Proceedings of a Workshop—in Brief

BMI and Beyond: Considering Context in Measuring Obesity and its Applications

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, BMI and Beyond: Considering Context in Measuring Obesity and its Applications, on April 4, 2023. The workshop was the first in a two-part series to explore the current science on measures of body composition, body fat distribution, and obesity.

This workshop focused on the efficacy of body mass index (BMI) as a measure of adiposity and obesity, morbidity, and mortality, as well as alternative measures and their impact on obesity prevention, treatment, and policy. Presentations highlighted different perceptions of BMI globally and across sectors, ethnic groups, cultures, and lifespan. Workshop sessions covered the scientific evidence for measures of body composition and fat distribution and the strengths and limitations of BMI as a measure of adiposity and health.

Nicolaas (Nico) Pronk, president at the HealthPartners Institute and chief science officer for HealthPartners, Inc., explained that the Health and Medicine Division established the roundtable 9 years ago to foster dialogue on critical and emerging obesity-related issues in public policy and the environment, and to identify effective strategies to address disparities. The roundtable has engaged leaders from diverse sectors that drive policy and shape the environment, including health care, industry, government, philanthropic and non-profit organizations, the financial sector, and academia. Through innovation collaboratives and public workshops, the roundtable aims to explore effective solutions that prevent, treat, and manage 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.

“OBESITY”: DEFINITIONS AND PERSPECTIVES

The first session, “Obesity”: Definitions and Perspectives, presented historical and anthropological perspectives of

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BMI as an accepted health measure and its subsequent societal implications. Edward (Ted) Fischer, cultural anthropologist, Cornelius Vanderbilt Professor of Anthropology, Management, and Health Policy, and director of the Cultural Contexts of Health and Wellbeing Initiative at Vanderbilt University, began the session by introducing his research on ways to integrate cultural insights into health policy and clinical care.

Fischer urged clinicians and society to look beyond the physiological processes explaining weight-related illnesses and to consider the “cultural and colonial and commercial context that interact with metabolic processes to produce certain health outcomes.” Viewing obesity through a cultural lens has yielded three predominant cultural insights: “Food is more than nutrition. Diet is more than individual choice. And health is more than weight” (Fischer et al., 2022).

Fischer asserted that body ideals are a social construct with historical origins from Western enlightenment and colonialism with European-centric body model roots. Adolphe Quetelet, a Belgian astronomer and statistician, developed the modern-day BMI measure based on the height and weight modeled after European adult males (Eknoyan, 2008; Strings, 2019). Subsequently, this body ideal served as the comparative model for all other body types, including people of non-European ancestry.

These body ideals have led to modern society’s negative judgments of people whose bodies differ from these ideals, including beliefs that weight is a personal choice marked by laziness or lack of willpower, Fischer continued. Society accepts cultural facts and believes them to be valid. The same is true for scientific facts, though based on empirical data and concepts developed through a Western- and European-centric lens. The result is that both types of facts contribute to society’s understanding of BMI and health outcomes. Recent research by Venkat Narayan suggests an alternative pathway to type 2 diabetes in South Asians in Chennai, India, which occurs at a lower BMI than Western populations (Venkat Narayan et al., 2022). By contrast, in the United States, 85 percent of Americans with type 2 diabetes also have obesity, and yet some Americans of normal weight are metabolically unhealthy. In other words, weight is not an unequivocal indicator of metabolic health.

Katherine Flegal,² a consulting professor at Stanford University and former senior scientist at the Centers for Disease Control and Prevention’s (CDC’s) National Center for Health Statistics, turned the discussion toward the evolution of BMI categories and healthcare coverage of obesity.

Flegal pointed to the 1995 World Health Organization (WHO) report on anthropometry that identified three BMI cutoffs for overweight. However, the report conceded that the cutoffs for fat mass or fat percentage could not be translated into cutoffs for BMI or increased health risk and were, therefore, “largely arbitrary” (WHO, 1995). According to Flegal, 2 years later, the International Obesity Task Force (IOTF), with funding from the pharmaceutical industry, brought attention about the obesity epidemic to health ministries by paying to distribute the interim consultation report to health ministers of all UN countries and to any others who requested it (James, 2008). In 1995, four scientists from IOTF also served on a committee at the National Heart, Lung, and Blood Institute (NHLBI) that established new guidelines for overweight and obesity. Flegal said that IOTF helped influence the use of updated categories of obesity (BMI 30 to 39.99) and severe obesity (BMI ≥ 40) included in both the 1997 WHO IOTF interim consultation report and the 1998 NHLBI Clinical Guidelines without a citation that justified the classification.

