S4E5: Invalidate BMI

Isis: And it is pronounced Isis, just because I in Spanish is E.

Harjit: So you kind of did mix a little bit of your Latinx roots in the name?

Isis: Yeah, for sure.

Margaux: I was just named after French wine, so nothing too fancy.

Isis: That is fancy.

Margaux: Okay, so we can go ahead and get started. Hey, everyone. Welcome to "Bundle of Hers" today. We have Harjit and Margaux in the virtual remote studio still. COVID raining on our parade always. But today, we have a special guest, Isis, who is a nurse at Primary Children's who has saved my butt so many times as an intern.

And today's topic is going to be about weight bias and fatphobia in medicine. I know we've talked about this in other seasons, but it continues to be a really prevalent thing for me, and that I've noticed now, especially as a resident. And I noticed that Isis has been posting stuff on Instagram, and we kind of started talking about it. So I wanted to have this conversation with Harjit and her.

Isis, would you like to introduce yourself briefly to our listeners? And welcome.

Isis: Thank you. Hi, everyone. My name is Isis. I am super excited to be here. It's my very first time doing anything like this, so I'm a little nervous, but I'm also really excited to just kind of get this conversation going and hopefully change people's minds. So, yeah. Hi.

Margaux: Hi. We're so excited to have you. And like I mentioned earlier, weight bias and fatphobia in medicine is such a big topic, we could probably do a whole podcast on it. But we wanted to focus on specifically BMI as a measure of health, how it's not valid for this conversation, and then our own personal experiences. It will be a two-part series, so make sure you tune in for the second part.

But we're going to talk a little bit about the brief history of BMI and how it really isn't valid based on the way that it was created for . . . it's not valid in today's population or for what we use it for. And then, like always on "Bundle of Hers," we're going to share our own stories regarding weight bias and fatphobia in medicine both in our own personal experiences and as providers.

Harjit: I'm really excited about this conversation. I think, like you said, we've talked about this before, but it's always prevalent and always relevant and something that we really should be critical about.

Margaux: Basically, I got this brief history from a very nicely summarized article called"The Bizarre and Racist History of the BMI," which was written by someone who goes by Your Fat Friend. And they link lots of different actually "evidence-based" articles that we would usually look at in medicine throughout this article. So I think it's a really nice article. I'm going to briefly go through it, but make sure you check out.

So, starting in the mid-1800s, a person named Adolphe Quetelet was a sociologist who was trying to identify the characteristics of what the "average man" was. And this was from his white Eurocentric perspective, of course.

So among other statistical and pseudoscientific theories that he developed, he came to believe that the mean of a population was its ideal. And thus, after studying a bunch of white French and Scottish, people who were assigned male at birth, or XY chromosomes, Quetelet developed an index, which he called Quetelet's Index, which is what we now know as the BMI.

So, historically, weight, like higher weight and fatness, used to be associated with health and wealth. It meant that you had access to food and you were secure. However, around the time of World War II, people started associating weight with heart disease, and life insurance companies actually started collecting data on height and weight among other metrics as a way to sort of determine how much to charge policyholders.

So, in and of it, we already know that Quetelet had a very condensed population of just white men from two countries. And then the second set of people is people who could afford life insurance policies, right? And then the other part was they were self-reporting their heights and weights. So insurance companies were trying to figure out how to utilize this information to create a best measure of health and ultimately a predictor of their bottom line, right?

Harjit: This just reminds me of a lot of things, like someone just decides to do something and everyone is like, "Oh, this sounds like a good thing to go along with."

Margaux: Exactly. It's totally arbitrary. Someone gets an idea or a theory and then they run with it, right? And sometimes it works and sometimes it can be harmful, like we'll see here.

So, in the '70s, another person named Ancel Keys did a study of about 7,500 men from five different countries, which were mostly white and concluded that Quetelet's Index, which he then called the BMI, was the most effective method of any of the ones that the life insurance companies were using to predict weight with health. So that was sort of the first time that BMI was linked to health.

And then in 1985, the National Institute of Health adopted the BMI into the definition of obesity and overweight making it fully a public policy and fully integrated into healthcare.

