Emily Liu

06 June 2013
Hips Certainly Dont Lie: The Alternate Method Arising from BMIs Insufficiency
One common way doctors and ordinary people alike diagnose themselves in terms of
body fat percentage is through the Body Mass Index (BMI). In fact, BMI is such a popular
indicator in determining whether one is severely underweight or severely overweight that its
adaptation and usage is universal in America. Invented by the Belgian mathematician and social
physicist Adolphe Quetelet, the BMI scale dates back to the early 1800s; since its invention,
the scale has thus become the standardized tool in establishing the body mass of a variety of
ethnically diverse people. This straight scale though, used for centuries and still relied on by
doctors, has its limits. The world is a melting pot of different people and because the BMI scale
was created around such closed variables, it does not take into account muscle mass or different
ethnical body proportions. This causes both doctors to misdiagnose their patients and people to
falsely believe in the wrong type of body image, thinking that they may be overweight or
underweight.
To place more emphasis on the impact of American obesity, it currently stands that the
United States is plagued with an obesity epidemic which has continuously spanned over many
decades. In fighting this war against obesity, millions of dollars have been poured into research
regarding the topic. In fact, the National Institutes of Health has estimated approximately $827
million to be spent in 2013 (National Institutes of Health). Vigorously funding for the vast
amounts of research concerning obesity already impacts the funding for other equally, if not
more important, medical research such as Alzheimers disease. Because such an amount is spent
towards obesity research, the reliability and usage of the BMI scale increases significantly. Thus,

a chain reaction is started; the annual increases of funding put towards obesity enforces the usage
of the BMI which then only increases the amount of cases of obesity misdiagnoses and both the
under and over treatment of obesity related diseases.
In countries such as America where BMI is highly regarded to as a determinant for
obesity, both reliability and usage increases, therefore misdiagnoses can ineffectively measure
what really is compared to what is originally perceived because of the growing scope of racially
diverse citizens. In part, the effects of wrongful diagnoses of the appropriate body type can cause
for unnecessary treatment or prescription of medications to treat so called malnutrition or
obesity. It may also cause for the overtreatment of overweight or obese patients; life
threatening diseases may also be overlooked, incorrectly handled, or even ignored because of the
tunnel vision medical practitioners have concerning obesity and its treatment (the HAES
files: Opportunity Costs).
Obesity as a whole brings about many problems simply by existing and will continue to
raise issues if preventative measures are not taken. The BMI, the gleaming solution whose
modernized usage was meant to expose obesity to early treatment and raise awareness ended up
falling short of any successful pre-diagnoses. This problem stems from common issues with the
BMI such as mishandling and abuse which can be seen as a failure to advocate for the correct
usage in environments most suited for the BMI index. Failure is a result of medical practitioners,
federal organizations such as the Centers for Disease Control and Prevention (CDC), and the
general public for not adhering to the intended purpose and use of the index since its introduction
in 1972 and the failure to adapt to or widely implement other simple and formulaic alternatives.
Adolphe Quetelets Quetelet Index was originally designed in order to measure and
describe the average man of his time period through a ratio of weight (kg) and height (m)

squared (Eknoyan 49); when that is compared to the reasons of why it is used today, there is a
frightening difference. Modern usage of the BMI is to determine body adipose, and that in itself
is not a major issue, except for the fact that it is done on a world wide scale. It is a well known
fact that the world is not majorly composed of Euro-Caucasians but rather consists of a
worldwide clash of races and ethnicities with varying body compositions and types. Therefore by
deviating from Quetelets intended use of the BMI, what results are many misunderstandings
with calculating ones correct body adipose and the stigmatizing of obesity which further leads to
cases where a patients symptom is concluded to be a result of their weight as opposed to any
other essential factors. There have been several cases where if the treatment for dangerous
illnesses was to be immediate, unnecessary hospitalization could have been prevented, but
because doctors readily diagnose a patients disease with their weight being the underlying cause,
what was once un-called for now becomes an urgent need. In the instance of 14 year old Kaleb
Provis, his medical examiner took notice of his weight before his painful knee symptoms and
placed him in the morbidly obese category according to the BMI scale. A month after being
dismissed, Kaleb then had to have costly emergency surgery performed on his knee due to an
infection that the doctor missed during diagnosis (Boys Infection Not Picked Up). This is one
example that fully emphasizes and confirms that there is a stigmatism of obesity that clouds the
correct judgment and performance of medical professionals. In addition, the BMI scale, instead
of exposing the risks of obesity, obscures the real risk of injury and in this situation, fails in its
performance.
Over the years, the infamous BMI has been found to be lacking in being able to
accurately diagnose the risk of obesity, obesity related diseases, and body fat percentage because
of its linear height and weight scaling. In order to repair the damages the BMIs inaccuracies

