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Endocr Pract. Author manuscript; available in PMC 2016 July 27.
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Published in final edited form as:

Endocr Pract. 2014 September ; 20(9): 977–989. doi:10.4158/EP14280.PS.

The American Association of Clinical Endocrinologists and the

American College of Endocrinology:
2014 ADVANCED FRAMEWORK FOR A NEW DIAGNOSIS OF OBESITY AS A CHRONIC
DISEASE

W. Timothy Garvey, MD [Chair, AACE Obesity Scientific Committee], Jeffrey I. Mechanick,

MD, FACP, FACE, FACN, ECNU [President, AACE], and Daniel Einhorn, MD, FACP, FACE
[President, ACE]
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The Purpose and Mandate for a New Diagnostic Approach to Obesity

The 2014 AACE/ACE Consensus Conference on Obesity was convened to establish an
evidence base that could be used to develop a comprehensive plan to combat obesity. The
Conference involved a wide array of national stakeholders (the “Pillars”) with a vested
interest in obesity, whose concerted participation would be necessary to support an effective
overall action plan. A key consensus concept that emerged from the Conference was that a
more medically meaningful and actionable definition of obesity was needed. It became clear
that the diagnosis based solely on anthropometric measures (e.g., BMI) lacked information
needed for concerted action among health care professionals, health care systems, regulators,
payers, and employers. Furthermore, the elements for an improved diagnosis should include
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both the anthropometric criterion together with an indication of the degree to which the
weight gain was negatively impacting the health of individual patients.

This document addresses this problem of diagnostic uncertainty, and is the first step in
removing this impediment for concerted and comprehensive action. This advanced
framework for a new diagnosis of obesity as a chronic disease translates the emergent
concept from the AACE Consensus Conference on Obesity into an actionable
recommendation. Because concerted action will be necessary, this framework will be
submitted to our Pillar partners for comment and recommendations. We will explore with
our partners new terminology to improve communication and implementation, and a new
diagnostic algorithm that is mapped to evidence-based risk-stratified patient subsets and
application of the AACE/ACE complications-centric obesity management algorithm. This
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document has been approved by the AACE/ACE Board of Directors, and will be distributed
to the 2014 Consensus Conference on Obesity Pillar representatives with a structured
questionnaire for comments. The goal will be to achieve consensus for a medically
meaningful and actionable diagnosis of obesity that will support access to rationally
delivered interventions for the prevention and treatment of obesity.

The Diagnosis of Obesity

A new definition and diagnostic strategy for obesity is required that is actionable, medically-
meaningful, and adds value to the health-promoting effects of weight loss. AACE/ACE
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defines obesity as a chronic disease characterized by pathophysiological processes that result

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in increased adipose tissue mass and which can result in increased morbidity and mortality.
In an environment that interacts with susceptibility genes to promote weight gain (i.e.,
obesogenic), many individuals have a body mass index (BMI) ≥ 25 kg/m2, which is
associated with increased likelihood for obesity-related complications and risk of
progressive obesity. The new obesity diagnostic algorithm incorporates two components: (i)
an assessment of body mass including validated ethnicity-adjusted anthropometrics to
identify individuals with increased adipose tissue placing them at risk; and (ii) the presence
and severity of obesity-related complications. Thus, the complete diagnosis does not simply
depend upon BMI level but also the impact of that weight gain on health. Individuals with
BMI ≥ 25 kg/m2 (or in certain populations a BMI of 23–25 kg/m2 with increased waist
circumference) then require evaluation for the presence and severity of specific obesity-
related complications to complete the diagnostic process. Each complication is evaluated for
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severity and impact on the patient’s health as Stage 0 (no complication is present), Stage 1
(complication is mild-moderate), or Stage 2 (complication is severe) using complication-
specific criteria. The staging of complications can be used to guide selection of treatment
modality and intensity of weight loss therapy in the context of the AACE obesity
management algorithm that is part of the AACE/ACE Comprehensive Diabetes Management
Algorithm (1).

