PODCAST: When Body Mass Index (BMI) Is Helpful & When It's Not

ZACH MOORE: Welcome to On Health with Houston Methodist. I'm Zach Moore. I'm a photographer and editor here, and I'm also a longtime podcaster.

KATIE MCCALLUM: I’m Katie McCallum. Former researcher, turned health writer, mostly writing for our blogs.

ZACH: And, Katie, when was the first time you heard the term BMI?

KATIE: Hm. I am not sure, actually. I know how I probably heard about it, but I don’t remember when.

ZACH: Yeah.

KATIE: I don’t know. When did you hear about it?

ZACH: I feel like I was handed one of these protractor, like, mathematical tools where you have like a little paper or plastic wheel and you spin it around and you sync up like weight, height.

KATIE: Okay. And it spits out your answer.

ZACH: Well, it -- Well, it didn’t spit out your answer. You -- It’s not a printer.

KATIE: But you called it a protractor.

[Laughter]

ZACH: Well, that’s --I guess a protractor, a mathematical geometric tool, I guess, is why that’s on my mind. And, yeah, back in the old days before smartphones, kids -- This was a tool you got perhaps in a health class, or gym, or something like that. And that’s where I first learned about it. And it is a more in-depth statistic than just stepping on a scale, right, Katie?

KATIE: Yes, it is. It’s more -- It takes in more than just your sort of when you would step on a scale the number it gives is just half of what’s being measured. It also measures your height which makes sense, right? Because people don’t just weigh different amounts for no reason. They weigh different amounts because they’re different heights.

ZACH: Right.

KATIE: And body types, and things like that. And so, like, what does that really mean? And I think the BMI is one way to try to make sense of that.

ZACH: Yeah. I use a baseball analogy when it comes to these statistics. Everybody knows batting average when it comes to baseball. That’s how many hits you get versus the outs you make and then that’s been the standard go-to statistic for offensive players in baseball.

KATIE: I’ll take your word for it.

[Laughter]

ZACH: For -- Well, for -- you know, since it started, you know, like a hundred and fifty years ago.

KATIE: I’m giving you a hard time. You know I’m not a big baseball fan.

ZACH: No. But that was the go-to. Like, whenever you see somebody’s baseball card that’s like the one statistic in bold there, the batting average.

KATIE: It’s the one I know. So, yes, your analogy is great.

ZACH: So, in recent years though, there’s been a push for a “on base” percentage which goes beyond just a batting average. It’s like, “Oh, well, did you get hit by a pitch? Did you get on base with a double play? Did you get walked?” And so, that tells you more about how successful you are, or productive you are on offense as a player in baseball than just your batting average. And so, to me, BMI is like that. I’m like, “Oh okay, that just takes a deeper look at, okay, what do these -- what do these numbers really mean.” And that’s kind of what we’re gonna unpack here today.

KATIE: Yeah, it sounds like it helps put it into context. I like that analogy. I think it’s good.

ZACH: Yeah.

KATIE: I think it’s apt because I don’t really know anybody who has a positive relationship with their weight. It’s like a really hard topic and, like, no one ever feels particularly good about it. And, I think, because we focus on numbers so much, right? And we -- And we, like, we focus on numbers, and we put them in this really one specific context that’s like, these numbers on a scale and this, like, is everything I need to know. And it’s unfortunate because our weight does affect our health. So, it should be something we want to talk about and have a proactive approach with. For instance, like, if you went to the doctor and your doctor put you on blood pressure medications, you wouldn’t be, like, embarrassed to bring it up. But if you went to go see the doctor and your doctor was like, “Hey, you might need to lose some weight.” Like, that’s probably the piece of your appointment you’re gonna leave out when you’re talking to your friend.

ZACH: Yeah. Like, “So, how did it go?” “It went fine.”

KATIE: Yeah, fine.

ZACH: Yeah.

KATIE: Everything’s fine.

ZACH: No, there’s certain health topics, like, you mentioned that, like, people just don’t wanna talk about it, right? And in public or in private, really. And weight is one of those things. Very -- It’s a very personal thing. We get in our own head about it, like, “Oh, what does that say about us?” And all that sort of thing, what other people think and --

KATIE: And we’re never happy with it. Like, it’s never a happy thing.

ZACH: Exactly.

KATIE: And I think BMI seems to be a very popular way. Once people hear about it, they’re like, “Oh, cool. Yeah, put my weight in context and my height, and tell me how I’m doing.”

ZACH: Mm-hmm.

