ABCDs of Adiposity: A New Way of Thinking About Weight and Health

Jeffrey I. Mechanick, MD, FACP, FACE, FACN, ECNU; Daniel L. Hurley, MD, FACE; and W. Timothy Garvey, MD, FACE

The world is bigger. Not that the planet itself has grown, but rather, people everywhere weigh more and body shapes and fatness are changing. In fact, the New England Journal of Medicine recently reported that more than 2 billion adults and children globally are overweight or obese, a number that includes obesity in 35 percent of the U.S. adult population. This is a critical problem since these body changes impact health, wellness and lifespan.

The challenge, despite all that has been learned from medical research, is that doctors and other healthcare professionals have not been able to help individuals significantly reverse unhealthy changes in body fat to improve health.

Many people still firmly believe that becoming overweight or obese is a lifestyle choice – faulting the individual for making poor choices in meal content, meal frequency and minimal physical activity. However, science is now clear that obesity is a disease due to interactions between the genes we have inherited, the environment we live in and our behaviors, some elements of which we clearly can change, but some of which we certainly cannot, such as genetics.

As a first step to advance the conversations surrounding excess weight, and because the word “obesity” is so loaded with negative associations, a new term has been developed by endocrinologists who are members of the American Association of Clinical Endocrinologists (AACE) and its educational arm, the American College of Endocrinology (ACE). (Endocrinologists are doctors who specialize in disorders of hormones and their glands and have a very special interest and expertise in problems caused by excess body fat.)

This new term is “Adiposity-Based Chronic Disease,” or ABCD for short. The ABCD term focuses on the parts of the body that contain fat (or “adiposity,” which does not carry the stigma that “obesity” does) and the concept of chronic disease, which means that the condition can be serious, far-reaching and needs to be managed throughout one’s lifetime.

In the proposed model for ABCD, the risk, presence and severity of adiposity complications are presented in three distinct stages:

STAGE 1: The person is carrying extra weight, but has no identifiable health complications from it.
STAGE 2: The person has mild or moderate complications as a result of excess body weight.
STAGE 3: The person has severe complications due to excess weight.
ABCD is not just related to having too much fat in the body, but also having an unhealthy distribution of fat (for example, too much fat in the belly or various organs, such as the liver, muscle, or around the heart), and/or having abnormal fat that produces unhealthy proteins that cause problems with other parts of the body (leading to diabetes, increased blood fats [such as cholesterol], high blood pressure, or heart disease).

So, how should we manage health problems associated with abnormalities in body fat? Let’s review four basic parts of the answer.

First, we have become familiar with the term “obesity” as referring to too much body fat. Scientifically, we define obesity based on the relationship of weight and height. This is known as the “body mass index” or “BMI” and is calculated by first multiplying the height in centimeters by itself (“squaring”) and then dividing this number into the weight in kilograms. (There are 2.54 centimeters in an inch and 2.2 pounds in a kilogram.) Or you can find easy-to-use, automatic BMI calculators on the internet that allow you to plug in your weight in pounds and your height in inches — EASY! A normal BMI is 18.5 to 24.9, an overweight BMI is 25.0 to 29.9, and an obese BMI is 30 and over.

However, there are problems using these classic definitions:

  • People have different body shapes, musculature and genetics. Thus, BMI does not apply to all people in the same way;
  • Certain types of body fat (abdominal [or “belly”] fat or fat inside liver or muscle cells) can have negative effects even if the total amount of body fat is normal;
  • Some people may have an increased BMI and yet do not have obesity-related problems or complications, and;
  • Using the word “obesity” is not acceptable to many people who have a weight problem, and it can have a negative meaning or confer a bad impression of the person, rather than just talking about the amount or effects of fat in the body.

Since ABCD is a chronic disease, it is best addressed by changing lifestyle in a way that lasts a lifetime, not just simply “dieting” to lose weight over a short time only to put it back on again when the diet is over. Lifestyle medicine embraces all the different ways you and your healthcare team can work together to treat chronic disease that do not use medicines or medical procedures such as bariatric surgery.