The diagnosis facilitates another mandate of the CCO that a comprehensive action plan to
combat obesity must include primary, secondary, and tertiary disease interventions. If the
BMI is < 25 kg/m2 (and waist circumference is not increased), these patients have normal
weight and are candidates for primary intervention to prevent obesity, perhaps through
healthy lifestyle education and reductions in the obesogenic nature of the environment. If the
patients are overweight or obese and have no complications (Stage 0), they are eligible for
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secondary intervention to prevent progressive weight gain and the emergence of obesity
related complications. Once complications develop, whether individuals are overweight or
obese, it has become clear that the increase in body weight is adversely affecting the health
of the individual, and tertiary interventions are required to prevent worsening of the disease
and to treat the complications. Thus, all patients with BMI ≥ 25 kg/m2 and obesity related
complications require tertiary interventions, and have Obesity Stage 1 if mild-moderate
complications are present (but no severe complications) and Obesity Stage 2 if severe
complications are present. The identification and staging of obesity-related complications is
based on complication-specific criteria. Table 2 illustrates the Advanced Framework to
incorporate the principles of primary, secondary, and tertiary interventions and treatment.

The new diagnosis aligns itself with a 4-step approach for the evaluation of patients with
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obesity, and entrains professionals by providing them with a structured paradigm for patient
management consistent with high quality care. The 4 recommended steps are: (i) screening
with BMI with adjustments for ethnic differences, (ii) clinical evaluation for the presence of
obesity- related complications using a checklist, (iii) staging for the severity of
complications using complication-specific criteria, and (iv) selection of prevention and/or
intervention strategies targeting specific complications as guided by the AACE/ACE obesity
management algorithm. These recommendations have been translated from concepts and

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evidence derived from the AACE/ACE Consensus Conference on Obesity on March 23–24,
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2014 in Washington, DC (2).

Rationale, Principles, and Development of the Diagnostic Approach

The 2014 AACE/ACE Consensus Conference on Obesity
The 2014 AACE/ACE Consensus Conference on Obesity was predicated on a belief that
concerted action among a diverse array of stakeholders is required for significant reduction
in obesity prevalence growth rates. The Conference convened on March 23–24, 2014 in
Washington, DC, and resulted in a portfolio of “affirmed concepts” (AC) representing the
validation of previously held concepts and practices, and “emergent concepts” (EC) that
became apparent only through the vigorous analyses and discussions emanating from the
multidisciplinary cohort of attendees that included insights from health care professionals,
government/regulatory entities, pharmaceutical industry, large employers, large payers, lay
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and professional organizations, educational organizations, and research sponsors (2). The
principal finding, reflected in EC.1, was that the diagnostic definition of obesity needs to be
improved. The justification for this is that conference participants, representing a broad base
of stakeholders in the American healthcare system with a vested interest in the problem of
obesity, identified the current definition as a major obstacle to concerted action. Despite the
paradigm shift suggested by increased numbers of organizations recognizing obesity as a
chronic disease, the diagnosis of obesity has not changed. The old diagnosis primarily relied
on the anthropomorphic measure of BMI (3,4), with uncertainties regarding how an increase
in BMI affects individual health. AACE/ACE has developed a new definition and diagnostic
algorithm, which is actionable and medically meaningful, and represents a translation of the
findings of the Consensus Conference on Obesity. The lack of a medically-meaningful
strategy and poor translation of accumulating scientific data regarding the pathogenesis of
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obesity as a chronic disease have also limited the effectiveness of public health initiatives.

Rationale and Underlying Principles

This new strategy is based upon current scientific evidence indicating that pathogenesis of
obesity conforms to the chronic disease model; that is, a disease that arises from the
interaction of susceptibility genes, environment, and behavior with overlapping or additional
subsets of gene-environment interactions determining the severity of the disease, impact on
health, and development of complications. The new strategy addresses these issues and
specifically incorporates the following attributes of an obesity chronic disease model:

• Obesity as a chronic disease (5);

• Obesity results from the complex interaction of multiple biological factors

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(e.g., susceptibility genes), environmental factors (e.g., built environment),

and behavior;

• High prevalence rates and an obesogenic environment place a majority of

individuals in many societies at some level of risk; therefore, all
individuals must be screened;

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• Screening should include BMI, but not exclude other measures that more
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directly quantify adipose tissue mass, in a preventive care model,

including adjustments for ethnic differences in risk thresholds and
modifiers to account for epidemiological, behavioral, and physiological
differences among individuals;

• The diagnosis of obesity prioritizes organ dysfunction resulting in

discernible complications as a marker of disease and disease severity;

• A complication-centric approach to management will target increasingly

aggressive therapeutic approaches to those patients with obesity-related
complications who will most benefit from treatment, thus optimizing
patient outcomes, benefit/risk ratio of intervention, and cost effectiveness
(1,6);
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• There is an emphasis on obesity-related complications that can be

ameliorated by weight loss therapy;

• The diagnosis appropriately designates individuals appropriate for

primary, secondary, and tertiary interventions for prevention and
treatment.

