Written by Lucy Walton
Body Mass Index (BMI) is used to measure an individual’s health in many healthcare settings and in national guidance. But what is the history behind BMI and is it a helpful and accurate measurement of health?
What is BMI?
BMI is a measure that uses height and weight to generate a score, which places individuals into different weight categories.
If your BMI score falls out of the ‘normal’ range, it is considered ‘unhealthy’ in our society. We are told that ‘health’ depends on an ideal body size with little regard for other factors including behaviours and measures such as blood pressure and heart rate, physical activity levels or lifestyle behaviours.
The History of BMI
So, where does BMI come from? In 1832, Adolphe Quetelet, a mathematician, created “the Quetelet-Index” (later named BMI) as a way to measure body weight in different populations (1). Until the 1970s height and weight charts were used to measure body composition with different charts for men and women. However, researchers started to notice that BMI appeared to be linked to overweight-related problems so began to use it in population-based studies, and then on an individual level.
BMI has been widely adopted in the medical world ever since as a way to categorise individuals into ‘healthy’ and ‘unhealthy’ categories based on their weight for height. Interestingly, Quetelet stated that the Quetelet-Index (BMI) was never meant to be used on an individual level.
How BMI has changed?
BMI, as we know it today, is not how it has always been. Originally, the ‘normal’ range for BMI was 20-27, but now the category is set at 18.5 – 24.9 with the addition of stigmatising labels. A BMI of 25-29.9 is categorised as ‘overweight’ and 30+ as ‘obese’. The change, made in the 1990s, resulted in individuals becoming ‘overweight’ overnight and increased fear of weight gain and the “obesity epidemic.” The BMI was increasingly being used worldwide, despite conflicting research to support the intended use of the measure.
So why the change?
It could be argued that pharmaceutical giants looking for profit are at the centre of the change. Two of the brands behind the biggest weight loss medications available at the time of the change began to fund research studies. These studies would conclude positive findings in favour of weight loss for health, in turn funding the company's medications. This issue regarding conflict of interest due to the involvement of these brands was never considered.
To this day, some doctors and healthcare professionals are trained in using BMI incorrectly. Assumptions are made that if an individual is in the overweight category they will automatically have health problems and if they are in the obese category more significant health concerns will arise.
This is not the truth, however. Studies have found that individuals in higher BMI categories who make positive lifestyle choices (i.e don’t smoke, drink within the recommended guidelines, eat five portions of fruit and vegetables a day and engage in regular physical activity) have been shown to have a similar mortality risk as those who are of ‘normal’ weight and also engage in those health-promoting behaviours (2). Not only this but it is estimated the risk of mortality for individuals in the 'overweight' category is 94% less than for those in the 'normal' weight category (3).
Is BMI a good measure of health?
BMI uses just two points of data, weight and height. BMI doesn’t account for an individual's body composition, for example, body fat percentage compared to lean body mass or physical activity status. This means that muscular people, including athletes, are often classified in the ‘overweight’ or ‘obese’ BMI categories despite being metabolically fit and physically well. Studies have shown that you can be metabolically fit and fat which means individuals in the ‘overweight’ or ‘obese’ BMI categories may also be wrongly stereotyped as ‘unhealthy’ (4).
Genetic Differences
Additionally, age, genetics or sex are not accounted for. Females naturally have a higher fat mass than males for many reasons, including hormone production, fertility and evolution in order to child bear. This is normal, yet when using BMI on an individual level, they are treated exactly the same.
Furthermore, BMI is not inclusive for all ethnicities and often fails to take into account the race of the individual which has an important impact on genetic body composition. Read more about Ethnic Diversity in Eating Disorders and the shortcomings of BMI in our blog post.
Relationship with Food
Another thing BMI fails to measure is an individual’s relationship with food which is a key part of how we nourish ourselves, with or without an eating disorder. This may include:
what they are eating
how much/often they are eating
how flexible they are with their intake and variety
their emotions towards food and their body
Without this insight, health professionals who do not have the appropriate knowledge about BMI might assume answers to these questions or ignore them which could lead to medical needs being missed or undiagnosed. An example of this could be an individual in a “normal” BMI range having a medical condition overlooked because they are assumed ‘healthy’.
Equally, individuals in larger bodies may be told to lose weight without proper medical investigations for their symptoms. Unfortunately, in the case of eating disorders and for this reason, many people do not receive the treatment they deserve. We discuss some of the common Barriers to Seeking Treatment for eating disorders further on the blog.