KATIE: But today we wanna talk about is that the right way to do all this still when we’re talking about our weight.

ZACH: Exactly. Who did we talk to today about that, Katie?

KATIE: We talked to Dr. Laura Choi. She is a weight loss surgeon here at Houston Methodist. She’s a great person to talk to about this because she spends pretty much every day talking to people about their weight in a way that is individualized to themselves, which I think is what’s gonna come out of this conversation. She’s gonna explain to us what BMI is, when it’s helpful, when it’s maybe not helpful. And if it’s not always helpful, what should we be thinking about when we consider our weight.

[Sound effect plays to signal beginning of interview]

KATIE: All right. We’re here with Dr. Choi. Thanks so much for being with us today.

DR. CHOI: Thank you for having me.

KATIE: I have a friend who I was talking to recently, and he’s pretty fit. He eats pretty healthy, works out most days of the week. And he was telling me that he recently ran across a BMI calculator, and he plugged in his numbers, and was pretty surprised because he got the result of not just being overweight per his BMI, but, like, trending towards obese, in the obese category of BMI. You know, He’s not sort of the epitome of health, I would say in my mind, but it kind of baffled me. You know, someone who seemingly, like, seemed pretty healthy but is getting a BMI number that seemed kinda concerning. It’s a big reason why I wanted to do this episode. Weight is a complex topic and, you know, BMI is one way that, you know, I think we talk about it. Wanted to kinda unpack today, when BMI is a good measurement, when it’s a measurement that sort of can lead to some confusion, what it means, everything like that. But to kick this off, I wanted to ask you maybe a tricky question. You know, when you’re talking about the quote unquote “ideal weight”, how do you describe it?

DR. CHOI: I would say there is no ideal weight.

KATIE: Okay.

DR. CHOI: And that’s really the clinical reality. Now, you know, as you talk about BMI and when it’s useful and when it’s not, I mean, those words all belong together in the same context because of the BMI categories that were created a long time ago. Somewhere in that category it’s dedicated towards ideal body weight. So, BMI is just a ratio. All it is is a height/weight ratio. It doesn’t take into account anything about the person’s frame or the amount of muscle mass, or the amount of fatty tissue actually. And so, BMI can be very helpful when we look at populations. So, when you look at large clusters of numbers and you look at percentages, and you kind of look at where, you know, people fall in the most density. But when you really apply it to one individual and try to make sense of what that BMI means, it can be very confusing like you said.

KATIE: Okay, that makes sense. Yeah.

DR. CHOI: You are perfectly in the norm.

[Laughing]

KATIE: Yeah.

DR. CHOI: And if you take your friend for an example -- and you gave me a lot of clues to -- and I was gonna state the punch line for you.

[Laughing]

Because I could have guessed that the BMI calculator spat out a number that said, “What?”

[Laughing]

KATIE: Yeah, pretty much. It’s like a Buzzfeed quiz. You click on it and you’re just like, “Ooh, yeah. I know I’m healthy. I’m about to get it, like, and be so proud of myself.” And then, yeah, he got the answer and he’s like, “What?”

[Laughing]

DR. CHOI: So, a BMI category does not equate health or unhealthy. And we have to remember, these numbers and categories were created a very long time ago. I think back in the 1920s or 30s, it was basically and actuary table by one of the large insurance companies.

KATIE: Oh interesting.

DR. CHOI: And they looked at the longevity of people and the clusters of BMI for those people. So, again, that’s kind of what I mean about BMI being useful in large population perspective. But you also have to remember about a hundred years ago, people looked very different than the way we look now. The food sourcing was different, you know. The amount of nutrition that everybody focuses on these days is different. So, you definitely see taller, bigger people. Just walk into a house that was built in the 1910s or 1920s. Most of us cannot even, you know, walk through a doorway. So, it kinda gives you a picture that society changes over time or a sense of what healthy is changes over time, and our size has changed over time. So, you know, those of us who are in that field of, you know, obesity medicine and bariatric surgery recognize that BMI is a not a perfect index, but it gives us somewhere to start off.

KATIE: Yeah.

DR. CHOI: And so, you know, when we have categories that go from low to high as unheathy low, and then there’s the ideal, and then there’s overweight, obesity, severe obesity, and so on. We’re really trying to get away with the words morbid obesity. I think that’s a very…

KATIE: Strong.

DR. CHOI: It’s a very strong flavor.

[Laughing]

KATIE: Yeah.

DR. CHOI: So, we still go by that and it’s a bit antiquated. But it’s pretty much the one universal number that we have. So, as much as we know that it’s not the most helpful or clear, we’re still using it, unfortunately.

