“Not thin enough”: the dangers of BMI
When Sophie (not her real name) was 14, she started developing an unhealthy relationship with food. She cut down on the amount and types of food she was eating, and became obsessed with exercising. “By the time I finished my exams, I looked gaunt; I only slept for a few hours a night, and I had not had my period for over two years,” she says. “My parents became increasingly concerned and took me to the GP who calculated my BMI. But because it wasn’t ‘low enough’ for me to be referred to an eating disorder specialist, they recommended I simply ‘eat more.'”
Predictably, Sophie’s health continued to decline: “There was no talk of the mental health issues I might be facing, and the whole BMI [body mass index] experience only validated my behaviour because if my GP didn’t think my weight was a problem, then it wasn’t.” It was only when Sophie’s parents paid for a private doctor that she first heard about the risks of organ failure if she continued at the rate she was going. “I was lucky,” she tells me, “I was living with my parents who spotted the signs and could take me to a professional outside of the NHS, but many do not have the luxury. The current system is failing people with eating disorders, and it needs to change.”
Sophie’s story is echoed across all of the UK, where thousands of people are failing to get adequate treatment. One of the culprits is the widely-used body mass index as a means of measurement. The term “BMI” was first established in a 1972 medical paper as a “relative weight index of general obesity.” In layman’s terms, it is a measure that applies height and weight to calculate a “healthy weight” score. To begin with, BMI was used as a way to measure the characteristics of entire populations. In recent years, it has been increasingly used as a health risk indicator for individual patients who are then put on weight loss or weight gain programmes if they score too high or too low. The world health organisation uses the BMI to categorise people as being underweight (BMI < 18.5), overweight (BMI > 25.0), obese (BMI > 30.0), or morbidly obese (BMI> 40.0).
Yet basing treatment around these scores means that many people who need help don’t qualify for it. Like Sophie, Joss Walden rapidly became ill after being denied treatment when she needed it most, as her BMI did not meet the “appropriate” criteria. After battling an eating disorder for most of her adolescent years, Joss received the appropriate help, but it was when she made the transition to adult treatment that her cat-and-mouse game with BMI began.
“When I moved to adult services, the issue started with BMI,” Joss tells me. “Everything became focused around weigh-ins, and I was only ever told to “eat more”. I kept slipping and slipping and eventually rang up a hospital in London pleading for help. The first question they asked me was “what my BMI was?” Even though it was on the cusp of being dangerously low, it was not “low enough.” At this point, with no help from any angle, I felt the only option was to get sicker. I thought to get one step forward; I had to take five steps back. Eventually, I was admitted and tube-fed. It was the worst physical and mental state I have ever been in my life.”
Luckily, this traumatic experience would be the last ever for Joss, who has now made a full recovery and works as a volunteer for BEAT, the UK’s leading eating disorder charity. With hindsight, Joss has realised just how problematic BMI was. “I was caught in the BMI cycle for years, and it’s a dangerous place to be in as it does not promote a healthy relationship with food.” She added: “It also perpetuates the stereotype that eating disorders are only serious when you’re severely underweight, but eating disorders can manifest in all shapes and sizes.”
As Joss’s story shows, someone who may have symptoms of an eating disorder could have a higher BMI due to their body composition, bone structure, muscle mass, or they may even engage in disordered food and exercise regimes that don’t result in extreme weight loss. Neither does BMI take age or gender into account – crucial factors when assessing whether someone has a healthy weight. The problem here is that if a GP tells people that their BMI is not “low enough”, by default, they are telling you that you are not “thin enough” and indirectly give the go-ahead to get even worse before you can get better. It’s akin to your local GP saying that you smoking a 20-pack of cigarettes a day isn’t enough for help and that you need to come back and smoke 60 before you can have the support to quit.
In light of the BMI’s pitfalls, campaigners have been fighting against the index. Earlier this month, an MP’s report compiled by the Women and Equalities Committee concluded that the use of BMI as a key health indicator should be scrapped as it contributes to eating disorders, disrupts body image and invites social stigma. The Chair of the Committee, Caroline Nokes MP, said that the use of BMI as a “healthy weight” measurement had become a “kind of proxy or justification for weight shaming,” and that “it has to stop.” It should, instead, be replaced with a “weight-neutral approach”, which works outside the confines of weight loss and encourages learning how to cultivate healthy habits and behavioural changes that can improve one’s health.
Deborah Watson set up “Wednesday’s Child”, a support community for those suffering from eating disorders after she herself suffered from anorexia nervosa for two decades. Watson, too, feels impassioned about scrapping BMI as an index. “It is such an outdated approach when assessing someone’s health, and in particular, potentially dangerous when used as the key focus of an eating disorder assessment,” she says. “More attention should be paid to that person’s thinking, their behaviours – their whole physical and emotional wellbeing.”
A startling 80 per cent of those within the Wednesday’s Child community – across all ages and genders – said that since the start of the first lockdown, they could not access treatment after a medical professional said their BMI was not low enough. Watson has heard from many who faced “dismissal” and a subsequent “a sense of humiliation” after they were not seen to be “thin enough” or “sick enough” for treatment. “This means they are often contending with the illness alone, whilst feeling they are not ‘sick enough’ to deserve support,” says Watson.
Around 1.25 million people in the UK suffer from an eating disorder, which carries the highest mortality rate of any mental health illness. The Women and Equalities Committee report also found that lockdown has had a “devastating” impact on those with or at high risk of developing eating disorders and in intensifying body image anxieties. The recent deaths of former Big Brother star, Nikki Grahame, and Trevor Phillips’s daughter Sushila, from anorexia nervosa serve as a powerful reminder of the threat we face from eating disorders if we continue to treat it as a trivial matter and not take it seriously.
“There is a clear need for more funding,” says Joss. “There are only around 600 beds in in-patient wards, and medical professionals need to have more training on the mental health behind an eating disorder. It’s far more complicated than just “eating more”. It’ll take a collaborative effort with medical professionals, government, clinical researchers to sit down and realise what needs to change.”
“People who go to their GP with concerns about their weight should be offered access to specialised mental health and eating disorder services regardless of their BMI,” says Sophie. “Advice to eat more “calorie-rich” food fails to address the underlying issues and is probably one of the last things someone with an eating disorder will do without sustained discussion and support.”
The idea that something as multifaceted as an eating disorder can be categorised by something as simple as a metric is reductive. Whilst BMI can be an effective tool for looking at population trends and screening, it is a counterproductive diagnostic tool for those suffering from disordered eating, triggering behaviours rather than managing them. To combat this endemic of disordered eating, there needs to be greater emphasis on physical and emotional health and wellness, supported by various treatments. It’s time for medical and political professionals to go back to the drawing board and re-evaluate the current measurements, treatments and funding for a disorder that continues to claim far too many lives.