Even though it’s become an increasingly prevalent condition in recent decades, the term obesity is a loaded word in our culture. It often carries a stigma and is associated with being lazy or weak-willed, lacking self-discipline or willpower and being noncompliant with recommended weight-loss treatments, experts say. In an effort to change that perception, the American Association of Clinical Endocrinologists, or AACE, and the American College of Endocrinology, or ACE, have proposed a new diagnostic term to describe obesity: adiposity-based chronic disease, also known as ABCD.
“There are people in the lay realm and the medical profession who view obesity as a lifestyle choice or the patient’s fault,” says Dr. W. Timothy Garvey, an endocrinologist, professor and chair of nutritional sciences at the University of Alabama–Birmingham who co-authored the ABCD position statement. “This is really a lifelong disease process that confers increased disability and mortality.”
In addition, the social judgment surrounding excess body weight is so strong and negative that many people object to the word obesity. In a study published in a 2012 issue of the journal Obesity, researchers asked 390 obese adults in primary care settings in the Philadelphia area to complete a questionnaire about the terms that are most and least acceptable to describe excess body weight. Out of the 11 terms that were offered, “fatness” was rated as the most undesirable, followed by “excess fat,” “large size,” “obesity” and “heaviness.” (The most preferred terms were simply “weight,” “BMI,” “weight problem” or “excess weight.”)
The rationale behind changing the name to ABCD? “Right now, obesity is relegated to a simple construct of having a [body mass index] over 30,” says co-author Dr. Jeffrey Mechanick, a professor of medicine and medical director of the Kravis Center for Cardiovascular Health at the Icahn School of Medicine at Mount Sinai in New York Cityand past president of AACE. “But the word obesity doesn’t confer sufficient information about the disease risks.” On the other hand, the ABCD term is based on a complications-centric approach to diagnosing, categorizing and treating excess body weight.
Indeed, the new terminology is designed to frame obesity as a chronic disease with unmistakable, discrete complications. It’s not just the amount of excess body fat that matters but its location, too. The proposed shift in terminology reflects growing recognition that fat distribution in areas where it doesn’t belong – particularly excess fat that’s stored in the abdomen and therefore around organs such as the liver and pancreas (often called visceral fat) – is more metabolically active than subcutaneous fat (which lies under the skin). Visceral fat makes and releases proteins called adipokines that promote harmful inflammation and metabolic abnormalities throughout the body, Mechanick explains. “Left untreated, it can lead to prediabetes or Type 2 diabetes, cardiovascular disease and stroke, chronic renal disease, depression, arthritis and other diseases,” he explains.
To determine if someone is carrying excessive body weight, the new nomenclature takes into account not just BMI but also the person’s waist circumference, waist-to-hip ratio, fat identified on advanced body imaging techniques such as ultrasound and MRI, and perhaps inflammatory markers on blood tests. Under the proposed model for ABCD, there are three distinct stages:
Stage 0: The person is carrying excess weight but doesn’t have health complications from it.
Stage 1: The person is experiencing mild to moderate complications – such as prediabetes or slightly elevated blood pressure – due to excess body weight.
Stage 2: The person has more severe complications – such as Type 2 diabetes or significantly high blood pressure – that are related to carrying excess weight.
As straightforward as this hierarchy seems, some experts who weren’t involved in the proposed name change have mixed feelings about it. “I have long opposed calling obesity a disease [because] obesity could – and in my view should – be defined as a form of drowning: in calories, addictive junk food and modern labor-saving technology rather than water,” says Dr. David Katz, director of the Yale University Prevention Research Center and past president of the American College of Lifestyle Medicine. “The idea of a disease may imply to the public and [health care] providers that the solution should be clinical rather than cultural – and in my view that’s a grave mistake, ” adds Katz, who is a U.S. News contributor and Best Diets panelist. On the other hand, Katz says he applauds the “emphasis on both lifestyle interventions and primordial prevention, where the focus is on the environment rather than the individual’s metabolism.”
One hope is that the new terminology will shake people out of complacency about the dangers of being considerably overweight and encourage them to take action to address it in a serious fashion, Mechanick says. Another goal is to have the new diagnostic term incorporated into the medical coding structure – such as the ICD-10, or the International Classification of Diseases – so that weight-loss interventions and treatments for weight-related complications will be more readily recommended and gain greater insurance coverage. In the meantime, experts behind the proposed change to ABCD will continue to garner co-sponsorship from other medical organizations such as the American Medical Association. “It usually takes two to three years for a change like this to happen,” Garvey says.
Which stage a patient’s excess weight falls into would inform the approach to treatment. In the past, if a doctor saw a patient with high blood pressure, he or she would likely treat that but not the patient’s obesity, notes Dr. Daniel L. Hurley, a consultant in the division of endocrinology, diabetes, metabolism and nutrition at the Mayo Clinic and president-elect of AACE. This means “we’d be missing half the diagnosis and half the treatment.” By contrast, the new framework promotes an approach to treatment that’s centered on managing both weight-related health complications as well as the excess body weight.
The approach to treatment for ABCD would include lifestyle changes (such as improving your diet and exercise habits, as well as your sleep-hygiene and stress-management strategies) for Stage 0; lifestyle changes and medication for stages 1 or 2; and perhaps stronger measures (such as bariatric surgery) for severe complications, Mechanick says. By focusing on the weight-related complications, the hope is that insurance plans would provide greater coverage for a patient to consult a dietitian, join a physical activity program or participate in behavioral interventions (for stress reduction or smoking cessation, for example).
“The ultimate goal is that we can bring evidence-based treatments to patients with this disease so we can help them and improve their quality of life,” Garvey says. “Patients need to understand this as a disease process like hypertension or diabetes, seek care for it” and take steps to manage it for the long haul.
