{"id":2982,"date":"2023-10-19T09:39:33","date_gmt":"2023-10-19T08:39:33","guid":{"rendered":"https:\/\/springerhealthcare.nl\/france\/?p=2982"},"modified":"2023-10-20T10:21:59","modified_gmt":"2023-10-20T09:21:59","slug":"why-bmi-is-flawed-and-how-to-redefine-obesity","status":"publish","type":"post","link":"https:\/\/springerhealthplus.nl\/shmigrate\/why-bmi-is-flawed-and-how-to-redefine-obesity\/","title":{"rendered":"Why BMI is flawed \u2014 and how to redefine obesity"},"content":{"rendered":"

[vc_row full_width=”stretch_row” content_placement=”middle” css=”.vc_custom_1663187695627{padding-bottom: 37px !important;background-image: url(http:\/\/springerhealthcare.nl\/wp-content\/uploads\/sites\/24\/2022\/09\/science_connect_back.png?id=2486) !important;background-position: center !important;background-repeat: no-repeat !important;background-size: cover !important;}” el_class=”sciencetitle”][vc_column][vc_custom_heading text=”Science Connect” font_container=”tag:h2|text_align:left|color:%23ffffff” use_theme_fonts=”yes” link=”url:https%3A%2F%2Fspringerhealthcare.nl%2Ffrance%2Fscience-connect-october-2023%2F”][vc_column_text css=”.vc_custom_1663186747780{margin-bottom: 40px !important;}”]A Springer Healthcare Initiative For Pharma Professionals<\/span>[\/vc_column_text][vc_column_text]OCTOBER 2023
\n<\/span>[\/vc_column_text][\/vc_column][\/vc_row][vc_row css=”.vc_custom_1538651642953{padding-top: 75px !important;}”][vc_column width=”3\/4″ css=”.vc_custom_1538657061395{border-right-width: 1px !important;padding-top: 0px !important;border-right-color: #8faec1 !important;border-right-style: solid !important;}”][vc_custom_heading source=”post_title” font_container=”tag:h1|font_size:40px|text_align:left|line_height:60px” google_fonts=”font_family:Merriweather%3Aregular%2Citalic|font_style:700%20regular%3A700%3Anormal” el_class=”title” css=”.vc_custom_1664358136969{margin-bottom: 30px !important;}”][vc_column_text css=”.vc_custom_1686833173052{padding-bottom: 0px !important;}”]The main diagnostic test for obesity \u2014 the body mass index \u2014 accounts for only height and weight, leaving out a slew of factors that influence body fat and health.<\/strong><\/span>[\/vc_column_text][vc_column_text el_class=”intro-box”]By McKenzie Prillaman<\/span>[\/vc_column_text][vc_single_image image=”2993″ img_size=”full” el_class=”hero-img”][vc_column_text css=”.vc_custom_1695902816200{margin-bottom: 30px !important;}” el_class=”sc-img-caption”]Players in an \u2018overweight football league\u2019 warm up before a match in Germany. To join, members must have a BMI of at least 31. Credit: Ina Fassbender\/AFP via Getty[\/vc_column_text][vc_column_text]

As an obesity physician, Fatima Cody Stanford has treated many people whose weight was causing them health problems. She has plenty of success stories: one woman, for instance, returned \u201cstunning\u201d cholesterol, blood-pressure and blood-sugar readings after working with Stanford for about ten years.<\/p>\n

But the woman still wanted more treatment. She was fixated on her body mass index, or BMI, which classified her as having obesity. \u201cShe wants to lose more weight\u201d, says Stanford, who is at Massachusetts General Hospital and Harvard Medical School in Boston.<\/p>\n

BMI, which is calculated by dividing weight by height squared, has been used for several decades as an international standard to determine healthy weights. It serves as a proxy for body fat, and higher numbers can indicate increased risk for metabolic disease and death.<\/p>\n

But BMI does not measure body fat, and it also ignores factors that affect how healthy someone is at a given weight, including age, sex and race. Not everyone with a high BMI has poor health or a raised risk of death1<\/sup>\u2013<\/sup>3<\/sup>.<\/p>\n