Flegal said that although national reports on BMI highlighted the prevalence of U.S. obesity, physicians did not treat obesity because the U.S. Medicare Coverage Issues Manual did not include obesity as a disease, which prevented reimbursement for related services. In addition, Flegal noted that in the United States, the culture of weight loss extends beyond adults who are overweight. Data from 2013 to 2016 indicated that nearly one-third of normal-weight or underweight adults were trying to lose weight (Martin et al., 2018). To leverage

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the attention on obesity, Flegal continued, an IOTF member who had joined CDC organized and chaired a CDC meeting about reimbursement of health care providers for obesity treatment, leading to the removal of language that “obesity is not an illness” in the Medicare Coverage Issues Manual.

Flegal said that Rubino et al. (2023) points out that obesity as a disease “defined exclusively by BMI threshold is intrinsically flawed” because it lacks measurement beyond height and weight and does not measure health risks. Prior to the late twentieth century, obesity was largely seen as a cosmetic issue and not a health risk (IOM, 2012). More recent publications support a shift in thinking from using BMI as a predictor of future disease or mortality to a clinical definition of obesity that measures existing illness (Bosy-Westphal and Müller, 2021; Rubino et al., 2023).

Donna Ryan, professor emerita at Pennington Biomedical and consulting advisor to companies for obesity management, emphasized that obesity is a disease with an etiology and pathogenesis. As evidence, Ryan offered the Soggy Bathroom Carpet Model of Over-Nutrition–Related Metabolic Disease Obesity (O’Rahilly, 2021), which posits that when the ability to store healthy fat is exceeded by a continuous positive energy balance, ectopic and abnormal fat stores lead to metabolic disease (Blüher, 2020). Type 2 diabetes is a prime example of a metabolic manifestation of obesity.

Ryan underscored that BMI is strictly a screening tool for obesity. Clinical judgment is required to diagnose obesity with evidence of excess abnormal body fat through waist circumference and cardiometabolic risk factors. Furthermore, Ryan indicated that modest and moderate weight loss produce health benefits; however, there is an essential need for alternative clinical measurements to determine if changes in fat mass and lean body mass are accompanied by general weight loss. While there are clinically applicable body composition methods to measure these changes, there are limitations, such as radiation exposure with dual x-ray absorptiometry (DEXA) and limited clinical study of digital anthropometry. Ryan asserted that clinical judgment will always be necessary for clinical diagnosis of obesity, including surrogate measures for treatment progress on health status. Future research could investigate how gender and racial biases intersect with weight stigma to advance clinical practice for obesity treatment.

TENSIONS AND PERSPECTIVES AROUND BMI

Jamy D. Ard, professor at Wake Forest University Baptist Medical Center and co-director of the Wake Forest Baptist Health Weight Management Center, began the next session by providing a clinical perspective of BMI in practice. Ard agreed with Ryan that BMI is a screening tool, though he offered that it also directs patient treatment, such as pharmacotherapy and surgery. For example, CMS determined that intensive behavioral therapy for obesity is only permitted and reimbursable for providers treating patients with a BMI of 30 or greater (CMS, 2011).

Furthermore, Ard explained that payers or employers use BMI for treatment allocation, meaning they use BMI cutoffs to determine therapies or treatments available to individuals. For example, a person with a BMI of ≥ 40 may be eligible for some therapies or interventions, while those with a BMI of 30 to 39.99 may not; it is payer dependent. Finally, Ard reminded participants that BMI is in the electronic health record, and Medicare requires providers to enter a BMI code for reimbursement for services for all patients.

The value of BMI is that it is easy to use, and the cutoffs are broadly understood; however, Ard said, challenges with BMI are frequent when interacting with patients without context as a screening tool and misunderstanding its meaning, which can harm the patient–provider relationship. Ard explained that some patients believe the only way to be healthy is to reach a normal BMI, but that clinicians know that when a person begins losing weight, immediate metabolic benefits happen. Some patients from various racial and ethnic backgrounds, Ard added, do not believe BMI applies to their health; in such cases, he advises redirecting the conversation to health. Ard lastly shared that explaining to patients the treatments available based on BMI cutoffs inconsistent with clinical judgment is a difficult

conversation—some resort to intentionally gaining weight to achieve a greater BMI for access to treatment.

