Beyond BMI: Understanding Body Composition and Obesity … — Transcript

Explore body composition beyond BMI to better understand obesity, health risks, and assessment methods with experts from the Obesity Action Coalition.

Key Takeaways

BMI alone is insufficient for diagnosing or treating obesity; body composition provides a clearer health risk picture.
Visceral fat is a critical factor in obesity-related health complications.
Multiple validated methods exist to measure body composition, each with benefits and limitations.
Obesity requires individualized, multifaceted care beyond just weight or BMI numbers.
Monitoring body composition changes can motivate and guide effective weight management strategies.

Summary

Obesity is a chronic disease characterized by excess fat accumulation that impacts health and requires lifelong care.
BMI is a screening tool for obesity risk but does not measure body fat or diagnose individuals.
Body composition, including percent body fat and fat distribution, is crucial for assessing health risks related to obesity.
Visceral fat around organs is linked to higher risks of heart disease, diabetes, and fatty liver disease.
Subcutaneous fat, while less risky, can still cause discomfort and health issues like sleep apnea.
The American Medical Association recognizes the limitations of BMI and supports alternative measures like waist circumference and body composition.
Adiposopathy refers to how body fat can negatively affect health through chemical and cytokine release.
Several methods exist to measure body composition, including DEXA scans, Bod Pod air displacement, and bioelectric impedance.
Healthcare providers need to consider accuracy, cost, and practicality when choosing body composition assessment tools.
Maintaining or increasing muscle mass during weight loss is important for overall health and function.

Chapters

Full Transcript — Download SRT & Markdown

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[Music] [Music] Welcome to OAC Health Talks. I'm Jon N. Glowski, president and CEO of the Obesity Action Coalition, and we are excited for you to join us for this educational series that dives deeper into specific health topics that we know are important

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to you and the OAC community. Health Talks are designed to empower you while providing straightforward, practical answers and insight from trusted experts. So let's dive into today's topic. Hi, I'm Dr. Nina Crowley, and I'm excited to be here with Dr. Angela Fitch

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to talk to you today all about body composition. So our agenda is going to be to first talk a little bit about the assessment of obesity, to talk about body composition, and really to hone in on what the change you might experience

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during weight loss may be, and finally find out how to find out your body composition. Thanks, Nina. You'll see this consensus on obesity as a disease from our Obesity Medicine Association, the Obesity Action Coalition, and the Obesity Society. We've all come together, many

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other associations and societies too, all came together to write this consensus statement because we felt as though it was important to acknowledge that obesity is a highly prevalent chronic disease that's characterized by excess fat accumulation or distribution

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that presents a risk to health and requires lifelong care. The importance here is the body mass index is used to screen for obesity, but it does not displace clinical judgment. BMI was never created as a certain measure that people

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should get to. It was created as an epidemiological tool to assess risk as it relates to disease related to body weight, but it doesn't measure body fat. And in fact, if you notice that definition, it talks about excessive fat

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accumulation that presents a risk to health. So that's what we're talking about today about body composition because really what we should be concerned about is our fat and how that relates to our health, not just the number on the scale. These are changing

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times, and now it's really time for a change. Understanding the disease of obesity: obesity is a multifactorial disease that requires a multifaceted, patient-centered, individual approach that one size does not fit all. The American Medical Association has a

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new policy recognizing issues and limited value of body mass index. BMI is for screening but not for diagnosis and treatment for an individual. It was never based that way. It was based to look at population data and not to look

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at an individual or an individual's treatment goals. The American Medical Association has suggested alternatives such as measuring waist circumference, body composition, and visceral fat, which is the fat around our belly that tends to help, tends to lead to more health

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conditions. Assessment and language really matters. When we assess for the presence of obesity, adiposopathy, and fat mass disease, we're initially looking at BMI as a screening tool, but really what we're looking at further here is percent body fat. Adiposopathy is just a fancy

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word for how our body fat can make us sick. So body fat releases chemicals and cytokines that make us unwell in certain circumstances. This can be genetic. It's related to our genes, our environment, everything together. It's not

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a one size or one condition type of issue. There's also fat mass disease, which is where just the mass of our extra weight leads to issues, say, with our knees or our back or other issues like sleep apnea. So it's

