Body mass index

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A graph of body mass index is shown above.[clarification needed] The dashed lines represent
subdivisions within a major class. For instance the "Underweight" classification is further
divided into "severe", "moderate", and "mild" subclasses.[1]
The body mass index (BMI), or Quetelet index, is a heuristic proxy for estimating
human body fat based on an individual's weight and height. BMI does not actually
measure the percentage of body fat. It was devised between 1830 and 1850 by the
Belgian polymath Adolphe Quetelet during the course of developing "social physics".[2]
Body mass index is defined as the individual's body mass divided by the square of his or
her height. The formulae universally used in medicine produce a unit of measure of
kg/m2. BMI can also be determined using a BMI chart,[3] which displays BMI as a
function of weight (horizontal axis) and height (vertical axis) using contour lines for
different values of BMI or colors for different BMI categories.

The factor for UK/US units is more precisely 703.06957964, but that level of precision
is not meaningful for this calculation.
To work from stone and pounds first multiply the stone by 14 then add the pounds to give
the whole mass in pounds; to work from feet and inches first multiply the feet by 12 then
add the inches to give the whole height in inches.

Usage
While the formula previously called the Quetelet Index for BMI dates to the 19th century,
the new term "body mass index" for the ratio and its popularity date to a paper published
in the July edition of 1972 in the Journal of Chronic Diseases by Ancel Keys, which
found the BMI to be the best proxy for body fat percentage among ratios of weight and
height;[4][5] the interest in measuring body fat being due to obesity becoming a discernible
issue in prosperous Western societies. BMI was explicitly cited by Keys as being
appropriate for population studies, and inappropriate for individual diagnosis.
Nevertheless, due to its simplicity, it came to be widely used for individual diagnosis,
despite its inappropriateness.
BMI provided a simple numeric measure of a person's thickness or thinness, allowing
health professionals to discuss overweight and underweight problems more objectively
with their patients. However, BMI has become controversial because many people,
including physicians, have come to rely on its apparent numerical authority for medical
diagnosis, but that was never the BMI's purpose; it is meant to be used as a simple means
of classifying sedentary (physically inactive) individuals, or rather, populations, with an
average body composition.[6] For these individuals, the current value settings are as
follows: a BMI of 18.5 to 25 may indicate optimal weight; a BMI lower than 18.5
suggests the person is underweight while a number above 25 may indicate the person is
overweight; a person may have a BMI below 18.5 due to disease; a number above 30
suggests the person is obese (over 40, morbidly obese).
For a given height, BMI is proportional to mass. However, for a given mass, BMI is
inversely proportional to the square of the height. So, if all body dimensions double, and
mass scales naturally with the cube of the height, then BMI doubles instead of remaining
the same. This results in taller people having a reported BMI that is uncharacteristically
high compared to their actual body fat levels. In comparison, the Ponderal index is based
on this natural scaling of mass with the third power of the height. However, many taller
people are not just "scaled up" short people, but tend to have narrower frames in
proportion to their height. Nick Korevaar (a mathematics lecturer from the University of
Utah) suggests that instead of squaring the body height (as the BMI does) or cubing the
body height (as the Ponderal index does), it would be more appropriate to use an
exponent of between 2.3 and 2.7[7] (as originally noted by Quetelet). (For a theoretical
basis for such values see MacKay.[8])

BMI Prime

BMI Prime, a simple modification of the BMI system, is the ratio of actual BMI to upper
limit BMI (currently defined at BMI 25). As defined, BMI Prime is also the ratio of body
weight to upper body weight limit, calculated at BMI 25. Since it is the ratio of two
separate BMI values, BMI Prime is a dimensionless number, without associated units.
Individuals with BMI Prime less than 0.74 are underweight; those between 0.74 and 0.99
have optimal weight; and those at 1.00 or greater are overweight. BMI Prime is useful
clinically because individuals can tell, at a glance, by what percentage they deviate from
their upper weight limits. For instance, a person with BMI 34 has a BMI Prime of 34/25
= 1.36, and is 36% over his or her upper mass limit. In Asian populations (see
international variation section below) BMI Prime should be calculated using an upper
limit BMI of 23 in the denominator instead of 25. Nonetheless, BMI Prime allows easy
comparison between populations whose upper limit BMI values differ.[9]

