“I’m just concerned about your health!”
Have you ever heard that from a family member or healthcare provider when they critique your weight or Body Mass Index (BMI)? Weight talk can be quite triggering, no matter where it’s coming from. We’ve all heard about the “risks of obesity*”, but how much should we actually worry about our BMI? There’s a ton of history and nuance to deconstruct.
*I typically do not use the stigmatizing words “obese” or “overweight” with clients. However, for the purpose of this post, we will use this language based on the different categories explained below.
History of BMI
Development of BMI
Back in 1832, Adolphe Quetelet, a Belgian statistician, astronomer, and mathematician developed what’s called the “Quetelet Index”, which is now known as the BMI. It’s the ratio of a person’s weight (kg) to height (m²). He came up with this tool to help portray the “normal man” – meaning white, European men at that time. Red flag alert – think of how frequently we use the BMI, and how it was not intended for women or people of color. He did not intend to categorize “obesity” – and did not develop the weight ranges.
QI eventually changed to BMI, which was coined by physiologist Ancel Keys in 1972. After WWII ended, there were increasing worries about associations of weight, chronic diseases, and death. This prompted studies regarding weight. Also, insurance companies wanted a way to predict policy holder’s body fat. A study with predominantly middle-aged males showed that BMI was a good predictor. This drove Keys to verify the BMI.
Again, these studies focused on white or male populations. Despite the research since then (see “Is BMI a reliable tool” section), we still use BMI as an indicator of health.
In the past 30 years…
In the mid-1990s, International Obesity Task Force (IOTF) was formed, and was heavily funded by drug companies Abbott and Roche. Both companies formulated weight loss drugs – Reductil (by Abbott) and Orlistat (by Roche). Sounds problematic – right?!
In 1998, the National Institute of Health lowered the BMI to be considered “overweight”. It was previously 28 kg/m² for men and 27 kg/m² for women, and lowered to 25 kg/m² – making millions of Americans “overweight”, without gaining a pound.
Current BMI ranges
- Underweight: Under 18.5 kg/m²
- Normal: 18.5-24.9 kg/m²
- Overweight: 25-29.9 kg/m²
- Obese: 30 kg/m²
- Obese Class 1: 30-34.9 kg/m²
- Obese Class 2: 35-39.9 kg/m²
- Morbid Obesity: 40 kg/m² and up
Is BMI a reliable tool?
If BMI was a reliable indicator of health, we would see higher death rates and health outcomes as the BMI increases. This is not the case. “Overweight” is often seen as a negative diagnosis, but this range has the lowest mortality rate – yes, lower than the underweight range. There is also a slightly lower mortality rate in the class 1 “obese” range than the “normal” range.
Even for those 65 and older, there was no difference in mortality rates between the “obese” and “normal” weight classes. Some literature also finds that there may be a protective effect of having a larger body during severe injury or sickness.
In a study with over 40,000 participants published in 2016, researchers reviewed health factors such as blood pressure, cholesterol & triglycerides, glucose, and insulin resistance and compared results among BMI categories. Participants were from the 2005-2012 National Health and Nutrition Examination Survey (NHANES). Almost 1/3 of the “obese” population was metabolically healthy. A similar percentage of “normal” weight were metabolically unhealthy. If BMI were a reliable health marker, then “normal” weight folks would nearly always be metabolically healthy and “obese” folks would nearly always be metabolically unhealthy. However, that was not always the case in this study.
Another Factor to Consider when Exploring Weight and Health: Weight Stigma
There’s no denying that there are studies linking “obesity” with chronic diseases like Type 2 Diabetes, Heart Disease, and Cancer. But are we really looking at the bigger picture of health?
An important factor to consider when thinking about weight and health is weight stigma.
Weight stigma is the negative attitude and beliefs towards others because of their weight. While this can transcend through all aspects of life (did you know someone at a higher weight is more likely to receive lower pay at work?), let’s talk about weight bias and medical care.
The following are ways someone at a higher weight might experience medical bias when trying to receive medical care at the doctor:
- Assumptions are more or they are not believed about their patient’s nutrition or eating habits
- Not being appropriately screened or tested for medical conditions because the ailment is being blamed on weight instead
- Not receiving the same referrals compared to thinner patients with the same ailments
- Medical treatment withheld until weight loss is achieved first
Obviously weight bias is going to lead to worse health outcomes if someone isn’t being appropriately screened and treated for medical conditions. But weight bias in medical care also leads to anxiety around going to the doctor, distrust in medical care, and even avoidance of medical care altogether.
Weight bias is also associated with:
- Worsening health markers: higher A1c, blood pressure, and cortisol levels
- Worsening eating and activity behaviors: increased binge eating, disordered eating, lower motivation for body movement
- Worsening psychological distress like depression, anxiety, poor body image and substance abuse.
Can people in larger bodies be healthy?
Yes! Fortunately, we have research to demonstrate this.
Several studies have shown that those in larger bodies that also have good cardiorespiratory fitness have lower associations with mortality and a significantly lower cardiovascular death risk compared to those in the “normal” weight category who are not fit.