How should we use BMI?
When BMI is used as a stand-alone outcome measure, it can take the focus away from important lifestyle behaviours such as good quality sleep, nutritional intake, managing stress, movement and physical activity, smoking, alcohol intake and social interaction (5).
Like any measure, it is not perfect and is known to both overestimate and underestimate adiposity (fat) levels in individuals (1,6). While BMI can be a helpful measure at a population level (1), using it at an individual level without considering a person’s history and other lifestyle behaviours is not accurate and can cause more harm to a person’s physical and mental health.
Should BMI be used in eating disorders?
BMI is a tool that is used in eating disorder treatment, both for diagnosis and to guide recovery. There is a debate among health professionals, people in recovery and those that have recovered about the suitability of using BMI. As mentioned, when used as a stand-alone measure, there will always be negative consequences of using BMI, especially in eating disorder recovery.
Some examples of this include:
Some treatment services have BMI cut-offs at a very low weight which results in many individuals being turned away from treatment (remembering that the majority of people with eating disorders are not underweight)
Using BMI to diagnose anorexia nervosa can result in people who have the diagnosis of "atypical" anorexia nervosa feeling that they are not sick enough to deserve or access treatment
While BMI can indicate severe malnutrition, you can be malnourished at any weight or shape (i.e. weight above the "underweight" range) with significant weight loss or severe energy deficiency
Not many people naturally sit below a BMI of 20 and unfortunately, many health professionals (and the NHS) use outdated BMI criteria listing the "normal" weight range as 18.5-25, instead of the 20-25 used by most eating disorder services. This can lead to many people in recovery stopping weight restoration prematurely out of fear of gaining too much weight
In recovery due to fear of weight gain, many people will become stuck, controlling their weight to hug the lower end of the "normal" weight range which inhibits full weight restoration and recovery
Using BMI as the only measure to guide weight restoration, without considering a person's weight history, medical history or education about what a healthy weight is can reinforce disordered eating behaviours as people engage in them to control their weight below where they would naturally sit
It is important not to get caught up in the BMI number or fitting into a particular category class. We are all unique and our medical history, weight history, lifestyle and so many other variables need to be considered before coming to any conclusions about what is best for you.
Reach out to us by completing our enquiry form to find out how we can help you on your journey towards recovery.
Lucy Walton
TCN Intern
Lucy is a Registered Associate Nutritionist and intern at TCN! With Lucy's background in nutrition and psychology, her aim is to help you become more confident in your food choices and enrich your mindset. You can find Lucy on Instagram @lutritionw and on her website here
REFERENCES:
[1] Euro.who.int. 2021. Body mass index - BMI. [online] Available at: <https://www.euro.who.int/en/health-topics/disease-prevention/nutrition/a-healthy-lifestyle/body-mass-index-bmi> [Accessed 6 August 2021].
[2] Matheson, E., King, D. and Everett, C., 2012. Healthy Lifestyle Habits and Mortality in Overweight and Obese Individuals. The Journal of the American Board of Family Medicine, 25(1), pp.9-15.
[3] Mackintosh, G., 2020. The BMI Lie (Podcast from Thinsanity Audiobook). [podcast] The Glen Mackintosh Show - A Health Psychology Podcast. Available at: <https://open.spotify.com/episode/7Bisj8IsqIEEdNceq8DIdK> [Accessed 6 August 2021].
[4] Barry, V., Baruth, M., Beets, M., Durstine, J., Liu, J. and Blair, S., 2014. Fitness vs. Fatness on All-Cause Mortality: A Meta-Analysis. Progress in Cardiovascular Diseases, 56(4), pp.382-390.
[5] Ng, R., Sutradhar, R., Yao, Z., Wodchis, W. and Rosella, L., 2019. Smoking, drinking, diet and physical activity—modifiable lifestyle risk factors and their associations with age to first chronic disease. International Journal of Epidemiology, 49(1), pp.113-130.
[6] Nuttall, F., 2015. Body Mass Index. Nutrition Today, 50(3), pp.117-128.
Talia Cecchele Nutrition is a team of registered dietitians that specialise in eating disorder recovery, disordered eating, digestive issues and sports nutrition. We aim to bring balance back to nutrition, help you to break free from food rules and find food freedom. We offer virtual consultations and group programs so whether you are based in London, the United Kingdom or around the world we would love to support you. To enquire about a private consultation please fill out a contact form.