What’s Obesity got to do With COVID-19 in America? Part I

Obesity and COVID-19

Recently I have read quite a few articles about the association of obesity and COVID-19. A high percentage of children who get very sick from COVID-19 are obese.  The CDC now lists obesity as one of the risk factors for COVID-19. Obesity has emerged as a major risk factor for bad outcomes from COVID-19.

I thought this would be an interesting topic to discuss.  But after taking a deeper dive I realized that this was a huge topic.  Body Mass index (BMI) debates, weight stigma, fatness versus fitness, then the layering of COVID-19.  This led me to believe that one post would not be enough.  So, in this article I will lay the foundation for Part II that will more directly address COVID-19 and obesity.

A Snapshot of Obesity

Summertime, I love drinking some sweet tea.  While drinking a less sugary version, I started reading the statistics on weight. Obesity is prominent in many parts of the world and the U.S. is the most obese country in North America. According to the World Atlas (2018), the U.S. ranks 12^th in the world. CDC provides an overview of the prevalence of obesity.  These rates are based on the standard BMI values. According to CDC an average adult American is 26 pounds heavier than in the 1950’s. Fast foods and sugary drinks are certainly part of the blame.  A Mexican official blamed a specific sugary soft drink  for his country’s obesity, and thus the main reason Mexico is being ravished by COVID-related disease. Some adults and kids in Mexico are drinking this soda morning, noon, and night.

Mapping Out Obesity in the U.S. (2018)

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What’s the Deal With BMI?

 I remember when I started my medical practice. We were encouraged to use the Metropolitan Insurance weight tables.  I threw them out because they were not appropriate for the Black population I was serving.  These weight tables were based on very thin Whites. When the BMI tool was first released around 1985 by the National Institute of Health, I embraced it.  At that time BMI less than 28 was considered healthy. Then in 1998, a BMI less than 25 was re-defined as a healthy weight. Since then, I have been using the revised level as a guide for my patients.  My electronic medical record automatically calculates the BMI. What could be easier than that? Some patients have complained that the measure is inaccurate, especially for Black people. 

From the pure medical sense, obesity is not about cosmetics-how you look or feel.  It is about the risk of certain diseases. The standard dictum has been that a BMI of 30 marks the cut off for obesity and signifies a value where the risk for diseases is greater. Obesity puts people at risk for diabetes, cardiovascular disease, and cancers.

BMI to Categorize Weight

The BMI is a simple measure of weight for height. BMI is an inexpensive and easy method to categorize weight.  That is one of the reasons that it is used in the medical office—quick and easy.  Other measures of obesity are not as efficient or simple.  Here is a CDC Adult BMI Calculator to determine what category you fall in. We use four categories- underweight, healthy weight, overweight, or obese. I have also included a table. Some of my patients use the table to gauge where they would land at various degrees of weight loss.

Since the release of the BMI scientists have pointed out that BMI is not accurate for those who are very tall, very short, or muscular. So this isn’t a good measure for Simone Biles or Lebron James, for example.  

Does BMI Apply to Black Folks?

BMI and Black folks-this has always generated a lot of discussion in my circles. You find people on both sides of this issue.  I saw the debate waged on this interesting 2012 post, MyFitnessPal. The discussion is still timely.

“I’m black/brown, heavy in the hips and thighs, and still a healthy BMI. They give a range for a reason. Some ethnicities will be on the lower end and some on the higher. Unless your body fat is low and you’re very muscular (more so will only apply to men as women can’t put on much muscle) you should fit in the BMI scale.  I know a lot of people disagree with the scales but they are pretty accurate for the average person.”

Respondent MyFitnessPal Post 2012

This study examined the relationship between BMI and fat percentage in different ethnic/racial groups. The study showed that races have different BMI’s at the same body weight.  It suggests that Black people have a higher healthy BMI than White people. A more recent study of multi-ethnic women concluded that race/ethnic BMI cutoffs would be more accurate in determining obesity.

There are studies reporting that Blacks have lower body fat (approximately 2 % less) and higher lean muscle mass than Whites at the same BMI.  We know that muscle weighs more than fat. A glob of muscle weighs 18% more than the same sized glob of fat. This information led some experts to suggest a BMI of 32 to define obesity in African Americans.

Is BMI a Measure of “Fatness”?