KATIE: So, to that end, when is it the most helpful? I mean, what do -- what do you -- what do you use it for in your day-to-day when you’re talking to your patients?

DR. CHOI: Well, we technically still have to use it for clinic criteria.

KATIE: Okay.

DR. CHOI: So, as a bariatric surgeon, these are standards set by NIH, Medicare, insurance companies. And so, this is -- These are the rules we have to live by right now. So, we know that when you are in the obese category, your BMI is over 30, and then, over 35, you qualify for surgery. If you have medical conditions that are associated with obesity, and then if your BMI is 40 or over, then you qualify for surgery based on your level of being overweight.

KATIE: Gotcha.

DR. CHOI: The average is about a hundred pounds overweight if you’re in the BMI of 40 or above. So, when we look at ideal BMI category it’s gonna be somewhere between 19 and up to 25. And in that range, we can’t really shoot for that as normal. Just because with the -- our current standards of how we look, and how we view each other, and how we access our level of health, it’s not the same thing as when people were looking at others in the -- in the 1920s, a hundred years ago.

KATIE: Gotcha. One quick follow up question. But you said something interesting that I wanted to touch on. I noticed recently when I was researching a sleep apnea surgery, there is a BMI qualification for it as well. So, I mean, when you’re talking about it’s used in sort of a medical context, is it pretty common to have that as a criteria for, you know, like the sleep apnea surgery? I think you had to be a certain BMI. And if you’re over a certain BMI, you weren’t eligible. Are there other factors like that to consider?

DR. CHOI: Absolutely. So, similar to what you just described, joint surgery.

KATIE: Okay.

DR. CHOI: Certain hernia surgery. Transplant surgery. So, these are things where they’re using a BMI to assess your level of holding on to excess fat. And so, when we have heavier patients undergo hernia surgery that requires mesh, they’re at risk for failure of the repair, they’re at risk -- higher risk for infections, and a recurrence of the hernia. Similarly for joints, when you have patients with higher, higher BMIs, they will have much more complication, much more bleeding risk, and failure of the prosthetic. That’s when we study large groups of people and look at the outcomes as a group. Then the BMI as a demographic can be helpful, because you can’t put in your weight.

KATIE: Yeah.

DR. CHOI: Right? Because the weight is even less helpful, because you can have a 200-pound person who’s either 6’ 1 or 4’ 11. And then, you can see very, very, different body types.

KATIE: Yeah.

DR. CHOI: So, the BMI at least sort of standardizes it with your height so there’s a little bit of, you know, looking at that as a useful index. But we have to be careful when we look at it to decide what a person with that BMI is going to be like.

KATIE: Okay. So, would you go as far as saying, you know, BMI -- I guess what I’m trying to get at is I’ve often -- I guess I’ve always thought, well, what BMI is most of time, is a way to comment sort of on your health status. So, would you kind of say maybe that’s not entirely always accurate enough to just say as a blanket statement?

DR. CHOI: But I think that’s kind of what the general population understands. Because we talk about obesity so much and there’s so much interest in weight loss as our population gets heavier and heavier. And just on that point, you know, that’s where we look at population base and look at, well, where are their BMIs? And we talk about certain percentage of people being over 30 and say, “Oh, certain percentage of Americans currently are obese. In 2030, we project that obesity rate to be even higher.” So, that kind of gives us a general framework about describing populations or describing where you fit in that curve of that population. But we definitely know there are better measures of looking at your health level, and it’s complicated. It’s not one simple thing. You know, rather than going with BMI, we have tried looking at central obesity. So, you look at your waist circumference, or you look at your waist to hip circumference ratios. Because we do know very clearly that when you carry more fatty tissue in your abdomen, it -- and we call that visceral fat, not just under the skin but inside of your abdominal cavity. You are at much higher risk of having cardiovascular disease, diabetes, and other metabolic problems.

KATIE: Gotcha. Do we have a way of just measuring the visceral fat?

DR. CHOI: We don’t. So, that’s why we generally use a circumference. So, the sizing of the, you know, girth we use as a very gross measure. But currently, we do have other ways to look at fat mass overall. And even then, we have to be careful because where you carry your fat points to different types of risks.

KATIE: Okay.

DR. CHOI: So, really, carrying extra fat in your abdominal cavity is the high risk for metabolic disease. But if you’re a little thigh heavy, a little hip heavy, but, you know, you’ve got a very small waist and, you know, your weight is distributed elsewhere, so we talk about the typical apple or the pear shape.

