One culture’s fat is another culture’s fit. Why the Body Mass Index could use a deep dive into our country’s melting pot.
As the light from the candles atop the bar flicker in the mirror, the couple waiting for their table share a small plate of elegantly prepared chicken livers. Sipping an unoaked Chardonnay, Dr. Canter reflects on her day as a family physician at a hospital in a rural, outer-ring suburb, 20 miles from the inner city where her husband, William Fairfax, serves as police captain.
Captain Fairfax was raised nearby, but the trendy neighborhood is nothing like what he remembers. Growing up, it was filled with immigrants from Eastern Europe and African-Americans who migrated from the South.
Presented a table, the couple orders: a duck confit (meat submerged and cooked in its own fat), Brussel sprouts and cheddar grits; and a cassoulet, a dish served in a skillet with a variety of meats, including pork sausage and lima beans. As they wait for their food, Dr. Canter begins the conversation: “I had a patient today who hasn’t been feeling well―lethargic, sore joints, you name it. She has had high glucose results since I’ve known her. Her blood pressure isn’t terrible. But I’m worried about her.”
Dr. Canter continues, “Her BMI is 31, so I recommended she change her eating habits―too much starch, fried foods and pork.”
“Sounds like what I grew up eating,” says the Captain.
“Yeah, but she’s my height, and weighs 25 pounds more than me. She needs to change or she’s going to have problems,’’ says Dr. Canter.
“Like?” asks the Captain.
“Diabetes or hypertension or heart disease, like about half of my patients,” Dr. Canter answers.
As the conversation turns to other topics, Patricia, the head nurse in Dr. Canter’s office, passes by their table. Surprised to see her, Dr. Canter remarks, “Patty, fancy seeing you here! I didn’t know you liked this place.”
Patty responds, “It’s expensive but one of the dishes reminds me of my mom’s oxtail stew.”
As comfort food has been elevated to haute cuisine, our love for the trend is evident. According to the 2016 America’s Health Rankings® Annual Report, the rate of obesity has increased nationally, from 27.8 to 29.8 percent of adults. But for Nurse Patty and others, obesity is a complex equation, not just a sum of what she eats. Factors include genetics, prenatal and early life influences, unhealthy diets, insufficient sleep, and lack of physical and social activity.
Compounding these risk factors, many people dismiss dietary recommendations made by health professionals. Patients across a variety of racial and ethnic groups have raised doubts about the use of body mass index (BMI), as the basis for those recommendations. Their skepticism is not without merit. And at the heart of their pushback lurks more than a hint of concern that it’s linked with bias against the poor, the rural, the ethnic.
Dr. Canter’s patients are black, white, Asian and Hispanic, with lifestyles and eating habits reflecting the traditions of their ancestors who settled here. Socio-economic concerns and access to healthy choices are still issues in many communities. Yet, as the availability of food education, and advancements in preserving and processing have changed, so to have mainstream perceptions of what’s healthy, what’s tasty and what’s shapely.
You hear it often: “My doctor says I’m obese though my stomach is flatter than hers.” “Does that affect my insurance?” “My entire family is big-boned, but we’re not obese.”
Many believe that BMI is not a fair or accurate measurement marker of wellness or obesity. And some physicians agree with them that being labelled with a ‘’bad’’ BMI might be counterproductive to good health. A journal article in Social and Personality Psychology Compass, “Weighed Down by Stigma: How Weight-Based Social Identity Threat Contributes to Weight Gain and Poor Health,” states that although “some lay individuals and health professionals assume that stigmatizing weight can actually motivate healthier behaviors and promote weight loss,” the stigma is consistently associated with poorer mental and physical health.
“Physicians should look at the whole patient and not only look at weight and BMI,” says John Boltri, M.D., professor and chair of the Department of Family and Community Medicine at NEOMED. Dr. Boltri is also the American Academy of Family Physicians Liaison to the National Diabetes Education Program (NDEP) Coordinating Committee Strategic Directions Group.
“There are some things that are not in patient’s control, like their genetics. And BMI is a tool for physicians to add to all of the data that they have about a patient. Treatment should be individualized to the patient’s needs, abilities and resources.”
A Measurement Under Fire
Apparently, blaming and shaming patients doesn’t work. And BMI as a measure? One flaw is that it does not distinguish between muscle and fat. A weightlifter may be labelled as obese, based on their BMI, and so might someone from a particular ethnic group.
Surprisingly, the BMI formula, which divides a person’s weight by their height squared, was devised in the 1830s by Lambert Adolphe Jacques Quetelet, a Belgian astronomer, mathematician and sociologist. The formula—not coined “body mass index” until 1972, by Ancel Keys, an American physiologist—was not originally intended to be used to direct a patient’s medical care. Today, the metric is opposed by those who feel that the same benchmark should not be used to compare the body mass of two genetically dissimilar groups, who have completely different body styles, cultures and diets.
