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Welcome back to the Barbell Medicine Podcast. I'm Dr. Jordan Fagenbaum. In this podcast, I'm going to talk about the Body Rowness Index, which is a relatively new measure of body composition that has been put forth as a replacement for BMI. Now, both BMI and the Body Rowness Index aim to characterize an individual's body composition. Specifically, they are both built as screening tools to identify those who are at risk of disease due to obesity. Now, obesity is a complex,
chronic disease that's influenced by multiple factors. As it is currently defined, obesity is a condition characterized by an increase in body fat that leads to abnormal function of the fat tissue, as well as abnormal physical forces due to the excess fat mass. Together, these mechanisms result in harmful metabolic, biomechanical, and psychosocial health consequences, such as diabetes, heart disease, chronic musculoskeletal pain, depression, and many more.
Note that this definition does not solely focus on the presence of body fat itself. Instead, we view excess body fat or adipose tissue as a sign of the underlying disease of obesity. This underlying disease results in the person achieving energy balance at a higher than healthy body fat level. Now, ideally, appetite and food related behaviors would match people's energy and nutrition needs.
So, for example, as energy stores like body fat increase, well, we would hope that appetite and energy intake would be suppressed, and spontaneous physical activity would increase. On the opposite, as energy stores like body fat decrease, well, we would think that appetite and energy intake would go up,
and spontaneous physical activity would go down. However, in the setting of obesity, these signals are often mismatched, and this is a big problem, because the rates of those with overweight and obesity are increasing in every single country in the world. Globally, over 2 billion adults are currently overweight, and over 650 million have obesity today. By 2025, that's just next year, it's predicted that there will be over 1 billion adults with obesity globally.
While obesity is very common, it's both underdiagnosed and under-treated.
For example, across 15 large healthcare organizations in the United States containing over 700,000 adult patients with the BMI greater than 30, which is the cut point that we use for diagnosing obesity currently, well, less than half of these patients had an obesity diagnosis on their medical chart, and the number of patients receiving treatment for obesity, such as intensive lifestyle interventions, medications, and or metabolic or bariatric surgery, well, that's even lower.
All told, we're not very good at diagnosing obesity, despite it being a growing medical problem that represents one of the top 5 risk factors for preventable death. Now, if you're someone who thinks BMI is trashed, you could make the argument that the low rates of diagnosis and even lower rates of treatment for obesity has been caused by using such a terrible metric.
It follows then that using a better instrument for obesity screening in diagnosis would then improve health, which is where the body-roundness index comes in. Now, after this quick break, I'll cover the latest science on the body-roundness index, when weigh in on whether or not I think it should replace BMI. This podcast is brought to you by Rosetta Stone.
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your future today. Pay non-client endorsement. Compensation provides incentive to positively promote Acorns, investing in involves risk, Acorns advisors LLC, and SEC registered investment advisor. Do important disclosures at acorns.com slash bbm. Okay, welcome back to the Barbell Medicine podcast, and we're talking about the Body Rownness Index. Now, as I mentioned at the beginning of the podcast, both BMI and the Body Rownness Index aim to screen for obesity,
which is a disease characterized by excess body fat. One question that immediately comes to mind here is, if we really want to know someone's body fat level, why not just directly measure body fat in the doctor's office or other clinical setting? In the mid-1990s, the World Health Organization, the WHO, published recommendations regarding body fat cut points where health risks increased due to excess fat. They proposed 25% for men and 35% for women.