KATIE: Okay.

DR. CHOI: Right?

KATIE: Gotcha.

DR. CHOI: So, the apple is the one that’s gonna have the more visceral fat, a higher health risks. That can give you some indication. We have some ways to measure your percentage of body fat versus a lean body mass. Some measures that are a little better than others, but, of course, the better measures are gonna be expensive, less available. And so, we do some substitutes that are a little easier to do maybe in a clinic and they’re not so expensive for the patient because, of course, insurance doesn’t cover these things.

KATIE: Yeah. Are you -- Are you kind of alluding to -- I’ve seen these things called, like, body fat scales or…

DR. CHOI: Smart scales.

KATIE: Yes, the smart scales. I got a ton of ads for them at one point and I bought one. I didn’t use it a ton though because actually it kept telling me I was like really overweight and I was, like, I’m pretty confident my weight’s okay. And then my water weight was really high. I don’t know. I just couldn’t tell how much I could trust it.

DR. CHOI: And I think that’s a difficulty because you really need someone to be able to interpret that language for you just a little bit. And there are, you know, categories of how much fat mass is healthy and it’s different for a woman than a man, and it’s different for, you know, Caucasians and Asians. And, you know, there’s a lot of ethnic variability, of course, gender variability. But what it’s helpful for, similar as a BMI, I would say, is looking at your own trending.

KATIE: Okay.

DR. CHOI: So, if you’re in a mode where you think you need to do something to get healthier. Whether that is, you know, some blood work you had done with your doctor’s office, and something looks abnormal, and they give you some advice. Or, you know, you start trying to do some exercise and you find you can’t do it and you -- and you recognize that you’re out of shape. And so, when you’re ma -- wanting to make some change or improve something about your health level, then I think having those measures where you start off, you know, with a certain percentage of body fat, and then after you work at it for a couple of months or, you know, several months, or a year, then you come back and do a repeat and kind of look at your trending.

KATIE: Yeah.

DR. CHOI: And it kind of gives you a sense of -- And so, if somebody had explained to you what all those values mean for your smart scale, you know, it is healthier to have a higher percentage of water, so that was a good thing.

KATIE: Oh, okay.

DR. CHOI: Think about -- Well, you might not remember the 80s.

[Laughing]

KATIE: I would’ve -- Yeah, I would have been -- I probably wouldn’t have been too aware of them, but I was around.

DR. CHOI: Yeah. But you know, our cultural sort of interest in health and, you know, wellness was on a different scale. And so, currently, you know, these are the things we talk about.

KATIE: Yeah.

DR. CHOI: Because these are the things that people, you know, are looking at social media, are talking to each other about and started -- you know, starting to focus on themselves. Because, you know, why did your friend suddenly look up his BMI? Right?

[Laughing]

KATIE: It must be a quiz or something you know, like, right? You know, really, it’s funny-- as you’re talking about -- Well, I don’t even think it was in a clinical context. It was just like something happens to make its way in front of you on the internet. And then all of a sudden, you’re like, “Oh, what’s the health metric that I never knew about, or this healthy topic, or tend, or idea?”

DR. CHOI: And, you know, I could make a guess. Maybe it was some sort of a health supplement company who said, you know, “Look at your -- let’s see where your BMI is? What does it mean? And it means you need something from me. Take this supplement.”

KATIE: Yeah, I hear you. We’ll have to look into that, but you’re probably not wrong.

DR. CHOI: You’ll have to give me the real answer afterwards.

KATIE: Yeah. Yeah.

[Music to signal a brief interjection in the interview]

ZACH: Dr. Choi has pointed out that BMI has its limitations. Could body roundness index or BRI be a better measurement? In addition to height and weight, body roundness index adds hip and waist measurements into the equation. This new term made the news cycle recently after new evidence suggested that this measurement might be a better tool for evaluating a person’s weight related health status. But this is just one study and Dr. Choi points out that for now, body roundness index isn’t considered a clinical term. Though it certainly emphasizes the concept that more visceral fat in the waistline area equals more health risks.

KATIE: Up after the break, Dr. Choi shares, if not BMI, how she recommends we think about our weight.

ANNOUNCER:  From annual checkups to managing chronic conditions, your health care should be personalized to you. At Houston Methodist, our primary care doctors provide customized care for you and your family with more than 40 convenient locations across greater Houston. We offer a variety of ways to get care, from in-person and virtual appointments to same day visits when you’re sick. Choose your doctor and schedule online at Houstonmethodist.org/stayhealthy. Houston Methodist, Leading Medicine. 

