Commentary
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Our Definition of Obesity and its Impact on Treatment
Johannes Hebebrand
In the current issue of Obesity, Garvey and Mechanick (1) propose a
diagnostic classification system for obesity based on the concept of
adiposity-based chronic disease (ABCD). The proposition builds on
a previously published tridimensional classification scheme for obe-
sity based on etiology, degree of adiposity, and health risk (2). Both
studies document the need to come up with a readily comprehensible,
evidence-based, and nonstigmatizing definition and classification of
obesity. In addition, the definition should allow for the recognition of
obesity as a medical disease.
A look at the International Classification of Diseases, Tenth Revision
(ICD-10) classification of obesity reveals a serious negligence of clini-
cians and scientists in the past to adequately define one of the most com-
mon human diseases. In the International Classification of Diseases,
Eleventh Revision (ICD-11) (World Health Organization), the situation
has improved in that the stigmatizing ICD-10 diagnosis “obesity due to
excess calories” (E66.0) was not perpetuated. However, in ICD-11, the
brief definition of obesity as “abnormal or excessive fat store secondary
to different causes including energy imbalance, drugs, and genetic dis-
orders” (3) begs several comments: (1) “abnormal” has the potential to
again stigmatize patients; (2) drugs and genetic disorders entail obesity
via an energy imbalance, too, thus precluding their listing in a row with
energy imbalance; (3) the reference to energy imbalance in itself rep-
resents an oversimplification of the complex regulation of body weight
in an obesogenic environment (4); and (4) the brevity of the definition
of obesity contrasts with other ICD-11 disease definitions (e.g., com-
pare to hypertensive diseases).
The proposed classification scheme of Garvey and Mechanick is
quite complex (1). For example, ABCD complications may very
well also occur in lean individuals, in which case the authors suggest
applying the specific disease codes. However, a high percentage of
body fat in a lean or normal-weight individual may render such a
person susceptible to the development of an ABCD complication. In a
patient with obesity, how is a physician to decide whether weight loss
Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.
Correspondence: Johannes Hebebrand (Johannes.Hebebrand@uni-due.de)
© 2020 The Authors. Obesity published by Wiley Periodicals, Inc. on behalf of The Obesity Society (TOS).
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited and is not used for commercial purposes.
See accompanying article, pg. 484. Received: 17 December 2019; Accepted: 17 December 2019; Published online 24 February 2020. doi:10.1002/oby.22740
www.obesityjournal.org 
Obesity
would improve the respective complication? An individual can have
obesity and an unrelated cause, for example hypertension. It appears
problematic to label every obesity-associated disorder as a complica-
tion of excess adiposity. Thus, advances in the molecular genetics of
complex diseases have revealed genetic correlations between BMI/
obesity and other diseases (5,6), thereby indicating a more complex
relationship than a mere dependence of such disorders on obesity.
Because Garvey and Mechanik suggest weight loss as an indicator for
the definition of complications, a general practitioner may be misled
to promote weight loss in a patient without first acknowledging and
discussing the a priori low probability of maintenance of an achieved
weight loss.
We need a consensus among all international obesity associations and
societies to come up with an ICD-compatible classification scheme
and, by necessity, a short definition of obesity. An elongated version to
be published separately and updated regularly would serve physicians
throughout the world as a guidance to the complex diagnostic issues at
hand. Importantly, the classification and definition shape the way physi-
cians perceive obesity and treat their patients accordingly.  O
Disclosure: The author declared no conflict of interest.
References
1. Garvey WT, Mechanick JI. Proposal for a scientifically-correct and medically actionable
disease classification system (ICD) for obesity. Obesity (Silver Spring) 2020;28:484-492.
2. Hebebrand J, Holm JC, Woodward E, et al. A proposal of the European Association
for the Study of Obesity to improve the ICD-11 diagnostic criteria for obesity based
on the three dimensions etiology, degree of adiposity and health risk. Obes Facts
2017;10:284-307.
3. World Heath Organization. ICD-11 for Mortality and Morbidity Statistics (Version:
04/2019). https​://icd.who.int/brows​e11/l-m/en. Accessed December 16, 2019.
4. Müller MJ, Geisler C, Heymsfield SB, Bosy-Westphal A. Recent advances in under-
standing body weight homeostasis in humans. F1000Res 2018;7:1025. doi:10.12688/​
f1000​resea​rch.14151.1
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6. Yengo L, Sidorenko J, Kemper KE, et al. Meta-analysis of genome-wide association
studies for height and body mass index in ~700000 individuals of European ancestry.
Hum Mol Genet 2018;27:3641-3649. doi:10.1093/hmg/ddy271
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