The Imperfections of BMI
Is BMI the Right Measure?
By Christine Craig, MS, RD, CDCES
For years, the Body Mass Index (BMI) has been the standard for determining body weight health, but are there other factors we should be considering?
In June of 2023, the American Medical Association (AMA) adopted a policy to clarify the use of BMI for medical care. And in 2024, the ADA Standards of Care1 followed, updating their recommendations for the use of BMI.
Both organizations reported BMI as an imperfect measure as it does not measure weight distribution or factor in weight-related health conditions. More accurate body measurement approaches are under consideration that may replace BMI in the future.
Person-centered care takes a collaborative approach and goes beyond assessing only weight/BMI change outcomes. Individualized care includes assessment of mental and physical health. Providers can learn to recognize weight bias and begin the paradigm shift to focus on inclusive care. We can assess how weight, BMI, and weight distribution apply to the individual.
The relative importance of body adiposity for an individual’s health is not be based on BMI alone. BMI is a calculated measure of weight in kilograms divided by the square height in meters (kg/m2), but it does not consider race, gender, and age in body composition and health risk. The AMA specially called out the “issues with using BMI as a measurement due to its historic harm…BMI is based primarily on data collected from previous generations of non-Hispanic white populations”.2
In 2004, the World Health Organization lowered cut-off points for obesity diagnosis to 27.5 kg/m2 for Asians based on evidence of disease at lower BMIs. A recent study examined racial and ethnic differences in anthropometric measures and diabetes risk.3 They observed for post-menopausal women waist circumference to be a better measure to predict diabetes risk; however, this predictor was strongest in Asian women and weakest in Black women. Within this study, they observed that for Black women, the trunk-to-leg fat ratio may be a better anthropometric predictor of diabetes risk.
The limitations of BMI resulted in both AMA and ADA recommending the use of BMI in conjunction with other measures. Per the AMA, these measures include but are not limited to “visceral fat, body adiposity index (hip to height ratio)4, body composition, relative fat mass (height to waist circumference)5, waist circumference, genetic or metabolic factors.”2
Health and weight-related health risk assessment need to encompass a holistic approach considering metabolic, psychological, and physical well-being. Assessment and intervention goals are individualized to account for these factors as well.
A focus on BMI alone can cause error on both sides, labeling those with high lean body mass or subcutaneous fat mass as overweight or obese and individuals who weigh less as healthy, potentially missing interventions and medical care.
BMI is the criteria often used for prescribing anti-obesity medications (BMI > 30 or > 27 with one or more co-morbidity), but insurance coverage usually does not account for individual factors that modify risk without significant time spent challenging authorization. For others, if considering BMI alone, the category label of overweight or obese may not accurately assess the individual’s actual health, and weight bias may trigger unneeded recommendations.
We can consider the value of monitoring weight at each visit and the measure’s usefulness to inform treatment decisions.6 We can use other measures that factor in visceral fat, especially if focused on improving cardiovascular and metabolic risk.7 A more accurate measure appears to be waist to height ratio, which seems to better identify a person’s risk for cardiovascular disease.
We can include shared decision-making when recommending interventions and account for “medical history, life circumstances, preferences, and motivation.” 1 Understanding the limitations of BMI and moving beyond the perception that normal BMI is healthy and overweight is unhealthy will inform our evidence-based practices and enhance equitable care.
- American Diabetes Association Professional Practice Committee; 8. Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes: Standards of Care in Diabetes–2024. Diabetes Care 1 January 2024; 47 (Supplement_1): S145–S157. https://doi.org/10.2337/dc24-S008
- AMA: Use of BMI alone is an imperfect clinical measure. June 2023. Downloaded from: https://www.ama-assn.org/delivering-care/public-health/ama-use-bmi-alone-imperfect-clinical-measure
- Luo J, Hendryx M, Laddu D, Phillips LS, Chlebowski R, LeBlanc ES, Allison DB, Nelson DA, Li Y, Rosal MC, Stefanick ML, Manson JE. Racial and Ethnic Differences in Anthropometric Measures as Risk Factors for Diabetes. Diabetes Care. 2019 Jan;42(1):126-133. doi: 10.2337/dc18-1413.
- Body Adiposity Index Calculator: https://www.mdapp.co/body-adiposity-index-bai-calculator-618/
- Relative Fat Mass Calculator: https://www.mdcalc.com/calc/10472/relative-fat-mass-rfm
- Puhl RM, Himmelstein MS, Speight J. Weight Stigma and Diabetes Stigma: Implications for Weight-Related Health Behaviors in Adults With Type 2 Diabetes. Clin Diabetes. 2022 Jan;40(1):51-61. doi: 10.2337/cd20-0071. PMID: 35221472; PMCID: PMC8865787.
- AMA adopts new policy clarifying role of BMI as a measure in medicine. June 24, 2023. Downloaded from: https://www.ama-assn.org/press-center/press-releases/ama-adopts-new-policy-clarifying-role-bmi-measure-medicine
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