Categories
A frequent use of the BMI is to assess how much an individual's body weight departs
from what is normal or desirable for a person of his or her height. The weight excess or
deficiency may, in part, be accounted for by body fat (adipose tissue) although other
factors such as muscularity also affect BMI significantly (see discussion below and
overweight). The WHO regards a BMI of less than 18.5 as underweight and may indicate
malnutrition, an eating disorder, or other health problems, while a BMI greater than 25 is
considered overweight and above 30 is considered obese.[10] These ranges of BMI values
are valid only as statistical categories
Category
Very severely underweight
Severely underweight
Underweight
Normal (healthy weight)
Overweight
Obese Class I (Moderately obese)
Obese Class II (Severely obese)
Obese Class III (Very severely obese)

BMI-for-age

BMI range kg/m2 BMI Prime

less than 15
less than 0.60
from 15.0 to 16.0 from 0.60 to 0.64
from 16.0 to 18.5 from 0.64 to 0.74
from 18.5 to 25
from 0.74 to 1.0
from 25 to 30
from 1.0 to 1.2
from 30 to 35
from 1.2 to 1.4
from 35 to 40
from 1.4 to 1.6
over 40
over 1.6

BMI for age percentiles for boys 2 to 20 years of age.

BMI is used differently for children. It is calculated the same way as for adults, but then
compared to typical values for other children of the same age. Instead of set thresholds
for underweight and overweight, then, the BMI percentile allows comparison with
children of the same sex and age.[11] A BMI that is less than the 5th percentile is
considered underweight and above the 95th percentile is considered obese for people 20
and under. People under 20 with a BMI between the 85th and 95th percentile are
considered to be overweight.
Recent studies in Britain have indicated that females between the ages 12 and 16 have a
higher BMI than males of the same age by 1.0 kg/m2 on average.[12]

International variations
These recommended distinctions along the linear scale may vary from time to time and
country to country, making global, longitudinal surveys problematic.
United States
In 1998, the U.S. National Institutes of Health and the Centers for Disease Control and
Prevention brought U.S. definitions into line with World Health Organization guidelines,
lowering the normal/overweight cut-off from BMI 27.8 to BMI 25. This had the effect of
redefining approximately 29 million Americans, previously healthy to overweight.[13] It
also recommends lowering the normal/overweight threshold for South East Asian body
types to around BMI 23, and expects further revisions to emerge from clinical studies of
different body types.

The U.S. National Health and Nutrition Examination Survey of 1994 indicated that 59%
of American men and 49% of women had BMIs over 25. Morbid obesitya BMI of 40
or morewas found in 2% of the men and 4% of the women. The newest survey in 2007
indicates a continuation of the increase in BMI: 63% of Americans are overweight or
obese, with 26% now in the obese category (a BMI of 30 or more). There are differing
opinions on the threshold for being underweight in females; doctors quote anything from
18.5 to 20 as being the lowest weight, the most frequently stated being 19. A BMI nearing
15 is usually used as an indicator for starvation and the health risks involved, with a BMI
less than 17.5 being an informal criterion for the diagnosis of anorexia nervosa.
Japan
Category
Normal
Overweight
Obese

BMI range kg/m2

from 18.5 to 22.9
from 23.0 to 24.9
25.0 and above

[14]

Singapore
In Singapore, the BMI cut-off figures were revised in 2005, motivated by studies
showing that many Asian populations, including Singaporeans, have higher proportion of
body fat and increased risk for cardiovascular diseases and diabetes mellitus, compared
with Caucasians at the same BMI. The BMI cut-offs are presented with an emphasis on
health risk rather than weight.[15]
BMI range
kg/m2
27.5 and above
23.0 to 27.4
18.5 to 22.9
18.4 and below

Health Risk
High risk of developing heart disease, high blood pressure, stroke,
diabetes
Moderate risk of developing heart disease, high blood pressure, stroke,
diabetes
Low Risk (healthy range)
Risk of developing problems such as nutritional deficiency and
osteoporosis

Health consequences of overweight and obesity in adults

The BMI ranges are based on the relationship between body weight and disease and
death.[16] Overweight and obese individuals are at increased risk for many diseases and
health conditions, including the following:[17]