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important that we look at all of these features, not just how much we weigh and what our BMI is, but what is our percent body fat. You'll see that normal for female is less than 32% and for males

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less than 25, right? And so again, that's kind of the goal we're trying to achieve is those goals versus just looking at a number on the scale. And where our adipose tissue or our fat mass location is matters to us,

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right? If you look at the picture on the left-hand side of the screen, you'll see that the blue represents subcutaneous adipose tissue, which is the body fat that's just under our skin. And then you have the visceral adipose

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tissue, which is in closer to our organs. So this is a cross-section of the human body as a CT scan of the human body looking at the cross-section across our body, right? And you'll see that yellow fat is that visceral adipose tissue around

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our organs, and that's what can increase our risk of diseases such as heart disease, diabetes, or other complications, fatty liver disease, etc. So we're really trying to get rid of some of those health conditions and focus on getting

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rid of some of that body fat. Certainly, subcutaneous fat, like I said, can have a risk for sleep apnea and also can just be uncomfortable or maybe, you know, make it a challenge for us to fit into an

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airline seat or use a seat belt extender, etc. But really getting rid of our visceral fat is also what plays a significant role as it relates to improving our health and our health outcomes. And Angela, I think the other

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point I always think about when I look at this slide is the image here on the right. So these are cut-throughs of whole-body MRI scans of folks, and they all have a BMI of 24. But if you look at the top left, that's

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someone who has a lot more lean tissue than the bottom right, someone who has a lot more of visceral adipose tissue and subcutaneous. So, you know, it's really not something we look at every day, but this is something that

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when you look at it this way, you can really see how just the weight on the scale would really mask the real difference in health risk that someone on the bottom right would have compared to someone on that top left. And clearly,

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I'm not a radiologist because I said it was a CT scan, but since it's an MRI, we will stand corrected because thank goodness I'm not a radiologist. So Angela, I pulled this actually from the Obesity Medicine

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Association's newest obesity algorithm, which I think is a really fantastic resource for healthcare providers. I really thought they did a good job outlining the different measures or measurement that we can do to assess someone's body composition, and they go

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through the method, they share the accuracy, how expensive it might be, as well as some limitations. So for healthcare providers, you know, we have to think about how are we going to be able to offer body composition technology to

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someone. We're saying this is an important measure. The AMA is supporting. We need different measures to tell people how they're doing, to assess their risk. It's not just about BMI, but we really need to think next, well, how are

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they going to do that? And so if you look here, there's some methods like underwater weighing. I don't know anybody who's doing that in clinical practice, but some of these are measures that we use almost as gold standards or

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reference measures to do the body composition test, and then we use other measures like bioimpedance or air displacement like the Bod Pod. We compare those results to these gold standard measures, and when we get something like 97 or 90% accuracy, we feel confident

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enough that these are the technologies we can use in a clinic setting that estimate the body composition with enough accuracy. So we're going to go through the three that the Obesity Medicine algorithm outlines, which are the DEXA, the air displacement,

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also known as the Bod Pod, and then bioelectric impedance. So I pulled an image of those here for you. The first on the left you may be familiar with is the DEXA scan. This is often referred to

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as a bone density test. This is a way that we can estimate body composition in three compartments. So we can look at your body fat, we can look at your bone density, and we can look at your lean

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tissue, that's everything else. The whole body. I can't say that word. The Bod Pod. This is a measure that looks at air displacement when you put someone in this little spaceship-looking device. And this, I don't see this as

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used as much in clinical practice. There's a lot of

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people's um practices and I know I would not want to do that in a doctor's office um they also require trained staff and so the bioelectric impedance analysis which you see a lot more about um because it's a lot more feasible that is

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a measure where you're looking at um the body composition from a a fat mass and fat free Mass but you're comparing it to those uh gold standard measures so the four compartment model for fat Mass it's four different measures they do on a big

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long research day to make sure they get all of the you know data there they compare that to bioimpedance and then they also do the muscle mass um and that's done through MRI which is the gold standard for muscle mass so talk

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about this a little bit more this is where um we have experience in the clinic setting and we'll even talk a little bit about some of the home devices that um people can have you know while they're not maybe as um as

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accurate or as um precise as the measurements that we're talking about here um they do offer some value for consistency and measurement for some folks so to me the patient is always first on my mind when I think about how

