Physique Mass Index (BMI) has lengthy been thought of a typical measure for assessing weight-related well being dangers and, extra lately, for figuring out appropriateness for anti-obesity medicines equivalent to GLP-1 receptor agonists semaglutide (Wegovy) and tirzepatide (Zepbound). ). to the FDA.

BMI, calculated from weight and top, offers a simplistic however flawed evaluation of well being. It was initially designed for non-Hispanic white populations and ignores nuances equivalent to muscle mass, fats distribution and ethnicity, which may affect sure danger elements. It’s an outdated measure that perpetuates healthcare inequities and misses the purpose when calculating cardiometabolic illness.

The notion {that a} “regular” BMI is right and an “obese to overweight” BMI is just not excellent solely exacerbates biases throughout the medical neighborhood and complicates our efforts to resolve the weight problems disaster. People with an obese or overweight BMI of > 25 and > 30, respectively, could also be wholesome. On the similar time, those that are throughout the “regular” BMI vary will not be. They might have extra visceral fats (the damaging sort that surrounds the organs) and related well being dangers. As well as, the anticipated fats accumulation as folks age additional complicates the reliability of BMI. We can’t choose well being solely primarily based on BMI.

Recognizing these limitations, the American Medical Affiliation (AMA) acknowledged in June 2023 that BMI is an imperfect measure and that measure waist circumference along with BMI could also be a greater method to predict weight-related danger.

Whereas BMI could also be helpful as a public well being measure, it doesn’t work nicely on a person stage to find out the necessity for drastic – and costly – interventions equivalent to GLP-1s for weight reduction.

AOM prescribing and cardiovascular danger

With the rising reputation of GLP1s for weight reduction, now we have seen a rise within the variety of sufferers visiting their GP surgical procedure searching for prescriptions. FDA labeling for anti-obesity medicines (AOMs) requires BMI standards of >30 or >27 with at the very least one weight-related comorbidity to qualify for a GLP-1. This criterion could be tailored for the Asian phenotype, which tends to build up extra visceral fats than subcutaneous fats.

Nevertheless, GLP-1 agonists usually are not acceptable for each affected person who qualifies for an AOM primarily based on BMI standards alone. These medicines are costly and carry unintended effects and different dangers. A current examine discovered that nearly two-thirds of individuals prescribed a GLP-1 receptor agonist and stopped taking it within the second yr. It’s clear that we can’t successfully deal with weight problems by merely writing prescriptions.

The current enhance in GLP-1 prescribing is predicted to extend healthcare prices for employers by 5.4 % this yr alone. We should extra rigorously choose to whom we prescribe these intensive medicines if we need to scale back prices and optimize long-term success for our sufferers. We have to take a look at varied medical metrics and lean on different evidence-based interventions to realize clinically significant weight lack of 5-10% of whole physique weight. Different evidence-based interventions might embrace medical dietary remedy offered by a registered dietitian and different, cheaper medicines that may deal with weight problems, equivalent to Contrave, Metformin or Topiramate, Zonisamide, Qsymia and Orlistat.

Specializing in the utmost quantity of weight reduction is just not the way in which to resolve our weight problems downside, neither is it essentially the most acceptable aim when different cardiometabolic danger elements exist. Essentially, we should prioritize decreasing cardiovascular and metabolic danger, which may typically be achieved by 5-10% weight reduction.

If we need to scale back the charges of hypertension, excessive LDL and kind 2 diabetes, we have to look extra carefully at different measurements equivalent to blood strain and waist circumference. Waist circumference is related to the next quantity of visceral fats when better than 35 inches for girls and >40 inches for males, and could be a excessive indicator of poor metabolic well being.

Prejudice and stigma related to BMI in healthcare

We should additionally take into account the bias and stigma brought on by the extensively accepted declare that BMI is linked to well being. Weight bias is harmful: The psychological stress that comes from residing in a bigger physique and experiencing bias from and throughout the medical neighborhood will increase the danger of despair, nervousness, substance abuse, poor physique picture, and missed diagnoses. In lots of instances, docs are susceptible to anti-obesity bias, which may cause them to dismiss the medical issues of somebody residing with weight problems.

We have to get a extra nuanced view of how BMI varies throughout populations, ethnicities and athletes when utilizing it as a well being measure. Coaching physicians to acknowledge the inherent biases surrounding weight stigma is important to transferring past the concept that weight is said to well being and additional that BMI is enough to find out who’s unhealthy sufficient to obtain remedy.

Complete, whole-person remedy is the answer

It's time we transfer past BMI and take a holistic strategy to really measuring well being. That would appear to be measuring blood strain, LDL ldl cholesterol and A1C, along with elements like physique composition, metabolic well being and psychological well being earlier than figuring out the suitable interventions.

An built-in, personalised remedy that goes past weight and focuses on psychological and bodily well being needs to be the gold normal for figuring out who will get a GLP-1. Serving to sufferers heal from the trauma, prejudice, and stigma they could have confronted requires a compassionate and empathetic strategy. Medical doctors skilled in cognitive behavioral methods might help sufferers promote a constructive relationship with meals and physique, whereas additionally screening and pursuing remedy if different, extra complicated psychological well being situations are current. Moreover, physicians ought to bear ongoing coaching to acknowledge and scale back weight bias, selling an setting of inclusivity and equitable care.

Profitable remedy requires interdisciplinary collaboration, integrating medical, dietary remedy and psychological interventions tailor-made to particular person wants. Working with registered dietitians to optimize vitamin, specializing in meals high quality relatively than simply amount and energy, and attaining an excellent and final result practical physique weight is essential. Consuming the best meals and optimizing vitamin when solely small meals are tolerated is essential for general well being and stopping fast weight reduction and lean physique mass.

Conclusion

The shortcomings of BMI as a well being measure necessitate a paradigm shift in healthcare practices. Overprescribing GLP-1 primarily based on BMI standards alone ignores essential points of particular person well being and perpetuates healthcare inequalities. Shifting ahead, we should embrace extra complete, personalised remedy methods that transcend BMI and deal with holistic well being elements. We will guarantee equitable entry to healthcare and higher affected person outcomes by prioritizing inclusivity, empathy, and evidence-based practices.

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