Obesity — a medical condition, not a willpower failure

Name: Dr (TCM) Attilio D'Alberto
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By Dr (TCM) Attilio D'Alberto | Traditional Chinese Medicine Practitioner, Wokingham, Berkshire

Obesity affects around 26% of UK adults and a further 38% are overweight — almost two-thirds of the adult population. The framing that obesity is principally a problem of willpower or moral character has been thoroughly rejected by modern medicine, and rightly so: obesity is a chronic, relapsing, multi-factorial disease shaped by genetics, hormones, neurobiology, gut microbiome, sleep, stress, socioeconomic factors and the modern food environment, in which weight regulation is governed by powerful set-point mechanisms that actively resist sustained weight loss. The treatment landscape has been transformed in the past five years by the GLP-1 and GIP/GLP-1 receptor agonist medications (semaglutide and tirzepatide), with weight-loss effects approaching those of bariatric surgery in some patients. This article covers obesity as a medical condition, the NICE NG246 framework, where conventional treatment has reached, and how the Chinese medicine view of Phlegm-Damp and Spleen Qi deficiency offers a useful constitutional framework alongside — not instead of — modern medical management. For the practical “how to lose weight” angle, see my dedicated blogs on Chinese medicine for weight loss, acupuncture for weight loss and hormonal weight gain.

On this page

What is obesity?
Why obesity is not a willpower failure
Comorbidities and health risks
Assessment under NICE NG246
Lifestyle treatment
GLP-1 and GIP/GLP-1 medication
Bariatric surgery
The TCM view — Phlegm-Damp and Spleen Qi deficiency
Acupuncture — what the evidence shows
Chinese herbs in obesity
Integrating TCM with GLP-1 and bariatric care
Weight stigma and the language of obesity
Cautions and what TCM cannot replace
When to see a practitioner
Frequently asked questions
Related reading
References

1. What is obesity?

Obesity is defined as excess body fat to a degree that meaningfully impairs health. In practice, it is most commonly identified using body mass index (BMI), with the standard cut-offs:

Healthy weight — BMI 18.5–24.9
Overweight — BMI 25–29.9
Obesity class I — BMI 30–34.9
Obesity class II — BMI 35–39.9
Obesity class III (severe obesity) — BMI 40 or above

BMI is a useful population measure but an imperfect individual one. It does not distinguish between muscle and fat, can overestimate body fat in athletes and underestimate it in older adults with sarcopenic obesity, and importantly does not capture body fat distribution. Central adiposity — fat carried around the abdomen and viscera — carries much higher cardiometabolic risk than peripheral fat at the same BMI. Waist circumference (over 94 cm in men, over 80 cm in women, with lower thresholds for South Asian populations) and waist-to-height ratio (kept under 0.5) are valuable additional measures.

In some ethnic groups — particularly South Asian, Chinese and certain other populations — cardiometabolic risk rises at lower BMIs, and lower BMI thresholds are recommended for both overweight (BMI ≥23) and obesity (BMI ≥27.5).

2. Why obesity is not a willpower failure

The single most important shift in modern obesity medicine is the recognition that body weight is regulated by powerful biological mechanisms that operate largely outside conscious control. Key points:

The body defends a weight set-point. Sustained calorie restriction triggers compensatory reductions in resting metabolic rate, increases in hunger hormones (ghrelin), and reductions in satiety hormones (leptin, GLP-1, PYY). These persist for years after weight loss, making weight regain the biological default and explaining the very high recurrence rates after dieting alone.
Genetic and epigenetic factors are substantial. Twin studies show heritability of BMI of around 70%. Multiple polygenic risk variants and rare monogenic obesities have been identified.
The modern food environment is obesogenic. Ultra-processed food is engineered to override satiety mechanisms; portion sizes have grown substantially; physical activity has been engineered out of daily life. Many populations that have not lived in this environment historically remain lean.
Sleep deprivation, chronic stress and circadian disruption all directly drive weight gain through hormonal mechanisms (cortisol, ghrelin, insulin resistance).
The gut microbiome meaningfully influences energy harvest, appetite regulation and metabolic health.
Many medications cause weight gain — including some antidepressants, antipsychotics, steroids, insulin, sulfonylureas and beta-blockers.
Socioeconomic factors matter enormously. Obesity rates are far higher in lower-income communities, reflecting food cost, food access, time, stress and the cumulative effect of disadvantage.
Hormonal contributions — thyroid dysfunction, PCOS, Cushing’s syndrome, hypogonadism, menopause and others can all contribute.