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are we going to apply these body composition measures in real life so first of course we have to think about size and weight limits the different devices have very different um weight limits and so even a dexa scan

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which can be commonly used um for you know Primary Care might refer you to get a bone density test um they and Angela you might even know more about this than I do but they do have limits for how big

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someone can be in the device and they end up sometimes estimating one side versus the other and extrapolating that number or estimating the rest of the body from that I've seen size limits from 250 to 350 lbs um they do have some

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at higher levels but those are pretty hard to come by and not very available to folks the other piece here is the comfortability on or in a device so if you remember looking at any device you have to go into you know we have to

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think about justes do people feel comfortable doing that are they going to fit in that there's a lot of um you know nervousness around um size and and devices that we have to be cognizant of um we also want to make sure that we're

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not continually putting someone on a device where they're going to exceed the weight limit that can be embarrassing and it can be frustrating and we're not getting the data that we need so we do want to look for a higher weight limit

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when we're looking for equipment that we can offer um to estimate someone's body composition the amount of time of course is important you know as as doctors like Angela know it's important not to have something that takes 30 minutes to slow

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down the flow in your clinic I also think that's important not to have something that you are um going to have to go off site for and have a referral and a send the send the results back and

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where did they go or they stuck in the facts or they you know there's there's a lot of administrative components that we need to think about in my previous role as a bariatric coordinator that that was all I thought about was how are we going

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to make the flow of all of this happen and so that was really important and then to the patient you know you want to be careful that you're not asking them to take a whole lot of time to find um

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out something that they're they're hoping that can help their care plan clothing required or not so again I mentioned that with the you know having to get down to a bathing suit or a swim cap I think that's unrealistic for most

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people um the bioimpedance devices usually are just take your shoes off and socks off so that you can pass that lowd dose electrical current through the feet through and that goes out through the hands um validation equations maybe

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that's not a practical consideration but that does have some differences between the devices that you'll see whether or not they're validated to an MRI or to dexa or to the four compartment model use of trained technicians that's a big

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one because I know with a um an X-ray tech that's a whole that's a whole another level I remember we used to have the the gastric band we had a c arm that we had to bring down from Radiology to

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fill a gastric band and that getting that technician around um you know that it wasn't easy and there was a lot to go into that so um we have to think for dexa if that's you know if that's

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something that you have available and um or is it something you can just get on the device and anybody in the clinic can you know punch in the numbers and give you your results and then understanding results um I add that because that's

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that's my role and and my current job is teaching providers how to teach their patients about results and it's a lot more than just here's the number you know the old here's the BMI on the chart you know we're really hoping your

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doctors and your health care providers are not doing that we're hoping that they take the time to go into understanding these results with you and helping you come up with reasonable action plans from the data that you're learning from these body composition

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measures so understanding the results there's so many different um measures out there there's very you know Vari Variety in the um companies and what they're offering so I wanted to you know kind of boil that down into a few areas

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that we're going to talk about so muscle mass and fat Mass are the two primary areas that folks want to know when we're looking deeper than weight at your body composition so with muscle mass you first look at

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the fat mass and the fat free Mass the fat free mass is everything in the body other than your fat mass and that can tell you um you know there's things that that can tell you about your health risk

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that can tell you about um you know how much muscle mass you're keeping it's kind of a proxy for that but we can get um even deeper than just your fat-free Mass we can look at the lean soft tissue

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or the lean body mass and that's what a dexa would tell you um that does include things like um connective tissue tiue and skin and and fluid and hydration so it's still not exactly what we're looking for um but we also can can

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narrow down to the skeletal muscle mass and that's really what we're wanting to protect um that skeletal muscle mass segmental would be if your um bio impedance device would be able to show you how much muscle you have in each arm

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and each leg and for some people it's important to know you know different parts of the body if you're wanting to train differently um or if you have an imbalance or for any other kind of medical reason so so there's a few

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different ways we can talk about your muscle that's becoming very important Angela is going to talk about that in a minute um as we're talking about significant weight loss and how it's affecting muscle so we'll come back to

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that um but as she talked about adiposopathy and your adapost tissue um we're wanting to look at how much of your body weight is made up of of adapost tissue um and not just how much but where is that located so for um

