TW: I talk about antifat bias and related racism and misogyny. Some of the words I use words can be triggering.
A man–a white, middle-class Belgian man who loved numbers–made a study of the ages and weights at which the people in his area died. It was 200 years ago, so people died a lot younger and for a variety of causes we now prevent. But because some men attached meaning to those numbers, I had to stand in a line of girls in only our bras and underwear. The physical education teacher measured our quads, stomachs and triceps with calipers, calling out the total number to the assistant who then wrote it down as part of our fitness record.
I remember a lot of humiliating P.E. moments, but fat measuring day ranks above them all.
And here’s the thing. The numbers are made up and the points don’t matter.
Really.
There is not now, nor has there ever been, any actual science behind the BMI.
But our insurance companies sure love those numbers: they charge people more, or deny them coverage, based on their arbitrary spreadsheets. In fact, insurance actuaries are the ones who took the Belgian man’s numbers and turned them into a full-blown business model. Unsurprisingly, the BMI has been used to inaccurately calculate the health risks for all genders and races. Still the insurance agencies continue their love affair with a BMI.
The diet and fitness industries love those numbers, too. The BMI built everything from celery juice to whey powder; 24 Hour Fitness to Goop. The sandy foundation doesn’t seem to matter. What matters is that hundreds of thousands of us are steeped in wrong and harmful ideas about what we should look like and we spend hundreds of thousands of dollars on books, trainers, specialty diet food and diet companies like Weight Watchers. While we starve ourselves, the diet and fitness industries glut themselves.
When I was 12, standing in line with girls who came in all sorts of shapes and sizes, we stared straight forward, trying not to meet anyone’s eyes. None of us walked out of that room feeling excited about P.E., puberty, ourselves or each other. That day, many (maybe all?) of us started a lifelong war with our bodies that resulted in disordered eating, restrictive eating and dieting. It also fueled cruel taunts preteens and teens seem so good at and which ran through our minds like an add for self-hate. All because a white guy with some political power wrote down the weights and ages of white men who died 200 years ago.
Quetelet, the Belgian man, also had very clear ideas about criminology. In fact, he’s the co-founder of positivist criminology which insists that white people are naturally law-abiding and Black people are naturally criminals. He helped start the pseudoscience that developed phrenology, another bastion of racist ideology masquerading as science.
The BMI fails to account for natural differences in body types even on a large scale, such as regional and ancestral differences. One example of how the BMI fails, Asian Americans are more likely to have “ideal” cardiovascular health than white Americans. Awesome! Healthy hearts=longer lives. But, they’re also less likely to smoke, less likely to have normal blood glucose and more likely to self-report eating a “healthy” diet (with no clear definition of what healthy means in the context of the study and no mention of the unreliability of self-reported eating patterns). And that’s before we even talk about how problematic it is to try to divide people, with our messy ancestry and varied histories, into discrete categories based on another myth: race.
Even Quetelet, who as you can see was no prince, said the index was not to be used to gauge ideal weight for individuals, only populations. Now, I don’t think it works for whole populations, either, but it absolutely doesn’t work for individuals. Unfortunately the US government and the World Health Organization have yet to unravel the insidious tentacles the BMI has woven through nearly every system, including airlines, social science studies, NASA and the US military. Using the BMI as a restriction for employment means that Black, Latine, some Indigenous nations, older adults, women, and, in a weird twist, extremely muscular people, are more likely to be automatically rejected.
One day in 1998, thousands of people in the US woke up fat without gaining a pound. The National Institute of Health had adjusted their numbers overnight, without any evidence to back them up. But, since there never was evidence for the usefulness of the BMI, it isn’t out of character that they arbitrarily changed the numbers.
