Why BMI is Bullsh*t with Margit I. Berman

In this week’s episode, we’re talking all about acceptance & commitment therapy (ACT) and why BMI is bullsh*t. In the appetizer, I’m going to explain a little more about what ACT is and why it’s so important for body image. For the main dish, I interview the amazing Margit Berman, who has a PhD in counseling psychology and is the author of A Clinician’s Guide to Acceptance-Based Approaches for Weight Concerns. For dessert, we chat about her previous work in human sexuality and talk about questioning your sexual fantasies.

In this episode, we cover:

• Acceptance & commitment therapy
• Health At Every Size
• Weight myths
• How to help your health without focusing on weight.
• Why BMI is bullsh*t
• Margit’s recommendations for BMI categorizations
• How BMI should really be used
• Why you should question your sexual fantasies

Content Warning [CW]: Just a heads up for this episode and blog post- I’m not going to remove weight category terminology, like the o-word. Reason being, Margit breaks down these categories, explains why the way we think about them is not true, and how our BMI biases impact the way that we treat people.

What is Acceptance & Commitment Therapy (ACT)?

To preface our interview today, I want to talk a little bit about ACT, which is a type of therapy born out of cognitive behavioral therapy (CBT). As Margit Berman describes it, ACT is a Buddhist approach to negative feelings.

Traditionally, the goal of therapy and psychiatry is to reduce and eliminate bad feelings and symptoms. The goal of ACT is different- it recognizes that it is human to suffer. The last time you felt sad was probably in the last 24 hours- we’re not going to be able to get rid of those feelings or eliminate suffering. What we can do instead is learn to sit with them and let them pass by so that we don’t get attached and they don’t get in the way of life.

What happens when most of us experience anxiety, sadness, or stress, especially,

• At a young age,
• When we are made by our parents not to feel safe,
• Or if we’re not taught how to process our emotions,

Is that we don’t learn how to sit with ‘negative’ feelings or work through them. We learn to shove them down, push them away, and run away from them. It’s little things like, “stop crying,” or “don’t be sad,” that have taught us it’s bad to feel sad, angry, ashamed, guilty, upset or whatever else. Whether or not you had a chaotic upbringing or had a trauma as a child, somewhere along the way you were taught that it’s not okay to feel emotions and that you should avoid them.

So instead of feeling the emotions, we numb, control food, and control our bodies to create order when we can’t control the other chaotic areas of our life. The thing is, life is chaos. Going with the flow and experiencing it all is what makes life beautiful. It takes a lot of time to learn that, especially when you’ve been doing the opposite your whole life.

What ACT does, is it teaches us to be okay with all of our feelings, and to let the negative ones pass by us.

ACT also teaches you to not attach ourselves to our thoughts- you are not your thoughts. When you attach to them and feel like they define you, you end up causing yourself WAY more pain and suffering than you need to. This work really is about letting these thoughts and feelings come and go and learning to acknowledge them, appreciate them, hold space for them, and then move on with life.

Why BMI is Bullsh*t with Margit Berman

While Margit describes that she’s always been interested in and taught women’s mental health around how body image interacts with eating disorders, she explains that ACT wasn’t always her favorite.

In graduate school, Margit received specialty training working with patients with eating disorders while getting trained in ACT. Her initial reaction to ACT was that it didn’t make any sense at all- the idea that it didn’t focus on improving client’s moods or get rid of their psychopathology was very confusing to her, and she was not a fan.

It was hard for her to wrap her head around ACT, because when people come to see clinicians for therapy, psychiatric, or psychological treatment, the goal is to feel better. If you can get rid of those bad feelings, they’ll get back to having a normal and happy life. On the other hand, ACT turns that entirely on its head. ACT incorporates Buddhist teachings and says that the experience of being human is one of suffering- we’re actually not happy all the time, and we’re not meant to be free of psychological suffering throughout the lifespan, or even the course of a day. Instead, it’s about not getting stuck in the psychological pain so we can move forward and learn how to live an effective, rich, worthwhile life as a richly deeply feeling human being.

After a seemingly unhelpful workshop on ACT, she was telling her husband about creative hopelessness, which is a technique to help folks see the techniques they have tried to make things better, examine whether or not they have worked, and create space for something new to happen. As an experiment, she decided to try the technique on her husband and saw it work right in front of her, which made her second guess her doubts about ACT.