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bioimpedance technology you can add something like your waist circumference so measuring the distance around your waist can actually add data to these algorithms that estimate your visceral adapost tissue and that's the fat around your organs and that's much more closely

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related to health risk and health status than simply just your weight on the scale and I know for me Angela you may have thoughts too I've been really interested to see folks who may have a high BMI they may even have a high body

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fat percentage but when we look at where that's located it may not be around their waist it might not be around their organs and for that person seeing that visceral adapost tissue at a lower level is quite encouraging when we're actually

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talking about connecting health and these parameters we're not talking about weight and so this is really to me one of the most exciting parameters that we can talk to patients about because it really does make that connection for

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them and when they're losing weight from that area we can see the connection to their long-term health so my question that I'm posing to you Angela to answer and uh is what happens to body composition during obesity care treatments and I pulled

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this picture because it's your hand and your muscle mass so um I thought you could address that for us here that's great Nita and yes I do think you know that when uh when people can see these changes happening right

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even when you know for some patients they will have uh gained 5 pounds of muscle mass and lost five pounds of of fat mass and their weight doesn't change but yet that's so much better for them right you know from a health perspective

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to have that increase in muscle and that decrease in fat and so that's why this is so important you know to look at these factors whether you're you're doing it at home on a on a home scale as

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you mentioned or more importantly when we do it repeatedly in the office at least we're getting a very accurate uh look at that so we can counsel patients better significant weight loss TI typically results in the loss of both

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fat and muscle mass the most important thing to remember and you're hearing a lot in the news right now right about how you know potentially um using medication to assist with uh weight management how people are losing muscle

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mass but that's been for a long time people have lost muscle mass when they've lost weight because that's what happens and in fact a lot of people that carry extra weight or live in a larger body actually have more muscle mass

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because if you can imagine you know when you um used to weigh 40 pounds heavier you were carrying around 40 pounds every day which is not an insignificant amount you know to carry around right like I mean this is like a 40 pound backpack is

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really hard to put on and and carry around all day excessive loss of muscle is rare but it's important to monitor so you can adjust treatment if needed or if you are a person that potentially has a lower muscle mass to start with we

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sometimes you know will guide the treatment or we should guide the treatment differently for that patient because the fact of the matter is our ultimate goal as humans is to get up out of the chair when we're 90 years old by

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oursel right to be strong enough to be able to have enough muscle mass to still do our activities a daily living you know as we live a higher quality life over time we lose muscle mass every year as we get probably over the age of of 30

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or 40 even so you know every year over 40 in particular we start losing muscle mass and if we don't you know if you don't use it you lose it type of thing right that's the the old adage and so

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really you know being mindful of that and following this can be helpful so that you can build back that muscle mass as needed when you lose muscle mass it reduces your resting metabolic rate so it makes it harder to lose weight the

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more muscle that you lose because muscle burns more calories than fat it's important to note that muscle um there's a lot of people that say that muscle um weighs more than fat and it actually doesn't uh meaning a pound pound of

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muscle is the same as a pound of fat it weighs the same the weight is the same but certainly a pound of muscle takes up a lot less space than a pound of fat does and so again you know it's more of

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a I tell patients all the time you know our goal in treatment should be to be leaner not lighter right we don't want to weigh less we want to be leaner and and more compact so to speak um and be

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stronger so when we look at um both fat mass and lean mass loss um over time with various different interventions these are dietary interventions alone so these are without any type of medication Assistance or surgery but when we lose

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weight over time you can see in the blue is the fat mass and the um gray is the lean mass so it's pretty normal essentially you can see here that when we lose weight that anywhere from 20 to

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30% of our weight loss is coming from our lean mass loss it's coming from our muscle it's coming from the fact that we also lose some fluid from that compartment too so the thing is is that it it's coming from that lean mass

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because when you lose weight your body just doesn't pick from your fat Mass unfortunately we wish it did but bodies don't do that and so again that's why it's important to really sort of do some strength training while your you know

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some resistance exercise doesn't have to be with weights or anything but some resistance exercise and consuming enough protein and that's why we harp on those two things you know during weight loss because we know that's how we try to

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protect from losing too much of that lean mass less lost you'll notice in that high protein diet it actually lost a little less of that lean mass we think because protein protects that lean mass from from going away this is data on surgical

