Proceedings of a Workshop—in Brief

Going Beyond BMI: Communicating About Body Weight

Proceedings of a Workshop—in Brief

The Roundtable on Obesity Solutions of the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine held a virtual public workshop, Going Beyond BMI: Communicating About Body Weight, on June 26, 2023. The workshop was the second in a two-part series to explore communications strategies and solutions to improve messaging around obesity and adiposity. The first workshop focused on measures of adiposity and obesity, including body mass index (BMI) and the impact of these measures on obesity prevention, treatment, and policy.

The second workshop built on the first, focusing on communication strategies to improve messaging about obesity and adiposity across diverse groups and sectors. The workshop presentations highlighted strategies to improve communication about defining and diagnosing obesity, weight bias, and stigma and challenges related to the cultural perceptions of body weight and adiposity. Workshop sessions covered strategies for mitigating structural factors and misinformation practices that lead to weight-related bias and stigma and offered suggestions to providers for shifting to a health-centric approach in obesity treatment.

Ihuoma Eneli, a board-certified general pediatrician, a professor at The Ohio State University, and the director of Nationwide Children’s Hospital Center for Healthy Weight and Nutrition, explained that the Roundtable on Obesity Solutions engages cross-sector leaders through innovation collaboratives and public workshops to compile information and advance solutions for the prevention, treatment, and management of obesity.

This Proceedings of a Workshop—in Brief highlights the presentations and discussions that occurred at the workshop and is not intended to provide a comprehensive summary of information shared during the workshop.¹ The information summarized here reflects the knowledge and opinions of individual workshop participants and should not be seen as a consensus of the workshop participants, the Roundtable on Obesity Solutions, or the National Academies of Sciences, Engineering, and Medicine.

COMMUNICATING HOW OBESITY IS DEFINED AND DIAGNOSED

The workshop began with an introductory session featuring three speakers. Francesco Rubino, the

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chair of metabolic and bariatric surgery at the King’s College London, kicked off the session. Rubino laid the groundwork for the workshop, asserting that while many organizations define obesity as a disease, it is not universally accepted as such and is widely conceptualized as a condition of risk for other chronic diseases (e.g., diabetes, hypertension). This in turn, Rubino explained, directly affects strategic and efficient intervention targets since obesity is not regulated like other diseases in terms of standards of care.

Many define obesity as a condition of excess adiposity that presents a health risk that is not, per se, a disease. To illustrate, Rubino pointed to fair skin as a risk factor for skin cancer, though it is not a disease. Rubio explained that medicine defines chronic disease as a harmful deviation from the normal function of an organism and that it is characterized by risk conditions, including previous conditions accepted as precursors for clinical disease, clinical manifestations, and potential complications.

Rubino continued that disease is associated with a clinical identity of signs and symptoms and/or with limits to the activities of daily living, none of which have been established for obesity. It is in other words, Rubino said, the clinical identity of a disease that distinguishes it from other diseases. There is a specific clustering, evolution, and timing of the clinical manifestations with the underlying disease process to characterize them as distinct from one another. BMI is not a clinical parameter and does not measure excess adiposity or indicate tissue or organ function but instead is an effective measure of estimating the population-level magnitude of obesity. Rubino then posed the natural remaining question: when an accurate measure of excess adiposity yields a diagnosis of obesity, will a clinical phenotype, clinical phase, or illness with demonstrative organ dysfunction be present?

Rubino asserted that the conceptualization of obesity as a condition of risk as opposed to obesity as a disease state has had broad ramifications beyond individual treatments, and he said that this is evident by obesity prevention strategies often applied or suggested to patients with severe obesity, complications, or comorbidities who require treatment and not prevention strategies that are not feasible or realistic. A downstream and unintended consequence is that patients may follow non-evidence-based treatment recommendations they get from information sources like social media. Rubino said that this lack of understanding and consensus of obesity as a disease and the disease process is fodder for the stigmatization of obesity.

