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Here we report the comparative performance of this framework versus conventional BMI-based classification using prevalence, incidence and mortality data from 844,108 adults across four cohorts in China, the UK, the USA and Spain. Complementing BMI with waist circumference and waist-to-height ratio data showed that BMI alone overestimated obesity in 1.2\u20133.1% and underestimated it in 5.2\u20138.6% of participants across cohorts. The combined anthropometric definition increased overall obesity prevalence by 3.3\u20137.4% relative to BMI-based classification. Clinical obesity accounted for 22.7\u201331.3% of total obesity, with an overall population prevalence of 5.6\u201310.9%. A large proportion of individuals (between 77.4% and 91.3%) with preclinical obesity at baseline showed no progression to clinical obesity over 10\u2009years. Increased mortality risk was associated with the combined anthropometric definition of obesity, but not with BMI-only obesity. Clinical obesity was associated with substantially higher all-cause mortality (hazard ratio 1.69, 95% confidence interval 1.64\u20131.73), whereas preclinical obesity conferred only modest risk (1.19, 1.14\u20131.24). These findings support the global adoption of the\n                    <jats:italic>Lancet<\/jats:italic>\n                    Commission diagnostic framework to improve obesity care and policy.\n                  <\/jats:p>","DOI":"10.1038\/s41586-026-11237-5","type":"journal-article","created":{"date-parts":[[2026,11,11]],"date-time":"2026-11-11T16:02:48Z","timestamp":1794412968000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Validation of clinical and preclinical obesity across global cohorts"],"prefix":"10.1038","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1089-7945","authenticated-orcid":false,"given":"An","family":"Pan","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"},{"role":"corresponding-author","vocabulary":"crossref"}]},{"given":"Shengping","family":"Yang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rafael","family":"Ramos","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-7552-2377","authenticated-orcid":false,"given":"Xianli","family":"Li","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jinchi","family":"Xie","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robert H.","family":"Eckel","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2021-528X","authenticated-orcid":false,"given":"Geltrude","family":"Mingrone","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jordi","family":"Blanch","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jingyuan","family":"Jiang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hongmin","family":"Liu","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shuohua","family":"Chen","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tingting","family":"Geng","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shouling","family":"Wu","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2129-547X","authenticated-orcid":false,"given":"Eric","family":"Ravussin","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7442-9323","authenticated-orcid":false,"given":"Jos\u00e9 Manuel","family":"Fern\u00e1ndez-Real","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8581-2515","authenticated-orcid":false,"given":"Francesco","family":"Rubino","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"},{"role":"corresponding-author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2026,11,11]]},"reference":[{"key":"11237_CR1","doi-asserted-by":"publisher","first-page":"221","DOI":"10.1016\/S2213-8587(24)00316-4","volume":"13","author":"F Rubino","year":"2025","unstructured":"Rubino, F. et al. 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G.M. reports consulting fees from Novo Nordisk, Boehringer Ingelheim, Eli Lilly, Medtronic, Fractyl and Recor. She is also a scientific advisor for Keyron, MetaDeq, GHP Scientific and Jemyll. R.H.E. reports receiving consulting fees from Novo Nordisk, the Healthy Aging Company and WW International. E.R. reports consulting fees from Energesis Pharmaceuticals, Eli Lilly, Merck, Amway, Novo Nordisk, Altimmune, AbbVie, Amgen, Orbimed and Boehringer Ingelheim. F.R. reports research grants from Ethicon (Johnson & Johnson), Novo Nordisk and Medtronic, consulting fees from Kailera and speaking honoraria from Medtronic, Ethicon, Novo Nordisk, Eli Lilly, Amgen, Regeneron\u00a0and Astra Zeneca. F.R. is also a member of the data safety monitoring board for GI Metabolic Solutions and the president of the Metabolic Health Institute, a non-profit organization.","order":1,"name":"Ethics","label":"Competing interests","group":{"name":"EthicsHeading","label":"Ethics"}}]}}