​Watching this past summer’s Olympics, one of my favorite breakout stars was Team USA Rugby player Ilona Maher. Maher has gained attention for promoting body positivity for young girls; she often talks about how her Body Mass Index (BMI) has always qualified her as overweight. While she was insecure about her larger size as a child, she now emphasizes her size allowed her to have the strength and athleticism to become a champion rugby player. As a mom with two young kids, Maher’s comments about BMI and childhood body image made me think about how frequently I see BMI numbers for my kids and how little I understand about what they mean, which led me to explore the topic.  

For each of my children’s After Visit Summaries (AVS) following pediatric visits, BMI is listed at the top. For children, BMIs are given a percentile and it is this that is used to categorize a child’s weight. The Center for Disease control provides the following definitions:

•  Underweight: less than 5th percentile
•  Healthy Weight: 5th to less than 85th percentile
•  Overweight: 85th to less than 95th percentile
•  Obese: 95th percentile or greater
•  Severe Obesity: 120% of the 95th percentile or greater 

While pediatricians have reported BMI for my children starting from birth, the American Academy of Pediatrics states that there are no accepted definitions for underweight, overweight, or obesity for children under two years of age. It is at age two that universal BMI screening is recommended for annual physicals.

Both physicians and parents can agree that a focus on childhood obesity prevention is important, both to mitigate possible health consequences facing children and to decrease the likelihood of obesity in adulthood. In fact, numerous studies have shown that children with obesity are more likely to also have obesity as adults. Early weight management in kids seems crucial; for example, a 2018 study found that a critical window for rapid weight gain is between the ages of two and six.

If early weight management is important, how do we monitor it? There are criticisms that BMI does not measure body fat or distribution and does not identify the factors leading to obesity in a patient. To address this, the American Medical Association issued a new policy in 2023 urging physicians to use other measurements, including visceral fat, body adiposity, waist circumference, and genetic/metabolic factors, as these measurements better predict obesity. Lending support to these recommendations, a study published in 2024 found that using waist circumference-to-height ratio is a more accurate predictor of fat mass in children compared to BMI.

Other studies suggest that physical activity levels, not BMI, have a greater impact on mortality. One metanalysis found that cardiorespiratory fitness predicted mortality risk better than BMI, with “fit” individuals categorized as overweight/obese having similar mortality risks to “fit” individuals with normal weights. In addition, “unfit” individuals had twice the mortality risk of “fit” individuals, regardless of BMI.

​However, despite growing debate regarding its use, BMI is still the CDC’s recommended obesity screening metric for children. Given this, when it comes to that ever-present BMI number, my takeaway is that it I shouldn’t fixate on it or let my children. It is just one piece of information to help understand the full health picture. As we saw this past summer, Olympic athletes come in many shapes and sizes, which highlights the significance of encouraging kids to discover the forms of physical activity that best suit their interests and abilities. 

                                                                                                     Matthew Johnson, M.D. 

​Right now, there’s a good chance you have a cup of coffee in your hand or within an arm’s reach. Whether you use it to transform from a zombie to a functioning human being in the morning, to provide an afternoon pick-me-up, or to give you an energy boost before you hit the gym, many of us love coffee and drink it regularly. But is coffee good for you?

Coffee lovers probably don’t think about its health benefits or risks when they grab their daily cup, yet this beverage has been the subject of a long history of debate. In fact, from 1991 until 2016, coffee was labeled as a possible carcinogen by the World Health Organization. Today, many still consider coffee to be a minor health vice that people enjoy because life’s too short not to live a little. After all, coffee contains caffeine and a slew of hard-to-pronounce compounds that sound unhealthy (chlorogenic acid, quinides, and kahweol to name a few); however, others tout the health benefits of coffee and point to its potential antioxidant and anti-inflammatory properties. To assess coffee’s impact on our health, we can look at its relationship to the two leading causes of death and sickness in the US: cancer and cardiovascular disease.
 