These critical issues have been acknowledged by the Lancet Commission on Obesity,² which first convened in 2019. Rubino said that the commission, composed of 27 commissioners, is developing a report on the consensus and background regarding the definition and diagnostic criteria of clinical obesity.

W. Timothy Garvey, a professor of medicine at the Department of Nutrition Sciences at the University of Alabama at Birmingham, stated that in 2012, the American Association of Clinical Endocrinology (AACE) released a position statement designating obesity as a disease based on criteria set by the American Medical Association. These criteria include (1) characteristic signs or symptoms, (2) results in harm or morbidity, and (3) impairment in the functioning of some aspect of the body (AMA, 2005; Mechanick et al., 2012). The AACE justification of obesity as a disease, Garvey said, pointed to BMI as a measure of adiposity (i.e., a sign or symptom), cardiometabolic and biomechanical complications (i.e., result in harm), and dysregulation of the satiety hormone for energy intake and dysfunction of adipose tissue (i.e., impairment).

AACE held the 2014 Consensus Conference on Obesity in Washington, D.C., with cross-sector, multidisciplinary participants (Garvey et al., 2014a), which, Garvey said, led to several subsequent obesity-related developments. The conference generated some novel findings and affirmed others, such as the limitation of a BMI-based medical diagnosis, unclear health implications across various racial/ethnic groups, the health benefits of obesity care to large employers, and the absence of actionable steps for health care policy, all contributing to stigma. However, the main takeaway, Garvey continued,

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was the idea that the diagnosis of obesity should involve two components: BMI to measure adiposity and the presence and severity of obesity complications (Garvey et al., 2014b).

The 2016 AACE clinical guidelines reframed obesity as an adiposity-based chronic disease (ABCD) characterized by three stages (Garvey et al., 2016). Stage 0 is assigned if a patient demonstrates no complications from obesity. Mild to moderate complications indicate stage 1, and the goal of treatment and prevention in that case is for the patient to lose enough weight to limit deterioration. Severe complications indicate stage 2, with the indicated treatment being medication or surgery, or both.

Garvey concluded that “adiposity-based abnormalities in adipose tissue, distribution, and function is a lifelong chronic disease that leads to complications that impair health and confer morbidity and mortality.” While obesity induces insulin resistance which is treated with weight loss therapy, end-stage manifestations of obesity require end-stage therapy which is laborious and expensive. The International Classification of Diseases (ICD-10) coding for obesity does not align with current science and is inaccurate, Garvey contended (WHO, 2016). Providers are challenged to treat patients with obesity efficiently and strategically because the ICD-10 coding guides medical billing in the United States. Garvey proposed alternative ICD-10 coding for obesity that is situationally specific and aligned with current science (Garvey and Mechanick, 2020).

Geoff Ball, a professor and the associate chair of research in the Department of Pediatrics and the Alberta Health Services Chair in Obesity Research in the Faculty of Medicine and Dentistry at the University of Alberta in Edmonton, Canada, turned the discussion to Arya Sharma and Robert Kushner’s evidence-based Edmonton Obesity Staging System (EOSS) and its application to pediatrics. EOSS identifies the consequences of obesity with increasing severity and offers strategies for prevention and management (Sharma and Kushner, 2009). The EOSS, Ball said, is designed to go beyond BMI, and research shows that the severity of health consequences increases with EOSS score and is not correlated with BMI as a standalone measure (Kuk et al., 2011; Padwal et al., 2011).

Ball said that he and his colleagues developed a version of the EOSS for pediatrics (EOSS-P) (Hadjiyannakis et al., 2016) to assess weight status and obesity in children. The EOSS-P groups risk factors into four domains: mental health, metabolic health, mechanical health, and social milieu health. Each domain receives a score of 0 to 3, and the domain with the highest score yields the EOSS-P score (0 to 3). Ball reported that anthropometrics consistently identified health risks using the EOSS-P across weight categories (Hadjiyannakis et al., 2019).

