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BMI Index Expires

BMI Index is outdated and replaced

     In case you missed it last month Canadian Researchers demoted the BMI (body mass index) as a diagnostic tool.

     The news came in the form of a publication in the Canadian Medical Association Journal called “Obesity in Adults: A Clinical Practice Guideline,” co-authorized by over 60 practitioners, advocates and researchers from a range of fields who recommended doctors change the way they diagnose, and, by extension, treat obesity.

     Bottom line; the BMI index was out and it was to be replaced by the EOSS (Edmonton Obesity Staging System).

     What’s the difference between the two classification systems? More than you think. The EOSS isn’t a tweak or an update; it’s actually an overhaul that could change the way we think about fat and a signal that we might finally rid ourselves of BMI, a controversial diagnostic tool that has been under fire for decades.

     At best, the BMI, which is devised by measuring waist circumference, weight and height, is a blunt instrument that doesn’t tell the doctor very much about the patient’s actual health. At worst, it’s been critiqued as a discriminatory tool that has worsened systemic racism, gender inequality and exacerbated biases against people living with obesity.

     By contrast, EOSS, which initially started out as a modest proposal published in 2009 by Dr. Robert Kushner and Dr. Arya Sharma, is a nuanced and holistic approach that puts patients at the centre of the treatment.

     It starts with the fact that when you look at BMI, it’s really just a measure of size. Your body mass index tells someone how big you are but it doesn’t tell anybody how sick you are. For example if we apply body mass index to a sumo wrestler, a physician may say that this very obese man who needs bariatric surgery, when in fact, that physician is dealing with a high performance athlete who is probably more fit than most people, including the physician doing the examination himself.

     It is not uncommon for people with the same BMI to have widely different results when it comes to related health issues that include blood pressure, mood disorders, sleep apnea, gastric reflux disease or reduced mobility. As such, the EOSS runs tests for all those other health problems and, in addition, consults the patients regarding their feelings about their level of functionality and mental health.

     The EOSS even has a category for people with a high BMI (30 or higher) but no co-morbidities: stage zero. In other words, perfectly healthy, regardless of what the BMI says.

     Over the years many critics have wondered if the BMI scale is arbitrary—a criticism that emerged in force in 1998 when the National Institutes of Health in the United States changed the guidelines for the “overweight” category from 27.8 to 25. That had the effect of reclassifying 2.9 million Canadians from “healthy” to being in the market for the next diet fad; despite the fact their weight remained the same. At that time my personal BMI was 27 and suddenly under the new guidelines, I was overweight.

     The markers used to classify underweight, normal weight, overweight and obese were not always the ones that we have today and in fact, between 1985 and 1995 they were constantly changing. When I tried to research the foundation of these classifications, they always seemed to be arbitrary and there was no real science attached to these labels.

     We have always had a fat phobia which is how we developed the BMI index in the first place. The new EOSS system is a more honest approach to health care.

     The issue is that people appear at the doctor’s office with any number of symptoms, but if they’re fat, the first thing they are told is to lose weight. I have witnessed people who have gone to the doctor with cancer and they were misdiagnosed. The cancer was missed because the doctor was focused on them losing weight and did not do a proper examination and follow up.

     One aspect of EOSS that addresses this problem is that physicians are advised to begin consultations by asking the patient if they want to even discuss weight. as opposed to jumping directly to that discussion  and (potential) misdiagnosis. There is a tremendous amount of discrimination against people suffering from obesity, which is a complex problem, given that this type of misdiagnosis disproportionately affects racialized populations who frequently have more stressful jobs and poor access to affordable fresh food and healthy activities.

     Many physicians, because of their own biases are denying full and equal health care to patients simply because they are overweight.

     This is especially troubling given the complications that COVID-19 adds to the systemic problems. People suffering from obesity often suffer worse outcomes, and all manner of experts (with no medical qualifications) are telling them to simply eat better and exercise more to safeguard against the infection.

     Being fat is used as a scapegoat. We can see very clearly why Black, Latino and Indigenous communities have higher rates of COVID-19 and serious complications, but that’s got more to do with the fact they are typically front-line workers in the health-care or service industries. So, we should not be surprised by the fact that disadvantaged communities are yet again experiencing greater negative health effects from COVID-19. They don’t have access to anything healthy and live in very unhealthy environments and our own biases look at them in a very disparaging way as fat people who are spreading the virus.

     Aside from the fact that it’s a little late to suddenly become thin in order to beat COVID, this pandemic is merely shining a light on a lot of aspects of medical care that have been in need of a fix since long before SARS-CoV-2.

     For years I have consulted with people who were told by their doctor that they have a weight issue. They were told that if they lost weight all those other symptoms would go away. And yet did they look further to find out the cause of all those other symptoms? Did they run all the tests? No. They simply assumed that if the weight came off everything would be better. This is not how a physician should treat a patient, any patient, let alone an obese one.

     When people come to me about diets and how to lose weight. I have always provided them with the answer they do not want to hear—try eating less and exercising more. This is no more helpful that telling somebody with depression to cheer up.

     Obesity may be a problem but in many cases it is not the real problem. By using EOSS, hopefully will examine every aspect of the patient’s health, do all the tests and send them to the required specialists so that people who are overweight are treated just as well as the rest of us. [print-link]