Jan. 18, 2024
31 | Beyond BMI - A Provider's Guide to Helping Patients Lose Weight: Part 2
Are you still relying on BMI as the end-all-be-all of health indicators? Let's unravel why it's time to break up with this outdated metric. Join me, Colleen Sloan, on the second episode of this 10-part series to help guide your patients on their weight loss journey.
If you're a primary care provider looking to enhance your nutrition counseling skills or simply seeking a refresher, join me as we make our patients healthier, one exam room at a time!
Grab the companion PDF at examroomnutrition.com/weightloss, and let's confidently guide our patients towards their best lives in 2024.
Resources and Articles:
Obesity Management in Adults - JAMA Review
AMAs new policy clarifying the role of BMI
ConscienHealth Blog - Our Rocky Relationship with BMI
Connect with Colleen:
Instagram
LinkedIn
Sign up for the Nutrition Wrap-Up Newsletter - Nutrition hot-topics and professional growth strategies delivered to your inbox each week.
Support the show!
If you love the show and want to help me make it even better, buy me a coffee to help me keep going! ☕️
Disclaimer: This podcast is a collection of ideas, strategies, and opinions of the author(s). Its goal is to provide useful information on each of the topics shared within. It is not intended to provide medical, health, or professional consultation or to diagnosis-specific weight or feeding challenges. The author(s) advises the reader to always consult with appropriate health, medical, and professional consultants for support for individual children and family situations. The author(s) do not take responsibility for the personal or other risks, loss, or liability incurred as a direct or indirect consequence of the application or use of information provided. All opinions stated in this podcast are my own and do not reflect the opinions of my employer.
00:00 - BMI Limitations and Other Measures
12:15 - Measuring Health in 2024
WEBVTT
00:00:00.621 --> 00:00:04.490
A person's BMI doesn't matter as much as we once thought.
00:00:04.490 --> 00:00:08.807
It cannot measure health, but it is a simple screening tool.
00:00:08.807 --> 00:00:12.307
Now, simple is useful but not comprehensive.
00:00:12.307 --> 00:00:26.349
I'm Colleen Sloan, registered dietitian and pediatric PA, and this is the Exam Room Nutrition Podcast, where I'm giving you the nutrition education you never had in school to help you become a confident, compassionate clinician.
00:00:26.349 --> 00:00:41.667
This is the second episode in our series titled A Provider's Guide to Helping Patients Lose Weight, and last week I gave you three crucial questions to ask your patient who wants to lose weight, and this week we are getting into some metrics and how we can measure the patient's outcomes.
00:00:41.667 --> 00:00:50.847
As a quick reminder, if you would like my notes on this series, I have created a companion PDF for you that summarizes each and every episode.
00:00:50.847 --> 00:00:56.003
You can find that for free at examrumnutritioncom slash weight loss.
00:00:56.003 --> 00:00:58.787
That's examrumnutritioncom slash weight loss.
00:00:58.787 --> 00:01:15.188
Now, before we get into the material for today, I wanted to add that helping patients lose weight should include interventions in all categories, including behavioral interventions, nutrition, physical activity, pharmacotherapy and possibly bariatric procedures.
00:01:15.188 --> 00:01:21.248
I firmly believe that evidence-based obesity treatment combines all of these interventions.
00:01:21.248 --> 00:01:28.927
However, I am a registered dietitian, so I'll be providing you guidance only on that which is within my scope of practice.
00:01:28.927 --> 00:01:36.426
Additionally, if your patient requires more guidance than you can provide, please don't just tell them to eat less and move more.
00:01:36.426 --> 00:01:41.725
Please refer them to an appropriate professional who can help in the areas that you can't.
00:01:41.725 --> 00:01:49.263
But for this series, I'm talking to my colleagues in primary care who are faced with the questions of weight loss daily.
00:01:49.263 --> 00:01:54.266
This information is to equip you with the knowledge to guide your patients appropriately.
00:01:54.266 --> 00:01:59.048
So let's get into BMI and why there might be better outcomes to measure.
00:01:59.640 --> 00:02:02.909
Bmi has long been used as a way to classify obesity.