That\u2019s why there is a small but growing movement to go beyond BMI when diagnosing and treating obesity, which the World Health Organization (WHO) recognizes as a chronic disease. In June, the American Medical Association (AMA)\u00a0called for more weight-related metrics<\/a>\u00a0to be used in conjunction with BMI owing to its imperfections and questionable history.<\/p>\n

But, with global rates of obesity having tripled over the past 50 years, and\u00a0a wave of cutting-edge weight-loss drugs<\/a>\u00a0now hitting the market, a high BMI still reigns as the main criterion for obesity treatment. Specialists worry that the surging demand for the drugs will exacerbate reliance on BMI as a solo diagnostic tool.<\/p>\n

\u201cWhen we look at just height and weight, we don\u2019t know anything about the health status of the individual,\u201d Stanford says.<\/p>\n

The \u2018average man\u2019<\/strong><\/h2>\n

The origins of BMI had little to do with health. About 200 years ago, the Belgian astronomer and mathematician Adolphe Quetelet obsessed over characterizing the \u2018average man\u2019. He recorded measurements of the human body \u2014 primarily in Western European men \u2014 and he found that weight roughly correlated with height squared. Dividing the two numbers to describe weight relative to height became known as Quetelet\u2019s index4<\/sup>. His work on what was considered \u2018normal\u2019 had a role in the origins of eugenics.<\/p>\n

In 1972, American physiologist Ancel Keys examined several height\u2013weight indices and found that Quetelet\u2019s was the best predictor of the thickness of body fat5<\/sup>. He renamed it the body-mass index and proposed that it was a better indicator of healthy body size than were the height\u2013weight tables commonly used at the time. These tables, based on actuarial data, showed weights associated with lowest risk of death and helped to set socially \u2018ideal\u2019 body sizes for much of the twentieth century.<\/p>\n

BMI does correlate with the risk of death at the population level: the risk is elevated at the low end of the BMI spectrum, at which a person is considered underweight, decreases in the middle and gradually upturns again at the higher end, at which the overweight and then obesity categories lie (the cut-offs between these categories were set by the WHO in 1993).<\/p>\n

But when looking at an individual, the clean cut-offs crumble. \u201cBMI is a somewhat crude metric for determining health risks,\u201d says Susan Yanovski, co-director of the Office of Obesity Research at the US National Institute of Diabetes and Digestive and Kidney Diseases in Bethesda, Maryland.<\/p>\n

A study1<\/sup>\u00a0published in July found that the risk of death for adults in the overweight category was similar to that of people at \u2018healthy\u2019 weights, echoing earlier analyses2<\/sup>,<\/sup>3<\/sup>. Another study6<\/sup>\u00a0found that about 30% of participants with obesity had good cardiometabolic health, defined by factors including blood pressure and cholesterol levels. Around the same percentage of people with a healthy BMI was deemed cardiometabolically unhealthy.<\/p>\n

The simplicity of BMI is probably what has kept it so prominent. \u201cBMI doesn\u2019t cost anything \u2014 it\u2019s cheap and quick,\u201d says Sarah Nutter, a psychologist and weight-stigma researcher at the University of Victoria in Canada. But the obsession with BMI, she says, \u201ckeeps us from being able to recognize that weight is not a good proxy for health\u201d.<\/p>\n

An imperfect measure<\/strong><\/h2>\n

There\u2019s no doubt that significant amounts of fat can harm organs, raise the risk of cardiometabolic conditions and wreak havoc on mental, physical and functional health.<\/p>\n

The problem comes with using BMI as a proxy for the amount of body fat. Two adults with similar BMIs could carry different amounts of fat. At a given BMI, older adults tend to have more fat and less muscle than younger adults do. Relationships between BMI, fat mass and health also differ between sexes: women, for instance, tend to have more body fat than do men at the same BMI. Even so, \u201cthe distribution seems to be actually way healthier in women\u201d, says Francisco Lopez-Jimenez, a cardiologist and obesity researcher at Mayo Clinic in Rochester, Minnesota. Their fat tends to lie in the buttocks, hips and thighs, whereas men usually accumulate belly fat, which is linked to poorer health outcomes.<\/p>\n