Cynthia Ogden, an epidemiologist at the National Center for Health Statistics, CDC, continued the discussion to highlight the utility of BMI in trends and distributions at the population level and illustrate a limitation of BMI as a measure of body fat or adiposity, particularly in differences among ethnic groups.

Ogden began by summarizing the strengths and limitations of BMI. She reminded participants that while BMI is simple, inexpensive, and valuable to observe body weight over time in a population, it is not a direct measure of body fat, does not distinguish the type of fat, nor distinguish between fat and lean mass. Furthermore, Ogden asserted considerable variability of the association between BMI and adiposity and BMI and health outcomes among ethnic groups. Accordingly, the BMI cutoffs vary in different countries in response to differing associations with health risks.

Ogden added that data vary due to differences in BMI cutoffs (e.g., WHO vs. CDC vs. IOTF) and data collection methods (self-reported vs. measured). Though Ogden offered that if public health professionals use the same cutoffs and methods, BMI is useful to monitor trends and the shift in the distribution of obesity in a population over time (Hales et al., 2018).

Ogden clarified that differences in BMI do not correlate with differences in body fat percentage, and BMI is not a good measure to compare body fat. For example, Black girls had a higher BMI than White or Mexican American girls, but body fat measured by DEXA scans did not differ (Flegal et al., 2010).

Stacy Wright, a Ph.D. student in Health Outcomes and Implementation Science at the University of Florida, shared her lived experience as a child with overweight and obesity and the effects on her mental and physical health as a Jamaican woman living in the United States. Wright explained that in her childhood, she worried most about how she felt and what others thought of her body and appearance. However, Wright did not worry about getting sick with a chronic disease, especially because doctors diagnosed only her adult family members with obesity, and they did not appear sick.

Wright recounted that she was a very athletic child. Even so, her mother monitored her eating habits and brought her to the doctor out of concern for her body size. After testing with bloodwork, the doctor reported that Wright was metabolically healthy. Nevertheless, Wright experienced shame and stigmatization as a person living in a larger body that shadowed her accomplishments through negative comments from fellow students and health care providers. Wright internalized this shame and tried several diets that did not produce sustained weight loss. Wright advocated for education opportunities for providers on weight bias, discrimination, communication with patients, and employment of a holistic and individualized approach to prevent, reduce, and treat obesity.

APPLICATIONS AND USES OF BMI, BODY COMPOSITION, AND BODY FAT DISTRIBUTION

Michael D. Jensen, Tomas J. Watson, Jr. Professorship at the Mayo College of Medicine and consultant in the Division of Endocrinology and Metabolism, began by asking participants, “Why are we interested in body fat and body fat distribution?” The reason, Jensen posited, is that adipose tissue is critical for metabolizing dietary fat. When eating a meal with fat, triglycerides go into the bloodstream, and adipose tissue stores the triglycerides by removing them. When not eating, adipose tissue releases the fat molecules into the bloodstream as an energy source for other tissues. Adipose tissue that is not functioning normally increases triglycerides in the bloodstream, leading to an increased risk for hyperlipidemia and diabetes.

Jensen continued that BMI and body fat are strongly correlated, though significant discrepancies remain. BMI does not distinguish fat stored in the visceral and subcutaneous areas. However, there is a somewhat positive relationship between BMI and visceral fat, which is predictive of larger fat cells, and together lead to metabolic dysregulation, increased triglycerides in the bloodstream, and adverse health outcomes. Jensen further explained that there are biological differences

between lean body mass and fat mass in men and women. When comparing body fat in young men and women with the same BMI, women hold nearly double the body fat percentage than men. Based on his analysis (unpublished), fat mass in women with a BMI of 30 to 35 can account for up to 50 percent of their weight, with typically less visceral fat than men.