Later, the American Association of Clinical Endocrinologists adopted them in their 2016 guidelines for treating obesity. But there's only scarce data supporting that these cutoffs for directly measuring body fat are accurate for predicting risk of medical complications, such as heart disease, type 2 diabetes, certain types of cancer, and more. In other words, just knowing someone's body fat percentage doesn't provide enough information about their health risks, mostly because it doesn't
provide any data on where the body fat is located. Generally speaking, humans distribute their body fat into two major sites within the body, subcutaneously, which means under the skin, or in the abdomen around the organs that's called belly fat. Excess body fat in the abdomen, also known as visceral adipose tissue, is recognized as an established risk factor that is strongly correlated with heart disease and things like heart attacks and stroke in addition to type 2 diabetes and all-cause
mortality. In contrast, the same level of body fat that is located elsewhere, such as in the arms, legs, and buttocks, well, that doesn't produce the same risk, and as you might expect, there's a growing consensus that visceral fat is much more dangerous to health than subcutaneous fat, since it entails more risk or more diseases. Add to that, the additional costs and resources needed to test body fat directly in the clinic, and you can see why this isn't a great option for
obesity screening. So that's where BMI came in, so Body Mass Index, or BMI, was adopted by the World Health Organization in the 1990s to replace a previous calculation known as ideal body weight, in an effort to predict someone's health risk due to excess body weight. Whereas ideal body weights were derived from the metropolitan life insurance's height and weight tables from the 1940s, BMI was a quick calculation that could be done for each individual quickly while they were
in the office, as well as for research purposes. Now BMI is an anthropometric measure that relates height and weight of an individual using the formula weight divided by the height squared. When it came time to replace ideal body weight, BMI was chosen because it seemed to scale pretty well with height, and as it currently stands, BMI is the primary screening tool for obesity and
overweight in the guidelines published by the U.S. Preventative Services Task Force, the American Heart Association, the American College of Cardiology, the obesity society, the Canadian Task Force on Preventative Health Care, the American College of Obstetrics and Gynecologists, the National Institute for Health and Care Excellence out of the UK, and of course the American Association for Clinical
Entercanologists, among many others. As you can see, there are many professional organizations that recommend the use of BMI, so how is it used in practice? For screening and diagnostic purposes, there are multiple cutoffs that correlate with various diagnostic labels. A BMI of less than 18.5 corresponds to an individual at risk for being underweight, whereas a BMI of 25 is used for
overweight and a BMI of 30 or higher is used for obesity. The current guidelines also recognize that individuals of different ethnic backgrounds may require different cutoff points to screen for health risks due to excess body fat. For example, it is suggested that a BMI cutoff point of greater than 23 should be used for screening and confirmation of excess adiposity, that's excess body fat, in South Asian, Southeast Asian and East Asian adults. As a screening and diagnostic
tool, BMI is okay. It's not great, but it's also not terrible based on established criteria for what makes a good medical test. For example, the term sensitivity describes the true positive rate of a test. That means the fraction of all people who have a condition, who also test positive for that condition with a given test. Now, the sensitivity of BMI as a diagnostic tool for excess body fat is quite low. It's about 36% for men and 49% for women when the cutoff point is 30.
This means that using BMI alone misses nearly two thirds of men and about half of women who are actually carrying too much body fat, but still have a BMI less than 30. On the other hand, BMI is very specific, meaning that it has few false positives. When the cutoff point of 30 is used for diagnosing obesity, BMI specificity is 95% to 99%. That's really good, but remember, it has a relatively low sensitivity, meaning it misses two thirds of men and about half of women who are
carrying too much body fat, but don't have a BMI greater than 30. This means that individuals who are quote skinny fat are unlikely to be diagnosed with obesity using BMI alone. To summarize, the biggest problem with BMI isn't that it overdiagnoses folks who are too jacked or too muscular, but rather that it misses too many people who are, in fact, carrying too much body fat, but don't
have a BMI of 30. Now, this runs contrary to the popular opinion in the world of resistance training and bodybuilding, where individuals often inappropriately dismiss the relevance or utility of BMI as part of the assessment process for obesity. Still, BMI is far from perfect, especially in situations of edema or dehydration, sarcopenia or sarcopenic obesity, large tumors, as well as specific populations such as elderly individuals where BMI tends to
underestimate the risk of disease. To overcome these limitations, most guidelines recommend getting a waste or conference as well to gather information about where the individual's body fat is distributed, in an effort to more accurately determine an individual's risk of health problems from
carrying too much body fat. Now, as I mentioned before, humans can store body fat under the skin, again, that subcutaneous fat or in the abdomen, belly fat or visceral adipose tissue, and most individuals tend to store about 85% of their body fat under the skin or subcutaneously,
whereas 15% is located in the abdomen. The relative amounts of body fat stored in a particular location, very significantly, however, among individuals based on sex, age, race, their activity level, certain medications, and of course the total amount of body fat. Now, we currently lack a definitive understanding about what causes fat to be stored under the skin
versus in the abdomen. Most of the proposed mechanisms for abdominal fat accumulation suggest this inability to store fat under the skin, which promotes an overflow of energy to be stored as fat in the abdomen. And the problem with the abdominal fat is that it can produce a number of inflammatory hormones called adipocines that are involved in obesity-related chronic disease.