Adult BMI charts don\u2019t reflect this variability. And the cut-offs between BMI categories \u2014 which are the same in most countries that use the index to diagnose obesity \u2014 are \u201csomething between science-based and arbitrary\u201d, says Lopez-Jimenez.<\/p>\n

\"A
A man has his heart rate, blood pressure and breathing monitored during an exercise test in Central Java, Indonesia. Alongside BMI, these measures could provide a more nuanced way to diagnose obesity. Credit: WF Sihardian\/NurPhoto via Getty<\/span><\/figcaption><\/figure>\n

 <\/p>\n

Regardless of a person\u2019s sex, excess fat is most dangerous when it surrounds organs. This deeper, visceral fat is more metabolically active than is fat that sits under the skin, and a surplus is associated with insulin resistance, heart disease and other metabolic issues. It can cause problems even at a healthy BMI, Lopez-Jimenez says. \u201cThe reliance on BMI is making us not see the reality of normal-weight obesity.\u201d<\/p>\n

And because BMI was developed using measurements from white people, people of colour \u201cdon\u2019t quite fit into these narrow parameters\u201d, Stanford says. Data suggest that body composition and location of fat vary between racial and ethnic populations.<\/p>\n

For instance, Asian people tend to be at a greater risk of conditions such as heart disease at lower BMIs than are white people, probably owing to differences in body-fat percentage and distribution. The WHO recommends that Asian populations use lower BMI cut-offs for overweight and obesity, which several Asia-Pacific countries now do.<\/p>\n

These omissions are why the\u00a0AMA adopted a policy in June<\/a>\u00a0to downplay the clinical use of BMI, calling it \u201can imperfect measure\u201d that has been used for \u201cracist exclusion\u201d and that has caused \u201chistorical harm\u201d. The policy suggests combining other metrics, such as waist circumference or body composition, with BMI.<\/p>\n

Specialists who spoke to\u00a0Nature<\/em>\u00a0advise using BMI as a screening aid, rather than a diagnostic tool, to flag who might benefit from further tests. \u201cIt gives me a sense of how much weight you\u2019re carrying,\u201d Stanford says. \u201cBut then I need to determine what the health is at that particular weight.\u201d Clinicians could take account of cholesterol, blood sugar and even family history and genetics, which play a large part in obesity and related conditions.<\/p>\n

But Stanford and others who have long scrutinized BMI worry that health professionals don\u2019t have time for extra diagnostic steps. In primary-care visits, \u201cthey have 15 minutes to cover everything about the person\u201d, she says. For instance, the US Centers for Disease Control and Prevention generally recommends that healthy adults receive cholesterol tests only once every few years.<\/p>\n

That\u2019s especially concerning with the\u00a0exploding demand for new anti-obesity medications<\/a>. In the United States, a person can be prescribed semaglutide for weight loss simply if their BMI is 30 (the lower bound of the obesity category) or more. With a BMI of between 25 and 30 \u2014 the overweight category \u2014 a person needs just one weight-related condition, such as high blood pressure, to get a prescription. \u201cIf you have 15 minutes in a visit,\u201d Stanford says, \u201cyou\u2019re going to follow the BMI \u2026 instead of really taking the time to see \u2018Do they need the medication?\u2019\u201d<\/p>\n

In Lopez-Jimenez\u2019s experience, the problem is compounded by patients requesting the medications \u2014 often for aesthetic, rather than medical, reasons.<\/p>\n

Beyond BMI<\/strong><\/h2>\n

Several efforts to define obesity beyond BMI have popped up over the years.<\/p>\n

Stanford is part of a commission of about 60 obesity specialists from around the world, brought together by the journal\u00a0Lancet<\/em>\u00a0Diabetes<\/em>\u00a0&<\/em>\u00a0Endocrinology<\/em>\u00a0and the Institute of Diabetes, Endocrinology and Obesity at Kings Health Partners in London. The group is coming up with diagnostic criteria by examining every major organ system to understand how weight affects health, Stanford says. She estimates that the full report should come out next year.<\/p>\n

