When a person's weight is so critically low that their organs are starting to fail, their low blood pressure is preventing adequate tissue perfusion, and their heart has atrophied to the point that they are at risk of cardiac failure then weight is a really important issue. In that situation, weight gain to a level that the person is out of imminent danger is essential.

Having said that, it is very unhelpful when clinicians focus largely on our weight, to the exclusion of our psychological state. When people who have never had an ED think of anorexia nervosa (AN) they immediately think 'thin'. Some (but fortunately not all) clinicians are the same. It is as though their aim in treatment is simply to encourage weight gain, to some 'magic' level, as rapidly as possible, and hope that their patient is cured, because their weight has reached the 'target' and they look recovered physically.

I firmly believe that achieving a weight at which our bodies function optimally (i.e. that 'magic' weight/weight range) is essential to recovery. I also know, on the basis of statistical probability, that that 'magic' weight/weight range will vary from one person to another. However, I know, from personal experience, that it is really important that the person is able to discuss his/her difficulties and attempt to resolve them as much as is possible through psychological therapy.

A person cannot recover from AN without gaining weight, and psychological therapy may be rather futile for people with very low weights; but what has helped me most in my recovery has been my psychiatrist recognising that I would not be mentally recovered at my so-called target/'magic' weight. There's a lot more to recovery than just weight gain and 'target' weights.

I get really frustrated with this, especially given the number of people I know on harm minimisation plans in the UK. I have several friends whose care plan entails being helped to maintain a BMI anywhere between 13-18, just to keep them out of hospital but with no expectation of further recovery and no thought to quality of life. When I was very ill last year I picked what I thought would be a healthy target weight range for me, and when I told the person I was seeing at the local EDU that I wanted to shoot for that she said I was being overambitious. A BMI of 20-21 is OVERAMBITIOUS?! Apparently she thought I would never cope and should set my sights on being a chronic patient at a much lower weight. Obviously I ignored her and got to my target anyway, because I'm cool like that :P but if someone had said that to me at any other time in my recovery when I wasn't so committed, it would have absolutely devastated me, made me think that I was hopeless and recovery impossible. It's not impossible, but it is not possible to fully recover whilst maintaining too low a weight. I think this is partly where the myth that eating disorders are incurable actually comes from. People maintain weights which are too low, still have overwhelming eating disordered thoughts and urges, and relapse again and again. I'm not saying that weight gain alone cures anorexia because it doesn't, therapy and other support is essential, but equally full recovery is impossible without full weight restoration.

I can't understand why professionals do this either. Seriously, if treatment teams are worried that the person will find it hard to cope at that weight, they should provide extra support for at least 6-12 months after weight restoration. My local EDU used to throw people out the door when they got to a BMI of 20 - and not just out of IP, out of outpatient therapy as well. Then they treat you like you're just stubborn and hopeless when you relapse and turn up again six months later. It would save so much money if they provided adequate aftercare rather than just getting someone to a medically stable weight and hoping for the best. Sorry, I know I'm preaching to the converted :P but this makes me so frustrated, angry and sad for all my friends who are treated this way.

I'm not really sure why treatment centers low-ball weight either. Are they trying to make is easier on us, psychologically? If so, they're not doing any favors. When I was in treatment, they "let me" discharge at the very low end of my ideal weight. Yes, I was healthy. My period came back, etc, but I still think it would have been good to get me a bit farther into the healthy range. I still find myself struggling to push higher. I know it'd be better for me, but it's hard to rationalize when I'm physically healthy, etc. There are HUGE emotional benefits though, and protection against relapse is a big deal (though I don't think I've realized this in the past until I've already relapsed).

Cathy,

I agree that weight shouldn't be the key focus in treatment, but without reaching an appropriate weight, the rest of treatment can be much more difficult than it needs to be. I've been weight restored for a while, and I'm definitely not recovered, nor would I claim to be. That being said, brain healing doesn't really begin until a person is at an appropriate weight.

