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# Why Won't BMI Die?

"BMI was first discussed in the 1830s by a Belgian statistician, sociologist, astronomer, and mathematician by the name of Lambert Adolphe Jacques Quetelet. It was known then as the Quetelet Index and was informed by Quetelet’s interest in finding “l’homme moyen,” or the average man. If that sounds biased and dicey, it's because it is.

At the time, actuaries were reporting high death rates. Quetelet’s goal was to study average human physical characteristics, in order to understand why so many people were dying, in case there was a correlation between weight, height, and death. It was designed to look at a pattern of deaths among a large population, as opposed to evaluate any one person's size or health.

Fast forward to 1972. The Quetelet Index became known as the Body Mass Index (BMI) when Ancel Keys, a physiologist (and not a medical professional), stated that it was essential to quantifying health on an individual level. Today, almost two centuries from its inception, everyone from family doctors to insurance companies still refer to BMI as a sort of first-line assessment of health, leading to higher insurance premiums and reductive doctor visits for people outside of the size of the "average man" in the 1830s, among other problems.

If you think it sounds a bit odd that we use an archaic system not developed by a doctor and certainly not taking into account that different people (and sexes) have different body types, you’re right.
What is BMI anyway?

BMI is currently used by medical professionals as a quick assessment to whether or not a person has a healthy weight, based on an estimation of body fat percentage. It does so by dividing your weight in kilograms by your height in meters squared.

As a result you've probably seen BMI calculators all over the Internet, simply requiring you to fill in your weight and height — and voila, they spit out a so-called picture of your health as represented by a single number. This estimate, however, doesn’t regard your race, age, gender, genetics, amount of body fat versus muscle mass, your lifestyle, or other measurements of health such as your cholesterol or blood sugar.

BMI is said to provide medical professionals with a sense of whether or not a patient is at risk for certain diseases, because obesity is correlated with a greater risk of heart disease, high blood pressure, diabetes, and some cancers, among other comorbidities. While there are well-documented health risks to finding yourself too far on both ends of the weight spectrum, there is no evidence that if you are healthy and are slightly above or below the very narrow range that BMI considers "normal" and "ideal," it has any effect on your overall health.
Is BMI effective?

The short answer is no. It doesn’t — and cannot — take into account your body composition, including your body’s ratio of lean mass to fat mass.

According to Scott Cunneen MD, FACS, FASMBS, Director of Metabolic and Bariatric Surgery at Cedars-Sinai Medical Center in Los Angeles, “While BMI does give the doctor a very basic guess at a patient’s body fat percentage, it is in no way the entire picture when it comes to his or her overall health or even amount of body fat.”

He continues, “For example, a 35-year-old-guy who hits the gym five days a week and has developed a lot of lean muscle may weigh considerably more than a 65-year-old man of the same height, but the younger man’s higher BMI does not automatically qualify him as unhealthy just because of the number on a chart.” Note that he is also again using the example of a man.

For women, particularly those who are tall and/or athletic and muscular, the "ideal normal" range can seem impossibly low. This is because it is based on the "ideal normal" weight of a woman in the 1830s when women were significantly shorter and almost never exercised or built up muscle mass. It's also why many professional female athletes have BMIs that erroneously put them in the "overweight" category, while women who smoke and don't exercise, but are thin, can be considered "ideal" and "normal."

In other words, athletes who have a lot of muscle are more likely to have a higher weight, which the BMI mistakes as a higher body fat range. In some people, such as older people who lose muscle mass, or thin people with very little muscle mass, BMI can underestimate body fat.

The limitations of BMI go beyond not figuring muscle and physical fitness into the equation, though. It further stigmatizes patients — especially obese patients — who do not fall into a “normal” BMI category, and can keep those who may need medical health the most, including to lose weight, out of their doctors' offices by unfairly increasing their insurance premiums.
BMI doesn't help patients

When Bee, 32, of Sacramento, California went in to see her doctor this year, she found that her BMI was the start and endpoint of the conversation. “The doctor used weight as an excuse for everything and didn’t look further,” she said.

