肥胖症的诊断、治疗困境及对策

doi:10.16150/j.1671-2870.2025.01.004

摘要/Abstract

摘要：

据世界卫生组织（World Health Organization， WHO）报道，2022年，全球成年人中超重人数达25亿，占43%；肥胖人群达8.9亿，占16%。肥胖发病年龄向低龄化转变，自1990年以来，全球青少年肥胖人数增加了4倍。我国超重及肥胖的发病率和增长速度均居世界首位，根据2020年最新发布的《居民营养与慢性病状况报告》显示，我国成人超重和肥胖率已达50.7%，预计2030年将达到65.3%。超重和肥胖会导致代谢性疾病、功能性疾病以及精神心理性疾病，是致死、致残的重要危险因素，已成为人类面临的最大的医疗挑战之一。目前，超重及肥胖主要通过体质量指数（body mass index， BMI）、身体成分分析及影像学技术进行诊断。相关生物标志物及基因组学的研究进展有助于肥胖症的早期识别和诊断。临床上常用的仅基于人体测量评估的方法，并不能反映脂肪分布和预测疾病预后。近年国内外专家均提出了肥胖症诊断治疗新的高级框架，强调肥胖的诊断评估应包括人体测量评估、体重相关并发症和严重程度的临床评估。由于肥胖诊断存在区域、种族差异，迫切需要制定符合我国人群特点的肥胖症诊断、分期和管理框架，从而提高对肥胖及其相关疾病的识别能力，规范患者管理策略。肥胖症药物治疗因其疗效较好、依从性好和无创伤而受到广大患者青睐。然而，药物治疗也面临不良反应、减重不减肌以及停药后反弹等问题，而开发小分子口服减肥药制剂以及开发联合治疗、多肽-偶联药物等治疗策略，可能为提高患者耐受性、改善减重体验、长期维持体重提供新的选择。

关键词: 肥胖症, 身体质量指数, 诊断, 药物治疗

Abstract:

According to the World Health Organization (WHO), 2.5 billion adults worldwide were overweight, accounting for 43%, and 890 million were obese, accounting for 16% in 2022. Notably, the onset of obesity has shifted towards younger age groups, with a fourfold increase in adolescent obesity cases worldwide since 1990. China has the highest prevalence and growth rate of overweight/obesity globally. According to the latest Report on Residents' Nutrition and Chronic Diseases (2020), China's rate of overweight and obesity in adults has reached 50.7%, a figure projected to reach 65.3% by 2030. Overweight and obesity can lead to metabolic, functional, and psychological disorders, serving as critical risk factors for mortality and disability. They have emerged as one of the greatest medical challenges facing humanity. Currently, overweight/obesity diagnosis relies primarily on body mass index (BMI), body composition analysis, and imaging techniques. Advances in biomarkers and genomics have facilitated the early identification and diagnosis of obesity. However, conventional anthropometric measurements in clinical practice fail to reflect fat distribution or predict disease prognosis. In recent years, experts both in China and abroad have proposed new advanced frameworks for obesity diagnosis and treatment, emphasizing that comprehensive assessment should integrate anthropometric measurements with clinical evaluation of weight-related complications and their severity. Due to regional and ethnic differences in obesity diagnosis, there is an urgent need to develop obesity diagnosis, staging, and management frameworks aligned with the characteristics of China's population, thereby improving the identification of obesity and its related diseases and standardizing patient management strategies. Pharmacotherapy for obesity is favored by many patients due to its good efficacy, compliance, and non-invasive nature. However, pharmacotherapy faces challenges including adverse effects, muscle loss during weight reduction, and weight rebound after discontinuation. Emerging strategies, such as developing small molecule oral drugs, combination therapies, and peptide-drug conjugates, may offer novel solutions to improve tolerability, optimize weight loss experience, and achieve long-term weight maintenance.

Key words: Obesity, Body mass index, Diagnosis, Pharmacotherapy

中图分类号:

R589.2

方萍, 韩峻峰. 肥胖症的诊断、治疗困境及对策[J]. 诊断学理论与实践, 2025, 24(01): 21-26.

FANG Ping, HAN Junfeng. Challenges and solutions in diagnosis and treatment of obesity[J]. Journal of Diagnostics Concepts & Practice, 2025, 24(01): 21-26.