INNOVATIONS IN COMMUNICATING ABOUT WEIGHT IN THE CLINIC AND BEYOND

Kofi Essel is a board-certified community pediatrician at Children’s National Hospital, an assistant professor of pediatrics, and the director of the School of Medicine and Health Sciences Culinary Medicine Program, the Community/Urban Health Scholarly Concentration, and the Clinical Public Health Summit on Obesity at The George Washington University (GWU). Essel began session two by shifting the discussion to obesity stigma, and ways to reduce weight bias, stigma, and shame among medical students. Essel reminded participants of the role of health care in stigma and bias, recalling past marketing campaigns with images of children with overweight and obesity that labeled patients as “obese people” by physicians.

Essel spoke about the Clinical Public Health Summit on Obesity at the GWU School of Medicine and Health Sciences. Using Shiriki Kumanyika’s Framework for Increasing Equity Impact in Obesity Prevention, medical students learn to think about population health and engage with patients with obesity using health equity and empathy tools (Kumanyika, 2017, 2019).

At the summit, medical students first completed a short exercise using the Harvard Weight Implicit Association Test and reflected on their test results and experiences engaging patients with obesity.³ Results were consistent

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with national studies showing that three-quarters of respondents automatically preferred thinner body frames over larger body frames (Essel et al., 2023).

Essel elaborated on the results, identifying four predominant reactions when students confronted their bias. Some students were skeptical of the test results or the test, denying their bias. Other reactions from students suggested an uncoupling of implicit versus explicit bias where students believed they inherently treat patients with obesity with dignity irrespective of their conscious or unconscious bias test results. Still others, Essel continued, expressed overt bias, meaning they consciously and directly ascribed judgment and personal responsibility to patients with obesity for their related health issues and even suggested that stigma is necessary and could motivate patients to care about their health. The fourth reaction was rugged individualism, where students applied their own lived experiences with weight management and often weight loss to patients with obesity while discounting other contributing factors and demonstrating reduced compassion.

Essel argued that medical education may amplify students’ pre-conditioned bias against patients with obesity but that this can be buffered by incorporating 10 steps into medical education (Alberga et al., 2016; Haqq et al., 2021; Kirk et al., 2020; MacInnis et al., 2020; Rubino et al., 2020). These steps are: (1) using tools to increase personal and professional awareness of obesity bias; (2) offering training to staff and colleagues to counteract their bias against obesity; (3) providing experiential learning opportunities from patients with obesity, teaching through sharing personal narratives; (4) recognizing the complexity of obesity as a disease and not solely the result of an unhealthy diet and lack of exercise; (5) respecting patients’ autonomy for their preference to engage with weight management; (6) focusing on health as the primary goal, not weight; (7) providing health care settings that accommodate and serve patients of different body sizes; (8) using people-first language; (9) offering non-stigmatizing images of people with obesity in marketing, clinical, and public health campaigns; and (10) advocating for all students and colleagues to take the pledge of the international joint statement to eliminate weight stigma (Essel et al., 2023; Rubino et al., 2020).

Robyn Pashby, a clinical health psychologist specializing in the cognitive, behavioral, and emotional factors of health behavior change, spoke about body positivity and obesity treatment as two divergent yet overlapping styles of understanding and thinking about obesity. Pashby pointed to several authoritative reports that define obesity but do not offer communication strategies to discuss it. For example, in the fields of science and medicine, people-first language (e.g., person with obesity) is preferred by many researchers and providers, though research indicates that patients prefer the terms “weight,” “healthy weight,” “chubby,” etc. (Brown and Flint, 2021; Puhl, 2020; Puhl et al., 2022).

