Weight, Part I

Medical management of eating disorders revolves around weight. Every day in residential treatment and at every appointment in outpatient care, getting on the scale is the focal moment for both patient and doctor. 

Weight fluctuations are central to many other illnesses and a good data point for progress or regression. But in treating people with eating disorders, doctors act as if weight is absolutely paramount. 

On the one hand, this seems reasonable. Eating disorder thought processes are almost exclusively about weight and body, so weight normalization appears to be key to recovery. Yet clinicians are often as focused or even more focused on the number on the scale than the person with the illness. Frequently, this dual obsession of patient and clinician sets up an unworkable battle. 

In all other illnesses, a clinician's focus is not on a data point but on health. Eating disorders cause many serious medical problems from anemia to kidney dysfunction to cardiovascular collapse. People routinely die from eating disorders. There are many physical signs and symptoms and clinical facts to address in addition to weight. 

In fact weight is often an elusive and confounding piece of information. Daily weights tend to reflect fluid shifts based on many factors. For instance, even a salty meal can lead to 2-3 pounds of extra fluid weight the next morning for anyone. Actual body mass rarely changes by even two pounds in a week, even for very underweight patients in residential treatment. 

So the question I often consider is why is the clinical world so focused on weight?

The first consideration is that abnormal weights upset clinicians, and weight normalization feels like healing a sick person. Most people with eating disorders whose weight has normalized actually suffer more because their eating disorder thoughts are so dominant. Treatment needs to address the psychological part of these illnesses as well, otherwise recovery is for the clinician's well-being, not the patient's. Focusing exclusively on weight reveals the unfortunate ignorance of many clinicians about recovery. 

The second factor is insurance companies. In order to avoid paying for care, insurance companies have limited the amount of care by assessing practical but very short-sighted data points. Weight is the primary focus. If a patient's weight is normal, then insurance companies limit access to care. Since people frequently change health insurance, these companies bank on providing a stopgap measure to save money. Long-term recovery is not a priority. 

If weight is not the central marker of successful recovery, how can clinicians and patients assess progress? I'll discuss that in the next post.