The Shortcomings of BMI As a Vaccine Eligibility Metric

Should we really be putting high BMI in the same category as pulmonary disease and cancer?

Image: Andriy Onufriyenko/Getty Images

On February 14, New York State released a new set of eligibility criteria for the Covid-19 vaccine. While the initial phases of the vaccine rollout focused on older adults, first responders, and other essential workers, the vaccine is now available to an estimated 4 million more New Yorkers who have a chronic health condition associated with an increased risk of contracting the virus or experiencing its severe consequences. On the list, which matches federal guidance from the Centers for Disease Control and Prevention: cancer, pulmonary disease, heart disease — and obesity, defined as a body mass index (BMI) of 30 or higher. But one of these things is not like the other.

People living with compromised immune systems are clearly more vulnerable to a lethally contagious virus. So too are people with lungs, hearts, and other organs already working too hard, who may not have the reserves needed to fight off the virus once it takes hold. But people living in bigger bodies don’t automatically experience limitations as a direct consequence of their weight. They are more vulnerable to Covid-19 for a different reason: stigma. And we should be clear that this is what we’re vaccinating against when we tell fat people that their body is a “comorbidity,” a disease waiting to ally itself with this other disease, and conspire against their survival.

Ask any fat person and they will tell you how anxiety-provoking even routine medical appointments can be. A 2019 survey of 400 Canadian doctors revealed that 24% were uncomfortable even having friends in bigger bodies, and 18% “felt disgusted” when treating a larger patient. This attitude pervades every medical specialty (I’ve previously documented it in the infertility field) and impacts the quality of care that fat people receive. A 2011 study found that medical students were more likely to blame people for conditions like respiratory distress if they were in a bigger body, and tended to prescribe weight-loss strategies rather than symptom management. Providers spend less time with patients with high BMIs and are sometimes even less willing to perform standard care such as pelvic exams at the gynecologist’s office. As a “small fat” person, I’ve seen how knowing my weight leads doctors to assume I don’t exercise or eat healthily. And that’s the mild end of the spectrum. Fat people are also likely to have eating disorders go undiagnosed, or even be reinforced by doctors eager to encourage weight loss. In May 2018, a Canadian woman named Ellen Maud Bennett died only a few days after receiving a terminal cancer diagnosis; in her obituary, her family wrote that Bennett had sought medical care for her symptoms for years, but only ever received weight loss advice.

There is no question that weight and health interact in many complex ways. But it’s also clear that the stigma fat people experience when they seek health care plays a significant role in their health outcomes. You cannot improve the health of someone who repulses you because you aren’t seeing them as fully human. We are only beginning to understand the extent of the damage caused by these attitudes because this same stigma impacts and influences all of the research done on weight and health, mostly without researchers noticing or acknowledging that it exists.

We should be clear that this is what we’re vaccinating against when we tell fat people that their body is a “comorbidity,” a disease waiting to ally itself with this other disease, and conspire against their survival.

With that as our baseline, it’s no surprise that the Covid-19 pandemic has also intertwined itself with medical weight stigma, as I reported recently. First came the flurry of research linking weight with worse Covid-19 outcomes: In April 2020, the CDC released a report noting that 48% of patients then hospitalized with Covid-19 had a BMI in the “obese” range (compared with 42% of Americans as a whole). A French study published in the journal Obesity around the same time found that Covid-19 patients with a BMI of 35 or higher were more likely to need a ventilator. Most recently, an analysis of 6,916 people with Covid-19 in California found that men with a BMI above 40 had a higher risk of dying from the disease than those with a BMI in the normal range, according to findings published in the Annals of Internal Medicine. More medical reports — and an even bigger storm of media coverage — followed.

None of this research proves that a Covid-19 patient’s high body weight caused their hospitalization, need for a ventilator, or death; it only establishes a tentative correlating relationship. The Annals paper, for example, found no increased risk for folks with overweight or obese BMIs below 40, and no relationship at all for women even at the highest end of the weight range. And none of the studies linking weight to Covid-19 complications have looked at whether a person’s experience of stigma impacted their quality of care, or their health prior to contracting the virus.

But I am not arguing to take high BMI off the eligibility criteria for vaccination. Fat people are at some heightened risk for severe Covid-19 and for much of the pandemic, the far more gripping fear has been whether they would receive equitable medical treatment if they became sick. “This fear has escalated to the point where lots of fat people really are quarantining themselves in their houses, afraid to go out in public, afraid to go to the doctor for other reasons,” said Linda Gerhardt, a fat activist and blogger who has written about her own experiences with medical weight stigma. “This is going to be with fat people for a very long time.” And their fear is not unfounded: Last spring, California published a draft of guidelines for medical triaging that allowed doctors to decide which patients get ventilators and other resources based on weight, among other factors. Fat and disability rights activists were successful in lobbying to have that guidance changed and are now working to ensure that these same groups receive vaccine priority.

Nevertheless, in setting the eligibility criteria at the lowest end of the obese category, New York and other states are reinforcing the same stigma that endangers our health. For many folks in bigger bodies, the simple act of getting weighed in a doctor’s office is a traumatic and risky undertaking; it could trigger a relapse in someone struggling to recover from an eating disorder or expose a patient to a new round of stigma from the health care providers who document that number. And the body mass index itself has long come under fire for its inability to accurately gauge health; plenty of professional basketball players and other larger and healthy people are classified as “obese” by its math. So we’re also likely prioritizing some unknown number of perfectly healthy people in larger bodies that shouldn’t be taking appointments from immunocompromised adults, and don’t need vaccinating ahead of other vulnerable groups, such as medically fragile or immunocompromised children who do not yet qualify for a vaccine.

Still, however vaccine priority lists shake out, more people vaccinated means fewer people dying of Covid-19. And that gets us closer to being able to do the real work of understanding and disconnecting weight, health, and stigma. So fellow fat people (even small fat, and fat and healthy people): We deserve to vaccinate ourselves against a medical system, and indeed, an entire culture, that so often blames us for its failings and fails to meet our needs. Let’s take our shot.

Author of THE EATING INSTINCT and forthcoming FAT KID PHOBIA. Newsletter: Everything else:

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