Exploring the Science
on Measures of Body
Composition, Body Fat
Distribution, and Obesity

_____

Amanda Berhaupt, Rapporteur

Roundtable on Obesity Solutions

Food and Nutrition Board

Health and Medicine Division

Proceedings of a Workshop Series

NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

This activity was 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; Found Health Inc.; 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. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-71517-1
International Standard Book Number-10: 0-309-71517-2
Digital Object Identifier: https://doi.org/10.17226/27461

This publication is available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.

Copyright 2024 by the National Academy of Sciences. National Academies of Sciences, Engineering, and Medicine and National Academies Press and the graphical logos for each are all trademarks of the National Academy of Sciences. All rights reserved.

Printed in the United States of America.

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2024. Exploring the science on measures of body composition, body fat distribution, and obesity: Proceedings of a workshop series. Washington, DC: The National Academies Press. https://doi.org/10.17226/27461.

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president.

The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president.

The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president.

The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine.

Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org.

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task.

Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies.

Rapid Expert Consultations published by the National Academies of Sciences, Engineering, and Medicine are authored by subject-matter experts on narrowly focused topics that can be supported by a body of evidence. The discussions contained in rapid expert consultations are considered those of the authors and do not contain policy recommendations. Rapid expert consultations are reviewed by the institution before release.

For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo.

PLANNING COMMITTEE ON EXPLORING THE SCIENCE ON MEASURES OF BODY COMPOSITION, BODY FAT DISTRIBUTION, AND OBESITY: A WORKSHOP SERIES¹

IHUOMA ENELI (Cochair), professor of pediatrics, The Ohio State University; director, Nationwide Children’s Hospital Center for Healthy Weight and Nutrition

NICOLAAS (NICO) P. PRONK (Cochair), president, HealthPartners Institute; chief science officer, HealthPartners, Inc.

S. BRYN AUSTIN, professor of social and behavioral sciences, Harvard T.H. Chan School of Public Health; professor of pediatrics, Harvard Medical School

W. SCOTT BUSCH, director of obesity medicine, Bariatric and Metabolic Institute, the Cleveland Clinic

CRAIG M. HALES, clinical reviewer, Division of Diabetes, Lipid Disorders, and Obesity, U.S. Food and Drug Administration

NATHANIEL KENDALL-TAYLOR, chief executive officer, FrameWorks Institute

MICHAEL G. KNIGHT, associate chief quality and population health officer; head of healthcare delivery transformation; and assistant professor of medicine, The George Washington University Medical Faculty Associates

___________________

¹ The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteur and the institution.

This page intentionally left blank.

ROUNDTABLE ON OBESITY SOLUTIONS¹

NICOLAAS (NICO) P. PRONK (Chair), HealthPartners Institute and HealthPartners, Inc., Bloomington, Minnesota

CHRISTINA ECONOMOS (Vice Chair), Tufts University, Boston, Massachusetts

IHUOMA ENELI (Vice Chair), Nationwide Children’s Hospital, Columbus, Ohio

JAMY D. ARD, Wake Forest University, Winston-Salem, North Carolina

HEIDI MICHELS BLANCK, Centers for Disease Control and Prevention, Atlanta, Georgia

JEANNE BLANKENSHIP, Academy of Nutrition and Dietetics, Washington, DC

JAMIE BUSSEL, Robert Wood Johnson Foundation, Princeton, New Jersey

DEBBIE I. CHANG, Blue Shield of California Foundation, San Francisco, California

LAURIE FRIEDMAN DONZE, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland

JENNIFER FASSBENDER, Reinvestment Fund, Philadelphia, Pennsylvania

AMENDA FISHER, Walmart, Bentonville, Arkansas

ALLISON GERTEL-ROSENBERG, Nemours Children’s Health System, Washington, DC

JAMIE GLONEK, Novo Nordisk, Plainsboro, New Jersey

J. NADINE GRACIA, Trust for America’s Health, Washington, DC

KAYLA JACKSON, The School Superintendents Association, Alexandria, Virginia

JOHN JAKICIC, University of Kansas Medical Center, Kansas City, Kansas

GABRIELLE N. JOHNSTON, American Council on Exercise, San Diego, California

PETER T. KATZMARZYK, Pennington Biomedical Research Center, Baton Rouge, Louisiana

REKHA KUMAR, Found Health Inc., New York, New York

THEODORE KYLE, The Obesity Society, Pittsburgh, Pennsylvania

BRUCE Y. LEE, City University of New York, New York, New York

MONICA V. LUPI, Kresge Foundation, Troy, Michigan

KYLE MACDONALD, Alliance for a Healthier Generation, Portland, Oregon

MYETA M. MOON, United Way Worldwide, Alexandria, Virginia

STEPHANIE A. MORRIS, SHAPE America, Reston, Virginia

___________________

¹ The National Academies of Sciences, Engineering, and Medicine’s forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteur and the institution.

