Here’s the Essence of the New Guidelines
Just last week, a client shared that obsessing over the body mass index (BMI) is what’s hindering her from finding inner harmony with her body—and she is certainly not the only one. As a weight-inclusive, eating disorder nutritionist, I can, unfortunately, remember numerous clients and patients who dreaded visiting a healthcare provider because they anticipated being criticized if their BMIs deviate from the “normal” range.
The BMI—which is a straightforward calculation assessing body fat based on height and weight—was invented roughly 200 years ago by a Belgian mathematician to swiftly gauge “obesity”* in the general (mostly white, male) population—not to determine an individual’s well-being.
By the 1970s, it erroneously became one of the most prevalent means of evaluating a person’s “health” and diagnosing disorders, including eating disorders. Here is what you should know regarding BMI, including the latest guidelines from the American Medical Association (AMA).
*As a healthcare provider who typically avoids employing stigmatizing and pathologizing language such as “overweight” or “obese,” please be aware that I utilize such terms in this article when I am quoting or paraphrasing sources.
Here’s the Essence of the New Guidelines
This summer, the AMA published fresh guidelines urging physicians to refrain from relying solely on BMI as the ultimate tool in their evaluations and diagnoses. The AMA’s guidelines were preceded by an examination of the BMI’s “troublesome” history and discuss alternatives to the BMI. Here are some of the primary points made:
- BMI does not accurately represent racial and ethnic minorities.
- The BMI does not take into account other relevant factors such as gender and age.
- It is being inappropriately utilized in clinical settings and in forecasting mortality rates in population-based studies.
- BMI can be detrimental to individuals with eating disorders because it does not “precisely capture” the manifestations and diagnoses of eating disorders outside of textbook anorexia nervosa.
- The AMA reports that employing BMI can impede access to eating disorder treatment and result in “inferior eating disorder treatment, predominantly due to insurance companies relying on BMI to cover inpatient treatment.”
BMI and Eating Disorders
The AMA also presented specific recommendations concerning eating disorders. Here’s what the guidelines propose:
- Educate all “school-based” physicians, counselors, educators, nurses, coaches, and trainers to identify unhealthy, atypical eating behaviors, as well as dieting and weight-restrictive behaviors in teenagers.
- Instruct and refer teenagers and their families for evidence-based and culturally-sensitive counseling when necessary.
- Utilize appropriate, culturally-sensitive resources and counseling tools regarding unhealthy eating behaviors and restrictions.
- Avoid relying solely on BMI as the sole criterion for appropriate insurance reimbursement, in certain diagnostic scenarios.
Fellow eating disorder dietitian Lauren Chaffin, MS, RD, LD, asserts that the BMI scale can be detrimental to individuals with eating disorders and may even contribute to the development of their unhealthy eating patterns. For instance, for those with a restrictive eating disorder resulting in a low weight, attaining a normal weight according to BMI can falsely indicate that the disorder is resolved, when in reality, the opposite may be true, Chaffin explains.
“Similarly, many individuals with a restrictive eating disorder may have a larger body size and therefore a higher BMI, which can lead to their concerns being disregarded and receiving harmful treatment at the doctor’s office,” she adds.
The Advantages of the New AMA Guidelines
According to eating disorder dietitian Jaclyn Leocata, MS, RDN, CDN, the new guidelines are a positive step towards reducing the focus on BMI in clinical settings. Not only do they acknowledge the sexist, racist, and ageist origins of the BMI, but they also highlight the importance of culturally-sensitive healthcare providers and resources, and recognize that mortality should be associated with metabolic health (such as insulin resistance, cholesterol, and blood pressure) rather than BMI.
When it comes to eating disorders, Kara Pepper, MD, LLC, a specialized physician in eating disorders, states that other benefits of the guidelines include recognizing that eating disorders stem from an excessive focus on treating obesity and recommending comprehensive screening for disordered eating behaviors.
Although eating disorders are mental illnesses that affect individuals of all body sizes (and BMIs), research demonstrates that weight stigma (negative beliefs and actions towards individuals in larger bodies) among healthcare providers, including the use of BMI, has a detrimental impact on the diagnosis, treatment, and recommendations for eating disorders.