have caused, more specifically those that have caused wrongful obesity diagnoses and health
complications in ethnic populations, a formulaic equation called the Body Adipose Index (BAI)
proposed in the University of Southern Californias Keck School of Medicine, by Dr. Richard N.
Bergman and his colleagues in a 2011 article titled A Better Index of Body Adiposity in
Obesity.
Dr. Bergmans index works similarly like the BMI where one would input specific
measurements and be given a percentage that would represent body adipose. More often than not
the BMI is unable to distinguish adipose from free-mass, simply put, the BMI cannot
differentiate body fat from other body compositions such as lean muscle. The BAI also calls for
height and hip circumference rather than the standard height and weight found in the BMI; this
only confirms its accuracy in calculating percent adipose as it has been discovered that both
most strongly relate to percentage adiposity (Nainggolan). By specifically providing a
percentage rather than correlating body adipose, the BAI works to precisely indicate a number
rather than a vague measurement. Also, research conducted in order to create the BAI was
heavily based off information from the BetaGene database which consists of relatives of
Mexican-Americans; further research was also conducted in the Triglyceride and Cardiovascular
Risk in African Americans (TARA) study (Nainggolan). Implementation of the BAI would
furthermore be as effortless as it was the adoption of the BMI. Simple enough, it would be
compliant in both households and hospitals or clinics as calculations are straightforward and
easy, require almost no upkeep or money, and be quickly executed in the settings previously
mentioned. Despite being the new gold standard in measuring body adipose, the BAI
experiences limitations similar to those of the BMI. Specifically speaking, the BAI is unable to
indicate where adipose may be built up and does not take into account other measurements that

have been deemed helpful in determining adipose percentage. However, while the BAI may
incur certain restrictions, the fact is that its benefits, particularly coverage, outperforms that of
the BMI and therefore helps more than it harms.
The BAI was originally designed with regards to a massive amount of data from the
BetaGene Database which consisted of mainly Mexican-Americans and relating ethnicities, such
as European Spaniards or Southern Americans; unlike the BMI whose information was originally
gathered from European Caucasians, further research was also done in a study involving African
Americans which leads its developmental progress into other areas. Seeing as a majority of the
world is non-white, this makes the formula highly adaptable to many world-wide differences; it
is also adaptable to situations where accurately obtaining ones weight would not be possible, in
remote or rural locations for example. Therefore, not only does this adjustment expand the use of
the BAI into other foreign grounds, but it also makes it applicable in territory that is, or would be
considered, underdeveloped.
Simply using data that is more realistic to current world demographics further signify
the impending fate of the BMI, though what pushes it further are the calculating variables that go
into the construction of the BAI. The main issue with the BMI is that utilizing both height (in
meters) and weight (in kilograms) when calculating makes it appear that people scale in a
perfectly linear fashion as they grow (Trefethen), therefore the formula makes short people
thinking they are thinner than they are, and tall people arethinking they are fatter than they
are (Wilton). What originally makes the BAI the best candidate for replacing the BMI is the
simple fact that rather than calling for height and weight, measurements of hip circumference
and height are used. Height is used in both indexes but specifically speaking, hip circumference,
as Dr. Mohammad Sayeed notes, has been found good for predicting diabetes, hypertension

and lipidemia. Because of Dr. Sayeeds observations, not only does hip circumference serve as a
valuable index for obesity, as previously mentioned, it is also undoubtedly important in
determining the risks for cardiovascular diseases related to obesity. Therefore, it can almost be
said that because of this exact change in measurements in Bergmans index, two birds are killed
with one stone; one particularly being that precise measurements of body adipose can be
calculated and obesity related diseases are exposed which allows for faster treatment.
Improvement is already made by removing one causal factor from the BMI, what more
though is that the mere construction of the BAI further proves itself better and as a result,
execution should be done as soon as possible. This proposal is not difficult to implement as
doing so only mainly requires a social acceptance of the formula and minor changes to be made
in health education. No major federal approval is necessary nor do any bills need to be passed.
Although since there will be no set in stone way to ensure that the BAI will clearly substitute for
the BMI, the most basic activity that must be done is to educate health professionals, such as
nutritionists, physical therapists, and doctors, to make certain that they are aware of how to use
it, why it is more effective when compared to the BMI, and guarantee that it will be utilized. The
most successful way to begin gaining usage of the BAI is to issue training in order to gain
comfort and familiarity. As Dr. Amy Sheon and her team briefly tackle in their dissertation
concerning the steps that should be taken at the start of implementation: Training may be
conducted as hands-on sessions during medical education seminars, through regular meetings of
groups, through on-demand web-based videos or interactive methods, or through dissemination
of print material (Registry-Based BMI Surveillance: A Guide to System Preparation, Design,
and Implementation). As soon as professionals familiarize themselves with the BAI, it will
seamlessly be integrated into the system by the professionals themselves without any major need