Pashby offered four strategies for providers to talk about obesity in their clinical practices. First, providers must understand their own erroneous beliefs. Body positivity, Pashby said, is misunderstood as promoting obesity, though the intention is acceptance of all body types and physical abilities. Echoing the point that Essel had made earlier, Pashby shared the observation that providers emphasize that weight loss is for health, whereas most people think of weight loss for aesthetics. She said that it is erroneous to assume that internalized weight bias could be remedied with weight loss. Second, Pashby said, providers should consider their biases and assumptions about obesity and overweight and how they affect their perspective of patients with obesity. For example, some providers may assume that all patients with obesity want to lose weight or be thin(ner) or that thin(ner) patients are healthier. Third, Pashby challenged doctors to make “better” assumptions, such as that patients are autonomous decision makers, that patients with obesity are knowledgeable about health and nutrition, and that such patients have likely experienced traumatic stressors as a person living in a larger body in the United States. The fourth strategy, Pashby said, is to learn about and adopt trauma-informed care (Green et al., 2015) with the intention of creating a patient–provider relationship that is safe, transparent, collaborative, and culturally sensitive.

Pashby gave some examples and scripts for providers to use in communicating with patients in different scenarios: consider the context of an appointment, talk to the patient about his or her thoughts and feelings and not just the outcomes, consider the barriers to making lifestyle changes, consider tone of voice, ask for consent, and use trauma-informed care. Pashby summarized by saying, “How you communicate directly affects a person’s health outcomes.”

ETHICS AND TRUST IN COMMUNICATING ABOUT THE INTERSECTION OF BODY WEIGHT AND HEALTH

The third session focused on ethics and trust in communicating about the intersection of body weight and health. Tracy Richmond, the director of the Boston Children’s Hospital Eating Disorders Outpatient Program and the STEP wellness program for youth with elevated BMIs, began by juxtaposing her roles in the field of eating disorders, which promotes body acceptance, and in the field of childhood obesity, where weight loss treatment is normalized. According to Richmond, weight loss medications and surgery, as outlined in the American Academy of Pediatrics (AAP) clinical guidelines (Hampl et al., 2023), have received considerable media attention, while less attention has been paid to the guidance provided on how to communicate with patients and families about weight and obesity.

Richmond pointed to research showing that if people do not perceive themselves as having overweight or obesity, they overall have better outcomes. She continued that while there have been studies that have shown that individuals who perceive themselves as overweight are more likely to report weight loss attempts, the outcomes are not good. Indeed, teenagers who were overweight and held positive beliefs about their weight status were less likely to adopt disordered eating behaviors (Hazzard et al., 2017; Sonneville et al., 2016a), had lower blood pressure later in life (Unger et al., 2017), fewer depressive symptoms (Thurston et al., 2017), and gained less weight over time (Sonneville et al., 2016b). Teens who were overweight and perceived themselves as such demonstrated fewer healthy behaviors (Hahn et al., 2018), more internalized weight bias (Puhl et al., 2018), and more attempts at weight loss though they gained more weight (Haynes et al., 2018). Richmond continued that her group’s research found that teens recognize their weight status and accurately self-assess their BMI relative to their weight status and BMI according to objective measurements.

Richmond argued that informing patients of their BMI (when they are aware of their weight status) introduces weight stigma and is more damaging than helpful. She added that doctors are the second most common source of weight stigma. Research shows that patients who experience weight stigma demonstrate poorer mental health status, increased disordered eating behaviors, and negative physiological health outcomes (Hunger and Major, 2015; Puhl and Suh, 2015; Tomiyama et al., 2018) and receive a lower quality of care from providers (Alberga et al., 2019; Aldrich and Hackley, 2010; Phelan et al., 2015).

Richmond indicated that when she was in medical school, a weight-normative approach was taught to treat obesity, focusing on weight and weight loss. Many in medicine are shifting to a weight-inclusive approach focusing on health behaviors and the social determinants of health as points for intervention and consideration rather than on an all-or-nothing focus on weight numbers. A weight-inclusive practice acknowledges previous experiences (e.g., past weight loss attempts, weight stigmatization from providers), uses respectful communication (e.g., “Is it okay to talk about weight?”; “fat” versus “obese”), and focuses on behaviors that enhance health and not weight loss (Association for Size Diversity and Health, 2020; Tylka et al., 2014; Weight Inclusive Nutrition and Dietetics, 2023).