This does not mean there is no role for medicines or procedures to help with ABCD, but lifestyle change is very important by itself or as an addition to other recommended treatments. Examples of lifestyle changes to manage ABCD include:

  • Proper nutrition – eating foods that are healthy and in such a way that the amounts are just right – not too little and not too much. For weight loss, the meal plan must focus on fewer overall calories;
  • Physical activity and strength training – making a special effort every day to move around, exercise, play sports and avoid sitting in one place for too long, either at work or at home;
  • Adequate sleep amount and quality – making sure there is enough time (usually about 7 hours) to sleep at night with minimal interruptions or disturbance;
  • No tobacco – this includes smoking, chewing, or any other ways tobacco is used;
  • Avoiding excessive alcohol – generally less than two drinks a day for men and one drink a day for women, but even less is better;
  • Developing a positive attitude and behaviors – focusing on positives in life, reducing stress, and socializing and engaging with family, friends and people in one’s community; and
  • Monitoring – keeping track of what is eaten, how much physical activity (such as steps) is done in a day, and setting goals for lifestyle changes to be made, as well as acknowledging the changes that have been made.

To completely manage ABCD will ultimately require that schools, employers, hospitals and governments emphasize and support healthy lifestyles for everyone, from cradle to grave.

The ABCD strategy includes recognition of the negative effects of abnormal adiposity on health – referred to as “complications.” Some of the most important ABCD-related complications include the following:

  • Type 2 diabetes mellitus – this is related to problems with the body’s insulin production and insulin action, resulting in higher than normal blood sugars, which in turn potentially affect the function of the kidneys, heart, eyes, brain, nerves and liver;
  • Hypertension – when blood pressure is too high, in turn it potentially affects the function of organs such as the heart, kidneys and brain;
  • Arthritis – this is when the joints wear down, become inflamed and cause pain. It is no surprise this is worse with increased body weight;
  • Depression – feeling sad is a complication in many people with ABCD, and it can be even worse when the person is bothered by their body shape and even teased by others;
  • Sleep problems – many people with ABCD have problems breathing at night, a condition called sleep apnea, which decreases the amount and quality of sleep, making them even more tired and even hungrier during the daytime; and
  • Additional health problems – ABCD is associated with increased risk for cancer and heart disease.

Recognizing and treating complications from abnormal adiposity is important. But the key to staying healthy and living a longer and happier life is not just to treat the complications from abnormal adiposity, but to prevent or lessen them.

Tactics are how strategies are turned into actions. ABCD tactics ideally should be personalized, taking into account unique individual factors such as family history and health risks, each person’s medical history and medications, likes and dislikes, and even ethnicity and culture. Examples of ABCD tactics proposed by AACE/ACE include the following:

  • Health messaging – using media and other public service announcements about the importance of comprehensive lifestyle changes and seeing your doctor about ABCD;
  • Education – informing everyone, including healthcare professionals, employers, government officials, and those in the health care industry and medical insurance industry about ABCD;
  • Programs – setting up specific activities in schools, workplaces, universities and communities to bring healthy and comprehensive lifestyle change directly to individuals;
  • Individual planning – to work with your “likes and dislikes” for meal/snack choices, for types of activity and exercise, for support/activity/social groups and other personalized features;
  • Medical research – to support the need to learn more about how ABCD affects the body and how specific lifestyle changes affect ABCD; and
  • Management protocols – to develop very specific guidelines, algorithms and other tools to help your doctors and healthcare team deliver the best ABCD care possible, using lifestyle medicine as well as drugs and procedures where appropriate.

AACE and ACE hope that the new Adiposity-Based Chronic Disease terminology and ABCD medical care plan will significantly contribute to improving individual health for you and those around you.

For more information about ABCD, health, endocrine care and healthy lifestyle change, visit