00:02:02.909 --> 00:02:11.985
Insurance plans use it to determine eligibility for bariatric metabolic surgery, and medical organizations have used it for decades as a determinant of health risk.
00:02:11.985 --> 00:02:21.209
Now, as a reminder, a BMI of 25 or greater is commonly used to define overweight and a BMI of 30 or greater to define obesity.
00:02:21.209 --> 00:02:27.387
Bmi does not measure excess adipose tissue or indicate tissue or organ function.
00:02:27.387 --> 00:02:33.008
It doesn't account for muscle mass or types of body fat and where that's located.
00:02:33.008 --> 00:02:39.628
But historically it has been an effective measure of estimating the population level magnitude of obesity.
00:02:40.259 --> 00:02:42.026
But where did we even get BMI from?
00:02:42.026 --> 00:02:43.001
All right guys?
00:02:43.001 --> 00:02:44.406
Time for a quick history lesson.
00:02:44.406 --> 00:02:52.330
It was created by a Belgian astronomer and mathematician, adolf Quettelette in 1832 as the Quettelette Index.
00:02:52.330 --> 00:02:58.727
The scale was created using data from predominantly European men to measure weight in different populations.
00:02:58.727 --> 00:03:18.675
Although Quettelette noted that it was a population level tool and not meant to be used on individuals, physiologists Ansel Keys reintroduced the calculation in 1972 as the Body Mass Index, and it has since been adopted by the medical community as a way to measure individual health.
00:03:19.721 --> 00:03:26.662
But health risks at a given BMI value can be different in different populations, genders and races.
00:03:26.662 --> 00:03:32.752
This leads some people to make some sensational claims that BMI is racist and sexist.
00:03:32.752 --> 00:03:41.466
Now, this is a very sensitive and controversial topic that does not suit the goals of my podcast, so we will not be addressing that issue today.
00:03:41.466 --> 00:03:48.925
Many other studies have shown that BMI cutoffs should be different in different ethnic populations, specifically the Asian populations.
00:03:48.925 --> 00:03:51.645
But two facts still remain.
00:03:51.645 --> 00:03:54.326
Number one, bmi is math.
00:03:54.326 --> 00:04:01.002
Bmi is nothing more or less than a ratio between height and weight as humans age from birth to adulthood.
00:04:01.002 --> 00:04:04.068
And number two, bmi has limitations.
00:04:04.068 --> 00:04:06.025
It is a screening tool.
00:04:06.025 --> 00:04:09.628
It has very real limitations as an individual measure.
00:04:09.628 --> 00:04:18.326
It does not measure excess body fat, fat distribution, health or fitness levels or account for individual differences in health risks.
00:04:19.379 --> 00:04:22.009
In a June 14, 2023 press release.
00:04:22.009 --> 00:04:31.863
The delegates at the annual meeting of the American Medical Association House of Delegates adopted a policy aimed at clarifying how BMI can be used as a measure in medicine.
00:04:31.863 --> 00:04:49.290
The AMA suggests that it be used in conjunction with other valid measures of risk, such as, but not limited to, measurements of visceral fat, body adiposity index, body composition, relative fat mass, waist circumference and genetic or metabolic factors.
00:04:49.290 --> 00:04:54.600
So if we shouldn't rely on BMI alone, what should we measure Now?
00:04:54.600 --> 00:05:00.252
At minimum, you should be screening for a secondary cause of obesity based on history and physical exam.
00:05:00.252 --> 00:05:06.372
So, for example, check for hormonal abnormalities, any psychiatric disorders and genetic syndromes.
00:05:06.372 --> 00:05:12.307
In addition to any medication side effects, weight-related comorbidities should be assessed as well.
00:05:12.307 --> 00:05:20.225
I want you to be thinking non-alcoholic, fatty liver disease, sleep apnea, prediabetes, diabetes, hypertension or reflux.
00:05:20.939 --> 00:05:30.571
It is critical that you pay attention to muscle mass and body composition, as protecting lean muscle mass should be a priority when working with individuals trying to lose weight.
00:05:30.571 --> 00:05:35.788
Okay, but what about measuring body composition First?
00:05:35.788 --> 00:05:38.505
What even is body composition Now?