Martin Wilkinson, a professor of politics and international relations at the University of Auckland, offered a well-known observation that the distribution of people with obesity among the population is uneven. In high-income countries, like the United States and New Zealand, people with obesity tend to be low-income. One distinction is that New Zealand has no farm subsidies—and so no subsidies for high-fructose corn syrup—and no food deserts, with fruits and vegetables readily available country-wide.

Poverty is a problem in many countries, and several policy options exist to address it. Though difficult to design and maintain, Wilkinson suggested that one option to relieve poverty is to give people money through a welfare system in such a way that they have secure and predictable income. Another option would be to change the environment so that jobs are available and pay well.

The unhealthy food choices of those in poverty is another area of concern, and Wilkinson said there are ways to discourage unhealthy choices and encourage healthier choices. With regard to body weight, one policy option would be to make healthier foods more affordable and accessible and to make unhealthy foods more expensive and difficult to access. This can be achieved through several routes, including taxing sugar or dietary fat and restricting promotions for junk food (e.g., “buy one, get one free”). Other policy options include restricting the display of unhealthy products at stores and limiting the density of fast-food restaurants in geographic areas. Wilkinson said that the overarching goal here is to make unhealthy food more expensive or harder to access and, ideally, make the healthy choice easy.

Wilkinson argued however, that most people do not identify health as the supreme for a good life and said that people often risk their health for another value. For example, grandparents would rather play with their grandchildren and take the risk of getting sick than not play with them and remain healthy. Similarly, athletes often set and work towards unhealthy goals that risk their body wellness. To apply this point to body weight, Wilkinson said, healthy foods and drinks are often more expensive and take more time to prepare for consumption, and people who eat cheap, convenient, unhealthy food and drink may well be acting reasonably given their circumstances of not having much money or time. If they are acting reasonably based on their circumstances, Wilkinson said here, making these foods and drinks more expensive or harder to get would make them worse off, not better off. Put another way, policies such as sugar taxes would reduce the welfare of the worst off, which is inequitable.

Thomas Lee, an internist at Brigham and Women’s Hospital, the chief medical officer of Press Ganey, and a professor at the Harvard T.H. Chan School of Public Health in Boston, Massachusetts, said that there is considerable variation in communication between the provider and the patient. He argued that trust is paramount to the patient–provider relationship and quoted from Frances Frei’s The Trust Triangle, which identifies authenticity, empathy, and logic as necessary to build trust between a provider and a patient (Frei and Morriss, 2020).

Lee also asserted that two features are reliably present when patients have high confidence in their providers: courtesy and respect. Another characteristic is the concept of hope, and Lee presented a checklist for providers to ensure its inclusion in the care process (Mylod and Lee, 2023). The idea is for patients to feel as if their health care team has the will and skill to help them achieve their goals. Finally, Lee offered the teachings of Confucius on the role of rituals and norms and acting in a predictable and familiar way. He said that predictable moments are how providers can hone their instincts, become more attuned to patients, build trust, provide hope, and help them change their behavior to improve their health.

STRATEGIES FOR IMPROVING COMMUNICATION ABOUT BODY WEIGHT

J. Nadine Gracia is the president and chief executive officer of Trust for America’s Health (TFAH), a nonpartisan nonprofit organization in Washington, D.C., that promotes optimal health and works to ensure that health equity and prevention are foundational to policy making and are supported by data and research to improve population health. TFAH uses a variety of strategies to inform and “make the case” to policy makers with evidence-based policy recommendations, data, solutions, promising examples and spotlights, and stories from the field.