Thanks for the response Carrie. Yes, I totally agree about specific aspects of brain healing going hand-in-hand with achieving a healthy weight. I also agree that body fat is not a bad thing. I am so much better now that I have some!

My main point, which was not immediately related to your post, is that I do feel that some clinicians become too embroiled in the issue of weight - so much so that they may exclude psychological recovery.

There are many reasons why people are triggered into EDs. Some people develop an ED after traumatic events such as sexual abuse, bullying or parental divorce. Others remain sick, not just due to starvation-related distortions of brain function, but because they are genuinely scared of life outside their ED. This is especially true for people who are weight restored, then relapse, are again weight restored - then relapse. Sometimes an ED is the manifestation of (e.g.) an underlying personality disorder or autism spectrum disorder that need attention.

Cathy,

Absolutely clinicians can become too embroiled on weight as the be all, end all recovery marker. And return to a healthy weight should be the starting point of the hard work of recovery not the ending point. Too much weight focus can be as bad as too little. If weight restoration cured EDs, then things would be much easier.

Gotta love how treatment providers are sometimes almost as distorted about weight as their patients. One of my "favorite" treatment moments was a conversation where my nutritionist (who did not weigh me) told me I was absolutely not to lose any more weight. I asked her what she thought I should weigh; based on my height, she responded with a range, the upper end of which was 10 lbs. BELOW my weight at the time. I'm a dense, muscular person, so people often assume I weigh less than I do, but even with all my nutritionist's experience, it somehow didn't occur to her to take that into account. She had one weight range for all 5'4" people, regardless of build. Even though some part of me knew that the numbers she gave me were far too low given my muscle mass & history, it was NOT helpful for my tenuous mental state at the time!

My team is specifically NOT giving me a target weight. Neither are they tracking it. We talked about it, and I know that right now my brain would play unkind games with any target number they gave me, because I would see it as some monolithic maximum, a "limit" instead of a goal, and would freak the hell out the closer I got because I would feel like I risked going above it. I was essentially a child when I started dieting (prepuberty), so I can't use my pre-ED weight as a baseline. They've told me that I can't settle at any weight at which I'm not having a period, so when that happens I guess we'll re-evaluate how far I have left to go.

THANK YOU for bringing attention to this issue! I've had various doctors in the past make some damn idiotic remarks about how much weight I needed to gain, sorry you've been put through the wringer on that too. Sigh.

Katy,

I have the same issue as you: I weigh more than I look like I do. And it's only the more enlightened of my therapists that doesn't really look at the weight itself all that closely.

Cammy,

To some extent, I think that paying less attention to the weight can also be helpful because they're not going to tell you "You're set! You're fixed!" at an arbitrary number.

I think low-range discharges and target-weight goals have more to do with money. It costs a lot in care that is often already uncompensated or under-compensated by third-party payers. You can't run a practice, an inpatient unit or a treatment program at all if you can't pay the bills. And if you routinely keep patients past the technically "healthy" point, some insurers may decide you aren't a preferred provider, which sends those patients to another facility that will.

It may be because I have only been treated in hospital-based inpatient units, but I have never had a "low-ball" target weight. I have been allowed to leave against medical advice at low weights and non-recovery weights, but my goal weight has always been *higher* than any weight I had ever been. I always freak out because my goal weight is more than what I weighed pregnant (and I gained 26 pounds and delivered a full-term 8 lb. 4 oz. baby). And, I had been considered healthy-weight/didn't meet any dx criteria for AN for seven years. Of course, I *did* relapse after my third child ... so maybe the BMI of pregnancy *is* the best range for me.

Back to reimbursement, though ... the treatment team told me at three different hospitals that the tables they were using were actually higher than expectations and based on the older MetLife projections, because it allowed them to diagnose *more* people and offer treatment, based on BMI.

M,

You raise some really good points. I really hate our healthcare system sometimes...

