A wise senior colleague told me in the 1990s, when I was involved in some medical committees, “Never stand between your colleagues and a barrel of money.” Maybe that’s a little harsh. I think Paul Keating, when he was Prime Minister, made similar observations about some of his state colleagues. I suspect this is not unique to medicine.
That’s not to say people don’t need to earn a living. They do. People have bills to pay and expenses. Everybody needs to earn a living, and that’s exactly the way the world should be. But equally, it needs to be done in an ethical way. That’s pretty much a statement of the obvious.
Moving away from body mass index alone to diagnose obesity may delay treatment for millions of patients, a group of experts from the Endocrine Society warned in a guideline communication.
We’ve spoken numerous times on the podcast about BMI, which is the Body Mass Index. For those who may not be familiar — if you’ve not listened before, welcome aboard. For regular listeners, it’s always nice to have you back.
Body Mass Index is your weight in kilograms divided by the square of your height in meters. So, for example, if you weigh 80 kilos and are 1.5 meters tall, then it’s 80 divided by 1.5 × 1.5.
In the mid-1980s, the cutoff for being overweight was lowered from 27.5 down to 25. The cutoff for obesity is 30. Under 25, you’re classed as a healthy weight. Below 20 was traditionally considered underweight, although that has since been lowered to 18.5. Above 30 is considered obese, and above 35 is considered extremely or morbidly obese. So, there’s a fairly narrow window.
Now, BMI was first developed in the 1800s as an actuarial tool. It was thought to be useful for insurance purposes and population studies, but it’s not particularly useful — in fact, it could be argued that it’s not useful at all in an individual circumstance.
Go to any AFL team, rugby team, basketball team, or in America, an NHL or NFL team. Many of the players are going to be classified as either overweight or obese because they have a lot of muscle. BMI does not take body composition into account.
It doesn’t distinguish between muscle mass and body fat, so it can be an unhelpful tool. It has a role, but reliance on it has led to many people being diagnosed as overweight when there’s actually nothing wrong with them. You can have a BMI between 25 and 30 and still be in very good health, even though technically you’re in the overweight range.
What this guideline is saying — and maybe I’ll come back to that in a moment — is this:
“How obesity is defined has real consequences for patients. Diagnostic definitions influence who qualifies for treatment, how clinicians manage care, and, in the American context, how insurers determine coverage for medications and surgery.”
That insurance issue also applies in other countries, although every country has its own system. This article comes from America, and we’ll put it in the description.
The article continues:
“Any new framework must be grounded in strong evidence, practical for everyday clinical use, and designed to improve rather than restrict equitable access to effective obesity treatment.”
That sounds very good. Quite difficult to argue against, really.
Well, actually, it is possible to argue against it, because there’s a fundamental assumption underlying all of this — namely, that everybody who might be a little overweight requires treatment, and that treatment is defined as medications and surgery.
I don’t see any mention of how these proposed changes might impact people’s ability to exercise, change their dietary patterns, or speak to a doctor, dietitian, nutritionist, or even a personal trainer about improving their eating habits.
So, inherent in this proposal are two assumptions:
First, we need to treat more people.
Second, that treatment necessarily revolves around medical interventions.
Now, there is a role for medical interventions. There is a role for medications — especially the newer GLP-1 inhibitors. I’m not going to mention trade names; you’re all familiar with them. There’s also still a role for bariatric surgery, although fewer people are undergoing bariatric surgery since the advent of GLP-1 medications.
But there also remains an important role for changing dietary patterns, food intake, and exercise.
Changing criteria doesn’t affect whether people can improve their diet or increase their activity levels.
I think it’s interesting that this commentary comes out of the Journal of Clinical Endocrinology and Metabolism, where they argue that a diagnostic overhaul may overcomplicate routine clinical care.
There never seems to be a problem when thresholds are lowered. When cholesterol cutoffs were reduced from 6.5 to 6 to 5.5 to 5, nobody thought that complicated matters. When blood pressure thresholds have been steadily lowered, nobody seems concerned.
But if we slightly loosen the definition — perhaps raise the threshold rather than lower it — suddenly that’s considered overcomplicating things.
The waist-to-hip ratio — the circumference around your waist divided by the circumference around your hips — is actually a more useful indicator of metabolic health. It’s not the only one, but it gives a better indication of whether someone is carrying excess fat around the middle.
Ideally, in women, the ratio should be below about 0.85, and in men, below 0.9. Different criteria exist, but those are roughly the accepted ranges.
And frankly, we don’t even need tape measures much of the time. You can often tell whether someone carries most of their weight around the middle versus elsewhere on the body.
