Diego Bellido
Head of the Endocrinology and Nutrition Department at the Ferrol Hospital Complex (CHUF) and President of the Spanish Society for Obesity (SEEDO)
Is the study of good quality? Are the conclusions supported by sound data?
“It is a robust study, involving more than 844,000 participants from four countries, including Spain. Its results support the view that combining measures of adiposity with clinical assessment allows for a better distinction to be made regarding prognosis. However, it does not yet prove that using this classification improves treatment or reduces complications. The proposal to adopt it universally requires further evidence.”
How does it fit in with existing evidence?
“It reinforces something we have been advocating for years: BMI is useful, but insufficient for assessing a person with obesity. Fat distribution and its impact on health are crucial. What is new is the provision of follow-up data supporting the distinction between clinical and preclinical obesity, although the debate on how to use it remains open.”
Are there any significant limitations?
“Yes. It is an observational study and clinical information was not collected in a standardised manner across all cohorts. Furthermore, the attribution of certain health conditions to obesity was estimated statistically, without individual confirmation. This means the progression figures must be interpreted with caution: the fact that a person does not develop clinical obesity according to these criteria does not mean they remain free from health problems.”
What are the advantages of incorporating other body measurements and organ function rather than just BMI?
‘BMI does not distinguish between fat and muscle, nor does it reflect where fat is accumulated. Measuring waist circumference and assessing organ function helps to better understand each patient’s situation. Two people with the same BMI may have very different risks and treatment needs.’
How important is it to distinguish between clinical and preclinical obesity?
"It can help to tailor the intensity of monitoring and treatment. When organ damage is already present, there is a greater urgency to act. When it is not detected, we must focus on prevention and assess individual risk. The ‘preclinical’ category should not be interpreted as the absence of risk, nor should it be used to delay appropriate treatment.”
Could this lead to over-diagnosis or over-medicalisation? What implications would it have for prescribing medication?
“There is a risk if a new diagnostic label automatically translates into a prescription. However, these criteria can also correct imprecise diagnoses based solely on BMI. The prescription of medicines must be based on the expected benefit, the risks and the patient’s circumstances. This study does not determine who should receive them nor does it alter their authorised indications.”
Are they applicable in routine clinical practice?
“Supplementing BMI with waist circumference and a clinical assessment is feasible and should form part of good care. The greatest challenge is to rigorously establish which abnormalities are due to adiposity and to do so using standardised criteria. Their incorporation requires training, time and straightforward protocols, without turning the assessment into an indiscriminate battery of tests.”