First, let’s look at the link between coffee and cancer. Two large academic studies, both published in 2017, provide insight into this relationship. The first found that coffee consumption was related to a lower risk of death from several cancers, including head and neck, colorectal, liver, and female breast cancers, but found a higher risk of death from esophageal cancer in coffee drinkers. The second study combined and re-examined evidence from many smaller studies to report that high coffee consumption (4+ cups per day), compared to low or no coffee consumption (0-4 cups per day), was associated with an overall 18% decreased risk of cancer. Additionally, high coffee consumers had lower risks of numerous individual cancers and no convincingly increased risk of any individual cancer, including esophageal cancer. Together, these studies suggest that coffee consumption is associated with a lower risk of developing cancer. 
 
Next, we can examine the relationship between coffee and cardiovascular disease, the #1 cause of death both in the US and globally. Coffee folklore suggests that coffee and caffeine cause elevated blood pressure, which then leads to heart disease; however, that’s not actually the case. Some evidence suggests no link between coffee and heart disease, while several other studies report that coffee consumption is actually linked to a decreased risk of cardiovascular disease. For example, a collection of studies, including over 1 million individuals, found that individuals with moderate coffee consumption (3-5 cups per day) had a lower risk of cardiovascular disease compared to people who do not consume coffee. Additionally, even people with the highest coffee consumption (5 cups per day) did not have an increased risk of cardiovascular disease.
 
Bringing all the evidence together, it appears that coffee drinking is linked to lower cancer occurrence, a reduction in cardiovascular disease, and even lower mortality from any cause. However, there are always caveats. First, these findings are relevant to the average adult, not pregnant women, kids, or people with specific health conditions who should decrease or eliminate coffee or caffeine intake. Second, as good as the research on this topic is, significant limitations remain because coffee consumption is linked to other behaviors, socioeconomic factors, dietary practices, etc. Therefore, it’s unclear if coffee is causing health benefits, or if coffee consumption is associated with other health-promoting practices or behaviors.
 
So, to answer the question, “Is coffee good for you?” the adage “everything in moderation” likely applies here. It’s safe to say the evidence supports that moderate (~4 cups per day) coffee consumption does not have adverse health effects and may even have multiple health benefits. This means that tomorrow morning or this afternoon, when you’re sipping your coffee, you can enjoy it a little more knowing that it’s both bringing you joy and possibly even supporting your health.

Author
Matthew is a resident physician in internal medicine at Brigham and Women’s Hospital in Boston, Massachusetts. He graduated from Harvard Medical School, where he developed a passion for clinical care and medical education. His career interests include cardiology, medical education, clinical research, and healthcare leadership. In his free time, he enjoys hiking, rock climbing, and reading. 

                                                                                                                     Joshua Petimar, ScD

If you’ve ever taken prescription medication, you know side effects can be a major concern. When listening to any pharmaceutical ad, you’ll hear a long list of potential side effects, from mild symptoms like upset stomach to serious issues like increased risk of infections and cancer. Side effects can introduce new health problems and cause people to stop treatment for their initial health issue. 

Side effects are a common concern for the 1 in 7 Americans taking an antidepressant. One worry patients have about taking antidepressants is potential weight gain. This is understandable as weight gain can translate into higher risk of chronic diseases like diabetes and heart disease. It’s also very difficult for most people to lose weight and keep it off. Some patients may be so concerned about weight gain that they stop taking their medication altogether, increasing the risk of depression relapse and hospitalization.
 
Given that antidepressants remain crucial to improving the health and well-being of those living with psychiatric disorders, research into understanding potential side effects is crucial. For example, wouldn’t it be great if patients and their doctors could predict which antidepressants would lead to the most or least weight gain before they start treatment?
 
Our new study, published in Annals of Internal Medicine, sought to answer this exact question. We compared average weight change among 180,000 patients in the U.S. who were prescribed one of 8 common first-line antidepressants for the first time (sertraline, citalopram, escitalopram, fluoxetine, paroxetine, duloxetine, venlafaxine, and bupropion). We followed the patients for 2 years and compared weight change at 6, 12, and 24 months.
 
