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President Donald Trump’s attack on immigrants continues, but this time he is excluding them from opportunity in the U.S. based on body size and chronic health conditions. This blatant act of discrimination, cloaked in public health, is scientifically unsound. It ignores decades of research challenging the Body Mass Index (BMI) as a health indicator, while discounting the worth and humanity of those with chronic health conditions and disabilities. It also exacerbates the racial inequities already present in our immigration system. This guidance sends a clear message — only people in certain bodies are welcome in the United States.
In a directive issued this month, the Trump administration instructed immigration officials to deem applicants ineligible for a visa if they are “obese” or have diabetes or other chronic health conditions. The administration argues that these individuals could become a drain on U.S. resources. Sadly, oppressing larger-bodied people through immigration policies is not new — New Zealand, for example, has been doing it for years.
Not only is exclusion based on body size unethical and discriminatory, it is scientifically unfounded. First introduced in the mid-1800s by a Belgian astronomer, the BMI is a poor indicator of health. In fact, the BMI was never intended for use at the individual level, but instead was designed to study natural variation in populations. It wasn’t until life insurance companies adopted it that BMI was utilized as an individual health marker. Afterward, BMI became even more medicalized (and profitable!) with developments in the pharmaceutical industry.
Despite its widespread use as a health indicator in the 21st century, BMI remains highly problematic. Using BMI as a proxy for metabolic health (e.g., blood pressure, blood sugar regulation, cholesterol, c-reactive protein) results in significant misdiagnosis rates, with nearly 30% of people with “obese” BMIs showing favorable cardiometabolic indicators, and 30% of people with “ideal” BMIs showing unfavorable cardiometabolic indicators. This is partially because the BMI cannot differentiate among fat, muscle, body fluid and bone. Further, other medical factors (e.g., inflammation, insulin resistance) drive many of the correlations we see between BMI and health. The relationships between weight and health, and between health behaviors and weight, are nuanced and complex. Even if it were ethical to determine immigrant eligibility based on health status, BMI would be a poor measure.
The Trump administration argues that body-size limits on immigration will save taxpayers money due to the high health care costs of “obesity,” suggesting that high body weight equates to being unhealthy and requiring additional health care. The evidence contradicts this assumption — in fact, causal links between body fat and disease remain hypothetical. Many large-bodied individuals are metabolically healthy (just as many thin people are metabolically unhealthy). Further, this thinking ignores systemic issues that contribute to health care costs (e.g., costs of overdiagnosis, insurers being permitted to charge more based on body size, iatrogenic harms of obesity treatment), falsely attributing these costs to people’s bodies, choices and morality.
Limiting immigration and visas by body size and chronic conditions reinforces false, age-old stereotypes about large-bodied and disabled people. These discriminatory narratives only result in further harm. There are far better ways of reducing health care costs (that prioritize people over profit) and improving the health of our immigrant communities than dehumanizing those with chronic health conditions or larger bodies. Rather than limiting costs, this policy limits the enrichment of our communities. Some of the greatest minds of our time live with disabilities or chronic illnesses; some of the greatest athletes have “obese” BMIs. Pursuit of the American dream should not be narrowly limited to those with a very specific genetic inheritance and a healthy ZIP code.
