Weight Goals in Anorexia Nervosa Treatment
By Jennifer L. Gaudiani, MD, CEDS-S, FAED, Founder & Medical Director, Gaudiani Clinic
As an outpatient internist who specializes in eating disorders, I regularly talk about weight goals in anorexia nervosa treatment with patients, families, and professionals. This is a critically important topic. Its complexity cannot be overstated, but I wanted to blog about some of the key themes I consider in hopes that it will help guide and clarify. I’d like to start by saying that I will make no distinction between individuals with the DSM-5 diagnosis of “anorexia nervosa” and those with so-called “atypical anorexia nervosa.” The latter have anorexia nervosa that doesn’t happen to result in a visibly emaciated body. I protest on grounds of sizeism: we don’t differentiate “low weight depression” from “depression.” I am a deeply dedicated practitioner of weight inclusive care, also known as Health At Every Size® (HAES®), so I work hard to apply one medical standard for all, not different standards based on body size. From this perspective, I want to acknowledge that inadequate caloric intake can impact all body systems regardless of body size or weight loss. In addition, everyone with anorexia nervosa will need nutritional rehabilitation, meaning the reintroduction of satisfying, body-honoring food intake. When I use words like “appropriate body weight” or “healthy weight,” I do not do so from a sizeist perspective. I use the word neutrally to identify that each person’s recovered size and shape will be different AND that attainment of medical and psychological stability through great nutrition will yield an appropriate body weight, unique for each person.
Attainment of appropriate body weight in anorexia nervosa is a critical element of full recovery. A person can be insightful, motivated, successful, and doing better than they were before, but unless they have achieved full weight restoration, they remain at medical and psychological risk and aren’t well. This is pretty well accepted. The questions now are: What might get in the way of good decision-making on this question? And how do we define this appropriate body weight, sometimes called full weight restoration?
What gets in the way of giving patients good guidance on this topic?
· The first one to mention is provider, familial, and societal unconscious thin bias. Almost all of us—me too—have been inculcated with the message from toddlerhood that thinner bodies are better. Thin privilege abounds in every part of society, where people in thinner bodies are consistently afforded easier passage through life compared with individuals in larger bodies: the ability to buy clothing easily from local stores, to sit in any chair available, to walk down the street without cutting glances or comments, to get hired, to dance in the front row of an ensemble, and to receive unbiased and complete healthcare, to name just a few examples. We all must recognize our internalized size bias therefore when considering weight restoration.
· In addition, there’s an understandable struggle to tolerate body distress in our beloved family members and patients. Where a loved one’s or dear patient’s eating disorder gives them distorted, miserable views of their bodies, we can find ourselves wanting to reduce the distress and supporting a lower target weight. This helps no one and can mistakenly reinforce that the eating disorder was right all along.
· Insurance pressures in higher levels of care can get in the way. The reality is that expert clinicians need to be using all the data to make the right recommendations for their patients without external reviewers interfering. Size biases and arbitrary rates of weight restoration not defined by a clinical team but by an anonymous person at a desk can all influence how messages around weight restoration are transmitted to a given patient.
· Some individuals have never existed within their adult bodies before. Some of my patients have been sick since adolescence and have never fully recovered, or did only briefly in treatment only to relapse immediately. Therefore, they’ve never actually experienced the shape and size of their natural adult body. This can be really hard to accommodate for the first time in one’s 20s, 30s, or even 40s. But a great therapist can help the patient learn to accept their adult body and remember that a body that seems utterly alien at first will feel more normal with time.
· People’s body shapes are quite different immediately following nutritional rehabilitation than they are after a year of stability. We evolved to survive starvation. Mother Nature has a million ways in which she helps a body stay alive through months of caloric deprivation. For one, people may hold extra weight in their abdomen and face, the “checking account” from which the body could rapidly use energy should intake drop again, for up to a year after nutritional rehabilitation. After that, bodies will tend to redistribute weight in a way that is congruent with the genetic blueprint for the person’s body. Many people vow not to relapse again because the process of adjusting after initial weight restoration is so painful and dysmorphic. Hang in there; it gets better.
So what goes into the decision process for weight targets? First and foremost, we have to understand that a person’s healthy weight is highly individual to their genetics, their medical history, their experiences with food and dieting/caloric restriction throughout their life, and their body’s unique responses to inadequate fueling and to nutritional rehabilitation. There is no one right size that fits all when it comes to healthy weight after anorexia nervosa. Thus anyone who uses an equation (such as a BMI or ideal body weight calculator) or simplifies this complicated situation is relying on tools that are inadequate. Here’s some of what I consider:
· Look at childhood growth charts. Someone who was 5th percentile throughout childhood and someone who was 95th percentile will likely be genetically destined to end up in pretty different bodies. This matters.
· Make sure you have the support of an expert dietitian who is eating disorder trained and ideally practices from a weight-inclusive framework. Unfortunately, many medical professionals, nutritionists, life coaches, and therapists have not yet done vital work on understanding their internalized thin biases, and they end up subscribing to and recommending practices that are grounded in diet culture. This is very harmful for everyone, but particularly so for those recovering from eating disorders.
· Consider medical complications of malnutrition, regardless of body weight. Thoughtful, expert medical evaluation throughout the recovery process helps bring objective (but not always measurable) evidence to this discussion. When the hands and feet feel warm consistently, the digestion is functioning well (taking into consideration related, primary diagnoses that may also be present like irritable bowel syndrome, small intestinal bacterial overgrowth, Crohn’s, etc.), sex hormones have returned to age-appropriate levels, energy and strength have returned congruent with ability, sleep has improved, and the individual’s pre-eating disorder personality shines through again (spontaneous, creative, funny, sarcastic, caring, engaged….), these are often great markers that they have arrived at a medically stable weight.
· Set a minimum weight, not a range. As a HAES provider, I have moved toward setting a minimum weight rather than a weight range for my patients, and I do so in concert with my patient, the rest of their outpatient team, and where appropriate, their family members. A weight range implies that there’s a weight above which they’ve gone “too high.” The reality is that many patients are destined to live in larger bodies genetically and after years of dieting and weight cycling. It’s not my job to set some arbitrary limit for “too high.” Rather, once someone has achieved their minimum appropriate weight based on the above criteria, I sit peacefully with this knowledge: as they transition from a prescriptive meal plan to an increasingly intuitive maintenance intake, their bodies will settle into a shape and size written by their genetics. That might be somewhat lower than “equations” might predict, or higher, or as expected.
· Bodies are miraculous and extraordinary; when given rest, ease from stress and trauma, and satisfying, adequate fuel, they know what to do.