When the BMI is Not Enough
I am a family nurse practitioner in a rural northern California clinic. I spend many hours a week talking to adults, parents and children about health behaviors.
I ask about food choices, soda/juice intake, and family meal plans, cooking styles, grocery shopping and fast food. We talk about cigarettes, alcohol and other drugs. We talk about exercise habits. Overwhelmingly, my patients are aware of the “obesity epidemic”; they want their children to choose broccoli over potato chips, they are “rethinking their drinks” (the popular public health campaign) and choosing water over soda (or at least believe they should be). They worry about diabetes. Few defend trips to McDonalds. They want to be “well.” I have been doing this for years; and it’s far from new in my profession.
The recession drags on here; more, it’s never been a rich place. Still, it’s far from a food desert. Our local school has a splendid garden to table food program; it supplies the cafeteria with fresh produce and adds a highly practical element to classroom health educational programs. We have community gardens and farmers markets. We have one of the best food banks in California (supplying people with some produce but also all too much high fructose corn syrup processed foods). We have of course our Safeway, plus a high end, locally owned supermarket. Both promote fruit, vegetables, and organics. We have two health food stores.
It remains, however, a poor community, with poverty more than twenty percent. Seventy percent of the elementary students qualify for free breakfast and lunch school programs. And our family advocacy center currently prepares weekend grocery bags for 80 homeless students and their families.
One result of this: in the population I serve it is common to find children and adults with a BMI (Body Mass Index) of well over the “allowed” 25% mark.
The question is why? I don’t believe is just a matter of the absence of healthy alternatives (we also have a sensational new rec center here). I believe that behaviors considering food and exercise issues (as well as smoking and drinking/drugging) are not simply bad decisions made by uniformed people; people without alternatives, though of course healthy alternatives are always indispensable. Health behaviors are complicated and occur in social, political, cultural and biophysical settings (the ecosystems of our bodies). The answer, it seems to me, is to be found not just in diet and exercise (or lack thereof) but in our (and my patients) whole way of life. So this will include housing, employment safety and security, educational opportunities, environmental exposures, family dynamics and other stressors that are clearly more important to a plan for “wellness” than is one single biometric measure.
I have to say straight out that I believe the BMI is useless as a tool for helping people live healthier lives. It is a crude measure of body fat, the ratio of weight to height that has somehow been elevated to a position of prominence in “the war against the ‘obesity epidemic.’’’ (A concept that is itself quite suspect.) The BMI does not take into account skeletal mass, ethnicity, gender, visceral v. subcutaneous adiposity (where the body fat is located), or functional issues (activity). Moreover, BMI “standards” reflect changing cultural ideas of optimal sizes and “normals” that are always evolving. The BMI is not derived from clinical assessment of well-being but from a mathematical formula. Yet, I am required to measure BMI on all children who have state sponsored insurance (Medical, Healthy Families, etc.) and I will lose the reimbursement if I do not document this. In fact, there is currently a national program (school-based BMI-measurement programs initiated by the CDV and implemented in 13 states) to collect the BMI on all school children. The new Physician’s Assistant in a nearby town has been hired with a primary task, to collect this data on every single student from Kindergarten to 12th grade.
Perhaps there is some utility in BMI as an epidemiological tool but it has little to offer as a tool for encouraging positive behavioral change. In fact it may do more harm than good.
Multiple studies, for example, have demonstrated systematic discrimination against people identified as “fat” in employment opportunity and advancement, in housing and in healthcare. Singling out “fat” people as the cause of rising healthcare costs can only discourage people from seeking care for what is itself a medical problem. Dr. Margot Waitz, a specialist in pediatric, adolescent eating disorders, has suggested that mass screening in schools for BMI may trigger eating disorders in students. And it is important to note that no studies I know of have demonstrated improved outcomes as a result of BMI surveillance.
What, then, is a predictor of poor health? Well, poverty for a start; it has long been understood as the primary factor in understanding poor levels of health and longevity. The problem is that to consider poverty we must shift our gaze from the individual (and individual “failings”) to the society, and the BMI won’t help us here.
Let me give you an example: I have a patient, a 15-year-old girl who presents wondering about diabetes because she is fat. She is well-dressed, well-groomed and plays on her school volleyball team. Her family shares a two bedroom apartment with another family. Her father has been deported. Her mother works two jobs in local hotels; she is diabetic. Maria’s food journal records frequent dinners of cereal and milk (easily accessible at the food bank). When her mom is not working she cooks traditional Mexican food, in abundance, greatly appreciated by all.
Helping people make healthy lifestyle decisions and acting upon them in conditions such as these is a very complicated business. (The County abandoned the field of affordable housing a decade ago). The fact is that everyone’s life story is different, and that each human being is constantly changing biophysical social ecosystems in continuous interaction with the environment. So two people may have the same BMI but completely different distribution of adipose tissue that may or may not represent a risk factor. This is about where the fat is on the body. Fat under the skin is generally harmless, whereas fat that surrounds internal organs can be a high risk factor for diabetes, stroke and heart disease. Some of my patients are on pharmaceutical products or have a pathology that leads to weight gain. I have families where parents are working 2 or 3 jobs (for altogether less than a living wage) and are forced by time and money to grab the quickest, easiest (high fructose) food for themselves and the children. I have parents who are farmworkers who have been exposed to estrogen disrupting chemicals in pesticides all their lives (chemicals known as obesogenic – causing weight gain). I have patients who have been sexually abused who may gain weight in a conscious or unconscious effort to protect themselves from further assault. Some of my patients overeat or eat the wrong food because they are lonely, or sad, or frustrated, especially those whose lives have been battered by trauma, racism, hopelessness and poverty.
I have to say, again, that none of this is really new. I have been grappling (as a primary care health provider) with these issues for 15 years. I have attended conferences, read articles, taken a university based certification program on how to treat obese children. I have recommended dietary changes, cooking classes, Michael Pollan’s Food Rules (a guidebook to grocery store shopping), exercise classes, walking and dancing. Of course I will continue.
What I have learned is that there are limits to what can be done on an individual basis when we live in a system that produces nutritionally poor food (sometimes toxic food) industrially to be sold for profit to underpaid consumers who are then blamed people for eating it.
Workplace coaches are not equipped to deal with the complexities of eating behaviors; neither are school yard peers. Monitoring BMIs whether in the workplace or the schools can’t take the place of clinical medicine or laboratory science and ongoing holistic healthcare, including social psychological assessment. And holistic healthcare concerns not just the individual but the family and community as well, and here it is impossible not to notice that “Wellness Programs” are most often connected to cost-shifting in the context of a collapsing social safety net. Mental healthcare is virtually non-existent here.
“Wellness” is not a single faceted phenomenon that can be solved with financial incentives or worse punishment: ‘Wellness programs’ like other surveillance based health programs focus on individual behavior and choices. They ignore the broader political and economic situations in which these choices are made and we are paying the price for this.
Faith Simon is a Family Nurse Practitioner with a specialization in pediatrics. She works in a rural northern California clinic. She has worked in Arizona, Appalachia, East Africa, Northern England and New York. She is Co-Chair of Mendocino Parents for Peace. She can be reached at firstname.lastname@example.org
This is a chapter in Which Way to Wellness, A Worker’s Guide to Workplace Healthcare, a free E-Pamphlet just published with the Support of the National Union of Healthcare Workers (NUHW).