“They've brushed off many concerns with the excuse of weight. I had what I'm pretty sure was a false negative COVID test this summer and they kept just saying my weight was affecting my asthma (which I didn't even have to any sort of extreme beforehand), even though I'd actually recently lost 20 pounds. It was humiliating, defeating, demeaning, dehumanizing, and quite terrifying while I was so sick to be dismissed so quickly because of my BMI.”

Bee, who has Polycystic Ovarian Syndrome (PCOS), said that her doctor won’t even further investigate the condition as a result of her BMI. “The only recommendations they'll give me for PCOS is for me to lose weight and take birth control.”

According to Sasha Ottey MHA, MT (ASCP), Executive Director of PCOS Challenge at The National Polycystic Ovary Syndrome Association, this weight bias is all too common and highly reductive, considering many patients do have a weight loss plan or eat well and exercise, yet still deal with PCOS and other endocrine conditions.

“Most health information (like BMI) is based on white men in early 1800s, but ethnic, body type, lifestyle, and sex differences need to be included in the care of any patients,” Ottey told Endocrine Web.

As Ottey says, one of the main issues with BMI mirrors one of the main issues in science in general. It was designed with white males in mind. According to an recent article published in the International Journal of Epidemiology, BMI has some massive gaps.

For one, the article says, it doesn’t apply to children. It doesn’t reflect women or any non-white group of people — and we know that there are important health differences among ethnic groups. And as mentioned above, it doesn’t accurately take into account the elderly and the many phases of life, or how our bodies change naturally over time.

There is also concern that BMI is inherently racist due to it being based on “ideal” white body types  — and that perpetuating its use upholds its racist origins.

Sabrina Strings, an assistant professor at the University of California at Irvine, told The HuffPost, “It is racist, and also sexist, to use mostly white men within your study population and then try to extrapolate that and create norms and expectations for women and people of color.”
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The article goes on discuss how the use of BMI can have detrimental effects on patients, alternatives to the use of BMI, etc.  Quite interesting.
2 Responses
Yeah, but he had a really cool name!  But seriously, maybe I've had odd docs, but I've never had one test my BMI.  I think those of us who were within what are considered healthy weight classes just by looking at somebody probably don't get the BMI treatment; that's probably reserved for those who are obviously heavier than they should be.  We also need to realize that racial differences aren't actually racial -- black people in Africa are largely pretty thin.  The problem isn't that different races have that many inherent differences, as DNA doesn't show a lot of difference between different races.  There are a few diseases that run in ethnic groups, but black people in the US have a problem because of economic disparity and housing discrimination -- they often live in food deserts, for example.  But if you compare poor white people with poor black people you see that it's wealth in the US that is the problem.  Almost very other country has better eating habits and a socialist health care system except those countries that are poor, authoritarian, and have no health care system, or countries that are authoritarian and the people have some really bad habits, such as alcoholism in Russia.  So if a female athlete goes to a doc, I doubt that doc is going to look at that person and talk BMI.  That person looks great and so the doc isn't going to bring up weight at all.  It's only when they see someone who is overweight that they are going to bring it up.  I also believe that most docs are horrid at their jobs, just as when you call a plumber or electrician it's a toss-up whether your problem gets fixed or not.  Humans are humans, and most of us end up in jobs we're awful at or don't care about.  I've always read that although overweight people have more health concerns, they don't necessarily live shorter lives, but they might live less healthy ones.  It might not be the weight -- it might be what causes them to be overweight, as it may be due to poor eating habits or sedentary lifestyles or disease states or harmful medications they are taking, all of which are bigger problems than just not being at an ideal weight.  Life, and health, are complicated, and they get more complicated when money is involved.  Which means Barb's main point is where the problem is, and that is, we need a better way to do things.  Peace.
You've had odd doctors.  They likely record your BMI and don't say anything unless it is out of whack.
I agree with specialmom - you have odd doctors...  Almost every doctor I've gone to in my adult life has discussed weight/BMI - even when I was obviously well within a "normal" range for BMI.  Even my husband's doctor records BMI and discusses weight loss/gain and my husband is also well withing normal BMI range.
Hmm. I just asked my husband, and neither he nor I have ever had a doctor talk to us about our BMI. I guess it's possible that they note it, but maybe not -- Kaiser does everything on a data model and maybe they have decided that BMI is not that logical.
Every doctor I have weighs me in and then asks or checks my height (PCP, ENT, endocrinologist, gynecologist).  They've never said "your BMI is...", but I assumed that was being calculated and noted.  (My BMI is frequently towards the high end of normal, even though I appear on the thin side of normal.)  We've never talked about me being on the high side of normal, and I lost about 30-35 pounds before being diagnosed with my thyroid issues.