Her Work In ACT Research

After graduation, Margit went back to the eating disorder clinic at the University of Minnesota to conduct a small case series on ACT for anorexia, an area of which there is no effective treatment. She worked with folks who didn’t get better under any other circumstances- these were people who clinicians had essentially run out of ideas with. Amazingly, it worked. The women improved to such a degree that they stopped getting admitted to the hospital and were able to move on with their lives. Although it was a small case series, the improvement was remarkable.

Margit was an early adopter of the work around size acceptance. In 1998, JAMA published an editorial saying that diets don’t work, so we should be advocating for self-acceptance among larger-bodied patients and advocating against fat stigma. For her, it made sense to bring ACT into body- and self-acceptance and integrating it with a HAES approach.

After her case series on ACT and anorexia, Margit wrote a grant to test a pilot trial of the program she had been using to turn it into a treatment that could be studied. In 2013, she started the “Accept Yourself” pilot trial as a first iteration of it, which led to a randomized control trial in 2015 and the two books that she’s written.

Setting Aside Unhelpful Struggles & Moving Forward

One of the things that inspired Margit to use ACT with women with eating disorders, was that this group is in general very driven, ambitious women. They often have big dreams that got totally sidetracked as they spent all their time and energy trying to feel better about their bodies. It struck her that if they could just work on the stuff they actually cared about and not get stuck in this effort to feel better, maybe they would accomplish something and move forward.

If you can convince a women her body is too fat, unacceptable, or unattractive, you can stop her from doing any other agenda that she might be working towards and get her invested in the counterproductive process of trying to control that. And the means we teach women to control their bodies is weight loss. While it may work in the short term, in the long term it is counterproductive. So, you end up with this situation where folks are following these rules they’ve been taught, but their problem is getting worse and worse- they’re hating their bodies more than when they started and they’re stuck in this cycle.

She has a theory that no one actually wants weight loss. She relates it to the lottery, and says that no one actually wants to win the lottery- they want the things that the money can buy. It’s the same with weight loss. People don’t actually want the goal weight; they want the things they think that weight will buy them- self-image, sexiness, health, and whatever else. She doesn’t help her clients get the weight loss, but instead, she helps them get all the things that the weight stands for.

That’s ACT in a nutshell- it’s setting aside these unhelpful struggles with yourself, your emotions, and your thoughts, and acknowledging that they’ll be there but focusing instead on what you care about now.

Weight Loss vs. Body Acceptance    

What’s so difficult about weight loss is that for a tiny number of people, it does work. There’s HUGE variability in how people respond to weight loss interventions. The reality is, for most people, weight loss efforts cause weight gain and body dissatisfaction.

Even ‘body positivity’ and the idea that you should love your body is difficult. You don’t need to have any particular feelings about your body. Instead, if you think of it as the only body you’ll ever get, ask yourself these questions:

• Can you move with this body?
• Can you live the life you want to live and move forward with it?
• Can you put the anger where it belongs? Instead of with your body, against this world that is discriminating against your body?

We need a world where weight loss isn’t a prerequisite for happiness; a world where we’ve dealt with our fat hared as a society and we no longer discriminate based on body size. You don’t need to change your body; we need to change how clothing is sold, how medicine is practiced, how airplanes work, and how people act. Not you.

Why BMI Is Bullsh*t & What BMI Categories Should Actually Be

If you had to guess, which BMI classification would you say has the highest risk of mortality? What you’d probably expect is not true.

Most people think that you can sum up the research on the health effects of weight in one phrase: weight is bad for you. In reality, it’s too nuanced to capture in a sentence.

While it’s true that living in a fatter body puts you at higher risk for various chronic diseases, what’s one other unchangeable demographic characteristic that puts you at higher risk for health issues? Being a man. Men have 7 years less life expectancy, but we never say that men need to change their gender to improve their health. We should be thinking about weight in that same way- it’s out of personal control.

In the 90s, BMI categories were made slightly more stringent. While it’s true that weight has changed across the world since the 70s, there are people who went to bed a normal weight in 1997 and woke up overweight according to the BMI.

