Physique Mass Index (BMI) has lengthy been considered a normal measure for assessing weight-related well being dangers and, extra not too long ago, figuring out eligibility for anti-obesity medicines like GLP-1 receptor agonists semaglutide (Wegovy) and tirzepatide (Zepbound), in keeping with the FDA.
BMI, calculated from weight and peak, provides a simplistic but flawed evaluation of well being. It was initially designed for non-Hispanic white populations and overlooks nuances like muscle mass, fats distribution, and ethnic background, which might affect sure threat elements. It’s an antiquated measure that perpetuates inequities in healthcare and misses the mark for calculating cardiometabolic circumstances.
The notion {that a} “regular” BMI is good and an “obese to overweight” BMI just isn’t supreme solely exacerbates bias inside the medical group and complicates our efforts to unravel the weight problems disaster. People with an obese to overweight BMI that’s, > 25 and>30, respectively, could also be wholesome. On the similar time, these inside the “regular” BMI vary will not be. They may have extra visceral fats (the damaging sort that sits across the organs) and the related well being dangers. Furthermore, as individuals age, their anticipated fats accumulation additional complicates BMI’s reliability. We are able to’t decide well being based mostly solely on BMI.
Recognizing these limitations, the American Medical Affiliation (AMA) acknowledged in June 2023 that BMI is an imperfect measure and that measuring waist circumference along with BMI could also be a greater approach to predict weight-related threat.
Whereas BMI could also be appropriate as a inhabitants well being measure, it doesn’t work nicely on the particular person degree to find out the necessity for drastic — and costly — interventions like GLP-1s for weight reduction.
AOM prescribing and cardiovascular threat
With the rising recognition of GLP1s for weight reduction, we’ve seen a surge in sufferers visiting their PCPs searching for prescriptions. FDA labeling for anti-obesity medicines (AOMs) requires BMI standards of >30 or >27 with at the least one weight-related comorbidity to qualify for a GLP-1. This standards could also be adjusted for the Asian phenotype, who are inclined to accumulate greater visceral fats over subcutaneous fats.
Nonetheless, GLP-1 agonists aren’t acceptable for each affected person who qualifies for an AOM based mostly on BMI standards alone. These medicine are costly, they usually include unwanted side effects and different dangers. A latest research confirmed that just about two-thirds of the individuals prescribed a GLP-1 receptor agonist, self-discontinued in 12 months two. It’s apparent we’re not successfully treating weight problems by merely writing prescriptions.
The latest surge in GLP-1 prescribing is predicted to extend employer healthcare prices by 5.4 p.c this 12 months alone. We have to extra rigorously choose whom we prescribe these intensive medicine if we need to scale back prices and optimize long-term success for our sufferers. We must always take a look at numerous medical metrics and lean on different evidence-based interventions to yield a clinically significant weight lack of 5-10% of whole physique weight. Different evidence-based interventions may embrace medical vitamin remedy a registered dietitian gives and different inexpensive medicines that may deal with weight problems, like Contrave, Metformin, or Topiramate, Zonisamide, Qsymia, and Orlistat.
Specializing in the utmost quantity of weight reduction just isn’t the best way to unravel our weight problems downside, neither is it probably the most acceptable goal when different cardiometabolic threat elements exist. Basically, we should always prioritize lowering cardiovascular and metabolic threat, which might usually be achieved via 5-10% weight reduction.
If we need to scale back charges of hypertension, excessive LDL, and sort 2 diabetes, we have to look nearer at different measurements like blood strain and waist circumference. Waist circumference is related to a better quantity of visceral fats when >35 inches for ladies and >40 inches for males and could be a excessive indicator of poor metabolic well being.
Bias and stigma related to BMI in healthcare
We additionally want to contemplate the bias and stigma created by the extensively accepted assertion that BMI correlates to well being. Weight bias is harmful: The psychological stress that comes from dwelling in a bigger physique and experiencing bias from and inside the medical group will increase the chance of melancholy, nervousness, substance abuse, poor physique picture, and missed diagnoses. In lots of instances, physicians are susceptible to anti-obesity bias, which might make them dismiss the medical considerations of somebody who resides with weight problems.
We have to take a extra nuanced view of how BMI varies throughout populations, ethnicities, and athletes once we use it as a well being metric. Coaching clinicians to acknowledge inherent bias round weight stigma is essential to shifting previous the concept that weight correlates to well being and additional that BMI is sufficient to decide who’s unhealthy sufficient to get on medicine.
Complete, whole-person-focused therapy is the answer
It’s time we transfer past BMI and undertake a holistic strategy to actually gauge well being. That will seem like measuring blood strain, LDL ldl cholesterol, and A1C, alongside elements like physique composition, metabolic well being, and psychological well being earlier than figuring out the appropriate interventions.
Built-in, customized therapy that goes past weight and addresses psychological and bodily well being must be the gold normal for figuring out who will get a GLP-1. Serving to sufferers heal from the trauma, bias, and stigma that they could have encountered requires a compassionate and empathetic strategy. Clinicians educated in cognitive behavioral methods will help sufferers foster a optimistic relationship with meals and physique whereas additionally screening and triaging to remedy when different extra advanced psychological well being circumstances are current. Additional, clinicians should bear ongoing coaching to acknowledge and mitigate weight bias, fostering an atmosphere of inclusivity and equitable care.
Profitable therapy requires interdisciplinary collaboration, integrating medical, vitamin remedy, and psychological interventions tailor-made to particular person wants. Working with registered dietitians to optimize vitamin, deal with meals high quality versus simply amount and energy, and obtain a super and lifelike physique weight is essential. Consuming the appropriate meals and optimizing vitamin when solely small meals are tolerated is essential to total well being and the prevention of speedy weight and lean physique mass loss.
Conclusion
BMI’s shortcomings as a well being measure necessitate a paradigm shift in healthcare practices. Overprescribing GLP-1 based mostly on BMI standards alone overlooks essential elements of particular person well being and perpetuates inequities inside healthcare. Shifting ahead, we should embrace extra complete, customized therapy methods that transcend BMI and handle holistic well being elements. We are able to guarantee equitable healthcare entry and improved affected person outcomes by prioritizing inclusivity, empathy, and evidence-based practices.
Photograph: aykut karahan, Getty Photographs
Gretchen Zimmermann is the Head of Cardiometabolic Care & Prescribing at Vida Well being.