- Question for Short Debate
- 2:30 pm
- Asked by
- To ask Her Majesty’s Government what assessment they have made of the effectiveness of Body Mass Index as a medical guideline.
- My Lords, this is a subject of which I have spoken in the past, but what inspired this debate in my name was the report and subsequent publicity from the House of Commons Women and Equalities Committee, chaired by Caroline Nokes MP. The report points out that on an arbitrary line with an ideal point in the middle, when it applies to people, most are not at that middle point. When that is used to identify health, you are effectively saying that a lot of people are not healthy. That idea is suggested as a good guide to what one should be—I have spoken about it in the past. However, not everyone is in the middle. The guide says that one should be X height and X weight.The report spoke about the damaging effect of body image, predominantly among the female population, particularly the young. It is yet another thing that says, “This is what you should weigh, look like and be.” But it should not be just like that. It is worth remembering that in the current environment this applies also to males. It is increasingly applied to all young people and, indeed, the whole population. There is an accepted norm. The internet has exacerbated a situation that has always been there.Most of us in this debate will have spoken about retouching photographs and making sure that they are idealised versions of people. That is now taken to a new level. Some of the work that we have been doing was referred to in a debate on a Private Member’s Bill last week regarding restricting plastic surgery. These issues are adding to the problems, but if this approach is taken as a medical guideline, you are getting the wrong information on which medical procedure might be taken. Given the information that is put out, along with the press coverage, we should be worried.I wish that I could have given some of my time to other noble Lords taking part in this debate. With conditions such as anorexia, someone can be told, “You are not light enough to receive help for that eating disorder, because you don’t hit a certain point on the graph.” Regardless of what that person’s frame or exercise patterns have been, by taking that decision, one is actually making someone’s medical condition more difficult to treat because somebody is looking at the guideline and saying, “This is where you should be.” This is a difficult situation for everybody. Certain medics will be better at this than others.Here, I should probably say why I took an interest in this issue in the first place. According to this measure, I, like everybody I played rugby with, was dead a while ago. As somebody who once had somebody put a hand on his shoulder and say, “You were born to play prop forward,” I possibly have a bit of an axe to grind. To use myself as an example, I once had a neck injury and a chap—he became best man at my wedding and I was best man at his—looked at me and said, “You’ve got a neck injury? What neck?” We have to carry a bit of this.
- 2:39 pm
- My Lords, I am grateful to the noble Lord for tabling the Question. We may be debating some of these broadly related issues in even greater depth in the future, because the facts of life are that we have one of the unhealthiest populations in the whole of Europe. We now have some opportunities to review what we have been doing and what we might need to do in the future to improve our health. I have been given a good briefing by Diabetes UK, and I express my gratitude to it because I am one of those on the cusp of developing type 2 diabetes. That has been identified by two factors: a blood test and a BMI measurement with my doctor.Without any doubt there are problems for those with eating disorders, and we need to address them, but we must be careful to ensure the right balance in dealing with the country’s health problems. The reality is that we have a greater problem—the numbers are much bigger—with people with excess weight than with those with too little weight.While we acknowledge that there can be challenges in using and interpreting BMI as a measurement, as the noble Lord pointed out, the call for it to be scrapped could negatively impact on the care of those such as myself who are at risk of diabetes. Used appropriately, BMI can provide valuable information for care focused on individuals that does not discriminate against anyone. It is important that healthcare professionals take a person-centred approach to discussing weight and health, use appropriate language and consider the use of BMI based on individual circumstances. There are instances where the use of BMI may not be appropriate, so healthcare professionals should take a person-centred approach to weight and health. We hope that the integration of care outlined in the White Paper will boost the role of personalised care.BMI is also an important tool for monitoring the population’s overall health and informing policy decisions. If we do not have that, we have to know what the alternative is to be able to make such assessments about the state of the nation’s health. Most recently, BMI data has been fundamental in the rollout of the QCovid population risk assessment, which identified 1.7 million people at increased risk of hospitalisation and death from coronavirus and enabled them to be added to the shielding list in March 2021. Without the use of BMI, that kind of population-based intervention would not have been possible and many lives would have been put at risk. I argue that we must retain what we have at the moment until something better is found.
