American Association of Clinical Endocrinologists and American College of Endocrinology Position Statement on the 2014 Advanced Framework for a New Diagnosis of Obesity as a Chronic Disease

W. Timothy Garvey, MD, FACE, Chair; Alan J. Garber, MD, PhD, FACE; Jeffrey I. Mechanick, MD, FACN, FACP, FACE, ECNU; George A. Bray, MD, MACE; Samuel Dagogo-Jack, MD, DM, FRCP, FACE; Daniel Einhorn, MD, FACP, FACE; George Grunberger, MD, FACP, FACE; Yehuda Handelsman, MD, FACP, FACE, FNLA; Charles H. Hennekens, MD, DrPH; Daniel L. Hurley, MD, FACE; Janet McGill, MD, FACE; Pasquale Palumbo, MD, MACP, MACE; Guillermo Umpierrez, MD, FACP, FACE

Disclosures

Endocr Pract. 2014;20(9):977-989.

Synopsis

Obesity is a chronic disease
Emergent Concept 1 (EC.1) from the American Association of Clinical Endocrinologists and the American College of Endocrinology (AACE/ACE) Consensus Conference on Obesity (CCO) calls for a new medically meaningful and actionable diagnosis of obesity
An advanced framework for further discussion and translation of EC.1 is provided
- The definition of obesity requires anthropometric and clinical descriptors
- The diagnosis and management of obesity requires a process of screening, evaluation of complications (using checklist), staging, and algorithmic management
This advanced framework has been approved by AACE and will be distributed to the wide array of stakeholders who attended the CCO for structured discussion and creation of a consensus diagnosis that is broadly actionable

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Table 1. The AACE Advanced Framework for a New Diagnosis of Obesity
Diagnosis	Anthropometric component	Clinical component
Overweight	BMI 25–29.9 kg/m²	No obesity-related complications
Obesity	BMI ≥30 kg/m²	No obesity-related complications
Obesity stage 1	BMI ≥25 kg/m²	Presence of 1 or more mild-to-moderate obesity-related complications
Obesity stage 2	BMI ≥25 kg/m²	Presence of 1 or more severe obesity-related complications

Abbreviation: BMI = body mass index

Table 2. The AACE Advanced Framework and Levels of Treatment and Prevention for Chronic Diseases
Diagnosis	Anthropometric component	Clinical component	Prevention/treatment
Normal weight	BMI <25 kg/m²	Primary
Overweight	BMI 25–29.9 kg/m²	No obesity-related complications	Secondary
Obesity	BMI ≥30 kg/m²	No obesity-related complications
Obesity stage 1	BMI ≥25 kg/m²	Presence of 1 or more mild-to-moderate obesity-related complications	Tertiary
Obesity stage 2	BMI ≥25 kg/m²	Presence of 1 or more severe obesity-related complications	Tertiary