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interventions so people that had surgery and it you have the uh weight loss on the x axis and the time on the Y AIS so 3 months 6 months 9 months 12 months 18 and 24 and so on you can see that again

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it's about that same ratio of about you know 70 to 80% of the the weight loss coming from fat Mass that's the gray in this in this graph and then the rest of it coming from fat free mass of which

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part of that is muscle mass so again it's normal to lose muscle mass when you lose weight but we're trying to protect that as much as possible here is a slide of medical interventions so this is a slide looking at seatide which is

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currently one of our medications that we use uh for uh obesity treatment in the clinic and you can see here where we have um this you know this person is starting out on the seatide with 43.4% total fat mass and ending up with

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39.4% fat Mass so they they lost that fat mass and in this case actually gained some lean body mass so again the point is from a percentage standpoint so the percentage is getting better and that's what we want to try to change we

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want that percentage to improve over time and that's what we're trying to to do because we know that getting rid of that body fat is what improves Health outcomes long term it's the fat that's not good for us not the fact that our

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weight is a number on the scale so how to get body composition analysis this is me and you can see I'm very excited to be on my new uh body composition scale that we got in the office so uh being

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able to do that for for myself here uh you know you can you can share in my excitement of getting the the new device many obesity care providers have bioimpedance devices in their office so this is a bioimpedance device many of us have that

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type of device as Nina mentioned because it is something that is um easier to do in the clinic it's under a minute of of doing the the procedure itself um it measures you very easily without you know like Nina said without getting

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undressed too much just taking off your shoes and your socks you can also find them at some gyms and wellness centers and fitness facilities like the IMCA or uh crunch they may have bioimpedance devices so some gyms also have a very

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similar type of device you can also U be referred to get a a dexa scan which is the same dexa that would be used for bone density but you have to ensure that they have body composition software attached to it so while all dexa SC

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While most dexa scanners can do body composition if they have the right software not all of the dexa scanners that you find like if you go to get your bone density done you can't just asked to do your body composition too so it

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just might not have that that on there plus it's not a covered benefit of your insurance unfortunately so because of that um typically when you go get a dexa to look at body composition there's a fee for that that's an extra charge

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whereas when you're doing it here in the office uh we typically include that as part of our care plan and I just wanted to end with you know we're talking of course with the OAC always about advocacy and so I think

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this is an area where patients really do have a role in advocating for moving the outcome of choice away from just weight on the scale to something more um meaningful like body composition so we do know and hopefully you know that

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providers do listen to their patients um I've I've seen that over the years I promise they're out there and if not the Obesity Action Coalition obesity provider locator will help you find someone who can um we we also know

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people people these days especially want to be competitive in their market so they need to be listening to their patients and what you're asking for so um if you have a provider who does not have this technology who has not talked

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to you about this technology please do use your voice to advocate for better outcomes and ask those questions and find out what the barriers may be they may know someone in the area who has something and they can make a referral

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um there's some ways around you know what they have exactly today and hopefully we can start you know moving the needle on and having more providers with this type of Technology um if you're undergoing a treatment with a

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goal of significant weight loss as we know many of you do um we believe that you should know where the weight is coming from so you know just like we're asking and demanding better care um with different treatment options with more

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access to dietitians and Behavioral Health and and exercise professionals we we would want to have better outcomes measurement and then share your data and your standards of care and sto stories to support your requests what I mean by

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that is um you know talk to your provider about your numbers and how it would be helpful to have more detailed information about where that weight is coming from the standard of care you know that's something that we all can do

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even as Healthcare Providers we're moving towards as you can see from the different societies and the American Medical Association we're moving towards better outcomes and sometimes it feels like it takes a long time but I know we talked recently about um advocacy on the

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hill for obesity care and we've been doing it for 10 or 11 years on one specific um piece of legislation and that feels like a really long time but I do feel like there's more energy and support for this more than ever these

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days so um so use that to support your request and and your story is important if you're someone who um was able to see a change or was able to stay motivated I think one of the most exciting parts of

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body composition analysis is the way that people can be motivated to do some resistance training and they might not have before they might have thought you know hey I don't want to get big and bulky with muscles and so you know I've

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just been walking or just been doing aerobic exercise and when they see their muscle mass at a low level they you know and see what happens as we age I think that's really a nice motivator to um to

