Is the use of BMI in healthcare actually doing more harm than good?
Warning: this article contains the topic of eating disorders.
The nurse told me to sit back down and I shuffled the short distance, my legs starting to tremble and my breath quickening. She tapped on her keyboard as unwelcome memories clouded my thoughts before she turned to me and with a soft voice laced with reprimand, told me that I should be careful of my BMI becoming any higher. Heart thudding, eyes brimming with tears, all I wanted to do was rush out of the door, but in that moment, something snapped and I couldn’t stay silent any longer.
I explained to the nurse through jagged breaths that I have a history of disordered eating and while I’m recovered now, I avoid triggers like weighing myself or calculating my BMI as they take me back to a dark time in my life. I emphasised that I felt fit and healthy and happy, more important to me than a number on a scale, and at a clothes size 8/10, I didn’t feel any need to make myself smaller.
Our demeanours switched. The nurse seemed flustered and embarrassed, while I was relieved to have finally asserted some control over the situation, rather than trying my best to hide my panic, as I’d done many times before in GP appointment rooms. In the years following my issues with restricting food, bingeing and purging, the times I’ve felt most triggered have been with doctors and nurses, being asked to step on scales and talk about weight, with what has felt like no sensitivity to how complex that can be for some of us. I’m not alone in this experience of feeling triggered and shamed by the NHS’ use of BMI.
“I have been told every time I go for a contraceptive pill check up that I am 'overweight' because my BMI is either borderline 'normal' or 'overweight'. Even when I had an eating disorder in my late teens/early 20s and lost a lot of weight, my BMI was high,” Molly, 29, tells me.
“It’s about what I feel comfortable with, and restricting and starving myself again does not make me feel comfortable. Nurses and GPs need to consider these things. [It] was never considered with any sensitivity towards me, even though they had my full medical record in front of them,” she adds.
When Grace*, now 18, went to the doctors about problems with her period two years ago, she was seen by a male doctor who warned her about her BMI. "I was weighed and measured, and he said my BMI was close to overweight. He told me that it ‘wasn’t horrendous but needed to watch it,’” she remembers.
“He was so nonchalant. Since then, I’ve put off going back because I'm so scared I’ll be weighed and told off for my weight. I’d rather not go and avoid embarrassment.”
For those of us who dread these kinds of exchanges with GPs and nurses, the findings of a new Parliamentary report by the Women and Equalities Committee might well ring true. The report says “use of the Body Mass Index (BMI) in determining if an individual’s weight is healthy should be scrapped immediately” as “BMI actually contributes to health issues such as eating disorders and people’s mental health by disrupting body image and inviting social stigmas.” It suggests, instead, a 'Health at Every Size' approach which “prioritises healthy lifestyle choices over correcting weight."
Beat, the UK’s leading eating disorder charity says that while BMI needs to be taken account of as well as other factors when monitoring the risk of eating disorders, “an excessive focus on weight and BMI can contribute to the development of an eating disorder."
What is BMI?
On the surface, BMI is an easy-to-understand calculation of a person's weight in kilograms divided by their height in meters squared. Results are placed on a scale going from underweight to obese.
But looking beyond the top line statistics, the system is outdated, biased and was never even intended to measure individual health when it was created back in the 1800s by Lambert Adolphe Jacques Quetelet, who studied human traits as they ‘related to crime and mortality’. Quetelet was not a doctor, and crucially, he based his work (and the subsequent ‘norms’ he defined) on white European men.
Fast forward to the 1970s and ‘80s, and the Quetelet Index was adopted first by health and life insurance companies, then in the medical profession, as the Body Mass Index we know today.
“It’s set up on the average height and weight of a European man so it's really bad at establishing different body types of people from different ethnic backgrounds. It's not good with women or children, and it strikes me that medical professionals need to be given more advice about measures in addition to BMI, looking at things like height-waist ratio,” says Caroline Nokes, a Conservative MP and Chair of the Women and Select Committee that published the report on BMI.
Why is BMI used?
Given the known flaws with BMI, it begs the question – why is it used as a default marker of health? The answer is clear – it’s a quick and easy option.