• Screening, diagnosis, and staging are relevant to management options, as

directed by the AACE/ACE Obesity Algorithm (1), which treats
complications as the end point of weight loss therapy, not BMI.

Development of the diagnostic approach: Questions to be vetted by Pillar partners

The new obesity diagnosis will require input from multiple stakeholders to assure broad-
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based acceptance and concerted action in a comprehensive plan to combat obesity.

Therefore, our pillar participants will be asked for feedback. Some questions requiring
vetting are included below.

a. Improvements in the Advanced Framework. Are there improvements

needed in the diagnosis to better indicate what are we treating and why are
we treating it?

b. Alternative medical term other than ‘obesity’. The term obesity has
been widely used in multiple contexts, and conveys a sense of
stigmatization for patients. Do we need new terminology when
approaching the prevention and treatment of this disease and its
complications from a clinical perspective? Should consideration be given
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to re-naming the chronic disease state in a format that effectively reflects

the concept of weight-driven disease, for example “adiposity-based
chronic disease (ABCD)”; this concept is consistent with the use of
alternative diagnostic labels for diseases identified by eponyms, popular
references, or antiquated terminology (“obesity” derived from obesitas,
obdere, or ob + edere all meaning “fatness” or “to overeat” and not
reflecting a pathophysiology).

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c. Role of waist circumference measurement. What is the optimal use of

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waist circumference? Should it be used as an essential criterion for the

anthropometric component in all patients or in subgroups of patients, and
what is its role in evaluating patients for risks of cardiometabolic
conditions (e.g., prediabetic states, cardiovascular disease risk, etc)?

d. Incorporation of overweight and obesity designations. What is the

rationale for discriminating between patients with overweight (BMI 25–
29.9) and obesity (BMI ≥ 30) in a medically meaningful diagnostic
algorithm? Should patients who are overweight by BMI (i.e., BMI 25–
29.9) never be referred to as patients with obesity even if they have
complications (e.g., Obesity Stage 1 or Stage 2)? Isn’t an overweight
patient with a given complication just as deserving of weight loss therapy
as an obese patient with the same complication, and, therefore, the
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distinction between overweight and obesity should not be retained? On the

other hand, is this differentiation warranted because the prevalence of
many obesity-related complications will increase as the BMI increases?
Other thoughts?

e. Concept of ‘pre-obesity’. Is there any advantage to adopting a diagnosis

of pre-obesity for overweight or obese patients without complications?

f. Cost effectiveness. The diagnostic approach should facilitate an

economically viable model for obesity care by targeting more aggressive
weight loss interventions to those patients with complications who will
derive the greatest benefit (i.e., highest benefit/risk of the intervention and
cost effectiveness). The process must not dilute resources needed for high-
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risk individuals requiring care and not expand aggressive interventions to

lower-morbidity patient populations beyond the capacity of our healthcare
system, while at the same time taking into account the ‘value’ of obesity
care in enhancing quality of life and disease prevention.

g. Elderly patients. How should the diagnostic and treatment paradigm for
obesity be modified for elderly patients (e.g., > 70 years of age)?

Screening, Diagnosis, Complications Staging, and Management of

Obesity as a Disease
STEP 1. SCREENING and THE ANTHROPOMETRIC COMPONENT OF DIAGNOSIS
1.1 All Americans must be screened using BMI.
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1.2 BMI ≥ 25 kg/m2 is one component of the diagnosis of obesity. Individuals with
BMI ≥ 25 kg/m2 meet the criterion for Overweight (BMI 25–29.9) or Obesity
(BMI ≥ 30), and then must be assessed for the clinical component (see Step 2)
to complete the diagnostic process. Patients with BMI ≥ 25 can have obesity-
related complications treatable by weight loss therapy whether they are
overweight or obese.

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1.3 In certain ethnic groups (e.g., South Asians), individuals with BMI 23–25
kg/m2 can still be diagnosed as obese on the basis of increased waist
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circumference using population and ethnicity specific threshold values as

delineated by the International Diabetes Federation (3,4,7,11).