JOSEPH NADGLOWSKI, JR., Obesity Action Coalition, Tampa, Florida

MELISSA NAPOLITANO, The George Washington University, Washington, DC

PATRICIA NECE, Obesity Action Coalition

MEGAN NECHANICKY, General Mills, Inc., Minneapolis, Minnesota

ANAND PAREKH, Bipartisan Policy Center, Washington, DC

SARAH A. WELLER PEGNA, National League of Cities, Washington, DC

BARBARA PICOWER, The JPB Foundation, New York, New York

MARGARET READ, Partnership for a Healthier America, Prince Frederick, Maryland

VICTORIA ROGERS, American Academy of Pediatrics, Portland, Maine

CHRISTY N. ROSS, National Association for the Advancement of Colored People, Washington, DC

SYLVIA ROWE, SR Strategy, LLC, Washington, DC

MARLENE SCHWARTZ, The Rudd Center for Food Policy and Health, Hartford, Connecticut

STEPHANIE A. NAVARRO SILVERA, Montclair State University, Montclair, New Jersey

TRACY SIMS, Eli Lilly and Company, Indianapolis, Indiana

JESSICA SMITH, Mars Wrigley, Hackettstown, New Jersey

KRISTEN R. SULLIVAN, American Cancer Society, Decatur, Georgia

SUSAN Z. YANOVSKI, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland

Staff

HEATHER DEL VALLE COOK, Roundtable Director

CYPRESS LYNX, Associate Program Officer

AMANDA NGUYEN, Program Officer

MEREDITH PARR, Research Assistant

ANN L. YAKTINE, Director, Food and Nutrition Board

Consultant

WILLIAM (BILL) H. DIETZ, the George Washington University, Washington, DC

Food and Nutrition Board Liaison

SHIRIKI KUMANYIKA, Drexel University, Philadelphia, Pennsylvania

Reviewers

This Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process.

We thank the following individuals for their review of this proceedings:

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by BARBARA HANSEN, University of South Florida. She was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteur and the National Academies.

This page intentionally left blank.

Acknowledgments

Staff thanks William (Bill) H. Dietz, the George Washington University, for providing his technical expertise in the preparation of this publication.

This page intentionally left blank.

Contents

ACRONYMS AND ABBREVIATIONS

1 INTRODUCTION

Introductory Remarks

Organization of This Proceedings

2 OBESITY: DEFINTIONS AND PERSPECTIVES

Cultural Approaches to Obesity, BMI, and Nutrition

BMI Categories, Drug Companies, and the Drive for Reimbursement

Clinical Context: How Can We Measure a Disease to Track Its Improvement?

Panel and Audience Discussion

3 TENSIONS AND PERSPECTIVES AROUND BMI

Tensions and Perspectives Around BMI: A Clinician Perspective

Body Mass Index: A Public Health Perspective

Lived-Experience Perspective

Panel and Audience Discussion

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

Adipose Tissue, BMI, and Fat Distribution

A Health System and Health Services Research Perspective on the Use of BMI to Diagnose and Treat Obesity

Occupational Health and Safety Lens on BMI

BMI Outside the Clinic: The Patient Perspective

Panel and Audience Discussion

5 LOOKING AHEAD

An Equity Framework Approach to Chart Needed Action

Obesity Treatment: How to Measure Success for Public Health

Looking Ahead: Clinical Assessment of Obesity

Panel and Audience Discussion

Closing Remarks

6 COMMUNICATING HOW OBESITY IS DEFINED AND DIAGNOSED

The Lancet Commission on the Definition and Diagnosis of Clinical Obesity

Adiposity-Based Chronic Disease and the Complications-Centric Approach to Disease Staging and Management

EOSS for Adults and Pediatrics

Panel and Audience Discussion

7 INNOVATIONS IN COMMUNICATING ABOUT BODY WEIGHT IN THE CLINIC AND BEYOND

Educating Future Clinicians About Weight Bias and Stigma

Navigating Discussions Gracefully in a Body Positivity Versus Obesity Treatment World

Panel and Audience Discussion

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

Weight-Related Stigma and Health Disparities

Poverty, Health Policy, and Obesity

Community and Public Trust Aspects of Communication

Panel and Audience Discussion

9 IMPROVING COMMUNICATION ABOUT BODY WEIGHT

Improving Communication About Body Weight from a Policy and Public Health Perspective: TFAH

A New Narrative on Childhood Obesity

Panel and Audience Discussion

10 PROMOTING CHANGE IN CULTURE AND PERCEPTION ABOUT BODY WEIGHT

A Socioecological Approach to Addressing Structural Racism and Weight Discrimination

A Lived-Experience Perspective on the Culture and Perception About Body Weight

Panel and Audience Discussion

Closing Remarks

REFERENCES

APPENDIXES

A Workshop Agendas

B Biographical Sketches of Workshop Speakers and Planning Committee Members

This page intentionally left blank.

Box and Figures

BOX

1-1 Workshop Series Statement of Task

FIGURES

2-1 New NIH terminology

2-2 Role of epicardial adipose tissue in cardiovascular risk

2-3 Growing understanding of how excess abnormal fat drives disease

3-1 Trends in women show increases in obesity and severe obesity in all racial/ethnic groups

4-1 U.S. Medical Expenditure Panel Survey 2011–2016: Predicted expenditure by BMI in adults ages 20 and over

4-2 U.S. Medical Expenditure Panel Survey 2011–2016: Predicted expenditure by BMI z-score in children ages 6–19

5-1 Framework for increasing equity impact in obesity prevention

5-2 U.S. jurisdictions that protect against weight discrimination

6-1 Categories of obesity complications

6-2 Comparison of staging system and anthropometric classification scheme for predicting all-cause mortality among people with overweight and obesity

6-3 The 4Ms of EOSS-P

6-4 Case #1: 12-year-old boy with severe obesity (BMI z-score: 3.4)

6-5 Case #2: 12-year-old boy with severe obesity (BMI z-score: 3.4)

7-1 Examples of people-first language

7-2 Sample script for Scenario 1

7-3 Sample script for Scenario 2

7-4 Sample script for Scenario 3

8-1 Weight-inclusive approach as opposed to the traditional weight-normative approach by clinicians

9-1 Image depicting structural racism in health

Acronyms and Abbreviations

___________________

¹ https://www.samhsa.gov/behavioral-health-equity/lgbtqi (accessed November 7, 2023).