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Going beyond BMI: Major overhaul of obesity diagnosis proposed

Jan 15, 2025 07:17 AM IST

The suggestions, according to the commission,are designed to address limitations in the traditional definition and diagnosis of obesity.

The body mass index (BMI) , a measure that dates back to 1832, is not a reliable measure of health or illness and needs to be used along with waist circumference and direct fat measurement to detect obesity, a global commission has recommended in a report published in The Lancet Diabetes & Endocrinology on Tuesday.

BMI, the commission added, is not a reliable measure, and can lead to misdiagnosis, especially because some people categorised as obese can be healthy. (Photo by Towfiqu barbhuiya on Unsplash) PREMIUM
BMI, the commission added, is not a reliable measure, and can lead to misdiagnosis, especially because some people categorised as obese can be healthy. (Photo by Towfiqu barbhuiya on Unsplash)

BMI, the commission added, is not a reliable measure, and can lead to misdiagnosis, especially because some people categorised as obese can be healthy. It has also suggested two new obesity diagnostic categories— “clinical obesity” (a chronic disease associated with organ dysfunction due to obesity alone) and “pre-clinical obesity” (associated with a variable level of health risk, but no ongoing illness).

The suggestions, according to the commission,are designed to address limitations in the traditional definition and diagnosis of obesity that hinder clinical practice and health care policies, resulting in individuals with obesity not receiving the care they need.

The chair of the commission, Professor Francesco Rubino, King’s College London (UK), said, “The question of whether obesity is a disease is flawed because it presumes an implausible all-or-nothing scenario where obesity is either always a disease or never a disease. Evidence, however, shows a more nuanced reality. Some individuals with obesity can maintain normal organ function and overall health, even long term, whereas others display signs and symptoms of severe illness here and now.”

“Considering obesity only as a risk factor, and never a disease, can unfairly deny access to time-sensitive care among people who are experiencing ill health due to obesity alone. On the other hand, a blanket definition of obesity as a disease can result in overdiagnosis and unwarranted use of medications and surgical procedures, with potential harm to the individual and staggering costs for society,” he added.

The findings of the commission are important because at least a billion people around the world are considered obese.

The problem is with the significance of the measure. Created by Belgian mathematician Adolphe Quetelet, BMI is calculated from the mass (weight) and height of a person and is expressed in units of kg/m2.

According to the commission, although BMI is useful for identifying individuals at increased risk of health issues, it is not a direct measure of fat, and does not reflect the distribution of fat in the body, and does not provide information about health and illness at the individual level. A BMI value of 30 is considered obese , although the benchmark is lower in some Asian countries.

“Relying on BMI alone to diagnose obesity is problematic as some people tend to store excess fat at the waist or in and around their organs, such as the liver, the heart or the muscles, and this is associated with a higher health risk compared to when excess fat is stored just beneath the skin in the arms, legs or in other body areas. But people with excess body fat do not always have a BMI that indicates they are living with obesity, meaning their health problems can go unnoticed.

Additionally, some people have a high BMI and high body fat but maintain normal organ and body functions, with no signs or symptoms of ongoing illness,” said Professor Robert Eckel, University of Colorado Anschutz Medical Campus who was part of the commission.

The authors instead recommend confirmation of excess fat mass (obesity) and its distribution around the body.

The methods recommended are at least one measurement of body size (waist circumference, waist-to-hip ratio or waist-to-height ratio) in addition to BMI; at least two measurements of body size (waist circumference, waist-to-hip ratio or waist-to-height ratio) regardless of BMI; direct body fat measurement (such as by a bone densitometry scan or DEXA) regardless of BMI; and in people with very high BMI (>40 Kg/m2), pragmatically assuming excess body fat.

The authors define clinical obesity as a condition of obesity associated with objective signs and/or symptoms of reduced organ function, or significantly reduced ability to conduct standard day-to-day activities, such as bathing, dressing, eating and continence, directly due to excess body fat. People with clinical obesity should be considered as having an ongoing chronic disease and receive appropriate management and treatments, they said.

The commission has set out 18 diagnostic criteria for clinical obesity in adults and 13 specific criteria for children and adolescents, including breathlessness caused by effects of obesity on the lungs; obesity-induced heart failure; knee or hip pain, with joint stiffness and reduced range of motion as a direct effect of excess body fat on the joints; certain alterations of bones and joints in children and adolescents limiting movement; and other signs and symptoms caused by dysfunction of other organs including kidneys, upper airways, metabolic organs, nervous, urinary and reproductive systems and the lymph system in the lower limbs.

The authors define pre-clinical obesity as a condition of obesity with normal organ function. People living with pre-clinical obesity, therefore, do not have ongoing illness, although they have a variable but generally increased risk of developing clinical obesity and several other non-communicable diseases (NCDs) in the future, including type 2 diabetes, cardiovascular disease, certain types of cancer and mental illness, among others, they said.

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