00:05:38.505 --> 00:05:48.197
Basically, measuring body composition is just assessing the proportions of your body, in which there are four main components fat, muscle, bone and water.
00:05:48.197 --> 00:05:51.781
Other components do contribute to weight, such as fluid and minerals.
00:05:51.781 --> 00:05:53.228
But we're trying to keep it simple today.
00:05:53.824 --> 00:05:58.896
Now let's discuss the most common ways of measuring body composition and their limitations.
00:05:58.896 --> 00:06:03.295
So the first way we have is hydrostatic weighing, and this is underwater weighing.
00:06:03.295 --> 00:06:08.375
This technique involves measuring your weight on dry land, followed by measuring it in water.
00:06:08.375 --> 00:06:14.211
To measure your weight in water, the patient will be seated undressed on a chair that is halfway submerged in water.
00:06:14.211 --> 00:06:21.052
According to the American College of Sports Medicine, this is the gold standard for calculating body fat because of its high accuracy.
00:06:21.052 --> 00:06:25.915
However, it is very time consuming and is probably not available everywhere.
00:06:25.915 --> 00:06:30.935
Usually, this type of measurement is only available at D1 universities.
00:06:31.904 --> 00:06:33.451
Number two is a BOD pod.
00:06:33.451 --> 00:06:36.774
This is testing that uses the principle of air displacement.
00:06:36.774 --> 00:06:41.927
During the test, the patient is enclosed in a computerized egg-shaped chamber called a BOD pod.
00:06:41.927 --> 00:06:46.495
Before the patient enters the chamber, body weight and volume measurements are taken.
00:06:46.495 --> 00:06:54.654
Then, when you're in the chamber, the body fat percentage is calculated by measuring the amount of air your body displaces upon entering.
00:06:54.654 --> 00:06:58.134
The BOD pod test is highly accurate and gives fast results.
00:06:58.134 --> 00:07:02.136
However, it needs technical expertise and it can be very expensive.
00:07:02.136 --> 00:07:09.870
Furthermore, I'm told that you have to wear a skin tight suit and that might not be comfortable or acceptable for all patients.
00:07:11.105 --> 00:07:19.353
The third way that we can measure body composition and you're probably very familiar with it is the DEXA scan, and most of us know this as a way of measuring bone density.
00:07:19.353 --> 00:07:25.932
However, it can also provide measurements of body composition, including muscle, bone and fat content in specific parts of your body.
00:07:25.932 --> 00:07:32.589
The scan generates a fat shadow image that shows the distribution of fat in the abdomen, arms, legs and pelvis.
00:07:32.589 --> 00:07:35.452
The DEXA scan does provide fast results.
00:07:35.452 --> 00:07:43.634
However, the machine is only available in some hospitals and research institutions, where it's typically reserved for research studies and not always for the general public use.
00:07:43.634 --> 00:07:48.415
The next way we can measure it is the Bioimpedance Analysis, or BIA.
00:07:48.415 --> 00:07:53.276
This test works on the principle that water and fat conduct electric currents differently.
00:07:53.276 --> 00:08:02.136
During the test, a small, harmless electric current is passed through the body and the speed at which the current travels helps detect the amount of body fat.
00:08:02.136 --> 00:08:07.115
If the current travels slowly, this usually indicates a higher body fat percentage.
00:08:07.115 --> 00:08:12.894
You can think of it like this the current will travel faster through water and muscle and slower through fat.
00:08:13.745 --> 00:08:22.978
Different machines will offer different measurements, but in general, most can tell you your muscle mass, your body fat, visceral tissue and body water composition.
00:08:22.978 --> 00:08:33.184
Some fitness centers actually have this, so this might be a really good option for patients, and it's becoming more and more acceptable as a great way for body composition measurement within clinics.
00:08:33.184 --> 00:08:35.765
Another option is the skin fold test.
00:08:35.765 --> 00:08:42.485
This test requires a special scale, called a Vernier caliper, to measure the thickness of various skin folds in the body.
00:08:42.485 --> 00:08:48.443
Thanks to the simplicity and low cost of Vernier calipers, the skin fold test is widely used to measure body fat.
00:08:48.443 --> 00:08:54.432
However, this method is not very accurate because it depends on how precisely the measurements are taken.