In a small study from the Journal of Clinical Endocrinology & Metabolism, participants (some had PCOS) worked out on the treadmill 3 times per week for 12 weeks. This resulted in lower Insulin Resistance & Triglycerides without a significant decrease in weight in participants with PCOS. The authors suggested that weight loss should not be the main intention of an exercise regimen.
What can I use to measure my health instead?
- Blood sugars, cholesterol levels, blood pressure, ect.
- Here’s a link to my PCOS Lab Guide for labs to monitor with PCOS
- Sleep quality
- Regular movement
- Strength and endurance
- Mental health
- Energy levels
- Balanced meals and snacks
- Low levels of stress about food and weight
How can I communicate this with my healthcare team?
As seen in the weight stigma section, it is extremely important to not delay medical care when you need it. This may require advocating for yourself.
- When you go in for a doctor’s appointment, if you are uncomfortable with it, request to not be weighed
- If there’s pushback, say that you would like to focus on other factors of health aside from weight, and only want to be weighed if it’s necessary to dose a medication
- If it is medically necessary to be weighed, feel free to do a blind weight so you don’t see the number on the scale
- If your provider blames a health condition on your weight, and advises weight loss, ask what they would tell someone in a smaller body who has that same condition
- Kindly ask that they focus on healthy behaviors and not weight. You can phrase it like this – “Thank you for the concern, but weight talk is pretty triggering for me. Could we focus on other recommendations that would benefit me aside from weight loss?”
- If your doctor continues to focus on weight, please know that you do not owe them a smaller body. If you are able to, consider finding a different doctor.
- Also follow pcos.nutritionist on Instagram for weight-inclusive support!
- Gaesser, G. A., & Angadi, S. S. (2021). Obesity treatment: Weight loss versus increasing fitness and physical activity for reducing health risks. IScience, 24(10), 102995. https://doi.org/10.1016/j.isci.2021.102995
- Childers, D. K., & Allison, D. B. (2010). The ‘obesity paradox’: a parsimonious explanation for relations among obesity, mortality rate and aging?. International journal of obesity (2005), 34(8), 1231–1238. https://doi.org/10.1038/ijo.2010.71
- Tomiyama, A., Hunger, J., Nguyen-Cuu, J. et al. Misclassification of cardiometabolic health when using body mass index categories in NHANES 2005–2012. Int J Obes 40, 883–886 (2016). https://doi.org/10.1038/ijo.2016.17
- Hobbes, M., & Gordon, A. (2021, August 3). The Body Mass Index . Retrieved January 24, 2022, from https://maintenancephase.buzzsprout.com/1411126/8963468.
- Moynihan R. Obesity task force linked to WHO takes “millions” from drug firms BMJ 2006; 332 :1412 doi:10.1136/bmj.332.7555.1412-a
- Hebert, J. R., Allison, D. B., Archer, E., Lavie, C. J., & Blair, S. N. (2013). Scientific decision making, policy decisions, and the obesity pandemic. Mayo Clinic proceedings, 88(6), 593–604. https://doi.org/10.1016/j.mayocp.2013.04.005
- Garabed Eknoyan, Adolphe Quetelet (1796–1874)—the average man and indices of obesity, Nephrology Dialysis Transplantation, Volume 23, Issue 1, January 2008, Pages 47–51, https://doi.org/10.1093/ndt/gfm517
- Callahan, A. (2021, May 18). Is B.M.I. a Scam? Https://Www.nytimes.com/. Retrieved January 24, 2022, from https://www.nytimes.com/2021/05/18/style/is-bmi-a-scam.html.
- Squires, S. (1998, June 4). About Your Bmi (Body Mass Index). The Washington Post, p. A01. Retrieved January 24, 2022, from https://www.washingtonpost.com/wp-srv/style/guideposts/fitness/optimal.htm.
- Nuttall F. Q. (2015). Body Mass Index: Obesity, BMI, and Health: A Critical Review. Nutrition today, 50(3), 117–128. https://doi.org/10.1097/NT.0000000000000092
- Samantha K. Hutchison, Nigel K. Stepto, Cheryce L. Harrison, Lisa J. Moran, Boyd J. Strauss, Helena J. Teede, Effects of Exercise on Insulin Resistance and Body Composition in Overweight and Obese Women with and without Polycystic Ovary Syndrome, The Journal of Clinical Endocrinology & Metabolism, Volume 96, Issue 1, 1 January 2011, Pages E48–E56, https://doi.org/10.1210/jc.2010-0828
Abstract: Effects of Exercise on Insulin Resistance and Body Composition in Overweight and Obese Women with and without Polycystic Ovary Syndrome | The Journal of Clinical Endocrinology & Metabolism | Oxford Academic (oup.com)
- Centers for Disease Control and Prevention. (n.d.). Defining adult overweight & obesity. Centers for Disease Control and Prevention. Retrieved January 26, 2022, from https://www.cdc.gov/obesity/adult/defining.html
- Harrison, C. (n.d.). WHAT IS WEIGHT STIGMA? [web log]. Retrieved January 26, 2022, from https://christyharrison.com/what-is-weight-stigma.