In a shift in how obesity is understood and treated in India, The Lancet Diabetes & Endocrinology Commission has introduced a new framework for defining and diagnosing the condition. The report, published recently in Diabetes & Metabolic Syndrome: Clinical Research & Reviews, questions the reliance on body mass index (BMI) as a primary measure, highlighting its limitations in accurately assessing obesity and its associated health risks.
The Commission’s new guidelines advocate for a broader view of obesity, reframing it as a chronic illness rather than simply excess weight. Obesity is now understood as a condition that affects the functions of organs and tissues, leading to complications such as heart disease, stroke, and kidney failure.
Dr Anoop Misra, Director of the Fortis CDOC Centre of Excellence for Diabetes, Metabolic Diseases, and Endocrinology in New Delhi, and one of the report’s authors, pointed out key issues with current obesity measures. “Obesity should not be reduced to excess weight alone; it affects the body on a systemic level,” he said. “Current BMI-based assessments often fail to accurately reflect adiposity, either underestimating or overestimating it.”
Dr Misra explained that the previous guidelines, published in 2009, relied solely on BMI, which overlooks critical factors. “Asian Indians, for example, tend to accumulate fat at lower BMI levels compared to Western populations, leading to conditions like type 2 diabetes at an earlier stage,” he noted. As a result, the updated guidelines now advocate for a more comprehensive approach that includes waist circumference, waist-to-height ratio, comorbidities, and the impact of obesity on daily activities, in addition to BMI.
The revised framework introduces two stages of obesity. Stage 1 is characterised by increased adiposity (BMI >23 kg/m²) without significant impact on organ functions or daily life. Stage 2 involves heightened adiposity that affects physical capabilities and raises the risk of comorbid diseases. Criteria for Stage 2 include a BMI over 23 kg/m², excess waist circumference or waist-to-height ratio, and symptoms that interfere with daily activities or suggest underlying health issues.
Dr Misra stressed that recognising these stages allows healthcare providers to tailor treatments accordingly. "For Stage 1, lifestyle changes such as improved diet and physical activity are recommended, while Stage 2 may require more intensive interventions, including medical therapies or surgery," he explained.
To enhance diagnosis, the Commission recommends moving beyond BMI, which can serve as a population-level indicator but is insufficient for individual assessment. Instead, a combination of body fat measurements and anthropometric data, such as waist circumference and waist-to-hip ratio, should be used.
“Diagnosing obesity requires a more nuanced approach,” said Dr Misra. “We must consider how excess fat affects organ function and daily life.”
Regarding treatment, the report suggests that interventions should be tailored to the severity of the condition. For individuals with preclinical obesity, lifestyle changes should be the focus, while those with clinical obesity may need more aggressive treatments to prevent further organ damage. The Commission also advocates for public health policies that address weight-based stigma and ensure equitable access to effective treatments. “Training healthcare professionals and policymakers is essential,” Dr Misra said, emphasising that education is key to overcoming biases and improving obesity management globally.