BMI Limits - Healthcare Held Hostage For A Weight Loss Ransom - Part 1

Part 1

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One of the ways that weight stigma harms fat people is through Body Mass Index BMI (and other weight-based) limits. BMI is a ratio of weight and height, and its use is deeply problematic in multiple ways. BMI and weight-based healthcare denials occur when people above a certain BMI or weight are refused medical procedures unless or until they meet the BMI or weight requirement. In part 1 of this three-part series, I’ll offer a general discussion of these limits, in part two I’ll provide some options and resources to help fight them, in part three I’ll share the story of someone who successfully fought BMI-based denial of surgery. I previously published specific resources to fight joint surgery denials and to fight denials for gender-affirming procedures. Moving forward I will be compiling resources for other common types of denials as well. If you have a specific request, please feel free to share in the comments or email me directly. I do want to note that, while this information can be helpful to people outside of the US, these posts will focus on the US healthcare system.

BMI limits are typically “justified” based on the idea that there are higher risks of complications during or after procedures for people above a certain BMI vs people below that BMI, or that higher-weight people’s outcomes won’t be as good as thinner people’s outcomes.

The first thing I want to point out is that this is blanket discrimination based on a simple height/weight ratio. The people whose care is being denied can and do vary wildly in everything from body composition to metabolic health and more. The use of BMI also codifies racism and anti-Blackness into the process and I urge you to read Sabrina Strings’: Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s: Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness to learn more.

BMI limits are based on, and further perpetuate, weight stigma. In our current healthcare system, research, tools, best practices, education, and training are very often developed based on thin bodies (and to the exclusion of fat bodies,) so even if someone believes that higher-weight people have more complications and/or worse outcomes, that wouldn’t be surprising due to the ways that weight stigma impacts every level of their care. What BMI-based denials do is take this weight stigma further by deciding that instead of getting better at providing care to fat people, or at least allowing them to consent to take possibly greater risks in order to get care that can improve their health, quality of life, or potentially save their lives, higher-weight people will simply be denied care unless or until they become thinner.

There are other issues with BMI limits as well:

The research that is used to justify these denials can be questionable (at best,) and/or contradicted by other evidence which is not taken into account.

Often patients are denied needed surgeries, but are then referred to weight loss surgery. This is particularly ridiculous when the risk cited in the former surgery is anesthesia (as if weight loss surgeries don’t also use anesthesia,) and/or the risks of the weight loss surgery far exceed those of the surgery the patient actually needs. When a doctor denies a needed surgery and refers the patient to weight loss surgery it’s important to understand that the doctor is mitigating their risk (of having a patient with complications/poorer outcomes) by recommending that the patient take much greater risk with their life and quality of life.

On the flip side, patients who have had their healthcare team push weight loss surgery on them for years can find themselves denied a surgery that they actually need/want when the time comes.

Sometimes a needed surgery is denied until either the person becomes thin, or until the situation becomes dire enough to be considered an emergency surgery, causing far greater risk since the person can’t plan for their procedure, and the surgery is performed by whatever surgeon and anesthesiologist are available. Sometimes those in power decide that what would be an emergency for a thin person does not warrant the needed treatment for a fat patient. This can and does lead to the death of fat patients.

On the other hand, fat people in the emergency room have been offered surgeries (for example, gallbladder removal,) but after weathering the acute attack have said that they would prefer to have the surgery in a way that was more planned, only to then to have the procedure denied due to BMI limits.

These limits can vary between surgeons, anesthesiologists, facilities, and insurance companies (including, and sometimes especially, workers compensation companies) who can have a financial incentive to deny them. That means that whether or not someone can get the procedures can be essentially arbitrary – if they happen to find the right practitioners, or facilities, or insurance company they will get the care they need. If not, they will be denied care and left to suffer.

Sometimes these denials are made because of a healthcare system that rewards/makes demands of surgeons and other practitioners for their “stats” which leads them to cherry-pick the cases that they assume will have the best outcomes. The change needed isn’t just in practitioners, but also in the system in which they work. (I’m working on a piece specifically about this.)

Sometimes these surgeries are denied because fat people may require more resources to recover, which could cut into the profits of the institution in which they would be recovering. Here again, systemic change is needed. People’s lives and quality of life must be valued over healthcare profits.

Sometimes the requirement isn’t for a specific BMI but for a percentage of weight loss. This proves the nonsensical nature of the entire enterprise. Let’s look at an example: If the weight loss requirement is 10%, then someone who comes in at 330 pounds would be required to lose 33 pounds to get surgery, putting them at a weight of 297. But a person who came in at 297 would be told that they needed to lose 29.7 pounds in order to get surgery.

Finally, asking people to get below a certain BMI is typically asking the impossible. Intentional weight loss attempts almost never lead to significant, long-term weight loss. This means that patients who need or want care that is being held hostage by a BMI limit have very few options.

Even those who (despite the evidence,) still claim that significant, long-term weight loss through behavior change is possible, agree on a rate of weight loss of about two pounds per week as a “safe” amount. So, if someone needed to lose just twenty pounds to meet the BMI requirement, they would delay their procedure by about two and a half months. If they had to be one hundred pounds lighter, that’s almost a year and, again, there is only a miniscule chance that they would be successful, with the most common outcome being that they regain the weight, very possibly regaining more and ending up heavier than when they started which makes them a “worse” candidate for surgery even by the “logic” of those who endorse BMI-based denials.  

Meanwhile, as people are spending weeks, months, or years trying to “make weight” for their procedures, their health issue is progressing, they are suffering, and they are being denied care that could help. This also leaves many people in a situation of having to choose between participating in dangerous interventions – from starvation diets to dangerous drugs and weight loss surgeries – or being denied necessary healthcare.

In addition to physical harm, there is the psychological harm of knowing that you aren’t seen as worthy of care. This can exacerbate intersectional oppression, for example for those who are seeking gender-affirming care, which is often held hostage for a weight-loss ransom.

In addition to causing physical and psychological suffering, in some cases such as organ transplants and other potentially life-saving procedures, this denial of care is fatal.

There have even been cases (as I wrote about way back in 2014 in my original blog) where BMI-based denials were simply used as a way to reduce medical costs and cut wait times for thinner patients. That is, simply put, unconscionable.

Regardless of the reason, demanding weight loss as the ransom to be paid for healthcare is simply wrong.

In part two we’ll discuss some options for fighting these denials.

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.