Lancet report offers a ‘new reframing’ for defining, diagnosing obesity
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Key takeaways:
- A commission report recommends using fat mass measurements to diagnose obesity instead of BMI alone.
- The definition of clinical obesity focuses on organ dysfunction and ability to perform daily activities.
A new international commission report has proposed new criteria for diagnosing obesity that could dramatically change the way it is categorized and managed in the future.
The Lancet Diabetes & Endocrinology Commission comprises 58 experts from around the world who were convened as part of a group to develop new recommendations for defining and diagnosing obesity. Francesco Rubino, MD, chair of the commission and professor of metabolic and bariatric surgery at King’s College London, said the recommendations will be practice-changing and provide a more systematic assessment of obesity.
“We hope the new reframing will increase the accuracy of diagnosis, and because of that, it will lead to a more personalized treatment of people with obesity, proportionate and appropriate to their individual needs,” Rubino told Healio.
Edward W. Gregg, PhD, one of the commissioners and professor of population health at the Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences and Imperial College London, said the commission was needed due to the ongoing debate of whether obesity is a disease and the lack of objective measures for diagnosing the condition.
“How overweight and obesity affects risk for different health conditions is really confusing to patients, the public and physicians,” Gregg told Healio. “I think this hopefully will bring some badly needed clarity to how we can more efficiently get care to people who really need it.”
Fatima Cody Stanford, MD, MPH, MPA, MBA, MACP, FAAP, FAHA, FAMWA, FTOS, commissioner, obesity medicine physician-scientist at Massachusetts General Hospital, associate professor of medicine and pediatrics at Harvard Medical School and Healio | Endocrine Today Editorial Board Member, said she expects the report to lead to transformative change in the way obesity is diagnosed and managed around the world. The report has been endorsed by 76 global medical organizations, including those from the U.S., such as the American Diabetes Association, American Heart Association, American Association for Metabolic and Bariatric Surgery, the American Association of Clinical Endocrinology, the Obesity Action Coalition and The Obesity Society.
“[The report] really speaks to what can be done when people come together to try and make a difference,” Stanford told Healio. “I think it can and will have the potential to change everything.”
Measuring body fat
One of the biggest points of emphasis in the report is that obesity should not be diagnosed using BMI alone. According to the report, WHO defines obesity for adults of European ancestry as a BMI of 30 kg/m2 or higher. However, Gregg said BMI is limited in its utility because it only considers a person’s height and weight.
“BMI has some real limitations in that you have people that are discordant,” Gregg said. “A person [may] have a high BMI, but they’re actually fairly healthy. This commission is providing some nice guidance to improve that situation, and I think that will bring more credibility to diagnosing obesity when it exists.”
Instead of BMI, the commission paper proposes measuring body fat to determine whether a person has obesity. Excess body fat can be defined by measuring waist circumference, waist-to-hip ratio or waist-to-height ratio, according to the report. For white adults, obesity is defined as a waist circumference of 102 cm or higher for men and 88 cm or higher for women; a waist-to-hip ratio of more than 0.9 for men and more than 0.85 for women; and a waist-to-height ratio of more than 0.5. Health care professionals may also use DXA scans or similar methods to measure excess body fat.
According to the recommendations, an adult should be diagnosed with obesity if they fulfill the definition of at least one criterion of excess body fat plus BMI, at least two criteria of excess body fat without using BMI, or as indicated by a DXA scan or another direct body fat measure.
“BMI is still useful but does not accurately define amount of adipose tissue or distribution,” Robert H. Eckel, MD, a commissioner, emeritus professor of medicine in the divisions of cardiology and endocrinology, diabetes and metabolism, and the Charles A. Boettcher II Chair in Atherosclerosis at the University of Colorado Anschutz Medical Campus, told Healio. “We need to define obesity before determining preclinical vs. clinical.”
Defining clinical obesity
Once a health care professional confirms a person has excess body fat, the commission’s report recommends conducting a further assessment to determine whether that person has clinical or preclinical obesity. Adults have preclinical obesity if they have no signs or symptoms of reduced organ or tissue function due to obesity, and they can complete normal, day-to-day activities, according to the paper. Clinical obesity is defined as obesity-related organ or tissue dysfunction or an inability to complete day-to-day activities.
“The key thing here is those signs and symptoms,” Stanford said. “It’s not just the signs and symptoms we can see based on a metabolic profile. What does the blood work show? What are the signs and symptoms the patient is showing up with? Are they telling you, ‘I can’t even walk to my door to open it,’ or ‘I can’t walk to the stop sign.’ These are types of things that we have to pay attention to.”
According to the commission, splitting obesity into preclinical and clinical definitions should alter how health care professionals approach each patient. The paper states that preclinical obesity management should focus on risk reduction to prevent clinical obesity or obesity-related diseases. Treatment should include health counseling for weight loss, monitoring of the patient and potential interventions for those at higher risk for clinical obesity. Stanford described preclinical obesity as a similar stage of obesity as prediabetes is in the development of type 2 diabetes.
Clinical obesity treatment should focus on reversing or improving organ dysfunction through evidence-based treatment and management, according to the commission, and each person’s risk should inform the type of treatment they receive. According to the authors, health care professionals should determine treatment success by the improving symptoms rather than weight loss.
Combating weight bias
The commission’s report also tackled challenges regarding weight bias and stigma. The authors described weight-based bias as a “major obstacle” in preventing and treating obesity. They said all stakeholders should be educated about weight stigma and reassess the way obesity is portrayed in public health.
“Weight bias and stigma cause major psychological and physical harm to people affected and also undermine decision-making at clinical, policy and political levels,” Rubino said. “We want to raise attention to this matter and recommend that both health care professionals and policymakers undergo appropriate training about this issue so they can be aware of the negative consequences and recognize the way it can affect their decisions and ultimately lead to the risk of discrimination of people affected by obesity.”
Stanford described weight-based bias and stigma as the “cornerstone” of the commission’s recommendations. She said she believes that the changes proposed in the report will reduce weight bias in and out of the health care setting.
“One of the things that we have suffered from in this entire ecosystem in looking at overweight and obesity is this hyperfocus on ... getting to a certain number on the scale or a certain BMI criteria,” Stanford said. “When people fail to get there, they [feel] there must be a flaw in who they are and sets us up for weight bias and stigma in the medical system. Our goal in shifting that narrative is saying that, this isn’t a flaw in you if you don’t meet these number metrics.”
The report also includes several statements from people living with obesity about how health care professionals must acknowledge and respect the social and emotional impacts of obesity and recognize how stigma from past health care experiences or society may affect a person with obesity.
The commissioners said they recognize that the changes proposed in the report will require an adjustment period. Stanford noted that more research needs to be performed using and assessing the new obesity definitions. She added that more work is needed to tailor these recommendations for treating pediatric obesity.
Eckel applauded the large number of obesity experts and organizations endorsing the report and said it is up to the medical community to put the recommendations into action.
“It’s now up to all of us to accept, adopt and promote this new way of assessing patients with or without obesity, and much research is needed going forward,” Eckel said.
For more information:
Robert H. Eckel, MD, can be reached at robert.eckel@cuanschutz.edu.
Edward W. Gregg, PhD, can be reached at edwardgregg@rcsi.ie.
Francesco Rubino, MD, can be reached at francesco.rubino@kcl.ac.uk; X (Twitter): @FRubino
Fatima Cody Stanford, MD, MPH, MPA, MBA, MACP, FAAP, FAHA, FAMWA, FTOS, can be reached at fstanford@mgh.harvard.edu; X (Twitter): @askdrfatima
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