Consensus is hard.
As a member of the Lancet Commission on Definition and Diagnostic Criteria of Clinical Obesity among 58 experts from around the world, our just released report aims to define clinical obesity and aid in clinical decision making and therapeutic interventions.
With over 1 billion people living with obesity worldwide, this report begins a conversation that is long overdue.
Even though the Lancet Report has been endorsed by 75 medical organizations around the world, continued debate on these issues is expected and welcome.
As a clinician who has treated patients with overweight and obesity for over 4 decades, I am passionate about helping all clinicians provide optimal obesity care to their patients.
One of the biggest challenges is identifying which patients warrant treatment, beyond just having an elevated body mass index (BMI). The Lancet report tackles this question head on.
Here are some of my key takeaways from this report:
1-It’s Time to Move Beyond BMI
Though BMI is a useful screening tool for obesity, it can lead to under-diagnosis of people who have a low BMI (with excess body fat) and experiencing harm to their health, or over-diagnosis of people who have a high BMI but do not have negative health consequences of obesity – think of a muscular athlete.
BMI is not a direct measure of fat, does not reflect fat distribution around the body and does not provide information about an individual’s level of health or illness.
Because abdominal fat is the most harmful to one’s health, the Commission recommends that any of these additional measurements be added to BMI to more directly assess body fat:
- a waist circumference
- waist-to-height ratio
- waist-to-hip ratio
These measurements can be done in the primary care office or at home by patients using a flexible tape measure.
2-It’s Time to Better Define the Disease of Obesity
The Commission introduces two new terms:
Clinical Obesity where the individual is experiencing signs and symptoms related to obesity, such as shortness of breath, chronic knee pain, elevated blood pressure, or limitations of daily living.
Pre-Clinical Obesity where the individual is NOT experiencing any signs and symptoms or limitations of daily living related to their weight.
The two conditions are determined by having one’s clinician perform a comprehensive medical history and physical exam, and reviewing pertinent laboratory tests.
3-It’s Time to Help Clinicians Target Treatment
These new recommendations are meant to ensure that individuals with obesity receive care that is evidence-based and tailored to their specific health status.
Individuals identified as having Clinical Obesity should receive comprehensive obesity care that may involve lifestyle management, pharmacotherapy or bariatric surgery.
Individuals identified as having Pre-Clinical Obesity should receive counseling regarding risk reduction, targeting prevention of further gain of body fat and maintaining health, although they may also warrant treatment (with medications, for example) based on higher risks of adverse health outcomes with changes over time.
Lifestyle modification to improve health is foundational and recommended for all patients with both clinical and pre-clinical obesity.
For clinicians looking to target treatment for patients who struggle with overweight or obesity, I’m excited to share that my next book, titled Patient Centered Weight Management: The Six Factor Professional Program and Toolkit, will be published by the Academy of Nutrition and Dietetics in Spring, 2025.
RK
Robert Kushner, MD