“Obesity Epidemic” or Body Shaming Epidemic?
Written by Marlena Tanner, RDN, CEDRD
History of BMI and Why it’s Problematic
Anyone who has been to a doctor’s office recently (or isn’t living under a rock), is probably familiar with the BMI or body mass index. For a screening tool that is heavily relied on in healthcare, it is difficult to imagine that the BMI equation was created by an astronomer and was never intended to be used in medicine. Adolphe Quetelet, the mastermind behind the body mass index, used it as a mere statistical exercise and warned against its use as a screening tool(1). Not to mention, he developed the equation using a population of exclusively white European men, making it incredibly inapplicable to the general population and ignoring ethnic differences in body composition(1).
Despite Quetelet’s warning, insurance companies got a hold of the concept and started using it to categorize people as “underweight”, “normal”, or “overweight” at the start of the twentieth century(2). They noticed a general pattern that those with a higher BMI had shorter lifespans despite limited research. They wanted neat and easy boxes they could put people into for insurance purposes and so it continued.
*As an aside, I have put the terms “underweight”, “normal”, and “overweight” in quotations as the terms don’t hold much meaning. When you categorize someone as “overweight”, it begs the question, “Over whose weight are they?” It seems more appropriate to use terms such as “larger body”, “set point”, “maintenance weight” and “restoration weight” because they are relative and individual to each client.)
Turning Point
As if our society wasn’t already in a weight frenzy and diet crazed mindset, the National Institutes of Health changed the thresholds for what is considered “overweight” and “obese” in 1998. This means that those previously in the “normal” category were “overweight”, and those who were “overweight” were suddenly “obese” overnight. The NIH based their new recommendations off a report by the World Health Organization two years prior. This paper was written by the Obesity Task Force which was conveniently funded by two big pharmaceutical companies that made and sold weight-loss drugs (1).
Unsurprisingly, recent and more representative research tends to favor the initial index, whereas people in the now “overweight” category (BMI of 25-30) have an association with lower all-cause mortality(3). These findings support the idea that the range for a healthy body mass index is much wider than the narrow 18.5 to 25, and that those with a slightly higher BMI may actually live longer.
If the BMI is so Illegitimate, why is it Still Used?
Doctors assess BMI and sometimes waist circumference at regular visits so they can screen for/diagnose “obesity” and offer lifestyle recommendations (which, based on their little nutrition background, can be vague and unhelpful (4).
Although the BMI is flawed, it can serve a purpose if it is used in addition to other determinants of health. Even in eating disorder treatment centers, we calculate BMI to give us another piece of the puzzle. For example, if we see someone with a very low BMI, it can be representative of malnutrition. Instead of stating we’d like to see them at a higher number (which will make potential clients think we just have an agenda to push them beyond their normal weight), we want to promote healing. A major component of healing physically is having regular menstruation. The risk of amenorrhea increases when BMI falls below 20, therefore, we like to see a BMI of 20, even though a BMI of 18.5 would be considered “normal.” Basically, the BMI is one tool that can be used, but should not stand alone.
In a treatment center like ours or in a doctor’s office, health professionals are able to use other information to assess a person’s well-being. They can screen for what the BMI cannot such as lab values, body composition and build, quality of sleep, substance use, mental well-being, etc. The problem is that now anyone can use a BMI calculator online and self-diagnose which can lead people to pursue restrictive diets, regardless of what category they fall into(2).
Schools Are Doing What?
A prime example of BMI being used inappropriately and not under medical supervision is school mandated BMI assessments. Some states across the U.S. are required to report the BMIs of students to track trends as public health surveillance and to inform parents of their child’s weight status(5). The CDC sets guidelines, or “safeguards” as they call it, on how to be “as sensitive as possible” such as making the process confidential and responding appropriately to weight concerns of children(5).
A 2017 documentary titled The Student Body follows a student uncovering this poor practice in a school district in Ohio. This particular school did not follow safeguards which is not surprising since they had gym teachers and sometimes a nurse taking the measurements who weren’t exactly trained in body image and eating disorder prevention. They forced kids to be weighed and measured in a room full of other kids and they sent letters home to the parents of children who were “overweight” and “obese.” One mom puts it well when she says the students won’t remember how nicely the school tried to frame the situation, but how they were told they are unacceptable and need to do something to change (6).
Weight Bias in Healthcare
What most people don’t know is there are other factors that can lead to poor health outcomes regardless of our BMI and dietary intake such as the stigma of living in a larger body.
Weight stigma is discrimination or stereotyping based on a person’s weight, shape, and/or size(7). As you can imagine, this type of discrimination can be a major risk factor in developing disordered eating and body dissatisfaction. Even family members constantly talking about how concerned and worried they are can be shaming. What is even more disturbing is weight stigma/weight bias is rampant among medical professionals. Research shows that providers spend less time with clients in larger bodies, provide less information, and view them as undisciplined and noncompliant (7). This can lead to a strained relationship between the clinician and the patient which may inhibit patients from seeking regular check-ups and preventative screenings like pap smears and breast exams, thus putting their health at risk.