None of this means lifestyle does not matter. It means lifestyle change is the foundation but is often insufficient for established obesity, and that medical and surgical interventions are not failures of willpower but rational responses to a biological condition that responds poorly to lifestyle alone.

3. Comorbidities and health risks

Obesity meaningfully raises the risk of more than 200 health conditions. The principal ones:

Type 2 diabetes — the single strongest obesity-related risk; around 80–90% of T2DM is attributable to overweight and obesity
Cardiovascular disease — coronary artery disease, heart failure, atrial fibrillation, stroke
Hypertension and dyslipidaemia
Metabolic dysfunction-associated steatotic liver disease (MASLD, formerly NAFLD) — see my fatty liver page
Obstructive sleep apnoea
Osteoarthritis — particularly of weight-bearing joints
Several cancers — endometrial, breast (post-menopausal), colorectal, kidney, liver, pancreatic, gallbladder, oesophageal adenocarcinoma and others
Gallstone disease — see my gallstones blog
Reproductive issues — PCOS, sub-fertility, gestational diabetes, pre-eclampsia, increased caesarean rates
Mental health — depression, anxiety, lower quality of life, weight stigma effects
Chronic kidney disease
GORD (gastro-oesophageal reflux disease)
Increased COVID-19 mortality — one of the strongest single risk factors identified during the pandemic

Importantly, modest sustained weight loss — 5–10% of body weight — produces meaningful reductions in many of these risks, particularly cardiometabolic ones. The goal is not necessarily reaching an “ideal” weight but reducing weight to a level that meaningfully improves health.

4. Assessment under NICE NG246

NICE NG246 (Overweight and obesity management, published 14 January 2025) supersedes the earlier CG189 and consolidates UK obesity guidance. Key elements of assessment:

BMI measurement with adjusted thresholds for South Asian, Chinese and certain other ethnic groups
Waist-to-height ratio — kept under 0.5; a marker of central adiposity
Assessment for comorbidities — blood pressure, glucose, lipids, liver function
Assessment of psychological and contextual factors — mental health, eating disorder history, social and environmental context, motivation
Identification of secondary causes where suspected — hypothyroidism, Cushing’s, PCOS, medication contributions
Person-centred, weight-inclusive language — with explicit attention to avoiding stigmatising framing

Treatment is stepwise: lifestyle support first; pharmacotherapy for those who meet criteria; bariatric surgery for severe obesity or where comorbidities indicate.

5. Lifestyle treatment

Lifestyle treatment remains the foundation of obesity management and is appropriate for every patient, although it is rarely sufficient alone in established obesity. The evidence-based components:

Dietary modification — the dietary pattern matters more than the specific named diet. Mediterranean-style, DASH-style and lower-carbohydrate approaches all produce comparable weight loss when adhered to. The principal common features: more vegetables and whole foods, reduced ultra-processed foods, reduced refined carbohydrate and sugar, adequate protein, mindful eating practices.
Very-low-calorie diets (VLCDs) and total diet replacement — can produce 10–15 kg weight loss over 12–16 weeks under medical supervision; the DiRECT trial showed remission of type 2 diabetes in around half of patients with this approach. Weight regain is the principal challenge.
Physical activity — less effective for weight loss alone than commonly believed (the “you can’t outrun a bad diet” reality) but crucial for weight loss maintenance, cardiometabolic risk, mental health, sleep, sarcopenia prevention and quality of life. Aim for at least 150 minutes weekly of moderate aerobic activity plus resistance training.
Sleep — sleep deprivation directly drives weight gain through hormonal mechanisms; treating sleep disorders (particularly obstructive sleep apnoea) is an under-recognised obesity intervention.
Stress regulation — chronic cortisol elevation drives central adiposity and insulin resistance.
Behavioural support — structured programmes (commercial or NHS Tier 2/3) typically produce 5–10% weight loss at one year, with meaningful weight regain over 2–5 years in most patients.

