Table 3.

Discussing weight and body mass index (BMI): problematic practices in medical nutrition and recommendations for improvement

Avoid	Try this instead	Why?
Using BMI categories (healthy, overweight, and obese) as a measure of health Example: Assuming cardiometabolic health because of a normal range BMI	Focus on lifestyle, diet, physical activity, and objective measures of health as better predictors of health outcomes	BMI can be a useful population-level tool, but on an individual level, focusing on this number can bias clinicians and often misses health markers with more utility and predictive value It is not clear if increased weight causes, or is simply correlated with, adverse outcomes
Focusing on weight as a modifiable risk factor in an individual’s health Examples:   • “You need to lose weight to be healthy and control your diabetes.”   • American Heart Association’s blanket recommendation to “lose weight” [73]	Use SMART goals to help patients adopt sustainable health practices, focusing on objective measures that are clearly linked to health outcomes:   • Time spent physically active   • Number of sugary drinks consumed   • Blood pressure   • Hemoglobin A1c   • Lipid profile   • Pulmonary function tests	Weight is less modifiable than many presume, and weight cycling causes adverse health outcomes Weight is not a modifiable behavior Many health benefits of lifestyle modifications occur independent of weight loss If weight is the primary endpoint and does not change, this can lead to loss of motivation for behavior change
Overlooking risks of underweight Example: American Heart Association’s “Definitions of Poor, Intermediate, and Ideal Cardiovascular Health” fails to mention BMIs < 18.5 [73]	Recognize and address health risks at all weights, including those individuals with low BMIs	Being underweight carries significant health risks despite being more socially and medically acceptable within Western culture The health risks of being underweight are often underappreciated within clinical interactions
Presuming presence, absence or severity of an eating disorder based on BMI Example: “This person cannot have an eating disorder because their BMI is normal.”	Be aware of and screen for eating disorders in patients of all weights when discussing nutrition, weight, and lifestyle	Eating disorder behaviors can be present in those with normal or elevated BMIs and carry significant associated health risks. BMI-based assumptions about eating disorder presence cause harm and create barriers to treatment
Perpetuating eating disorder thoughts and behaviors Examples:   • “You look great, have you lost weight?”   • “You should cut out all carbs.”   • “I’m having a cheat day.”   • Silent curriculum emphasizing weight as “bad” and weight loss as the goal for health	Diet culture can be pervasive and addressing this explicitly is essential in discussions about health Prioritize communication and education that emphasizes unbiased markers of health Communicate to patients that steps towards health can be accomplished at any weight	Focusing on weight loss can cause or exacerbate eating disorder cognitions and behaviors Physicians and educators have a privileged place in society and serve as role models to students, patients, and the public; the way we discuss nutrition and weight has ripple effects Modeling healthy approaches to nutrition, weight, and exercise is protective and health promoting for all
Reinforcing fear or ignoring harm regarding medication effects on weight when treating other health conditions Examples:   • Overemphasizing risk of weight gain when prescribing oral contraceptives or selective serotonin reuptake inhibitors   • Underplaying risk of cardiometabolic effects of antipsychotics	For all medications and treatment plans, become aware of the likely side effects, their rates, mitigating factors, and cultural discussions that occur outside of the exam room Provide a chance for patients to discuss their concerns and be aware of evidence to be able to counsel appropriately without bias or reactivity	Patient and provider bias regarding weight gain from medication can pervade interactions over health for many medical conditions. For many common medications, the Internet and cultural conversations, particularly around weight gain, will affect adherence and provider use, which should be addressed in an evidence-based manner within clinical interactions
Using shame and fear tactics as a motivating strategy for behavior change Example: “Your weight is killing you.”	Prioritize communication and education that emphasizes patient autonomy, values, and health   • “What concerns do you have about your health?”   • “What are your thoughts about your weight?”   • “What goals do you have for your health?”   • Ensure adequate practice in motivational interviewing during medical training	Using shame or fear can be counterproductive in moving patients towards a better state of health Motivational interviewing which emphasizes a patient’s values, motivations, skills, and autonomy, has the greatest evidence base in fostering behavior change