The Weight of Numbers Sep 14, 2013

by RICK RADER, MD * EDITOR-IN-CHIEF

This past January first put me in a league with half of all Americans when we made a New Year's resolution. The league I was in was characterized by our rounding the bases with less speed, less grace and less ease. Our league was literally the "big league," and our resolution was to lose weight.

No surprise that weight loss is the number one resolution made by those who make resolutions. The percentage of those who fail is a staggering 88 percent. That's 156 million failed resolutions. The numbers are enough to drive you to a pint of Cherry Garcia. And while I've created a perfect segue into describing the frailties of both the ventromedial and dorsolateral prefrontal cortexes (the will power regions of the brain) I won't. I prevailed and stepped on the scale every Tuesday morning to see and celebrate (I'm told it was not a very flattering "end zone" dance) a small but steady weight loss.

Six months later, I arrived at my physician's office for my annual "let's look under the hood" physical exam. I climbed onto the scale for the ritualistic weigh in. I welcomed the sound of the nurse sliding the block weight down on the scale from where she first placed it in anticipation of my last recorded weight. After positioning the block weights into their respective slots to satisfy the balance beam the nurse glanced down at the file (yes a file, not a laptop, not an iPad and not a tablet....so much for the adoption of the electronic health record), smiled and said, "Well Dr. Rader, I am impressed with your weight loss, it's fantastic, your BMI (body mass index) is now within the normal range, what an achievement, you are indeed a healthy specimen, congratulations."

So I start to step off the scale deciding whether to offer a simple "thank you" or embellish on the toils of the struggle she says, "Whoops get back up there while I measure your height."

So I stand as straight as I can and she drops the bar down on the middle of my skull and scribbles a note in the file. "Dr. Rader it looks as if you lost a couple of inches in height, probably due to vertebrae compression and as a result your BMI puts you back into the unhealthy obese category."

I immediately experienced the first stage of confronting bad news, "denial." "That's impossible" I said with a raised voice, "20 seconds ago you said I was a healthy specimen, and now I'm back to being obese. What changed?" "Your height changed and it changed your BMI. The numbers don't lie, now go have your blood drawn down the hall."

"Wait a minute, I'm still the same person, still have the intrinsic height, my overall height didn't go away, I'm just compressed." The judge, resplendent in her floral scrubs, refused to debate the issue, ignored my plea for an appeal and pointed to the lab for my next "patient experience" (as they call it now).

Hearing that everything "under the hood" was perfect should have been the high point of my day but I was fixated on the dancing BMI and the sound of Nurse Ratched declaring, "The numbers don't lie." The odyssey of my being "perfect" one moment and "imperfect" the next, (based on "numbers") haunted me back to my office.

When I returned to my office my assistant Susan smiled and said, "Well how did it go, bet they were blown away with your weight loss."
I mumbled something under my breath and when she said, "What did you say?" I said, "Crank up your computer and log onto the National Library of Medicine, we have some research to do."

This was not an unusual request to Susan, in fact it's one she hears several times a day and she is usually one click away from waking up the Pub Med gods.

"Find me articles on the impact of height loss on BMI, and when you find them print out about four pounds worth and have them delivered to my doc's nurse with a black rose."

So what did we find out, other than the fact that I have a low threshold for a short lived accolade?

For one thing, height loss is related to aging changes in the bones, muscles, and joints. People typically lose about 1 cm (0.4 inches) every 10 years after age 40. Height loss is even more rapid after age 70. You may lose a total of one to three inches in height as you age.
Regarding the question of "which height is the true height" (the before or after height due to age related changes to the spine) it seems medical science is baffled. In her article, "Gauging Body Mass Index in a Changing Body," medical journalist Gina Kolkata writes, "Despite intense public interest in the problems of excess weight, there is no consensus among medical scientists about whether older people should use their new heights or their old heights in determining their preferred weights. The lack of agreement, experts say, illustrates the folly of blind adherence to charts and graphs showing ideal and not-so-ideal body mass indexes." I didn't include Kolata's article in my four pound compendium to Nurse Ratched; only those articles that supported my support of using the "old" height made it into the brown accordion file (with the black rose) destined for her desk.

And while I got over my short lived rant, I thought about the legions of exceptional parents and their exceptional kids who have their days and lives dictated by numbers. Numbers that define the validity and level of services that the numbers themselves designate. Numbers that signify that their children can't or won't receive services that might ultimately change the very numbers that defined them to begin with. The weight of the numbers weigh heavy on the special needs community; numbers that should be ignored or calculated with other numbers that mean something else, that are balanced with the number one thing that is most valued by exceptional parents...the number of times they hear, "let's try that and see what happens."

Regardless of my height, my BMI and notations in my chart one thing is for certain; I'm skipping that pint of Cherry Garcia...for now.

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