AACE Releases Adiposity-Based Chronic Disease (ABCD) 2025 Guidelines: Top Highlights from Consensus Statement

Top highlights from the article include:

1. From BMI to Complication-Centric Staging

The new AACE framework replaces BMI-centric classification with a clinical staging system based on the severity of obesity-related complications and diseases (ORCD).

• Stage 1 (Preclinical Obesity): No known ORCD, but at risk; treatment aims to prevent onset.
• Stage 2 (Mild to Moderate): Presence of one or more mild-to-moderate* ORCD.
• Stage 3 (Severe): One or more severe*, or multiple, ORCD present.

While BMI remains a useful screening tool, diagnosis now requires assessment of both anthropometric measures (such as BMI, waist circumference, and waist-to-height ratio) and the clinical severity of complications. This staging enables treatment intensity to be matched to an individual's health risk, rather than focusing solely on weight.

2. Adiposity-Based Chronic Disease (ABCD)

ABCD is defined as a heterogeneous, progressive, chronic disease driven by abnormal neuroendocrine control of energy balance. This leads to excess or abnormal adiposity, which in turn drives downstream complications. These complications can impair quality of life, increase morbidity, and raise the risk of mortality.

3. A New Treatment Paradigm

The 2025 guidelines introduce a hierarchy of pharmacological therapies, emphasizing second-generation obesity medications that have shown ≥15% weight loss in clinical trials, levels that can prevent or reverse many complications. For the first time, medications are prioritized based on their proven effectiveness in specific conditions, enabling more precise and personalized obesity care.

4. Medication Priorities by Clinical Indication:

• MACE Prevention: Semaglutide is currently the only drug shown to reduce major adverse cardiovascular events (MACE) in patients without diabetes. Tirzepatide is under evaluation.
• Type 2 Diabetes: Tirzepatide and semaglutide are first-line due to their effectiveness in both weight loss and glycemic control.
• Metabolic Dysfunction-Associated Steatohepatitis (MASH): Semaglutide and tirzepatide, both medications, improve liver histology and fibrosis.
• Heart Failure with Preserved Ejection Fraction (HFpEF): Tirzepatide improves symptoms, physical function and heart failure outcomes, while semaglutide improves symptoms and physical function.
• Chronic Kidney Disease (CKD): Semaglutide is preferred for patients with type 2 diabetes due to evidence of slowed estimated glomerular filtration rate decline.
• Obstructive Sleep Apnea (OSA): Tirzepatide, recently FDA-approved for OSA (Dec 2024), and phentermine/topiramate are preferred.

First-generation medications, such as phentermine/topiramate and liraglutide, remain viable, particularly in early ABCD stages or where newer drugs are inaccessible due to cost.

5. Role of Surgery

Metabolic and bariatric surgery continues to play an important role in severe obesity treatment. It is recommended for patients with a BMI ≥40 kg/m² or ≥35 kg/m² with complications. It may also be considered for those with BMI between 30–34.9 kg/m² if they have severe cardiometabolic disease. The most commonly recommended procedures remain sleeve gastrectomy and Roux-en-Y gastric bypass.

6. Comprehensive and Compassionate Care

The AACE emphasizes individualized, nonjudgmental care that also addresses weight stigma, mental health, and social determinants of health.

Providers are encouraged to assess internalized weight bias (IWB), which can affect mental well-being and treatment adherence. Screening for depression, anxiety, and disordered eating is advised. Social and cultural factors should also be evaluated to tailor care effectively.

7. Lifestyle: The Foundation of Long-Term Success

Although medications and surgery play important roles, lifestyle interventions remain foundational to managing ABCD.

• Nutrition: High-protein, nutrient-dense diets (≥1.2 g/kg/day protein) are encouraged to support lean mass during weight loss. Limiting ultra-processed, high-calorie foods is key.
• Physical Activity: A combination of aerobic and resistance training is advised, with a target of 150–300 minutes of physical activity per week to support weight maintenance.
• Sleep and OSA Screening: Poor sleep disrupts energy balance and metabolic health. High-risk individuals should be screened for OSA and coached on sleep hygiene.

8. Long-Term Management & Monitoring

As a lifelong disease, ABCD requires ongoing management. The guidelines call for regular follow-up to monitor metabolic adaptation, prevent weight regain, and adjust therapies based on patient response and the reversal of complications. Ongoing tracking of clinical markers such as A1C, blood pressure, and lipids is essential.

The 2025 AACE Consensus Statement represents a paradigm shift in obesity care. By reclassifying obesity as Adiposity-Based Chronic Disease (ABCD) and emphasizing a complication-centric, individualized, and long-term approach, the new guidance moves away from outdated, weight-focused models. The goal is not just weight loss, but improving health outcomes, reducing disease burden, and enhancing quality of life through evidence-based, patient-centered care.

*The degree of severity for ORCD is based on clinical judgement, incorporating findings from physical examination, laboratory testing, and/or other diagnostic procedures, as well as a person’s symptomatology, in ways that apply to each individual complication.

Reference: Nadolsky K, Garvey WT, Agarwal M, Bonnecaze A, Burguera B, Chaplin MD, Griebeler ML, Harris SR, Schellinger JN, Simonetti J, Srinath R, Yumuk V. American Association of Clinical Endocrinology Consensus Statement: Algorithm for the Evaluation and Treatment of Adults with Obesity/Adiposity-Based Chronic Disease - 2025 Update. Endocr Pract. 2025 Sep 18:S1530-891X(25)00977-2. doi: 10.1016/j.eprac.2025.07.017. Epub ahead of print. PMID: 40956256.