1.4 If an individual is edematous, elderly with sarcopenic obesity, or highly

muscular, then clinical judgment and/or DXA should be employed to identify
individuals with high risk for obesity based on fat mass with attention to
gender differences in body composition.

Ethnic Specific Values for Waist Circumference: International Diabetes

Federation Consensus World Wide Definition of Metabolic Syndrome
www.idf.org
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Population Male Female

United States ≥ 102 cm ≥ 88 cm
or 40 in or 35 in

Europids (Caucasians) ≥ 94 cm ≥ 80 cm
or 37 in or 31 in

South Asians, ≥ 90 cm ≥ 80 cm
Chinese, Japanese or 35 in or 31 in

South and Central Use South Asian criteria until

Americans more specific data are available

Sub-Saharan Africans, Use Europid criteria until more

Eastern Mediterranean specific data are available
and Middle East (Arab)

1.5 Individuals who meet the anthropometric criterion for the diagnosis of
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overweight or obesity would then be evaluated for obesity-related

complications, i.e., the clinical criterion that constitutes the second component
of the diagnostic algorithm. In this way, the anthropometric criterion is
necessary but not sufficient for a complete diagnosis, which requires, in
addition, the pathophysiological component as reflected in complications or
risk of complications as a marker of disease severity.

STEP 2. THE CLINICAL COMPONENT OF DIAGNOSIS and OBESITY-RELATED

COMPLICATIONS
2.1 Individuals who meet the anthropometric criterion for overweight or obesity
must then undergo evaluation for the presence or absence of obesity-related
complications, the clinical criterion, to complete the diagnosis of obesity.
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2.2 Initial evaluation is standard for ‘new’ patient visits, and would include 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, in addition to assessment
of diet, meal pattern preferences, and physical activity. An obesity-focused
review of systems could be obtained using a form that the patient could fill out
in the office or prior to the initial visit

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2.2 Diagnostic evaluation includes a stepped evaluation protocol and checklist for
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the presence of obesity-related complications based on information from the

initial visit, with an emphasis on those complications that can be ameliorated
using weight loss therapy, as illustrated in Table 3. The initial basic clinical
evaluation is sufficient to determine whether many obesity related
complications are present or absent, or to strongly suspect their presence. In
many instances, further evaluation may be necessary according to standards of
care to confirm the presence of obesity related complications as alluded to in
Step 3.

STEP 3. DISEASE STAGING and COMPLICATIONS-CENTRIC APPROACH

3.1 If any obesity-related complications are identified, individuals should undergo
further evaluation to stage the severity of each complication
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3.1 In many cases, the confirmation of the presence of an obesity related

complication, and the staging of the severity of the complication, can be
accomplished using the information obtained at the initial ‘new’ patient
evaluation. Other complications may require additional testing as
recommended by standards of care to confirm the presence of the complication
and/or to stage the severity of the complication. Table 4 proposes criteria for
staging of obesity related complications for purposes of illustration, but, in
many cases, subspecialty expertise will be required for optimization of these
criteria.

3.2 Staging is completed for each of the identified complications using

complications-specific criteria (see Table 4) and staged as:
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• Overweight and Obesity Stage 0 represent diagnoses for those

patients who satisfy the anthropometric criterion, BMI 25–29.9
for Overweight and BMI ≥ 30 for Obesity, and who do not
have obesity-related complications (Stage 0).

• Obesity Stage 1 represents the diagnosis of obesity for those

patients who satisfy the anthropometric criterion (e.g., BMI ≥
25 kg/m2) and have one or more mild-to-moderate obesity
related complications (but none severe).

• Obesity Stage 2 represents the diagnosis of obesity for those

patients who satisfy the anthropometric criterion (e.g., BMI ≥
25 kg/m2) and have one or more severe obesity related
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complications.

• For patients with Obesity Stage 1 and Obesity Stage 2, no

distinction is made for patients with overweight or obesity
based on BMI alone since excess weight in either case is
adversely affecting health and all patients have one or more
complications that can be treated by weight loss therapy. While
the prevalence of complications increases as a function of BMI,

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the advanced diagnostic framework will identify all

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individuals, whether overweight or obese, who have mild-

moderate or severe complications and who will benefit from
weight loss therapy.

