BMI has had little direct influence on my life so far. The doctors I have encountered have never first calibrated my height and weight to determine whether I deserve extreme scrutiny or care. One look at my body has made the case obvious. The fact that I cycled to school every day, played various sports at school, slept and ate well, and was perfectly healthy was not even of consequence enough to be enquired about when I visited a doctor for a head injury at age 13. Just one look and a few questions about the accident later, my father and I left the hospital with a single recommendation: lose weight.
At 23, for the first time, I realise the significance of the BMI and the insidious role it plays in people’s lives including my own. A person’s weight has been equated to their self-worth and considered indicative of physical health as well as morality. A a tool for discrimination against fat bodies, the BMI is used to measure fatness as it classifies people into underweight, normal, obese, or morbidly obese categories. Doctors in several countries are able to use the BMI to discern whether a patient deserves to be cared for with respect or shunned and ignored.
BMI is also a source of revenue for insurance companies that are allowed to charge clients a higher premium if they lie above a certain BMI. Cigna TTK lists a BMI below 25 as eligible for a discount while most companies retain the right to refuse cover in case of a BMI above 37. No such provisions are in place for an underweight BMI. But it’s vile nature comes from its origin being steeped in racism, sexism, and scientific inaccuracy.
The Body Mass Index was invented two centuries ago by a Belgian academic, Lambert Adolphe Jacques Quetelet. He was a mathematician, astronomer, statistician, and a sociologist with many works credited to his name. Although remarkably, he was neither a physician nor did he study medicine.
Quetelet is credited with founding the field of anthropometry and phrenology, a pseudoscience that predicted mental traits based on the bumps on the head. However, he is known chiefly for his work identifying the characteristics of l’homme moyen — the average man. He believed that the mathematical mean of a population could be calculated to represent its ideal and his quest to prove so precipitated into the BMI, a way of quantifying l’homme moyen’s weight. Originally called Quetelet’s Index, his formula was derived from the measurements of French and Scottish subjects and observed that “weight increases nearly as the square of the height after growth periods in infancy and adolescence are finished”. This is also the current BMI formula which is weight by the square of height in meters. Therefore, the Index was designed exclusively for white Western Europeans, centring them as the ideal. Despite the eugenicist nature of his work, Quetelet was clear on one detail, that his index was an instrument of statistics designed to measure populations and not individual fat or health. However, the decades to come had something entirely different in store for his index.
Inaccuracy in Insurance
With the turn of the next century, health insurance companies had begun to gain footing in North America and thus began the search for a way to accurately identify a person as fat. Their actuaries generated weight tables which predominantly included data on middle-class white men. With similar flaws as the Quetelet index, these only represented those who had the means to buy insurance. Weight and height were self-reported (often inaccurately) and did not even take age into consideration. Despite the distorted data, these weight standards were adopted by physicians appointed by insurance companies to produce reports on the link between obesity and mortality.
Ancel Keys Reinvents the BMI
The quest for a means to determine fatness witnessed a watershed transformation in the 1950s with the work of the scholar, Ancel Keys. Keys believed that the rates of heart disease among American businessmen were related to their weight and diet. The primary concern was with the ability to accurately label someone as fat when Keys uncovered the Quetelet index and renamed it the Body Mass Index. With a team of researchers, he undertook the Seven Countries Study to examine the link between diet, weight, and coronary heart disease upon which he based the BMI. However, their research found no association between coronary death or heart attacks and established that the extremities of both over and under-weight posed the greatest threat. Moreover, the research subjects were mostly from white countries including the United States of America, Finland, and Italy with the exception of Japan and South Africa. The researchers further recognised that their findings were not applicable to the South African subjects included in the study.
Regardless of a deficiency of empirical data linking it with terminal illnesses, Keys viewed obesity as obscene. In a landmark paper, published in the Journal of Chronic Diseases, he argued in favour of the use of the BMI while admitting that it was a less than perfect measure of fatness. The paper read:
“Again the body mass index […] proves to be, if not fully satisfactory, at least as good as any other relative weight index as an indicator of relative obesity. Still, if density is truly and closely (inversely) proportional to body fatness, not more than half of the total variance of body fatness is accounted for by the regression of fatness on the body mass index.”