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do those things and and there health behavior things that we may have known we wanted to do but somehow seeing that data for you as an individual really helps put some energy behind that becoming one of your um one of your

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goals and um yeah I think I don't know Angela do you have other thoughts on how patience if you know one of one of my thoughts is when I talk about this to folks I'll have patients tell me well

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this is great I would love this but my doctor's office doesn't have it and I think a lot of times we sort of stop there like oh yeah that's unfortunate we need to get them to get it but are there

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other ways that people can advocate for this or or get body comp analysis done in a different way I think they should ask right and really sort of you know the more people talk about it like you said the more people are going to get it

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there are some places opening up you know at at different areas that will that will offer it at gyms and such you know so that you can and and you can pay a fee you know typically to do that um

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you know we're trying to Advocate to get this covered as part of insurance as you know too because this is something we feel like is an important test that we should be doing that could be something that would be covered by insurance right

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now it's not so it's typically can be an extra cost and just to also add you mentioned you know home devices right home devices are not as accurate as the devices we have in the office so just know that that it's not going to be

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matched up to what you're seeing in the office but you can use it for trending the biggest thing to remember about home devices is you get kind of what you pay for meaning usually you have to pay a

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little bit more for something to be a little bit U more accurate or a little bit you know more precise so um usually you know if you're getting something for for really deep discount it pro might be quite as high quality as something that

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costs a little bit more and the other key is to remember when you're doing bioimpedance like the home scales that measure your body fat percentage you cannot let your skin touch each other and that's very challenging on the home

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devices because you know our our legs tend to touch each other in various spots and especially when we're standing there you know um typically right after we get out of the shower or something you know we don't have any clothes on so

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making sure that you um put something between your legs so that they don't touch or somehow you know make it so that your your legs are apart and not touching is key to get a better accurate measurement at home that's what I tell

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patients when they have uh when they might have a home scale because they can't get into the office to get checked I also always add the caveat for for folks um you know again with a 18-year history in bariatric surgery um I saw a

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lot of patients who became um overly focused on the number on the scale you know part of why I do this is to Advocate against that and can that that can be quite detrimental to someone's quality of life um and so my only worry

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with a home scale is that when you have a lot of data and you're someone who sort of wants to gravitate to doing that frequently I think people can over measure and then make silly or or unfounded decisions like oh this is

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higher today so I'm going to not eat what I just ate for that last meal because that has to be the reason that there's a difference and I mean really the whole point of all of this is giving

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you a better outcome metric to see the results of the efforts and the efforts is all that hard work that you're putting into the daily choices that you're making I think sometimes those frequent check-ins with weight or um

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bioimpedance or body composition um data can be counterproductive and so you know while we know individualized care and a patient- centered approach means everybody's got a different plan that's going to work for them I do see that as

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a trend for people who have access to that too often I agree and it's very important to recognize that you know our body weight and changes in our weight fluctuates on a daily basis even throughout the day so

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you know we can't really focus on a number too much right it's all about the the ultimate long-term goal um which is improving our health and improving our quality of life well thank you thank you OAC for having us talk about this

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important topic and hopefully if people need to reach us we're um we're linked to all of the oas's channels the OAC has a variety of educational opportunities for you throughout the year but one of the best places you can

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turn to for Quality unbiased education is our resource Library simply visit obesity action.org library to check out our brochures articles guides videos and more Health talks also be sure to subscribe to our YouTube channel to get notified about any future educational

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events thanks for joining us [Music] [Music]

Topics:obesitybody compositionBMIvisceral fatadiposopathyDEXA scanBod Podbioelectric impedanceweight losshealth risks

Frequently Asked Questions

Why is BMI not sufficient for diagnosing obesity?

BMI is a screening tool designed to assess population risk and does not measure body fat or fat distribution, which are more directly linked to health risks.

What is the difference between visceral and subcutaneous fat?

Visceral fat surrounds internal organs and is associated with higher risks of diseases like heart disease and diabetes, while subcutaneous fat lies under the skin and can cause discomfort but is less harmful.

What are common methods to measure body composition?

Common methods include DEXA scans, Bod Pod air displacement, and bioelectric impedance, each varying in accuracy, cost, and clinical practicality.

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