STEP 4. TREATMENT: IMPLEMENT AACE/ACE OBESITY MANAGEMENT ALGORITHM

AFTER DIAGNOSIS AND COMPLICATION STAGING ARE COMPLETE (Figure 2)
4.1 Steps 1–3 diagnose obesity on the basis of both anthropometric criteria and
clinical criteria that reflect the impact of weight gain on health as manifest by
the presence and severity of obesity-related complications. The staging of
complications in Step 3 helps guide treatment decisions in the context of the
Obesity Treatment Algorithm shown in Figure 2, which is part of the
AACE/ACE Comprehensive Diabetes Treatment Algorithm (1). Obesity
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management never precludes specific complication-related treatment outside of

weight loss therapy when needed. The selection of treatment modality and
intensity will require clinical judgment and individualization of therapy,
however, Table 5 proposes treatment approaches based on diagnostic category
that would generally apply in many individuals.

4.2 Overweight and Obesity Stage 0 are indicative of the absence of obesity-
related complications. From the perspective of cardiometabolic disease, these
patients have been referred to as the “healthy obese” (8,9), and, in this
instance, biomechanical and other complications of obesity would similarly not
be present. While therapy should be individualized and based on clinical
decision-making, patients with Overweight/Obesity Stage 0 would generally be
treated with lifestyle modification employing meal patterns that promote health
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(10), behavior modification, and increased physical activity primarily intended

to prevent progressive weight gain and/or the emergence of complications in
the future. More emphasis on weight reduction and hypocaloric diets may be
warranted with BMI ≥ 30 or in patients with rapid increases in body weight.
These individuals require interventions for the secondary phase of treatment/
prevention of chronic disease.

4.3 Obesity Stage 1 is indicative of the presence of one or more obesity-related

complications, each of which are mild-moderate in severity, based on
complication- specific criteria. Effective treatment of these complications can
generally be accomplished by moderate weight loss (e.g., 3–10% weight loss).
While therapy should be individualized based on clinical judgment, in general,
patients with Obesity Stage 1 would be effectively treated with intensive
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lifestyle/behavioral therapy or the combination of a lifestyle modification

program that emphasizes caloric reduction in conjunction with a weight loss
medication. Obesity Stage 1 includes both overweight and obese patients with
one or more mild-moderate complications that can be ameliorated by weight
loss. The emphasis, therefore, is on improving the patient’s health and treating
both weight and weight-related complications and not just weight or the BMI
level per se. Therefore, these individuals require interventions for the tertiary

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phase of treatment/prevention of chronic disease, intended to lessen disease

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severity and treat complications.

4.4 Obesity Stage 2 is indicative of the presence of one or more obesity-related

complications that are severe based on complications-specific criteria (see
Table 3). Stage 2 complications generally have a more adverse impact on
individual health, and/or require more aggressive obesity management with a
greater degree of weight loss (e.g., ≥ 10% weight loss) in order to effectively or
optimally treat the obesity-related complication. While therapy should be
individualized and based on judgment, in general, patients with Obesity Stage
2 would effectively be treated with intensive lifestyle/behavioral therapy in
conjunction with a weight loss medication or with bariatric surgery. Obesity
Stage 2 includes both overweight and obese patients with one or more severe
complications that can be ameliorated by weight loss. The emphasis, therefore,
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is on improving the patient’s health and treating complications and not the
BMI level per se. As indicated for Obesity Stage 1, these individuals require
interventions for the tertiary phase of treatment/prevention of chronic disease.

4.5 Patients meeting the diagnosis for Obesity, whether Stage 0, 1, or 2, have a
lifelong disease and will need ongoing follow-up and re-assessment for both
anthropometric and clinical components of the diagnosis. For example, a
current diagnosis of Obesity Stage 0 does not assure the perpetual absence of
complications; these patients may convert to Stage 1 or Stage 2 in the future
indicating the need for more aggressive weight loss therapy. Similarly patients
with Overweight and no complications are at risk of future weight gain in our
obesogenic environment, and require lifestyle modifications and ongoing
follow-up.
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Appendix
AACE Obesity Scientific Committee (OBCOM)

Dennis M. Bier, MD

Nancy J.V. Bohannon, MD, FACP, FACE

George A. Bray, MD, MACP, MACE

Rhoda H. Cobin, MD, MACE

Michael Bush, MD
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J. Gary Evans, MD, FACE

