The Obesity Podcast Ep. 3: Redefining Obesity: The Lancet Commission | J&J MedTech

This episode features Francesco Rubino (King’s College London) and  Dr. Riccardo Cohen (President of IFSO) discussing their leadership of the Lancet Commission on Obesity Diagnosis. They explain why obesity has historically been treated as a risk factor rather than a disease, and how their work has established the first formal diagnostic framework. The Commission, comprising 56 global experts, distinguished between preclinical obesity (excess adiposity without organ impairment) and clinical obesity (with signs, symptoms, or organ dysfunction). They describe the long, sometimes contentious process of reaching consensus, the importance of separating diagnosis from treatment guidelines, and the implications for clinicians, patients, and policymakers. The framework is presented as a turning point in obesity medicine, enabling clear diagnosis, guiding treatment intensity, and shaping future management strategies worldwide.

Transcript

SPEAKER_03 0:16

Hi everyone, my name is Marco Büter, and I welcome you to the new episode of our obesity podcast. I'm a barietic surgeon. I'm also a barietic scientist, and I'm the current chair of the scientific committee of the European chapter of IFSO. And I'm hosting this podcast not alone, and I'm uh very pleased, and it's my pleasure to also welcome Paulina.

SPEAKER_01 0:39

Hello, my name is Paulina Salminen. I'm a bariatric surgeon in Finland and currently the uh president of the IFSO European chapter. Today, I'm happy to let you know that we want to use this podcast to talk openly about obesity, the disease, the people living with it, and the treatments available in order to fight stigma and share knowledge. And we're privileged to have with us the our two guests. Please, could Francesco and Ricardo you introduce yourselves?

SPEAKER_02 1:11

Well, I'm Ricardo Cohen. I'm a bariatric surgeon. I'm the current president of IFSO. And um, as well as our two hosts, uh, we do I do a lot of research on bariatric surgery and mainly the combination of strategies that this will be the future of obesity care. And I'm very pleased to be here with you guys, besides being good friends.

SPEAKER_00 1:37

I'm Francesco Rubino, I'm a bariatric surgeon too. I've been uh working in different countries, Italy, France, United States, and now I've been uh chair of metabolic and bariatric surgery at uh King's College London in uh UK for the last uh decade or so. My interest is uh generally uh the practice of bariatric surgery, but also the mechanism behind its effectiveness, especially on diabetes. And more recently, um I've uh got a keen interest in improving and perfecting the diagnosis of obesity.

SPEAKER_03 2:08

From all the possible topics that we could choose to discuss with you guys today, because there are so many, you're so active in the field for so many times. Um we've chosen your recent activity basically, which is your work on the Lancet Commission. And that was about the definition of obesity, right? So, what is it all about? Maybe I start with you, Francesca. What how did that all start?

SPEAKER_00 2:35

So, this is uh Lancet Diabetes and Dochnology Commission on Clinical Obesity, the definition and diagnosis of clinical obesity. The title of the commission already says it all. Uh, it's a definition of a disease entity, uh, obesity as a disease, and also uh the definition of the diagnostic framework that allows us to detect disease when there is, or to rule it out when there isn't. And this is a novel concept in obesity because we have never used a diagnosis before. We use classification. So for the first time, we now have a formal diagnosis, clinical diagnosis for obesity.

SPEAKER_02 3:10

Despite you mention, we need to highlight the audience that it's a diagnostic framework and not a treatment guideline. So this leads to a lot of confusion in the field because people mix diagnosis with treatment and they're separate, of course.

SPEAKER_03 3:27

Before we go into details of what this commission came up with, you know, maybe you can take us through the process.

SPEAKER_00 3:35

Well, in 2019, I started to think about this issue of like obesity as a disease. A lot of my patients, like a lot of your patients, a lot of your patients have uh clearly an ongoing disease, you can tell. Uh and yet, even when we try to propose this thing, a lot of people push back and say, you know, obviously it's not a disease, etc. To me, that was an interesting observation. So the question is why the question of obesity as a disease is so polarizing. Why there are so many opinions? Normally, for it, for it, what is a disease or is not a disease is very factual. It's you know, it's uh it's something that the medical profession decides, not the politicians, not somebody else. And it's very much based on objective evidence. So why could this be so contentious? And now looking into this, I realized that the reason is that we never define, we forgot to define obesity as a disease. We define it as a risk factor, we define it as a side both size issue, but never really as a disease entity. And that was the what drove me to discuss this with some Lancet editors as a potential initiative, and they say, well, this is such a fundamental question that warrants a Lancet commission, and that's how we started.

SPEAKER_02 4:43

And actually, this matches with what we did during COVID. During COVID, we wrote a paper, remember that, on who to prioritize with surgery. It was about surgery only, not medical treatment of obesity. So that turns on a light. So if we prioritize something, we should not base on a BMI. And that was the foundation of it, because we have an algorithm there, not based on BMI, but based on the severity of the disease. So this is an important message.

SPEAKER_01 5:14

I was just gonna try to picture it in my head because you have this great idea and then you get it started, you get all the experts there. How hard was it to get everybody on board to understand that what was actually the target and aim of that uh Lancet Commission?