BMI may not be perfect but I do believe that it is an easy, objective way to get the conversation started about health and body weight. However, it is only part of the equation in determining health. An important point to note is that the BMI doesn’t directly measure body fat, so it is not a good measure of fatness. BMI also does not account for fat distribution. People with accumulation of body fat in the abdominal region (visceral) have a markedly higher risk of developing Type 2 diabetes and cardiovascular disease. Excess visceral fat increases total mortality (death).

Does BMI Predict Overall Health?

Health risks are linked to fat content of the body which BMI does not accurately reflect. The BMI doesn’t account for the differences in fitness levels, body composition (muscle mass, bone density), or nutritional attributes that can help predict health and longevity.

What is a better measure of healthiness?  Well, metrics like cholesterol, blood pressure, glucose and level of physical activity are the best measures.  Even if a person has a high BMI these metrics more accurately correlate with health.

Beyond Body Mass Index: Are Weight-loss Programs the Best Way to Improve the Health of African American Women? Includes valuable insights.  Important points in this article include:

• Research increasingly highlights fitness over fatness as an indicator of health and well-being.
• People who are overweight or obese with good heart-lung fitness have similar death rates to people with normal BMI and good heart-lung fitness levels. 
• Death was shown to be dependent on cardiorespiratory fitness and not BMI.
• A high BMI did not automatically put you at greater risk of death.
• Moderate physical activity, moving the body can improve health even in the absence of weight loss.

Obesity Stigma- Shaming and Blaming

In real world scenarios, nobody is carrying around a BMI calculator.  In our ‘fat phobic’ society, people use the naked eye to determine who is fat.  Jobs, schools, health care settings, social acquaintances, even family don’t rely on the BMI. These judges use their personal radars to make assumptions about whose body is too large, even without knowing anything about them.  Thus, weight can hold a person hostage in the aforementioned arenas.

“More than “40% of Americans classified as obese…experience stigma on a daily basis, a rate far higher than any other minority group.”

Michael Hobbes, Huffington post

Fame and fortune does not shield from weight stigma. Check out this video with Oprah Winfrey and Joan Rivers (1985).  Whew!  It is still illustrative. Oprah tapped her hand on the chair, as Joan referred to an African American actress as a pig! She implored Oprah to lose weight. What are your thoughts?

Trying to make money and earn a living may be hampered by weight.  People who are obese are less likely to be hired, earn lower salaries, and are promoted less. Obese employees may be viewed as lazy, not competent, unprofessional, or unattractive. Now imagine if you are fat, Black, and female.

In schools and on playgrounds children perceived as obese bear the brunt of the jokes and bullying. Weight based bullying is one of the most common forms of bullying in youth. Teachers may also exhibit biased behavior towards these students.  The weight bias for kids spills over into post high school education. Despite equal academic achievement and test scores, obese teens have lower acceptance rates to college.

The medical community unfortunately, has not been exempt.  In general, obese patients receive poorer health care. Fat patients are blamed and shamed for being fat. There is often no acknowledgment that obesity is a disease, a CHRONIC disease.  There are no quick fixes like the old adage ‘just push back from the dinner table‘ implies. I have tried to talk to my patients with larger bodies about being healthy, adopting healthy behaviors rather than a focusing on losing weight.

5 Ways we can Reduce Weight Stigma:

1. Recognize that obesity is a chronic disease. Obesity can be influenced by genetic factors, medications, mental, and other factors. Additionally, living in an obesogenic environment with food deserts and fast food forests can be contributory.

2. Examine your own biases about weight. Harvard University’s, Project Implicit, has tests to assess weight bias.

3. Think about how you would like to be treated as a human being, regardless of body weight.

4. Work to educate others about weight stigma and encourage them to challenge negative attitudes.

5. If you are obese- don’t internalize the blame or shame others try to place on you. Look in the mirror and see yourself saying back, “I am beautiful”. Talk to a therapist about coping with stigma.

COVID-19’s Impact

Skin color, body weight, social class…. always something to shame or blame. In the U.S. we are not willing to embrace the differences that make us a unique Nation.  This virus is far less discriminant than we are.  It does not discriminate! COVID-19 infects the young-old, rich-poor, thin-fat. Remember that although the BMI has limitations, it is a simple measure to start the conversation about weight. We can debate about what constitutes obesity, but the virus is snatching the lives of people with higher BMI’s. 

Teachaser: 

Why is obesity a risk factor for developing severe COVID-19?  My next post will explain.

Dr.TeaNT