for federal activity. The benefits of the BAI would better assist an audience that the BMI could
never reachthe conflicting sexes and ethnics. It would simply be implemented in settings
where the BMI is also common, that is, hospitals and clinics. Realistically, the execution is at
little to no cost in terms of specialized staff as all it requires is a simple calculation that can be
done by any health professional including a doctor, nurse, dietitian or personal trainer" (Qtd. in
Neporent) nor would it require any weekly, monthly, or annual upkeep or special equipment such
as its technological counterparts, the duel energy x-ray absorpiometry scanner (DEXA) or a large
tank for hydrostatic weighing. Because of these factors, it is the most rational in terms of time
and money; its format allows for quick execution in different environments and cost of usage is
very minimal.
Regardless of being the best at hand, the Body Adipose Index also incurs similar issues
that were present with the Body Mass Index such as not being able to specifically indicate where
adipose may be built up and not taking into account stomach fat (waist-circumference). As it is
undeniable that the BAI cannot spot locate adipose, its hip circumference is reliable enough as a
valuable obesity index (Sayeed et al.) that while waist circumference is important, it becomes
redundant to require both measurements. Further limitations that the BAI encounters
independent of the BMIis that often, hip circumference is difficult to obtain, particularly on
obese people (Qtd. in Rettner). However, the main and possibly most important issue with the
BAI is that while it can accurately determine body adipose in Mexican-Americans and their
relatives (Spanish and South American, for example), along with African Americans, it has yet to
be confirmed whether the BAI works with Caucasians. While this may seem to take on a
devastating toll and also make it appear like the BAI cannot be refined to address every race or
ethnicitys body composition, it must be acknowledged that the majority of the world is non-

white. Therefore, while it is unsure whether or not the BAI will perform accurately in a EuroCaucasian population, the fact is that it must be applauded that the BAI could possibly address
the part of the world that is not of Caucasian descent.
Despite there being a vast amount of expensive and fixed technological alternatives, the
Bioelectrical Impedance Analysis (BIA), unlike many of its hi-tech counterparts, is cheap and
relatively portable, which makes its coverage just as effective as the BAI. This is more than
enough to fully implement the BIA and to gain social acceptance in household and clinical
settings. More importantly, the BIA has undergone a considerable amount of technological
improvements over recent years, making it more reliable than previously. Regardless of its
inexpensiveness, convenience, or reliability, its sensitivity is its own demise. As noted within a
restatement of a conference via the National Institutes of Health in 1995, because it conducts an
electric current flow through body tissue, it requires the standardization and control of many
variables that can impede accuracy such as, air and skin temperature, body position, and
hydration ("Bioelectrical Impedance Analysis in Body Composition Measurement"). The BIA is
also not accurate when recording single measurements of individuals, which defeats the purpose
of having it serve as an alternative for the BMI. Because of the BIAs limitations, especially
those that concern sensitivity, the BAI continues to be the superior substitute for the BMI. It is
more than cost efficient, accessible, and simple to use. Compared to the BIA, the BAI can be
utilized individually and within a wide scope of individuals. Little to almost nothing is able to
complicate the performance of the BAI which makes it not only a reliable tool, but one that is
capable of continuous reliability.
Both the worldwide and American obesity crisis is more than just what it is, or what it
seems to be. Moreover, what usually tags along with an obesity epidemic is the wide spread risk

of cardiovascular related diseases such as heart attacks or strokes in which 70% originates from
American obesity (Obesity Related Statistics in America). Despite that, treatment is available
and injuries are preventable. What hinders the discovery of these illnesses though, both general
and cardiac, is the BMI. It is believed to be the shining light in exposing risks for obesity but
instead of living up to such an unbelievable modern expectation, it falls flat and causes more
harm than good. Generally it is never a good idea to keep outdated and broken objects so what
good does it do to place such heavy reliance on an obsolete index? In order to restore what has
been ruined, the BAI offers hope with its gleaming new hip circumference and diverse
background. Not many resources, neither time nor money, need to be sacrificed for the execution
this index. More than anything right now there is a need for official and public support in order
for the index to gain recognition. Support in this does not mean rallying for the implementation
in front of the Congressional building but instead small, simple steps such as replacing BMI
usage in your household with the BAI. Realistically, success is within reach and not as far off as
one would think. It is only in time when the ending of one of the most deadly rising health issue
of the 21st century will commence and accordingly become less detrimental to the health of the
public, but that will not happen unless changes are made and the best solution at hand, the BAI,
begins its implementation.

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