Goodbye BMI, or almost. The body mass index will no longer be enough to determine whether a person is obese and to decide how to treat it. The current definition, which considers a patient ‘obese’ if he or she has a BMI of 30 or more, “excludes many people who could benefit from treatment.”
The EASO, European Association for the Study of Obesity, therefore dictates “a new framework for the diagnosis, staging and management of obesity in adults”. Published in ‘Nature Medicine’, it will allow “to modernise the diagnosis and treatment” of the pathology “taking into account all the latest developments in the field, including the new generation of drugs for obesity”. Medicines whose administration can be evaluated even when the body mass index is less than 30, equal to 25 or greater.
“Despite the widespread recognition of obesity as a multifactorial, chronic, relapsing and non-communicable disease, characterized by an abnormal and/or excessive accumulation of body fat, the diagnosis of obesity is still in many contexts based exclusively on BMI threshold values and does not reflect the role of adipose tissue distribution and function in the severity of the disease”, explains EASO in a communication that also reports the name of the Italian Luca Busetto, associate professor of the Department of Medicine of the University of Padua, vice-president of the scientific society for the Southern region.
One of the key innovations in the criteria drawn up by the Easo working group, composed of experts including the present and past presidents of the association, it therefore concerns “the anthropometric component of the diagnosis of obesity”. And it states in black and white that “BMI alone is insufficient as a diagnostic criterion” and that “body fat distribution has a substantial effect on health”. The waistline in the crosshairs: “The accumulation of abdominal fat is associated with an increased risk of developing cardiometabolic complications”, warn the specialists, and therefore represents “a stronger determinant of the development of the disease than the body mass index, even in subjects with a BMI lower than the standard threshold (30) for the diagnosis of obesity”.
Abdominal or visceral fat, warns EASO, “is an important risk factor for the deterioration of health even in people with low BMI and without obvious clinical manifestations”. Therefore, the new European indications also consider obese “subjects with a BMI lower” than 30, “between 25 and 30, but with increased accumulation of abdominal fat and presence of any medical, functional or psychological impairments”. Thus “reducing the risk of undertreatment in this particular group of patients, compared to the current definition of obesity based on BMI”.
The authors clarify that in their recommendations the “pillars of anti-obesity treatment” “substantially adhere to currently available guidelines: behavioral modifications, including nutritional therapy, physical activity, stress reduction and sleep improvement have been agreed upon as the main cornerstones of management” of the disease, “with the possible addition of psychological therapy, obesity medications, and metabolic or bariatric procedures (surgical and endoscopic)”.
Regarding the last two options, EASO specifies, “the steering committee discussed the fact that the current guidelines are based on evidence from clinical trials whose inclusion criteria were mostly based on anthropometric cut-offs, rather than on a comprehensive clinical assessment”. Therefore, “in current practice, the strict application of these criteria precludes the use of anti-obesity drugs or metabolic/bariatric procedures in patients with a substantial burden of obesity disease, but low BMI values”.
Now it’s changing: “The use of drugs – the experts recommend – should be considered in patients with a BMI of 25 or greater, a waist-to-height ratio of more than 0.5 and the presence of medical, functional or psychological impairments or complications, regardless of current body mass index cutoffs”. For the authors of the new criteria, “this statement can also be seen as a call to pharmaceutical companies and regulatory authorities to adopt inclusion criteria that are more in line with the clinical staging of obesity and less “tied” to traditional BMI cutoffs when designing future clinical trials with obesity drugs”.
The aim of EASO is to “bring the management of obesity closer to that of other chronic non-communicable diseases”, for which the focus is “not on short-term intermediate results, but on long-term health benefits”.
“Defining personalized long-term treatment goals”: this, according to the specialists, should guide “the discussion with patients from the beginning of treatment, considering the stage and severity of the disease, the available treatment options and possible side effects and concomitant risks, the patient’s preferences, individual factors that determine obesity and possible obstacles to treatment. The need is emphasized – conclude the authors of the new indications – for a global long-term or lifelong treatment plan, rather than a short-term reduction in body weight”.
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