- 2:43 pm
- My Lords, I am grateful to the noble Lord for introducing the debate. BMI is used globally as a tool to assess a person’s size. It is a quick and cheap way to make estimations about an individual’s potential risk of disease or poor health. However imperfect a measure of health it is, I doubt that our discussion here, or the Select Committee’s report, will change the way doctors measure their patients and the risks to their health. The overall message of the report, however, drawing attention to the damaging nature of weight stigma and the consequences it can bring, is of course important.Whatever measure used, what is also important is for healthcare professionals to feel able, without embarrassment, to discuss patients’ health and weight with them and, by using appropriate language, explain the long-term consequences of an unhealthy lifestyle. People need knowledge, support and encouragement, as well as a healthier environment, to make the changes necessary to improve their own lifestyles and thus take pressure off the health system.Excess weight is one of the few modifiable factors for Covid, and our high obesity figures are one of the reasons why this country has been so badly hit. But even before the virus, it was clear that the unhealthy lifestyles so many in this country now lead were resulting in preventable diseases such as type 2 diabetes, liver disease, heart disease, some cancers, arthritis, the wearing out of hip and knee joints, and the discomfort of general ill health. Many of these conditions can be reversed by changing to a healthy diet. People need—and polling of up to 80% approval shows that they want—informed choices. The Government’s population-wide Better Health agenda is crucial to providing this. I commend them for the bold approach in the obesity strategy and urge them to stick to it.Advertising works. If it did not then the food industry, particularly the ultra-processed and fast-food industry, would not do it. A KFC “Mighty bucket for one”, apparently the perfect meal for one person, contains 1,155 calories—over half the suggested intake. It is currently advertised everywhere. Young people are bombarded by paid influencers via social media. This needs to stop for their health’s sake.
- 2:46 pm
- My Lords, I am grateful to the noble Lord, Lord Addington, for introducing this debate and delighted to follow the noble Baroness, Lady Jenkin of Kennington. She takes food extremely seriously. I remember going to dinners with her when she took her own meagre dinner with her, because she was raising funds for charity by living on a very small amount to demonstrate not only that it is possible but the miserable lives that so many lead.When we think of that sort of poverty and lack of food, to think of people in this country deliberately starving themselves is particularly difficult. Nevertheless, BMI is only part of identifying eating disorders. It is, however, a very important public health measure, and I agree with the noble Lord, Lord Brooke of Alverthorpe, that we should not throw out a measure which works helpfully as a public health guide. For instance, the shielding during Covid that was brought into play for those who had a particularly high BMI has proved effective.Nevertheless, when GPs or other specialists use BMI it should be only part of an armoury of tools at their disposal. It is certainly not the only way in which eating disorders could or should be discovered. What is painfully clear is that people with anorexia are obvious just on sight; no GP needs to look at a BMI reading to spot anorexia. All too often, though, I fear that GPs are reluctant to diagnose eating disorders, in part because of the lack of services to deal with those conditions quickly when they need to be dealt with immediately. Anorexia is one of the most, if not the most, pernicious forms of mental illness and extremely hard to treat, but it is better caught early, as with so many diseases. Doctors use judgment and have to be relied upon to use it when wielding BMI as part of their armoury of tools.Most important, though, is coping with the outbreak of obesity that has now hit this country, as the noble Baroness, Lady Jenkin, pointed out. Excess weight is a huge problem and really needs to be dealt with as a matter of urgency for this country. It was highlighted by Covid but it will become much worse, as many have put on weight during the lockdowns. BMI will be part of the measures for dealing with that.
- 2:49 pm
- My Lords, the noble Lord, Lord Addington, will not be surprised if I turn to sport to assess the effectiveness of BMI as a medical guideline. Ashling O’Connor, one of the finest sports journalists of her day, wrote at the turn of the century about the need for the Ministry of Defence to take note of modern sports science after its long-held physical standards for new recruits were excluding exceptional candidates, including top rugby players. The Army’s weight limit, based on the BMI classification, was based on a calculation that divided height in metres squared by weight in kilograms. That would have discounted many Olympic gold medal winners.Much was made at the time of the case of the two finest Olympians this country has produced. Sir Matthew Pinsent would not have been admitted to the ranks, as he weighed more than 17 stone, because, standing 6 foot 4 inches, his BMI would have been above the limit of 28. Sir Steve Redgrave—five times rowing gold medallist in an exceptionally tough endurance sport and in my opinion the finest athlete this country has ever produced—would only have sneaked in under the bar, with a BMI of 27.6. Ray Stevens, winner of a silver medal in judo in Barcelona in 1992, would definitely not have qualified at 6 foot and 15 stone, despite being able to bench press for 25 reps and run competitive half marathons. It is therefore not surprising that the English Institute of Sport discounts the outdated BMI test in favour of a more sophisticated method, such as skinfold callipers which squeeze subcutaneous tissue, and dual energy absorptiometry and body scanners measuring bone density.Of course, we should place BMI in context, which, with slight variations over time, is your weight in pounds times 703 divided by your height in inches squared. Being based simply on height and weight, it takes no account of body fat percentage, muscle mass, bone thickness or genetic disposition to a certain frame. It assumes that everyone has the same percentage of lean tissue and fat tissue and it takes no account of those athletes who clearly have much more lean muscle mass than the average person. These facts seriously challenge the base assumptions behind the BMI formula. It exaggerates thinness in short individuals and fatness in tall and muscular individuals. The higher muscle content—in other words, lean mass—in athletes skews BMI, as lean mass is approximately 22% denser than fat tissue.