Health expenditures reached $4.3 trillion in 2021, though expenditures did not translate into positive health outcomes in the United States (Martin et al., 2023; Roser,

2020). Gracia indicated that the understanding of the potential causes for the worsening health outcomes in terms of obesity has evolved over the past 20 years. For example, the recognition of obesity as a disease and a broader understanding of the social determinants of health, health equity, and weight stigma, are lessons that have informed TFAH’s priorities.

Gracia turned the discussion to TFAH’s current priority areas that focus on inadequate funding for obesity prevention and public health (TFAH, 2022). The Centers for Disease Control and Prevention (CDC) receives 31 cents per person for obesity prevention grant programs that are evidence-based, such as the CDC’s State Physical Activity and Nutrition program (SPAN) (CDC, 2023a; grants.gov, 2023). As a result, while all states are eligible to apply, the CDC has enough funding for programs in only 16 states each fiscal year, leading to a significant missed opportunity for the other 34 states, U.S. territories, and tribes. Furthermore, between 2011 and 2023, CDC funding for chronic disease prevention did not keep pace with the increasing public health issue of obesity in the United States (CDC, 2023b).

Gracia urged participants to recognize the opportunity with the Biden–Harris administration’s National Strategy on Hunger, Nutrition, and Health (White House, 2022) to advocate for and educate about obesity prevention and treatment, emphasizing the social determinants of health.

The second speaker of the session, Jennie Day-Burget, a senior communications officer at the Robert Wood Johnson Foundation (RWJF), talked about obesity narratives. At the inception of its commitment to preventing and reducing childhood obesity, RWJF worked to shift popular narratives about obesity away from individual responsibility and blame and towards narratives inclusive of the policies, systems, and environment changes needed to nurture healthier communities for children. Day-Burget said that with the backsliding towards individual responsibility narratives during the COVID-19 pandemic, RWJF doubled down on its work to shift away from harmful narratives, launching a refreshed effort in 2023 to develop a new narrative on childhood obesity. Research has found that kids link feelings of shame, sadness, and embarrassment with terms like “fat” and “weight problem” and inadvertently create a narrative about obesity and diseased bodies (Kyle and Puhl, 2014; Puhl et al., 2017).

Day-Burget said that RWJF previously collaborated with TFAH on the annual report, F as in Fat, to use shock-value language and garner media attention. While the report received media coverage, Day-Burget admitted that the title caused harm.

Since then, Day-Burget said, RWJF has taken steps to improve the narrative about obesity. RWJF no longer focuses on obesity-rate data and instead promotes the perspectives of community thought leaders and emphasizes systems-level solutions that could improve the built environment for better health outcomes. RWJF has also shifted to use people-first language, removing blame from individuals and refocusing on systems.

Day-Burget reported that RWJF has completed research analyzing how popular media, including Twitter, covers obesity, stigma, and bias. There were promising indications that mainstream media is beginning to use positive language, signaling a shift in cultural norms. Day-Burget said that social media still uses antiquated language with high engagement and promotes offensive and negative narratives about weight.

A 16-month study by the RWJF examined structural racism in health messaging. Results identified a formula for three steps to engage audiences about obesity and weight, acknowledging structural racism in society: (1) start with a shared, values-based ideal statement; (2) move into a positive vision and problem statement without using disparities data; and (3) end the message with a call to action and a unity statement.

STRATEGIES FOR PROMOTING CHANGE IN CULTURE AND PERCEPTION AROUND BODY WEIGHT

Natalie Slopen, an assistant professor in the Department of Social and Behavioral Sciences at the Harvard T.H. Chan School of Public Health and an affiliated faculty member at the Center on the Developing Child at Harvard

University, kicked off the final session, which was intended to share strategies for promoting change in culture and perceptions concerning body weight. Slopen introduced the socioecological model (SEM) to frame the discussion and provide insight into the interconnected systems of oppression for structural racism and obesity stigma. The SEM considers layers of systems where structural racism has guided the development and perpetuation of inequitable social environments, shaped the social determinants of health, and led to discriminatory treatment of minoritized individuals, leading to long-term health consequences. In addition, she said, the SEM can help identify leverage areas in which to address inequities and design interventions.

