Charts and and Metrics (kindly fuck off)
Inspired in part by @Snotdok’s post, Hippocrates and Hypocrisy: Unhealthy Healthcare (and in part by this piece on some new obesity research), and by my own continuing interest in the subject of health, wellness and fitness (vs. fatness), I offer this rant.
I should start by saying I have a tendency towards more data when it comes to health. I would be the first to volunteer to plug myself in to a Star Trek-style full-body diagnostic, with everything from hormone levels to dietary intake. I’d go through it every morning, seriously. I’d love to see and think about the connections between numbers and feelings. But much of that data can be distracting, too.
I yadda yadda yadda-ed all this last week, but I want to rewind:
We’re living in an unhealthy time in American history. We have a troubled food culture, a strong industrial food lobby, a lot of stress on the family food budgets, and it seems like the toll it all takes on the average person is just getting higher. The fact that shows like The Biggest Loser even exist — that there are thousands of people piling in to try out for it every cycle for how many years now? — is just one example of that toll. Health care providers might suggest cost-related measures, I’m sure, to demonstrate the state of our lifestyle-related health problems. We have a huge diet industry in the U.S. as well, but it doesn’t seem to have made a dent in our health problems, in spite of the increasing emphasis in our media on beauty and physique (see: women’s supposed “health” magazines). I’d have to look at the various statistics much, much more closely, but I would suspect that even if our median isn’t creeping upwards, that those on the high end are rising (not that I like the BMI as a measure, but just how long has the NCHS tracked 50+ as a separate category?).
We live in a culture of polar opposites when it comes to nutrition and physical activity; fast food on every corner and a new USDA plate image that recommends half our dinner plate be made up of fruits and vegetables. Just which one of the fast food joints is supposed to offer that plate? The fast food dominance is not unaided by government, either… but I’ll leave that to others to make those arguments. So back to those opposites: on one end of the spectrum, the popularity of sports like ultra running seem to be rising, and kids’ sports training ramping up to the extent that surgeons are seeing a rise in career-ending injuries to pre-teens. And at the other end, bariatric surgeries are increasing in frequency and obesity continues to rise in children.
But this was supposed to be a post about the BMI chart, our obsession with numbers, and why all those metrics — but particularly the BMI, as a measure of individual health — draw way too much focus for our own good.
The arguments against the BMI as a measure of individual health are well-stated elsewhere. BMI = Body Mass Index, “a measure of body fat based on height and weight that applies to adult men and women,” according to the NIH. Simply put, BMI is used by physicians and other health care providers as a proxy for measuring body fat, by dividing weight by height squared (kg/m2) (converted for pounds and inches in the U.S.). That mathematical formula is a rough proxy indeed, as even NIH says that it can over- or under-estimate body fat for athletes and less active people, respectively. The BMI is a measure of mass. Muscle is more dense than fat, so while someone can build muscle and lose fat, if they remain at the same weight their BMI would remain the same. It’s agnostic of body fat, and not an indicator of a person’s fitness or of health or wellness — and it was never intended to be used as such.
The formula itself was created around 1850 by the brilliant Belgian mathematician, astronomer and statistician Lambert Adolphe Jacques Quetelet – and appropriately named The Quetelet Index. Dr. Quetelet was not a health professional and he was not interested in fat or health risk. He was fascinated by the idea of using statistics to draw conclusions about societies – and the “average man.” Some of us will remember the 20th century figure portraying the average family as having 2.4 children. Not only was his formula not health related, it was never meant to be used on individuals, only on populations. — Jon Robinson, PhD, MS, the HAES Files
To an information-obsessed person like me, this just doesn’t compute. Why continue to use a metric that’s so poor?
So what *are* the best measures of health?” Good question. Health — that’s what we really want to measure, isn’t it? Not girth, not mass, not even body fat, necessarily, but overall health, regardless of weight. Maybe fitness. But we’re measuring individual health; my health. What’s comfortable on me, in terms of body fat % and activity level, may not be comfortable on you. I play roller derby with a BMI of… ok, maybe I’m not ready for that much revelation. It’s not where I want to be, but I do it, and I enjoy the hell out of it, and I’m going to keep doing it in part to build a healthier body.
Outputs vs. Inputs (and I’m not talking about Calories)
BMI and weight are also measures of outputs — results — rather than the inputs of behavior/practices, and I’m slowly coming to believe that putting so much focus on those outputs is misguided. How useful are those goals in motivating a person’s training? The BMI charts set a “normal” range for weight, establishing singular goals for weight loss. I can’t tell you how often I’ve heard friends say “I’m going to do X/Y/Z, drop 30/50/100 pounds before summer/the reunion/next year, and then it’ll be so great!” We all know people who say that. We are people who say that, maybe. I have a friend who has struggled through numerous weight management programs, beginning each time with the goal of getting back to a certain number on the scale; talking always about “dropping the weight” as if it’s something both surgical and final, as if it’s a finish line. Not about a 10% reduction, but a reset or return to some perfect point on the scale where guilt and shame were banished.