As for the US eating worse than other countries, I'm not actually sure that is true (could be, I'd love to see the data if it is).  I lived in Manchester, UK for four years in early 2010s, and the people I worked with ate some pretty interesting meals.  Who am I to judge what is healthy or not, but frequently, people would eat a curry loaded up on a giant pile of rice (like 2-3 times what I now have with dinner if I make some coconut-lime chicken with rice), and they'd have it with potato "chips"/large potato wedges as a side dish.  People (including me) would go to the pub every Friday, consume a huge amount of alcohol (I would sometimes have 2 pints of beer, but that ended when I started training for marathons and realized that I did not enjoy sweating out a huge amount of alcohol on Saturday morning long runs), and then eat fish and chips or a curry after (that also ended with marathon training - I can't eat fried foods and run the next day, so I just don't eat fried foods now).  We would have "tea time" at 10am and 4 pm every day, which often involved cookies and very frequently involved cakes for birthdays or just for fun.  People in the UK would swear their portion sizes were smaller than the US, but from what I saw, they were eating at least the same amounts if not more compared to people I've worked with in the US.  The heavy meals I saw consumed reminded me a lot of the types of foods and how much people used to eat in the US in the '80s.  No one I worked with was overweight (and neither was I, at the time).  So I'm not buying "Americans just eat more."  It could be we are much less active (driving versus walking to taking public transportation, etc.).

As for Europeans not being as overweight as the US today, that's true, but there is still a huge worldwide obesity crisis, including in European/Western countries with socialized health care.   In 2016, the US obesity rate in adults was 36.2%.  New Zealand was 30.8%,  Canada was 29.4%, Australia 29.0%, UK at 27.8%.  Some of those countries have socialized medicine (they all probably do, but I'm aware of the UK and Canada), and all of those numbers indicate obesity is also a significant problem outside the US, even if it is not as high as the US yet.  If you don't think 27.8% obesity is problematic, I don't know what to say.

https://www.cia.gov/library/publications/the-world-factbook/rankorder/2228rank.html

I was curious about the racial differences, because I'm aware different races often have different idealized body types for women, and would be surprised if there weren't differences in how fat was stored, and came across this article:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2728780/

Racial differences in body fat distribution among reproductive-aged women

We examined the influence of race/ethnicity on body fat distribution for a given body mass index (BMI) among reproductive-aged women. Body weight, height, and body fat distribution were measured with a digital scale, wall-mounted stadiometer, and dual-energy absorptiometry (DXA), respectively, on 708 healthy black, white, and Hispanic women 16–33 years of age..... the distribution of body fat for a given BMI differs by race among reproductive-aged women. These findings raise questions regarding universally applied BMI-based guidelines for obesity and have implications for patient education regarding individual risk factors for cardiovascular disease and metabolic complications.
Well, you're citing countries that all are English, basically, and you're right, the English eat horribly and that's where the US got it from.  As for me having odd doctors, how would you know, Mom?  How many doctors have you seen in your life?  Fewer than I have, I'm older than your are and I've lived on opposite sides of the country.  My wife is more fleshy and overweight than I am and has also never had a doctor talk to her about BMI.  I gained 50 pounds when I was taking Paxil, and never once did any doc I saw say a thing about it until the very end.  The only time I measured my BMI was on a device sitting around the gym once, and at least according to it I didn't come out all that great, so who knows?  I wasn't really overweight all that much at the time and was pretty muscular, so I ignored it.  My experience with docs is, they work quick, they don't really care all that much because they have so many patients lined up, and so what they do tend to rely on most are your labs and what they can see.  My point, though, wasn't to demean BMI, it was to say, we all can tell by looking at ourselves in the mirror what's going on with our bodies.  If the belly is getting larger, you have a problem.  Pretty easy.
I picked the English speaking countries because those were the top countries that are often referred to as "Westernized", which includes most of Europe, as well as those listed and the US  (Western culture is commonly said to include Australia, Canada, all European member countries of the EFTA and EU, the European microstates, New Zealand, the United Kingdom, and the United States.)