Abbreviation: BMI = body mass index

Table 3. Checklist of Obesity-related Complications ^a
Obesity-related complication		Identification based on information available in initial evaluation	Possible secondary tested needed to confirm presence of complication, stage complication, or guide therapy
	Metabolic Syndrome	waist circumference, blood pressure, triglycerides, HDL-c, fasting glucose (ATPIII criteria)	initial evaluation completes diagnosis; screen for cardiovascular disease
	Prediabetes	fasting glucose	repeat fasting glucose completes diagnosis of impaired fasting glucose, but patient should be further evaluated with 2-hour oral glucose tolerance test to identify Prediabetes due to impaired glucose tolerance or diabetes based on elevated 2- hour glucose value and/or with HbA1c; screen for cardiovascular disease
	T2DM	fasting glucose	overtly elevated or repeat fasting glucose completes diagnosis, but patients with moderate elevations in glycemia may require further evaluation with 2-hour oral glucose tolerance glucose value or HbA1c or both; screen for cardiovascular disease and microvascular complications
	Dyslipidemia	fasting triglycerides and HDL-c with lipid panel	initial evaluation completes diagnosis; lipoprotein subclasses may further define risk
	Hypertension	systolic and diastolic sitting blood pressures	repeat blood pressure completes diagnosis; further testing may include ambulatory blood pressure monitoring; screen for complications of hypertension
	NAFLD	liver examination, liver function tests	additional studies are needed for diagnosis: imaging, liver biopsy as indicated
	PCOS	physical exam, review of systems	additional studies are needed for diagnosis: hormonal testing
	Obstructive sleep apnea	physical exam, review of systems	additional studies are needed for diagnosis: neck circumference, sleep study
	Osteoarthritis	physical exam, review of systems	additional studies are needed for diagnosis: radiographic imaging
	Urinary stress incontinence	physical exam, review of systems	additional studies may be indicated: urine culture, urodynamic testing
	GERD	physical exam, review of systems	additional studies may be indicated: endoscopy, esophageal motility
	Disability/immobility	physical exam, review of systems	initial evaluation may complete diagnosis, functional testing may be needed
	Psychological disorder and/or Stigmatization	physical exam, review of systems	additional studies may be needed: psychological testing and evaluation
	Obesity secondary to genetic syndromes, hormonal disease, iatrogenic medications	physical exam, review of systems, review medications and supplements, family history	additional studies may be needed: genetic testing, hormonal testing
Other obesity-related complications or disease processes that could be treated with weight-loss therapy: Improvement in risk of surgery and anesthesia; idiopathic intracranial hypertension/pseudotumor cerebri; primary prevention of cancer in high-risk individuals and families; secondary prevention of breast cancer; congestive heart failure; infertility; "low testosterone"/hypogonadism; back pain; lower extremity venous stasis and edema; thrombophlebitis; prior to pregnancy to improvement in maternal/fetal outcomes; chronic lung disease, including asthma; chronic kidney disease/renal protection; reductions in quality of life.

Abbreviations: BMI = body mass index; GERD = gastroesophageal reflux disease; HbA1c = glycated hemoglobin; HDL-c = high-density lipoprotein cholesterol; LDL-c = low-density lipoprotein cholesterol; NAFLD = nonalcoholic fatty liver disease; NASH = nonalchoholic steatohepatitis; PCOS = polycystic ovary syndrome; T2DM = type 2 diabetes mellitus ^a Initial evaluation in patients with obesity (BMI ≥25 kg/m²) includes: history, physical examination, review of systems, blood pressure, waist circumference, fasting glucose, fasting lipid panel (total cholesterol, LDL-c, HDL-c, triglycerides), creatinine, and hepatic transaminases.

