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The "holy cow" of eating disorder treatment

Posted Apr 30 2009 1:04pm
If you follow my writing (doesn't everyone?) you will share my shock that a paper challenging the importance of weight would make me happy.

"Anorexia nervosa-Irony, Misnomer and Paradox" by the esteemed Bryan Lask and Ian Frampton has this incendiary introduction: "professionals tend to hold the same morbid preoccupation with weight, BMI and targets as do our patients"

Now, I would start with a tiny disagreement: I think a bigger problem is that the profession does NOT pay enough attention to weight. The medical establishment does, and nutritionists do, but most eating disorder patients are seen by psychotherapists primarily or exclusively until they are so ill that their prognosis and treatment is indeed centered around weight restoration and targets.

The arguement of the paper is not that weight restoration doesn't matter. The argument is that weight is a poorly understood, poorly measured, easily gamed proxy for real medical measurement. And this is indisputable. Sitting around staring at the number when we don't make the targets based on good science and the numbers change for many reasons and even at best the number on the scale isn't measuring recovery of the brain.

But there we are: isn't the problem that the scale is the only measure we really have or agree on. The body compensates for malnutrition almost to the point of death and the other measures available are of likely harm but never of HEALTH. We can't measure mental wellness. We can't weigh stability.

I'm ready to agree that weight is a silly measure but I need two things before I let go of this rung: alternatives, and some assurance that regaining medical health is considered a minimum if not sufficient goal of treatment.

Because most ED treatment ignores weight restoration altogether. It only considers a patient needing nutrition or medical intervention when far below optimal health. This is like getting rid of swimming lessons and lifeguards at pools and instead having a speed dial to the ambulance when someone is found lifeless.

And without any measures at all, we are back to trying to convince anosognosic patients (and yes, the authors use that term - one up to now I thought I was the only one using for EDs, hoping that others would take it up!) to stop their behaviors on the strength of our brilliant advice and cogent arguments. Without measures we are left as families to keep feeling and saying "you are not well" but lacking confidence ourselves that we are making sense. We leave clinicians unable to intervene until life is threatened, and bystanders confused and angry.

Yes, it is not about the weight. But bring me other measures and assure me that that it is at least about the weight being healthy, because that cannot be assumed.
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