SPEAKER_02 5:32

And that was an ongoing thing. It was not during the selection of the experts, but during the process of the following.

SPEAKER_01 5:38

I can imagine, but that's but maybe you need to imagine that.

SPEAKER_00 5:42

Even the selection wasn't easy because obviously Lancet commissions have their own rules. They have to be global, uh globally representative. Uh, and also, particularly in this case, because if you want if you want to have a diagnosis of obesity, it cannot be European, American, Brazilian. It must be working worldwide. And it's not a management framework which may have differences because obviously, depending on the healthcare system, you might have better different resources, different situations, and so management frameworks can and should to some extent be different depending on the location and the circumstances. But diagnosis can't. Diagnosis has to be one and for everybody. There's only one way humans have and worldwide, one way humans can have a disease: Crohn disease, Parkinson disease, diabetes are the same thing in every in every country. So the same was for for obesity, and that's why we had to really be balanced in representative representing all continents and of course all disciplines.

SPEAKER_03 6:41

So, how how many representatives were there in that commission in the end?

SPEAKER_00 6:45

56 total. Uh, and uh with a balanced representation, as much, of course, you can do for depending on productivity, academic uh output, etc., from America, from South America, from Europe, from Asia, from Africa as well.

SPEAKER_03 6:58

So as far as including patients' representatives. So that's already, you know, how long did that process take?

SPEAKER_00 7:05

It took uh more than a year and uh and a half, probably, just to make the selection, because besides obviously having us appointing a steering committee that makes a selection on based on certain criteria, then finally you make a pre-selection, and then of course there are rules, conflict of interest, unfortunately, very strict conflict of interest rules.

SPEAKER_03 7:19

So it's it wasn't and I and I bet there are colleagues that were not chosen to be part of that commission that stopped talking to you. I'm I'm asking for friends.

SPEAKER_00 7:28

We can always blame, we can always blame the editors at the Lancet. But no, the reason is obviously they're way more experts than the ones that could fit a commission. And they're the commission that by any uh stretch of imagination means that those are the best people in the world, those are just meant to be representing the best people.

SPEAKER_02 7:46

If I can be more intimate, during the review of the paper, that took one year. Have you ever seen this? One year of the review of the paper?

SPEAKER_03 7:53

Because it was reviewed by people that were not on the commission, exactly.

SPEAKER_02 7:58

And during the review, which we cannot disclose the exact wording, there are people who said, You people at the Lancet Commission don't know what you're doing. I know. In in in the in a you're an editor of a big journal.

SPEAKER_01 8:11

So did that was that actually stated in the uh yes, peer review. Okay, exactly. Interesting.

SPEAKER_03 8:17

Do you mind to share one or two names? We don't know. I'm just kidding.

SPEAKER_00 8:21

No, we don't know who it was, but that no, definitely that it was uh, but I think it's okay. It's uh it's normal to uh to think about something so important why why I wasn't uh part of it, and then obviously there are many, many people who would have been perfect uh members of this commission. It's simply that Lancet at some point say, you have too many from Europe, you have too many from America, you have to you have to make some and and how often did you meet? Too often. I think I I calculated a total of uh at least I had to as a chair, I had to attend all each and every of them. And I think it's north of 800 meetings.

SPEAKER_02 8:54

But but in the beginning it was more intensive. It was more intensive, it was weekly, weekly, weekly, and there was some experts on other chronic diseases to teach us what is a disease. Seems very kindergarten, but it's not.

SPEAKER_01 9:08

It kind of sounds like that. That's uh how did you actually organize the work of that commission? Because you have 56 people, you cannot, you know, work on every single part of that uh process with the whole group. So, how did you manage to organize it in a way that uh you were able to kind of work towards the same goal, but then combining uh all of the work that they did?

SPEAKER_00 9:32

Well, we had um meeting, monthly meetings for the whole group, and then there were bi-weekly or weekly meetings of subcommittees, so even subgroups were meeting and you know, and then report to the broader group, but every the whole group anyway had to meet every regularly every month.

SPEAKER_02 9:47

This is the whole group, but the subgroups were weekly, and after the first two years, they were bi-weekly or with with a uh a longer interval as needed, as needed, on demand.

SPEAKER_00 9:59

And I think we need to say in public, we need to be thankful to a lot of commissioners because um if you saw that situation, uh for us it was very convenient. I was in London, it was 1 p.m. on Monday afternoons, but then some of our colleagues will connect at 5 a.m. and others at 2 a.m. on the other side of the way. And they were there, and it was really something that would we will remember forever. I mean, the the passion that people put in these things and is extraordinary, and nobody actually received a dime for their time, nobody was compensated. It was just generally in genuine interest to be part of something important.

SPEAKER_01 10:32

For the cause, yeah, they're very committed, yeah.

SPEAKER_03 10:35

Yeah, that's that's very nice, but I can assume that there are emotions involved and and and conflicts. And and can you tell us how you made decisions in the group that must be defined somehow, right? At some point, you have to make a decision to move on. How how was that defined and how did you deal with conflicts?

