The ABCD’s Approach for Obesity Treatment and Why Muscle Matters

As the end of the year approaches, we frequently spend more time with family and friends, reflecting on the past and planning for the year ahead, including opportunities to improve health. Among other aspects of health, many New Year’s resolutions concern losing weight.

Obesity impacts more than 40% of older adults. The Obesity Society defines obesity as a chronic disease that increases risk of other conditions, such as cardiovascular disease, cancer and diabetes, and is associated with premature mortality. Treatment for obesity can include lifestyle and diet modifications, medications, and/or surgical interventions to induce changes in body weight and reduce complications.

Traditionally, body mass index (BMI) has been the focus for identification and treatment of obesity. More recently, the American Association for Clinical Endocrinology (AACE) has introduced a new diagnostic term, adiposity-based chronic disease (ABCD), to shift from a weight/BMI-centered obesity diagnosis to an approach that aims to improve health through prevention and treatment of complications (see Table below).

Table: AACE Complications-Centric Care Model for Adiposity-based Chronic Disease (ABCD)



Step 1: Assess BMI

Calculate BMI. Current thresholds for overweight (≥25 kg/m2) and obesity (≥30 kg/m2). Lower thresholds may apply for adults of Asian descent.

Step 2: Assess Stage

Assess for the presence and severity of ABCD complications utilizing stages 1, 2 and 3. Examples of ABCD complications include prediabetes, hypertension, dyslipidemia, heart disease, reflux, sleep apnea, and kidney disease.

  • Stage 1 = No ABCD complications
  • Stage 2 = ≥1 Mild/moderate ABCD complication(s)
  • Stage 3 = ≥1 Severe ABCD complication(s)

Step 3: Implement Plan

Apply comprehensive lifestyle modifications that encompass all aspects of health; may include the following:

  • Nutrition
  • Physical Activity
  • Sleep
  • Counseling and behavior therapy
  • Medications
  • Surgical interventions

Abbreviations: AACE, American Association of Clinical Endocrinology; ABCD, adiposity-based chronic disease; BMI, body mass index.

Weight Loss Guidance and Muscle

For older adults with obesity and/or ABCD complications, weight loss may be a part of the treatment plan. AACE recommends weight loss between 5% to 15% to improve ABCD complications. However, some people with more severe ABCD complications may benefit from more weight loss. Medications, such as semaglutide and tirzepatide, have been approved for the treatment of obesity. When combined with intensive lifestyle interventions, these medications can induce significant weight loss (i.e., more than 10% within 6 months). Intensive lifestyle interventions usually focus on achieving a calorie deficit to assist in weight loss using a holistic approach to improve nutrition, physical activity, sleep and mental health.

‘Preserving muscle during intentional weight loss is important for healthy aging but can be impacted by age and chronic disease.’

Rapid weight loss leads to significant changes in body composition, including loss of muscle. Muscle supports body strength, movement and balance. Muscle is also an essential organ for insulin sensitivity, protein and glycogen storage, and immune function. Loss of muscle can be a sign of malnutrition and sarcopenia, which are conditions that can increase risk for falls, reduced strength and quality of life.

Preserving muscle during intentional weight loss is important for healthy aging but can be impacted by age and chronic disease. Adults naturally lose between 3% and 8% of their body’s muscle with each decade of life. Obesity and diabetes may further contribute to loss in muscle vitality, as older adults (ages 65 and older) with these conditions can have two-fold greater loss of muscle compared to adults without diabetes.

Protein: Essential Macronutrient for Muscle

Protein is an important macronutrient, providing amino acids, which are the building blocks for maintaining muscle, providing energy, and forming proteins needed for metabolism. The Recommended Dietary Allowance (RDA) for protein in adults is 0.8 g/kg body weight/day. Yet, older adults may require up to 1.2 g/kg body weight daily to build and preserve muscle. Unfortunately, nearly half of older adults (ages 50 and older) do not meet protein recommendations and are more likely to have reduced intake of other nutrients, too. This may be due to changes in taste, poor oral health, delayed stomach emptying, and mood-related and other changes associated with aging.

Monitoring and maintaining adequate protein intake for older adults pursuing weight loss through various strategies, including obesity treatment medications, is crucial to promote healthy weight loss and maintain muscle. In combination with resistance exercise, increasing protein intake (especially at breakfast and lunch) to achieve an even distribution of protein throughout the day may be necessary to support muscle. Oral nutrition supplements also can be helpful to support the nutrition needs of patients pursuing weight loss. In addition, older adults on obesity treatment medications could seek the support of a registered dietitian nutritionist who can help monitor protein intake and provide individualized diet recommendations.

Check out these additional resources for more information:

Carley Rusch, PhD, RDN, LDN, is a medical science liaison for the Nutrition division of Abbott, in Columbus, Ohio.