[Music plays to signal resumption of interview]

KATIE: Part of the other reason I wanted to talk about this with you is that if not BMI, and, you know, if these things get complicated at the individual level, how do you recommend someone think about their weight and know that, “Hey, maybe it is time to go see someone and figure out if I am healthy.” Or go get that blood test like you mentioned or go find some help to potentially help manage your weight. Like, what are the signs that you would recommend if it’s not a BMI calculator?

DR. CHOI: I think this is difficult because individuals are going to have different threshold for thinking they’re healthy versus not healthy. And it’s such a big combination of a lot of things like your diet and your sleep cycle. You know, whether you’re drinking alcohol frequently, or using other substances, and what your activity level is. And, you know, this is what I really say to my patients, ‘cause all of my patients as they’re losing weight get fixated. And they all wanna have a goal weight. They all want me to tell them where their weights should be. I really believe that’s the wrong way to look at it. And I really say to patients, you know, “Whe -- Do you feel comfortable in your own skin? Do you feel like if you wanted to be physically active that you could?” And maybe if you, you know, wanted to play soccer and you tried last weekend with your friends, and you couldn’t keep up, hey, maybe that’s a motivator for you to do something different. And, you know, if you recognize that your weight is going up, your pants don’t fit anymore, and you’re, you know, a little uncomfortable moving around, then I think that’s where you would think about making some changes. And assessing sort of yourself and your sense of self. Because, you know, even as people lose weight, there are some patients who reach a certain weight and they say, “I really don’t wanna lose anymore weight. I’m afraid of losing more weight.” So, personally, people have a different set point where they feel comfortable, they’re comfortable with their own image in the mirror and how they’re presenting themselves. And so, it’s really difficult to give a generalized advice about where your weight should be and what, you know, your target should be.

KATIE: Yeah. I love that answer though because I think framing it around mobility and activity is a very kind of wholesome place to look at it with. I know sometimes, you know, I’ll get focused on, “Oh my gosh, I’ve put on four or five pounds in the last month.” And I’m like, I can tell my jeans are tighter. You know, I know I’m still, like, healthy. But I can get so fixated on just the emotional part of weight which I can still do all my workouts. I still have all the energy I need. And yeah, I probably had a bad month and now this is my motivator to maybe, like, tighten up the diet a little bit. Like, I think of Easter, and I think of how for whatever reason that’s the holiday my mom still, like, gets me candy and stuff. And so, it’s the only time our pantry is just full of candy and sweets, and you feel bad throwing it away. So, then you’re like, “Okay, we just gotta get through this candy. Let’s do it slowly.” But then you’ve gone three months having a piece of chocolate every night. And so, then the next three months you’re like, “Oh, yeah. I want all this still for the,” -- You know, it just catches up to you. And I like the idea of thinking of it in the physical way in the sense of can I still be my active, mobile…

DR. CHOI: Functional way.

KATIE: Yeah.

DR. CHOI: You really wanna be functional, and if you wish to do something that’s physically active then you should be able to do that and enjoy it. And I think that’s where we set some level of, “This is where I wanna get to.”

KATIE: Yeah.

DR. CHOI: And so, when, you know, rather than having goals about, “Oh I wanna be down to, you know, a hundred and fifty pounds or certain number BMI, maybe it’s something more like, “I wanna run a 5K.” Your goal should not be to reach a certain number, because that’s meaningless. And it kinda gives you an exercise in a figurative way to do to get to a point without really recognizing what the point was.

KATIE: Right.

DR. CHOI: So, you know, rather than having a number of pounds to reach, I really talk about having goals. There are so many things and so many options these days that focus on physical activity. That you’ve got so many choices and so many interesting things to spend your time rather than on the screen, how so many kids are doing, and we need to get those kids out there, and running, and working. And as adults, they’re gonna have the same interests. So, that’s really important.

KATIE: Yeah, absolutely. I’m glad the conversation went this direction too ‘cause one of my questions for you was gonna be, we’re so number-centric when it comes to weight and is there another way to think about it? And I just love this -- It’s funny, it seems so simple as you say it. With something like weight, I think all of us, no matter our weight, can sometimes just get really fixated on that number.

DR. CHOI: Number. We are a very number-fixated society, you know. We talk about numbers about everything because we like to compare ourselves to everybody. We like to see where we stand. We wanna be better than most people.