SPEAKER_00 10:56

He deals with conflict better than me.

SPEAKER_03 10:58

Yeah, so I guess at some point you need someone to declare conflict, right? And then no, the conflicts were subliminal, okay, they were not explicit.

SPEAKER_02 11:09

My almost 30 years friend here is much more emotional, and we would get together, not only us two, but some different people, and try to find the best solution for that conflict. So this is the way it went. There are some people who were outliers who were not explicitly uh show their feelings or their opinion. So we try to manage this, and the final thing is it was successful. We got the paper finally and the idea that oh, the whole concept. But there were several hurdles during this process.

SPEAKER_00 11:47

But you ask what how we managed to do that. I think there's been a mechanism that was very successful, and and then it might be used for other initiatives as well. It works pretty well. When we started this commission, um, it was clear that we had different opinions on some of the core issues. And if you start, you take a step back and just listen to everybody, it was very clear early on that on many issues, nobody was entirely right and nobody was entirely wrong. And so if you start from that assumption and say, here is not a matter of making uh my opinion prevail on over yours, obviously, but it's also not even trying to make the sum of opinions and try to get into the media now the mean. It's more to say what's wrong in my opinion and what's right in yours and vice versa, so that we can come and find a common ground. And that process, I you know, an iterative process, eventually led to uh go from very distant positions going down to uh common ground. And it's very entirely feasible.

SPEAKER_02 12:50

That was not per protocol. That happened. That happened.

SPEAKER_00 12:54

No, it it is it is in part um per protocol in the sense that we had these meetings where we we were asking you to say your pleas, asking there before we actually start making Delphi. You don't start making Delphi to open an opinion, you start having different opinions, and then we prepare the Delphi only afterward.

SPEAKER_02 13:11

But we we got agreement on major points before the Delphi. It was something natural, it was not something imposed, it was natural. There were some excellent researchers there, basic scientists, clinicians that top-notch people, and even them, they listened, and the final agreement was done. It was it was an very interesting and educational experience.

SPEAKER_00 13:34

And I want differences where at the end, not so much on um the the evidence. The difference really uh stemmed from the fact that we did not understand clearly, all of us, including myself, uh, what we were trying to do until we actually were well into the process. So when we you say we want to make a diagnosis of obesity, it's really difficult to grasp what the red really that means. And until you do, you come up with this uh knee-jerk reactions of, oh, we should define obesity as a disease. When is it, oh, when there is diabetes? Well, that is exactly why it's not a disease, but we need to we have to reverse engineer our understanding of obesity before we actually can make progress. And once we did it, 100% control.

SPEAKER_02 14:17

But then what is a disease? I remember the words, remember the psychiatrist, that he in in the middle of his presentation, he started to explain what is a disease with signs and symptoms and major and minor criteria to children. Because people said, no, no, no, but it's obesity is not like this. Why obesity is not like this? Obesity should be. And and we learned a lot the way he was very did didactic. Yeah. And then we learned some people learned, yeah, it's a disease. So not always.

SPEAKER_01 14:50

But that's actually, I wanted to go back to my first question, is that is exactly what you said, because I think starting that commission, people coming in, they did not realize what the target scenario actually was. They had no idea what you guys were actually aiming to do.

SPEAKER_02 15:05

Even very good friends of ours that were interested in the world.

SPEAKER_01 15:08

I fully understand that. So maybe like a ballpark idea, at which point did everybody reach that, you know, common ground? How long did it take?

SPEAKER_00 15:17

Well, at the beginning, I think some some of us, at least, uh, might have thought, well, this is a great opportunity. We're gonna just say that obesity is a disease, which was is what we wanted to say all along, and we're gonna say it from the pages of a prestigious journal, and maybe we just find a way to make it uh um cogent proposition. But that wasn't what we were trying to do. We were trying to find out how to diagnose disease in obesity. Once you are confronted with that task, then you realize that all the answers were given before. The typical thing, obesity is a disease because it causes 240 others. That's not the answer. And that's why you start saying going from the differences to understanding that we really needed to go back to the to the board and uh and then re-engineer etc.

SPEAKER_02 16:05

Even the concept of relapsing. A relapse is something that may improve by itself. So obesity is not relapsing, it's a disease. So a relapse, for example, an autoimmune disease will relapse, and Crohn's disease will go better and worse by itself. So obcity will never improve by itself. Even that concept, we need to relearn and re-engineer the thoughts of all the commissioners.

SPEAKER_03 16:28

So so congratulations already to that part of the work. I mean, getting 56 people together over a period of four years, coming up with a paper of more than 40 pages. No, no, no, no, no, no, no.

SPEAKER_02 16:41

Through a 25, 27 plus references. Yeah.

SPEAKER_00 16:45

Which is part of the second appendix is another 40.

SPEAKER_03 16:48

So it's 80, 80 pages and the reviews, then the reviews is about about 300 pages. So obviously, I need to check the numbers before I actually host before so many, many pages.

SPEAKER_01 17:00

But and of course, our hats off for you. That's extremely important work.