00:08:54.432 --> 00:08:58.750
Repeated measurements made by different people may not provide accurate results.
00:08:58.750 --> 00:09:02.188
Furthermore, it only measures subcutaneous fat.
00:09:02.188 --> 00:09:13.405
It's not measuring the fat that's around the organs, which is the more concerning dangerous fat, and honestly, this isn't very patient-friendly because nobody really wants their arm fat and waist fat pinched and measured.
00:09:14.240 --> 00:09:16.927
Another method available is the waist to hip ratio.
00:09:16.927 --> 00:09:22.652
This is a simple measurement of the circumference of an individual's waist compared to that of the hips.
00:09:22.652 --> 00:09:27.390
Now, there are guidelines for measurements, but there is no uniformly accepted protocol.
00:09:27.390 --> 00:09:32.101
The measurement is taken with the patient standing up straight and they need to breathe out.
00:09:32.101 --> 00:09:38.591
Use a tape measure to measure midway between the lower rib and the iliac crest on the mid-accelery line.
00:09:38.591 --> 00:09:43.070
Often, this is the smallest part of your patient's waist, just above their belly button.
00:09:43.070 --> 00:09:45.326
This is their waist circumference.
00:09:45.326 --> 00:09:52.427
Next, measure the distance around the largest part of their hips or the widest part of their buttocks over the greater trochanters.
00:09:52.427 --> 00:09:53.903
This is the hip circumference.
00:09:53.903 --> 00:09:59.350
Calculate the weight to hip ratio by dividing the waist circumference by the hip circumference.
00:09:59.350 --> 00:10:07.844
The World Health Organization defines abdominal obesity as 0.9 or less in men and 0.85 or less for women.
00:10:07.844 --> 00:10:18.249
In both men and women, a waist to hip ratio of 1 or higher increases the risk of heart disease and other conditions that are linked to being overweight.
00:10:18.840 --> 00:10:21.828
As with any body composition measurement, there are limitations.
00:10:21.828 --> 00:10:35.488
Certain people won't be able to get an accurate measure using waist to hip ratio, including people who are shorter than 5 feet tall and people who have a BMI of 35 or higher, and this is not recommended for use in children.
00:10:35.488 --> 00:10:44.908
It's also really easy to make mistakes while checking the waist to hip ratio, because you need to take two separate measurements and it can be hard to get an accurate measurement of the hips.
00:10:44.908 --> 00:10:49.451
It also cannot distinguish between subcutaneous and visceral abdominal fat.
00:10:49.451 --> 00:10:53.470
Additionally, some patients might not be comfortable with this type of measurement.
00:10:53.470 --> 00:10:59.985
And lastly, a whole body MRI is actually a gold standard to measure skeletal muscle mass and visceral muscle tissue.
00:10:59.985 --> 00:11:04.190
However, a whole body MRI is often not feasible and it is very expensive.
00:11:04.879 --> 00:11:11.104
As you can see, each method of measuring body composition comes with its own strengths and weaknesses.
00:11:11.104 --> 00:11:17.501
These are, at best, estimated guesses, due to each of them having their own amount of error margin.
00:11:17.501 --> 00:11:23.652
This is why it's important to consider multiple factors when it comes to monitoring your patient's success.
00:11:23.652 --> 00:11:31.908
So now you know why BMI doesn't tell the whole story about your patient's health and that it's not the only metric you should be monitoring.
00:11:31.908 --> 00:11:35.870
I want you to consider what is the most feasible for your patient.
00:11:35.870 --> 00:11:44.831
You need to consider cost, accessibility and patient comfort, okay, but what should you monitor in a patient who is working towards weight loss?
00:11:44.831 --> 00:11:47.967
This is where a shared decision model is ideal.
00:11:48.720 --> 00:11:51.408
Ask the patient what can we track beyond your weight?
00:11:51.408 --> 00:11:53.725
How would you like to measure your success?
00:11:53.725 --> 00:12:00.846
Successful weight loss treatment involves every part of the person, so ask them what's important to you?
00:12:00.846 --> 00:12:04.019
I want to leave you guys with something to think about Now.
00:12:04.019 --> 00:12:12.250
I firmly believe that someone with excess weight can be perfectly healthy, and likewise, someone with a normal body weight can be completely unhealthy.
