Effective management of adults with obesity and adiposity-based chronic conditions means optimizing overall health, with clinical goals in addition to weight reduction, according to a new consensus statement from the American Association of Clinical Endocrinology (AACE).

“Nearly a decade has passed since the previous Weight Bias Internalization Scale, during which obesity has been reframed from a behavioral challenge to a complex, chronic, relapsing disease,” said statement co-author Juliana Simonetti, MD, an associate professor and director of obesity medicine at the University of Utah in Salt Lake City.

The updated consensus guidelines, published in Endocrine Practice, “reflect the latest medical advancements in obesity care and provide practical, easy-to-use clinical tools, including step-by-step algorithms to guide busy clinicians,” Simonetti told Medscape Medical News.

The term adiposity-based chronic disease (ABCD) was introduced by the AACE in 2017 to identify obesity as a chronic condition, lead author Karl Nadolsky, DO, an endocrinologist at Michigan State University College of Human Medicine in East Lansing, Michigan, and colleagues wrote in the statement.

A diagnosis of ABCD goes beyond BMI and refers to the dysregulation of energy balance that results in abnormalities in mass, distribution, and function of adipose and the need to treat adiposity as a disease that impairs quality of life and increases the risks for morbidity and mortality, they explained.

Staging and Severity of ABCD

A key point for clinicians is the use of staging and severity of ABCD to inform interventions. One of the visual algorithms divides ABCD into three stages based on the severity of obesity-related diseases and complications. Stage 1, also called preclinical obesity, refers to individuals with excess adiposity but without obesity-related diseases or complications. Stages 2 and 3 include individuals with excess adiposity and complications such as osteoarthritis, lymphedema, obstructive sleep apnea, prediabetes and metabolic syndrome, thromboembolism, and disability that limits activities of daily living. Stage 2 or 3 patients also may have obesity-related diseases including diabetes and metabolic dysfunction-associated steatohepatitis.

Actions for stage 1 patients focus on risk reduction and secondary prevention via lifestyle and consideration of first-generation obesity medication with expected weight reduction of more than 5% to less than 15%. Actions for stages 2 and 3 include medications and potential surgery, with a strong preference for second-generation obesity medications, such as semaglutide and tirzepatide, for those in stage 3.

“The consensus guidelines go a step further by offering specific recommendations for dietary and physical activity approaches in patients receiving incretin-based therapies, while also emphasizing the importance of multidisciplinary care,” Simonetti told Medscape Medical News.

“However, additional research is needed to better understand the long-term effects of potential nutritional deficiencies, changes in bone and muscle health, optimal dietary interventions, and the overall impact of this new class of medications that produce substantial weight loss,” she added.

The guidance also presents a hierarchy of preferred medications for ABCD based on current clinical trial data and grouped by the main complication to be targeted (type 2 diabetes, obstructive sleep apnea, cardiometabolic concerns) and includes explanations of the risks and benefits of different medication options.

In addition, the algorithm advises clinicians to consider the ongoing challenges of weight bias and stigma that may cause internalized weight bias in patients, with a negative impact on physical and mental health-related quality of life. To assess patients for internalized weight bias, the authors recommend the Weight Self-Stigma Questionnaire and the Weight Bias Internalization Scale.

Ultimately, a person-centered approach involves empathy when addressing healthcare concerns and presentation of the full range of evidence-based options for medical and surgical treatment, as well as lifestyle intervention, the authors wrote.

Getting Clinicians to Go Beyond BMI

Clinicians will need education about this more holistic approach and the definitions for staging with the terms ABCD and Obesity-Related Complications and Diseases (ORCD), said Richard Siegel, MD, an endocrinologist and co-director of the Diabetes and Lipid Center at Tufts Medical Center in Boston.

And several elements of the algorithm may take a while to integrate into clinical practice, said Siegel, who was not involved in authoring the new guidance.

For example, the new guidance recommends defining excess adiposity by measurements other than BMI, such as waist circumference and waist-to-height ratio, based on data from a 2025 report from The Lancet Diabetes and Endocrinology Commission.

“Waist circumference and other measures of body composition are not routinely done in primary care offices or even endocrine offices,” said Siegel. “DXA [dual-energy x-ray absorptiometry] scan is ordered to assess for osteoporosis but may not be covered by insurance for overall body composition.”

Another consideration is whether insurance companies will change criteria for medication to consider adiposity measurements and ABCD staging rather than BMI alone, he added.

Applying the Algorithms

“All of the algorithms are useful visually, although they are a bit complex and will require somewhat of a paradigm change in the entire system to be put into effect,” Siegel said.

In addition, new data on clinical outcomes for second-generation weight-loss medications for indications other than weight management, such as ORCDs, may inform how the algorithm plays out in practice, he said.

More long-term research will be needed to determine whether the algorithms can be applied equitably in primary care, and access to second generation medications may be limited based on differences in insurance coverage and copay, Siegel told Medscape Medical News.

The new guidance was supported by the AACE. 

Simonetti and Siegel disclosed having no financial conflicts of interest. 

Heidi Splete is a medical journalist based in the Washington, DC, area, with more than 25 years of experience covering a range of medical specialties.