I can hear some people say, “But people with higher BMI are more likely to have (insert something like heart disease/stroke/high cholesterol).” But when we look at those numbers, we’re looking at the problem the wrong way around (see the study above referring to Asian Americans and high glucose levels). We’re taking the results (poor health outcomes) and assuming they’re linked to BMI which was 100% made up and then misapplied to (checks notes) the entire Western world. Instead, we should be talking about healthcare in a time of antifat bias. Doctors are more likely to prescribe weight loss without taking into account family history of illness, current symptoms, and without running any tests. Disabled fat people have a harder time finding care that doesn’t depend on weight loss first. And try finding a doctor to provide gender affirming medical care if you’re trans and fat. All of that is assuming the person can get in to see a doctor in the first place. Doctors will literally tell people they won’t see them unless the would-be client loses weight. Consequently, people with higher BMI numbers are less likely to seek for or receive preventative medical care–would you go to a doctor who looked at you and, without running any tests, told you to change your eye color or height? Assuming that it’s even possible, in what way would changing those things alter, say, brain cancer?
We’ve changed the language. When I was in P.E. way back in the 1900s, teachers and government officials used ‘fat’ like a swear word. Now, we have influencers and people in our social groups who insist on being ‘healthy’ but they mean the same thing (I’m looking at you, Gwyneth Paltrow and Antoni Porowski. Also Yoga Pants Mom in the pickup line. You know who you are.)
It’s time to retire the BMI. Send it out to pasture. Put it in the “Bad Ideas Hall of Fame.” Most importantly, challenge anyone who still uses it as a guide for anything other than the average age and weight men in Belgium died 200 years ago. For my part, I refuse to let the pediatrician weigh my children until/unless it’s necessary for prescription dosage (even then, the dose is often too low. My children all need higher doses of anesthesia and lidocaine, just like their dad does. Almost like things are less BMI, more genetic). I also refuse to allow my doctor to weigh me and it’s been liberatory. Once, a woman behind me at the doctor’s heard me say, “I’m not going to be weighed,” and she cheered, “Wait! Can we do that? I want to do that.” Dear reader, yes, you can.
I anticipate some of our readers in the medical field will have feelings about my refusal. Why? In the U.S. doctors sometimes don’t get paid by insurance companies unless they a include the client’s BMI info. If that client is “above average BMI” the doctor will have to check a box that tells the insurance companies that they’ve told the client to lose weight. Yes, this sucks. Yes, we should have a different system. But just because insurance companies demand something of my doctor doesn’t mean I have to play along. Sometimes, we need a little creative obstruction, so I’m going to share some ideas 1. Refuse to be weighed. If the doctor asks your weight, and if it’s not needed for a prescription, tell them a number that, according to the BMI, is ideal for a person your height; 2. Ask the doctor why they need the information. Have an open conversation about why the BMI is trash. Then ask them to help you engage in creative obstruction. 3. Preach the good word of fat activism on social media, in your peer groups, in Relief Society. 4. Challenge antifat speech, including in TV shows, movies and on social media.
These won’t be useful suggestions for everyone. I’m white, abled, middle-class, cisgender and I have a ton of thin privilege. But if more of us refuse to go along meekly in a system that hurts our siblings, including children, the system is more likely to change. After all, the BMI hasn’t always existed–it isn’t inevitable that it will always exist.
As an act of healing my middle school self, I bought a bikini. This year, the beach has been getting my glorious, rounded, fleshy middle-aged body, complete with cellulite, stretch marks, sagging boobs and a stomach that overhangs the bikini bottoms. And it’s felt divine.
For more reading, I recommend Sonya Renee Taylor here: https://thebodyisnotanapology.com and Aubrey Gordon here: https://www.yourfatfriend.com
The Body is Political: Part 1 (Intimate Partner Physical Abuse)
The Body is Political: Part 2 (Intimate Partner Sexual Abuse)
The Body is Political: Part 3 (Women Denied What Men Control)
The Body is Political: Part 4 (Gay All Year)
The Body is Political: Part 5 (My Political Body)
10 Responses
One point you either don’t know or neglected to mention is that the way we measure BMI is totally wrong. It is not supposed to be measured by taking your weight and height and using their standard formula because muscle weighs more than fat. Notice when you put grease in water, the grease floats. How BMI is supposed to be measured is to dunk you in water, then measure the water that you displace. Difficult to do, so they use a “short cut” that totally forgets that muscle weights more per square inch than fat does. This is why people with lots of muscle may have a “bad” BMI, but have very little body fat. They weigh more because of muscle tissue. Not fat.
