Exactly whose weight are you over?

I’ve never really liked the terms “overweight” and “underweight,” at least how they’re used by the medical establishment. But for the longest time, I really couldn’t put my finger on why. Part of it, I knew, were the way that these terms have so much judgment attached to them–that if you’re not “normal” weight, you’re doing something wrong and Dr. Whitecoat is going to tell you how to fix it. Sometimes that is the case, but sometimes it’s not.

More recently, though, I finally figured out what the issue was.

Underweight and overweight are relative terms, yet they are used by many medical professionals as absolutes.

So what the hell do I mean by that? Right now, I am sitting on top of (over) my couch and under my roof. If I moved, I could be sitting over my roof and my couch. If my couch were a little higher off the ground or I was shaped more like a pancake, I could be writing under the couch and the roof. Basically, “over” and “under” only describe your position relative to something else.

Of course, things like “normal weight range” could be something you’re relative to. And that would be an adequate use of the terms, if they were used that way (and if “normal weight range” were a little better at capturing all the aspects of health). Your current BMI is greater than/less than population norms. The problem with things like population norms is that they aren’t individual measures. They say that, on the whole, most people are healthier when their BMIs are between X and Y. Exactly what that X and Y should be is the subject of much debate in the medical community, but the precise values aren’t important to this discussion here.

I have no problem with the creation and use of population norms. I have LOTS of problems with these norms being used to determine an individual’s health. Say a doctor tells you that you’re “overweight.” This means that, ipso facto, you’re unhealthy and you must lose weight or you’re going to die of OMG TEH FATZ. Maybe you’re overweight relative to population norms.

The question to ask is: exactly whose weight are you over?

Certainly, if you’re completely sedentary, have velcroed your sweatpants-covered ass to the couch and do nothing all day but stuff Twinkies in your gob, then you might have some changes you wish to make for your overall well-being. But if you eat a varied diet, if you move your body, if all measures of health are good, and your weight is stable, then let me ask again: exactly whose weight are you over? You might be overweight relative to population norms but at a perfectly healthy weight FOR YOU.

And even if you’re not. Even if you are unhealthy, you don’t deserve judgment from doctors, nurses, me, or anyone else. You know far better than I about your life.

As it relates to eating disorders, and anorexia in particular, is that a BMI of 18.5 is generally used as some sort of magic number. Once you’re over that magic BMI, you’re considered no longer underweight and, therefore, no longer needing help. It’s how it worked with my insurance company. When I was IP, I was discharged the day (that very day) my BMI crossed over that magic number. I had no warning. Insurance just cut out.

Other people have been told that they don’t need to gain any more weight once their BMI is over 18.5. Why? Because they are no longer underweight. Their weight is normal, their eating disorder is fixed.

The problem is that only a very small segment of the population has a BMI that naturally falls at 18.5. Although someone might technically be within population norms at that BMI, they are still underweight FOR THEM. The problem is that the term “underweight,” again, is being misused as an absolute measure. Someone might be at a normal weight relative to the population but at a very unhealthy weight for them. My natural weight seems to fall at the upper end of what is considered a “normal” weight range. So I can be at a weight that is normal according to the CDC and WHO but is very underweight for me.

We need to stop using the terms underweight and overweight as these magical, absolute measures and instead start measuring them relative to each individual. Some people might have to gain an unhealthy amount of weight to match my BMI and build. And plenty of others would have to lose an unhealthy amount of weight. It’s all relative to you and your DNA and environment. I think we would improve the health of lots of people by stopping to say that there’s some universal weight at which you’re over or underweight and instead start measuring these things relative to each individual.

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10 Responses to “Exactly whose weight are you over?”

  1. Oh Carrie, this makes me actually rather jealous. Why can’t I write like you?

    Brilliant brilliant brilliant…

  2. Yes, so very true! Great post, as always.

    They are even thinking about doing BMI testing in schools now as a “cure” to the obesity epidemic. I think that will just start unhealthy thoughts about weight at an ever earlier age. How did our society get this way? Very disturbing.