[Laughing]

So, and it -- I think it’s also a very human thing. And I think, you know, you’ve got a great point ‘cause, you know, regarding numbers, that’s basically, you know, what BMI is there for. It’s to have some sort of an objective, non-shifting way to look at something because humans love to be concrete and look at something fixed and say, “That’s where I belong.” Just think about all the lessons from the COVID pandemic.

KATIE: Mm-hmm.

DR. CHOI: We recognized even earlier on that when patients were in the obese or higher category, they had much more severe disease, much higher risk of death. But then the really interesting thing was when you looked at the ideal body weight and the overweight category, guess who did better?

KATIE: Oh.

DR. CHOI: Yeah. Overweight.

KATIE: Interesting.

DR. CHOI: So, it kind of speaks to the value and the function of your own fatty tissue. We have fatty tissue for a reason, you know.

KATIE: This is very interesting. I didn’t know this.

DR. CHOI: It’s a very, very useful evolutionary adapting -- Ah what do I call it? Like a system.

KATIE: Mm-hmm.

DR. CHOI: For a person to be able to store energy on their body…

KATIE: Yeah.

DR. CHOI: And be able to utilize it when the intake of energy is less. So, it’s supposed to be like a closed cycle where you have input, storage, then output. Not input, storage, input, storage.

KATIE: Yeah.

DR. CHOI: Because this is where we are now.

KATIE: Yeah.

DR. CHOI: And you look at our, you know, early human life, we were constantly physically active. We were either running away from a predator, looking for food, building shelter, trying to survive, and we didn’t have guarantees of food at regular intervals. And so, this body fat that we carry was completely critical to the survival of humans and, of course, you know, other animals, so that when you did find food, you were able to store the excess that you didn’t use. And then you’d have that to use when you are in a, you know, food deprived state and so, you would continue to thrive. But behind that has to be a strong drive to find food. And so, it kind of corelates and, you know, this is -- this is one of the, you know, very interesting kind of theories and thoughts about why we are dealing with so much obesity currently because we’re still that same human with the same genome and, you know…

KATIE: Same drive.

DR. CHOI: But different behavior.

KATIE: Yeah.

DR. CHOI: Right? Different behavior and same drive, that’s true. And so, we have that incredibly strong urge to find food and get food, and, of course, eat the food. But the food that’s available is so enriched, so processed, and so available, and so often.

KATIE: Yeah.

DR. CHOI: That it kind of misfires, you know, your natural rhythm of hunger, satiety. And also, as you carry more fat mass that in itself changes how your body functions. So, one of the higher -- highest risks of, you know, gaining weight is having a higher body fat mass.

KATIE: Mm-hmm.

DR. CHOI: And that seems ironic, ‘cause if you think about it, good system, if you have a high body fat content, you should be less hungry ‘cause you have a lot of ba -- lot of money in your bank. Right? And that’s where we have to recognize the value of fat mass and not just looking at our fat mass as something to lose, right?

KATIE: There’s value there.

DR. CHOI: There’s value there, and there’s need, and usefulness. And it -- an origin of function for that. It’s just when things go off a little bit out of balance, that’s when -- where we run into trouble.

KATIE: Yeah. I -- It’s interesting too because you’re talking about sort of, you know, how our ancestors were and we evolved over time, and you know, food was sparse as you mentioned. So, they -- You know, you eat a lot because you might not have food tomorrow. And I’m guessing, you know, obviously at some point food became more available because we started preserving it.

DR. CHOI: Right. But now we’re farming it.

KATIE: Yeah, and farming it. But now we do all this -- Yeah, we do all this for no reason almost now, because other than we’re -- We live busy lives and sure we wanna be at the store every day, but food is very available to us all year round. You know, we can -- I don’t know. It is -- It’s just an interesting way of go -- I like this concept of our drive is still there but maybe, like, out of context a little with what it was built to do.

DR. CHOI: Yeah.

KATIE: Which I think, I mean, I’m assuming is why weight is so complicated. That it’s -- a lot of it is in our mind.

DR. CHOI: It is. And a lot of it is in our brain and our, you know -- How parts of the brain talk to each other, and how the brain talks to other organs, and how the gut, the GI tract, is like a communicating organ. And as it functions as a barrier, whatever comes into it will also affect its function. Whatever comes into it is also going to affect how the brain receives messages about what’s going on in the body. And so, when we look at obesity and, you know, people who are gaining weight and people who don’t feel like they ever have to work at their weight, it’s not a matter of, will power. It’s not a matter of a conscious decision most of the time. It’s how the brain functions and it drives your behavior. We’re animals, we just are.

