To Live or to Die by BMI Anti-Black Racism and the Black Community’s Struggle with Obesity

 Let’s Have an Uncomfortable Conversation

There is no debate that obesity is a serious condition that disproportionately impacts the Black community in America. In 2018, Black Americans were found to be 1.3 times more likely to experience obesity and 20 percent less likely to participate in consistent exercise compared to white people.¹ Black women are 50 percent more likely to experience obesity compared to their white counterparts. However, the tools we use to classify obesity are a little out of date.

What is BMI?

Body Mass Index is the measurement of weight (kg) divided by the square of height (m).² BMI is a tool that is used to detect possible risks associated with high body fat and to categorize patients by weight. BMI is used by life insurance companies, electronic health records, and healthcare providers to quantify disease risk.³

Let’s Take a Closer Look at the Origins of BMI

Adolphe Quetelet was a mathematician from Belgium who became very interested in using statistics to define the “average man,” an idealized concept of physicality.⁴ Quetelet found that using a ratio of weight and squared height was the best way to quantify body size and growth. This number was named the Quetelet Index in 1832. Weight tables came into the picture as a result of observations by life insurance companies in the early 20th century. Louis Dublin, vice president of Metropolitan Life Insurance Company, noticed an increase in deaths of policyholders who were obese. He collected data on the matter and found that people of the same height and sex exhibited a vast range of weights. To account for this, he took that range of weights and divided them into small, medium, and large. Insurance companies then decided what weight category was “desirable” and used this number to inform their policies and payouts. The topic of obesity was of growing concern, and by the time of World War II, medical professionals needed a reliable index of weight for clinical and epidemiological studies. In 1972, Ancel Keys, an American physiologist, performed a study that compared the different weight indexes available to clinicians and decided that the Quetelet Index was the most accurate. He then renamed that index to the Body Mass Index, and this ratio was then adopted by medicine.

One of the main criticisms of the Body Mass Index at the time was its ability to be generalized to other populations.⁴ Studies on BMI relied on data from white populations, therefore it did not account for any physical differences in frame and weight distribution for other ethnic groups.

This shortcoming has several serious implications, especially for Black Americans.^3,4

 BMI, Eugenics, and Racism

Discrimination against Black people for their body size originated during chattel slavery when Europeans “observed” enslaved Africans and presumed that they were more sensuous and that they ate too much.⁵ Sabrina Strings, author of Fearing the Black Body: The Racial Origins of Fat Phobia, is an expert on the topic of obesity science and anti-Blackness. In an interview with NPR, Dr. Strings discusses how slave owners differentiated between the enslaved and the free.
After centuries of slavery, it became difficult to tell who was enslaved just by their skin tone, so “they decided to articulate new aspects of racial identity.” Dr. Strings elaborates that appetite and size were two key indicators of a person undeserving of freedom.

 BMI and racism were brought together by Francis Galton, known as the Father of Eugenics.⁶ Galton used the Quetelet Index as the basis for his theories about eugenicist breeding practices - he was concerned with turning Quetelet’s “average man” into an extraordinary one, and this vision did not include people of color or obese bodies.

 Charles Davenport came shortly after Galton and was convinced that there was some racial component to obesity.^6,7 His research conflated a “healthy” body with an attractive body, thus promoting the concept that Black people are “unhealthy” and therefore undesirable. A key component of eugenics is associating physicality with moral value, demoralizing bodies that do not fit within the established aesthetic.

From Strings, S. (2023a, July 1)7

BMI is not a one-size-fits-all solution

The problem with BMI lies within its ability to serve as a “catchall proxy for body fat, nutritional status, and health risk.”8 Relying too much on BMI may unfairly inform diagnoses and exacerbate pre-existing stigma and distrust between Black Americans and the medical community.
 
Given how deeply ingrained BMI is within our healthcare system, it might not be realistic to just do away with it altogether, but adjusting the cut points for ethnicity and educating providers on diagnosing and treating obesity in the Black community is a good start. Dr. Fatima Stanford, an obesity medicine physician-scientist at Harvard Medical School, proposed new BMI cut points that are adjusted for both ethnicity and gender.⁹ These new BMI thresholds are a better predictor of future morbidity and mortality associated with obesity because they are “based on association with metabolic disease” relative to each subgroup, allowing for a more personalized assessment of risk.

 

Obesity in the Black community is a sensitive, nuanced topic that requires special attention from healthcare providers to ensure that Black patients are being treated holistically. BMI may be a useful tool for assessing populations and providing a metric that predicts health risks and disease, but we must all be careful to only see BMI as a part of the picture.

 

By Alexis Jackson, A Master’s of Medical Science student at the University of Kentucky

Sources

1.     Department of Health and Human Services. (2022). Obesity and African Americans. Office of Minority Health. https://minorityhealth.hhs.gov/obesity-and-african-americans

2.     Centers for Disease Control and Prevention. (2022, June 3). About adult BMI. Centers for Disease Control and Prevention. https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html

3.     Centers for Disease Control and Prevention. (2022, June 3). About adult BMI. Centers for Disease Control and Prevention. https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html\

4.     Eknoyan, G. (2007). Adolphe Quetelet (1796 1874) the average man and indices of obesity. Nephrology Dialysis Transplantation, 23(1), 47–51. https://doi.org/10.1093/ndt/gfm517

5.     NPR. (2020, July 21). Fat phobia and its racist past and present. NPR. https://www.npr.org/transcripts/893006538

6.     Farber, S. A. (2008). U.S. Scientists' Role in the Eugenics Movement (1907–1939): A Contemporary Biologist's Perspective. Zebrafish, 5(4), 243-245. https://doi.org/10.1089/zeb.2008.0576

7.     Strings, S. (2023a, July 1). How the use of BMI fetishizes white embodiment and racializes fat phobia. Journal of Ethics | American Medical Association. https://journalofethics.ama-assn.org/article/how-use-bmi-fetishizes-white-embodiment-an d-racializes-fat-phobia/2023-07

8.     Stern, C. (2021, May 8). Why BMI is a flawed health standard, especially for people of color. The Washington Post.https://www.washingtonpost.com/lifestyle/wellness/healthy-bmi-obesity-race-/2021/05/0 4/655390f0-ad0d-11eb-acd3-24b44a57093a_story.html

9.     Race, ethnicity, sex, and obesity: Is it time to personalize the scale? (n.d.). https://www.mayoclinicproceedings.org/article/S0025-6196(18)30807-3/pdf