SPEAKER_03 17:05

Yes. How would you summarize you know, the key findings the commission came up with? So someone is not in the field of obesity treatment, uh, understands why this is such an earth-shaking activity.

SPEAKER_00 17:24

The editor of uh The Lancet during the launch uh event said um uh publicly, so I can quote him, uh, this is a before and after, a sharp before and after moment in the history of obesity and probably of medicine. And I think if it's probably not exaggerating, because uh if you look at the history of obesity, historically, we would never actually have been able as a medical profession to have a unifying framework that explains the spectrum of obesity. Even Hippocrates and Gallen have discovered that obesity could be a disease and could not and could be just a risk factor, even a normal um reaction to the environment. So, how you put all this together and why we never did it before, it's an another uh event of your of your uh podcast, but I think it's what is important is now we have a diagnostic framework that really reflects the spectrum of obesity. So we can now know where obesity is a disease clearly and objectively. Now at the presentation and at present, and and and where is a preclinical condition, and because of course the two things require warrant different types of approaches.

SPEAKER_03 18:29

So this is new, right? Separating into preclinical obesity and clinical obesity. Obesity is new, but not in medicine. All right. Well, I understand, but so what different uh differs between these two uh stages of one disease?

SPEAKER_02 18:47

It's a spectrum. Preclinical obesity is the excess adiposity without signs and symptoms of obesity. So it demands preventive strategies, risk stratification, and the adequate intervention. And the intervention may be with uh, for example, type 2 diabetes is another disease, but the person has preclinical obesity, and weight loss is a way to put diabetes into remission. So we have preclinical obesity and diabetes. So you treat preclinical obesity to get diabetes into remission. But if you don't have any risk, an example for surgeons, you have colonic polyps and a carcinoma of the colon. They're the same spectrum of disease with different strategies. So you will never do a oh we'll never often do a colectomy for a polyp. You will never do an endoscopic resection for a colon cancer mostly.

SPEAKER_00 19:42

So let me, because maybe that's that's uh in fact, the the implications, but you may ask how we came up with this uh idea clinical and preclinical. In fact, what we did was we looked at the rest, looked at the rest of medicine, and then you ask yourself, what is the normally defined disease? Now, what defines disease is not a philosophical thing, it's very clear in medicine, very clear. Sometimes we philosophize, but it's clear. Diseases are characterized first and foremost by the cli by a clinical identity. They have a defined clinical manifest, a set of clinical manifestations, and they have a natural history, which is very typical, and determines their prognosis. So you know that diabetes, what it looks like clinically, people make a lot of urine, people make uh they eat a lot, they have hunger, etc. That's how this diabetes was conceived as a disease, then eventually get diagnosed by hyperglycemia. But what defined diabetes were the set of symptoms, and the same applies to Parkinson, to like dementia, and to everything. So, how the symptoms are determined? The symptoms are determined, make no mistakes, there's no other reason, by the fact that one or more organs are not able to function normally. If they're impaired, if your heart is beating too fast, or if your lungs are not able to exchange, etc., then you're gonna have signs or symptoms of that impairment. That's a big thing. That's what the clinical reason. That's what makes a disease, uh the illness, and that's what defined disease. So the question we had to face was does obesity always cause symptoms? Does it always affect your organs? And the answer is not really, not always. But when it does, how does it? How does it? It's not like anything, it has to be a specific uh impairment that obesity does. So that exercise took a lot of time because we had to screen all the systems in the or in the organs and say, does obesity have an effect? Is there any evidence? If it does, what does it look like? Uh, what kind of effects? How is it different than the effect of um diabetes on kidneys and the obesity effects on kidneys? So, this is a a lot of work behind those syntaxes. We just didn't come up with that.

SPEAKER_02 21:44

And then you come back to the definitions. Preclinical obesity is excess I deposit that can be measured by anthropopatic parameters or even more specific uh exams like DEXA or MRI. And clinical obesity is a disease at the moment, at the present. So it's excess I deposited with a disease. That are present with a clinical rationale, a pathophysiological rationale, and a health impact rationale. So those are the three rationals that base a disease that allows a differential diagnosis, and those diseases has have complications as well. So it's a disease defined not by the Lancet Commission, by the dictionary.

SPEAKER_00 22:19

Let's just for clarity, excess adi obesity means excess adiposity. That's the definition of obesity. Now, excess adiposity is a physical phenotype. It could be the symptom of another disease. You can have excess adiposity because you have cushing, right? So excess adiposity is just the sine qua non is the prerequisite of having potentially a disease due to obesity. Then when you have excess obesity adiposity, you have to define if it's clinical or preclinical.

SPEAKER_03 22:47

So both stages have that in common as a basis for both.

SPEAKER_00 22:53

Yeah, otherwise it's something else.

SPEAKER_01 22:55

If we're taking this down to the uh physician that actually has that patient in there, so they're trying to figure out.

