August 16, 2011

Weighing the awkward and unsatisfying truth

It seems SO simple but it just isn't. We need to stop these terrible fights of opposite poles: weight matters vs. weight doesn't matter. Without normalizing medical health and behaviors we CAN NOT expect to normalize mental health. But here is the awkward, unsatisfying truth: there is no tablet from the mountaintop to tell us what to do with an individual patient. There is no magic number, no quick chart, no inarguable calculation.

Sorry, but it just isn't simple and it is still critical. We have to accept that. It's "state not weight."

Thank goodness for C&M and Dr. Treasure to the rescue!



  2. Patients are just as bad as parents/clinicians when it comes to this. There are two arguments: a) I am FINE at a BMI below (insert barely healthy number) because I have small bones/never weighed more than this before my ED (which started when I was 12)/I look too big over it/BMI doesn't mean anything anyway OR b) everyone in recovery MUST reach a BMI of (insert plausibly healthy number) or above or they are lying to themselves and not really recovered. This translates to: no one in recovery must be thinner than I am or I will feel like a massive pig.

    Taking away the certainty of "once you get to BMI XX you can quit gaining weight" is terrifying for anyone in recovery. It was terrifying for me - I wanted something to cling to, like the fact that I had 40 (30, 20, 10, 5) lbs left to gain and to gain those pounds I needed to eat so many calories in such an order and so on. Telling me that my body would decide where my weight ended up would have freaked the heck out of me. Eventually I came to that conclusion on my own, taught myself to eat intuitively and realised that my weight was quite happy where it was anyway. But I can see why people are so obsessed with the idea of target weights. It must be similar for parents, who want that reassurance that their child really is healthy.

    Just one of many complicated aspects of recovery!

  3. As Katie says, just one of the complicated aspects of recovery. No wonder the poor doctor here has her head in her hands. However watch it to the end and you will see her clap for joy when her pupil understands that it's state not weight.

  4. I agree that this is all very complicated.

    I struggle to get my BMI above 19. It is not that I feel that "no one in recovery must be thinner than I am or I will feel like a massive pig" (quote Katie, above), but rather, I struggle physically to consume more than approx. 2500 kcal each day. (I actually don't count calories any more, but I follow a rough meal plan each day which I know amounts to an energy intake of approx. 2500 kcal/day). Very occasionally I manage to consume nearer 3000 kcal in a day, but I feel physically sick and so cannot stand the thought of doing it again.

    At a BMI of 19 (which I am right now, having gained a couple of kg over the past couple of months) I still feel slim; actually too slim - especially in my upper body. Moreover, my AN never had anything to do with body image/physical appearance, so I didn't deliberately restrict food and over-exercise to look a certain way, or to be thinner than everyone else! As a child (pre-AN) I was always one of the tallest in my class at school, yet one of the lightest in weight. Do I say that as an excuse? No, it is a fact.

    I feel that I eat intuitively, despite following a rough meal plan in my head (the purpose of which is to ensure that I do eat enough to maintain my weight). If I consume less than approx. 2500 kcal per day I feel hungry and so I eat more in response to this hunger. This usually coincides with increased physical activity - which increases my appetite.

    I have normal hormone levels, normal blood count, electrolyte levels, liver function tests (etc.) and my bone density has increased massively from 5 years ago when my BMI was around 13. In terms of my mood: it is infinitely better than it was when I was very underweight, restricting food and over-exercising. I am still an anxious person, but I had been anxious right from being a baby.

    Do I need to gain more weight to be healthier - either physically or psychologically? I really don't know. But if I gained more weight I wouldn't feel too fat and I wouldn't be disappointed. Therefore, I would dispute anyone arguing that I am deliberately keeping my weight at the level it currently is. In fact, no doctor I see nowadays is concerned about my weight.

  5. Cathy, it is important that we remember that not all ED patients experience their eating disorder as relating to their size. I also believe that far fewer ED patients would interpret the experience that way if we didn't impose that meaning on them early and often.

    Most patients still DO have that experience, though, so that needs acknowledging as well.

  6. Hi Laura, like you I believe that far fewer ED patients would interpret their experiences in the context of body image if that wasn't imposed upon them. Nowadays it seems to be taken for granted that EDs are caused by body dissatisfaction or are 'about' body image. And I also agree that for some people body dissatisfaction or fear of fatness may feel very relevant to them.

    I guess that the main point I was making in my comment above is that some professionals insist upon pushing an individual's BMI above 20 when in recovery from AN. If a person lost weight from a BMI of 20 or above, then it is more likely that their body's 'set point' is above 20. But if they had never been at a BMI above 19, then it may be that they are perfectly healthy with a BMI of 19. And, of course, BMI is only a VERY rough indicator of 'healthy' weight.