Alan J. Garber, MD, PhD, FACE

J. Michael Gonzalez-Campoy, MD, PhD, FACE

Yehuda Handelsman, MD, FACP, FNLA, FACE

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David Heber, MD, PhD

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Daniel L. Hurley, MD, FACE

Samuel Klein, MD

Harold Lebovitz, MD, FACE

Karl Nadolsky, DO

Xavier Pi-Sunyer, MD

John A. Purcell, MD, FACE

Carla Romero, MD
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Candice Rose, MD, MS

John A. Tayek, MD

Farhad Zangeneh, MD, FACP, FACE

AACE/ACE Obesity Consensus Conference Writing Team

Samuel Dagogo-Jack, MD, DM, FRCP, FACE

George Grunberger, MD, FACP, FACE

Janet McGill, MD, FACE

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Pasquale Palumbo, MD, MACP, MACE

Guillermo Umpierrez, MD, FACP, FACE

References
1. Garber AJ, Abrahamson MJ, Barzilay JI, Blonde L, Bloomgarden ZT, Bush MA, Dagogo-Jack S,
Davidson MB, Einhorn D, Garvey WT, Grunberger G, Handelsman Y, Hirsch IB, Jellinger PS,
McGill JB, Mechanick JI, Rosenblit PD, Umpierrez GE, Davidson MH. American Association of
Clinical Endocrinologists’ Comprehensive Diabetes Management Algorithm 2013 Consensus
Statement – Executive Summary. Endocrine Practice. 2013; 19:536–557. [PubMed: 23816937]
2. Executive Summary of the AACE/ACE Consensus Conference on Obesity.
3. World Health Organization (WHO). Geneva: WHO; 1998. Report of a WHO consultation on
obesity. Obesity: preventing and managing the global epidemic. Available at:http://
Author Manuscript

whqlibdoc.who.int/hq/1998/WHO_NUT_NCD_98.1_(p1-158).pdf
4. National Heart, Lung, and Blood Institute. The Clinical Guidelines on the Identification, Evaluation,
and Treatment of Overweight and Obesity in Adults: The Evidence Report. Bethesda: National
Institutes of Health; 1998. NIH Publication No. 98-4083
5. Mechanick JI, Garber AJ, Handelsman Y, Garvey WT. American Association of Clinical
Endocrinologists' position statement on obesity and obesity medicine. Endocrine Practice. 2012;
8:642–648. [PubMed: 23047927]

Endocr Pract. Author manuscript; available in PMC 2016 July 27.

 Garvey et al. Page 11

6. Garvey WT. New tools for weight loss therapy enable a more robust medical model for obesity
treatment: rationale for a complications-centric approach. Endocrine Practice. 2013; 19:864–874.
Author Manuscript

[PubMed: 24014010]
7. Alberti KG, Eckel RH, Grundy SM, et al. Harmonizing the metabolic syndrome: a joint interim
statement of the International Diabetes Federation Task Force on Epidemiology and Prevention;
National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation;
International Atherosclerosis Society; and International Association for the Study of Obesity.
Circulation. 2009; 120:1640–1645. [PubMed: 19805654]
8. Wildman RP, Muntner P, Reynolds K, et al. The obese without cardiometabolic risk factor clustering
and the normal weight with cardiometabolic risk factor clustering: prevalence and correlates of 2
phenotypes among the US population (NHANES 1999–2004). Archives of Internal Medicine. 2008;
168:1617–1624. [PubMed: 18695075]
9. Guo F, Moellering DR, Garvey WT. The progression of cardiometabolic disease: validation of a new
cardiometabolic disease staging system applicable to obesity. Obesity (Silver Spring). 2014;
22:110–118. [PubMed: 23894121]
10. Gonzalez-Campoy JM, St. Jeor S, Castorino K, Ebrahim A, Hurley D, Jovanovic L, Mechanick JI,
Author Manuscript

Petak SM, Yu Y-H MD, Harris KA, Kris-Etherton P, Kushner R, Molini-Blandford M, Nguyen QT,
Plodkowski R, Sarwer DB, Thomas KT. Clinical Practice Guidelines for Healthy Eating for the
Prevention and Treatment of Metabolic and Endocrine Diseases in Adults: Cosponsored by the
American Association of Clinical Endocrinologists/The American College of Endocrinology and
the Obesity Society. Endocrine Practice. 2013 Sep-Oct;19(5):1–82. [PubMed: 24129260]
11. www.idf.org.
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Synopsis
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• Obesity is a chronic disease

