An initiative of the Robert Wood Johnson Foundation
Expert Perspective

Health Is More than Weight

Ted Fischer

Tatiana Paz Lemus


November 15th, 2022


By Ted Fischer, Cornelius Vanderbilt Professor of Anthropology and Tatiana Paz Lemus, Program Manager, Vanderbilt Cultural Contexts of Health and Wellbeing Initiative

For decades, we’ve relied on the body mass index (BMI), a simple ratio of height and weight, to tell us who is healthy and who is not. Today, it’s clear that our overreliance on this measure has caused harm to the children we’re trying to help. 

Anti-fat bias is widespread, even among health providers. And when we use BMI to put large bodied kids into categories of “obese” or “overweight,” we inadvertently activate that weight-based stigma. This can cause lasting psychological trauma in kids—manifested through low self-esteem, stress, anxiety, isolation, and eating disorders—which in turn contributes to poor health outcomes. One study found that weight discrimination may shorten life expectancy, regardless of BMI.

In recent years, the limitations of BMI have become clear—even for BMI-for-age charts that take into account that children’s bodies are still growing and developing.

Tatiana Paz Lemus, Project Manager at Vanderbilt University’s Cultural Contexts of Health and Wellbeing Initiative

First, BMI is a measure of body size, it is not a measure of health. There are many large-bodied children and adults who are healthy according to metabolic measures. In fact, a 2016 study found that half of those in the “overweight” and a quarter of those in the “obesity” BMI categories had healthy metabolic measures, while over 30% of those in the “normal” weight category had unhealthy metabolic measures. Using weight cutoffs and treating everyone with obesity as having a life-threatening disease regardless of their metabolic health inadvertently characterizes all large bodies as unhealthy.

Second, BMI measures weight, it doesn’t measure body fat. Obesity is defined as abnormal or excess adipose tissue that results in increased health risks. Yet BMI is a poor predictor of body fat, particularly for children under nine years. Importantly, it does not distinguish between different types of body fat or location–which matter significantly more to health risk than total fat mass. It also cannot differentiate between fat and muscle.

Finally, standards for BMI are based on Western ideals and European body types. A “normal” body size for a child is often thought of as slim or athletic—yet thinness is a Western ideal with racist roots. During the slave trade, Western scientists portrayed Black bodies as excessively sensous, reflected in their body sizes and shapes. Europeans on the other hand were viewed as disciplined and self-controlled, as evidenced by thin bodies. Developed 200 years ago, the BMI subtly encodes these biases about the ideal body size. And while the BMI has been updated since then, it is still based primarily on data from Euro-American body types and does not adjust for ethnicity or race, despite the fact that different populations tend to have different body compositions. What’s more, BMI-for-age growth charts are based on data sets that exclude extremes despite the wide range of body sizes among children, presenting a biased view of average or “normal.”

Other countries have started on this journey, and there is much we can learn from them. For example, in the UK, researchers have tried an alternative method for assessing children’s body fat which combines height, weight, and waist circumference to better understand body composition. In Japan, annual checkups include a battery of laboratory tests in addition to body size measures to assess risk of metabolic disease.

From the day they are born, we monitor our kids’ weight. We ask at their birth: “What did the baby weigh?” And we ask as they grow: “What percentile are they in?”

Once classified as overweight, children are often reduced to this single aspect of their health. We focus on weight to the exclusion of other conditions, prescribing diet and exercise and feeding into narratives about personal responsibility—blaming large bodies on a lack of self-control and bad parenting.

What if instead we focused on children’s wellbeing, not just their weight? Then we would begin to craft policies that provide not just better nutrition and exercise, but also better schools, built environments, systems of care, foodways, and transportation that can help all kids thrive.

Ted Fischer, Cornelius Vanderbilt Professor of Anthropology at Vanderbilt College of Arts and Science

There is no universal ideal body nor a single size for good health. We need to move beyond a weight-centered view of health, and avoid shaming and blaming those living in large bodies. 

About the Authors

Ted Fischer
Ted Fischer is a Cornelius Vanderbilt Professor of Anthropology. He directs the Cultural Contexts of Health and Wellbeing Initiative at Vanderbilt College of Arts and Science.
Tatiana Paz Lemus
Tatiana Paz Lemus is an anthropologist and project manager at Vanderbilt University’s Cultural Contexts of Health and Wellbeing Initiative.