A good health plan, that has you working out a lot to built up muscle but not dieting, will actually raise your BMI. So you get healthier and your insurance company hears that you just gained more fat.
How they did it in your gym class, by pinching up a bit of body fat and measuring it with calipers is better, but still very inaccurate. It measures body fat on the outside, but not the fat around your internal organs. And guess which kind of fat kills you faster. Well, it isn’t that inch you pinch. The fat surrounding your heart and liver kills you faster. Which is one reason diabetes kills, is because diabetics store more fat around their stomach and not on their hips. Distribution of fat matters as well as total amount of fat.
Like Bryn says, the way BMI is used is as good as worthless. But we make a big deal out of it. And even if measured accurately, it tells only one factor about your total health. There are so many other things that are a bigger influence. Like, has your doctor ever asked you if you were abused as a child? Well, they are finding that childhood abuse increases the risk of all stress related disease, because it affects your stress hormone output for life. It increases risk of poly cystic ovaries, diabetes, and heart disease. But has your doctor ever asked about that? Has he asked if you grew up poor? That makes a difference as well as current family income, because living paycheck to paycheck is stressful. Has your doctor asked if you have a gun in the house? That also increases your risk of death.
And they are finding that fat shaming also kills fat people. It isn’t just the fat, but the discrimination that fat people face. They earn less at work even. And being fat is the one thing that it is still just fine to joke about. No Polish or blond jokes. Those are discriminatory. But fat jokes are still fine in our society.
Thank you for this. I especially appreciate the deeper dive into concomitant risk factors as well as discrimination. Those are so huge, and talking about them is super helpful. Please consider doing a guest post.
I touch on the muscle issue briefly when I discuss who would be automatically denied employment based on BMI. That line could absolutely be developed more fully.
The emphasis on working out concerns me. Disordered eating can also involve longer, more frequent, or heavier workouts, so focusing on exercise can also be harmful. Similarly, depending on the workout, muscle mass may or may not increase. Long distance running, for example, or other cardio-heavy workouts, may decrease overall muscle mass. Conversely, weight lifters often have higher muscle mass than non-weight-lifters, but the cycle of gain and cut can increase their risk factors regardless of their work out routine, BMI, or overall weight. Focusing on exercise also perpetuates a myth that people have higher fat mass because of some personal flaw, like the failure to eat healthy (even without dieting) or the failure to exercise. Exercise may or may not be something disabled people, people in poverty, etc can access, and those are the same people who are more routinely harmed by BMI reliance. This leads to increased negative health outcomes because of the reasons you mentioned.
An issue I didn’t touch on because I didn’t have space, but which is relevant to this conversation, is the higher risk for death and coronary events in patients without cardiovascular disease when their body weight fluctuates, including loss and gain. And since restrictive eating, dieting, and heavy workouts rarely reduce weight long-term, our obsessive focus on weight and BMI is actually increasing risk factors for fat people (and for people who consider themselves fat).
I would argue that they way they did it in PE is not better since calipers are notoriously imprecise, the teacher often grabbed muscle because she had to get a measurement even if there was no exterior fat, and the social/personal cost was so incredibly high that there is no way to make it better. It also perpetuated the myth that fat is bad, and that fat people need to work out harder and eat better.
Any way of measuring BMI is based on flawed assumptions to begin with, so any way of measuring it is harmful. It always involves weight and never measures fat distribution. Even the most accurate measurement of BMI, which is currently hydrostatic underwater weighing, has a negative effect on healthcare. An undo amount of emphasis is placed on weight, with the always-correlated-focus on the mythical, irrelevant BMI, means even people who have low BMIs (regardless of how those are measured) are always assumed to be healthier than those with higher BMIs. Very skinny people, with or without high muscle mass, can have a low BMI (regardless of how it’s measured), and can still have fat surrounding their internal organs which is more highly correlated with some health problems. For these reasons, even hydrostatic underwater weighing (regardless of which method is used) cannot accurately indicate health risks or fat distribution, which means it, too, is unhelpful in a medical setting. If we really cared about looking at risk factors associated with fat distribution, the only way to do that is to do a detailed and long term medical history for each individual accompanied by an MRI to determine if and where internal fat is building up.
