Beyond BMI: adiposity‑based chronic disease - why we are ahead of the pack at Downscale.

Understanding the 2025 AACE Guidance on Obesity Management

The 2025 American Association of Clinical Endocrinology (AACE) guidance reframes obesity as an adiposity-based chronic disease (ABCD). This complex, chronic, and relapsing condition requires long-term management, with Body Mass Index (BMI) being just one small aspect of the overall picture.

Beyond BMI: Adiposity-Based Chronic Disease

The new AACE algorithm encourages clinicians to look beyond a single BMI cut-off. Instead, it focuses on assessing adiposity-based chronic disease (ABCD) by combining various factors, including:

Body size
Fat storage locations
Metabolic health
Functional limits
Obesity-related complications (ORCD)

Conditions such as type 2 diabetes, fatty liver disease, sleep apnoea, osteoarthritis, cardiovascular disease, and mental health issues are considered to determine the severity of obesity and guide appropriate treatment intensity, rather than fixating on a specific number on the scales.

Treating the Whole Person

The 2025 guidance emphasises person-centred and complication-centred care principles. Key components include:

Shared decision-making
Acknowledging individual priorities
Considering social context and mental health

The guidance strongly advocates for recognising and reducing weight stigma in healthcare, promoting respectful, non-blaming conversations. It encourages care environments that focus on improving health, function, and quality of life rather than solely on weight.

Obesity as a Chronic, Relapsing Disease

Both AACE and the 2025 Standards of Care in Overweight and Obesity categorise obesity/ABCD as a chronic, progressive, and relapsing disease that typically requires long-term or lifelong management. The aim is to achieve sustainable improvements in complications and overall wellbeing through:

Ongoing nutrition
Physical activity
Psychological support
Medical and surgical options when necessary

Regular review and adjustment are essential, moving away from one-off “weight loss programmes.”

Where Medicines Fit – At a High Level

The 2025 guidance provides comprehensive algorithms on when and how various treatment tools can be employed, including lifestyle changes, psychological approaches, and a range of medical and surgical options.

Due to strict regulations in Australia regarding the promotion of specific prescription medicines, this blog cannot discuss individual drugs or make treatment recommendations. Decisions about medication should always occur in a personalised consultation with a qualified prescriber, using the original guideline documents as a reference.

Key Messages for Everyday Practice

The 2025 endocrine guidance encourages a pivotal shift from asking “How do we get this BMI down?” to “How do we best care for this person living with a chronic, relapsing disease that affects multiple body systems?” This entails:

De-emphasising BMI
Assessing complications and functional abilities
Partnering with individuals in a non-stigmatising manner
Planning for long-term support rather than short-term dieting or treatments

For clinicians and interested readers seeking detailed treatment algorithms, the original documents are available at the following links:

Conclusion

Understanding and managing obesity as a chronic, relapsing disease requires a holistic approach. The 2025 AACE guidance marks a significant shift towards comprehensive care that respects the individual's unique circumstances and promotes long-term health and wellbeing.