American Association of Clinical Endocrinologists and American College of Endocrinology Provide New Framework for Diagnosing and Treating Overweight and Obesity
The American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) released a position statement in September 2014 detailing a framework for the diagnosis and treatment of obesity (Table I).
Because certain ethnic groups (eg, South Asians) may have obesity at a BMI of 23 to 24.9 kg/m2, the AACE/ACE recommends further evaluation with measurement of waist circumference and use of ethnicity-specific criteria in risk analysis delineated by the International Diabetes Federation. In addition, patients who are edematous, elderly with sarcopenic obesity, or highly muscular, should be evaluated further, using clinical judgment and/or dual-energy X-ray absorptiometry to define body composition.
Checklist of Obesity-Related Complications
The position statement includes a checklist of obesity-related complications to consider when evaluating a patient, including the following: metabolic syndrome, prediabetes/type 2 diabetes, dyslipidemia, hypertension, polycystic ovary syndrome, obstructive sleep apnea, gastroesophageal reflux disease, and more conditions. The statement also provides a staging of these complications to show, which can be improved by weight loss.
Treatment Strategies by Obesity Stage
Primary prevention strategies for patients at risk for obesity include healthy eating patterns, lifestyle modification, reduced calorie meals, health education, physical activity, and sleep hygiene. The following treatment strategies are proposed:
- Overweight and Obesity Stage 0 (absence of any weight-related complications): lifestyle changes/reduced calorie meal plan, physical activity, intensive behavioral/lifestyle therapy, sleep hygiene.
- Obesity Stage 1(presence of 1 or more weight-related complications, each mild-moderate in severity, and ameliorated by weight loss): lifestyle changes/reduced calorie meal plan, physical activity, intensive behavioral/lifestyle therapy, sleep hygiene, and consider adding weight loss medications.
- Obesity Stage 2: intensive behavioral/lifestyle therapy, sleep hygiene, weight loss medications, or bariatric surgery, and aggressive treatment of complications. The emphasis is on improving health and treating complications, not the BMI per se.
The position statement was the outgrowth of AACE/ACE’s March 2014 Consensus Conference on Obesity: Building an Evidence Base for Comprehensive Action.
Although the BMI is a useful clinical calculation that helps stratify health risk for most patients, there are many people for whom the BMI is misleading. The elderly may develop sarcopenia and have BMIs that are not in the obesity range, yet have complications of obesity. Similarly, edema may increase the BMI without an effect on fat mass. On the other hand; athletic people may have increased lean muscle mass, leading to an increased BMI, but no risk of obesity-related complications.
Data from the National Health and Nutrition Examination Survey (NHANES) 1999-2002 database documented that at a BMI of 40 or more, 37.5, 48.7, and 72.7 percent of patients do not have any demonstrable dyslipidemia, hypertension, or diabetes mellitus, respectively. Conversely, 17.5, 23.6, and 26.4 percent of patients do have diabetes mellitus, hypertension, or dyslipidemia at BMIs that define them as being lean or underweight, respectively. These data document that the BMI calculation alone is not the best way to predict morbidity or mortality.1,2
In 2014, Cerhan and colleagues pooled data from 11 prospective cohort studies, and came up with 650,386 Caucasian adults aged 20 to 83 years. They documented that for every level of BMI from 15 to 50, the risk of all-cause mortality was increased with progressively higher waist circumference 5-cm increments.3 Their large study validated the National Cholesterol Education Program's (NDEP) recommendation to include waist circumference as one of the elements in the diagnosis of dysmetabolic syndrome. It supports the concept that adipose tissue dysfunction (adiposopathy), including the accumulation of visceral fat, is an important contributor to metabolic and cardiovascular risk.4
AACE and ACE have re-coined the definition of obesity to include both BMI and waist circumference for risk stratification. The new recommendations for treatment hinge on the incidence and severity of complications rather than BMI. Implementation of these recommendations will allow for early intervention, and turns weight management into a primary treatment target.
1. Bays HE, et al. The relationship of body mass index to diabetes mellitus, hypertension and dyslipidaemia: comparison of data from two national surveys. Int J Clin Pract. 2007;61(5):737-747.
2. Bays HE. "Sick fat," metabolic disease, and atherosclerosis. Am J Med. 2009;122(1 Suppl):S26-S37.
3. Cerhan JR, et al. A pooled analysis of waist circumference and mortality in 650,000 adults. Mayo Clin Proc. 2014;89(3):335-345.
4. Gonzalez-Campoy JM, et al. Bariatric endocrinology: principles of medical practice. Intl J Endocrinol. 2014:917813.