Hypertension

Dyslipidemia (for example, high LDL cholesterol, low HDL cholesterol, or high
levels of triglycerides)
Type 2 diabetes
Coronary heart disease
Stroke
Gallbladder disease
Osteoarthritis
Sleep apnea and respiratory problems
Some cancers (endometrial, breast, and colon)

Applications
Statistical device
The BMI is generally used as a means of correlation between groups related by general
mass and can serve as a vague means of estimating adiposity. The duality of the BMI is
that, whilst easy-to-use as a general calculation, it is limited in how accurate and pertinent
the data obtained from it can be. Generally, the index is suitable for recognizing trends
within sedentary or overweight individuals because there is a smaller margin for errors.[18]
This general correlation is particularly useful for consensus data regarding obesity or
various other conditions because it can be used to build a semi-accurate representation
from which a solution can be stipulated, or the RDA for a group can be calculated.
Similarly, this is becoming more and more pertinent to the growth of children, due to the
majority of their exercise habits.[19]
The growth of children is usually documented against a BMI-measured growth chart.
Obesity trends can be calculated from the difference between the child's BMI and the
BMI on the chart.[citation needed]

Clinical practice
BMI has been used by the WHO as the standard for recording obesity statistics since the
early 1980s. In the United States, BMI is also used as a measure of underweight, owing
to advocacy on behalf of those suffering with eating disorders, such as anorexia nervosa
and bulimia nervosa.[citation needed]
BMI can be calculated quickly and without expensive equipment. However, BMI
categories do not take into account many factors such as frame size and muscularity.[18]
The categories also fail to account for varying proportions of fat, bone, cartilage, water
weight, and more.
Despite this, BMI categories are regularly regarded as a satisfactory tool for measuring
whether sedentary individuals are underweight, overweight or obese with various
exemptions, such as: athletes, children, the elderly, and the infirm.

One basic problem, especially in athletes, is that muscle weight contributes to BMI. Some
professional athletes would be overweight or obese according to their BMI, despite
carrying little fat, unless the number at which they are considered overweight or obese is
adjusted upward in some modified version of the calculation. In children and the elderly,
differences in bone density and, thus, in the proportion of bone to total weight can mean
the number at which these people are considered underweight should be adjusted
downward.

Medical underwriting
In the United States, where medical underwriting of private health insurance plans is
widespread, most private health insurance providers will use a particular high BMI as a
cut-off point in order to raise insurance rates for or deny insurance to higher-risk patients,
thereby reducing the cost of insurance coverage to all other subscribers in a lower BMI
range. The cutoff point is determined differently for every health insurance provider and
different providers will have vastly different ranges of acceptability. Many will
implement phased surcharges, in which the subscriber will pay an additional penalty,
usually as a percentage of the monthly premium, based on membership in an actuarially
determined risk tier corresponding to a given range of BMI points above a certain
acceptable limit, up to a maximum BMI past which the individual will simply be denied
admissibility regardless of price. This can be contrasted with group insurance policies
which do not require medical underwriting and where insurance admissibility is
guaranteed by virtue of being a member of the insured group, regardless of BMI or other
risk factors that would likely render the individual inadmissible to an individual health
plan.[citation needed]

