1 in 5 overweight adults could be reclassified with obesity according to new framework

Embargoed for release until 5:00 p.m. ET on Monday 7 July 2025   

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Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.   
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1. 1 in 5 overweight adults could be reclassified with obesity according to new framework

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-02547 

Editorial: https://www.acpjournals.org/doi/10.7326/ANNALS-25-02327

URL goes live when the embargo lifts             

A cross-sectional and longitudinal analysis examined the distribution of people by obesity level using the European Association for the Study of Obesity’s (EASO) new framework and determined the risk of death of those newly diagnosed with obesity by this framework. The study found that according to the new framework, 1 in 5 US adults were reclassified as having obesity. However, their mortality risk was similar compared with adults with normal weight. The researchers say the EASO framework may provide a more sensitive tool for diagnosing obesity disease earlier than BMI alone. The study is published in Annals of Internal Medicine.

EASO recently introduced a new framework to define obesity that incorporates anthropometric measures beyond body mass index (BMI) and clinical comorbidities; however, the framework has not been validated. Researchers from Ariel University, Tel Aviv University, and Holon Institute of Technology studied data from 44,030 US adults aged 18 to 79 who participated in NHANES (National Health and Nutrition Examination Survey) from 1999 to 2018 to examines the distribution of overweight and obesity and determine the prevalence of complications and the risk for death of those newly diagnosed with obesity by this framework. The researchers found that with the new definition of obesity, 18.8% of the study population, who were previously identified as overweight based on BMI alone, were now newly classified as obese. The most prevalent complications among persons newly identified as having obesity were hypertension (79.9%), arthritis (33.2%), diabetes (15.6%), and cardiovascular disease (10.5%). Similar mortality risk was found among the newly identified persons with obesity compared with adults with normal weight, whereas persons with BMI of 30 kg/m² or greater had almost a 20% higher hazard of dying. However, when compared with persons with normal weight who did not have major morbidities, newly identified persons with obesity had 50% higher hazard of dying, although this higher risk was no greater than the higher risk seen among persons with normal weight and comorbidities. Higher risk was seen among persons with obesity compared with persons with overweight according to both the new EASO framework and the traditional BMI definition. The findings suggest that further studies are needed to examine whether persons newly identified as having obesity by the EASO framework would benefit from obesity treatment. 

Media contacts: For an embargoed PDF, please contact Gabby Macrina at gmacrina@acponline.org. To contact the researchers, please email corresponding author Prof. Orna Reges at orna.reges@gmail.com, or Prof. Dror Dicker at daniel3@013.net.  

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2. Across all BMI categories, postmenopausal women with larger waist circumference at greater risk for death

Findings demonstrate that using waist size alongside BMI slightly improves mortality predictions in healthy postmenopausal women

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-00713

Editorial: https://www.acpjournals.org/doi/10.7326/ANNALS-25-02327

Summary for Patients: https://www.acpjournals.org/doi/10.7326/ANNALS-24-00713-PS

URL goes live when the embargo lifts             

A prospective cohort study found that stratifying BMI categories by BMI-specific waist circumference thresholds modestly improved mortality risk stratification in postmenopausal women, with larger waist circumference predicting greater mortality in women across BMI groups. The findings support recent International Atherosclerosis Society (IAS) and International Chair on Cardiometabolic Risk (ICCR) recommendations to include waist circumference measurement with BMI in patient screenings to identify high-risk obesity phenotypes. The study is published in Annals of Internal Medicine. 

Researchers from the Fred Hutchinson Cancer Center and colleagues analyzed data for 139,213 postmenopausal women aged 50 to 79 years from the Women’s Health Initiative, a multicenter, population-based study with enrollment from 1993-1998 and follow up through 2021. The participants were divided into three cohorts: development cohort (67,774 participants), Validation Cohort 1 (48,335 participants with a high prevalence of overweight or obesity), and Validation Cohort 2 (23,104 participants from diverse, geographically separate centers). Researchers developed three models to predict mortality risk: a mortality model; the mortality model plus BMI (BMI model); and the mortality model plus BMI plus BMI-specific waist circumference thresholds (BMI-WC model). BMI categories included normal weight, overweight, and obesity classes 1 to 3, and were stratified by prespecified waist circumference thresholds of ≥80, ≥90, ≥105, ≥115, and ≥115 cm, respectively. Validation Cohort 1 had a higher prevalence of large waist circumference (21.9%), according to BMI-specific waist thresholds, than Validation Cohort 2 (18.2%). Nearly all women with obesity-2 or obesity-3 had waist circumference of 88 cm or larger - the current guideline for women and independent of BMI. After stratification, the researchers found that mortality risk was greater for BMI categories with larger waist circumference than their counterparts with normal waist circumference. Additionally, mortality risk was similar for women with normal weight or overweight and large waist circumference and women with obesity-1 and normal waist circumference. Overall, stratifying BMI categories by waist circumference thresholds modestly improves risk stratification for all-cause mortality in healthy postmenopausal women with a high prevalence of overweight or obesity. These results suggest that clinical guidelines for assessing adiposity would benefit from the incorporation of waist circumference with BMI measures. 

