Why I Don’t Use BMI When Counseling Patients

Going to school to become a dietitian, there was a big focus on learning about how to treat certain health conditions using nutrition, and often, the focus was on reducing weight in order to improve someone’s health. Case studies on patients with heart disease, for example, would include prescribing a heart-healthy diet but more often than not, also on weight-loss goals. Whenever we got a case study, we would have to calculate BMI often as the first question, and state whether or not the person was ‘overweight’, ‘obese’ or not, and use this going forward. It definitely colored a lot of our nutrition recommendations.

As health practitioners, and especially dietitians, we are taught within a very weight-centric education system. Weight-centric or weight-normative approaches are defined as “an approach that views weight as a determinant of health and emphasizes weight management to promote health and well-being”.

But wait, where did the terms ‘overweight’ and ‘obese’ even come from? 

These words are used to describe those in larger bodies, but they are also used very commonly by medical practitioners to represent weight being abnormal. For example, ‘overweight’ implies that there is a correct weight to be and that someone is over that weight, which needs to be changed. The word ‘obese’ originates from a Latin word which translates to ‘having eaten until fat’. This term is basically assigning illness to a certain size and makes someone feel like they are the cause of a certain health condition based on their habits.

Why is this problematic?

Thinking about when we do go to the doctor, oftentimes the first thing we do is step on the scale. But a lot of the time, our weight isn’t the reason we are seeking care. It can be the first thing that practitioners latch onto during a healthcare visit. For this reason, a lot of people in larger bodies put off going to the doctor due to the fear of being shamed for their weight. This is particularly dangerous as this leads to stress and gives more time for illnesses and conditions to persist, and possibly worsen, over time.

Not to mention, studies have shown that doctors actually spend less time, provide less education, take symptoms less seriously, and provide less health examinations to patients with higher BMIs. In certain studies, researchers have found that practitioners view “obese” patients as lazy or undisciplined, which is just unacceptable quite frankly!

All of these factors affecting those in larger bodies actually leads to worse quality of care for them.

There are so many sources of weight stigma that people may already face in our society, outside of the world of healthcare. This weight stigma has been linked to an increase in stress, blood pressure, inflammation, anxiety, disordered eating behaviors like binge-eating, and more.

Internalized weight stigma is so real in our society too. Studies have shown when someone thinks of themselves as ‘overweight’ or ‘obese’, they are more likely to have poor health outcomes in the future, regardless of their actual weight or BMI.

In fact, telling people they need to lose weight is not a good motivator for someone to make sustainable positive behavior changes. Comments related to weight or needing to change it make people actually less likely to make long-term health behavior changes, and behaviors related to food and exercise get worse.

One study found that 79% of women who experienced weight stigma coped by eating more food and refusing to change their diet. Women in the ‘overweight’ or ‘obese’ category with internalized weight stigma report more frequent binge-eating episodes compared with women of the same BMI who had not reported internalized weight stigma.

Because of this, the long-term consequences of weight stigma like chronic stress and worsening behaviors around food and exercise make weight stigma an independent risk factor for both disease and mortality, no matter what someone’s weight actually is.

So what do we do instead? We remove the association between body size, weight, and health, and look at the whole person. How are their stress levels, digestion, sleep, or food and water intake? Remember, it’s never as simple as the number on the scale, and health can be found at every size. It is actually impossible to tell anything about someone’s health based on their size. Being at a higher body size does not actually cause disease.

Certain diseases may be associated with certain weights, there is no causation between weight and disease. It’s important to distinguish between correlation and causation when it comes to size and health!

This is a key understanding and backbone of the Health At Every Size approach that many dietitians have adopted in recent years. This and more is why I believe it is possible to be healthy at any body size and why intuitive eating is so important to make sure we are fueling our bodies instead of focusing only on calories in, calories out, to achieve a certain body size that society has deemed appropriate.

Want to learn more about intuitive eating? Are you struggling with health practitioners and weight stigma that you have experienced in the past? I am here to help and want to hear from you! Feel free to email me or send me an Instagram message to discuss this more!

Source: Unapologetic Eating: Make Peace with Food and Transform Your Life by Alissa Rumsey, MS, RD

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