Body mass index (BMI) has long been considered a standard measure for assessing weight-related health risks and, more recently, for determining eligibility for obesity medications such as the GLP-1 receptor agonists semaglutide (Wegovy) and tirzepatide (Zepbound). to the FDA.
BMI, calculated from weight and height, provides a simplified but flawed assessment of health. Originally designed for non-Hispanic white populations, it overlooks nuances such as muscle mass, fat distribution, and ethnic background that may influence certain risk factors. It is an outdated metric that perpetuates health care disparities and misses the mark when calculating cardiometabolic disease.
The perception that a “normal” BMI is ideal and an “overweight to obese” BMI is not ideal only exacerbates bias within the medical community and complicates our efforts to solve the obesity crisis. People with a BMI of overweight to obese, i.e. > 25 or > 30, can be healthy. At the same time, those who are in the “normal” BMI range may not be in the “normal” BMI range. You could have excess visceral fat (the dangerous kind that accumulates around organs) and the health risks that come with it. Additionally, the expected accumulation of fat as we age further complicates the reliability of BMI. We cannot judge health based on BMI alone.
The American Medical Association (AMA) recognized these limitations and in June 2023 acknowledged that BMI was an imperfect measure Measure waist circumference in addition to BMI could be a better way to predict weight-related risk.
While BMI may be useful as a measure of population health, it does not work well at the individual level to determine the need for drastic—and expensive—interventions like GLP-1 for weight loss.
AOM prescription and cardiovascular risk
With the increasing popularity of GLP1 for weight loss, we have seen an increase in the number of patients visiting their primary care physicians seeking prescriptions. FDA labeling for anti-obesity medications (AOMs) requires BMI criteria of >30 or >27 with at least one weight-related comorbidity to qualify for a GLP-1. This criterion can be adapted to the Asian phenotype, which tends to accumulate more visceral fat than subcutaneous fat.
However, GLP-1 agonists are not suitable for every patient who is a candidate for AOM based on BMI criteria alone. These medications are expensive and come with side effects and other risks. A recent study showed that nearly two-thirds of people were prescribed a GLP-1 receptor agonist and self-discontinued it in the second year. It is clear that we are not effectively treating obesity by simply writing prescriptions.
The recent increase in GLP-1 prescriptions is expected to increase employers’ healthcare costs by 5.4 percent this year alone. We must choose more carefully who we prescribe these critical care medications to if we want to reduce costs and optimize long-term outcomes for our patients. We should look at various clinical metrics and rely on other evidence-based interventions to achieve clinically meaningful weight loss of 5-10% of total body weight. Other evidence-based interventions could include medical nutritional therapy provided by a registered dietitian and other less expensive medications to treat obesity, such as Contrave, metformin or topiramate, zonisamide, Qsymia, and orlistat.
Focusing on maximum weight loss is neither the path to solving our obesity problem nor the most appropriate goal when other cardiometabolic risk factors are present. Fundamentally, we should prioritize reducing cardiovascular and metabolic risk, which can often be achieved through 5-10% weight loss.
If we want to reduce the incidence of high blood pressure, high LDL and type 2 diabetes, we need to take a closer look at other measurements such as blood pressure and waist circumference. Waist circumference is associated with a higher amount of visceral fat when it is >35 inches in women and >40 inches in men and can be a strong indicator of poor metabolic health.
Bias and stigma associated with BMI in healthcare
We also need to consider the bias and stigma created by the widely accepted claim that BMI is related to health. Weight bias is dangerous: The psychological stress that comes from living in a larger body and bias from and within the medical community increases the risk of depression, anxiety, substance abuse, poor body image and missed diagnoses. In many cases, doctors tend to have a bias against obesity, which can cause them to disregard the medical concerns of a person living with obesity.
We need to take a more nuanced look at how BMI varies across populations, ethnicities, and athletes when we use it as a measure of health. It is critical to train physicians to recognize the inherent bias associated with weight stigma in order to overcome the idea that weight is related to health and that BMI is enough to determine who is unhealthy enough to receive medication to take.
Comprehensive treatment that focuses on the whole person is the solution
It’s time to move beyond BMI and take a holistic approach to truly measuring health. This may involve measuring blood pressure, LDL cholesterol and A1C, along with factors such as body composition, metabolic health and mental health, before determining the right interventions.
Integrated, personalized treatment that goes beyond weight and focuses on mental and physical health should be the gold standard for determining who receives a GLP-1. Helping patients heal from the trauma, bias, and stigma they may have faced requires a compassionate and empathetic approach. Doctors trained in cognitive-behavioral techniques can help patients develop a positive relationship with food and body while also screening and initiating therapy when other more complex mental illnesses are present. Additionally, physicians must continue to educate themselves to recognize and mitigate weight bias, thereby fostering an environment of inclusivity and equitable care.
Successful treatment requires interdisciplinary collaboration that integrates medical, nutritional and psychological interventions tailored to individual needs. Work with registered dietitians to optimize nutrition, focus on food quality rather than just quantity and calories, and achieve an ideal and optimal result realistic Body weight is crucial. Consuming the right foods and optimizing nutrition when only small meals are tolerated are critical to overall health and preventing rapid weight loss and loss of lean body mass.
Diploma
The inadequacies of BMI as a measure of health require a paradigm shift in healthcare practice. Overprescribing of GLP-1 based on BMI criteria alone overlooks critical aspects of individual health and leads to health care disparities. In the future, we need to pursue more comprehensive, personalized treatment strategies that go beyond BMI and consider holistic health factors. We can ensure equitable access to healthcare and better patient outcomes by prioritizing inclusivity, empathy and evidence-based practices.
Photo: Aykut Karahan, Getty Images
Gretchen Zimmermann is the director of cardiometabolic care and prescribing at Vida Health.