BMI categories were never meant to be a personal value judgment. 

They were not invented as a health-screening tool.

They were invented for epidemiological researchers to look at trends in large groups and large populations- and they’re fine for that. They’re easy to measure and they’re cheap, but they don’t show what people think they show.

So did making BMI criteria more stringent improve our ability to predict mortality? No. We learned that the highest risk category by far is being underweight. If you’re underweight, you’re twice as likely to die than someone of a normal weight category. If we’re worried about anything, we should be worried about those with BMIs of 18.5 or less.

When it comes to BMI categories and mortality risk, the longest living people in order from least risk of mortality to greatest risk of mortality are the:

1. Overweight category
2. Normal weight or mildly ob*se category
3. Extremely ob*se category (they have a modest increase in mortality)

…

4. Underweight/malnourished category (they have the highest mortality risk by far) 

Since we know that people in the underweight BMI category have the greatest risk of dying, the BMI cutoffs should look like:

• Underweight BMI 20 should be less than 20. We should focus attention on underweight patients and make sure their health is good.
• Normal weight BMI from 20.5/21 to about 35. It should include a broader range of weights, and these folks shouldn’t worry about their long-term mortality.
• Larger bodied BMI of 35 or more. You could flag this group for the slightly increased risk of mortality.

When she’s teaching medical students, Margit puts up a picture of a model with a BMI of 17.5, which is the cutoff for being considered anorexic. This woman looks like the picture of health in beautiful fit running pictures; essentially the way health has been programmed in our heads. Regardless of whether she has anorexia or not, she shows this photo to point out to clinicians that this is what a woman with anorexia looks like. She looks great. She looks like what you’ve been taught you’re supposed to look like. She looks like what most women think they should look like. So don’t let the fact that she looks great stop you from checking her labs and her blood pressure to make sure she’s not going to walk out and have a cardiac arrest. She meets the criteria for anorexia, which is a highly deadly disease.

To put this into perspective, if you looked an Angelina Jolie based on her body type and tried to make assumptions about her health without looking at her body type as unhealthy or as a risk, but you’re looking at bigger bodies as a risk, that comes down to bias. That is not based on what the research and the statistics actually show, so we need to stop pretending that’s what they’re telling us.

This is the heuristic she wants clinicians to use- if you’re not as worried about your thinnest-bodied clients as you are your largest-bodied clients, then you have it in your head backwards. If you’re going to worry about anyone just based on body type, it should be on your thinnest clients, not your largest.

Why You Should Question Your Sexual Fantasies

To finish off the interview, I asked Margit if she had any fun facts or misconceptions about sex from when she was teaching human sexuality. She said that she always tries to leave people with the notion that the gender differences we make so much of in the bedroom are constructs- they’re not the reality of the situation.

The idea that men have greater sex drive and always want sex and women have less sex drive and never want sex, and the script that Americans have for sex is such a narrow idea of what sexuality is. 

People who research sexual fantasies have found that there are about 5 or 6 sexual fantasies that many people have. What’s interesting, is that’s not your own creativity- you’ve pulled that image from somewhere along the way and they’ve gotten stuck in your head and affected your sexuality.

Margit encourages people to interrogate their sexuality and be creative around it:

• Is your set of ideas around what’s hot or what it would be fun to do actually what you find hot and want to do or is that something you’ve picked up along the way?
• Can you alter it and play with it and try something differently?
• What kind of sexuality would you like to have, versus just what’s programmed and automatic for you?
• Who gave you your set of fantasies and is that yours? If not, can you be creative and make your own? 

I would recommend that anyone and everyone, especially clinicians, should read (and review!) Margit’s book, including the workbook. She will also be teaching a workshop on the ACT approach at the American Psychological Association’s conference next August, and giving a talk for the Minnesota Psychological Association in May.

This post was transcribed and edited by Brittany Allison, Intuitive Eating Counselor. You can find her on Instagram @brittybfit.

Mentioned in this episode:

• A Clinician’s Guide to Acceptance-Based Approaches for Weight Concerns by Margit Berman
• A Workbook of Acceptance-Based Approaches for Weight Concerns: The Accept Yourself! Framework by Margit Berman

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