The BMI’s Rise to Fame
Once re-introduced, the use of Quetelet’s imperfect index spread like a wildfire across continents. The World Health Organisation and the National Institute for Health have been instrumental in its rise in fame. In 1995, a report on obesity published by the WHO recommended the application of the index for the classification of fatness in individuals. While the author of the report also categorised it as an “arbitrary method of association between BMI and mortality.”
A Dietary Guideline published by the organisation in the same year listed a system of assessing obesity in American individuals based on their corresponding BMIs. In 1998, the NIH adopted these categories and thereby ensued the contagious panic of the obesity epidemic.
Weight is Just a Number
Ever since, despite research showing that the reason behind illnesses and mortality risks involves social, economic, and environmental factors; government policies have focused on weight and the individual responsibility of becoming thin. Policies have been specifically aimed at closing the BMI gap between the white and the black communities in the US. This is despite the numerous occasions when researchers proved that the reason behind the gap is a higher bone density and muscle mass among black people, two factors that the index does not account for. Nevertheless, there has been little relaxation in the obsession with fatness as a health risk among black women in particular and people in general.
With multiple industries including the health and wellness, diet, and insurance depending upon the pathologizing and fear of fatness, the preoccupation with adipose has only increased. A 2015 study published by the Harvard University and the University of Sheffield argued that there are 6 different types of fatness each with its own etiology and recommended differing treatments directed at each one. Soon after, researchers at Massachusetts General Hospital had identified 59 types.
Moreover, the BMI as a homogenous form of measurement, devised by and for white men, does not account for racial or gender-based differences. A study published by the Endocrine Society showed that the BMI overestimates obesity for Black people. On the other hand, the WHO discovered that the universal standard of the BMI underestimates health risks among Asian communities which may lead to a misdiagnosis of certain conditions. It also did not take the difference in weight distribution among those assigned male and female at birth into consideration, putting the latter at a greater risk.
To Do No Harm
While medical parochialism keeps the BMI alive, its repugnance stems from the fact that its application is based on the apocryphal notion that fatness is a disease. The link between obesity and mortality has been refuted by many leading researchers like Lindo Bacon, Lucy Aphramor and others who have shown that the health risk associated with fatness is exaggerated and unfounded in unbiased research. While there is no permanent way to make fat people thin as almost 97 percent of dieters fail, the deliberate quest to lose weight via food restriction and excessive exercise actually makes people susceptible to many of the diseases that are associated with fatness.
“For decades, the medical community has ignored mountains of evidence to wage a cruel and futile war on fat people, poisoning public perception and ruining millions of lives,”Michael Hobbes wrote for The Huffington Post.
The benefits of the obsession with and over-valuations of thinness and the unrestrained application of the BMI have been few beyond the amassing of wealth by capitalist organisations. The overweight category has only reinforced the idea of a normal weight as something to be aspired to. Thereby actively keping public policy from making effective changes to people’s lives. When in fact it is poverty and inaccessibility to necessary services like physical and mental health care, food, education, and accommodation as well as genes that determine a person’s weight and eating habits.
Studies continually show that anti-fat bias has adverse effects on marginalised bodies. Yet doctors continue to perfunctorily recommend weight loss, while many others refuse to attend to fat patients. The practitioner bias puts them at risk of being under/mis-diagnosed, or as is common, many forgo even so much as a visit to the doctor to avoid being humiliated. The fear of fat has also led to an increase in instance of eating disorders, the deadliest of mental disorders. Eating disorders tend to go undiagnosed in fat people as these behaviours are rather encouraged in them. Moreover, Keto, avocado, quinoa, gourmet vegan cuisines, and swimming pools and gyms are a monopoly of the wealthy. The stress, ceaseless shaming, and dysmorphia only make matters worse.
Movement for Peace
Many health care practitioners have begun adopting Health at Every Size as a peace movement. It focuses on promoting everyday healthy behaviours rather than an obsession with weight. But weight stigma is institutional and normalised to such an extent that there are miles to go before we no longer have to suck in our stomachs and are just allowed to breathe.