  3. Well put. The bit about the pancake gave me great visuals and lots of snickers. The rest simply resonated as “truth.” The BMI, after all, was simply a formula based on a particular set of people at a particular time- it certainly doesn’t represent every gosh darn person on the planet. The overall person needs to be considered- people are not just statistics and numbers.

  4. One more thing- a friend of mine recently told me that her employer is mandating a weight/BMI check for its employees and deciding each individual’s health care premiums based on where they come in. It’s hard for me to believe that that’s even legal, but it’s what’s going on in some places! Horrible!

  5. Thanks for this article, good to hear someone with a like-minded opinion on the matter. These socially constructed ideas of under- and over- weight, and the corresponding value judgements attached to them, are so prevalent in society that they are present not only in healthcare, mental health care, but also in the treatment of eating disorders (ED).
    I have witnessed some very damaging behaviour by health professionals, in the treatment of persons with ED, based on the person not being “underweight enough” to receive any input from Mental Health services, let alone ED services. The impact being that the person, not only continues in damaging and destructive patterns of behaviour, but also has their confidence and self esteem damaged by the idea that they are not “underweight enough”.
    So often in people with ED this is interpreted as “failure” (a damaging facet of ED not seen in many areas of MH) coinciding with society’s value judgement so wrongly attached to the “failed dieter” and to women without strict control over their food intake, weight, body shape.
    The fact remains that the vast majority of people with ED, men and women alike, are not below a certain pre-decided definition of “underweight” .
    The consequences of the current medical approach are
    1. People with ED are not only denied treatment from ED services, but any assistance with MH services
    2. Likely reduction in individuals seeking help after rejection based on weight
    3. Being “thin enough” for treatment can become an aspiration, even when treatment is not wanted.

    If health professionals are going to make any inroads into treating all ED then attitudes need to change around the strict definitions of under- and over- weight and professionals trained.

    • Not being “good enough” at having an eating disorder because I didn’t get my BMI low enough – that is precisely how I felt\feel about myself. Despite the fact that I was becoming a danger at work, and could only function on the most basic level. I wasn’t underweight enough, so I didn’t feel that I could even manage to have an ED properly. Luckily, my psychiatrist thought this was nonsense :)

      • Glad your psychiatrist is one of the “smart” ones. ;)

        I can be dramatically underweight FOR ME and in extreme medical danger from starvation while still within the “normal” range on BMI. I didn’t recognize that then, but it’s still true.

  6. As much as I agree that BMI on its own should never be used as a measure of health, as a medical professional I feel that I can’t agree that sometimes the difficult topic of weight (high or low) should not be discussed and should not be raised. After all people do come to medical professionals generally for health advice.

    Population norms are used for all sorts of measurements of health including blood pressure, sodium levels, hormone levels, glucose etc.. If you take enough measurements soon enough one of them is going to fall outside the normative range. Now this does not necessarily make you unhealthy but the further you fall away from the range the more likely it is that your health is being affected and in fact that other measurements will be abnormal as well.

    Now most of us will accept that if our glucose is too high, or our iron levels too low that we should perhaps do something about this. We should not think that our weight is likely to be an exception. Granted that the number on the scale is much more vague in terms of health than a glucose level but it still does have some usefulness. The main problem is that we as a society place much more value on this number than any other number and that certainly should not be the case. As you rightly say there are numerous measures of health and if one number is just a bit off the normal range it probably doesn’t mean anything.

  7. As usual, great post! I agree that general weight and BMI standards are usually only useful to a certain extent. They give a reference of a starting point for an appropriate weight range for somebody in ED treatment. I find it so important to continually reevaluate the target weight range for clients throughout their ED treatment stay as I want to be sure that the target weight range is appropriate for that particular individual (ex: based on medical stability, growth charts if appropriate, etc). Once a healthy weight range is figured out for that specific individual, I do find it helpful in ED treatment to stick to that target weight range, however. Let the ED slide with a 1 pound weight loss outside of the individualized weight range and it can be a slippery slope to further weight loss and a relapse.

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