SPEAKER_02 23:04

So how would that, how did how would you interpret the Lancet Commission to a person that, you know, or a colleague that is trying to think about the best uh But it's good to highlight that people sometimes confuse us that we are adding more things for the general practitioner to think about, and it's not you it's a good history, physical examination, and a set of exams, they're very simple and available everywhere, including in the middle of Africa. So you have the diagnosis of obesity, meaning excess I deposity, and the preclinical stage and the clinical stage, they're the different spectrum of the same disease. So it's a good history, risk stratification, and then you with you you can teach a general practitioner, or even without any big involvement on obesity care, that that's the way to go. You have signs and symptoms, and then you can treat him or her accordingly. This is clinical obesity. For the preclinical obesity, this person should be stratify it's his or her risk, and the adequate strategy, even surgical, clinical or not, should be adequate and fit for each person.

SPEAKER_01 24:22

When a patient comes and sees you, how do you do the diagnosis?

SPEAKER_00 24:27

Well, so the important thing in the Lancer Commission framework is that it's for clinicians, uh, and is and it's designed by clinicians as well. So clinicians, unlike an epidemiologist, don't have to look at the uh risk or probability. They have to tell a person in front of them you have a disease or you don't. And they have to put a pen, uh, ink on a certificate to certify that diagnosis. So they need to have a degree of certainty, uh and you need an accurate diagnosis to be able to do that. So the first step is to say, has this person in front of me really obesity? Does that person have obesity? And if you use BMI, you may not be able to tell. You may have somebody with muscles or uh somebody who doesn't have the BMI very high but still has excess adiposity. So what we recommend is that you measure the BMI. That it's only a screening tool. It flags somebody who might have excess adiposity. Then you need to have at least another measure to feel confident that you are dealing indeed with a case of obesity in the clinic. We're not measuring it in the in databases in the clinic. So it's an individual. And once you do that, you can have waist circumference, you can have uh white waist to height, waist to hip. So if you have two consistent measures, you could say, well, realistically, regardless of BMI. If you have uh including BMI, or regardless of BMI, if you have BMI over 40, there are not so many things at that level that other than excess adiposity. So you can say pragmatically, this person has it.

SPEAKER_02 25:53

We took some weeks to find a 40. You remember the discussion? Is it what what is the BMI that we pragmatically can assume?

SPEAKER_00 26:00

And it's and it's just uh obviously a pragmatic uh assessment. But once you do have excess adiposis, you are a clinician, you say, okay, I figured out this person has excess adiposity. Now, I don't I can't use as a clinician a scale of population-based um assessment of risk to say what is the probability of this person having some disease. The probability doesn't apply to clinical diagnosis. It's it's yes or no, it's black or white. So then you say, okay, let me make a medical history, let me ask these questions. Uh, do you are you do you have shortness of breath or other things? And if you are concerned, you do a whatever test it takes, an echocardium, etc. You might discover that a person has heart failure or lung uh restriction, etc. That would be clinical obesity, right?

SPEAKER_02 26:41

But that may allow a differential diagnosis, as all other diseases. So it's not complex, it's the opposite. We do some anthropometric parameters and you do some relatively simple exams like echocardiogram, uh blood pressure, uh, a set of a cluster of metabolic alterations. So it's not bracket science.

SPEAKER_03 27:02

So just to make sure I got it right, so start with measurement of excess fat, right? That defines obesity, and then you have to decide whether it's preclinical, no organ damage, clinical organ damage.

SPEAKER_00 27:17

Um organ impairment, not necessary damage. It's an impairment, okay, though.

SPEAKER_03 27:21

It's a dysfunction of the it could be a damage, but it's not necessary. Something that can be you know classified in a zero-one answer, right? This is yes or no. Right? So this new classification only makes sense if it has implications for the treatment, right? Um I understand it correctly that so far we basically considered obesity as preclinical obesity in all cases, because the decision whether someone needs to be treated or not.

SPEAKER_00 27:57

We have uh is you know dealt with obesity as a development.

SPEAKER_03 28:00

You know, it's like it's by chance, right?

SPEAKER_02 28:03

But but as you start it, you need to have linked to treatment strategy. So so far, and the example of bariatric surgery has been uh looked as a prophylactic intervention because the definition of obesity is always a risk factor that may or may not uh and rightly so, but not alone, right?

SPEAKER_03 28:25

I mean, there's so much more to it than just prophylaxis, exactly.

SPEAKER_00 28:28

But see, it's like a like a blanket. You can't obesity is a spectrum, and you have a blanket that the way we used before is a diagnostic framework that uh was only pulled in one direction. So if you pull it in the direction of risk, you cover the fact that obesity is indeed a risk for many. Yeah. But then you uncover the part that obesity is also a disease. But if we were to go with the labeling obesity as a disease, just as some people suggested, then you cover the disease and then you uncover in that framework, you don't pick up the risk. The person who has a risk, but not yet a disease. Now, what Ricardo is saying, management uh is the next step. And then how you inform management is well, we the diagnosis is not a management framework. However, it gives you the fundamental information to develop a management framework because it's the best strategy. Because if it's a risk, you cannot treat somebody with the same intensity as you would treat somebody who has a disease. And so you want to know if that is a disease or is not a disease. On the other hand, doing all this preventative, including pre-operative uh weight loss uh strategies that don't serve anybody when somebody already has a disease, you know, is it only because you never had a diagnostic framework to say this person hasn't ever crisp as a disease? So so that's why you identify, then you approach the risk with risk mitigation strategies, which could be even pharmacological, or and then you approach the disease with whatever it takes, but as a disease.