And then in 1998, the NIH lowered the threshold for overweight and obese, and that sort of led the way into the rhetoric for the "obesity epidemic" and this very reductionist idea that obesity is linked . . . or sorry, that BMI is linked to health.

So, basically, what sums up from the story is that there are so many flaws in the way that BMI came to exist for us, right? First of all, it was never meant to be a measure of health. Second of all, it was only ever validated in white male populations. So how could we use it as a tool for all populations, whether you're black, brown, woman, a female, or not?

And actually, more current research suggests that there are different types of obesity. One from Mass General Hospital suggests that there are, like, 59 different types and some of them are more associated with certain things than others. And so this idea that BMI can just solely represent one thing is really flawed.

Also, there's research to show that the BMI overestimates fatness in black people and underestimates it in Asian populations. And so you can really over or underdiagnose based on the BMI. And so the BMI is not a great tool, and the fact that we're still using it sort of blows my mind after doing this research.

So us, having gone through nursing school and medical school, I think we really learned to associate BMI with health as one of the vital signs almost, and that made me start to think about, "Well, what actually is health?" And so I wanted to open that question to you guys. What does health mean to you?

Isis: I really enjoy that you brought up how weight is a vital sign because I was just having this conversation with someone the other day. I work in a pediatric hospital, so we always make sure that we get a weight. Just for worst-case scenarios, we want to know like specific drugs that we would use and stuff like that.

But as an adult, when I go see my doctor, every single time they want my weight. And I just realized not that long ago that why is weight of a vital sign? And I just keep asking myself that. Actually, the last time I went in, I'm like, "Nope, I refuse to get weighed." And it was a little empowering and kind of weird.

But I feel like in school, in any kind of medical-related school, you're going to learn that health is the absence of illness, right? Being overweight or having weight issues does not always define your health.

Margaux: Exactly. And when you think of the other vital signs like heart rate or blood pressure, those are things that . . . I mean, even a slightly elevated blood pressure isn't necessarily a sign of poor health. It could be like white coat syndrome, right? In that moment you are really anxious, but it's not a long-term measure of your health.

But the way I feel like that we're taught to think about those is to look at those objective measures and take them on a more longitudinal view sometimes, right? And when we're so rushed and doing things and we have so many patients, we look at these numbers and then we just attach these associations and these assumptions when in reality, like you're saying, whether you're overweight or underweight, that one visit doesn't necessarily mean you're unhealthy.

And I like what you said. Health is the absence of illness. And when I was thinking more about "What is health?" initially my mind was going to numbers and these objective values, and I think that's how we're taught to think about it. But if I think about it more in an abstract level, I think . . . and when I feel healthy is when I feel probably good biologically, psychologically, and socially. When those three things are sort of in harmony . . . even if one is off or the other, I feel healthy or I feel good.

And so I think when we only think about vitals, these numbers as vital signs and objective data, we are really not looking at people holistically and health holistically.

And then I think that, in turn, causes a lot of harm for patients, because like you said, I get so much anxiety about going to my physical and getting weighed and having the doctor chide me because my BMI is not normal either. But I'm like, "But I feel healthy." So I think we are really doing our patients a lot of injustice.

And then, again, there's this whole point that BMI doesn't apply to everybody, and when we are attaching this idea of health to a standard that isn't even validated for you, that feels really bad and we're doing a lot of harm there.

Harjit: Yeah. I agree with that, and even for me, I think the way both of you defined health is basically how I see health. Health is a state of being where you are content and your body is content, and like you said, Margaux, biologically, psychologically, and socially.

And having a measure of what that is, it's kind of limiting us as people too because you can't define health with one thing. And that's unfair. I think that limits the uniqueness of every single human being.

And I think the issue with BMI is it's tied to weight, and then weight is tied to body image, and then body image is tied to so many . . . from the government, to the media, to education. It's literally seeped in everything.

I think it's so interesting that one person thought of this thing called the BMI. And I think when I think of BMI growing up, I used to be like, "Oh, weight is something . . . I know it's a number. BMI is a more of a mathematical equation." There's so much academia tied to the word BMI, which is also messed up because it's like, "Is this really like academic?" Because it's not changing. It's not growing. It's the same freaking thing, you know?

