Might Clinically Obese Patients Have Treatment Denied Under Proposed Diagnosis Changes?
BU emerita professor who served on international commission suggests doctors look beyond BMI to diagnose obesity
Distinguishing between clinically impaired patients with obesity and those who are unimpaired would improve diagnosis, supporters say, while some worry that it might prompt withholding preventive treatment from those not yet sick. Photo by Unsplash/i yunmai
Might Clinically Obese Patients Have Treatment Denied Under Proposed Diagnosis Changes?
BU emerita professor who served on international commission suggests doctors look beyond BMI to diagnose obesity
Body mass index (BMI), doctors’ go-to metric for adjudicating a person’s healthy weight for decades, has had long-recognized limitations. Determined by dividing people’s weight by their height, BMI was the subject of a recent report by an international commission, with almost 60 experts from diverse medical specialties, that recommends two key changes in diagnosing obesity.
But the proposal has some doctors worried about denying necessary treatment to patients.
In addition to measuring BMI, the commission urges doctors to also measure blood pressure and other vitals and a patient’s body fat, also called adiposity. It also recommends that high-adiposity patients be classed either as “clinically obese,” meaning they have weight-related illness or pain and therefore a chronic disease, and the “preclinically obese,” who aren’t yet experiencing illness and would be considered at risk for disease.
Will the recommended changes cause doctors to possibly withhold treatment until complications set in? That seems unlikely, according to Barbara Corkey, a commission member and an emerita professor of medicine and biochemistry at Boston University’s Chobanian & Avedisian School of Medicine.
“The commission sought to achieve consensus” about defining and distinguishing between clinical and preclinical obesity, Corkey says. “The idea was to differentiate and to be more specific about what was the disease, what was treatable, and what we meant when we talked about these things.”
The commission—which met over Zoom for about two years before issuing its report, Corkey says—said that it didn’t know if diagnosed obesity would rise or drop under the recommendations, but that they are intended to aid in making diagnosis more precise, at a time when obesity is rising globally.
BU Today asked Corkey and Ivania Rizo, an assistant professor of medicine at the Chobanian & Avedisian School of Medicine and director of obesity medicine at Boston Medical Center, BU’s teaching hospital and Boston’s safety net hospital, about the recommendations and whether there might be possible drawbacks to them.
Q&A
with Barbara Corkey and Ivania Rizo
BU Today: Dr. Rizo, do you agree with the suggested changes?
Rizo: Yes. The proposed reframing of obesity as a clinical illness—when it results in organ dysfunction or significant limitations in daily activities—addresses long-standing shortcomings in how obesity is defined and diagnosed. This definition moves BMI alone toward a more nuanced, functional model and allows for better alignment with the diagnostic principles used in other chronic diseases. It acknowledges the complexity of obesity, validates the lived experiences of patients, and helps avoid both underdiagnosis and overdiagnosis.
BU Today: What about concerns that adopting the change might lead to denial of disease-preventing care in some obese patients?
Rizo: That is a valid concern. The commission draws a clear line between preclinical obesity and clinical obesity. While this distinction can improve clarity, there is a potential risk that some insurers or policymakers may limit treatment coverage to only those meeting the clinical obesity definition. The commission does recommend proactive monitoring, counseling, and intervention—even in preclinical obesity—based on individual risk. However, without policy safeguards, some patients may indeed be denied preventive care.
Without policy safeguards, some patients may indeed be denied preventive care.
Corkey: I’m saying “no” [to the concern] unambiguously. Prior to our commission, obesity was primarily recognized as a lifestyle issue. Patients who want to get treated for their obesity with drugs that are expensive have to pay for it out of pocket. The issue is, if you have a limited amount of money, the people who are already suffering from this disease, with real clinical manifestations, get first dibs on the treatment. If we had the resources, I would certainly think that it would be useful to treat people with pre-obesity. So I don’t think it’s a matter of saying you shouldn’t treat those people. It’s a matter of priority that people who need it the most should be given priority.
In my preferred world, I would treat everybody. I think that would be wonderful. But if we can’t treat everybody, then we should give priority to those who have the greatest disability, the clinically obese, defined by the commission. It’s the way we treat everyone in medicine. The people who are most acutely ill get first dibs. If you go into an emergency room [with a non–life-threatening problem] and someone comes in with a heart attack, guess what happens? You wait until I deal with that.
[The commission] isn’t saying that we don’t think we should treat people with a BMI over 30. We’re saying that we’d like a better definition. It requires that there be some disability, some problem, and BMI may or may not be a problem. It’s the inability to do the normal things in life, take care of your children, do your job. If those things were affected, they’re a higher priority than if you want to be better looking.
BU Today: Is it up to individual doctors and nations’ medical associations to decide whether to adopt the recommendations? How much weight will the American Medical Association [AMA] and US doctors give to the commission’s suggestions?
Rizo: Yes, the adoption of these recommendations will largely depend on national and professional regulatory bodies, such as the AMA in the United States. While the commission’s recommendations carry significant weight due to their international scope and robust consensus, their implementation is not automatic. The AMA and US-based societies will likely evaluate these recommendations through committees and may issue guidelines accordingly. Given the widespread endorsement by over 76 organizations globally and the high degree of consensus among experts, these recommendations are poised to influence US clinical and policy standards, especially among specialists in endocrinology and obesity medicine.
Corkey: Of course, we have no power to enforce anything. Each nation and each organization can choose to adopt it or not. We have quite a big list of organizations that were in favor of what we were doing and supported us. I can’t imagine why anyone wouldn’t pay attention to it.
I think the commission’s defining it that way with such a large group is a tool that’s useful for insurance companies, so they cover things that are defined as disease [and] don’t cover things that are not defined as disease.
In my preferred world, I would treat everybody. But if we can’t treat everybody, then we should give priority to those who have the greatest disability.
BU Today: Is it the general medical consensus that we’re currently too reliant on BMI?
Corkey: That’s the biggest point. Someone with a lot of muscle mass, as sumo wrestlers [have], has a high BMI, but it causes them no problem. You need to have something the matter with you. You need to have altered blood lipids or malfunctioning of your knees because your knees can’t handle the weight. You need something that could be called a disability or a disease or a defect, and that’s how we would prioritize.
Obesity is not necessarily a disability or disease. The whole area of obesity is very, very poorly understood by many in the population. There’s still a predominant concept that it’s bad behavior, that you’re in charge of your body weight—and it’s complete nonsense. There’s plenty of evidence that it isn’t true.
Rizo: Yes, medicine has long been very reliant on BMI, despite its well-documented limitations. BMI does not distinguish between fat and lean mass, overlooks fat distribution, and fails to capture the functional consequences of excess adiposity.
The commission’s two-step diagnostic model—confirming excess adiposity and then assessing for signs of illness—is a significant improvement. If this model is not adopted, the next-best fix would involve using BMI only as a screening tool and requiring additional measures (e.g., waist circumference, direct fat measurement) plus functional assessments to guide diagnosis and treatment decisions.
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