Table 4. Staging of Obesity-related Complications That Can Be Improved by Weight Loss ^a
A] Prediabetes, Metabolic Syndrome, and T2DM
Stage 0 (none) Stage 1 (mild-moderate) Stage 2 (severe)	No risk factors related to insulin resistance (WC, BP, HDL-c, TG, fasting glucose). This is equivalent to CMDS 0 (9) 1 or 2 risk factors (WC, BP, HDL, TG; CMDS stage 1) Prediabetes, Metabolic Syndrome, or T2DM (CMDS stages 2–4)
B] Hypertension
Stage 0 (none) Stage 1 (mild-moderate) Stage 2 (severe complication)	BP <130/85 mm Hg BP ≥130/85 mm Hg in absence of other risk factors BP target not met despite use of anti-hypertensive medication(s) BP ≥130/85 mm/Hg in high-risk individuals: CMDS 2–4, smoking, African, congestive heart failure
C] Hypertriglyceridemia/Dyslipidemia
Stage 0 (none) Stage 1 (mild-moderate) Stage 2 (severe)	TG <150 and HDL-c ≥40 in male and ≥50 in female TG 150–399 and/or HDL-c <40 in male and <50 in female in absence of other risk factors TG ≥400 in absence of other risk factors TG ≥150 and HDL-c <40 in male and <50 in female in high-risk individuals: CMDS stage 2–4
D] Sleep Apnea
Stage 0 (none) Stage 1 (mild-moderate) Stage 2 (severe)	No symptoms, AHI <5 AHI 5–29 with no or mild symptoms AHI ≥30; AHI 5–29 with severe symptoms and/or clinical sequences
E] NAFLD
Stage 0 (none) Stage 1 (mild-moderate) Stage 2 (severe)	No steatosis Presence of steatosis but no inflammation or fibrosis Steatohepatitis (NASH)
F] PCOS
Stage 0 (none) Stage 1 (mild-moderate) Stage 2 (severe)	Does not meet criteria, absence of PCOS 1 or 2 risk factors (WC, BP, HDL-c, TG: CMDS stage 1) and no infertility/anovulation Infertility/anovulation Oligomenorrhea; Menorrhagia; Prediabetes/Metabolic Syndrome/T2DM (CMDS stage 2–4)
G] Osteoarthritis
Stage 0 (none) Stage 1 (mild-moderate) Stage 2 (severe)	No symptoms and no radiographic joint changes Mild-moderate symptoms and functional impairment (e.g., validated questionnaire) and/or mild-moderate anatomical joint changes Moderate-severe symptoms and functional impairment (e.g., validated questionnaire) and/or moderate-severe anatomical joint changes; S/P knee or hip placement surgery
H] Stress and Urge Urinary Incontinence
Stage 0 (none) Stage 1 (mild-moderate) Stage 2 (severe)	No symptoms and/or normal rodynamics Mild-moderate symptom severity score Severe symptom severity score
I] GERD
Stage 0 (none) Stage 1 (mild-moderate) Stage 2 (severe)	No symptoms or findings Mild-moderate symptoms Severe symptoms; Erosive esophagitis, Barrett's Esophagus (if not accompanied by progressive weight loss)
J] Disability/Immobility
Stage 0 (none), Stage 1 (mild-moderate), Stage 2 (severe)
K] Psychological Disorder/Stigmatization
Stage 0 (none), Stage 1 (mild-moderate), Stage 2 (severe)
L] Other Complications
Specific staging criteria could also be established for the following complications and other disease processes that can be prevented and/or treated using weight loss therapy: •Idiopathic intracranial hypertension/pseudotumor cerebri; primary prevention of cancer in high-risk individuals and families; secondary prevention of breast cancer; congestive heart failure; infertility not associated with PCOS; "low testosterone"/hypogonadism; sexual function related to the mechanical aspects of coitus; back pain; lower extremity venous stasis and edema; thrombophlebitis; deep vein thrombosis; gastric ulcers; maternal/fetal risk of pregnancy; improvement in risk of surgery and anesthesia; chronic lung disease including asthma; gout; chronic kidney disease/renal protection; poor quality of life.
Abbreviations: AHI = apnea hypopnea index; BP = blood pressure; CMDS = cardiometabolic disease stage; GERD = gastroesophageal reflux disease; HDL-c = high-density lipoprotein cholesterol; LDL-c = low-density lipoprotein cholesterol; NAFLD = nonalcoholic fatty liver disease; NASH = nonalchoholic steatohepatitis; PCOS = polycystic ovary syndrome; T2DM = type 2 diabetes mellitus; TG = triglycerides; WC = waist circumference

^aWhile there is an evidence base for the complications-specific criteria below that are used to stage the severity of obesity-related complications, several criteria may require additional expert scrutiny, critique, and research for optimization.

Table 5. Diagnosis and Management of Obesity ^a
Diagnosis		Complications-specific staging and treatment
Step 1	Step 2	Step 3	Step 4
Anthropometric component (BMI^b)	Clinical component	Complications-specific staging^c	Suggested therapeutic interventions^d (based on clinical judgment)
25–29.9	Presence or absence of obesity-related complications Metabolic conditions Prediabetes Metabolic syndrome T2DM Hypertension Dyslipidemia NAFLD/NASH Sleep apnea PCOS Osteoarthritis Stress incontinence GERD Disability/immobility Psychological disorder or stigmatization	Overweight stage 0	Healthy meal pattern/physical activity Lifestyle modification/reduced calorie meal plan/physical activity
≥30		Obesity stage 0	Lifestyle modification/reduced calorie meal plan/physical activity Intensive behavioral and lifestyle therapy
≥25		Obesity stage 1 (1 or more mild-moderate complication)	Lifestyle modification/reduced calorie meal plan/physical activity Intensive behavioral and lifestyle therapy Consider adding weight-loss medications to lifestyle therapy program if BMI ≥27^e
≥25		Obesity stage 2 (at least 1 severe complication)	Intensive behavioral and lifestyle therapy Consider adding weight-loss medications to lifestyle therapy program if BMI ≥27^e Consider bariatric surgery in patients with BMI ≥35
Abbreviations: BMI = body mass index; GERD = gastroesophageal reflux disease; NAFLD = nonalcoholic fatty liver disease; NASH = nonalchoholic steatohepatitis; PCOS = polycystic ovary syndrome; T2DM = type 2 diabetes mellitus