You wrote "Almost very other country has better eating habits and a socialist health care system except those countries that are poor, authoritarian, and have no health care system, or countries that are authoritarian and the people have some really bad habits, such as alcoholism in Russia. " and I gave examples of countries that do have socialized health care (UK, Australia, New Zealand, and Canada all do, I just looked it up).  As far a I know, none of these countries are poor or have an authoritarian governments, and they are pretty close to the US in terms of obesity.

Obesity is worldwide crisis.   I didn't list the bunch of Pacific islands (and Kuwait) that outrank America in percentage of obese people, because you were referring specifically to countries with better health care and wealth.  Between the US and New Zealand (I was very surprised to see New Zealand has such a high rate), there are 8 countries from the Middle East/Arabian peninsula, and the Bahamas.  Between New Zealand and the UK, there are countries from South America, more islands, more Middle East, and South Africa.  It isn't a predominantly American problem or English speaking problem, this is a worldwide problem.

Do all these countries have better eating habits than most Americans?  Maybe, but that seems kind of judgmental and may not actually be true based on the article Barb shared about people now having to eat less and exercise more to weight the same as people did in the '80s.

When I was in the UK, they would constantly say things on TV like "we have an obesity problem, but at least we are not as bad as the US".  That is true, but saying 27.8% is not as bad as 36.2% is ignoring the fact that the obesity rate in the UK was 7% in 1980 and it is now quadruple that.

I think you were making the point that poor white Americans and disadvantaged minorities have less access to fresh foods and face economic hardships that make buying healthier foods impossible.  Poorer income groups have higher obesity rates, but even in wealthier groups, obesity rates are high.   This is from the CDC:

During 2011–2014, the age-adjusted prevalence of obesity among adults was lower in the highest income group (31.2%) than the other groups (40.8% [>130% to ≤350%] and 39.0% [≤130%]). The age-adjusted prevalence of obesity among college graduates was lower (27.8%) than among those with some college (40.6%) and those who were high school graduates or less (40.0%). The patterns were not consistent across all sex and racial/Hispanic origin subgroups. Continued progress is needed to achieve the Healthy People 2020 targets of reducing age-adjusted obesity prevalence to <30.5% and reducing disparities (5).