- 2:52 pm
- My Lords, when I entered this House, 25 years ago, it was my noble friend Lord Addington’s body mass that aided the House of Lords in becoming unbeatable in the annual tug of war with the House of Commons. I am very pleased about that.Yesterday’s Question Time in the Lords gave us a dry run for some of the issues being raised in today’s debate when the noble Lord, Lord Robathan, drew attention to a report by the World Obesity Federation linking obesity and deaths from Covid. The full range of the debate about obesity was on show, from those advocating making obesity not socially acceptable to the noble Lord, Lord Bethell, making it clear that it was not the Government’s intention to shame those who are overweight.If obesity is the health challenge that I believe it is then we need to get the science right. We have heard from my noble friend Lord Addington and the noble Lord, Lord Moynihan, reasons why we should give credence to the advice of Caroline Nokes and the Women and Equalities Committee on not using the body mass index for weight shaming and recommending that it should be scrapped. But as the noble Lord, Lord Brooke, indicated, we have also had advice from Diabetes UK, which says,“while we acknowledge that there can be challenges in interpreting and using BMI as a measurement, the call for it to be scrapped could negatively impact on the care of those living with or at risk of diabetes.”So the Committee will be interested to hear the Minister’s assessment of the validity of BMI in assessing weight and health risks.I would also be interested in the Minister’s response to the challenges raised yesterday and today regarding poverty and obesity in both parents and children as well as the problems caused by the promotion, particularly to young women, of unrealistic ideals of body image, which all too often can lead to anorexia and other health harms. We must not lose sight of the fact that obesity brings with it ill health and threats to life, but countering it requires sensitivity and understanding as well as practical help based on sound science. It is a difficult path to tread. I look forward to hearing about that in the Minister’s reply.
- 2:55 pm
- I thank the noble Lord, Lord Addington, for introducing this short debate on the effectiveness of the body mass index. I am pleased to have the opportunity to contribute.My focus will be to highlight the effect of childhood obesity, which we know is significantly increasing. This is where the Government urgently require further action in tackling significant inequalities in physical and mental health outcomes. It also represents a major challenge for the Government’s levelling-up agenda with regard to opportunities and outcomes for our young people.The effects of weight bias and obesity stigma can be particularly severe for children. They can experience a greater chance of being bullied, leading to low self-esteem and poorer academic performance, which can severely affect their life chances. It is tragic, too, that many children growing up will also have associated health risks, such as type 2 diabetes, cancer and heart disease.When used appropriately, body mass index can provide valuable information for care focused on individuals that does not discriminate against anyone. It is important that healthcare professionals take a person-centred approach to discussing weight and health, use appropriate language and consider the use of BMI based on individual circumstances.There are also clear opportunities for highlighting the contents of food. Retail outlets also must step up and support a move towards much clearer food labelling, particularly with additional nutritional and calorific labelling on the front of packaging in our supermarkets, cafés, restaurants and takeaways. Let us not forget all those highly calorific soft drinks, which must be addressed. We need stricter guidelines regarding rules on advertising. Evidence shows that children who are already classed as obese or overweight eat more in response to advertising.
- 2:58 pm
- My Lords, I thank the noble Lord, Lord Addington, for his passionate introduction to this debate.I applaud the Women and Equalities Committee’s work highlighting the impacts of the use of BMI on eating disorders and people’s mental health by disrupting their body image. Eating disorders are not niche. The 2019 NHS health survey found that“16% of adults … screened positive for a possible eating disorder”.Covid has increased the pressure on eating disorder services hugely, with referrals across the country increasing by 75% on average.There is still an overreliance on BMI by GPs when diagnosing eating disorders to determine who is unwell enough to access treatment. Hope Virgo’s “Dump the Scales” campaign has literally hundreds of people, mainly young women, sharing how damaging it was to be told that they were not thin enough for treatment. It drives them deeper into this pernicious illness, which I know about from our family’s experience. Indeed, the evidence shows that early intervention is far better and offers the best hope of recovery.The Government and the NICE guidelines are clear: BMI should not be used on its own as an arbiter of whether to offer treatment, yet GPs are still doing this. Why? First, there is inadequate training for GPs and other health professionals about eating disorders. The issue was identified by the Parliamentary and Health Service Ombudsman in his report on eating disorder services in 2017, in the follow-up report by the Public Administration and Constitutional Affairs Committee in 2019, and in the Cambridgeshire and Peterborough coroner’s prevention of future deaths report last month, to which the Secretary of State has to respond formally by next Wednesday. Will the Government now lead a strategy to improve eating disorder education in the medical profession, including embedding it in the curriculum? For GPs already in surgeries, a screening tool should be produced to ensure that, instead of relying on BMI, they ask the right questions of patients, with clear guidance on the language to use.
- 3:01 pm