<i>Clinical Obesity</i> – a new journal for a new clinical era

Clinical Obesity has been established by the International Association for the Study of Obesity (IASO) and Wiley-Blackwell to meet the growing need for disseminating clinical research into obesity. The extraordinary worldwide growth in obesity prevalence in adults and children alike over the past 30 years is only matched by the extraordinary projections of continued increases over the next 30 years. In any arena of clinical care (primary care, internal medicine, general surgery or secondary care specialities), healthcare professionals are facing a new patient profile – the obese individual with all of his/her risk factors and associated diseases. These are often severe and complex. Obesity thus presents a parallel with the needs of the 1970s when the growing elderly population (with its own risks, diseases and special considerations of old age) generated the medical specialty of geriatrics. The creation of a new specialty has already occurred within the field of laparoscopic surgery where the bariatric or even metabolic surgeon is now a recognized training track and career for many. Unfortunately, the fields of primary care and internal medicine have moved more slowly, perhaps because there is both a dearth of effective medical interventions for the obese, and also a lack of recognition of patients' medical problems. The severity of obesity has long been defined in terms of body mass index (BMI). While always recognized as a crude tool, even when, as it now often is, refined by other anthropometric measures such as waist circumference, it poorly describes the individual obesity phenotype. Individuals with a BMI as low as 28 may have metabolic syndrome and established type 2 diabetes, while others, despite a BMI of 60 may be free of metabolic complications. The reasons behind these varying phenotypes remain unclear, but dependence upon BMI ill serves the clinical management of obesity and its associated diseases. Many obesity guidelines are based upon anthropometric criteria and thereby miss guiding the clinician and patient to appropriate care. A landmark paper by Sharma and Kushner in 2009 pointed out the limitations of anthropometric classification of obesity stating that BMI ‘. . . neither tells us whether or not a given patient has relevant risk factors, co-morbidities or impairments in quality of life nor whether . . . the patient's health would indeed improve with obesity treatment’(1). For example, a patient with a BMI of 30 kg m−2 who has type 2 diabetes, hypertension and reduced quality of life will generally require more aggressive treatment than a patient with the same BMI who has no concurrent medical problems, yet both patients by BMI ‘only’ have class I obesity and would meet the current guideline criteria for provision of lifestyle modification and possible consideration for pharmacotherapy. Sharma and Kushner went on to propose adding a staging according to the functional status of the individual, akin to cancer staging (which relates the size of the tumour and its spread). This has now been formalized as the Edmonton Obesity Staging System (2). In the Edmonton Obesity Staging System, stage 0 represents individuals with no obesity-related risk factors, physical or psychological symptoms or functional limitations, and moves through stages where these factors are mild, moderate, significant, up to severe (stage 4). An alternative way of phenotyping the obese individual was proposed by Aylwin and Al-Zaman (3) and has since been further developed by the obesity groups at Kings College Hospital and Imperial College London. This assigns a ‘severity score’ of 0, 1 or 2 to a number of criteria based alphabetically on the airway (obstructive sleep apnoea), BMI, cardiovascular risk, diabetes, economic consequences (unemployment, need for social care), functional status, and so on. Neither system has ‘official recognition’ but they, and the need for obesity specialists, point to the way in which the status of obesity needs to be raised, to that of a disease worthy of serious people treating the disease seriously. It is in this context that Clinical Obesity aims to foster the dissemination of clinical translational research to strengthen the scientific understanding of obesity as a disease, and the evidence base for rational obesity management. The journal will aim to publish papers of true translational research – i.e. how fundamental knowledge of the genetics, cell biology and physiology can be, or have been, applied to a better understanding of the complexities of obesity as a disease, and risk for disease, or to treatment and clinical care. Review articles of clinical importance will be welcome, and we hope to provide an international perspective wherever possible. We will not aim to publish papers on animal-based research, or basic studies in molecular biology, physiology or biochemistry that may better be placed in IASO's affiliated journal, the International Journal of Obesity. The acid test will be whether papers help to change understanding and practice of clinicians (including non-medical professionals) treating obesity and its related diseases. Success may be measured in terms of a move from regarding obesity merely as an excess BMI to a complex but fascinating area of medicine and clinical endeavour. I look forward to a successful launch and growth of the journal, and to a decline in the health burden of the disease and diseases of obesity.

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