https://www.cdc.gov/mmwr/volumes/66/wr/mm6650a1.htm

31.2% in the highest income group is the lowest rate of obesity, and that is not a "good" level of obesity.  Presumably wealthy people have better access to healthier foods, access to health care and probably more education, and yet the obesity rate is still higher than most other westernized countries in wealthy people alone in the US.  It's not just a poor people problem.
It's not good, but it's quite a lot better than the other numbers.  You're citing 11% differences, and in health terms or any other terms, that's a huge huge statistical difference.  A lot of people have always been fat.  It used to be considered a sign of prosperity and health to be corpulent.  Those Pacific Islands used to force feed their nobility, literally like a goose or duck being raised for pate.  So it became genetic over centuries of doing it and is why American Samoa punches way over its weight, ahem, in sending players to the NFL.  Now, I don't really know about Canada and New Zealand and Australia, if you look at pictures people there doesn't appear to be the problem you have in the US, where if you look at any gathering in the middle of the country or the South you will see a whole lot of fat people.  You don't see that in videos from those countries, and when I've been to Canada I don't see it, so I'm not sure about it.  The definition of obese can be murky.  Frankly, if you look at videos from England you don't see a ton of obesity either.  Just look at your typical political gathering in those countries, which you can only see if you watch public television as the other channels only cover Trump these days, and you don't see a bunch of fat people.  Even in the US, it varies wildly by state and city.  You can just use your eyes and see that.  In the gilded age, the rich got fat -- really fat -- on purpose.  European nobility got fat on purpose.  I'd also say that westernized applies to most of the world nowadays.  China is following completely western economic and political policies, and they have adopted increasingly western ways of eating.  Japan westernized in the late 18th century.  South Africa is pretty westernized.  And again, the MIddle East may be what you say, but again, we see a lot of video from that part of the world and the men are not fat.  The women, on the other hand, are, probably because of the repressive dress codes.  You certainly make a very good case, and it demands attention, but it's not what we see.  Again, just look at any Trump rally and tell me that's what a rally in Australia looks like.  It doesn't.  Maybe all those fat people in those places are hiding.  It is possible.  I'm saying more, you have done the homework, but it's not what we see.  Interesting stuff, as usual.  Peace.
Of course 11% difference is a "statistical difference", but we are talking about total numbers of individual people who are obese.  Comparing total numbers to where they were 20 or 30 years ago shows all these countries trending upwards, just behind the US's curve.  Just because they aren't at the same level as the US yet doesn't mean it isn't also a huge problem for those countries, just like it is in the US.  One in four people obese in the UK today, compared to one in 13 people 30 years ago, is still a major problem.  Yes, it is much better than America's 1 in 3, but still a huge problem.

You wrote: "A lot of people have always been fat.  It used to be considered a sign of prosperity and health to be corpulent.  Those Pacific Islands used to force feed their nobility, literally like a goose or duck being raised for pate.  So it became genetic over centuries of doing it and is why American Samoa punches way over its weight, ahem, in sending players to the NFL. "

I can't find evidence that this (the genetic component you mentioned) is true.  And I could just choose to let that comment go (and probably should), but I don't think it's fair to people of Polynesian descent to just state something like that as fact.  What is true for nobility is not necessarily true for the whole populations.  For example, Henry VIII was overweight, but I doubt this means all British people are predisposed to being fat.  And the royalty that was force fed calories to be fat gained weight because they were eating too many calories, not because they were chosen because they had "fat genes".  Royalty overeating doesn't not make a whole population evolve to be fat, that's not how evolution works.  Now, if say, the most overweight man was selected to be king (not by birth right, but just based on how fat he was, and only if that fatness was caused genetically) and then he was allowed to have hundreds of children, then, that trait could be passed on through artificial/sexual selection, but I really don't think that is how royalty was chosen.

The author suggests the cause of obesity in Pacific Islanders is a combination of factors:  WWII bringing in Americans, French, and British industrialization.  Pacific Islanders adopting a more sedentary lifestyle over just a few decades, compared to Europe and North America transitioning over a couple centuries.  Their diet also changed from mainly fish, vegetables, and fruit to rice, sugar, flour, soda, and beer.  There may also be a genetic component, but researchers appear to have conflicting views on this (it was thought Pacific Islanders had evolved to store fat more efficiently since resources can be limited in an island environment, but lately many researchers no longer support this claim and now opt for lifestyle changes as the cause, specifically a more sedentary lifestyle and a more calorie dense diet.  One abstract I found does reference levels of uric acid levels in Polynesian/Micronesian populations as a factor that could contribute to obesity:  https://pubmed.ncbi.nlm.nih.gov/25928990/   ).  It seems like the current consensus is lifestyle changes and possibly a genetic component, although genetically there has not been conclusive evidence found yet.  Pacific Islanders have not "always been fat" or "evolved to be fat" from centuries of royalty being fat.