^aAll patients with BMI ≥25 have either Overweight stage 0, Obesity stage 0, Obesity stage 1, or Obesity stage 2 depending on the initial clinical evaluation for presence and severity of complications. These patients should be followed over time and evaluated for changes in both anthropometric and clinical diagnostic components. The diagnoses of Overweight/Obesity stage 0, Obesity stage 1, and Obesity stage 2 are not static, and disease progression may warrant more aggressive weight loss therapy in the future. Patients with increased BMI due to muscularity should be excluded.
^bIn certain ethnic populations, waist circumference should be assessed if the BMI is 23 to 25 kg/m². If the waist circumference is elevated using ethnic population-specific cutoff values, this positive risk factor identifies a patient who could benefit from weight loss and per se meets the criteria for an Obesity stage 1 diagnosis. Waist circumference is also used in the clinical evaluation of all patients for Metabolic Syndrome.
^cStages are determined using criteria specific to each obesity-related complication; stage 0 = no complication; stage 1 = mild-tomoderate; stage 2 = severe.
^d Treatment plan should be individualized; suggested interventions are appropriate for obtaining the sufficient degree of weight loss generally required to treat the obesity-related complication(s) at the specified stage of severity.
^eBMI ≥27 is consistent with the prescribing information mandated by the Food and Drug Administration for weight-loss medications.

Table.
Ethnic-specific Values for Waist Circumference: International Diabetes Federation Consensus Worldwide Definition of Metabolic Syndrome (www.idf.org)
Population	Male	Female
United States	≥102 cm or 40 in	≥88 cm or 35 in
Europids (Caucasians)	≥94 cm or 37 in	≥80 cm or 31 in
South Asians, Chinese, Japanese	≥90cm or 35 in	≥80 cm or 31 in
South and Central Americans	Use South Asian criteria until more specific data are available
Sub-Saharan Africans, Eastern Mediterranean and Middle East (Arab)	Use Europid criteria until more specific data are available

Authors and Disclosures

W. Timothy Garvey, MD, FACE, Chair¹, Alan J. Garber, MD, PhD, FACE², Jeffrey I. Mechanick, MD, FACN, FACP, FACE, ECNU³, George A. Bray, MD, MACE⁴, Samuel Dagogo-Jack, MD, DM, FRCP, FACE⁵, Daniel Einhorn, MD, FACP, FACE⁶, George Grunberger, MD, FACP, FACE⁷, Yehuda Handelsman, MD, FACP, FACE, FNLA⁸, Charles H. Hennekens, MD, DrPH⁹, Daniel L. Hurley, MD, FACE¹⁰, Janet McGill, MD, FACE¹¹, Pasquale Palumbo, MD, MACP, MACE¹², Guillermo Umpierrez, MD, FACP, FACE¹³, on behalf of the AACE Obesity Scientific Commitee

¹Chair of the Department of Nutrition Sciences, University of Alabama at Birmingham; Director of the UAB Diabetes Research Center, GRECC Investigator and staff physician at the Birmingham VA Medical Center, Birmingham, AL. ²Biochemistry and Molecular Biology & Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX. ³Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY. ⁴Pennington Biomedical Research Center, Baton Rouge, LA. ⁵University of Tennessee, Memphis, TN. ⁶Diabetes and Endocrine Associates, Scripps Whittier Diabetes Institute, University of California San Diego, LaJolla, CA. ⁷Grunberger Diabetes Institute; Internal Medicine and Molecular Medicine & Genetics, Wayne State University School of Medicine, Bloomfield Hills, MI. ⁸Metabolic Institute of America, Tarzana, CA. ⁹Florida Atlantic University, Boca Raton, FL. ¹⁰Mayo Clinic Medical School, Rochester, MN. ¹¹Division of Endocrinology, Metabolism & Lipid Research, Washington University, St. Louis, MO. ¹²Mayo Clinic, Scottsdale, AZ. ¹³Emory University Department of Medicine/Endocrinology, Atlanta, GA.

