Practitioners Urged to Move Beyond BMI in Obesity Management

The European Association for the Study of Obesity (EASO) has announced a framework for diagnosing, staging, and managing obesity in adults. Published in Nature Medicine, this new approach advocates for a shift away from the traditional reliance on body mass index (BMI) as the primary diagnostic criterion, proposing instead a more comprehensive method that incorporates the latest scientific advancements and new obesity medications.

Despite widespread acknowledgment of obesity as a multifactorial, chronic, relapsing, non-communicable disease characterized by excessive fat accumulation, BMI remains the sole diagnostic tool in many settings. However, according to the study, the simplistic measure fails to account for the complexities of adipose tissue distribution and its impact on disease severity.

The EASO Steering Group, comprising current and former Association Presidents and other experts, has issued a series of statements aimed at aligning obesity management with contemporary scientific knowledge. They highlighted a significant innovation in their framework: the anthropometric component of the diagnosis. According to the authors, "BMI alone is insufficient as a diagnostic criterion. Body fat distribution has a substantial effect on health. Abdominal fat accumulation, in particular, poses a higher risk for cardiometabolic complications and is a stronger determinant of disease development than BMI."

The new framework underscores the importance of abdominal (visceral) fat as a critical risk factor for health deterioration, even in individuals with a low BMI who have not yet shown clinical symptoms. It includes people with lower BMI (≥25–30 kg/m²) but increased abdominal fat and associated medical, functional, or psychological impairments in the definition of obesity. This approach aims to reduce the risk of undertreatment for patients who fall outside the traditional BMI-based definition.

The recommended treatment pillars remain largely consistent with existing guidelines: behavioral modifications such as nutritional therapy, physical activity, stress reduction, and sleep improvement are essential. Psychological therapy, obesity medications, and metabolic or bariatric procedures are also considered when necessary. However, the steering committee noted that current guidelines often exclude patients with significant obesity-related health issues but low BMI from receiving obesity medications or undergoing bariatric procedures due to strict adherence to anthropometric cut-off values.

To address this gap, the committee suggests a more inclusive approach. "We propose that obesity medications should be considered for patients with a BMI of 25 kg/m² or higher and a waist-to-height ratio above 0.5, along with medical, functional, or psychological complications, regardless of current BMI cut-offs," the authors stated. They urge pharmaceutical companies and regulatory bodies to adopt clinical trial inclusion criteria that reflect the clinical staging of obesity rather than traditional BMI thresholds.

The EASO experts concluded, "This statement will move obesity management closer to the management of other chronic diseases, focusing on long-term health benefits rather than short-term outcomes. Defining personalized therapeutic goals from the beginning of treatment, considering the disease stage and severity, available options, potential side effects, patient preferences, and barriers to treatment, is crucial. Emphasis should be on a long-term or lifelong comprehensive treatment plan rather than short-term weight reduction."