• Emergent Concept 1 (EC.1) from the 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 of obesity requires a process of screening,

evaluation of complications (using checklist), staging, and
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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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Figure 1.
AACE/ACE Diagnostic Algorithm for the Disease of Obesity
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Table 1

The AACE Advanced Framework for a New Diagnosis of Obesity

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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 one or more mild-to-moderate obesity

related complications

Presence of one or more severe obesity related

Obesity Stage 2 BMI ≥ 25 kg/m2 complications
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Table 2

The AACE Advanced Framework and Levels of Treatment and Prevention for Chronic Diseases
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DIAGNOSIS ANTHROPOMETRIC CLINICAL COMPONENT PREVENTION/

COMPONENT 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

Presence of one or more mild-to-

Obesity Stage 1 BMI ≥ 25 kg/m2 moderate obesity related complications
Tertiary
Presence of one or more severe obesity
Obesity Stage 2 BMI ≥ 25 kg/m2 related complications
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Table 3

Checklist of Obesity Related Complications.*

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Obesity Related Complication Identification based on Possible secondary tested needed

information available in to confirm presence of
initial evaluation complication, stage complication,
or guide therapy
Metabolic Syndrome waist circumference, blood initial evaluation completes diagnosis;
pressure, triglycerides, HDL screen for cardiovascular disease
cholesterol, fasting glucose
(ATPIII criteria)

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

Type 2 Diabetes Mellitus fasting glucose overtly elevated or repeat fasting glucose
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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 initial evaluation completes diagnosis;

with lipid panel lipoprotein subclasses may further define
risk

Hypertension systolic and diastolic sitting blood repeat blood pressure completes diagnosis;
pressures further testing may include ambulatory blood
pressure monitoring; screen for
complications of hypertension

Non-Alcoholic Fatty Liver liver examination, liver function additional studies are needed for diagnosis:
Disease tests imaging, liver biopsy as indicated

Polycystic Ovary Syndrome physical exam, review of systems additional studies are needed for diagnosis:
hormonal testing
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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

Gastroesophageal Reflux physical exam, review of systems additional studies may be indicated:
Disease endoscopy, esophageal motility

Disability/Immobility physical exam, review of systems initial evaluation may complete diagnosis,
functional testing may be needed

Psychological Disorder and/or physical exam, review of systems additional studies may be needed:
Stigmatization psychological testing

Obesity secondary to genetic physical exam, review of systems, additional studies may be needed: genetic
syndromes, hormonal disease, review medications and testing, hormonal testing
iatrogenic medications supplements, family history
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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 not
associated with PCOS; “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; Gout;
Chronic Kidney Disease/Renal Protection.

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*
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.
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Table 4

Staging of Obesity-Related Complications That Can Be Improved by Weight Loss.*

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A] Prediabetes, Metabolic Syndrome, and Type 2 Diabetes.

Stage 0 (none) No risk factors related to insulin resistance (WC, BP, HDL, TG, fasting
Glucose). This is equivalent to Cardiometabolic Disease Stage 0
(CMDS) (9)
Stage 1 (mild-moderate) 1 or 2 risk factors (WC, BP, HDL, TG; CMDS stage 1)
Stage 2 (severe) Prediabetes, Metabolic Syndrome, or Type 2 Diabetes (CMDS stages
2–4)
B] Hypertension
Stage 0 (none) Blood Pressure < 130/85 mm/Hg
Stage 1 (mild-moderate) BP ≥ 130/85 mm/Hg in absence of other risk factors
Stage 2 (severe complication) BP target not met despite use of anti-hypertensive medication(s)
BP ≥ 130/85 mm/Hg in high risk individual: CMDS 2–4, smoking, African
American, congestive heart failure
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C] Hypertriglyceridemia/Dyslipidemia
Stage 0 (none) TG < 150 and HDL-c ≥ 40 in male and ≥ 50 in female
Stage 1 (mild-moderate) TG 150–399 and/or HDL-c < 40 in male and < 50 in female in absence of
other risk factors
Stage 2 (severe) TG ≥400 in absence of other risk factors
TG ≥ 150 and HDL-c < 40 in male and < 50 in female in high risk
individual: CMDS stage 2–4
D] Sleep Apnea
Stage 0 (none) No symptoms, Apnea Hypopnea Index (AHI) < 5
Stage 1 (mild-moderate) AHI 5–29 with no or mild symptoms
Stage 2 (severe) AHI ≥ 30
AHI 5–29 with severe symptoms and/or clinical consequences
E] Non-Alcoholic Fatty Liver Disease
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Stage 0 (none) No steatosis

