Could Moving Obesity Diagnosis Beyond BMI Delay Treatment

The framework moves beyond body mass index (BMI) to require evidence that excess body fat causes measurable organ dysfunction for a diagnosis of clinical obesity, and it introduces a “preclinical obesity” category for individuals without organ dysfunction.

• The article discusses concerns raised by the Endocrine Society regarding The Lancet Commission’s framework for defining obesity.
• The commentary argues that this redefinition could complicate diagnosis, impede timely treatment, and affect access to care and coverage for interventions.

• The piece presents a conceptual and clinical appraisal of the Lancet obesity framework, highlighting practical implications for everyday clinical practice.
• It emphasizes the need for an evidence base that translates into usable, accessible criteria for clinicians, insurers, and patients.
• The authors advocate for a framework grounded in tangible clinical risk and functional impact rather than strict mechanistic proofs of causation between fat and organ dysfunction.

• Implementation and treatment access:
• Requiring demonstration that organ dysfunction is caused by excess body fat may be difficult to apply in routine settings.
• The approach could delay treatment initiation and create barriers to accessing obesity therapies.
• Stability and reliance on diagnostic testing:
• The concept of “preclinical obesity” is described as conceptually unstable, with its definition contingent on the intensity and availability of diagnostic testing.
• Exclusion of diabetes criteria:
• The Lancet framework excludes type 2 diabetes from its clinical criteria for obesity, which the authors view as inconsistent with current scientific and clinical evidence.
• Feasibility and equity concerns:
• The proposed framework entails complex measurements and diagnostic evaluations that may not be feasible across diverse clinical environments.
• There is concern that these requirements could aggravate existing health inequities by limiting who can be diagnosed and treated under a formal framework.

• The authors outline a more practical strategy for diagnosing obesity that centers on clinical risk and functional impact rather than insisting on a single, exact causal proof.
• They suggest adopting established staging concepts to characterize obesity progression and severity.
• The overarching aim is to ensure that new definitions enhance patient care and access to treatment without introducing unnecessary barriers.

• Amy Rothberg, MD, emphasizes the need for simpler, earlier identification of obesity that does not rely on rigid diagnostic thresholds.
• Rothberg also advocates prioritizing access to treatment by focusing on potential improvements in daily life and safety, rather than proving a precise etiologic mechanism.
• Ranganath Muniyappa, MD, PhD, frames the issue around the real-world consequences of diagnostic definitions—particularly for care management and insurance coverage—while underscoring the necessity for definitions to be grounded in robust evidence and practical clinical use.
• Additional contributors span institutions including Weill Cornell Medicine-Qatar, Stanford, NYU Langone, and Cedars-Sinai, reflecting a broad, multidisciplinary perspective.

government agencies or NIH/HHS positions.

• The discussion reflects a commentary and conceptual appraisal rather than new empirical data.
• The authors acknowledge that their claims are contingent on the practical realities of diagnostic testing availability, clinical workflows, and insurance policies.
• The authors declare funding from the Endocrine Society and note that individual viewpoints may not represent U.S.

• The piece situates the Lancet framework within ongoing debates about how obesity should be defined in clinical and policy contexts.
• It raises practical questions about how diagnostic criteria shape who gets treated, who receives coverage for medications or surgeries, and how clinicians prioritize intervention.