You wrote "where if you look at any gathering in the middle of the country or the South you will see a whole lot of fat people."  I'm not sure if you've spent a lot of time in the middle of this country (US), but I've been to plenty of gatherings in Ohio with zero obese people.  I guess it depends on who you hang out with.  I don't actually see that many obese people at the grocery store or my nephew's soccer games in Ohio either.  It just seems like you are singling out "middle America".  (Don't get me wrong, obesity is a huge problem here, it is also a huge problem worldwide.)

As for overweight people, I'm sure I see tons because something like 70% of adults in Ohio are overweight as of 2018.  California has an overweight percentage of 60.7% as of 2012 (the only year I could find quickly), so, there is a good chance that for most Americans, wherever you are, you also see overweight people frequently.  It's not just a "middle of the country" or "South" problem. This may just be venting at this point, but I'm tired of people on the East and West Coasts referring to obesity as just a Midwest and Southern problem, it is not.  It is a huge problem for the whole country.  Just because obesity rates are lower in California than Ohio does not mean the obesity rate is "good" in California.   1 in 3 in Ohio, 1 in 4 in California, 1 in 5 in Colorado, that still puts tremendous stress on the health care system, and that is still a huge number of people that may suffer from physical health problems, mental health problems, or early death because of their weight.  Colorado's rates are much better than Ohio's, but still much higher than they were even 20 years ago.  That means more people are dying earlier, or having  a lower quality life than may have had otherwise.  (And why do I even care if someone in California thinks obesity is a Midwest/South problem?  Maybe it's the same reason I get annoyed when Ohio is referred to as a flyover state.  It seems to belittle or demean.)

I've seen very few obese people in videos of protests here in the US, but most of those takes place in cities and obesity rates tend to be lower in urban areas. I've also seen all sorts of people of all sizes in the UK.  I think it can be said that there are more Americans who are massively obese compared to the UK (I'm 98% sure there are statistics that show this), so even if there are similar numbers of overweight or obese, the amount the average person is overweight or obese by is much higher than the US than the UK (which I think is the point you were making).  I lived in Manchester, UK, and didn't really see all that many obese people in Manchester, but I was mostly in the city, and mostly taking public transportation, but there was enough news coverage of the obesity crisis there that I'm well aware Manchester is not a representative of the entire country, and that it is also a problem there.  Also, my local Krogers is not representative of all of Ohio, apparently, because I do not see 1 out of 3 people with a BMI over 30, but I still believe the data that shows that Ohio has a rate of 35%.

As for the Middle East, the article about Pacific Islanders also suggests similar factors (diet change and adopting a westernized culture, which is apparently very sedentary) is a cause as well.   There also appears to be a cultural preference for girls to be heavier and those who are overweight or obese are more likely to be chosen as brides, because weight signifies beauty, fertility, and success, at least in some countries.  There is  a nice Wikipedia page discussing the different factors for the different countries, discussing what is thought to contribute to these levels.