Jensen offered that regardless of BMI and visceral fat, the adipocytes’ size is most predictive of metabolic dysregulation because they produce fewer adipocyte storage proteins leading to inefficient triglyceride removal from the bloodstream after meals and increased fatty acid release while fasting. That is, a positive relationship exists between BMI and fat cell size, and the amount of visceral fat is a more accurate predictor of fat cell size than BMI.

David Arterburn, a general internist, senior investigator at the Kaiser Permanente Washington Health Research Institute, and affiliate professor in the Department of Medicine at the University of Washington, turned the discussion to BMI in health services. Arterburn explained that his research in health services aims to understand how best to organize, finance, and deliver high-quality health care to patients.

Arterburn explained BMI’s quick progression and retirement as a quality measure in the health care setting as a determinant for treatment and care. The National Committee for Quality Assurance (NCQA) created the Adult BMI Assessment (ABA) as a performance measure (NCQA, 2023). In 2009, BMI was documented in 40 percent of outpatient visitors, but 10 years later, more than 80 percent of outpatient visitor health records included a BMI assessment. However, in 2020 NCQA discontinued ABA because the electronic medical record automatically calculated BMI, and its performance was not measured alongside lifestyle counseling or other interventions.

Arterburn transitioned to discussing how BMI relates to health care expenditures, referencing a study that estimated that adult patients with a documented normal or healthy BMI (18.5 to 24.9) were predicted to have 43 percent lower health care costs than patients with a BMI ≥ 35 (Ward et al., 2021). Arterburn then described alternative measures of adiposity or visceral fat. In a clinical setting, waist circumference is cost-effective even after training staff and purchasing measuring tape. However, barriers include patient – provider discomfort and difficulty securing the tape measure around the waist. Arterburn then explained that whole-body DEXA is more accurate, but costs about $200 per test, while a CT or MRI are better measures than BMI, but are also more expensive. Arterburn concluded that BMI is a more cost-effective and efficient measure despite its limitations.

Therefore, Arterburn advocates for additional adiposity-risk screening measures (i.e., alternative anthropometric measures) to narrow the patient population at greatest risk for adverse health outcomes related to visceral fat and to determine who would benefit most from lifestyle, pharmaceutical, and surgical interventions. However, an increase in patient treatment for obesity-related health risks dramatically increases the cost of health care.

Alberto Caban-Martinez, a board-certified physician-scientist, associate professor of public health sciences, and deputy director of the M.D.–M.P.H. Program at the University of Miami, shifted to offer a perspective on how occupation might impact individuals’ weight status and associated health risks. Caban-Martinez challenged participants to think about how the work environment could support body weight management in U.S. workers.

“Work,” Caban-Martinez argued, “is an intrinsic and important social determinant of health.” He added that work determines economic stability, area of residence, and neighborhood, which governs access to education, healthy and nutritious food, and health care through health insurance. Looking at trends in the U.S. workforce from 1986 to 2002, some occupational groups had an increased risk for obesity. For example, men employed as policemen and firefighters exhibited a 2 percent increase in the rate of obesity, and women employed in motor vehicle operations had a nearly 6 percent increase over the 16 years studied. Other occupations demonstrated a decrease in the rate of obesity over time; these included men in personal service occupations and farm work

and female secretaries and stenographers (Caban et al., 2005). Caban-Martinez reasoned that identifying at-risk occupational groups provides the opportunity to surveil and offer workplace interventions (Caban et al., 2005).

Caban-Martinez pointed to sedentary responsibilities, among other factors, as the reason for the increased rate of obesity in some occupations (Streeter et al., 2021; Tanofsky-Kraff et al., 2013). To characterize the prevalence of overweight and obesity among recruits and incumbent military personnel, the U.S. Army Research Institute of Environmental Medicine is seeking alternative measures for body fat, such as DEXA scans and bioelectrical impedance, and comparing results to the traditional waist circumference measurement. Other research in the civilian workplace found that people who worked full-time from home before, during, and after the COVID-19 pandemic were more likely to spend time sitting and less likely to exercise compared with those working in a hybrid arrangement.

Caban-Martinez urged participants to consider working with employers, their employees, and the work environment for opportunities to reduce sedentary behavior and support healthy body weight management through physical activity such as walking meetings (Kling et al., 2016).

