- Having obesity, or a BMI over 30, makes you eligible for the coronavirus vaccine in some states.
- But BMI’s faults as a metric of health, stigma, and lack of awareness are holding some people back.
- The system is imperfect, but you didn’t make it. Getting the shot if you’re able benefits us all.
- Visit the Business section of Insider for more stories.
The other day, Clare Rager texted five of her girlfriends.
“I’m going to be eligible for the vaccine purely because of my body weight, and no other reason,” she wrote. “Do you think it’s a terrible thing for me to do, to get in there and get a vaccine?”
Rager is a lawyer who works entirely from home, in Cambridge, Massachusetts. She’s 33, and has no obesity-related conditions like diabetes or hypertension.
If you saw her walking down the street, she says, “you might think, ‘That woman’s chubby, but you certainly wouldn’t think, ‘Oh, she has a scary medical condition. So to some degree, I can pass as not eligible to be in this group.”
“This group,” in her case, means people with obesity – a body mass index (BMI) over 30. In her state and several others, the condition makes you eligible for an early coronavirus vaccine, just like cancer or Alzheimer’s.
Unlike those conditions, the BMI-based definition of obesity is faulty. The term is stigmatizing. There's debate as to whether being in a larger body really does increase your risk of complications from COVID-19, or if the real risk is medical bias towards fat people.
Sometimes, people who technically have obesity don't know they fit the BMI criteria.
But health experts agree: If your BMI makes you eligible for the vaccine, don't hold back. Yes, the rollout is imperfect, and BMI is a poor indicator of health. But you didn't make the rules.
To conquer this pandemic, we need shots in arms. Not getting the vaccine can hurt us all.
Some people with high BMIs are reluctant because the metric is a poor indicator of health
According to the CDC, 42% of American adults have obesity. All that means is they have a certain height-to-weight ratio. It doesn't tell us about how much body fat they have or where it's stored, how active they are or how healthy they eat, or anything about their race or socioeconomic status.
After all, BMI was originally developed as an epidemiological tool to assess largely white, 19th century European populations, not as a substitute for individualized diagnoses.
"On an individual level, BMI may not be a perfect indicator of someone's health risk. It's one of several measurements that we have to assess health risks," Dr. W. Scott Butsch, director of obesity medicine at the Cleveland Clinic, previously told Insider's Gabby Landsverk.
As such, some people who qualify as having obesity but don't think they're at an increased risk of sickness from COVID-19 are questioning the ethics around getting a vaccine.
Michelle Dimuzio, a 32-year-old designer in Brooklyn, is one of them. At her last doctor's appointment in the fall, her lab work painted a picture of a young woman in perfect health. She's been even more active since then -- switching her default transportation from the New York City subway to her bike.
But her 5-foot-4, size 12 body has a BMI over 30, making her eligible for the vaccine. She's getting her first dose this week.
"Part of me feels a little guilty," she told Insider, since some people, like first responders, haven't been able to find appointments in a chaotic scheduling system. "It's kind of mixed feelings."
The stigma of having obesity is holding people back
When New Jersey governor Phil Murphy opened up vaccine eligibility to people with obesity, some residents slammed their inclusion, as well as the inclusion of smokers, saying Murphy was rewarding poor lifestyle choices.
Rager has seen the same complaints in her parent Facebook groups. "I don't think the people who are getting the vaccine because they have asthma or another health-related risk factor are necessarily getting the same side-eye from their friends," she said.
—Amanda Levitt (@FatBodyPolitics) February 21, 2021
The shame comes from within, too. People with obesity - whether they are in good health or have health complications - may feel the need to justify their worth against the faulty societal impression that a higher weight equals a bad diet equals a bad person.
For Molly Shoemaker, a 31-year-old human resources professional in New York, challenging that stigma has taken years of work.
After growing up believing her body was worse than her peers, she's finally come to a place of body acceptance, turning to influencers who embrace "midsize fashion," or sizes between straight and plus-sized. She's learning to love running and lifting weights because of how it makes her feel rather than as a way to control her body size.
"To have all of that be reduced to one word, 'obese,' based on a system that doesn't take into account race, body type, level of activeness definitely stings," Shoemaker told Insider. "It's made me feel like I can't really be excited about getting the vaccine, because the reason I'm eligible is shrouded in taboo."