Today\u2019s most widespread framework came from an overwhelmed obesity clinic. Around 2,000 people were on the waiting list for the service at the Royal Alexandra Hospital in Edmonton, Canada, in the mid-2000s, says Arya Sharma, then the clinic\u2019s medical director. The average wait was almost 18 months, and the clinic worked on a first come, first served basis.<\/p>\n

Sharma thought that BMI probably wasn\u2019t a good indicator of who to prioritize for urgent care. \u201cIt tells me how big you are,\u201d says Sharma, who is now based in Berlin. \u201cIt doesn\u2019t tell me how sick you are.\u201d<\/p>\n

He co-created a five-step system7<\/sup>, published in 2009, that accounts for physical, mental and functional health in addition to BMI, called the Edmonton Obesity Staging System (EOSS). A person who has several weight-related conditions, such as difficulty moving, heart disease and anxiety related to obesity, would be at a higher stage than someone with the same BMI but with fewer or less-severe health problems.<\/p>\n

EOSS was folded into the 2020 Canadian clinical guideline for obesity in adults, and late last year, versions were\u00a0launched in Chile<\/a>\u00a0and\u00a0Ireland<\/a>. It\u2019s Chile\u2019s first comprehensive guideline for obesity care, says Yudith Preiss Contreras, a clinical nutrition specialist at MEDS Clinic in Santiago, who was its lead developer. \u201cEverybody\u2019s using our guideline.\u201d<\/p>\n

Still, the greater push to go beyond BMI has just begun. \u201cYou\u2019re starting to see this seep into guidelines,\u201d Stanford says. But \u201cthat translation into clinical practice will be a larger hurdle to overcome.\u201d<\/p>\n

Nature<\/em>\u00a0622<\/strong>, 232-233 (2023)<\/p>\n

doi: https:\/\/doi.org\/10.1038\/d41586-023-03143-x<\/em><\/p>\n

References<\/h2>\n
    \n
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    1. Visaria, A. & Setoguchi, S.\u00a0PLoS ONE<\/em>\u00a018<\/strong>, e0287218 (2023).<\/li>\n
    2. Flegal, K. M., Kit, B. K., Orpana, H. & Graubard, B. I.\u00a0JAMA<\/em>\u00a0309<\/strong>, 71\u201382 (2013).<\/li>\n
    3. Li, J.\u00a0et al.<\/em>\u00a0PLoS ONE<\/em>\u00a016<\/strong>, e0253696 (2021).<\/li>\n
    4. Eknoyan G.\u00a0Nephrol<\/em>.\u00a0Dial. Transplant.<\/em>\u00a023<\/strong>, 47\u201351 (2008).<\/li>\n
    5. Keys, A., Fidanza, F., Karvonen, M. J., Kimura, N. & Taylor, H. L.\u00a0J. Chron. Dis.<\/em>\u00a025<\/strong>, 329\u2013343 (1972).<\/li>\n
    6. Tomiyama, A. J., Hunger, J. M., Nguyen-Chu, J. & Wells, C.\u00a0Int. J. Obes.<\/em>\u00a040<\/strong>, 883\u2013886 (2016).<\/li>\n
    7. Sharma, A. M. & Kushner, R. F. Int. J. Obes<\/em>. 33<\/strong>, 289\u2013295 (2009).<\/li>\n<\/ol>\n<\/li>\n<\/ol>\n[\/vc_column_text][vc_column_text]\u00a9 2023 Springer Nature Limited.[\/vc_column_text][\/vc_column][vc_column width=”1\/4″ css=”.vc_custom_1538657003956{padding-top: 0px !important;padding-bottom: 0px !important;}”][vc_custom_heading text=”ISSUES” font_container=”tag:h3|font_size:12px|text_align:left|color:%23333333|line_height:18px” use_theme_fonts=”yes” el_class=”titlewidget”][vc_column_text el_class=”columnflex” css=”.vc_custom_1664404002021{margin-bottom: 40px !important;}”]

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