Diagnosing Weight - Reframing BMI
By Dr. Ryan Oughtred, Weight Loss Doctor in Vancouver
Many patients, when I first see them, have already looked up their BMI (a measure of weight versus height) and declared themselves as "obese." What a way to start a relationship—misinformation, stigma, and internalized bias staring us straight in the face. Self-blame and shame are usually in lockstep with that initial statement. Thus begins the hard work of apologizing for what might have been said or done in the past, unlearning misconceptions, and setting the stage for an approach that offers hope.
Reframing BMI: A Starting Point, Not a Diagnosis
In order for patients to access treatments through their insurance and for doctors to be compensated for treating those patients, most medical systems necessitate that a label be created to justify the reason for the visit—a diagnosis. The challenge with drawing lines in the sand to make a diagnosis is that they are inevitably imperfect. When we get it wrong, we may needlessly label and possibly stigmatize a healthy individual, or we might miss an opportunity to treat a condition that could progress and lead to irreversible harm.
Right now, the most common measure we use to aid in the diagnosis of weight issues is the Body Mass Index (BMI). This simple calculation has limitations—it can inadvertently label healthy individuals as having obesity and simultaneously miss people who may already have dysfunctional body fat. Not only that, but BMI is just a snapshot in time and tells us nothing about a person’s prior weight history and current weight trajectory.
I recently attended an obesity conference in the USA where a case study approach was used for many of the lectures. I was surprised that the vignettes did not elaborate on an individual’s current weight trajectory and history of highest weight. We were then asked, "Doctor, what would you recommend to this patient?" This approach not only reinforces a non-collaborative, non–patient-centered approach that is flawed in how we manage weight, but it also fails to recognize that Adiposity-Based Chronic Disease (ABCD)—another term for obesity—is the lifelong, nuanced condition that it is. An individual that is gaining 2-5 lbs per month vs one that is weight stable ought to be considered quite differently. Especially when we know that weight is progressive, and it is often hard to return back to lower levels of body fat once higher levels have been reached.
Why Specialized Care Matters
While this may seem like a self-serving recommendation, I do think that referring to a health professional with specialized education and experience in this area, like myself, makes sense. We do this for other health problems—we defer the diagnosis until we have gathered more information and perhaps referred the patient to an expert in that body organ (a cardiologist or nephrologist, for instance). Given the complexity of the adipose tissue organ (body fat), this approach is logical, especially since we already do this for other body systems. Perhaps in the future, we will have better diagnostic tools, but for now, the best approach we have is a complex and holistic one.
Factors Considered in a Comprehensive Weight Assessment
If I were to see you as a patient, what are some of the factors I would consider in assessing benefits of weight loss or weight management?
Do You Even Want to Talk About It?
Ask permission to discuss weight and related terminology.
Current and Past Health
Paying close attention to other organs and systems impacted when body fat becomes unhealthy.
I use the Edmonton Obesity Staging System, which has been around for quite some time. Staged approaches to ABCD/obesity are superior, in my opinion.
History of Weight
Since childhood, but particularly since young adulthood.
Highest past weight.
Degree to which weight has fluctuated over time.
Drivers/common features of past weight gain (medications, psychosocial factors, mechanical issues, etc.).
Current weight trajectory.
BMI and Body Shape
Weight, height, body shape.
Waistline (optional)
Family History
Weight history as well as general family health history.
Health Behaviours
Current and past nutrition and physical activity.
Individual Values, Goals, and Expectations
Patient-centred approach to assessment—"What do you think?"
While this list does not encapsulate all the information that I would gather, it emphasizes how weight acts more like a screening tool to ask more questions and investigate how weight is impacting health. Thus, BMI should not be the deciding feature to recommend therapy; it is a starting point to a complex discussion that centres around the individual.
The Debate Around Labels
In a recent Medscape article, Miriam E. Tucker summarized the debate around the challenges of labels related to obesity. You can read more about that here.
Some are moving toward the diagnostic label of "Clinical Obesity" rather than just "obesity." I personally don’t see how that change greatly decreases stigma for patients, but perhaps it might for health professionals. I have written in the past about how discontinuing the use of the word "obesity" may help individuals seek help earlier and decrease overall stigma.
We know that most patients don’t remain on obesity treatment, and thus their conditions relapse and worsen over time. I suspect that wanting to not be "obese" anymore or to no longer be "on treatment for obesity" would be a desirable goal from their perspective. What if the condition for which you are being treated had a neutral name that didn’t elicit much emotion? What if you knew that condition was largely genetic and required treatment long term to manage it? Maybe you would be less likely stop treatment?
Offering Science and Hope in Weight Management
As a weight loss doctor in Vancouver, my goal is to provide a patient-centred approach that moves beyond labels and focuses on comprehensive, individualized care. Whether it's through my personalized weight loss program, shaping health behaviours, discussing obesity medications, or providing education on your journey, I am here to help.
If you're interested in a holistic and compassionate approach to weight management, feel free to reach out. Together, we can create a plan tailored to your individual needs and goals.