I’m standing outside the exam room, reviewing Marcus, my 16-year-old patient’s growth chart, specifically his BMI. It’s up again, and my heart sinks. I feel that all too common rush of frustration and disappointment and, “Why am I here and what is the point?” “Am I just here to document weight gain in my patients?” Marcus has been coming to my pediatric weight management clinic for over two years and has high triglycerides, pre-diabetes, non-alcoholic fatty liver disease, and pre-hypertension. His mom is hilarious and always acts shocked when I show her and Marcus his growth chart. She cusses at him in Spanish. Marcus doesn’t care about any of it. He feels fine, and his weight isn’t at the level of societal ostracization like many of my patients. About every other visit, we talk about his grandmother’s diabetes and how horrible it would be to have to take medication or have an amputation. Marcus doesn’t care. He’s muscular, so his BMI is high. He’s a cute kid who’s getting noticed by girls, having fun, and starting to party with his friends. His mom feels powerless like she has no control over Marcus and his apathy about his failing grades. “Marcus is lazy. Marcus doesn’t respect me. Marcus never listens.” I review his most recent lab studies, follow up on referrals I made and talk about his risks of fatty liver disease progressing and the potential to reverse it. I watch his face, hoping for some reaction. Marcus doesn’t care. I don my motivational interviewing hat and start counseling on self-directed health behavior change. Marcus agrees to drink more water just to get his mom and me off his back. He checks the clock. It’s been another three-hour visit with our multi-disciplinary team every two to three months, and he’s missing classes he’s failing. Marcus, his mom, and his younger siblings are stuck in a small exam room while the team comes in and out. I’ll work on Marcus’ chart note later, probably on the weekend; it will take me at least 30 minutes to complete. I’ll see Marcus in a couple of months, stand outside his door and feel the rush of disappointment, frustration, and failure as his BMI will surely be up again. Marcus won’t care. His mom will act shocked and cuss at him in Spanish. Marcus is unbroken. If his BMI is not a problem for him, then why is it a problem for me as his doctor? Me and BMI: We go way back. Way back to 2004, when I started a healthy living clinic for children and adolescents in my private pediatric practice, a multi-disciplinary approach. BMI was measured using BMI wheels that I got donated, and I remember touting the studies to parents that showed BMI correlates to cardiovascular disease risk in children. At the end of the eight-week summer program, I measured participants’ BMI again. Many were up, and I felt the wave of disappointment, frustration, and failure. My focus on BMI had me ignoring the many measurable wins, like the fun the kids and their parents had moving together, the increased family mealtimes, the decrease in screen time, measured increase in quality of life, the connection to other kids, and families with the same struggles. Like everything in life, there is a duality. BMI is a shade of grey to me. How has body mass index (BMI) been used? In my experience, BMI has been used to determine treatment, referrals including to eating disorder treatment programs, to fund clinic visits through insurance billing, to determine levels of care, and for research grants and within communities as data to measure program outcomes. If you narrow it down, BMI is used as a measure to get funding. I’m not saying that, in general, BMI isn’t a helpful measure as a general assessment. It’s merely one measure; in reality, healthcare, childhood obesity researchers, funding agencies, and public health have been too BMI-focused. We do know that BMI is not an accurate measure of health for every body. The individual harms potentially outweigh any good for the whole. Has there been any BMI good for the whole? BMI is a shame trigger, and shame does not create health transformation. Coaching research shows that transformation requires positive emotion activation or PEA, and shame drives negative emotion activation or NEA. BMI can be dehumanizing, whittling an individual’s health down to an arbitrary number. Believe me, I’m Dr. Karla, ActivistMD, the TikTokdoc disrupting weight stigma and bias in health care. I’ve heard story after story of patients whose doctors created harm by using BMI to weight shame and blame. We all know that BMI measurements have not been helpful in affecting change, at least on a large population level. The COVID-19 pandemic has certainly taught us that. Let’s stop being so BMI and solution-focused. What if the patient wants to follow their BMI? Then, share it. BMI or body mass index can be helpful if the patient finds it so. During my own weight loss journey, I followed my BMI because one of my measures of success was getting my BMI to the middle of the “healthy range.” There may be benefits to researchers, community-level data gathering, and getting resources to schools that need it. But at what cost to the individual? One of the harms I’ve noticed through the years of working to address the childhood obesity epidemic (stay with me because I am challenging it) is focusing on diet culture calories in/calories out solutions and compliance and not addressing the core problem, which is an epidemic of insulin resistance, with compassion. One of the reasons we as physicians follow expert committee recommendations that are very BMI-focused is because we are afraid to get it wrong. Fear of being wrong is baked into medicine. The stakes are high if you get something “wrong.” For physicians, instead of focusing on BMI, focus on health behaviors habit sticks, family-based programming, quality of life measures, and look at your whole patient. Ask permission to talk about weight and BMI, screen for disordered eating and mental health diagnoses, and make referrals and follow-ups. Don’t make your patients’ BMI mean anything about them or you as a doctor, or your effectiveness. What is clear is, that focusing on BMI has not been helpful and is keeping us stuck. During the next clinic visit, I didn’t even bother looking at Marcus’ growth chart before walking into the exam room. It was summer, and I assumed Marcus had filled his days with video games and Mountain Dew. I grabbed his chart, knocked on the door as I opened it, looked at Marcus, and noted a difference. I glanced at his growth chart and saw that his BMI had decreased. “Wow, great job, Marcus. Looks like your BMI has gone down.” “OK,” he responded as I show him his growth chart. Marcus doesn’t care. “What have you been doing?” “I don’t know. I’ve been working with my dad. We work outside.” “That’s awesome. It’s definitely working for your health.” “I like it. I like making money. I get more Mountain Dew to drink too.” “I bet you’re drinking more water too. I hope you are.” “Probably.” Mom pipes in, “Now, there are more girls calling Marcus and more problems because he has money!” Maybe Marcus is onto something? BMI is irrelevant. Maybe we should not care about BMI. Maybe we should let BMI go quietly into the night. Source
