Obesity as a clinical and public health problem: is there a need for a new definition based on lipotoxicity effects?

The risk functions for obesity (defined as the quantitative relation between degree of obesity throughout its range and the risk of health problems) have been used to define 'obesity' as an excess storage of fat in the body to such an extent that it causes health problems leading to increased mortality. The lipotoxicity theory implies that the fat stored in droplets of triglycerides in the cells are biologically inert and that the metabolic dysfunctions are primarily due to the increased exposure of the cells to fatty acids. If this is true, it has profound implications for the interpretations of the multiple epidemiological studies of the risk functions. It is obvious from all these studies that the sizes of the fat depots are risk indicators of health effects in various ways. Paradoxically, the sizes of the fat stores are also indicators of the preceding implementation of the ability of the body to protect itself against the toxic effects of the free fatty acids. The current risk of metabolic dysfunctions appears to be determined by the balance between the rate of loading of the body with fatty acids and the rate of eliminating the fatty acids by either triglyceride storage or oxidation. The progress in the development of the dysfunction then depends on the persistence of the imbalance leading to future cumulative exposure of the cells to the toxic effects of the fatty acids rather than on the current size of the fat depots. This may be considered as a reason for changing the definition of obesity to one based on better estimates of future risks of health problems derived from later metabolic dysfunctions rather than on the past coping with the exposure to the fatty acids by storage as triglycerides. Implementation of such definition would require a test that measures this residual capacity to avoid excess exposure of the cells to the fatty acids before the metabolic dysfunctions have emerged. In analogy with the glucose tolerance test, a fatty acid tolerance test may be needed to identify individuals who are at a level of risk for developing lipotoxicity induced metabolic dysfunctions such that they require intervention. This test would ideally be a single biomarker that would determine residual capacity for adipose expansion, fatty acid oxidation and safe ectopic lipid deposition.