Limitations and shortcomings

This graph shows the correlation between body mass index (BMI) and percent body fat
(%BF) for 8550 men in NCHS' NHANES 1994 data. Data in the upper left and lower
right quadrants show some limitations of BMI.[20]
The medical establishment has acknowledged major shortcomings of BMI.[21] Because
the BMI formula depends only upon weight and height, its assumptions about the
distribution between lean mass and adipose tissue are inexact. BMI generally
overestimates adiposity on those with more lean body mass (e.g. athletes) and
underestimates excess adiposity on those with less lean body mass. A study in June, 2008
by Romero-Corral et al. examined 13,601 subjects from the United States' Third National
Health and Nutrition Examination Survey (NHANES III) and found that BMI-defined
obesity was present in 21% of men and 31% of women. Using body fat percentages (BF
%), however, BF%-defined obesity was found in 50% of men and 62% of women. While
BMI-defined obesity showed high specificity (95% of men and 99% of women
presenting BMI-defined obesity also presented BF%-defined obesity), BMI showed poor
sensitivity (BMI only identified 36% of the men and 49% of the women who presented
BF%-defined obesity).[20]
Mathematician Keith Devlin and a restaurant industry association The Center for
Consumer Freedom argue that the error in the BMI is significant and so pervasive that it
is not generally useful in evaluation of health.[22][23] University of Chicago political
science professor Eric Oliver says BMI is a convenient but inaccurate measure of weight,
forced onto the populace, and should be revised.[24]
A study published by JAMA in 2005 showed that overweight people had a similar
relative risk of mortality to normal weight people as defined by BMI, while underweight
and obese people had a higher death rate.[25]
In an analysis of 40 studies involving 250,000 people, patients with coronary artery
disease with normal BMIs were at higher risk of death from cardiovascular disease than
people whose BMIs put them in the overweight range (BMI 2529.9).[26] In the
overweight, or intermediate, range of BMI (2529.9), the study found that BMI failed to
discriminate between bodyfat percentage and lean mass. The study concluded that "the
accuracy of BMI in diagnosing obesity is limited, particularly for individuals in the
intermediate BMI ranges, in men and in the elderly. These results may help to explain the
unexpected better survival in overweight/mild obese patients."[20]
A 2010 study that followed 11,000 subjects for up to eight years concluded that BMI is
not a good measure for the risk of heart attack, stroke or death. A better measure was
found to be the waist-to-height ratio.[27] However, a 2011 study that followed 60,000
participants for up to 13 years found that waist-hip ratio was a better predictor of
ischaemic heart disease mortality.[28]
BMI is particularly inaccurate for people who are fit or athletic, as the higher muscle
mass tends to put them in the overweight category by BMI, even though their body fat
percentages frequently fall in the 1015% category, which is below that of a more

sedentary person of average build who has a healthy BMI number. Body composition for
athletes is often better calculated using measures of body fat, as determined by such
techniques as skinfold measurements or underwater weighing and the limitations of
manual measurement have also led to new, alternative methods to measure obesity, such
as the body volume index. However, recent studies of American football linemen who
undergo intensive weight training to increase their muscle mass show that they frequently
suffer many of the same problems as people ordinarily considered obese, notably sleep
apnea.[29][30]
BMI also does not account for body frame size; a person may have a small frame and be
carrying more fat than optimal, but their BMI reflects that they are normal. Conversely, a
large framed individual may be quite healthy with a fairly low body fat percentage, but be
classified as overweight by BMI. Accurate frame size calculators use several
measurements (wrist circumference, elbow width, neck circumference and others) to
determine what category an individual falls into for a given height. The standard is to use
frame size in conjunction with ideal height/weight charts and add roughly 10% for a large
frame or subtract roughly 10% for a smaller frame.[citation needed]
For example, a chart may say the ideal weight for a man 5'10" (178 cm) is 165 pounds
(75 kg). But if that man has a slender build (small frame), he may be overweight at 165
pounds (75 kg) and should reduce by 10%, to roughly 150 pounds (68 kg). In the reverse,
the man with a larger frame and more solid build can be quite healthy at 180 pounds
(82 kg). If one teeters on the edge of small/medium or medium/large, a dose of common
sense should be used in calculating their ideal weight. However, falling into your ideal
weight range for height and build is still not as accurate in determining health risk factors
as waist/height ratio and actual body fat percentage.
A further limitation of BMI relates to loss of height through aging. In this situation, BMI
will increase without any corresponding increase in weight.
The exponent of 2 in the denominator of the formula for BMI is arbitrary. It is meant to
reduce variability in the BMI associated only with a difference in size, rather than with
differences in weight relative to one's ideal weight. If taller people were simply scaled-up
versions of shorter people, the appropriate exponent would be 3, as weight would
increase with the cube of height. However, on average, taller people have a slimmer build
relative to their height than do shorter people, and the exponent which matches the
variation best is between 2 and 3. An analysis based on data gathered in the USA
suggested an exponent of 2.6 would yield the best fit for children aged 2 to 19 years old.
[31]
The exponent 2 is used instead by convention and for simplicity.
As a possible alternative to BMI, the concepts fat-free mass index (FFMI) and fat mass
index (FMI) were introduced in the early 1990s.[32]