Some people may not know they qualify
Other people with BMIs over 30 may unintentionally deny themselves the vaccine simply because they're unaware they fit in that category. One 2016 study found that, while 7 in 10 Americans have obesity or overweight, only 36% think they have a weight problem.
With the pandemic leading to weight gain for some, people may have creeped into the obese category without realizing it.
Dr. Gregory Poland of the Mayo Clinic says it makes sense people don't see their weight as out of the ordinary because, in America, being overweight is ordinary. "We call that 'normal,'" he said. "But when you look at health, it's a decidedly abnormal situation."
People with obesity may be at higher risk of severe illness
Research has shown overweight and obesity are linked with a higher rate of hospitalizations and complications from the coronavirus.
A study out in August found that the higher a person's BMI within the obese and severely obese range, the more likely they were to die from COVID-19. That was the case even when controlling for factors like underlying conditions, race, and socioeconomic status. The risk was most "striking," the authors wrote, among men and people under 60.
The potential reasons are multifold, but many experts point to excess body fat's ability to impact the immune system and lung function. "Obesity is a state of chronic immunosuppression," Poland said.
Particularly among people who carry their body fat around the middle, a high BMI can activate inflammation and weaken the body's anti-inflammatory response, making them more susceptible to illness, research suggests.
Extra weight around the chest and in the belly can also physically restrict breathing, which can be dangerous in a condition that affects the respiratory system like COVID-19.
Even if weight isn't a direct cause of complications from COVID-19, weight stigma puts you at higher risk of poor treatment
Not all health experts agree weight or body fat alone cause an increased risk of complications from COVID-19.
Christy Harrison, an anti-diet registered dietitian who hosts the Food Psych podcast, told Insider weight stigma, which itself is linked to negative health outcomes, may be to blame for the correlations.
She pointed to past research on the 2009 H1N1 pandemic that at first linked obesity with a higher risk of complications. But it turned out the association was eliminated when researchers accounted for the fact that smaller-bodied H1N1 patients were more likely to get better treatment.
She suspects a similar finding will emerge for COVID-19.
All the more reason, then, to get a vaccine if your body size makes you eligible.
"If you can avoid getting COVID, you can save yourself from potentially having to endure not only severe illness and residual complications, but also weight-biased medical care that could possibly worsen your outcomes," she said.
Getting vaccinated can also help higher-weight people manage the stress and anxiety that comes with fearing a disease broadcasted as deadly to them.
Harrison said that while the fight against weight stigma continues, "it's helpful to take whatever olive branch this healthcare system may be offering you, if only to help you avoid having to engage with that system any more than is necessary."
No matter why you're eligible, you're worthy of a vaccine
The pandemic has ushered in a shaming epidemic in the US. First, people were ridiculed for going outside. Then, for taking a relatively safe vacation. And now for getting a vaccine before their "turn" - or in case of people with obesity, even when it is.
But refusing the vaccine when you're eligible isn't doing a good deed. It may even be holding us back from conquering the pandemic once and for all.
"I want everyone who is eligible to get vaccinated, for the good of society," Harrison said. "The more people who get the vaccine, the more quickly we move collectively toward herd immunity, which helps reduce the number of deaths and severe cases overall. Getting vaccinated helps protect others, as well as you and your loved ones."
As former CDC Director Tom Frieden said in a February briefing related to vaccine tourism, "a person is a person."
That's the argument Rager's text chain agreed upon. She's now constantly refreshing her browser in search of an appointment.
"We need needles in arms, and as much as it would be great to get every really old person first and every healthcare worker second and so on down the real priority lines," she said, that's not reality. "I feel like I'm doing my part of that by getting an appointment and getting a vaccine."
Shoemaker came to the same conclusion. "Does it feel strange to get the vaccine before my 60-year-old parents in North Carolina? Yes," she said. "But I figured not getting the vaccine wasn't helping anything either."
Ethicists agree. Gabriel Lázaro-Muñoz of the Baylor College of Medicine, told NPR the government's guidelines aren't intended to judge people's worthiness. "We're not focused on which of these lives we think might be more valuable to society," he said. "We're prioritizing just saving lives, period."
In many cases, the vaccine scheduling system isn't perfectly fair. In others, BMI may not be reflective of risk. But those are structural issues, not individuals' responsibility.
"I think BMI is a fully bulls--t thing," DiMuzio said, "but if that's the standard they're going to use, then so be it."