A Number That May Not Add Up
By JANE E. BRODY APRIL 14, 2014, 12:01 AM 75 Comments
In July 1998, the National Institutes of Health changed what it means to be overweight, defining it as a body mass index of 25 or greater for adults. The cutoff had been 28 for men and 27 for women, so suddenly about 29 million Americans who had been considered normal became overweight even though they hadn’t gained an ounce.
The change, based on a review of hundreds of studies that matched B.M.I. levels with health risks in large groups of people, brought the country in line with definitions used by the World Health Organization and other health agencies. But it also prompted many to question the real meaning of B.M.I. and to note its potential drawbacks: labeling some healthy people as overweight or obese who are not overly fat, and failing to distinguish between dangerous and innocuous distributions of body fat.
More recent studies have indicated that many people with B.M.I. levels at the low end of normal are less healthy than those now considered overweight. And some people who are overly fat according to their B.M.I. are just as healthy as those considered to be of normal weight, as discussed in a new book, “The Obesity Paradox,” by Dr. Carl J. Lavie, a cardiologist in New Orleans, and Kristin Loberg.
Unlike readings on a scale, B.M.I. is based on a person’s weight in relation to his height. It is calculated by dividing weight in kilograms by height in meters squared (or, for those not metric-savvy, weight in pounds divided by height in inches squared and the result multiplied by 703).
According to current criteria, those with a B.M.I. below 18.5 are underweight; those between 18.5 and 24.9 are normal; those between 25 to 29.9 are overweight; and those 30 and higher are obese. The obese are further divided into three grades: Grade 1, in which B.M.I. is 30 to 34.9; Grade 2, 35 to 39.9; Grade 3, 40 and higher.
Before you contemplate a crash diet because your B.M.I. classifies you as overweight, consider what the index really represents and what is now known about its relationship to health and longevity.
The index was devised in the 1830s from measurements in men by a Belgian statistician interested in human growth. More than a century later, it was adopted by insurers and some researchers studying the distribution of obesity in the general population. Though never meant to be an individual assessment, only a way to talk about weight in large populations, B.M.I. gradually was adopted as an easy and inexpensive way for doctors to assess weight in their patients.
At best, though, B.M.I. is a crude measure that “actually misses more than half of people with excess body fat,” Geoffrey Kabat, an epidemiologist at the Albert Einstein College of Medicine, has noted. Someone with a “normal” B.M.I. can still be overly fat internally and prone to obesity-related ills.
Calling B.M.I. an imperfect predictor of a person’s health risks, the Centers for Disease Control and Prevention cautions doctors against using it as a diagnostic tool.
For one thing, body weight is made up of muscle, bone and water, as well as body fat. B.M.I. alone is at best an imprecise measure of how fat a person may be. When Arnold Schwarzenegger was Mr. Universe, his B.M.I. was well in the obese range, yet he was hardly fat.
Another problem: the distribution of excess body fat makes a big difference to health. Those with lots of abdominal fat, which is metabolically active, are prone to developing insulin resistance, elevated blood lipids, high blood pressure, diabetes, premature cardiovascular disease, and an increased risk of erectile dysfunction and Alzheimer’s disease.
But fat carried in the hips, buttocks or thighs is relatively inert; while it may be cosmetically undesirable, it is not linked to chronic disease or early death.
Furthermore, a person’s age, gender and ethnicity influence the relationship between B.M.I., body fat and health risk. Among children, a high B.M.I. is a good indicator of excess fat and a propensity to remain overly fat into adulthood. But for an elderly person or someone with a chronic disease, a B.M.I. in the range of overweight or obesity may even be protective. Sometimes — after a heart attack or major surgery, for example — extra body fat can provide energy that helps the patient to survive. An added layer of fat can also protect against traumatic injuries in an accident.
On average, women have a higher percentage of body fat in relation to total weight than do men, but this does not necessarily raise their health risks. And African-Americans, who tend have heavier bones and weigh more than Caucasians, face a lower risk to health even with a B.M.I. in the overweight range.
Physical fitness, too, influences the effects of B.M.I. In an editorial in JAMA last year, Dr. Steven B. Heymsfield and Dr. William T. Cefalu of the Pennington Biomedical Research Center in Baton Rouge, La., noted that “cardiorespiratory fitness” is an independent predictor of mortality at any level of fatness.
While experts continue to debate whether a person can be “fit and fat,” Keri Gans, a dietitian in New York and former spokeswoman for the Academy of Nutrition and Dietetics, points out that physical activity and a healthy diet tend to offset the risks of being overweight.
“You don’t need to be thin to be fit,” she said. At any weight, fitness can reduce the risk of developing heart disease, lung disease, diabetes or high blood pressure.