Varying standards

It is not clear where on the BMI scale the threshold for overweight and obese should be
set. Because of this the standards have varied over the past few decades. Between 1980
and 2000 the U.S. Dietary Guidelines have defined overweight at a variety of levels
ranging from a BMI of 24.9 to 27.1. In 1985 the National Institutes of Health (NIH)
consensus conference recommended that overweight BMI be set at a BMI of 27.8 for
men and 27.3 for women. In 1988 a NIH report concluded that a BMI over 25 is
overweight and a BMI over 30 is obese. In the 1990s the World Health Organization
(WHO) decided that a BMI of 25 to 30 should be considered overweight and a BMI over
30 is obese, the standards the NIH set. This became the definitive guide for determining if
someone is overweight.
The current WHO and NIH ranges of normal weights are proved to be associated with
decreased risks of some diseases such as diabetes type II ; however using the same range
of BMI for men and women is considered arbitrary, and makes the definition of
underweight quite unsuitable for men.[33]

Global statistics
Researchers at the London School of Hygiene and Tropical Medicine calculated the
average BMI for 177 countries using UN data on population, WHO estimates of global
weight, and mean height from national health examination surveys.[34]
Ratio
Relative
Relative
Relative
of male Relative
Average size of Male size of Female size of
[show]Country
to
size of
BMI[35] average BMI male
BMI female
female ratio
BMI
BMI
BMI
BMI

See also

Allometric law
Body water

Other measures of obesity:

Body adiposity index

Body fat percentage
Body volume index
Ponderal index
Rohrer's index
Sagittal Abdominal Diameter (SAD)
Waist-hip ratio
Waist-to-height ratio

References
1.

^ "BMI classification". Global Database on Body Mass Index. WHO.

2006. Retrieved July 27, 2012.
2.
^ Eknoyan, Garabed (2007). "Adolphe Quetelet (17961874)the
average man and indices of obesity". Nephrology Dialysis Transplantation 23 (1):
4751. doi:10.1093/ndt/gfm517. PMID 17890752.
3.
^ E.g., the Body Mass Index Table from the National Institutes of Health's
NHLBI.
4.
^ Beyond BMI: Why doctors won't stop using an outdated measure for
obesity., by Jeremy Singer-Vine, Slate.com, July 20, 2009
5.
^ Keys, Ancel; Fidanza, Flaminio; Karvonen, Martti J.; Kimura, Noboru;
Taylor, Henry L. (1972). "Indices of relative weight and obesity". Journal of
Chronic Diseases 25 (67): 32943. doi:10.1016/0021-9681(72)90027-6.
PMID 4650929.
6.
^ "Physical Status: The Use and Interpretation of Anthropometry". WHO
Technical Report Series 854: 9.
7.
^ Korevaar, Nick (July 2003). "Notes on Body Mass Index and actual
national data".[self-published source?][unreliable medical source?]
8.
^ MacKay, N.J. (2010). "Scaling of human body mass with height: The
body mass index revisited". Journal of Biomechanics 43 (4): 7646.
arXiv:0910.5834. Bibcode 2009arXiv0910.5834M.
doi:10.1016/j.jbiomech.2009.10.038. PMID 19909957.
9.
^ Gadzik, James (2006). "'How much should I weigh?' Quetelet's
equation, upper weight limits, and BMI prime". Connecticut Medicine 70 (2): 81
8. PMID 16768059.
10.
^ "BMI Classification". World Health Organization.
11.
^ "Body Mass Index: BMI for Children and Teens". Center for Disease
Control.
12.
^ "Health Survey for England: The Health of Children and Young People".
13.
^ "Who's fat? New definition adopted". CNN. Retrieved 2010-04-26.
14.
^ Shiwaku, K; Anuurad, E; Enkhmaa, B; Nogi, A; Kitajima, K; Shimono,
K; Yamane, Y; Oyunsuren, T (2003). "Overweight Japanese with body mass
indexes of 23.024.9 have higher risks for obesity-associated disorders: A
comparison of Japanese and Mongolians". International Journal of Obesity 28
(1): 1528. doi:10.1038/sj.ijo.0802486. PMID 14557832.
15.
^ "Revision of Body Mass Index (BMI) Cut-Offs In Singapore".
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^ World Health Organization. Physical status: The use and interpretation
of anthropometry. Geneva, Switzerland: World Health Organization 1995. WHO
Technical Report Series.
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^ "Executive Summary". Clinical Guidelines on the Identification,
Evaluation, and Treatment of Overweight and