SPEAKER_02 29:51

Colon cancer and colon polyp. Exactly. Pre-diabetes and diabetes.

SPEAKER_03 29:56

It's sort of a triage tool, basically. Right. Yeah, diagnosis is always a preclinical obesity. You know, you can do prevention, you can do pharmacology, you can also do surgery, but once you have diagnosed clinical obesity, you need therapy quickly.

SPEAKER_00 30:14

Practical implication for surgeons, for instance. I have on my waiting list uh for surgery, patients who have preclinical and clinical obesity, right? So in the in colorectal surgery, you don't put people with polyps and people with cancer on the same waiting list, right?

SPEAKER_02 30:29

Or diverticulitis and cancer.

SPEAKER_00 30:30

Equally. But that doesn't mean that you don't treat the verticulitis or you don't treat polyps, you treat them too. But obviously, the type of resection is going to be smaller. The type, the timing that you have is going to be more, you know, you can ask it's everything is different. But if you don't make the distinction, you can't do that. With obesity, we never we were never able to make that distinction that people do between polyps and cancer. Now finally we can.

SPEAKER_01 30:52

Now, when we have this diagnostic framework with the Lancet Commission, is that was it really targeted for clinicians or health care payers?

SPEAKER_02 31:03

For healthcare payers, for policymakers, for clinicians, and for patients. Because you can tell now to a patient that she or he has a disease and you put his or her disease into remission because the signs and symptoms went away with the treatment. And you can tell them that indeed they have a risk factor and they should be treated because the risk factor after the stratification is high. So you need treatment. So it's a win-win-win-win, five-win situation.

SPEAKER_00 31:30

Your question is important. And the answer is all of them. I mean, a patient needs to know if they have a disease or not yet. And you can't tell a person who has a disease that they don't have it, because that would be malpractice. But equally, you can't tell somebody you have a disease just to be on the safe side if they don't. We are obliged to speak to patients with clarity and tell them exactly if they have a disease or not. And when they don't, it's our duty just as much as our duty is to detect disease, to actually rule out disease. And with obesity, we had no chance to do so before because we didn't have a framework for that. So we need to do to know that for the patient. Of course, it informs the policymakers.

SPEAKER_02 32:10

Because they can prioritize.

SPEAKER_00 32:17

That's that's a fundamental mistake. Policymakers don't and pick diagnoses. What they do and pick and choose is when you have a treatment algorithm, because that depends on resources, etc. But they don't deconstruct or and pick diagnosis. Once you make a diagnosis of Crohn, it's Crohn. When it's making a diagnosis of cancer, it's cancer. Uh, diabetes is diabetes. Then you can have it, a way you manage it, and then payers can decide to cover it more or less, but they will not choose a symptom of clinical obesity and not the other. So that's why a diagnosis, once it's made, is made.

SPEAKER_01 32:49

Yeah, I fully get that.

SPEAKER_00 32:50

It's blunt.

SPEAKER_01 32:52

After the paper is out, because this is uh with all research and everything, when the paper is out, you need to actually implement it somehow. And this, I think, for policymakers would be crucial because we're currently under treating these patients, of course. They're not within active treatment, and that is one of the biggest challenges, I think, in our field, that we get people and patients to actually understand that they uh they they are entitled to have treatment if they have that diagnosis. And now we have a diagnostic framework. How is there like a pragmatic plan to further implement uh the Lancet Commission for to advance this, that we get more patients within treatment?

SPEAKER_00 33:35

Well, there are many things you need to do. Communication is very important. Uh, also, of course, we need to refine the diagnosis. The diagnosis is just the first step. Then there is the staging and then there is the management framework. At the moment, we have staging standards that are very blurry and treatment framework that don't distinguish clinical from preclinical because there wasn't. So, what we need to do, the next step is to score clinical clinical, preclinical obesity as a risk factor, and stage the disease of clinical obesity. And then, of course, have a management framework that for each of those two will give you the it will inform payers to do what is most uh evidence-based, etc. So it will take some time to actually get to the full scope of this project. But the first step is to have a diagnosis and to have a disease diagnosis definition very clearly. Without that, anything else is blurry, so we couldn't do it.

SPEAKER_02 34:23

And Paulina, we are always only eight months old. Your babies, the paper was out on January the 16th.

SPEAKER_01 34:29

Because that would be my next question, because usually it's it's evaluated that uh getting a research result out into a clinical practice, the median is 17 years.

SPEAKER_02 34:38

So come on, you guys have like we shook the market, we shook the market. Even even different opinions raise the awareness that we need a diagnosis, not a classification. So obesity is class one, class three. Today I heard class seven obesity during a presentation. So it's a class, it's a classification while we have a disease active as clinical obesity, and preclinical obesity is a risk factor, then may need treatment or not, and this is the way to go. So we're spreading the news.