KATIE: Yeah. Well, and I think too, we did an episode on weight loss medications and the new ones, the injections. And, you know, I mean, correct me if I’m wrong, but a lot of them work by just making you not think about food essentially in some ways. Of – your brain just doesn’t -- you don’t – you’re are not as hungry. You don’t want the food.

DR. CHOI: Right. And I think that’s the result of what you see from the medication. So, what it’s doing is it is affecting parts of the brain that sense satiety or minimizes the hunger, or, you know, it’s signals that go -- usually come from the gut.

KATIE: Okay.

DR. CHOI: And then you’re injecting a large amount of that, that will go, you know, beyond the brain barrier and be able to affect those parts of the brain that control hunger and satiety. And so, the end result is that some people get excellent effects and have no hunger, no food noise, they feel very in control about what they eat, and then there are people who don’t receive the same benefit. So, we recognize that people have different brain chemistries. People have different…

[Laughing]

Ways that their body communicates to other parts.

KATIE: It’s so complex.

DR. CHOI: The more you know the more you know we don’t know.

KATIE: I was about to say it. Yeah, kinda sounds like the more we know, the more we don’t. Yeah. Okay. Crazy. Is there anything else that you think that we should talk about in terms of BMI, or how we should all be thinking about weight and how it might impact our health that I haven’t asked you about yet?

DR. CHOI: Well, I think, you know, as we started, the BMI is just not a great index for an individual to use for any specific means or determine that they are “blank” because of that BMI. But I think it’s a way to trend that might be helpful. And I always caution everybody to just use it as a general guide, but you can’t fixate yourself on those category names and, you know, label yourself “obese,” or label yourself as “overweight.” It’s all a matter of good function, good sense of feel about yourself and your ability to be a productive human being. You have to be careful about labels and that’s really unfortunate about that. But so far, we haven’t really come across any other indices. And I don’t think that we really can because you just look at human beings, you know, and look at a group of human beings, you look at how different and diverse everybody looks and, you know, behaves. And so, with that type of diversity that we live with, which is wonderful, it’s hard to put everybody on that same linear scale and line them up ‘cause you’re gonna have -- I mean, it’s like a three-dimensional plot.

KATIE: Exactly. It sounds like we’re, yeah, parallel scales going different directions.

DR. CHOI: Right. But I think that’s what’s wonderful and that’s what’s unfortunate about, you know, how society sort of creates this, you know, one type that they call ideal. And all women should look like that, or all men should look like this, and all, you know, kids should look like this. And we don’t, and we don’t have to. I think that’s the part that I would want everyone to recognize. You don’t have to fit into any category. You have to look at yourself and, you know, maybe with the help of a physician, who can look at some bloodwork, you know, look at some testing, and look at your age, and where you are, and even your ethnicity. And put that all into context and say, “Hey, you know, your organ systems are working well. Your bloodwork is showing that everything looks within normal range. And, you know, let’s look at your physical fitness and let’s look at your, you know, function and daily lifestyle to maybe get you better energy.” You know, I think what I ask my patients who are in the process of losing weight, the first thing is, “How do you feel?”

KATIE: Yeah. I love that.

DR. CHOI: “How do you feel?” And, you know, “How is your energy level?” You know, and, “How are you sleeping?” It’s the functional things that are super important. And, you know, I could tell on their faces how they feel sometimes, you know. And that’s really the goal…

KATIE: Yeah.

DR. CHOI: To let other people just see your face and be able to tell that, “Hey, that person looks healthy.”

KATIE: Yeah. And feeling good.

DR. CHOI: Yeah. Feeling good.

KATIE: All right, well, thank you so much for being here with us today. This was a really interesting conversation about -- I know a pretty complicated topic, so thanks for taking the time to chat with us.

DR. CHOI: Thank you for having me. It’s been a pleasure.

[Sound effect plays to signal end of the interview]

ZACH: So, Katie, BMI might not be the gold standard measurement that some people think it is these days.

KATIE: Definitely not for the individual person, I think that’s what we heard. I mean, I think it’s there to look at trends, so population trends.

ZACH: Yeah. Demographics, people groups, that sort of thing.

KATIE: Yeah.

ZACH: Big picture. Totally tracks. But once you start getting more granular, person to person, it might not be as effective.

KATIE: Yeah. It sounds like the only reason she might talk to people about it is because the insurance companies still use it.

[Laughter]

ZACH: Yeah.