Media contacts: For an embargoed PDF, please contact Gabby Macrina at gmacrina@acponline.org. To contact corresponding author Aaron K. Aragaki, MS please email Kat Wynn at kwynn@fredhutch.org.    

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3. Study finds approved drugs often have broader label populations compared to trial populations

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-03242

URL goes live when the embargo lifts             

A cross-sectional study analyzed the differences between trial populations and approved label populations in the US, EU and Switzerland for new drugs. The study found that overall, approved label populations were broader than trial populations, with this difference more pronounced in the US. The findings suggest the need for post-approved trials and surveillance for drugs for which broadening has occurred. The results are published in Annals of Internal Medicine.  

Researchers from the University of Zurich, ETH Zurich, Harvard Medical School and Yale School of Medicine compared the criteria of the trial population with the approved label population for 263 new drugs approved by the US Food and Drug Administration (FDA), European Medicines Agency (EMA), and Switzerland’s Swissmedic between 2012 and 2023. They classified eligibility criteria into five categories - age, disease subtype, disease severity, patient fitness, and prior therapy – and compared the criteria between the trial population and label population. Drug indications were classified as congruent (label and trial population match), more restrictive (label population more restrictive in at least one category) or broader (label population more extensive in at least one category). Among all three agencies, approved label populations were overall broader when compared to trial populations. Patient fitness was the most frequent category with broader label populations followed by disease severity. The third most frequent category with a broader label population was age in the US and prior therapy in the EU and Switzerland. Among more restrictive approved indications, disease severity was the most frequent category in the US, EU, and Switzerland. The authors note that it could be helpful for both patients and physicians if regulatory agencies specify to what extent label populations are congruent with trial populations. 

Media contacts: For an embargoed PDF, please contact Gabby Macrina at gmacrina@acponline.org. To contact corresponding author Kerstin N. Vokinger, MD, JD, PhD please email Lst.vokinger@ius.uzh.ch.  

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4. Number of medical cannabis certifications in Pennsylvania spikes after anxiety added as qualifying condition

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-25-01037

URL goes live when the embargo lifts             

A brief research report examined changes in the medical cannabis certifications after Pennsylvania added anxiety disorders as a qualifying condition in 2019. The study found that adding anxiety disorders as a qualifying condition was associated with anxiety disorders rapidly becoming the most common qualifying condition. This rapid increase may be due to the relatively lower requirements for an anxiety diagnosis or the increase in anxiety diagnoses during COVID-19. The results are published in Annals of Internal Medicine.  

Researchers from Johns Hopkins University and University of Pittsburgh analyzed restricted data on 1,730,600 individual medical cannabis certifications from Pennsylvania’s Department of Health from November 2017, the start of Pennsylvania’s medical cannabis program, to December 2023. 1,593,790 of those certifications were issued after anxiety disorders were added as a qualifying condition. Before anxiety was added as a qualifying condition, chronic pain and post-traumatic stress disorder (PTSD) comprised 67.07% and 15.84% of qualifying conditions for certifications, respectively. After anxiety was added, 60.26% of certifications were for anxiety, and shares for chronic pain and PTSD decreased to 41.47% and 10.97%, respectively. The researchers note that whether adding anxiety as a qualifying condition is beneficial or harmful depends on what alternative treatments affected patients would otherwise pursue without access to medical cannabis.

Media contacts: For an embargoed PDF, please contact Gabby Macrina at gmacrina@acponline.org. To contact corresponding author Coleman Drake, PhD, please email Allison Hydzik at HydzikAM@upmc.edu or Elaine Vitone at VitoneEG@upmc.edu.    

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