SPEAKER_00 35:08

The most difficult thing will be to make uh many of us, it was difficult for us, so we anticipated it would be difficult for everybody. We were just a representation of the community of obesity specialists. Obesity specialists have a big issue. We have never seen, we we were never born in a field that had a disease diagnosis. Never. So now we we substituted diagnosis with this management frame, with the Edmonton scoring system, with the with other things that are very good for what they could do at the time. But without a definition in diagnosis, those are those are no replacement for that. So we many of us will say, What is diabetes? Because diabetes is in the management framework correctly, but diabetes could not be in the diagnosis of another disease. But it's it's easy, but it's easy.

SPEAKER_02 35:52

We don't need obesity to make the diagnosis of diabetes. Why vice versa?

SPEAKER_03 35:57

I mean, you brought up examples of different diseases, right? Which are classified in a similar comparable way, like polyps and colon cancer? I think the difference between those diseases and obesity is the stigmatization in the in the head of all people, you know, participating in the treatment and dealing with obesity. And that most of all also includes the patients, which internalize that stigmatization. So, how do you think will that classification help to fight that stigma? And and will it help?

SPEAKER_02 36:33

That's an easy answer. We went from corpulence to biology, we went from corpulence to a diagnosis of a real disease at the present. So this transforms obesity as a lifestyle or a lack of willpower to an active disease at the moment that impairs the quality of life of the person. So this is the main message to the patient. And then if you give some antidepressants to a patient with depression and the psychiatrist uh remits depression, he has remission of depression. What's remission of obesity? No, no, it's not curable, it's a disease that you're gonna live forever. No, we can put the signs and symptoms into remission with the proper treatment of clinical obesity.

SPEAKER_00 37:17

But the stigma is a problem, it's very complex. We've heard all sorts of things, and people who always use the stigma flags to oppose things that they don't like. You know, if you don't like the framework, this I can say that helps uh stigmatize the other one. Say it. So people have to be much more rejective. The reason why there is stigma is that we judge character based on body size. That's the bottom line. And when you define disease based on body size, you compound the issue, which is what we've done so far. By saying obesity is a disease because of the corporality of it, the physical part. You're actually compounding the problem of stigma because you're making a body size, which is already used to judge character inappropriately, now become also the reason why people have a disease. And you say, well, if you if you have a disease, it's I am authorized to, as a form of tough love, to kind of stigmatize because it's you know I'm I'm doing it in the interest of the subject. That's completely wrong. So what the can the what this new diagnosis does, it removes the um it tells us that we cannot judge character based on body size, but we also cannot judge disease based on body size. And that's how you unplug what fuels stigma.

SPEAKER_02 38:29

It's biology, it's not it's not a lack of willpower or a impair character.

SPEAKER_03 38:34

Yeah, you and I, and we all know that. And and I I'm certainly convinced that this classification will help to convince people who still think otherwise.

SPEAKER_01 38:45

Listening to some of the comments after the Lancet Commission came out, there were um a wide variety of uh different perspectives. We heard it all.

SPEAKER_00 38:55

Yes.

SPEAKER_02 38:56

And we keep we keep hearing them.

SPEAKER_01 38:58

Yeah. But what what what perhaps is the most common mistake that uh people when they read it that they would think that you're one of the top ten most common mistakes?

SPEAKER_02 39:10

Yes. Or only one.

SPEAKER_01 39:11

Or like maybe top top three or two.

SPEAKER_02 39:14

I can start three. Why you did not add type 2 diabetes as a criterion for obesity? And we can answer why the diabetologist didn't add obesity as a criterion for diagnosis of diabetes. So this is one of the top three, I think. You go to the podium.

SPEAKER_00 39:30

So we can Yeah, I think that's the the most uh obvious uh issue is again, as I said before, the misunderstanding of diagnosis for uh management framework. A lot of our colleagues were hoping that the Lancet Commission would either label obesity as a disease, blanket, or come up with a sophisticated management framework that is all inclusive so that we can treat everybody. But they don't understand that obviously we were bound to a different um task. We were bound to define a diagnosis. So we didn't have the luxury of saying, let's put anything that warrants treatment of obesity. We have to be very specific. What is this clinical obesity, how and why is different than other diseases, how you create a diagnosis again? That's a completely different exercise. So until people actually start realizing what the commission is and how different it is from anything we had before, guidelines, like you know, NIH guidelines for surgery, the Edmonton scoring system, the King's scoring system, those are all different things. There's apples and oranges. So when they start understanding the diagnosis, I think people uh appreciate. And probably you notice this. People in other fields of medicine, when they see the Lancer Commission framework, they say this is a no-brainer.

SPEAKER_02 40:42

We have more not only doctors, journalists that you spoke with.

SPEAKER_00 40:46

We have a little bit more difficulties in making this understood by obesity specialists because we, and it's not a critic to my colleagues, it's just because I was in the same situation, you were in the same situation. We shouldn't pretend that we are uh immune to that problem. We were always thinking, how we define another scenario where we need to treat obesity. That is the wrong question. The question was, is obesity a disease? If so, what does it look like?