KATIE: So, but as far as, you know, what Dr. Choi is talking to people about and, you know, other doctors, I’ve never had my doctor mention my BMI either, now that I’m thinking about it. I think people often think it’s this -- or you see it, you know, somewhere on the internet, you take the quiz, you think it's this metric that means something. But now that I’m thinking about it, I don’t think my doctor ever brought it up to me. Which should have been the first hint…

[Laughter]

that there’s better ways to think about our weight.

ZACH: Yeah. I also like how -- what she points out it’s kind of an older statistic. It’s like --

KATIE: It’s super old. I didn’t realize how old it was.

ZACH: I thought it was more recent, maybe I don’t know…

KATIE: Yeah.

ZACH: Around 2000 or something.

KATIE: Yeah, no.

ZACH: Right? No. More like around 1900.

KATIE: She said, “a hundred years old.”

ZACH: Yeah.

KATIE: Which at first, I had to be like, “What would that even be?” So, yeah, a very old number, insurance companies care about it. Maybe that’s about it. I did love how she talked about the way we should be kind of thinking about our weight and how she recommends people think about their weight. It’s very functional. It’s very, like, “Could you do your workout that you usually do? Are you having a harder time going up and down the stairs?” Like, “How do you feel? Are you tired?” I really liked that because as we mentioned off the top, I hate the, like, numbers on the scale part of this.

ZACH: Yeah. We’re so obsessed with numbers and ranking and all these things. And you can get lost in it, you know. And then it gets discouraging and then you look at these statistics and, like your progress versus something else like that. And, yeah, I thought it was a, you know, very uplifting conversation you had that kind of put you -- put you in the right mindset about this ‘cause mindset is just as important as anything else when it comes to these things.

KATIE: Totally agree. It came at the perfect time for me as I’m sure everyone can tell from the interview. When I talked to her, I was kind of in this weird, shameful spot about my own weight ‘cause I was like coming off like a couple months where I’m just -- I was just like -- I got in a bad habit and then you know how these things build. And I had been kind of feeling weird about my weight. But her message sort of, like, brought me back to center of, “Stop thinking about what’s on the scale, think about how you feel.” It’s also just a more positive way to think about it. And it tied into -- we talked about the smart scale. The reason I stopped using my smart scale was because it kept spitting out these individual numbers that were making me, like, feel bad about myself. I don’t think I’m unhealthy, but the numbers were kind just like, and then I got -- It just made me kind of feel negative. So, I’d stop using it, but her point to use it to look at trends over time, like, I’ve pulled it back out. And instead of looking at the specific numbers, I’m going straight to, like, the little graphs where they, like, show me week to week. And eventually, it’s gonna start showing me month to month, and then year to year. And then I’m gonna be able to see if there’s wild fluctuations in these trend lines. Like, Yeah, I need to go talk to my doctor and maybe do some bloodwork, or maybe it is my weight, maybe it’s something else. I really liked that part of it. Again, the very functional, like, practical way for me to care about the health impacts of weight without going to negative town.

ZACH: Negative town?

KATIE: Yeah.

ZACH: No one wants to go to negative town. No.

KATIE: It’s so easy to do when you’re talking about your weight.

ZACH: Absolutely. Absolutely. Well, finding the right tools, the right metrics for you personally. Everybody’s health journey and weight journey is different. So, that’s an important part of the journey there. Find the -- Finding the right tools to help you along the way.

KATIE: And I think not staying in a silo with it. Like, if you do a BMI, if you do the BMI calculator on the internet and you get a weird result, like, don’t just file it away and…

ZACH: Right.

KATIE: You know, go talk to your doctor.

ZACH: Yeah.

KATIE: Like, there could be an explanation that’s important. It could be something, like, in the example I kinda teed off with her of a person who has a lot of muscle, so it throws their BMI off. Or, you know, there could be something else and a blood test will show it. Like, I think using it as a tool to then go have a conversation makes sense, but not something to fixate on.

ZACH: Yeah. If nothing else, we have an annual physical which we all recommend, right? You go to your doctor they say, “You have any concerns?” And if you have this, that’s the perfect time to bring it up. “Hey, I have this BMI reading. Is that good for me?” And based off everything else they know they can give you an important opinion there. And then you have all the information you need, and you can decide where to move forward from there.

KATIE: Yeah. Exactly.

ZACH: All right. All right. That’s gonna do it for this episode of On Health with Houston Methodist. Be sure to share, like, and subscribe wherever you get your podcasts. We drop episodes Tuesday mornings, so until next then, stay tuned, and stay healthy.