RE: body-weight fluctuation associated with increased mortality https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6856014/
RE: long term weight loss maintenance (TW: the article includes words largely considered by the fat community to be slurs, as well as harmful assumptions that fat in and of itself is bad) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5764193/
RE: validity of skin fold calipers (note that the researchers assume measuring external body fat is valid so their conclusion pushes another method of measurement) https://pubmed.ncbi.nlm.nih.gov/20040894/
RE: reliability of 3 different hydrostatic underwater weighing methods https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1478276/
Also this article discusses methods to assess body composition on children with cerebral palsy (who have higher rates of malnutrition) https://pubmed.ncbi.nlm.nih.gov/31158551/
On the calipers, the method may get a more accurate picture of body fat than strictly weight, but the application of the method has to be done properly, and pinching up muscle isn’t “done properly”. That is just being sloppy. And like I said, it still fails to measure internal fat.
And a more accurate method of measuring a flawed concept still is a flawed concept. Like, if I think a cup of feathers weighs the same as a cup of water, using a more accurately sized cup isn’t going to make my flawed assumption be any more true. When one starts with a flawed assumption, better accuracy doesn’t change a thing.
But I guess my point was that the people trying to use BMI, take short cuts in trying to measure it that make the whole thing even more meaningless.
I love the comparison to a cup of feathers. That’s brilliant.
Reminds me of Fitness for Life back at BYU. The teacher used calipers to grab a hunk of my thigh, which, since I was a ballet dancer and ran several miles three or four times a week, was pretty much muscle. She still called out some incredibly high number for the fat content in my thigh. I mean, seriously??
Ugh, those required courses are so ridiculous when applied to every person, and can be downright troubling when they perpetuate poor science. I feel like fitness for life classes for ballet dancers/runners should focus on joint care and injury rehabilitation.
I really agree that the whole point needs to be to stop focusing so much/any attention to weight or body fat because doing so causes more harm than good. Shame never did help a person take better care of themselves, even if it was possible to diet or exercise to lose weight or fat. And the problem is that if you do lose weight, you have to continue to diet for life or it comes right back plus some.
The not focusing on weight is what I like about my current doctor. He has never once said one word about my weight or my husbands, and both of us are overweight to obese. Recently I went in and I had lost about 15 lb. He didn’t say a word. If he had, I think I would have chewed him out. Every time my diabetes medication is adjusted, I lose or gain weight, mostly gain.
Your doctor sounds like he gets it. That’s a lucky find—I’m guessing you had to search for someone like him. There used to be a Reddit with people listing doctors like yours but I haven’t looked for it in awhile. And again, if you have the spoons, I think your perspective would be an incredibly helpful one for Exponent II. Guest posts can be anonymous and the sisters who help with guest posts are kind and brilliant.
I’m a Canadian who’s spent time in online Mormon spaces for the last 17 years, and it’s usually my policy to stay out of discussions about US politics and healthcare.
But even after all this time, I’m still occasionally blindsided by the differences between universal healthcare and insurance companies. Are you saying it’s standard procedure to be WEIGHED when you visit your doctor? That’s absolutely appalling.
I applaud your courage in standing up to such nonsense.
Not only standard procedure, but often required by insurance companies (who have a lot of influence on the medical field and on legislation). There’s been a movement for years and years to have universal healthcare, but every single time we get even close, stories crop up about people not being covered because of universal healthcare, or not getting the help they need. And of course tired claims of “communism” and “socialism” because most US folx don’t understand the difference and are convinced socialism doesn’t already exist in the US (we just reserve it for older people and corporations). It’s like they took what’s happening in the US and misapplied it to countries with universal healthcare. And they do it completely unironically.