“In a world where we are very stressed and the health care system is overwhelmed, something that is really easy to measure is quite useful in a sense, so I guess that's why BMI has become such an important measure of health. That’s the only positive thing I can think of to say about it. On the downside, there are so many negative things,” says Dr Natasha Larmie, a weight-inclusive GP.
Is BMI accurate?
According to GP Natasha, BMI is “completely inaccurate" as studies show that it accurately predicts health "about one out of every three times". She adds that it's biassing, and used to deny people their basic human rights.
"Anyone in this country is entitled to fertility treatment on the NHS, unless their BMI is over 30, in which case they’re not,” she adds.
MP Caroline has heard "too many stories" from people who've been denied vital healthcare, including contraceptive treatment, on the basis of their BMI. She's also aware of prospective adopters who've been told that their BMI is too high to adopt children.
"The reality is that... BMI is not a good indicator of individual wellbeing at all,” Caroline says.
BMI: Rooted in racism
Quetelet’s original index asserted whiteness as the norm, and in an age of racist science, it was used to support the idea that people of colour were somehow inferior.
“That’s the history of the BMI. This hatred and intolerance of fat people, if you study it and look back at where it all comes from, it's massively rooted in racism,” Natasha says.
The National Institute for Health and Care Excellence, which provides guidance for healthcare in England, has reported that the BMI cut-off points that determine if someone is overweight might not be appropriate for people from Black, Asian and Minority Ethnic groups and there have been calls for more diverse research into the subject.
“What is considered unhealthy when it comes to white women might not actually be unhealthy for Black women - in fact it might be the optimum health for some Black women and yet they are being discriminated against, pigeon-holed, and treated in a way that is not ideal for people of their ethnicity,” Natasha adds.
The impact on people from Black, Asian and Minority Ethnic backgrounds is profound.
“I have been a plus-size woman for most of my life, and fat shamed consistently because of it. On a number of occasions, I have been ignored and disregarded by the health care system because of my weight, when most of the issues I face have nothing whatsoever to do with my size, but just unfortunate luck in that instance. I have had many conversations with doctors over the years to take away their view on the BMI scale and deal with me on a human level but it’s a constant fight,” says Celestina Diamond, 33.
According to the BMI system, Celestina is morbidly obese, and she feels that label is far from helpful.
"Thankfully I love being curvy... but sadly, not all plus size people are like me. A lot of them do not have the confidence I have and they take these awful words and internalise it.”
The new report highlights that in the national weighing and measuring programme, Black children were more likely to be classified as overweight or obese, creating a skewed picture from a young age. As Black children grow into adults, the racial bias in BMI could even be stopping them from having families.
“[BMI is] quite controversial in the adoption world. As part of the process, people being assessed to become an adopter have to take a medical exam and their BMI has to be below a certain level. Social workers I work with don't like it because we really need Black families to come forward as we’re always struggling to recruit them, and it's another potential barrier for them doing so. We're reviewing it now,” says George*, 28, who works in the adoption field.
MP Caroline describes BMI as "a very blunt tool to measure somebody's potential ability as a parent" and feels it is "utterly shameful if decisions are being made in that way that discriminates against people from different ethnic backgrounds."
BMI: What needs to change?
The Government is expected to respond to the report by early June and Caroline hopes that response will be around how a better, more inclusive system can be used instead of BMI.
The report is urging for a Health at Every Size approach to be implemented, something GP Natasha is already doing with her patients, focusing on general wellness including diet, exercise, stress management and good sleep, rather than just weight.
“I won't hold my breath,” says Natasha, “but I hope that the Government will listen… and will do a 180 degree turn when it comes to their anti-obesity policies, because once we adopt a Health at Every Size approach, that's not just going to improve the lives of fat folk like me, that's going to improve everybody's life.”
Natasha suggests that as a means of voicing your experiences and thoughts on this topic and other health-related issues, you can take part in an England-wide Department of Health Survey which is open until June. “Healthcare is designed for men, and it's important that women get a say,” she says.
You can find help and support related to eating disorders at Beat’s website or by calling the Beat helpline on 0808 801 0677.
*Names have been changed.
Cosmopolitan UK's current issue is out now and you can SUBSCRIBE HERE.
Like this article? Sign up to our newsletter to get more articles like this delivered straight to your inbox.
Follow Megan on Twitter
You Might Also Like