Slopen referred to Zinzi Bailey’s definition of structural racism, “the totality of ways in which societies foster racial discrimination through mutually reinforcing systems . . . . These patterns and practices in turn reinforce discriminatory beliefs, values, and distribution of resources” (Bailey et al., 2017, p. 1455). Slopen asserted that structural racism shapes the environment in which people grow up, learn, work, and play, affecting access to healthy foods, a safe environment, and physical activity.

Although some research suggests that socioeconomic status (SES) rather than structural racism is responsible for health inequities, Slopen argued that SES is incomplete and fails to account for community context. In a recent study, Dolores Acevedo-Garcia introduced the Child Opportunity Index 2.0 and ranked communities using 29 dimensions of opportunity to characterize contextual advantages and disadvantages for children (e.g., early education centers, home ownership) (Acevedo-Garcia et al., 2020). That study found significant differences in community context and opportunity for children not explained by income or SES, with 66 percent of poor black children and 50 percent of poor Hispanic-Latino children residing in very low-opportunity neighborhoods, compared with 20 percent of white children.

Slopen listed four priorities for addressing structural racism and obesity stigma. First, she emphasized the importance of using comprehensive approaches to address root causes of structural racism and stigma. Second, she said, attention needs to be paid to creating more equitable social and structural environments for all individuals. The third priority is developing strategies that foster awareness, empathy, and understanding in order to challenge weight-related discrimination. And fourth, strategies should be developed to inspire and promote political will and commitment to a more equitable future.

Brian Castrucci, the president and chief executive officer of the de Beaumont Foundation and a public health advocate with lived experience, shared his story as a person living in a larger body. Castrucci has gained and lost weight several times throughout his life and experienced ridicule and stigma from providers. As a 13-year-old, Castrucci lost 50 pounds and, upon seeing his pediatrician, was told he was still fat. More recently, Castrucci lost 70 pounds in response to a heart attack, and, when visiting with his endocrinologist, he was told he was still fat and needed to lose more weight. Weight stigma persists, Castrucci said.

To further illustrate this point, Castrucci did an internet search for “conversion therapy,” which aims to convert kids who identify as LGBTQ to be heteronormative. This search yielded results of several organizations condemning this type of therapy and offering support. Castrucci then did a second Internet search for “fat camp,” which yielded “the best fat camp for families,” revealing a stark difference in how U.S. society and culture view overweight and obesity versus LGBTQ individuals.

Castrucci asserted that obesity was medicalized, which shifts the blame to individuals and is historically similar to the medicalization of drug use. To de-medicalize obesity in our language, actions, and policies would require recognizing the social determinants of health as critical factors determining housing, salary, and the availability of healthy foods and directly affecting nutrition and possibly weight. Indeed, Castrucci said, misinformation in medicine promotes conflicting beliefs and leads to inaccurate and unrealistic strategies for weight loss. Castrucci pointed to social media advertising that preys on fear (e.g., “Overnight ways to lose weight,” keto or low-carbohydrate diets). Castrucci urged participants to consider a person with a larger body

boarding a plane without larger seats. To have obesity is a deep fear for Americans, and there is societal resistance to enacting change, he said.

Castrucci closed by suggesting that health information is not valued or regulated. He noted that if a layperson opens a primary care clinic, he or she can receive jail time for impersonating a physician, but it is legal for a layperson to give nutrition advice without training. “How,” he asked, “do we shape a society that allows people to be healthy at every weight, prioritizes health, and gives people the information they need to make healthy choices?”

CLOSING REMARKS

Nicolaas P. Pronk, the president of the HealthPartners Institute and the chief science officer for HealthPartners in Minneapolis, summarized the workshop. Among the key points raised, he said, were the challenge of defining obesity and reconsidering the health implications with diagnosis, perhaps with a staging system. Pronk said that there is a critical need to support evidence-based and medically actionable clinical treatment in ICD coding and that, based on the presentations, BMI is an incomplete clinical parameter.

