Fildes et al.1 present sobering data on the reality of sustained weight loss for individuals with obesity. These authors concluded that current approaches to weight loss have failed and suggest, “research to develop wider reaching public health policies is needed to prevent obesity at the population level.” We agree that advances in research and policy should be leveraged to promote population health. However, we assert that this can best be achieved by shifting the focus away from markers of weight such as body mass index (BMI). BMI is a notoriously crude predictor of cardiometabolic health as well as mortality.2 Indeed, individuals with grade 1 obesity (BMI = 30.00–34.99 kg/m2) actually have a comparable risk of all-cause mortality to individuals considered to have a “normal” weight (BMI = 18.50–24.99 kg/m2).3
Beyond merely relying on a crude marker of morbidity and mortality, the weight-focused approach to public health can actually contribute to poorer mental and physical health by promoting mood disorders (e.g., depression), poor body image, and eating pathology.4 Emphasizing weight (and weight loss in particular) can also perpetuate the stigma associated with obesity–stigma which itself has significant consequences for the health of individuals with obesity. Experiencing or anticipating weight stigma can lead to increased eating, activation of physiological stress systems, decreased physical activity, and health care avoidance. Moreover, weight stigma actually predicts weight gain over time in large longitudinal studies, including the nationally representative Health and Retirement Study.5,6 Therefore, when viewed through the lens of public health ethics, continuing the dominant weight-centric approach may violate the core principles of beneficence and nonmaleficience.7
Where, then, should we focus, if not on weight? There are many candidates that more directly assess an individual’s health risk (e.g., blood pressure, fasting blood glucose, cholesterol, or triglycerides). We believe the evidence is particularly strong regarding the role of fitness as a more effective focus than weight. Cardiorespiratory fitness repeatedly outperforms measures of fatness (e.g., BMI) in predicting cardiovascular and metabolic health as well as cardiovascular and all-cause mortality.2,8
The evidence is clear: sustained weight loss is an untenable goal for the vast majority of individuals with obesity and a fervent emphasis on weight is likely to do more harm than good. Thus, to effectively promote the health and well-being of all individuals (regardless of their size), researchers, clinicians, and policymakers should eschew weight as the primary outcome of interest.
References
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