Years ago, as a young lawyer working in a narrow corner of Florida workers' compensation, I helped employers recover money from the Florida Special Disability Trust Fund. Section 440.49, Fla. Stat. This was a pre-Americans with Disabilities Act (ADA) effort to encourage hiring, retention, and accommodation of those with medical conditions. The statute included a list of "preexisting permanent physical impairments," which might form the foundation for recovery. See I am what I am (July 2013). What I was when I penned that was (still) obese.
I was troubled, in that regard, when I discovered that one of the qualifying foundations was obesity:
"Obesity if the employee is 30 percent or more over the average weight designated for her or his height and age in the Table of Average Weight of Americans by Height and Age prepared by the Society of Actuaries using data from the 1979 Build and Blood Pressure Study."
There was a chart in the back of the FWCI Reference Manual (the Workers' Compensation Institute used to be the Florida Workers' Compensation Institute). The first time I used the chart for a case, I surreptitiously checked my own weight against the chart. I was deeply troubled to find I was obese. When I complained about that, a friend assured me "you are just big-boned." That did not really make me feel better. Yes, back then I had feelings and that hurt them.
I noticed then that the listings were divided with different values for men and women and at different ages ("in indoor clothing," whatever that meant). For example, someone five foot eight inches tall would have an "average weight" of 138 pounds (female, age 15-16) to 168 pounds (male, age 50-59). I was six feet tall, and my body weight was none of your business. But, notice here that obesity is conditional on age.
I was reminded of this when a story crossed my news feed in June regarding Queen Latifah and the "stigma around obesity." She described how she responded when told her body mass index (BMI) equated with obesity; she told the trainer "I'm just thick." This alerted me to the conversation about BMI and its origins, efficacy, and flaws. It got me thinking about airplane seats also, see The FAA and Seats (August 2022). The Buzzfeed article regarding Ms. Latifah led me to do some research.
The Washington Post concluded in 2021 that "BMI is Flawed," and that there is a disparate impact on "people of color." I have written about racist medicine in the past. See Race-Based Medicine (August 2021); Hippocrates, Harm, Racism (May 2022). The Hippocrates article provides some insight into the manner in which racism has influenced medical care criteria and decisions. Various professional groups are "reexamining" guidelines and advice with an eye toward the potential or probability of bias and untoward outcomes.
The Post describes instances in which people have been denied medical care because their weight is a contraindication or discouraging factor. In some instances, care is allegedly denied to those with a BMI exceeding some threshold. BMI can also be a benefit. In some instances, the high BMI might encourage care. For example, in the recent Great Panic of COVID-19:
"certain jurisdictions prioritized people with higher BMIs in vaccine distribution plans because some research suggests that obesity can be a risk factor for more severe covid-19 outcomes"
The Post says that the BMI has "long been controversial." There are critics who say it is "overinterpreted as a catchall for body fat, nutritional status, and health risk." Others are more critical still, noting its "origin is racially problematic." The BMI idea was invented by a mathematician, not a doctor(s). It is based upon averages from studies the mathematician considered, and was based upon "a sample of White, European men," that the mathematician saw as "ideal." The mathematician's idea was labeled as the "BMI" by a physiologist in 1972.
Over the last 200 years, the measure has been used in insurance underwriting, in actuarial tables, and in making medical analyses and decisions. The Post suggests there may be evidence to support that different "metrics" might be aptly applied instead as regards different ethnicities, including "people of color" and those of Asian descent. The article describes how BMI plays a role in reaching a diagnosis and how the application of the "white European men" standard may lead to underdiagnosis or overdiagnosis depending on how it is engaged or perceived.
Despite that, weight is an important metric and can impact physical well-being, and beyond.
I was contemplating these various articles, and reminiscing on my "big-boned" past when Yahoo published a story about a dancer named Cheryl Burke and her "body dysmorphia." She frankly lamented her frustration that "the nation decided to call me fat." This story is not about BMI per say, but is about perceptions of weight. She described how she denies others' perceptions that she "look(s) amazing" and instead perceives herself in the mirror as "someone who is overweight."
Ms. Burke describes how she is "doing the work" to find a "better place in her relationship with her body." She describes a family environment history of a persistently dieting mother and the self-image she has as a dancer. She notes that in this regard, she has "been judged my whole life." Is it possible that in the same way she looks in a mirror and sees a "fat" person that some of the rest of us look in the mirror and see someone that is not?
This all implicates the ongoing discussion of obesity in this country generally. In How Can They Both Increase (February 2019), I noted the dramatic increase in obesity in America. Both exercise efforts and obesity were reportedly increasing, albeit perhaps in different subsets of American society. But, be that as it may, obesity is increasing, and there are arguments that we are measuring that based upon some 200-year-old mathematician data about European males. Despite the potential for flaws in that metric, the rates are nonetheless increasing despite the metric remaining static.
Since there are charts specific to women, and since the BMI calculators differentiate on gender, there have likely been further efforts in the last 200 years, beyond that original "European Males" sample. The fact that has occurred suggests that further study and adjustment is both possible and practical. Is there a reason for differences based on genetic heredity that is similarly justified to the gender distinctions already recognized?
Accepting that BMI may be a flawed standard, or even that it is a racist standard as some argue, the fact remains that many believe obesity is a significant health concern. Harvard contends that "Excess weight, especially obesity, diminishes almost every aspect of health." Seeming to support the example of Ms. Burke, this may include mood. The causes include direct stress on our structure (skeletal, nervous, etc.) as well as "complex changes in hormones and metabolism." The Centers for Disease Control (CDC) lists many health challenges that pose "increased risk" for those with "overweight or obesity."
Thus, it seems that we have some valid concerns with the increasing rate of obesity and the health challenges that it may cause or to which it may contribute. But, we have concerns about the standard or definition that is being applied, BMI, and whether it is appropriate, predictive, and unbiased. In the mix, we have medical decisions being made or influenced based upon the BMI standard. Injured workers may be receiving care they do not want/need (over-diagnosis) or being denied care they want/need (under-diagnosis).
As with the other reconsiderations of standards discussed in Race-Based Medicine (August 2021) and Hippocrates, Harm, Racism (May 2022), there should perhaps be some urgency to the consideration of whether the BMI is the best that science can do in establishing definition and standard. In the meantime, it is likely that avoidable harm is being done, whether physical, emotional, or both. And, there are costs associated with both under and over-care. See Someone has to Pay (May 2016).
