Clinical and Preclinical Obesity in Korean Adults from 2014 to 2023 (Diabetes Metab J 2026;50:127–38)

Article information

Diabetes Metab J. 2026;50(4):821-822

Publication date (electronic) : 2026 July 1

doi : https://doi.org/10.4093/dmj.2026.0199

Hun Jee Choe¹, Soo Lim²

¹Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea

²Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea

Corresponding author: Soo Lim https://orcid.org/0000-0002-4137-1671 Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea, E-mail: limsoo@snu.ac.kr

We sincerely thank Drs. Han Na Jung and Chang Hee Jung for their thoughtful comments and interest in our recent publication, ‘Clinical and preclinical obesity in Korean adults from 2014 to 2023’ [1]. Using nationally representative Korea National Health and Nutrition Examination Survey (KNHANES) data from 2014 to 2023, our study represents a large-scale application of the Lancet Commission framework in Koreans, estimating the prevalence and temporal trends of clinical and preclinical obesity. We appreciate the opportunity to clarify key methodological considerations and to highlight priorities for future validation and implementation in Asian populations.

Our study was motivated by the well-recognized limitation of body mass index (BMI): it is an accessible screening measure of body size but an imperfect surrogate for identifying adiposity distribution and the obesity-attributable health burden [2]. In line with the Lancet Commission’s conceptual shift toward a functional, complication-based definition [3], we observed substantial discordance between BMI-based categories and the clinical obesity construct.

First, we fully agree that the operational definition of ‘excess adiposity’ must be ethnicity- and population-specific. For this first large-scale application of the Lancet framework in Koreans, we used World Health Organization (WHO)-recommended Asian-specific thresholds in the primary analysis: BMI ≥25.0 kg/m² or waist circumference (WC) ≥90 cm in men/ ≥85 cm in women, or waist-to-height ratio (WHtR) >0.50 [4]. These criteria stem from a 2002–2004 WHO Expert Consultation, which documented higher body fat and cardiometabolic risks (e.g., diabetes, cardiovascular disease) at lower BMIs in Asians compared to other populations, based on dual-energy X-ray absorptiometry (DEXA) and related studies [5]. In our cohort, among 22,755 individuals who met excess adiposity criteria, 19,100 (83.9%) had BMI ≥25 kg/m², 22,667 (99.6%) had WHtR >0.50, and 19,128 (84.1%) had elevated WC—demonstrating the varying sensitivities of these anthropometric surrogates. These sensitivity differences across criteria, as shown in our cohort, validate Drs. Jung and Jung’s concerns regarding the framework’s dependence on embedded thresholds.

Our findings should not be interpreted as endorsing any single cut-off as definitive. Rather, they illustrate the need for outcome-anchored calibration of anthropometric thresholds in Asians—particularly given that visceral adiposity and ectopic fat can be disproportionately high at lower BMI levels [6]. Future studies must identify optimal BMI, WC, and WHtR thresholds for predicting incident cardiometabolic events and mortality, and should prioritize ethnicity-adapted visceral adiposity assessment in Asians where BMI underestimates burden.

Second, we concur that age-related increases in clinical obesity (10.3% in 20s to 46.9% in 70s, despite stable BMI approximately 24 kg/m²) necessitate cautious interpretation. Clinical obesity should reflect excess adiposity causing reproducible organ dysfunction or impairment plausibly attributable to obesity; yet multimorbidity, aging, and socioeconomic factors complicate causal attribution, risking inconsistent classification. Although we mitigated age-related confounding factors through age-standardized estimates, establishing causality and prognostic performance across age strata requires longitudinal follow-up.

Third, confirmatory assessment of adiposity is conceptually appealing but currently limited by the lack of harmonized standards for body fat percentage (BFP) across age, sex, and ethnicity. BFP can be measured using bioimpedance or imaging-based modalities, but fixed cutoffs may systematically misclassify individuals—particularly older adults and women, in whom body composition changes (e.g., sarcopenia and fat redistribution) are most pronounced. In KNHANES data, direct body composition measures such as DEXA are not uniformly available across survey years; thus, our population-level analysis necessarily relied on pragmatic anthropometric surrogates. Establishing population-specific reference standards for BFP and/or visceral adiposity (e.g., imaging-derived visceral fat areas) and testing whether these measures improve prediction of hard outcomes beyond BMI- and waist-based indices should be a high research priority to translate the Commission’s recommendations into real-world practice.

In conclusion, we are grateful for Drs. Jung and Jung’s insightful comments, which underscore the central challenges and opportunities in implementing the clinical obesity framework in Asian populations. We hope this constructive dialogue will stimulate further research and facilitate clinically meaningful, equitable obesity risk stratification and management in Koreans and other Asians.