Stage 1 (mild-moderate) Presence of steatosis but no inflammation or fibrosis
Stage 2 (severe) Steatohepatitis (NASH)
F] Polycystic Ovary Disease
Stage 0 (none) Does not meet criteria, absence of PCOS
Stage 1 (mild-moderate) 1 or 2 risk factors (WC, BP, HDL, TG: CMDS stage 1) and no
infertility/anovulation
Stage 2 (severe) Infertility/anovulation
Oligomenorrhea; Menorrhagia
Prediabetes/Metabolic Syndrome/T2DM (CMDS stage 2–4)
G] Osteoarthritis
Stage 0 (none) No symptoms and no radiographic joint changes
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Stage 1 (mild-moderate) Mild-moderate symptoms and functional impairment (e.g., validated

questionnaire) and/or mild-moderate anatomical joint changes
Stage 2 (severe) Moderate-severe symptoms and functional impairment (e.g., validated
questionnaire) and/or moderate-severe anatomical joint changes
S/P knee or hip replacement surgery
H] Stress and Urge Urinary Incontinence

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Stage 0 (none) No symptoms and/or normal urodynamics

Stage 1 (mild-moderate) Mild-moderate symptom severity score
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Stage 2 (severe) Severe symptom severity score

I] Gastroesophageal Reflux Disease
Stage 0 (none) No symptoms or findings
Stage 1 (mild-moderate) Mild-moderate symptoms
Stage 2 (severe) 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
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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.

*
While 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.
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Table 5

Diagnosis and Management of Obesity

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Complications-Specific† Staging and

Diagnosis Treatment
Step 1 Step 2 Step 3 Step 4

Anthropometric Clinical Component Complications- Suggested Therapeutic

Component – Specific Interventions Δ
BMI* Staging† (based on clinical judgment)
Presence or Absence of • Healthy Meal
Obesity Related Pattern &
Complications Physical Activity
• Metabolic Conditions • Lifestyle
25–29.9 Overweight Modification/
→ Prediabetes Reduced Calorie
Meal Plan/
→ Metabolic
Physical Activity
Syndrome
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→ T2DM
• Lifestyle
→ Hypertension Modification/
Reduced Calorie
→ Dyslipidemia Meal Plan/
Obesity Physical Activity
≥ 30 → NAFLD/NASH
Stage 0 • Intensive
• Sleep Apnea Behavioral and
• PCOS Lifestyle
Therapy
• Osteoarthritis
• Stress Incontinence • Lifestyle
Modification/
• GERD Reduced Calorie
Meal Plan/
• Disability/Immobility
Physical Activity
• Psychological Disorder or
• Intensive
Stigmatization Obesity Behavioral and
Stage 1 (one Lifestyle
≥25 or more mild-
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Therapy
moderate
complications) • Consider adding
weight loss
medications to
lifestyle therapy
program if BMI
≥ 27‡

• Intensive
Behavioral and
Lifestyle
Therapy
• Intensive
Behavioral and
Lifestyle
Obesity Therapy with
Stage 2 Medications if
≥25 (at least one
severe BMI ≥ 27‡
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complication)
• Consider
Bariatric Surgery
in patients with
T2DM and BMI
35–39.9
• Consider
Bariatric Surgery

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 Garvey et al. Page 21

Complications-Specific† Staging and

Diagnosis Treatment
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Step 1 Step 2 Step 3 Step 4

Anthropometric Clinical Component Complications- Suggested Therapeutic

Component – Specific Interventions Δ
BMI* Staging† (based on clinical judgment)
in patients with
BMI ≥ 40

Note: All patients with BMI ≥ 25 have either Overweight, 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.
*
In certain ethnic populations, waist circumference should be assessed if the BMI is 23–25 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 meets the criteria for an
Obesity Stage 1 diagnosis. Waist circumference is also used in the clinical evaluation of all patients for Metabolic Syndrome, and, if elevated per
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se, indicates Overweight Stage 1.

†
Stages are determined using criteria specific to each obesity-related complication. Stage 0 = no complication; Stage 1 = mild-to-moderate; Stage 2
= severe
Δ
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
‡
The BMI ≥ 27 is consistent with the prescribing information mandated by the Food and Drug Administration for weight loss medications.
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