00:12:12.250 --> 00:12:14.787
But what is our definition of healthy?
00:12:15.399 --> 00:12:17.486
How do we measure health in 2024?
00:12:17.486 --> 00:12:20.407
Is it lab values, like cholesterol and A1C?
00:12:20.407 --> 00:12:24.969
Is it their mental health, like confidence, self-esteem and stress levels?
00:12:24.969 --> 00:12:28.687
Is it physical health, like stamina and strength?
00:12:28.687 --> 00:12:31.186
Is it body fat distribution?
00:12:31.186 --> 00:12:32.984
What about quality of sleep?
00:12:32.984 --> 00:12:36.067
Or maybe is it their digestive health?
00:12:36.067 --> 00:12:40.910
I'm curious to know what you think and how we should be measuring health in 2024.
00:12:40.910 --> 00:12:44.769
Join the conversation on Instagram and tag me at Exam Room Nutrition.
00:12:44.769 --> 00:12:46.447
Well, that's it for today, guys.
00:12:46.447 --> 00:12:56.967
I'll see you next week where we talk about the psychological factors you cannot ignore and how helping your patient be aware of and manage their stress and emotional eating will be key to their success on this journey.
00:12:56.967 --> 00:13:01.929
As always, let's continue to make our patients healthier, one exam room at a time.
00:13:01.929 --> 00:13:11.650
And as a quick reminder, if you would like my notes on this series, I have created a companion PDF for you that summarizes each and every episode.
00:13:11.650 --> 00:13:14.907
You can find that for free at exam room.
00:13:14.907 --> 00:13:16.812
Nutritioncom slash weight loss.
00:13:16.812 --> 00:13:17.943
That's exam room.
00:13:17.943 --> 00:13:19.634
Nutritioncom slash weight loss.
00:00:00.621 --> 00:00:04.490
00:00:04.490 --> 00:00:08.807
00:00:08.807 --> 00:00:12.307
00:00:12.307 --> 00:00:26.349
00:00:26.349 --> 00:00:41.667
00:00:41.667 --> 00:00:50.847
00:00:50.847 --> 00:00:56.003
00:00:56.003 --> 00:00:58.787
00:00:58.787 --> 00:01:15.188
00:01:15.188 --> 00:01:21.248
00:01:21.248 --> 00:01:28.927
00:01:28.927 --> 00:01:36.426
00:01:36.426 --> 00:01:41.725
00:01:41.725 --> 00:01:49.263
00:01:49.263 --> 00:01:54.266
00:01:54.266 --> 00:01:59.048
00:01:59.640 --> 00:02:02.909
00:02:02.909 --> 00:02:11.985
00:02:11.985 --> 00:02:21.209
00:02:21.209 --> 00:02:27.387
00:02:27.387 --> 00:02:33.008
00:02:33.008 --> 00:02:39.628
00:02:40.259 --> 00:02:42.026
00:02:42.026 --> 00:02:43.001
00:02:43.001 --> 00:02:44.406
00:02:44.406 --> 00:02:52.330
00:02:52.330 --> 00:02:58.727
00:02:58.727 --> 00:03:18.675
00:03:19.721 --> 00:03:26.662
00:03:26.662 --> 00:03:32.752
00:03:32.752 --> 00:03:41.466
00:03:41.466 --> 00:03:48.925
00:03:48.925 --> 00:03:51.645
00:03:51.645 --> 00:03:54.326
00:03:54.326 --> 00:04:01.002
00:04:01.002 --> 00:04:04.068
00:04:04.068 --> 00:04:06.025
00:04:06.025 --> 00:04:09.628
00:04:09.628 --> 00:04:18.326
00:04:19.379 --> 00:04:22.009
00:04:22.009 --> 00:04:31.863