    My rationale for describing that I wouldn't mind being heavier is really a means of explaining that I do not deliberately restrict food to maintain a BMI of 19. I actually eat rather well. I always opt for full fat dairy and I never consume 'diet' foods. I eat when I am hungry, even if this is at a time when I wouldn't normally eat.

    When I was anorexic I was terrified of changing my behaviours and of weight gain, though not because I equated weight gain with body dissatisfaction. I equated weight gain with anxiety, and my existence being 'out of order'. Predictably my anxiety levels skyrocketed as I gained weight and I have spent a lot of time in counselling developing alternative means of controlling anxiety. I no longer have the fears I had while anorexic.

  7. We are now in the territory where I came unstuck for 3 weeks whilst trying to write this. The fixation on numbers (both for parents and patients) is something we come across a lot on the Around the Dinner Table forum, especially the wretched BMI. As I said in the film "The focus on BMI has distracted clinicians from the real process of recovery".

    Is this because weight and BMI are used as the major tools to gauge "recovery" because they can be measured in clinical terms, rather than the rather airy fairy "optimum function", which cannot be written in a chart or used as a statistical measure? Do we need to redefine recovery in clinical terms to incorporate those things which are not measurable, chartable and therefore can not be used for an RCT? How do we define returning health, if not by weight gain first and the orthostatics second for primary care physicians and parents and other care givers? Are we too focused on weight? If we don't use weight gain as a PRIMARY recovery tool, we are left in the airy fairy "wanting to get better" and "finding the bottom" areas of treatment. However, optimum function is just as difficult to define in clinical terms.

    And, as a parent, I wanted a number to aim for, just like Katie! The disappointment for many parents/carers of reaching that number and the symptoms of ed still remaining firmly entrenched is disheartening and can quite often be where many give up. And yet, others start recovering before getting to a target weight (something I think Katie was describing). Because everyone is different.

    Everyone's weight is different at different times of day, let alone over a month. We have known patients hospitalised on the forum at a BMI of 19 with dangerously low heart rates. Yet Cathy is healthy at the weight range. So how can we possibly rely on this ridiculous (and nonsensical) BMI to measure a patient's health - a desperately flawed statistical measure? If we don't use it, what is the alternative?

    Take it away, Cathy, my friend.

  8. Hi Charlotte, in response to some of the things you have said (above), I think that that one of the difficulties, when gaining weight with AN, is that it takes time for the brain/mind to adjust to that weight gain. Often, treatment involves pushing weight gain at, say, 1-2 pounds each week until the person is no longer underweight by BMI standards, or has attained the weight they were before they got sick (and is healthy in body). That may take a few weeks or a few months. But it takes MUCH longer for the brain/mind to change. That has been the case for me.

    But there are often other things that help the mind to change, like pushing boundaries, socialising, taking up new hobbies/activities etc. When a person is anorexic they are sort of stuck in a 'bubble'. Life doesn't move on and the person is often totally absorbed in their behaviours. Removal of those behaviours can leave a void, with the person wondering how they are supposed to start living. I know that I was terrified of doing social things and trying anything new for a long time after I had gained weight. I have had to push myself to do new things and now I enjoy socialising - (although I will never be a pubbing, clubbing person, for example).

    I have sometimes wondered whether further weight gain would help my OCD.... That is difficult to know, because I had OCD from being a 3 yr old - i.e. long before the onset of AN. Anyhow, I still aim to gain more weight and have resorted to lifting light weights and consuming protein supplements in order to be physically stronger - and hopefully gain more weight.

  9. Cathy, I certainly wasn't saying that people are universally sick or healthy at a BMI of 19, just that there are a subgroup of people with anorexia who will insist on remaining at the very low end of the acceptable BMI range because they are too scared to let their body decide where it wants to be. Which is quite understandable really, as anorexia is a terrifying pain in the butt of an illness. To be honest, my BMI hasn't been over 20 since February 2010 - it lurks between 19.2 - 19.8 most of the time - but that's not because I deliberately keep it below 20. My weight is stable around the centre of that range, my mindset is fine, I don't use behaviours, I get my periods and it's extremely hard for me to push my weight higher than that. My sister closest to me in age naturally maintains a similar range. I think maybe the anorexia changed my set point a little, since I was ill for so long - but I would be happy to go with the flow if my body randomly decided to gain more weight at some point. Like you, I have digestive problems, so maybe there's some malabsorption going on.

    I guess this is another problem with target weight - myself, Cathy and at least one of my other friends have trouble maintaining our weight because of long term damage from the ED. My other friend struggles to keep her BMI over 18, but she is mentally completely healthy - she just has dreadful gastroparesis. Trying to get her up to a BMI of 20 would be very physically painful for her, emotionally frustrating (as she can't stand counting calories or obsessing over her intake anymore, and she would have to to gain) and possible counterproductive, as it could worsen her digestive problems. I absolutely believe in full and prompt weight restoration, and I don't think that people with eating disorders are usually the best judges of where their target weights should be, but it's all terribly complicated.