Take the example of a bodybuilder who may weigh a lot because of muscle mass, versus someone of the same weight whose excess weight is primarily abdominal fat. BMI doesn’t distinguish between the two.
So, far from overcomplicating things, the waist-to-hip ratio may actually simplify them.
There are also scales and body composition tools that provide useful indications. And people are different. Different ethnic backgrounds and body types mean that a one-size-fits-all BMI tends to capture many people inaccurately.
It’s useful, perhaps, to return to where we started. Lowering thresholds expands the number of people who qualify for treatment. Again, I’m not saying that’s necessarily wrong. But the lower the threshold, the more people we instantly convert from being healthy into being patients requiring treatment.
That treatment may indeed be beneficial. As we said before, there is a role for it. But it also creates an income stream for those providing those services.
And I want to make this very, very clear: there’s nothing intrinsically wrong with offering treatment. I’m not suggesting it’s unethical.
The question is whether we need to expand the number of people who qualify for that treatment, especially when simpler approaches might help many of them — and when some of those people don’t require treatment at all, particularly not medical or surgical treatment.
So, the words of my colleague from the ’90s do, I think, ring true.
Before we finish up today, in a similar vein, a group of diabetes professionals is proposing changing the term “pre-diabetes” to a three-stage classification system aimed at promoting earlier treatment and risk reduction.
Again, fine in principle.
We’re all going to shuffle off this mortal coil one day. Nobody gets out alive. But we talk about being alive — we don’t talk about being “pre-dead.”
There is a point at which a medical condition is diagnosed. Before that point, you simply don’t have it.
Anybody who doesn’t have cancer isn’t classified as “pre-cancerous.” There are certain lesions that may be precancerous, but that’s entirely different.
Similarly, if you don’t have high blood pressure, having normal blood pressure doesn’t mean you have “pre-hypertension.”
And the idea that normal blood sugar — even if it’s close to the cutoff — should be called “pre-diabetes” ignores the purpose of having cutoffs in the first place.
It means you don’t have diabetes.
Maybe you’ll develop it one day, but you don’t have it now.
So, calling it pre-diabetes is a bit like saying someone who is alive is “pre-dead.” No.
Reclassifying it is essentially a way of lowering the threshold further, lowering the point at which we classify people as diabetic.
As we discussed earlier, this also interacts with insurance systems, treatment qualifications, and coding systems. It potentially increases access to treatment, which is fine if people genuinely need it.
But if they don’t, then we risk overtreating people — and that’s a real concern.
There are conferences every year on overdiagnosis. I attended one many years ago. It was a good conference, although at times a little arcane. Unfortunately, I think advocates in this space could do a better job of communicating the message that we don’t need to classify everyone who might get sick one day as already having a problem — or a “pre-problem.”
In all of this, what often gets lost are the simple changes people can make for themselves.
If you feel you need to lose weight — and some people do, for various reasons — the first step is looking honestly at your eating patterns and making changes where needed.
The two key factors are always quantity and quality.
And if what you’re doing isn’t working, then you need to change what you’re doing. It really is that simple. People don’t always like hearing that, but it’s true.
You can also increase your activity levels and do more exercise. But you can never outrun a bad diet.
So, do we really need more labels? Do we need to reclassify people who don’t currently have a medical problem? They may have an issue they’d like to address, but that doesn’t necessarily make it a medical condition.
Do we need to lower thresholds and increase the number of people who require treatment?
Personally, I don’t think so.
I don’t think the path we’ve been following — and continue to follow — is particularly useful.
It simply creates more patients out of people who, yesterday, were not patients.
It increases costs and, perhaps worst of all, it becomes disempowering. It implies that people are incapable of making changes themselves.
But they are. And you are.
If you want to make changes, you can do it — and you can start today.
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Dr Joe Kosterich – Doctor, Health Industry Consultant and Author
Doctor, speaker, author, and health industry consultant, Joe is WA State Medical Director for IPN, Clinical editor of Medical Forum Magazine, Medical Advisor to Medicinal Cannabis company Little Green Pharma and Course Chair, and writer for Health Cert. He is often called to give opinions in medico-legal cases, has taught students at UWA and Curtin Medical schools and been involved in post graduate education for over 20 years.
A regular on radio and TV, Joe has a podcast – Dr Joe Unplugged, has self- published two books and maintains a website with health information. He has extensive experience in helping businesses maintain a healthy workforce.
Past Chairman of Australian Tobacco Harm Reduction Association, current Vice President of Arthritis and Osteoporosis WA, Joe previously held senior positions in the Australian Medical Association and has sat on numerous boards.
