Tuesday, March 9, 2010

The Curious Case of Body Mass Index

Whether it’s before we start losing weight, in the process, or close to the end, we all ask the question, “Where is goal?”

For a lot of us, goal is a scale number that incorporates a BMI number of 25 or below since anything above 25 is considered overweight, right? But, as we’ve talked about before, BMI isn’t always an accurate indicator of health or healthy weight, especially – as I found out reading my blogging partner Barbara Berkeley’s latest blog on Refuse to Regain – for those of us who’ve been morbidly obese.

Here’s part of Barbara’s blog. To read it in its entirety, visit Refuse to Regain.

The patient in front of me is Mr. C, a 308-pound man who has been sent by one of my favorite referring doctors. This doctor truly cares about the health of his patients and it shows. In fact, Mr. C’s physician is a triathlete, eats for health and practices what he preaches. He’s never been overweight. His clients are devoted to him and Mr. C is no exception. But Mr. C. is worried. He genuinely wants to lose weight but the doctor he so much wants to please has told him that he needs to reach 170 pounds: the white or “healthy” zone of the BMI chart.

“Doc,” he says earnestly. “Is that possible? I’ve never been that light, not even in high school.”

Twenty years ago, the term BMI was part of the foreign language of doctors, a measurement that was recorded on the chart and remained obscure to patients. Today, nearly every dieter understands, (and sometimes obsesses about), his or her niche on the BMI chart.

…I have a somewhat different take on BMI. Yes, we know that weight gain impacts our health negatively. We know that even small amounts of weight gain put us at risk. But what happens once the horse is out of the barn? Once we have gained that weight, incurred that new risk, what then? Are the rules for “healthy” BMI the same after gain has occurred? This question brings us to a larger and more fascinating issue: Is there some permanent change that occurs within us once we have been overweight that changes those rules? I believe the answer is yes.

What I call POWs (previously overweight people) seem to be quite different from NOWs (never overweight people). As someone who was a NOW in my earlier years and is now a POW, I can attest to the fact that my physiology has changed. Can I prove this scientifically? No. We have now crossed over into the area of observation and opinion. Read on with that knowledge.

In my view, weight gain occurs when the normal mechanism that controls and stabilizes weight is damaged by over-exposure to elements of the SAD (standard American diet). Once the damage is done, I believe that we remain prone to weight gain. We can prevent this by avoiding the foods that caused the damage in the first place, but we must be extra careful. Most POWs cannot eat mindlessly anymore.

This tendency to weight regain may also have to do with fat cells which remain in the body, but which no longer contain fat. No one knows if depleted, empty cells signal the brain or cause other kinds of hormonal havoc. So what does this have to do with optimal BMI? When we gain weight, the body has to manufacture new fat cells to store the oily triglycerides which are being created. These cells are supported by a scaffolding of connective tissue and muscle. After weight loss, the fat cells are emptied, but some of the tissue may remain. Many POWs find that they simply cannot lose enough weight to reach the white area (or normal range) of the BMI chart. This may well be because the BMI chart is based on the weights of those who have never been heavy, in other words, the weights of NOWs. Since NOWs have never manufactured new fatty tissue, their baseline weights are lower.

I love what I do, but I have written before about the one part of my job I don’t enjoy. That would be the very last phase of a patient’s weight loss. Almost without exception, my patients are unhappy with their final weights. This happens even when they have lost 60, 80, or 150 pounds. Each one longs to get down “just a little more!” Each one feels like a failure for not reaching the white zone (of the BMI chart). This is the point at which BMI charts become tyrannical, and for no good reason. The rules for optimal BMI in the POW are different, just as pretty much everything else is different for POWs. Since there are no established guidelines for optimal weight in the POW, I can only offer my own take.

1. If you have been significantly overweight, a loss of 20% of your pounds is highly successful and is what I usually target. If you’ve lost more, great!!
2. Your optimal BMI should be the one at which you have eliminated or greatly minimized any weight related medical issues (especially blood pressure, diabetes, and lipids). In some people, remnants of the problem will remain, but the vast majority can expect significant improvement and decrease of medications.
3. Your optimal BMI should be one at which you can comfortably maintain.