6. GLP-1 and GIP/GLP-1 medication

The GLP-1 (glucagon-like peptide-1) and dual GIP/GLP-1 receptor agonist medications have transformed obesity treatment in the past five years. The principal agents:

Semaglutide (Wegovy for obesity, Ozempic for diabetes) — weekly injection. The STEP-1 trial (Wilding et al, New England Journal of Medicine 2021) showed mean weight loss of around 15% at 68 weeks — a result without precedent for a single medication.
Tirzepatide (Mounjaro) — dual GIP/GLP-1 receptor agonist, weekly injection. The SURMOUNT-1 trial (Jastreboff et al, New England Journal of Medicine 2022) showed mean weight loss of around 20–22% at 72 weeks at the highest dose — approaching some bariatric surgery outcomes.
Liraglutide (Saxenda) — daily injection, the earlier-generation GLP-1; less effective than semaglutide but still useful in some patients.

These medications work by enhancing satiety, slowing gastric emptying and reducing food reward signalling. Common side effects are gastrointestinal (nausea, constipation, occasional vomiting), usually settling over weeks. Important practical points:

NHS access is limited — semaglutide via specialist weight management services, tirzepatide via NHS planned rollout
Private prescription is widely available but expensive (around £150–200+ per month)
Weight regain occurs after stopping — these are treatments for a chronic condition, not a temporary intervention
Muscle loss is a known issue — resistance training and adequate protein intake during treatment are important
Several specific contraindications exist — medullary thyroid cancer history, MEN-2, pregnancy
Significant interactions with insulin and sulfonylureas in diabetic patients

7. Bariatric surgery

Bariatric surgery remains the most effective long-term treatment for severe obesity, with sustained 25–35% body weight loss in many patients and meaningful reductions in mortality, diabetes, cardiovascular events and certain cancers. The principal options:

Roux-en-Y gastric bypass — the “gold standard” in many centres; combines restriction with hormonal effects
Sleeve gastrectomy — technically simpler, increasingly common, produces similar early weight loss
Adjustable gastric band — now much less commonly performed
Duodenal switch and one-anastomosis gastric bypass — more powerful but more complex options

NHS access is via Tier 4 weight management services and depends on BMI thresholds, comorbidities and engagement with lifestyle support. Surgery is not a quick fix — it requires lifelong dietary, vitamin and lifestyle adjustment, and around 10–30% of patients regain meaningful weight over 5–10 years. But for severe obesity with cardiometabolic complications, it remains the most effective single intervention available.

8. The TCM view — Phlegm-Damp and Spleen Qi deficiency

Traditional Chinese medicine has a sophisticated framework for obesity that has been used clinically for centuries. The classical patterns:

Spleen Qi deficiency with Phlegm-Damp accumulation — the foundational pattern in obesity. The Spleen in TCM transforms food into Qi and Blood; when deficient, food is incompletely transformed, accumulating as Damp and over time consolidating into Phlegm — the TCM correlate of excess body fat. The classical descriptions of this pattern (heavy, sluggish, tired, prone to swelling, particularly damp climates and after sweet food) align remarkably well with the modern picture of metabolic obesity.
Liver Qi stagnation contributing to weight gain — stress, frustration and emotional eating produce Liver Qi stagnation which both directly drives appetite and indirectly damages the Spleen. The TCM correlate of stress-driven and emotional-eating-pattern obesity.
Stomach Heat with excess hunger — the pattern of large appetite, fast eating, preference for rich and spicy food, with halitosis and constipation features.
Kidney Yang deficiency — the colder, more constitutional pattern; common in post-menopausal weight gain and ageing-related metabolic slowdown.
Blood stasis — chronic obesity pattern with cardiometabolic complications; reflects the inflammatory and vascular dimensions of obesity

The TCM treatment principle — strengthen the Spleen, resolve Damp and Phlegm, regulate the Liver, support the Kidney, and address the constitutional pattern over time — aligns conceptually with the modern multi-target obesity approach.