Now, to combat that, there's robust evidence showing that both exercise and energy restriction can preferentially reduce abdominal fat in those who store most of their fat there. With that in mind, let's turn our attention back to waist circumference measurements.
Now, it's plain to see it's very easy to do a waist circumference in the clinic. It's quick, cheap, and otherwise not too imposing, but it's also highly correlated to the amount of abdominal fat in both men and women, measured by very precise measures of body fat in that area like MRI and CT. Also, self-measured waist circumference values are both accurate and reproducible when individuals
have been instructed on how to take their own measurements. To comment on the utility of waist circumference, the obesity society in one of their consensus statements said, it is possible that waist circumference measurement could be an effective clinical tool for identifying metabolically obese, but lean patients who might benefit from lifestyle therapy, but who would not have been considered for treatment because of a normal BMI.
Also, waist circumference could be used to identify those who are metabolically normal, but who have excess body fat who do not require aggressive obesity therapy because they do not have a market increase in cardiometabolic risk. Now, the current guidelines recommend
obtaining a waist circumference for those with the BMI between 23 and 35. If you're lower than that, it is highly unlikely that you're carrying too much body fat, and if you're above 35, it's highly likely you are, and so at that point, they're like, what's the point of adding a waist circumference? Now, a waist circumference of at least 102 centimeters or approximately 40 inches in men indicate abdominal obesity, although a lower cutoff of 94 centimeters or 37 inches has been
suggested. In women, a waist circumference of 88 centimeters or approximately 35 inches indicates abdominal obesity, with a lower target of 80 centimeters or 32 inches being suggested as a more aggressive cutoff for intervention. Generally speaking, combining BMI and waist circumference together do pretty well for identifying those at risk of disease from carrying too much body fat, outperforming metrics like waist hip ratio,
waist height ratio, and so on. My personal feeling here is that these two metrics, BMI and waist circumference, are good enough if they're widely used together. The problem is, I think that relatively few clinicians are using both BMI and waist circumference together in practice. Whether this is contributing to underdiagnosis and under treatment of obesity is speculative, but I can
appreciate that using two separate measurements to diagnose obesity is harder than one. Now, to combat this problem, some researchers have tried to combine BMI and waist circumference values into an equation that would spit out a single value, which would subclin A, B, U, to diagnose obesity. Now, none of these performed really well, and for one reason or another, there hasn't been a lot of success when it comes to improving BMI. That leads us to this relatively new clinical tool
called the Body Roundness Index. The Body Roundness Index aims to model an individual's body shape to predict their body composition and body fat distribution, in an effort to better characterize an individual's health risk from excess body fat. Theoretically, assuming the shape of the body as an ellipse with the long axis being represented by height and the short axis by waist circumference, the Body Roundness Index can be calculated as the eccentricity of this ellipse via human modeling
on a scale from 1 to 20, with one being more narrow and 20 being more round. The variables used are pretty standard, as calculating the Body Roundness Index requires an individual's height, their age, weight, sex, race, and waist circumference, and all of these things tend to influence body composition and body fat distribution. The formula itself isn't that straightforward, but I've linked to a Body Roundness Index calculator in the description below.
Now, I use that calculator, and when plugging in my own data, my Body Roundness Index score is 2.3, which correlates to a body fat of 14.1%, and about 1% of that is belly fat or visceral adipose tissue, which means that despite having a BMI of 29.6, which classifies me as overweight, nearing obesity, the Body Roundness Index says I'm in the healthy zone, and as far as the accuracy of that body fat percentage, I think that's pretty close. So in the general population,
the average Body Roundness Index is 5.62, which has gone up over the past 20 years. It's higher in Mexican-American individuals, followed by non-Hispanic black individuals, and then non-Hispanic white individuals tend to have the lowest Body Roundness Index score on average. A similar trend was also observed based on education, with those obtaining a college level education having the lowest Body Roundness Index, and those with lower levels of education having a higher
Body Roundness Index score. Using a data set on over 30,000 adults in the United States, researchers found a U-shaped relationship between Body Roundness Index and Health Risk, a Body Roundness Index score of 4.5 to 5.5 that represents the bottom of the U, which correlates with the lowest risk of mortality from all causes. On the lower end, Body Roundness scores of less than 3.4 have a 25% increased risk of all-cause mortality.
