There is always a lot of talk and anxiety about a so-called “ideal body weight” (IBW) in patients with anorexia nervosa. It is sometimes called “expected body weight” “goal weight” or “minimum weight for health.” Any way you put it, the subject generates more heat than light.
In an attempt to clarify the issue of goal weights for other doctors and for parents I wrote a short essay called “Determining ideal body weight” in children and young adults. In the essay, goal weight or IBW is based on careful assessment of Tanner Stage (pubertal stage), growth charts, pre-morbid weight (i.e. before the illness) and parental size and shape for each individual child. It is emphatically not based on BMI charts.
I am aware that psychiatrists and therapists in general do not examine their patients physically. I think this fact makes them the wrong people to make a diagnosis of an eating disorder, and is reminiscent of ancient Chinese practices where doctors were not allowed to examine women, but rather pointed to body parts on a small figurine. Physical exam is an important part of any accurate diagnostic work-up. If you can’t make an accurate assessment of a child’s pubertal trajectory (Tanner stage), send them to someone who can, and let them make the diagnosis.
So, having written this little essay, and having been asked to help set guidelines for general practitioners in the UK I was confident I had the bases covered. Imagine my surprise when Charlotte told me that in the UK, kids are not routinely weighed throughout childhood and therefore no growth charts are generated by their doctors. And I have since been alerted to the possibility that this may also be the case in Australia and New Zealand.
Stop the presses! Grave danger of paradigm shift! Re-think, re-think.
A few years ago at an EDRS meeting, Bryan Lask threw down a challenge that nearly everyone ignored. His challenge has remained with me like a pebble in my shoe. He asked: “who owns this weight obsession in anorexia nervosa?” and suggested we stop weighing patients altogether.
Kartini Clinic’s treatment orientation mandates weight recovery as the foundation of treatment, so I couldn’t really conceptualize not weighing our patients, even though we do not share their weights with them. How could we manage to restore our patients physiologically without weighing them? How could anyone? Further, this information from Charlotte challenged me to imagine creating a personalized weight goal without the ability to look at a patient’s growth chart or know their pre-morbid weight.
Well, since they have not weighed kids in the UK, why start now?
After giving this issue some thought, my suggestion to Charlotte is this: work towards a “state” rather than a “weight”. By this I mean, begin to re-feed and continue to do so until heart rate, pulse and blood pressure differentials (orthostatics), hormone status, and menstrual status (females only) normalize, until growth resumes, tanner stages advance, etc.
Let someone else own the weight obsession; maybe we can give it up.
Thoughts, anyone?
