Body mass index. It’s a two-hundred year-old joke that perpetuates medical laziness. Everybody knows it, even the people who use it. Even its creators knew it wasn’t good for what people use it for now. There is over a century of evidence, if not more, that it isn’t useful for what people use it for. Yet here we are with the World Health Organisation using it as an indicator for an individual's health. Doctors use it to tell me I’m fat. I’m not fat, I’m just told I am.
The gender nurse squinted at her BMI calculation tool, looked at me, then back at her widget. “Well it says thirty,” she almost murmured incredulously. She looked at me again appraisingly, “Thirty is the referral ceiling so you’re fine.”
“So what you’re saying is if I gain any weight at all, I won’t be referred.” I straightened. “I walk four miles a day, three to five days a week. Double that if I have errands. I bet you my legs are mostly muscle.” They were - are - pure muscle, but I wanted to seem conservative. Credible.
“Wow, yes well that would do it. Muscle is a lot heavier than fat and if your legs —“ she glanced at them and could see for herself that I was correct. I was in a midi skirt but sat down it showed enough.
“So I have to lose muscle mass or I won’t be referred?” I pinched at my ribs to show there was nothing to grip, “These are my ribs. I’ve nothing to lose here, either.”
“Well you’re in the range and they do take personal differences into account…”
“If they bounce the referral back without looking at it — and I was told in the welcome workshop they would — then there is no chance for them to make an individual assessment.” I sighed. “I guess I have to lose weight then.”
“Thirty is in the range so you’re safe. Just maintain your lifestyle and it will be fine.”
“Doctor Thomas wants to see BMI twenty-eight. I know that because I have friends with him. If he wants to see twenty-eight, so do other surgeons.”
The nurse shifted in her chair, but didn’t break eye contact, “Well thirty is the referral ceiling. I can’t account for what individual surgeons want, but as of this appointment you have nothing to worry about.”
My expression softened, “I see this whole process as a series of barriers, because that’s what it is. You’ve given me a barrier. I’ll break it because I have to.”
"ATTEMPTS TO SET MY MIND AT EASE WERE MADE, BUT THERE WAS NO DENYING THE HARD FACTS OF THE MATTER: I WAS ALMOST TOO FAT FOR SURGERY."
She was rescued by the return of her colleague with my documents, but the impact of the exchange endured through the rest of the appointment. Attempts to set my mind at ease were made, but there was no denying the hard facts of the matter: I was almost too fat for surgery.
What was particularly frustrating about the revelation was how surprised the nurse was that my BMI is that high. She didn’t think it was to look at me. She saw what most people tell me they see: a tall, reasonably slim, broad-framed woman in good health. Not a person one would expect to turn around one day and say they were counting calories. The sort whose friends discourage from losing weight.
The friends around me knew I was under pressure; their reaction was to share my frustration and outrage. What was particularly interesting was how friends reacted when they learned I was watching my weight without the context of the gatekeepers. They grew concerned. They would make careful suggestions that perhaps I shouldn’t. Worried noises about my health ensued. Once I explained, there was anger.
Being told I need to watch my weight hurts. I’m always worrying about my weight. When my dad died and I lost my home, I lost a lot of weight. Too much, all the wrong way for all the wrong reasons. I didn’t develop an eating disorder, but conversations with a friend that does have a severe eating disorder taught me that I have many of the same feelings. Learning about her disease revealed my own narrow miss, and the things that happened that stopped me from going down that road. It’s sobering.
The good news is I came away without an eating disorder and I kept off most of the weight I lost. However it happened, I needed to lose that weight. But in that moment, while the nurse was squinting at her calculator wheel, I had the thoughts: I’ll just stop eating for a while. And that frightened me. I might not have developed a disease, but the seeds were in my mind.
"IT’S DAUNTING TO SEE HOW EASILY A PERSON CAN BE DERAILED."
It’s daunting to see how easily a person can be derailed. To feel it in yourself and know you mustn’t give in. To have that dialogue with the dark parts of yourself and find what compromises you can make: how far we can go without losing ourselves. I needed to do something, but the things I wanted to do were potentially life-threatening.
And I did do something. I started counting calories. The compromise was to set a very small target over a long period of time, so the counting was no more than a monitoring exercise. Promises were made to myself: not to get upset if I went over target. To remember it’s an estimation. Yeah, I’d like to lose those four kilograms but that wasn’t the point.
Everyone, particularly women, is held hostage at one point or other by BMI. Our bodies are policed, and we let them do it because we have needs that won’t be met if we don’t. Fat shaming is second nature to health professionals to the extent that they don’t even think about it. The systems and measures in place just do it without their active intent.
This isn’t because health professionals want it that way, it’s just baked into the culture of health and human services. Throw in the gatekeeping that every gender service in the world engages with, and we have a recipe for disaster. I avoided developing a dangerous disorder despite the harmful messages I’m receiving but many aren’t so lucky. If the medical profession really wants to help, they will fight this rather than make excuses for using an inappropriate measure out of laziness.