Comparison of BMI and the body mass/body surface ratio: is BMI a biased tool?

For decades we are used to judge our body composition by using the body mass index (BMI). Since the BMI denominator can be considered as a substitute for body surface area (BSA), the body mass/body surface ratio (BM/BSA) can be calculated. For a distribution of BM/BSA values comparable to the distribution of normal BMI values, the range 35.5-39.9 kg/m2 is chosen as normal, although it covers BM range 50 to 90 kg. The proposed normal BM/BSA range suggests that heavy adults with less than 2 m of height are not obese only if they are less than 90 kg. If the described limitations of the BM/BSA ratio are valid, then the BMI should be regarded as a biased tool, less applicable to individuals with body masses outside the 55 to 90 kg BM range. If we consider many health problems related to the increased body mass, it is possible that the BMI should be used with caution in heavy individuals.