https://en.wikipedia.org/wiki/Obesity_in_the_Middle_East_and_North_Africa
I originally said you've done the homework, and it's impressive, but now I am a bit more hesitant.  I'm not sure your statistics are accurate or aren't, I really couldn't say without doing an exhaustive literature search, and I have no desire to do that as I agree with you in the main.  But you are severely confusing in the above addition being overweight with being obese.  Which is it?  These are two very different things.  As for Polynesians, I would have thought this was a pretty well known factoid.  You forget, the nobility used to intermarry.  They do have genetic characteristics not shared by the rest of the population.  Henry VIII did in fact originally marry a relative.  In Hawaii, the royal family used to literally lay around all day being force fed, a tradition they brought over from Polynesia.  The nobility only married other members of the nobility.  We all know, I should hope, that the European nobility intermarried so much they brought upon themselves inordinate amounts of hemophilia and other diseases the general population did not share.  So yes, it does get into evolution if you continually reproduce within a small gene pool.  It is also true people in the great middle of the US living out side the major urban areas are heavier than those who settle in urban areas, and it is also true that certain places, such as Australia or Colorado or California or Wyoming are much more into serious outdoor pursuits than people in other places.  People do have cultural aspects that affect weight.  Other than saying that one needs to know one's history to know about this stuff, I'll leave it there and anyone who wants to can do their own study and make their own conclusions.  I also have never seen Ohio in the great middle of the country, although it has been put there.  Ohio is in the East, as far as I'm concerned, and is a largely urban place with some rural areas but it is an industrial area that has come into hard times recently but it was one of the first places people went when they figure out how to cross the Appalachians and take their stuff with them.  Now, I've lived for many years on both coasts, and I can only go on what I see.  Statistics are only as good as the number of people you're able to contact and observe and study.  But again, I said, you've done the homework and it's impressive, so if your response hadn't been what it was the subject would have been closed with kudos to you for telling us all this interesting stuff.  Fair?  Peace.
Let me just add, I was trying to pay you a complement, not stir anything up.  Still am, but the waters appear muddier.  So again, kudos to you for tickling our curiosity bones.
I use the normal guidelines for overweight versus fat (BMI between 25-30 is overweight, BMI over 30 is obese).  I very frequently see overweight people in suburban Ohio (and was one, at least as recently as 2017), but I do not see all that many "obese" people where I am, based on the BMI definition.  And I'm going to hazard a guess and say that there are probably more super obese people in the US and in particular the midwest and South than other countries with similar obesity rates.    I only brought up "overweight", because I rarely see people who are "obese" in my neck of the woods, and it was suggested that most gatherings in middle America are full of fat people, so I guess it depends on what you call "fat".  I was using overweight just to say that I'm very aware that many people in Ohio are overweight, but I do not see many obese people on a daily basis.  And, it is quite possible the representation I see at Krogers is very different from what I might see at Walmart.   (According to the data I could find, about 35% of Ohioans are obese, 70% are overweight or obese.)  Sorry for the confusion.  According to the CDC, Ohio's obesity rate is 34.8%, Ohio is tied with North Dakota and Missouri ranked 13th highest obesity in the US, so I guess I would lump Ohio in with states with highest obesity rates.

I only brought up other countries and cultures in the first place because you were mentioning other countries have "better eating habits and socialist health care" and that is why America has an obesity crisis.  The disagreement there comes from the problem that the whole world has an obesity crisis.  America is way ahead of the field when it comes to a large population and just how obese people can be, but at least for westernized countries, but we are all well ahead of where we were 40 years ago (or 20) in terms of weight.  Even countries with socialist health care have a huge problem (not as big as the US, but still very big).

Maybe I am overly sensitive about this topic - my own weight problems were related to my thyroid, which is probably not true for most, but going through my weight gain and loss had led me to think more empathetically towards other people with weight issues.  And, apparently I can gain 40 pounds without changing my diet (which involved zero fast food, fried foods, or mammal meat, and very little processed foods in general) and still exercising, just by my immune system destroying my thyroid.  By saying American's have bad eating habits and lack of socialist healthcare (I believe everyone should have access to quality healthcare myself) is the problem seems to miss the point entirely that Americans need to exercise more and eat less to be the same weight they were in the '80s (Barb135 posted an article about this recently), this was overwhelmingly true for me in a very compacted 3-4 year period (2015-2016 gained 35-40 pounds, 2017 lost 40 pounds by counting calories and increasing my running).  While what happened to me, thankfully, is not what is happening across the world, it certainly puts the obesity epidemic into a different perspective for me.  It's a complicated issue, it affects the whole country (and world), and I care about these people struggling through this, I would love for the answer to be "just eat a better diet", but the solution may not be that easy, it certainly was not for me.  I lost my weight by eating less, exercising to a point many would consider excessive and some probably consider harmful, but to improve my health, I actually needed to lose my thyroid completely and take a couple years to get to the right dose of thyroid hormone.  My diet was never the problem.  I'm much less judgmental of obese people for this reason.

I'm willing to just choose to disagree on the Polynesian thing.  I'm not saying Polynesians may not be genetically predisposed to obesity.  I just found an article from 2016 about Samoans (around 50%) having a "thrift" gene that allows them to store fat better, which is hypothesized to have been selected for by the often perilous conditions traveling across the ocean and surviving in conditions where food might have been scarce.