9. Acupuncture — what the evidence shows

Acupuncture for obesity has a moderate evidence base, with the strongest evidence in combined acupuncture and dietary support for modest weight loss (typically 1–3 kg additional weight loss over diet alone in randomised trials). The mechanisms are likely multi-factorial: autonomic regulation, possible effects on appetite-regulating peptides, stress regulation and the supportive structure of regular sessions. Useful applications include:

Adjunctive weight loss support alongside dietary and lifestyle work
Auricular (ear) acupuncture — particularly the “hunger point” protocol; modest evidence for appetite reduction
Stress regulation — addressing the cortisol and Liver Qi stagnation dimension
Sleep support — treating insomnia and improving sleep quality as part of weight management
Constitutional treatment — addressing the underlying Spleen Qi deficiency and Phlegm-Damp pattern
Adjunctive support during GLP-1 treatment — helping with nausea, supporting Spleen function during the appetite-suppression phase, and addressing post-treatment relapse-prevention work

For specific point selection and protocols see my detailed blogs on acupuncture for weight loss and Chinese medicine for weight loss.

10. Chinese herbs in obesity

Chinese herbal medicine for obesity targets the underlying TCM pattern rather than the weight itself. Commonly used formulae include:

Liu Jun Zi Tang — Spleen Qi tonic with Phlegm-resolving action; foundational formula in the deficiency-with-Phlegm pattern
Ping Wei San — for Damp accumulation in the Middle Burner with bloating and heaviness
Er Chen Tang — the classical formula for resolving Phlegm-Damp
Xiao Yao San — for the Liver Qi stagnation pattern with stress and emotional eating
Bao He Wan — for food stagnation features with overeating
Da Chai Hu Tang — for the metabolic syndrome picture with Liver-Gallbladder Heat features
Modified Si Miao San — for Damp-Heat presentations

All herbs prescribed at this clinic are pharmaceutical-grade granules from Sun Ten in Taiwan, within individually-tailored formulae. Several obesity-related herbs interact with GLP-1 medication, metformin, insulin and antihypertensives; this is checked on every prescription.

11. Integrating TCM with GLP-1 and bariatric care

The growing use of GLP-1 medication and bariatric surgery has created clear new clinical roles for TCM:

Supporting GLP-1 side effects — particularly nausea and constipation; acupuncture and gentle Spleen-supportive herbs help
Addressing the “Ozempic mood” — some patients on GLP-1s report low mood, fatigue and reduced general drive; the TCM Spleen-Qi-deficiency framing offers a useful supportive approach
Post-bariatric digestive support — for nausea, dumping syndrome, malabsorption, fatigue
Muscle preservation — resistance training and protein intake are the priority, but TCM constitutional support helps
Long-term maintenance — addressing the constitutional patterns that drove the obesity in the first place reduces relapse risk after either GLP-1 or surgical intervention
Stress, sleep and mood support — the dimensions often inadequately addressed by medical and surgical obesity care

12. Weight stigma and the language of obesity

Weight stigma — both internalised and externally encountered — is a meaningful contributor to poorer health in people with obesity. Stigmatising language and assumptions in healthcare lead to under-treatment, delayed diagnosis of unrelated conditions and worse health outcomes. NICE NG246 explicitly addresses this, recommending person-first, non-judgmental language (“a person living with obesity” rather than “an obese person”), and explicitly recognising obesity as a chronic disease deserving of medical care rather than moral judgment.

From a TCM perspective, the constitutional and pattern-based framing has the advantage of being inherently non-judgmental — the patient is not their body weight, they have a particular pattern of imbalance that can be addressed. Many patients find this framing more sustainable than the willpower-and-failure narrative they have lived under for years.

13. Cautions and what TCM cannot replace

Established obesity needs medical assessment — blood pressure, glucose, lipids, liver function, comorbidity screen; this is not optional.
Lifestyle alone is rarely sufficient for established obesity. The biology defends against sustained weight loss; medical and surgical interventions are appropriate in many cases.
GLP-1 medications and bariatric surgery are evidence-based and appropriate for many patients; they are not failures of character or a substitute for lifestyle work, but powerful additional tools.
Eating disorders — particularly binge eating disorder, which is common in obesity — need psychological assessment and treatment alongside weight management.
Crash diets and very restrictive regimes — often promoted online; produce short-term weight loss followed by reliable regain and meaningful metabolic harm. Not recommended.
Avoid herbal weight-loss products bought online — the over-the-counter weight-loss herbal market includes products contaminated with sibutramine, amphetamines and other unlisted pharmaceuticals; cases of acute liver injury and cardiovascular harm are well documented.
Herb-drug interactions — tell your prescriber and your herbalist about everything you take.