So I have a Body Roundness Index score of less than 3.4, remember it was 2.3, but I'm not particularly worried, as most of the association with low Body Roundness Index, scores, or low BMI, well those are seen in those over the age of 65, primarily, and we see this in body fat testing as well. All of these measures are basically picking up nutritional status and or chronic disease that can lead to reduced body fat and reduced body weight
as a function of those disease processes. Now on the other side of the U, those with a Body Roundness Index score of greater than 6.9 have a 50% increased risk of mortality from all causes, which is being attributed to excess body fat in this case. Okay, so let's compare it to BMI
and some other measurements. The Body Roundness Index appears to work better than either BMI or waste or comforts alone when it comes to predicting the risk of heart disease, metabolic syndrome, type 2 diabetes, reduced kidney function, and even all-cause mortality as we previously discussed. This is especially true in populations where standard BMI cutoffs, remember that's 25 or overweight and 34 obesity, are already known to be off, such as those of Asian descent and or elderly
individuals. Now this makes sense because it's combining all of the data collected by BMI and waste or comforts together and adding other known factors that affect body composition and the distribution of body fat, such as age, race, and sex. So the question is, should the Body Roundness Index replace BMI? And I'm not so sure, mainly because I don't think that the current reason for the underdiagnosis and ultimately the under-treatment of obesity is related to our current screening
tools. In other words, I don't think many people are going to the doctor unaware that they're carrying too much body fat or presenting themselves in a way that their healthcare provider is oblivious to their body composition and subsequent risk from carrying excess body fat. Instead, I think that many doctors and other healthcare providers don't have the time and necessary resources to adequately
counsel patients on obesity. Plus, there's still a ton of obesity stigma not only amongst the public, but in medicine too. So if forced to speculate, I'm skeptical that replacing BMI and waste or comforts with the Body Roundness Index would improve outcomes related to excess body fat. I do think that most people don't think highly of BMI, so perhaps the Body Roundness Index
would generate some interest amongst those who have been disenfranchised by BMI. It could also function as a more compelling conversation starter for healthy lifestyle change and other interventions in the clinic, particularly if changes in someone's Body Roundness Index could be used to predict someone's health trajectory down the line. Now, we have to get some more longitudinal data on Body Roundness Index so we could better characterize what amount of change is necessary to improve health
for both prediction and monitoring purposes. But I'm open to the idea that if we were to start using Body Roundness Index, things could improve. Overall, I think it's a very well-thought-out tool that's built on a solid foundation of research. I'll be interested to see if it gains widespread use and what the further research reveals. All right, that's it for this episode of the Barbell Medicine podcast. If you liked this episode, share it with a friend and leave us a five-star review.
Thanks for listening and we'll catch you next time. Hey guys, before we get into the podcast, I wanted to let you know that we're launching Barbell Medicine Plus so that we can expand on what we're doing with the podcast, the website, and beyond. Now, over the past 300-plus episodes, Dr. Barock and I have tried our best to be one of your go-to resources for legit evidence-based health and fitness information. But now, with your help,
we want to do more. Barbell Medicine Plus subscribers will enjoy ad-free listening and for nearly all of our episodes, receive access to an executive summary and an article, along with the transcript, a video version of the podcast, and exclusive access to a private forum to ask Dr. Barock and I questions, which will answer on a monthly podcast that's released only to our subscribers. We'll be publishing other exclusive content for plus members as well, and we've already uploaded
a lot of resources for our subscribers and we'll continue to expand this offering. If you want to support what we're doing and become a Barbell Medicine Plus member, head over to barbomethison.com, slash plus, and sign up to be a Barbell Medicine Plus member today. That's barbomethison.com slash plus, thank you in advance for your support. Let's get into the episode. If your player scores second, you get your stake back in cash. Everyone knows that most
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