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. 2025 Oct 1;8(10):e2537619.
doi: 10.1001/jamanetworkopen.2025.37619.

Implications of a New Obesity Definition Among the All of Us Cohort

Lindsay T Fourman  1 , Aya Awwad  1 , Alba Gutiérrez-Sacristán  2 , Camille A Dash  1 , Julia E Johnson  1 , Allison K Thistle  1 , Nikhita Chahal  1 , Sara L Stockman  1 , Mabel Toribio  1 , Chika Anekwe  1 , Arijeet K Gattu  1 , Steven K Grinspoon  1
Affiliations

Implications of a New Obesity Definition Among the All of Us Cohort

Lindsay T Fourman et al. JAMA Netw Open. .

Abstract

Importance: A recent Lancet Commission proposed an obesity definition that integrates body mass index (BMI [calculated as weight in kilograms divided by height in meters squared]) with anthropometric measures, marking a paradigm shift in how obesity is conceptualized and classified.

Objective: To determine the clinical implications of the new definition of obesity.

Design, setting, and participants: This population-based longitudinal cohort study leveraged data from the All of Us cohort. Participants in All of Us with complete anthropometric data were enrolled between May 31, 2017, and September 30, 2023, with a median follow-up of 4.0 (IQR, 1.7-4.7) years.

Exposure: Obesity classified by traditional and new definitions.

Main outcomes and measures: Obesity was defined by the new framework using sex- and race-specific thresholds as (1) BMI above the traditional obesity threshold plus at least 1 elevated anthropometric measure or BMI greater than 40 (BMI-plus-anthropometric obesity) or (2) at least 2 elevated anthropometric measures with BMI below the traditional obesity threshold (anthropometric-only obesity). Obesity was categorized as clinical or preclinical based on organ dysfunction and/or physical limitation.

Results: Among 301 026 individuals (183 633 [61.0%] female; median age, 54 [IQR, 38-65] years), 206 361 (68.6%) had obesity according to the new definition vs 128 992 (42.9%) according to the traditional definition, due to inclusion of individuals with anthropometric-only obesity. Among the overall cohort, 108 650 individuals (36.1%) had clinical obesity according to the new definition; this prevalence increased with age, as 24 498 of 45 018 individuals 70 years or older (54.4%) had clinical obesity. Compared with no obesity, odds ratios of organ dysfunction were 3.31 (95% CI, 3.24-3.37) for BMI-plus-anthropometric obesity and 1.76 (95% CI, 1.73-1.80) for anthropometric-only obesity per the new definition. In longitudinal analyses, clinical obesity conferred elevated risks of incident diabetes (adjusted hazard ratio [AHR], 6.11; 95% CI, 5.67-6.60), cardiovascular events (AHR, 5.88; 95% CI, 5.38-6.43), and all-cause mortality (AHR, 2.71; 95% CI, 2.41-3.05) compared with no obesity or organ dysfunction. Preclinical obesity was also associated with increased risks of incident diabetes (AHR, 3.32; 95% CI, 3.08-3.58) and cardiovascular events (AHR, 1.40; 95% CI, 1.27-1.55), albeit to a lesser degree.

Conclusions and relevance: In this cohort study, adoption of the new definition of obesity significantly increased obesity prevalence with major implications for clinical practice and public policy. The new framework effectively stratified individuals at high risk of organ dysfunction and long-term complications while introducing anthropometric-only obesity and preclinical obesity as distinct entities warranting further study.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Fourman reported receiving grant support from Chiesi Farmaceutici SpA and personal fees from Chiesi Farmaceutici SpA and Theratechnologies outside the submitted work. Dr Grinspoon reported receiving personal fees from Marathon Asset Management LP and Exavir Therapeutics during the conduct of the study and grant support from Kowa Pharmaceuticals America Inc, Gilead Sciences Inc, and Viiv Healthcare outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Prevalence of Obesity by the Traditional and New Definitions Among the All of Us Cohort
The inset highlights the low prevalence of high body mass index (BMI) but nonelevated anthropometric measures under the traditional BMI-based obesity definition.
Figure 2.
Figure 2.. Differential Characteristics of New Obesity Phenotypes
BMI indicates body mass index.
Figure 3.
Figure 3.. Longitudinal Risks of Adverse Health Outcomes by New Obesity Phenotype in the All of Us Cohort
A and C, Cumulative incidence plots with shaded 95% CIs depict the probability of each longitudinal outcome by obesity phenotype. B and D, Forest plots display hazard ratios (HRs) with 95% CIs for each longitudinal health outcome among subgroups. The unadjusted model includes only the exposure variable (obesity phenotype). The demographics model adjusted for age, sex, and race, with additional adjustment for smoking status in the analysis of cardiovascular (CV) events. BMI indicates body mass index.
Figure 4.
Figure 4.. Longitudinal Risks of Adverse Health Outcomes by Clinical Obesity Status Per the New Definition of Obesity in the All of Us Cohort
A and C, Cumulative incidence plots with shaded 95% CIs depict the probability of each longitudinal outcome among individuals with clinical obesity, preclinical obesity, and no obesity with or without organ dysfunction. B and D, Forest plots display hazard ratios (HRs) with 95% CIs for each longitudinal health outcome among these 4 subgroups. The unadjusted model includes only the exposure variable (obesity and organ dysfunction status). The demographics model adjusted for age, sex, and race, with additional adjustment for smoking status in the analysis of cardiovascular (CV) events. BMI indicates body mass index.
See this image and copyright information in PMC

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