TL:DR

• Overdiagnosis and overtreatment is a problem

• Fat & Healthy is entirely possible

• Weight based bias and stigma are major obstacles in healthcare and training is needed to create #StigmaInformedSystems

• Pre-clinical - clinical 'obesity' OR #MeasureHealthNotWeight

• Watch out for that 'harbinger' language...

The recent Lancet Commission report, titled “Definition and diagnostic criteria of clinical obesity,” addressing the limitations of BMI and the need for a more nuanced understanding of ‘obesity’ has landed.

At Nutriri, a weight-neutral organisation committed to equitable healthcare and reducing weight stigma, we see this as a partial step in the right direction.

However, while this acknowledgment of BMI’s flaws is significant, there is still much work to be done to ensure equitable healthcare for people of all sizes.

Recognising the Problematic Nature of BMI

The report underscores a critical truth: BMI is an inadequate measure of health. It fails to account for the complexity of human health, and weight itself. This is something that many in the weight-neutral and fat advocacy communities have been saying for years. BMI’s one-size-fits-all approach often leads to harmful oversimplifications, which undermine effective healthcare and policy decisions.

Additionally, the report highlights the dangers of overdiagnosis and overtreatment of ‘obesity’, which can often stem from stigma in practice. Mislabeling individuals as unhealthy based solely on their weight perpetuates a cycle of unnecessary medical interventions and reinforces weight-based discrimination. This underscores the need for healthcare systems to move toward stigma-informed approaches that prioritise holistic health assessments over reductive metrics.

The Lancet Commission starts dismantling a deeply flawed metric. However, we must further develop to ensure that this translates into weight neutral real-world practice - a significant challenge given how ingrained BMI - in any format - is in healthcare systems worldwide.

Rubino et al.’s Intentional Use of Language and the unsurprising MEGA list of Declarations of Interest

The commission appears to offer only a cursory acknowledgment of the impact of stigma. Notably, the word "stigma" appears as the final term in both the "conclusion" and the "strengths and limitations" sections of the report. The concluding two lines state: "It is our hope that such reframing can inform public health policies, facilitate identification of appropriate targets for prevention versus treatment strategies, and contribute to overcoming misconceptions that reinforce weight-based bias and stigma." (It's worth noting that the commission included 10 reference papers focused on the impact of stigma among the 178 other papers included in their report.)

Of course we support the principle of prevention at Nutriri, but prevention of what? For us, the primary concern is poorer health outcomes. However, as one might expect from the extensive list of declarations of interest (among the 58 contributing experts, 38 listed Novo Nordisk, 29 mentioned Eli Lilly, and 20 cited Boehringer Ingelheim as pharmaceutical companies that have funded their work or in which they hold shares), the focus remains heavily on "solving obesity." ✳️ We leave it to the reader to determine whether "solving obesity" can remain a viable objective within a healthcare system free from stigma.

Intentional use of the word “harbinger” - often used to create a sense of impending doom or disaster. This can be a powerful rhetorical tool, but it can also be misleading and manipulative. By framing a particular event or trend as a "harbinger" of something negative, it can create undue fear and anxiety in the public. Getting the controversial “pre” in use is a very lucrative tool afterall.

The Gap Between Theory and Practice

Despite evidence that people can be healthy at higher weights, many continue to face systemic discrimination in healthcare settings.

For example, fat individuals are often denied access to fertility treatments and experience weight stigma during their maternity care based solely on their BMI. This systemic bias not only undermines their health but perpetuates the stigma that fat bodies are inherently unhealthy or undeserving of care. 

Assuming that weight is the root cause of health issues without examining other contributing factors leads to flawed conclusions and inequitable care.

Whilst moving away from the current model is a positive step, the new proposed approach still carries massive bias. Any attempt to reduce health to a body size only seeks to further isolate people from accessing the healthcare system and add to the bias and inequality they face. 

The Lancet Commission’s recommendations must be paired with actionable strategies to dismantle these barriers and ensure equitable healthcare access for all.

Tackling Weight Stigma Through Training

One of the report’s most crucial points is its acknowledgment of weight stigma as a significant obstacle to effective healthcare. Weight-based bias not only harms patients but also compromises the quality of care they receive. Healthcare professionals and policymakers urgently need proper training to address and reduce these biases.

At Nutriri, we are in our tenth year of listening to the workforce and how it feels to deliver on ‘healthy weight’ policy. The trainings we offer have been, and continue to be built with the lived experience of those at the coal face of health. Facilitated to gently unearth bias and even self-stigma, with tools and knowledge to approach patients of all sizes with respect, empathy, and evidence-based care.

One theme we consistently hear is that measuring BMI is simply getting in the way of great healthcare and support! This training is an essential step toward creating a healthcare system where everyone, regardless of size, receives the care they need.

Moving Forward Together - Weight Neutral First

The Lancet Commission’s report is a critical acknowledgement of the need for change, but is ‘BMI reform’ the answer? What is the benefit to the patient to continue to surveil their body size in the “name of health”? And even if weight change were truly a goal worth pursuing we’ve learnt time and time again that the annual probability of ‘obese’ patients achieving ‘normal’ weight is extremely low and any beneficial behaviours (which are likely the real reason why health is seen to improve) tend to diminish once the weight change stops. And then there’s GLP-1’s with their more than significant health risks; thyroid cancer, pancreatitis, kidney failure….

Co-creating weight neutral triage is urgently needed to start to rebuild trust and equity in our systems of care and community support. 

To create truly equitable healthcare for fat individuals, we must:

• Advocate for the removal of BMI-based barriers to care.

• Commit to comprehensive, weight-neutral training programs to eliminate weight stigma.

• Emphasise the development of stigma-informed healthcare systems that prioritise equitable, evidence-based approaches.

At Nutriri, we are proud to be part of this health equity building movement. By focusing on evidence-based, stigma-free approaches, we help build a healthcare system that values and supports people of all sizes. The Lancet’s Commission has opened the door; now, it’s up to all of us to walk through it and create meaningful change.