From a Gizmodo article on this study : https://gizmodo.com/how-a-powerful-obesity-gene-helped-samoans-conquer-the-1784266550
"Starting around 3,500 years ago, ancestors of Samoans began the arduous task of settling the 24 major island groups of Polynesia. This colonization process—one of the most extreme examples in all of human history—took possibly thousands of years to complete. “They had to endure voyages between islands and subsequently survive on those islands,” study co-author Ryan Minster told New Scientist.

"The problem, however, is that Samoans no longer require this gene. This would explain why upwards of 80 percent of men and women in Samoa are now overweight. “Samoans weren’t obese 200 years ago,” noted McGarvey. “The gene hasn’t changed that rapidly—it’s the nutritional environment that changed that rapidly.”"

What I am disagreeing with you on is the idea that these genes were passed down because royalty were overweight because they were forced to eat, and then passed that gene on to their descendants.   If only half the Samoans have this gene and 80% are overweight, it suggests that there are probably many genes, which makes sense, especially if strong selection was going on over thousands of years. I wasn't saying there isn't a genetic connection, just that it is unlikely to have come from genes passed down from the royal lines, and I still think that is true unless I see evidence that convinces me otherwise.   And becoming overweight in one lifetime by overeating is not the same as passing on a hemophilia gene in European royalty.   The gene itself does not make one obese, since this gene has been present for thousands of years, but Samoans were not obese until very recently.  When combined with a modern diet, which came to many of these islands about 80 years ago, it certainly increases the chances of obesity immensely.

It is quite possible I'm confused about what your original hypothesis was.  An alternative to the "thriftiness" gene for ocean voyages hypothesis is that obesity was selected for as a desired trait in a mate because it was culturally desired because heavier woman are thought to be more fertile, or larger men more powerful and wealthy.  I personally find this hypothesis less likely than the thriftiness one, but the great thing is that there can be competing hypotheses and unless one is proven right or eliminated, both are possible.  It appears that this type of mate preference happens today is some cultures (I'm not sure about the genetic component though - there may be, I just don't know).  How much is from diet and purposefully putting weight on versus genetics?  I don't know.

I guess one conclusion I can make from what we know about Polynesians are that there are some genetic traits that greatly increase the risk for obesity.  Polynesians had been mostly isolated from outsiders for thousands of years, so you can't quite draw the same conclusions about other races, but, it does suggest that genetic background, even in America, might also contribute to obesity (and, as I said in an earlier comment, there are racial differences, especially in how much and how fat is stored in women).

Anyway, I didn't mean to start any arguments,  clearly I've had too much time on my hands to think about obesity this week.  (I was tapering for a marathon which I ran by myself yesterday, which apparently  meant I was running less and thinking more).  I actively try to stop myself from the powerful "someone on this internet is wrong" compulsion and try to just let it go, but this week I failed.  And - I don't think you are wrong, I think we might disagree on the cause of Polynesian/Pacific Islander obesity, and how much a problem worldwide obesity is compared to in the US, but I think we do agree on most of the things discussed.

Finally, I just want to say that I am aware of and love Hawaiian culture.  I'm lucky that my parents have taken us to Hawaiian many times growing up (and as adults).  I especially like Lomi Lomi salmon served at luaus, which we were always told means "massage", and that it is named that because in between meals, the Hawaiian kings would have their stomach massaged to make room for more food.   (I'm less a fan of the roasted pig.)
I guess they've tracked health issues that happen in the overweight category of the BMI and the obese category.  I shoot for being in the sweet spot with BMI.  Right below oveweight (by one) and no where low BMI which is too hard to maintain.  Is it full proof?  No.  Some people can be healthy at a heavier weight.  But I think statistically, being below the 'overweight' zone leads to the best health for people.  I only track my bmi year to year at my physical.  My son is tracking his through a nutritionist that is using it to help him understand he needs to gain weight.