This obsession with BMI and weight and a certain image of what healthy looks like? It’s fed by those so-called health magazines, featuring ever-smaller women with ever-smaller bathing suits (ever-more photoshopped) on its cover. The focus on body ideals throughout the media as well as in medicine (and now, in surgery) sets people up for reaching/not reaching the end, w/o enough attention on the details — when it’s the details that matter. Surgery, fasts, etc. are all about getting you to a result, skipping over not some mythical “hard part”, (as if near-starvation while maintaining exercise isn’t hard), but the practice of healthy habits that should be at the forefront. Let me say that again: It’s not the BMI goal that’s important, but the healthy habits. Praise and revel in those habits, because that’s what you’re doing right now, and that’s what should matter. If you only make the BMI matter, then slippage means failure, and that awful cycle again.
My point: we should let go — at least a bit — of the big end goals and cures, and focus on enjoying and appreciating what all of our bodies can do. Get us through the day, go for a walk, ride a bike, play with our kids, run, do yoga, and on and on. Focus on what you do for you body and what it does for you. Ignore the pictures on the front of the magazines, ignore weight and BMI and body fat % and anything other than how you feel and what you’re doing. Are you running now/more/faster/further? Are you sleeping better? Are you living the life that you want to live??? That should be your yardstick, along with the practice of those healthy habits.
That said, I still believe that some assessment/data can be helpful to creating good health. But the trick is to make them more a part of your habits, and less about setting goals. I’d like to speed up my lap times on the derby track, and I’m working on both strength and endurance in the gym, and pushing every time we practice those laps, to make that happen. Will reducing body fat % and/or overall mass help as well? For me, yes. So it’s helpful to check in with that data periodically, to see whether the work I’m doing is changing those numbers, too. But I have to do it that check-in carefully, and quickly move on before I start thinking of it as a yardstick for virtue.
BMI and Shame
The use of the BMI has limited positive uses in health care. Though it might be useful at the margins, it’s a poor measure of an individual’s health. What about the negative uses or effects of the BMI? For one, it’s a polite way of shaming fat people.
Diagnoses of overweight, obesity etc. are now most commonly based on BMI. BMI is raised as a value-neutral metric, but it’s not. Label someone obese, and you’re shaming them, piling on all the baggage of what society believes about overweight people. And that baggage and accompanying shame can trigger a horrible downward spiral that anyone who’s ever struggled with their body image can relate to. Shame is unproductive as a motivational tool, and yet the food and diet industries are practically obsessed with it. Even the Federal government isn’t above shaming as a tactic in dealing with public health:
“Hence, in dealing with obesity, public health officials have exhorted us to exercise, recommended changes to food labelling, advocated the banning of trans fats in restaurant food, issued dietary guidelines, and set forth exercise recommendations, all of which – as the authors note with keen insight – rely at one level on shaming the people they are trying to help.” – XXL: Obesity and the Limits of Shame (foreword)
Measuring Health and Wellness
Health and wellness should be our primary focus, but how should we define and measure them? There’s no easy index for measuring wellness, or the big picture of an individual’s health. So what’s the best measure of your overall health? YOU. What do you want to be able to do? What kind of life you want to live? Are you actively living, enjoying your community and the world around you? It seems like that’s what we should be measuring, somehow.
I’ll end with this example: I recently re-discovered cycling over the summer, on a comfort/hybrid bike that I really only bought to be able to ride to the market in the summer or out to the garden. It’s cute as heck, and I bought equally cute panniers to be able to carry produce home from the market; I really only thought about it in the cute and fun and minimally active category. But over the course of a couple weeks’ vacation in Northern Wisconsin last summer, casual rides increased to a 40-mi trip one day, and I was hooked on the feeling of being out on a bike, going from town to town — even on that “comfort” bike, which is actually not comfortable at all on long rides. I ended up buying a road bike in the fall on something a little more than a whim and a sale, and joined a women’s cycling group soon after. With the guidance of a local bike shop’s competitive cyclists, I enjoy both the cycling group work and the fun that we have riding (and eating and drinking!!) together. I might also do some sprint triathlons with it, but I’m not aiming to win any medals — high-level, competitive cycling is not the life I have in mind. My vision for a healthy life includes 50-60 mile group rides with my women’s cycling group on any given weekend, maybe a century ride every couple of years, and always a good cold beer afterwards. Comfort and my own endurance matters to me; BMI doesn’t. It’s the same with derby: I want to be fast enough and quick enough to do what I need to do on the track for my team, but I don’t need to weigh in under a particular mass or body fat percentage, and setting those goals only holds me back from my best work. Working on my speed and agility is productive, and may lead to a drop in body fat; but those BMI charts and other metrics just aren’t part of my goals anymore.