha
**Hypertophy is when a fat cell expands to being full, and hyperplasia is when fat cells multiply.
***All of this was based on BMI data. Given the Commission’s ‘consensus’ about how awful the BMI is, it’s terrible science to create an illness based on it. But that’s o*esity for you!
****OK this one was from me- sarcasm helps me cope!