参考文献 25

[1]	FRÜHBECK G, BUSETTO L, DICKER D,et al. The ABCD of obesity: an EASO position statement on a diagnostic term with clinical and scientific implications[J]. Obes Facts, 2019, 12(2):131-136.
[2]	YUMUK V, TSIGOS C, FRIED M,et al. European guidelines for obesity management in adults[J]. Obes Facts, 2015, 8(6):402-424.
[3]	World Health Organization. Obesity & overweight[EB/OL]. 2024. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight.
[4]	NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3663 population-representative studies with 222 million children, adolescents, and adults[J]. Lancet, 2024, 403(10431):1027-1050. doi: 10.1016/S0140-6736(23)02750-2 pmid: 38432237
[5]	中华医学会内分泌学分会, 中华中医药学会糖尿病分会, 中国医师协会外科医师分会肥胖和糖尿病外科医师委员会, 等. 基于临床的肥胖症多学科诊疗共识(2021年版)[J]. 中华内分泌代谢杂志, 2021, 37(11):959-972.
	Chinese Society of Endocrinology (CSE), Diabetes Society of China Association of Chinese Medicine (DSCACM), Chinese Society for Metabolic and Bariatric Surgery (CSMBS), et al. Multidisciplinary clinical consensus on diagnosis and treatment of obesity(2021 edition)[J]. Chin J Endocrinol Metab, 2021, 37(11):959-972.
[6]	WANG Y, ZHAO L, GAO L,et al. Health policy and public health implications of obesity in China[J]. Lancet Diabetes Endocrinol, 2021, 9(7):446-461.
[7]	GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990—2019: a systematic analysis for the Global Burden of Disease Study 2019[J]. Lancet, 2020, 396(10258):1223-1249.
[8]	PAN X F, WANG L, PAN A. Epidemiology and determinants of obesity in China[J]. Lancet Diabetes Endocrinol, 2021, 9(6):373-392.
[9]	中华医学会糖尿病学分会. 中国2型糖尿病防治指南(2020年版)[J]. 中华糖尿病杂志, 2021, 13(4):315-409.
	Chinese Diabetes Society. Guideline for the prevention and treatment of type 2 diabetes mellitus in China (2020 edition)[J]. Chin J Diabetes Mellitus, 2021, 13(4):315-409.
[10]	LIN Z, FENG W, LIU Y,et al. Machine learning to identify metabolic subtypes of obesity: a multi-center study[J]. Front Endocrinol (Lausanne), 2021, 12:713592.
[11]	LI S, YU H, ZHANG P,et al. The Nonlinear relationship between psoas cross-sectional area and BMI: a new observation and its insights into diabetes remission after Roux-en-Y gastric bypassp[J]. Diabetes Care, 2021, 44(12):2783-2786. doi: 10.2337/dc20-2907 pmid: 34645667
[12]	LI S, ZHANG P, DI J,et al. Associations of change in body fat percentage with baseline body composition and diabetes remission after bariatric surgery[J]. Obesity (Silver Spring), 2024, 32(5):871-887.
[13]	WHARTON S, LAU D C W, VALLIS M,et al. Obesity in adults: a clinical practice guideline[J]. CMAJ, 2020, 192(31):E875-E891.
[14]	ARONNE L J, SATTAR N, HORN D B,et al. Continued treatment with tirzepatide for maintenance of weight reduction in adults with obesity: the SURMOUNT-4 Randomized clinical trial[J]. JAMA, 2024, 331(1):38-48. doi: 10.1001/jama.2023.24945 pmid: 38078870
[15]	FRÜHBECK G, BUSETTO L, DICKER D,et al. The ABCD of obesity: an EASO position statement on a diagnostic term with clinical and scientific implications[J]. Obes Facts, 2019, 12(2):131-136.
[16]	GARVEY W T, MECHANICK J I, BRETT E M,et al. American Association of Clinical Endocrinologists and American College Of Endocrinology comprehensive clinical practice guidelines for medical care of patients with obesity[J]. Endocr Pract, 2016, 22():1-203.
[17]	BUSETTO L, DICKER D, FRÜHBECK G,et al. A new framework for the diagnosis, staging and management of obesity in adults[J]. Nat Med, 2024, 30(9):2395-2399. doi: 10.1038/s41591-024-03095-3 pmid: 38969880
[18]	ASHWELL M, GUNN P, GIBSON S. Waist-to-height ratio is a better screening tool than waist circumference and BMI for adult cardiometabolic risk factors: systematic review and meta-analysis[J]. Obes Rev, 2012, 13(3):275-286. doi: 10.1111/j.1467-789X.2011.00952.x pmid: 22106927
[19]	NORDMO M, DANIELSEN Y S, NORDMO M. The challenge of keeping it off, a descriptive systematic review of high-quality, follow-up studies of obesity treatments[J]. Obes Rev, 2020, 21(1):e12949.
[20]	MÜLLER T D, BLÜHER M, TSCHÖP M H,et al. Anti-obesity drug discovery: advances and challenges[J]. Nat Rev Drug Discov, 2022, 21(3):201-223.
[21]	LE ROUX C W, STEEN O, LUCAS K J,et al. Glucagon and GLP-1 receptor dual agonist survodutide for obesity: a randomised, double-blind, placebo-controlled, dose-finding phase 2 trial[J]. Lancet Diabetes Endocrinol, 2024, 12(3):162-173.
[22]	JASTREBOFF A M, KAPLAN L M, FRÍAS J P,et al. Triple-hormone-receptor agonist retatrutide for obesity - a phase 2 trial[J]. N Engl J Med, 2023, 389(6):514-526.
[23]	FRIAS J P, DEENADAYALAN S, ERICHSEN L,et al. Efficacy and safety of co-administered once-weekly cagrilintide 2·4 mg with once-weekly semaglutide 2·4 mg in type 2 diabetes: a multicentre, randomised, double-blind, active-controlled, phase 2 trial[J]. Lancet, 2023, 402(10403):720-730. doi: 10.1016/S0140-6736(23)01163-7 pmid: 37364590
[24]	ARNOLD C. After obesity drugs' success, companies rush to preserve skeletal muscle[J]. Nat Biotechnol, 2024, 42(3):351-353. doi: 10.1038/s41587-024-02176-5 pmid: 38443623
[25]	PETERSEN J, LUDWIG M Q, JUOZAITYTE V,et al. GLP-1-directed NMDA receptor antagonism for obesity treatment[J]. Nature, 2024, 629(8014):1133-1141.