In an article titled “Why are there race/ethnic differences in adult body mass index–adiposity relationships? A quantitative critical review,” researchers reviewed race-ethnic differences across non-Hispanic white, non-Hispanic black and Mexican American adults. The researchers considered their anatomic body composition basis and potential biologically linked mechanisms, using both earlier publications and new analyses from the U.S. National Health and Nutrition Examination Survey.
What did they find?
In reviewing the relationship of BMI to adiposity (obesity), researchers discovered that at the same body mass index and height, body component and regional body mass proportions differ across race/ethnic groups. They also concluded that more in-depth studies are needed to elaborate on race/ethnic differences in body shape and composition and how these differences relate to clinical risks of having certain chronic conditions.
Here’s another point: BMIs that are in a “healthy range” for one population group may not be for another group. A 2017 Newsweek article, “There’s a Dangerous Racial Bias in the Body Mass Index,” cites a study by Dr. Alka Kanaya, a professor of medicine at the University of California, San Francisco, suggesting that Americans of South Asian descent who have BMIs within the healthy range are two times more likely than whites with similar BMIs to have an increased risk for heart disease, stroke and Type 2 diabetes. The BMI of one is not equal to the BMI of another.
In this example, BMI is demonstrated to be a better measurement for health outcomes than it is for obesity. But while a high BMI might not mean that a person is fat, all individuals still need balance, maintaining the social-physical activities, environment and food choices necessary for wellness to go along with the numbers.
There are a number of tools, such as weight circumference, to estimate obesity—but obesity is just one factor in estimating a patient’s health or disease states. Adds Dr. Boltri, “Just a 5 to 10 percent weight loss can lower your risk for diabetes, lower your blood pressure and improve your sense of well-being.”
What’s the takeaway?
It’s ok to enjoy favorites from all cultures every now and then, whether in our own kitchens or dressed up for white-tablecloth restaurants. With the right balance in our lives, BMIs charts don’t have to be the bane of our existence. And based upon the 2016 America’s Health Rankings,® which show that obesity decreased in Ohio from 32.6 to 29.8 percent of adults, some of us may already be headed in the right direction.
If we keep going, there should always be enough room for a piece of granny’s pie.
Melting Pots—and Pans
Northeast Ohio’s diet exemplifies a melting pot of cultural cuisines.
One layer comes from the hunting and gathering traditions, and the staples―corn, beans and squash―of Native Americans. Add in the recipes for baked beans, salt pork and molasses brought by American settlers from the Western Reserve. Then, stir in the German immigrant traditions of sausages, sauerkraut, and meat-and-potatoes meals. Next, add flavors from The Great Migration of African-Americans who traveled from the South, where their ancestors were forced to eat the animal parts that slave-owners threw away.
Ohioans have a long tradition of eating what situations of the past and their newly settled land afforded them.
During the early 19th century through the early 20th century, British and Irish immigrants, and then many Southern and Eastern Europeans and Jews also came to the U.S. As Northeast Ohio’s economic potential grew, so did the emigration from other countries with Italians, Austro-Hungarians, and Russians―and so did our mixture of cultures.
People brought their own dishes, spices and ways to prepare them―a melting pot of diets. Ohioans feast on pierogis, pastas and paprikash; stuffed cabbage, kielbasa and pizza; chicken, from the Serbian fried in Barberton, Ohio to southern fried found throughout Northeast Ohio (both deep-fried in lard); and baked goods, from coconut bars and cannolis to paczkis and sweet potato pie.
Immigration acts prohibited large-scale immigration after World War I. According to the Encyclopedia of Cleveland History new sources of migrants including blacks from the American South met this need. In the 1920s, Cleveland saw the first group of Spanish-speaking immigrants arrive from Mexico. After World War II, people from Appalachia moved north to Ohio, lured by the rubber industry in Akron. Puerto Ricans came to work in the steel mills of Lorain, and then, following the Cuban revolution of 1959, came an influx of Cubans.
Northeast Ohioans became exposed to spicy foods and chiles, fried plaintains and yucca, along with seasonings and sauces like annatto, cilantro and sofrito. From these groups came a mixture of Native American foods, and African, Caribbean and Spanish cuisines.
From the 70’s on, Northeast Ohio drew interest from groups of Asian immigrants―Chinese, Koreans, Indians and Pakistanis―as well as others from Southeast Asia, Central and South America and the Middle East.
These cultural influxes enhanced our tastes for legumes, from chickpeas to soy beans; exotic meats, fish and fowl; and fruits, seasonings and drinks.
The migration and settlement of a wide variety of racial and ethnic groups define the foods we eat in Northeast Ohio today and our food choices today are as diverse intra-culturally as they are outside of them.
This article was originally published in the Spring 2018 issue of Ignite magazine.