00:04:31.863 --> 00:04:49.290
00:04:49.290 --> 00:04:54.600
00:04:54.600 --> 00:05:00.252
00:05:00.252 --> 00:05:06.372
00:05:06.372 --> 00:05:12.307
00:05:12.307 --> 00:05:20.225
00:05:20.939 --> 00:05:30.571
00:05:30.571 --> 00:05:35.788
00:05:35.788 --> 00:05:38.505
00:05:38.505 --> 00:05:48.197
00:05:48.197 --> 00:05:51.781
00:05:51.781 --> 00:05:53.228
00:05:53.824 --> 00:05:58.896
00:05:58.896 --> 00:06:03.295
00:06:03.295 --> 00:06:08.375
00:06:08.375 --> 00:06:14.211
00:06:14.211 --> 00:06:21.052
00:06:21.052 --> 00:06:25.915
00:06:25.915 --> 00:06:30.935
00:06:31.904 --> 00:06:33.451
00:06:33.451 --> 00:06:36.774
00:06:36.774 --> 00:06:41.927
00:06:41.927 --> 00:06:46.495
00:06:46.495 --> 00:06:54.654
00:06:54.654 --> 00:06:58.134
00:06:58.134 --> 00:07:02.136
00:07:02.136 --> 00:07:09.870
00:07:11.105 --> 00:07:19.353
00:07:19.353 --> 00:07:25.932
00:07:25.932 --> 00:07:32.589
00:07:32.589 --> 00:07:35.452
00:07:35.452 --> 00:07:43.634
00:07:43.634 --> 00:07:48.415
00:07:48.415 --> 00:07:53.276
00:07:53.276 --> 00:08:02.136
00:08:02.136 --> 00:08:07.115
00:08:07.115 --> 00:08:12.894
00:08:13.745 --> 00:08:22.978
00:08:22.978 --> 00:08:33.184
00:08:33.184 --> 00:08:35.765
00:08:35.765 --> 00:08:42.485
00:08:42.485 --> 00:08:48.443
00:08:48.443 --> 00:08:54.432
00:08:54.432 --> 00:08:58.750
00:08:58.750 --> 00:09:02.188
00:09:02.188 --> 00:09:13.405
00:09:14.240 --> 00:09:16.927
00:09:16.927 --> 00:09:22.652
00:09:22.652 --> 00:09:27.390
00:09:27.390 --> 00:09:32.101
00:09:32.101 --> 00:09:38.591
00:09:38.591 --> 00:09:43.070
00:09:43.070 --> 00:09:45.326
00:09:45.326 --> 00:09:52.427
00:09:52.427 --> 00:09:53.903
00:09:53.903 --> 00:09:59.350
00:09:59.350 --> 00:10:07.844
00:10:07.844 --> 00:10:18.249
00:10:18.840 --> 00:10:21.828
00:10:21.828 --> 00:10:35.488
00:10:35.488 --> 00:10:44.908
00:10:44.908 --> 00:10:49.451
00:10:49.451 --> 00:10:53.470
00:10:53.470 --> 00:10:59.985
00:10:59.985 --> 00:11:04.190
00:11:04.879 --> 00:11:11.104
00:11:11.104 --> 00:11:17.501
00:11:17.501 --> 00:11:23.652
00:11:23.652 --> 00:11:31.908
00:11:31.908 --> 00:11:35.870
00:11:35.870 --> 00:11:44.831
00:11:44.831 --> 00:11:47.967
00:11:48.720 --> 00:11:51.408
00:11:51.408 --> 00:11:53.725
00:11:53.725 --> 00:12:00.846
00:12:00.846 --> 00:12:04.019
00:12:04.019 --> 00:12:12.250
00:12:12.250 --> 00:12:14.787
00:12:15.399 --> 00:12:17.486
00:12:17.486 --> 00:12:20.407
00:12:20.407 --> 00:12:24.969
00:12:24.969 --> 00:12:28.687
00:12:28.687 --> 00:12:31.186
00:12:31.186 --> 00:12:32.984
00:12:32.984 --> 00:12:36.067
00:12:36.067 --> 00:12:40.910
00:12:40.910 --> 00:12:44.769
00:12:44.769 --> 00:12:46.447
00:12:46.447 --> 00:12:56.967
00:12:56.967 --> 00:13:01.929
00:13:01.929 --> 00:13:11.650
00:13:11.650 --> 00:13:14.907
00:13:14.907 --> 00:13:16.812
00:13:16.812 --> 00:13:17.943
00:13:17.943 --> 00:13:19.634