14. When to see a practitioner

Reasonable indications to consider TCM support for obesity include:

Established obesity where lifestyle alone has reached its limit and constitutional support is wanted
Co-management alongside NHS Tier 2/3 weight management services or specialist obesity care
Adjunctive support during GLP-1 treatment — nausea, mood, sleep, constitutional dimensions
Post-bariatric recovery support
Patients with strong Phlegm-Damp, Spleen Qi deficiency or Liver Qi stagnation features who fit the TCM pattern framework
Stress-driven and emotional-eating-pattern obesity where Liver-soothing and Shen-calming work supports behavioural change
Hormonal weight gain in menopause or post-pregnancy

I see patients with obesity at my Wokingham, Berkshire clinic and offer online herbal consultations for patients elsewhere in the UK.

15. Frequently asked questions

Is obesity really a disease, or is it just lifestyle?

Modern medicine increasingly recognises obesity as a chronic, relapsing, multi-factorial disease in which biology, environment and behaviour interact. The framing of obesity as purely a lifestyle choice or willpower failure is both factually wrong and clinically harmful — it leads to under-treatment and stigma. Lifestyle matters, but it operates within powerful biological constraints.

Should I take Ozempic, Wegovy or Mounjaro?

That is a discussion for your GP or specialist. These medications are highly effective but expensive, have side effects, require long-term use, and have specific contraindications. They are appropriate for many patients with established obesity, particularly with cardiometabolic complications. They are not appropriate for cosmetic weight loss in normal-weight individuals.

Can Chinese medicine help me lose weight?

Chinese medicine offers modest direct weight loss effect, and a meaningful supportive role: addressing the constitutional patterns that maintain weight, supporting GLP-1 side effects, helping with stress and emotional eating, and helping with post-bariatric recovery. Most clinical TCM practice in obesity is supportive rather than primary.

Why do I always regain the weight?

Because the body actively defends a weight set-point. After weight loss, metabolic rate falls, hunger hormones rise, satiety hormones fall, and these changes persist for years. This is biology, not failure. Sustainable weight management almost always needs ongoing intervention — lifestyle, medication or surgery — rather than a one-off effort.

Is it safe to combine Chinese herbs with GLP-1 medication?

Generally yes when prescribed individually by a qualified practitioner aware of the medication. Some specific interactions matter — particularly herbs that affect blood glucose or slow gastric emptying further — and these are managed through pattern-appropriate prescribing and careful monitoring.

What about the “Ozempic face” and muscle loss?

Rapid weight loss from any cause produces facial fat reduction (the unflattering “Ozempic face”) and meaningful muscle loss, which has long-term metabolic consequences. The mitigations are adequate protein intake (1.2–1.6 g/kg body weight per day during active weight loss), resistance training and gradual rather than maximal weight-loss targets. TCM constitutional support helps but the basics matter most.

Chinese medicine for weight loss — the practical TCM weight-loss approach
Acupuncture for weight loss — specific points and protocols
How to lose hormonal weight gain — cortisol, oestrogen, insulin, thyroid
Sweeteners and weight gain — the TCM view
Fatty liver (MASLD)
Gallstones — symptoms, treatment and TCM
High blood pressure
Chinese food therapy

17. References

National Institute for Health and Care Excellence. Overweight and obesity management. NICE guideline NG246. Published 14 January 2025. nice.org.uk/guidance/ng246
Wilding JPH, Batterham RL, Calanna S, Davies M, et al. Once-Weekly Semaglutide in Adults with Overweight or Obesity (STEP-1). N Engl J Med. 2021 Mar 18;384(11):989–1002.
Jastreboff AM, Aronne LJ, Ahmad NN, Wharton S, et al. Tirzepatide Once Weekly for the Treatment of Obesity (SURMOUNT-1). N Engl J Med. 2022 Jul 21;387(3):205–216.
Lean MEJ, Leslie WS, Barnes AC, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet. 2018 Feb 10;391(10120):541–551.
Bray GA, Frühbeck G, Ryan DH, Wilding JP. Management of obesity. Lancet. 2016 May 7;387(10031):1947–56.
Müller MJ, Geisler C, Heymsfield SB, Bosy-Westphal A. Recent advances in understanding body weight homeostasis in humans. F1000Res. 2018 Jul 30;7:F1000.

This article is for general information and does not constitute medical advice. Established obesity requires medical assessment. Always consult a qualified healthcare practitioner before changing treatment.