“These new guidelines draw attention to something that professionals in the field of eating disorders have long acknowledged: patients may have significant medical or nutritional concerns that are not reliant on their weight or BMI,” adds Anna Tanner, MD, FAAP, FSAHM, CEDS-S, Vice President of Child and Adolescent Medicine for Veritas Collaborative and The Emily Program.
However, Dr. Tanner does not believe that the guidelines will necessarily improve the prevention, diagnosis, and/or treatment of eating disorders. “Nevertheless, this statement is a positive initial step in dismantling misconceptions that directly equate weight with health.”
The Disadvantages of the New AMA Guidelines
There appears to still be a significant journey towards more compassionate and evidence-based healthcare. While the guidelines explore alternative approaches to assessing health, they also introduce weight-focused alternatives that perpetuate harmful and weight-stigmatizing healthcare practices.
“Regrettably, the new statement continues to emphasize the detection of ‘obesity’ and advises providers to focus on additional weight-related measures such as ‘measurements of visceral fat, body adiposity index, body composition, relative fat mass, waist circumference, and genetic/metabolic factors,'” adds Dr.
Tanner. “These evaluation standards maintain the notion that we can completely ‘quantify’ well-being.
Further, the guidelines suggest that physicians embrace the concept that fixating on slimness is just as detrimental to a person’s physical and mental well-being as “obesity,” which implies that carrying extra weight leads to physical and mental illness. “I believe that it is necessary to address weight stigma and prejudice in the medical setting before the new guidelines can have any impact on the treatment of eating disorders,” says Leocata.
In fact, such weight stigma can be the very factor that harms a person’s health, not their weight itself. For instance, research indicates that weight discrimination can amplify allostatic load or the cumulative impact of chronic stress on overall health.
“If the recommendation is to continue including other resources that focus on body size/composition, it is simply another way for providers to concentrate on and continue advocating intentional weight loss,” adds Leocata. “Consequently, this will perpetuate disordered eating, weight cycling, and eating disorders.”
Dr. Pepper emphasizes that the guidelines still acknowledge the need for BMI in diagnosing eating disorders, and the recommendations for detecting eating disorders are applicable to teenagers, thus overlooking the millions of adults who struggle with eating disorder behaviors.
So, What’s the Alternative to BMI?
Something not mentioned in the new guidelines is that there exist weight-inclusive methods to evaluate a person’s health and accurately diagnose, prevent, and treat life-threatening illnesses like eating disorders. These methods are backed by research.
“No measurement should serve as the primary determinant of health, and medicine must move beyond the notion that health can be quantified,” explains Dr. Tanner. “Instead, medical providers must learn to take a highly individualized approach to assessing health.”
Providers and patients can explore the Association for Size Diversity and Health’s alternative, evidence-based paradigm known as Health at Every Size. It presents a framework of principles that include weight inclusivity, body diversity, mindful eating for well-being and enjoyment, respectful non-stigmatizing care, and more.
While the weight-centric paradigm (which relies on regular use of BMI) concentrates on physical health and weight, the weight-inclusive approach examines the whole person and takes into account factors such as financial, social, and occupational health. As a weight-inclusive practitioner, Leocata advises evaluating a person’s behaviors, such as their food intake and variety, physical activity, stress levels, and sleep patterns, while Dr. [Doctor’s Name]
Tanner proposes examining laboratory findings, vital indications, and hormonal well-being.
“Furthermore, what worries does this individual have regarding their figure and weight, and how does it affect their eating and physical activity habits, as well as their satisfaction with their body?” states Dr. Tanner. “Health-related issues can arise when there are eating disorder behaviors without any fluctuations in weight. On the other hand, individuals with a ‘troubling’ BMI may have excellent health in these medical and psychological aspects.”
Personally, I truthfully do not pay attention to a client’s BMI. What concerns me is the overall well-being of my client, which usually encompasses vital indications (blood pressure, heart rate, and occasionally weight), laboratory values, nutritional intake, bodily signals, emotional welfare, self-care, regulation of the nervous system, eating and exercise habits, and their connections to food, body, and physical activity.
Dr. Tanner emphasizes that healthcare professionals can mistakenly make assumptions about eating disorders based on weight and BMI. “Providers need to be trained to identify eating disorder behaviors such as restriction, purging, binge eating, and selective eating, and understand that these behaviors can be present in any patient, regardless of age, weight, or gender.