We found that all medications were associated with weight gain after 6 months, except bupropion. Patients gained about 0.3-0.4 kg more weight (about 0.7-0.9 lb.) if they took escitalopram, paroxetine, or duloxetine compared to sertraline (the most commonly prescribed medication). However, many of these differences narrowed when we looked at weight change after 12 and 24 months. In contrast, patients gained about 0.2 kg less weight (about 0.4 lb.) after 6 months if they took bupropion rather than sertraline. At 12 months, they were expected to gain 0.7 kg less weight (about 1.5 lb.), and at 24 months, they were expected to gain 0.9 kg less weight (about 2 lbs.). 






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​These results led us to conclude that bupropion was associated with the least amount of weight gain among the 8 antidepressants we examined. Of course, bupropion might not be right for all patients. For doctors who prefer SSRIs (the most common subclass of antidepressants) and are concerned about their patients’ weight, they might consider sertraline or fluoxetine. Of the SSRIs we studied, these were associated with the least amount of weight gain in the first 6 months—when patients might be more likely to stop taking their medication due to side effects.
 
Of course, weight gain is just one component of antidepressant treatment. Doctors must balance a drug’s potential to treat a specific patient’s health issues with other side effects that could impact their life. For antidepressants, other common side effects include upset stomach, diarrhea, headache, and sexual dysfunction. Some of these might be more concerning to patients than weight gain. Patients and doctors need to have a conversation about which medication is right for their health and well-being before beginning a new treatment. Hopefully, our study will help doctors better communicate the risks of weight gain to their patients and enable them to make more informed decisions about their treatment.

Peter Rentzepis, BA 

​We’re living in GLP-1’s world now. Across the country – from TV to social media to doctor’s offices – the clamor for these new weight loss drugs is deafening, and for good reason. In the seminal STEP trials for semaglutide (brand name: Ozempic/Wegovy) and SURMOUNT trials for combined GLP-1/GIP agonist Tirzepatide (brand name: Mounjaro/Zepbound), the highest doses conferred average weight loss of ~10%-20% for up to two years in those with obesity.

​The Scope of Overweight and Obesity in the US
According to the most recent National Health and Nutrition Examination Survey (NHANES), 42.4% of US adults have obesity (BMI≥30), which translates to ~110 million people using 2020 US Census data. The benefit of GLP-1s likely extends further considering that they have had drastic effects in people with BMIs down to ≥27.
Costly Considerations
Given the overwhelmingly positive results and media coverage of GLP-1s, demand is up and stock is hard to come by. This comes despite eye-popping costs; per the manufacturers’ websites, monthly list prices for GLP-1s average around $1,100 for Mounjaro/Zepbound and Ozempic/Wegovy.
Fortunately, the patient rarely pays the list price due to insurer/manufacturer negotiations and insurance coverage. However, even after discounts negotiated within this system, the net price (i.e., the actual “cost to the system”) of these therapies remains staggeringly high, estimated between ~$8,000-$14,000 per year for Wegovy.
Underlying these trends is the concern (which has come up in both academic studies and national news media) that high prices will exacerbate existing health disparities among those who are more likely to have overweight/obesity (Black and Latino Americans; those with less education), as well as those of lower socioeconomic status who are more likely to have high deductible health plans, high co-pays/co-insurance, and/or catastrophic coverage only.
Balancing the Scale: Outcomes vs Price
Beyond weight loss alone, GLP-1s could reduce the risk of a host of conditions, including cardiovascular disease, chronic kidney disease, nonalcoholic fatty liver disease, and type 2 diabetes. However, with their inflated cost, can the US healthcare system afford these therapies?
Cost-effectiveness models have been mixed, with industry-associated papers suggesting the medications are well-priced for the expected net benefit in the long-term (given these medications can be lifelong), while independent reviews suggest it’s too expensive. Regardless, the scale of the obesity epidemic suggests that these medications could bankrupt US healthcare system in the short-term, costing up to $1 trillion/year (2022 total drug spending in the US was $405.9 billion).
Where Are We Now?
The cost dilemma of these therapies is already making waves, even with patient uptake in its infancy. Some private insurers are limiting spending while others pulling coverage completely due to increasing costs. In the public sector, Medicare only covers the drugs for those with previous cardiovascular disease, while several Medicaid programs cover it for broader populations. But between mounting clinical evidence and political/public initiatives, it may become harder to deny insurance coverage of these medications.
So what should we do? Some potential paths forward include allowing Medicare to negotiate on weight loss drugs (i.e., adding a special case to the Inflation Reduction Act), letting market competition eventually drive prices down (there are 70+ obesity drugs in the current pharma pipeline), or looking to other countries’ drug pricing models for sustainable renovation of our system (the US price for Ozempic is >2x higher than any other country).
Regardless of the short-term fix, the most important step is to address the stigma, disparities, and capitalistic food industry that underpin the obesity epidemic. In doing so, we can get at the root cause and – hopefully – reduce the need for these medications in the first place.