Number three is probably the most important guideline, because weight loss is of no consequence if it ends in regain. POWs who push themselves to very low weights often do so at the expense of muscle tissue. If you start to look wasted, your vital muscle mass may be dissipating. At such low weights, and without muscle to help out with calorie burning, you will have to make do with what I call “two peas and a bean.” That’s not fun, that’s not life, and that’s not sustainable.

Shoot for maintenance, comfort, health, mobility. These will stand you in good stead whatever your BMI zone.

15 comments:

Shelley said...

Thank you for this. I'm off to read the entire post at RTR now, but #3 is where I'm most concerned with...otherwise my entire journey will have been for nothing if I regain everything I worked so hard to lose.

Susannah said...

Very interesting. After a 90 lb. loss (yea me!) my BMI is 27, being 5'10" and 180 lb. My personal goal is 160 lbs. which will take hard work since I am maintaining easily here at 180. However, I see the last 20 lbs. right around my middle.
That said, I cannot imagine going to to the low end of the "normal" weight white area. BMI of 22 would be 140 lbs.!! Seriously, I would look and feel like a famine victim. At age 52, well, it wouldn't be pretty.
Could I have been a person with a BMI of 22 if I had never become a 270 lb. person? Fascinating!

midlife_swimmer said...

great post! I gave up listening to recommended weights for myself years ago. I would like to get to a healtheir weight than I am at now.... but have realistic goals as far as where I will end up.

Cammy said...

Such an awesome post--thank you for sharing it! I managed to accidentally get about 7 pounds below my personal goal weight. Even though that was 5 pounds higher than the standard charts indicate, I looked "drawn" (according to trusted friends) and I couldn't maintain it. Where I am right now seems to be where my body is comfortable, and I'm happy enough with that. I look better, even if I do have a squishy middle, and I feel fantastic. I really don't care what the charts say. :)

Thanks again for the fantastic article!

Lori said...

I still struggle with this. I know that what I really need to do is to get a BodPod scan done so that I know my true body fat percentage.

As long as I keep of the weight I have lost, that means more than the current "BMI" number, but there is still that part of me that feels a need to keep going. Unfortunately, many doctors are no help at all as they go by the charts, too!

EmpowerMePhotoGuy said...

I think you're right, there shouldn't be so much emphasis on reaching that certain target point, the important thing for many people is just to get to a weight that rules out an increased risk of ill-health. Any extra moves towards lowering their BMI should only be made after this point. Of course, it's true what you say about people who have lost weight being empowered to lose more, always going for one more pound. Interesting post!

Marcia said...

This was a great post. I've watched every season of The Biggest Loser. And I remember the first season that they had twentysomethings who did NOT lose any weight compared to the older folks.

And I kept saying "the older folks used to be skinny. Kids never were."

Then I did read an article that talked about how hard it is to lose weight if you are fat as a teen, because that's when the most fat cells are made.

People who have always been skinny don't get it.

Lisa W said...

I have stared at the BMI charts for hours trying to figure out how I would ever get to 25. I am a budding POW (love that term) and am trying to set a goal weight. I asked my doctor for his opinion and his advice was in line with this article. Thanks for the confirmation.

Lisa said...

I think this is a great post. I think that a lot of people wanting to lose weight have a certine number amount to lose too which they can get hung up on.

- Lisa
http://inweighovermyhead.blogspot.com/

debby said...

Thanks so much for sharing this here, Lynn. I don't always get over to Refulse to Regain on a daily basis. This is something I have been thinking about for a while.

Sunny said...

I can only speak for myself, and BMI is completely accurate and realistic for me. Maybe it works better for shorter people? I don't know. I just know I trust it for me. Sorry.

Debbie said...

I loved this post and I am going to read the entire post for myself. I have a high BMI and myself. I am working toward a healther weight and trying not to think about my high BMI.

Taryl said...

That is such a great post, thank you for linking it!

This is a topic I really struggle with, as what the BMI says I should weigh and what my experience says I should weigh have about a 30 pound discrepancy.

So screw the chart, I am going for healthy, happy, and maintainable for life! Numbers are so overrated when they aren't your blood sugar, cholesterol, or any other 'real' marker of health!

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SeaShore said...

Thank you for sharing this. I keep arguing with myself about those last 5 pounds until I get to the magical and elusive BMI<25. At this point, I see my focus shifting from weight loss to fitness. I just need to ditch the "so close, but so far" and "failure" crap that keeps playing in my head.