Personal Experience
While I am not in a larger body myself, my BMI (that pointless number we discussed earlier), puts me in the “overweight” category. Ironically, when I went to get a yearly check-up and physical exam as clearance to do this dietetic internship, I received a poor and vague lecture on diet and exercise from my doctor. While I tried my best to brush the comments off and trust my own body (and my bachelor’s degree in nutrition), the experience struck me because it is not the only time this has happened.
Through my own eating disorder experience, I had countless poor encounters with medical professionals. When I sought a remedy for amenorrhea, I was prescribed a mega dose of hormones to regain menstruation with no inquiry about my eating and exercise behaviors. At the time, my ED enjoyed not being discovered, but I now see that the doctor missed the true etiology of the amenorrhea due to being uneducated about this topic.
When my long-time restriction started to backfire, I started binge eating and gaining weight. This time, the doctor discussed my growth chart with me and explained her concern with my rapid weight gain. When I tearfully disclosed my struggles with eating, I received minimal empathy and general weight loss advice. As you can imagine, I left feeling unheard, defeated, and invalid. Unfortunately, this kind of experience is not uncommon.
Emerging Research
Since the incorrect stereotype that being in a larger body is equivalent to poor diet and lifestyle is so ingrained in our society, it is difficult to accept that this isn’t true. While there are countless studies on body weight and its relation to health outcomes, the results are correlational, not based on causation (1). One major confounding factor that is almost never accounted for is weight stigma.
While it isn’t commonplace yet, more and more studies (using large sample sizes), are uncovering the effects of weight stigma on health. One recent study found that experiencing weight stigma is an independent risk factor for physical health outcomes like diabetes and heart disease, despite actual body size (8).
What’s more is that a 2017 study found those who experience weight-based discrimination have almost 60 percent greater odds of being physically inactive, regardless of BMI, which may also increase risk of disease (9).
It is our hope as eating disorder professionals that more research continues on weight stigma to uncover the major damage it can have on health, and that it reaches medical professionals to improve the care they provide to patients in larger bodies.
Weight Cycling
Another factor that can lead to poor health outcomes independent of body size is a concept called weight cycling. Rapid and frequent weight fluctuations as a result of yo-yo dieting is also detrimental to health, particularly increased risk of death from all causes and death from cardiovascular disease, independent of confounding factors like BMI, pre existing conditions, and smoking (10)
This creates a vicious cycle because people pursue weight loss in an attempt to improve their health which only puts them at greater risk. If they then develop health problems as research suggests and they seek help, they are only told to lose weight over again as a “cure” (1).
Consensus
Research about the etiologies of our supposedly “ever-growing obesity epidemic” is constantly changing. For now, it is widely accepted that diet, exercise, and other lifestyle factors determine our body size because they have been correlated in studies. What is currently showing more evidence on disease risk is the effects of weight stigma and weight cycling which are not controlled for in mainstream research. From countless research on genetics, the gut microbiome, processed foods, and more, we can’t say for sure what is at the root of our increasingly unhealthy population (it’s likely a combination of many factors). However, the effects of weight discrimination and yo-yo dieting appear to be more legitimate causes of adverse health outcomes than our body mass index.
For more information on the topics discussed in this blog post, check out the following resources:
Health at Every Size (HAES), haescommunity.com
Association for Size Diversity and Health (ASDAH)
“Sick Enough” by Jennifer Guadiani
The Student Body documentary
The Globalization of Beauty documentary
References
Harrison, C. (2019). Anti-diet: Reclaim your time, money, well-being, and happiness through intuitive eating. New York, New York: Little, Brown Spark.
Singer-Vine, J. (2009). Beyond BMI: Why doctors won’t stop using an outdated measure for obesity. Retrieved from https://slate.com/technology/2009/07/why-are-doctors-stillmeasuring-obesity-with-the-body-mass-index.html
Flegal, K., Kit, B., Orpana, H., Graubard, B. (2013). Association of all-cause mortality with overweight and obesity using standard body mass index categories: A systematic review and meta-analysis. Journal of American Medical Association, 309(1): 71–82.doi:10.1001/jama.2012.113905
National Institutes of Health (n.d.) Overweight and obesity. Retrieved from https://www.nhlbi.nih.gov/health-topics/overweight-and-obesity
CDC (2017). Body mass index (BMI) measurement in schools. Retrieved from https://www.cdc.gov/healthyschools/obesity/bmi/bmi_measurement_schools.htm
Webber, M. (Producer and Co-Director) & Webber, B. (Co-Director) (2017). The Student Body. United States: Gravitas Ventures.
NEDA (2018). What is weight stigma? Retrieved from https://www.nationaleatingdisorders.org/weight-stigma
Hunger, J.M. et al (2015). Weighed down by the stigma: How weight-based social identity threat contributes to weight gain and poor health. Social and Personality Psychology Compass, 9(6): 255-268.
Jackson, S.E. and Steptoe, A. (2017). Association between perceived weight discrimination and physical activity: A population-based study among English middleaged and older adults. BMJ Open, 7(3).
Diaz, V.A. et al (2005). The association between weight fluctuation and mortality: Results from a population-based cohort study. Journal of Community Health, 30(3): 153- 65.