Address correspondence to
American Association of Clinical Endocrinologists, 245 Riverside Ave., Suite 200, Jacksonville, FL 32202. E-mail: publications@aace.com. DOI:10.4158/EP14280.PS

2013-2014 AACE Obesity scientific committee
W. Timothy Garvey, MD, FACE, AACE Obesity Scientific Committee Chair
Dennis M. Bier, MD
Nancy J.V. Bohannon, MD, FACP, FACE
George A. Bray, MD, MACP, MACE
Michael Bush, MD
Rhoda H. Cobin, MD, MACE
Samuel Dagogo-Jack, MD, DM, FRCP, FACE
J. Gary Evans, MD, FACE
Alan J. Garber, MD, PhD, FACE
J. Michael Gonzalez-Campoy, MD, PhD, FACE
George Grunberger, MD, FACP, FACE
Yehuda Handelsman, MD, FACP, FNLA, FACE
David Heber, MD, PhD
Daniel L. Hurley, MD, FACE
Samuel Klein, MD
Harold Lebovitz, MD, FACE
Janet McGill, MD, FACE
Karl Nadolsky, DO
Pasquale Palumbo, MD, MACP, MACE
Xavier Pi-Sunyer, MD
John A. Purcell, MD, FACE
Carla Romero, MD
Candice Rose, MD, MS
John A. Tayek, MD
Guillermo Umpierrez, MD, FACP, FACE
Farhad Zangeneh, MD, FACP, FACE

2014 consensus conference on obesity pillar pa rticipa nts
These individuals and/or organizations were invitees to the 2014 AACE/ACE Consensus Conference on Obesity, have reviewed the Advanced Framework for a new Diagnosis of Obesity as a Chronic Disease, and agree to participate in the further development of the diagnosis with the goal that it will help facilitate concerted action across multiple stakeholders in a comprehensive plan to combat obesity.

Academy of Nutrition and Dietetics
Hollie Raynor, PhD, RD, LDN, Director of Public Health Nutrition at University of Tennessee, Knoxville, TN
Accreditation Council for Graduate Medical Education
Mary Lieh-Lai, MD, FAAP, FCCP, Senior Vice President
American Academy of Physician Assistants
Lawrence Herman, PA-C, MPA, DFAAPA, President
American College of Sports Medicine
John Jakicic, PhD, Professor and Chair, Department of Health Physical Activity, & Director, Physical Activity and Weight Management Research Center, University of Pittsburgh
American Psychological Association
Lynn Bufka, PhD, Assistant Executive Director, Practice Research and Policy; and Suzanne Bennett Johnson, PhD, Distinguished Research Professor, Florida State University College of Medicine
American Society for Metabolic and Bariatric Surgery
John Morton, MD, MPH, FACS, FASMBS, President-Elect
American Society of Bariatric Physicians
Jennifer Seger, MD, ABFM, Board Trustee; Director, Bariatric Medical Institute of Texas Medical Weight Loss Program, San Antonio, Texas
Association of Program Directors in Endocrinology, Diabetes & Metabolism (APDEM)
Ann Danoff, MD, FACP, President
Solveig A. Cunningham, PhD
Assistant Professor, Rollins School of Public Health, Emory University
Humana
Andrew Renda, MD, MPH, Program Manager, Chronic Care Strategies
IMS Consulting Group
Matthew Maryniak, MBA, Principal
Scott Kahan, MD, MPH
Director, National Center for Weight and Wellness, George Washington University, Washington DC
Lillian F. Lien, MD
Medical Director, Duke Inpatient Diabetes Management, Associate Professor of Medicine in the Division of Endocrinology, Metabolism, and Nutrition, Duke University Medical Center
David Marrero, PhD
J.O Ritchey Professor of Medicine & Director, Translational Research Center, Indiana University School of Medicine, Indianapolis, IN
Novo Nordisk, Inc.
Todd Hobbs, MD, Diabetes Chief Medical Officer, Clinical Development, Medical & Regulatory Affairs; and Jason Brett, MD, Sr. Medical Director, Obesity; Clinical Development, Medical & Regulatory Affairs
Obesity Action Coalition
Mr. Joe Nadglowski, President/CEO
Takeda Pharmaceuticals
Dr. Steve Chen, Executive Medical Director; and Mansi Mehta, RD, LDN, Product Manager, Obesity Marketing
Vivus, Inc.
Santosh Varghese, MD, Vice President, Medical & Regulatory Affairs, Pharmacovigilance, and QA

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American Association of Clinical Endocrinologists and American College of Endocrinology Position Statement on the 2014 Advanced Framework for a New Diagnosis of Obesity as a Chronic Disease

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