​Resistance training is a form of exercise that improves strength by training muscles against external resistance. This may include the use of free weights, machines, bands, and bodyweight exercises. There is increasing evidence that resistance training can improve body composition, prevent bone loss, improve mental health, and decrease CVD risk factors.

​Despite its many benefits, the 2018 National Health Interview Survey found that less than one third of US adults are meeting the weekly recommendation for resistance training, with only 30% of men and 23% of women meeting the two-days per week recommendation. Further, men have consistently had a higher prevalence of meeting the guideline than women since 1998.
 
This raises the question, "why are women less likely to initiate resistance training and how do we break down these barriers?” A systematic analysis found that the most common barriers were social factors, including gender-based stigma and lack of social support. Some women in the study expressed barriers associated with appearance, such as not wanting to look too “big” or “bulky.” Furthermore, people who were participating in resistance training shared experiences of being told by other gym goers or by their family and friends that, “women shouldn’t be muscular.”
 
While fear of looking too muscular is a common barrier, performing resistance training two days per week is unlikely to lead to the appearance of disproportionate muscle enlargement. Nonetheless, there are still many options for women to practice resistance training besides strictly weightlifting. These include body weight exercises, Pilates, and yoga; all of which use compound exercise to train multiple muscle groups simultaneously.
 
In addition to gender-based, physical appearance stigma, lack of knowledge of how to use weights or design training plans are other common barriers to resistance training. These barriers are especially pronounced in older women.
 
To address these barriers, here are a few solutions with a focus on three S’s: support, simplicity, and schedule:

1. Support: Group based training

 
Group training classes are easily accessible through commercial gyms and community programs. These classes help promote social support and provide technical knowledge to those who are unsure of how to get started. Moreover, affiliation and competition through group training can increase self-efficacy and comfort in the exercise environment. These benefits motivate individuals to continue training in the future.

1. Simplicity: Think outside the gym

 
There are countless, free workouts with certified trainers online. While these workouts are typically conducted individually, there are still many online communities for those participating in home resistance training. Therefore, individuals who prefer to work out at home can still find social support without having to join a gym. Additionally, home workouts can include bodyweight exercises, such as squats, lunges, and pushups, which can help develop strength and stability, and can be a simple way to get started without equipment.

1. Schedule: Meeting the two days/week recommendation

 
Another key component of resistance training success is to stick to a routine. Individuals who want to make it a habit can aim to prioritize it as part of their schedules at least twice per week. Strength training works by introducing the muscles to a new challenge. They have to adapt and become stronger in response to stimulation, and consistency will help women experience the benefits.
 
These are just a few ways that women can initiate resistance training and incorporate it into their routines. Keeping in mind the many benefits of resistance training will also be helpful for those thinking of getting started. Ultimately, the process of getting stronger can empower individuals by fostering confidence, enhancing physical and mental health, and promoting a sense of accomplishment.