Faith Anne Heeren, a doctoral student at the University of Florida and founder and president of OCEANS (Outreach, Community, Engagement, Advocacy, Non-discriminatory Support), a non-profit advocacy group for adolescents with obesity, shared her lived experience as a person and a patient living with obesity and her access to care (OCEANS, 2023). At a doctor’s visit, Heeren recounted the interaction between her mother and doctor about her weight. The provider told her mother not to serve cookies after dinner without sharing actionable steps to support her daughter’s health. Heeren explained that she continued to gain weight in childhood and adolescence and developed high blood pressure and insulin resistance. Eventually, Heeren learned about the Healthy Lifestyles program at Duke University that offered bariatric surgery for teenagers.

Heeren underwent bariatric surgery, and her insulin resistance and high blood pressure resolved and her confidence increased. “Having access to high-quality, evidence-based treatment allowed me to recognize obesity for what it is, a chronic disease and not a punishment for moral failing,” said Heeren.

Heeren shared how her hardships and stress during the COVID-19 lockdown led to considerable weight gain. As a result, she was experiencing excessive daytime sleepiness and joint pain, so she met with a provider to discuss anti-obesity medications to lose weight. On February 14, 2023, Heeren began taking the medication Topiramate while continuing her behavioral intervention. Heeren shared that she has achieved clinically significant weight loss since February and has increased energy, decreased joint pain, and a plan to monitor her bloodwork to compare to her baseline. However, Heeren’s health insurance will not cover weight management services, so her weight management plan is compromised.

LOOKING AHEAD

Pronk began session four by sharing his perspective on the best ways to move forward with BMI in the context of obesity if, after all, “a risk factor is not a disease.” Pronk recalled the presentations and sessions that provided insights and considerations about the relationships between BMI and the definition of obesity and diagnosis, the social and clinical implications, and the lived experiences of people living in larger bodies.

S. Bryn Austin, professor of social and behavioral sciences at Harvard T.H. Chan School of Public Health, professor of pediatrics at Harvard Medical School, a scientist in the Division of Adolescent and Young Adult Medicine at Boston Children’s Hospital, and founding director of the Strategic Training Initiative for the Prevention of Eating Disorders: A Public Health Incubator, began her talk with a definition of health equity from Braveman et al. (2017):

Referencing Shiriki Kumanyika’s Framework for Increasing Equity Impact in Obesity Prevention, Austin explained its intent to guide the selection of interventions to reduce disadvantage and improve equity. Austin clarified that her focus was on the fourth quadrant of the framework that focuses on policy and systems change interventions for people living in larger bodies (Kumanyika, 2017, 2019). Austin stated that weight stigma and discrimination threaten people living in larger bodies—through disparaging associations of negative personal characteristics, lower earnings, a lower likelihood of being hired or promoted, a greater likelihood of being fired, lower ratings by teachers in schools and college admissions, inaccessible public settings, and social isolation. Austin pointed out the connection between inequities and a higher risk for depression, anxiety, eating disorders, and physiological stress.

Austin said that in 95 percent of America, there is no protection against weight discrimination for people living in larger bodies (UConn Rudd Center for Food Policy and Health, 2017). “Without laws to prohibit weight discrimination, people will continue to be unfairly fired, suspended, or demoted because of their weight, even if they demonstrate good job performance and even if body weight is unrelated to their job responsibilities.”

Referring again to the framework, but shifting to the equity issue of personal safety from discriminatory practices affecting people living in larger bodies, Austin suggested expanding access to health care by eliminating barriers to mitigate this threat, although she admitted it is challenging to agree on them. Austin urged participants to consider universal weighing as a barrier to health care, meaning routine weight and BMI surveillance. Using a SWOT (Strengths, Weaknesses, Opportunities, Threats) Analysis, Austin detailed the strengths, opportunities, weaknesses, and threats of universal weighing, reminding participants that BMI is a poor health indicator and the cause of persistent discrimination against people living in larger bodies and disproportionately minority communities.

Craig M. Hales, clinical reviewer for the U.S. Food and Drug Administration Division of Diabetes, Lipid Disorders, and Obesity, pointed out that in most chronic health conditions such as diabetes, hypertension, and hypercholesterolemia, there is a diagnosis, treatment, and goal(s) to measure success in each area. However, Hales emphasized that this is not the case for obesity as a disease. While BMI is an accepted metric for overweight and obesity, and there are various available treatments for those conditions, the measure of success in obesity treatment is not precise. In addition, professional societies have different clinical practice guidelines for obesity treatment (Bays et al., 2019; Jensen et al., 2013). Several presentations indicated BMI as a screening tool to monitor overweight and obesity trends in the United States. However, Hales pointed out that clinical guidelines are lacking, which prevents the development of outcome-focused metrics for public health surveillance, as observed in Healthy People 2030.