Margaux: Yeah. It's frustrating when you do look through . . . and to know that there is evidence out there, like peer-reviewed evidence that says that the BMI is not valid, but yet we're still continuing to use it probably because that's what we've always done.

I think a lot of people don't recognize the harm in exactly what you were saying, Harjit. By defining someone by this number, there are so many downstream effects that can come into your own conscious and the way you think about yourself and value yourself.

And the other part of this that we'll get into more in the second half is how much our society . . . this is where the fatphobia comes in, and that really, to me, means that we are afraid of gaining weight. But why? Because weight has been . . . I don't want to say criminalized. What's it called? Villainized?

Harjit: No, it's been pathologized.

Margaux: Yes.

Harjit: That's the issue. The issue is it's been pathologized. We're saying that being over a certain weight, you have an illness. But it's like, "No, you don't have an illness." Sorry, I'm talking so passionately about this because that's the point. The point is we pathologize fat people. And I say the word fat people not in any derogatory way, but that's just . . . some individuals don't mind that word because it's them reclaiming that word, right? It's pathologizing something that shouldn't be. That's the issue.

Margaux: Yeah. With the word fat, there's this whole movement of body liberation and fat liberation where we are taking the word "fat" back. And that means different things to different people, and if you choose to identify that way or not. But I think something common is if someone says, "Oh, I'm so fat," and then your friends are like, "No, no, no," that is the embodiment of fat phobia, right? We're so afraid to even be called fat when we're trying to navigate our own feelings about our body because it is so strongly tied to this idea that fat is pathologized.

And it comes back to the fact that body weights amongst different populations and different races have not been studied. And so what is healthy and normal in a certain population or race is completely different than what would be for the white standard that the BMI was made for. And also, this idea that there's only one ideal weight for all people everywhere is just BS that you wouldn't consider like genetics and stuff, right?

Isis: Right. And it's funny because I have a 10-year-old. So her dad is half Tongan, half white, and I'm full Hispanic, and she takes on his genes. She is super tall. She's not heavier set, but she's pretty built. And she's athletic. She does karate three times a week. So she has a lot of muscle.

I took her into the pediatrician and they were like, "Oh, well, we should talk about her BMI." And I completely lost it. I was like, "Nope, we are not doing that. BMI doesn't take into consideration muscle mass, bone density, her genetics." Why are we still talking about it? Why are you going to allow this one portion of who we are to define us?

Margaux: Right. And especially when it's a doctor's office and I think a lot of people take that to heart and that's where you can get the body image issues, is like, "Oh, they think something is wrong with me." When, like you're saying, she's completely healthy and active and she is just who she is and there is nothing wrong with her. And yet she can so easily be made to feel like the opposite.

Harjit: Also, Isis, I love this example that you gave for several reasons. And I think the first thing is that there's this culture that we go to the doctor's office and it's supposed to be a protective space. It's supposed to be a space where we're vulnerable. And when we're vulnerable, we're easily influenced, right? That should be a sacred place, but it's not.

And also, I just want to, again, applaud you for advocating for yourself and your daughter and saying, "No, we don't need to talk about this." Because the truth is, even though me, as someone who now has the title of a doctor, I don't know everything, and I am here to provide care for you in a collaborative way. And so I really want to just applaud you for doing what you did and standing up for what you felt was right.

Isis: Thank you. That means a lot.

Margaux: Yeah. You're so amazing. And I think that we'll end Part 1 here and continue with our own experiences with weight bias and that phobia and sort of navigating that through our childhood and up to now in Part 2. So thank you for tuning into Part 1 of "Bundle of Hers." You can always follow us @bundleofhers on Instagram. And make sure you tune in for Part 2. Here's a sneak peek of the next episode.

Isis: Just recently, maybe like two years ago, I jumped on the self-love journey and it has helped me grow significantly. But if I sit down and think about it, I think it all started back in 6th grade. We had some coats donated to our school. I remember being so excited to get a coat and not being able to get one because I couldn't find one that fit me.

I feel like as healthcare providers, people come to us when they're most vulnerable. We have the power to educate people and guide them towards happiness, because I always associate healthiness and happiness together.