SPEAKER_02 41:10

Yeah, but Paulina, your question is the top number one, I think, is why diabetes is not included. And we that's an answer. You know that diabetes facilitates infection. So why not putting infection in a criterion for diabetes? That's it's a nonsense. But why adding another disease to say that obesity is a disease? Obesity has its own identification with signs and symptoms. Why should I rely on other diseases to make it a disease? So I think this is the commonest. Yeah, it's a top number one. So we have three to from two to ten, they're common, but this is the number one.

SPEAKER_00 41:41

And the other one is preclinical obesity. A lot of people don't like the definition of preclinical obesity. They think that this encourages encourage the delays treatment. But let me give you an example. Um, I mean, we never say that preclinical obesity shouldn't be managed. We just say that it's different than clinical. Uh, oncologists would never say that defining the difference between cancer and polyps will encourage not to take care of polyps or to you know screen or even remove them when appropriate. Um, so the other people in other fields, we have this idea that obesity, the only way to make a treat is to label it as a disease and that would change everything. That would that would not be what solves our problems and our patients' problems.

SPEAKER_01 42:21

Definitely. So, as a pragmatic person, please tell me what is the actual next step that you're already, I'm sure you're already doing it.

SPEAKER_00 42:31

So is that uh we we are planning to do uh an initiative linked to a Congress, the first World Congress on clinical obesity, which will incorporate this uh exercise, a research exercise to define and score uh the risk in preclinical obesity and to stage the disease in clinical obesity because clinical obesity may have different mortality if you have heart involvement compared to knees or or musculoskeletal involvement. So you definitely need to have a staging for it. So that would be our second uh step. And then I think after that you can actually create a framework for management that is both sensible to the diagnosis and sensible to the resources of the fact that.

SPEAKER_01 43:10

So first we're gonna have actual uniform standardized definitions so we could actually compare also different studies and assessing the management uh algorithm that we're able to.

SPEAKER_00 43:22

We already see that clinical and preclinical obesity have much different mortality. Uh, we have studies that are about to be published that show preclinical obesity has no impact on mortality versus clinical obesity as a system.

SPEAKER_02 43:35

It's a worldwide experience in not only one country, so it's reproducible all over the world.

SPEAKER_00 43:38

So the two categories already separate, but then of course you need to stage within clinical obesity and score within preclinical to be more sophisticated.

SPEAKER_01 43:47

Yeah, that sounds very good. So that's gonna be the next step. When is that gonna be finished?

SPEAKER_00 43:51

Give us a little bit of time four years. As soon as we can. Four years.

SPEAKER_03 43:58

And you can invite all the other non-56 people that actually wanted to be in the accommodation. No, absolutely. That's true.

SPEAKER_00 44:06

It has to be uh open to other people, yes.

SPEAKER_03 44:09

Yeah, I mean, you know, this classification opens up so many great opportunities scientifically, clinically.

SPEAKER_02 44:17

Classification is a diagnosis, classification is class diagnostic framework.

SPEAKER_03 44:23

After one hour, I'm still not getting welcome to my walls.

SPEAKER_01 44:28

It really does because having the diagnostic framework actually is the basis that you can build everything.

SPEAKER_02 44:35

You can treat any disease without a diagnosis. You don't just treat something. I'm gonna treat everybody.

SPEAKER_01 44:40

It's kind of crazy that it took us all this time to understand that.

SPEAKER_03 44:44

And and I'm I'm curious whether we already know enough about the diagnosis in order to be able to score the risk of preclinical obesity. I I I I assume this will be an active field of the city. Everything in medicine, everything in medicine is never the final word, it's a moving target.

SPEAKER_00 45:04

But I think we do we know enough about what makes the risk in uh excess adiposity. It's not the the size of the excess adiposity. Sometimes it's the final history, sometimes it's where the adiposit is located, and so on. So there will be factors we could use to score the risk.

SPEAKER_01 45:18

Yeah, I think this is uh we've been privileged to have you here. And and like I said, hats off for for all the contribution that you did for this field by starting this. You still have 16 plus some years to go to have it implemented in clinical practice, but I think you just have to start somewhere, otherwise, it's never gonna happen. So that's uh I really appreciate. And uh, Marco, you want to say final words?

SPEAKER_03 45:44

Well, thank you very much for your time. I I personally learned a big deal, and I'm really looking forward to all your experience.

SPEAKER_01 45:52

Marco, it's a diagnostic framework.

SPEAKER_03 45:54

Yeah, but did I say again classification?

SPEAKER_00 45:56

No, you need to be able to thank you very much, Francesca.

SPEAKER_03 46:03

That means a lot to me, you're right. So, yeah, that's okay. You're gonna be able to do that. Yeah, I didn't expect anything else from you. So, thank you very much for your time and congratulations one more time, and really looking forward to what you still have, you know, in your bank and how you will shape in 20 years. How you will shape the future of obesity in the next 10 years. We'll do it together. Yeah, we'll do it again. Thank you very much.

SPEAKER_01 46:26

Thank you so much.