Speakers in session two demonstrated that learners are not blank slates, that they hold biases, and that they often respond to being shown their biases with denial or overt bias. Pronk said there is a need to shift health care treatment of obesity so that it is focused on improving health, not on losing weight per se, and there is a desperate need for better communication in discussing obesity with patients and families.

Speakers in session three on ethics and trust in the context of weight and health demonstrated that individuals with higher body satisfaction were less likely to describe themselves as having overweight or obesity and that weight stigma is linked to physical, psychological, and mental health. While there is an ongoing paradigm shift toward weight inclusivity, change is slow, as evidenced by Castrucci’s most recent anecdote about his endocrinologist. Pronk summarized discussions on policy by saying that policy work is not only complicated, but it is also complex because sometimes health may not be the most important value in a person’s life. Policy makers need to think more upstream in the context of larger systems and be cognizant of the unintended consequences of equity-focused policies that may inadvertently produce inequitable results. Pronk also said that building trust between providers and their patients requires authenticity, empathy, and logic. Patients are inclined to trust their providers, and research consistently shows that courteous and respectful providers earn patients’ confidence.

Speakers in session four discussed the importance of data and storytelling to advocate for equitable health policy effectively. Despite high health care spending, Pronk said, life expectancy in the United States has been declining, and obesity is a key factor. While the obesity narrative has shifted towards a systems and environmental change perspective, there is a critical need for increased awareness of the impact of providers’ language and words on patients’ success, Pronk said. People-first language is a starting point, and communicating about shared values is critical for inclusive communication.

Speakers in session five emphasized the importance of recognizing obesity stigma in the broader context of structural racism and the interconnected systems of oppression that perpetuate harm. Pronk said that identifying critical points that shape communities using the social–ecological model could help identify effective intervention opportunities. However, the first step is to set priorities that address structural racism and obesity stigma with comprehensive interventions that create equitable and social environments along with strategies that foster awareness, empathy, understanding, and the political will to create a more equitable future for all.

REFERENCES

DISCLAIMER This Proceedings of a Workshop—in Brief has been prepared by Amanda Berhaupt as a factual summary of what occurred at the meeting. The statements made are those of the rapporteur or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

REVIEWERS To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Tracy Zvenyach, Obesity Action Coalition, and Robin Blackstone, Blackstone Health, LLC. Leslie J. Sim, National Academies of Sciences, Engineering, and Medicine served as the review coordinator.

STAFF Heather Cook, Amanda Nguyen, Cypress Lynx, and Meredith Parr, Food and Nutrition Board, Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine. Staff thanks William H. Dietz, The George Washington University, for providing his technical expertise in the preparation of this publication.

SPONSORS This workshop was partially supported by the Academy of Nutrition and Dietetics; Alliance for a Healthier Generation; American Academy of Pediatrics; American Cancer Society; American Council on Exercise; American Society for Nutrition; Blue Shield of California Foundation; Bipartisan Policy Center; Eli Lilly and Company; General Mills, Inc.; The JPB Foundation; Kresge Foundation; Mars, Inc.; Nemours Children’s Health System; Novo Nordisk; Obesity Action Coalition; Partnership for a Healthier America; Reinvestment Fund; Rudd Center for Food Policy and Health; Robert Wood Johnson Foundation; SHAPE America; Society of Behavioral Medicine; The Obesity Society; Trust for America’s Health; Wake Forest Baptist Medical Center; and Walmart.

For additional information regarding the workshop, visit https://www.nationalacademies.org/event/06-26-2023/going-beyond-bmi-communicating-about-body-weight-a-second-workshop-in-the-series.

SUGGESTED CITATION National Academies of Sciences, Engineering, and Medicine. 2023. Going beyond BMI: Communicating about body weight: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/27288.

Health and Medicine Division Copyright 2023 by the National Academy of Sciences. All rights reserved.