GLP-1受体激动剂的发展彻底改变了肥胖症的治疗，使患者能够减轻多达20%或更多的体重，诺和诺德的Wegovy片剂最近也在英国上市。尽管取得了这一药理学飞跃，医学界仍然缺乏公认的肥胖症临床定义，这阻碍了这些昂贵疗法的合理应用和资金拨付。从历史上看，肥胖被视为一种谱系而非单一疾病，但20世纪的人寿保险业利用身体质量指数（BMI）将所有肥胖重塑为一种风险状态，而忽视了患者个体是否真正患病。

单纯将肥胖定义为统计学风险，或相反地将其定义为统一的疾病，都带来了重大的医学挑战。将所有肥胖宣布为疾病可能会过度诊断数百万从未产生不良健康后果的人，使他们面临肌肉流失或胰腺炎等药物副作用，以及代谢手术风险（该手术的死亡率低至0.1%，严重并发症发生率为1%至4%）。然而，仅将肥胖视为风险状态会使那些遭受直接身体伤害（如呼吸、心脏或行动不便）的患者被拒绝治疗，除非他们患有糖尿病等共病。

为了解决这一混乱，一个由56名专家组成的《柳叶刀》委员会提出将临床肥胖（即过量脂肪导致器官功能障碍）与临床前肥胖（一种风险状态）区分开来。该框架得到了76个医学组织的认可，使治疗能够根据需要进行比例校准，从而为制药商带来可持续的商业和临床回报。通过将肥胖诊断与区分风险与活动性疾病的其他医学领域保持一致，卫生系统可以更有效地分配资源，并避免成本效益模型的崩溃。

The development of GLP-1 receptor agonists has revolutionized obesity treatment, allowing patients to lose up to 20% or more of their body weight, with Novo Nordisk's Wegovy tablet form recently becoming available in Britain. Despite this pharmacological leap, medicine still lacks a universally accepted clinical definition of obesity, which hampers the rational deployment and funding of these expensive treatments. Historically, obesity was viewed as a spectrum rather than a uniform condition, but the 20th-century life-insurance industry used the body-mass index (BMI) to define all obesity as a risk state, ignoring whether individual patients were actually ill.

Defining obesity purely as a statistical risk or, conversely, as a uniform disease presents major medical challenges. Labeling all obesity as a disease risks over-diagnosing millions of people who will never develop adverse health outcomes, exposing them to drug side-effects like muscle loss or pancreatitis, and metabolic surgery risks, which carry a 0.1% mortality rate and 1% to 4% serious complication rate. However, treating obesity only as a risk state denies necessary treatment to patients experiencing direct physical harm, such as respiratory, cardiac, or mobility issues, unless they present with a comorbidity like diabetes.

To address this muddle, a Lancet commission of 56 experts proposed distinguishing clinical obesity, where excess fat causes organ dysfunction, from pre-clinical obesity, which is a risk state. This framework, endorsed by 76 medical organizations, allows treatment to be calibrated proportionally to need, facilitating sustainable commercial and clinical returns for drugmakers. By aligning obesity diagnostics with other medical fields that separate risk from active disease, health systems can allocate resources more effectively and avoid the collapse of cost-effectiveness models.

Source: Medicine can treat obesity, but can’t agree on what obesity is

Subtitle: Labelling it a disease means millions will get treatment they may not need, writes Francesco Rubino

Dateline: Jul 09, 2026 05:23 AM