Michael G. Knight, internal and obesity medicine physician, medical director at The George Washington Medical Faculty Associates, and assistant professor at The George Washington University, offered his clinical perspective on defining obesity. He referenced the Obesity Medicine Association’s definition of obesity as “a chronic, relapsing, multifactorial, neurobehavioral disease wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces and results in adverse metabolic, biomechanical, and psychosocial health consequences” (Obesity Medicine Association, 2017). Knight pointed out that BMI would never accurately measure obesity because it is a multifactorial disease.

As a clinician, Knight continued, the Edmonton Obesity Staging System is a pictorial of how a clinician comprehensively thinks about individuals to determine their morbidity and mortality risk. “Are there other comorbidity effects? Is there any organ damage? Is there an end-stage level? What are the mental and psychological effects?” Knight concluded that like HbA1c in assessing

diabetes management and health risk, BMI is one number to consider when assessing a patient’s health.

CLOSING REMARKS

Ihuoma Eneli, board-certified general pediatrician and professor at The Ohio State University, and director of Nationwide Children’s Hospital Center for Healthy Weight and Nutrition, affirmed that “Health is not merely the absence of disease.” Body mass index is a surrogate measure of body fat with strengths and limitations as a measure of adiposity and health.

Eneli summarized that using BMI is simple, inexpensive, non-invasive, and valuable as a standardized and objective screening tool. A high BMI is correlated with body fat, which is correlated with health. Because of this, BMI guides treatment recommendations and reimbursement from insurers and serves as an objective endpoint in clinical trials. In children, BMI tracks a child’s growth.

However, Eneli continued, BMI is not a direct measure of body fat and, importantly, does not capture fat distribution. BMI does not distinguish between lean body mass and fat mass, nor does it account for the differences by race and ethnicity. Scientific evidence does not support the current BMI cutoffs to define obesity as a disease, and a change in BMI is not always consistent with changes in body fat, as observed in patients who have undergone bariatric surgery.

Eneli also stated that BMI does not measure adipocyte size, an emerging measure of fat cell dysfunction. The larger the adipocyte, the more likely it will be dysfunctional and the more likely it will be associated with adverse health impacts. Alternative measures to BMI are costly or unavailable for clinical use, though digital anthropometry holds promise.

Eneli explained that BMI is misinterpreted in health care, by employers, and in public health, and as a result, the measure leads to bias, stigma, and discrimination that compound health impacts, particularly among people living in larger bodies. Eneli suggested that clinicians discuss with patients the use of BMI as a screening tool and evaluate risk factors for health conditions.

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WHO (World Health Organization). 1995. Physical status: The use and interpretation of anthropometry—Report of a WHO Expert Committee. https://apps.who.int/iris/bitstream/handle/10665/37003/WHO_TRS_854.pdf?sequence=1&isAllowed=y (accessed May 18, 2023).

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 Rebecca L. Pearl, University of Florida. 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; Bipartisan Policy Center; Blue Shield of California Foundation; Eli Lilly and Company; General Mills, Inc.; The JPB Foundation; Kresge Foundation; Mars, Inc.; National Recreation and Parks Association; Nemours Children’s Health System; Novo Nordisk; Obesity Action Coalition; Partnership for a Healthier America; Reinvestment Fund; Robert Wood Johnson Foundation; Rudd Center for Food Policy and Health; SHAPE America; Society of Behavioral Medicine; Stop & Shop Supermarket Company; The Obesity Society; Trust for America’s Health; Walmart; and Wake Forest Baptist Medical Center.

For additional information regarding the workshop, visit https://www.nationalacademies.org/event/04-04-2023/bmi-and-beyond-considering-context-in-measuring-obesity-and-its-applications-a-first-workshop-in-the-series.

SUGGESTED CITATION National Academies of Sciences, Engineering, and Medicine. 2023. BMI and beyond: Considering context in measuring obesity and its applications: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/27185.

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