These weights that I was given were not discharge weights- I never got near a "discharge" weight before insurance crapped out and I got sent home. These were long-term weight goals and I interpreted them as such. Most of the time, even the MDs knew I wouldn't be able to stay long enough for anything approaching full weight restoration. I've also left treatment at sub-optimal weights for a variety of reasons (some ED-driven, a few not).

Being at a healthy weight doesn't totally protect you from relapse- my last relapse this spring was after I had been at a healthy weight for a few months (though I promptly sank below that by a few pounds and, um, oops). Still, I think this is an important issue and I am so glad to see everyone discussing it!

This is a really interesting issue and I think most of my points were covered (rather eloquently, I might add) in the comments above. I was told that I was past critical at points in IP stay, only to be discharged the next day due to insurance issues (or lack thereof). They were more than willing to throw me on a huge, generic meal plan and send me to "process" groups, but once the money was out, so was I.

I know a general range of where I need to be, but I find that I'm having to convince others that it's a problem. My GP just last month questioned why I was asking for blood work, said my weight was a little low but my EKG was fine and went on his way. They see thin, they think "eat" and problem solved. If it were that easy, we wouldn't be having this discussion.

Recently I've realized that in order to even give myself a fighting chance, I have to first restore the weight. I can work on "issues" and try to process things all I want, but I can't truly recover without recovering the physical aspects of my health. By staying thin, I'm staying stuck. If I still have the same issues and problems 30lbs from now, at least I'll know that the physical conditions aren't at the root of the dysfunction.

Now if I could just snap my fingers and gain 30 lbs, be fine with that and move on...

I have never had this problem with treatment in Canada. . .

My first hospital stay gave me a BMI of 20 -- my second gave me a BMI of 21 (which I promptly freaked out about because I honestly thought no one should weight more than a BMI of 20 -- this was however, based on growth chart) and my last stay,a minimum of a BMI of 20 was recommended.

This was always relieving for me because it was very similar to what I weight pre-ED. I was around a BMI of 20-21.5 in my early teens, so this made sense to me. I am actually triggered when people tell me that their target weights are lower than a BMI of 20 because I wonder why they can "get away with" staying slimmer while I cannot. It also makes me question my target weight.

Katie -- if someone had told me my target weight was "overambitious" I would have definatley freaked out and taken that the wrong way!

I am suprised that clinicans can feel OK with how they practice if they are giving out target weights that predispose indiivudals to relapse.

A:)

I don't often comment but Carrie, your blog is fantastic, a wealth of information that has taught me so much about the illness that has destroyed over a decade of my life.

I went into IP at 16 (UK) and was allowed to leave at a BMI of 17 after freaking out at anything above this...I "needed" to start a new term at school so off I went back home. You know what's coming! I relapsed and have spent since then consumed by anorexia to some degree...I still wonder what would have happened if I'd been MADE to stay to a BMI 20...I expect my poor bones wonder too. Treatment is all based on BMI here. When I tried to ask for help a few years ago at a BMI 15/16 I was told by an Eating Disorder psychologist that she couldn't help me "until I was weak enough to need a wheelchair" beacuse she had people worse than me to help first and they'd tried to help me when I was younger and it hadn't worked. My formal complaint letter didn't get me anywhere!

Anyway, rant over,brilliant post and excellent comments as always!

Hi, I'm not sure if this is the appropriate place to ask this... but I am concerned that my treatment team focussed more on getting me to a certain weight than on my body composition. I guess building muscle takes a lot more time than putting on fat, and their goal is to get me to a medically stable weight ASAP. But I am now stuck with a body that is, well, plainly overfat, even though I'm at a BMI of 20. I never had exercise issues before, and now it's all I can think about - building some muscle to replace the fat.

Do you know if the body has a "set point" of muscle-to-fat ratio that it'll try to go back to once it's being given adequate calories?

Needless to say I'm still pretty deep it the body image stuff. I just feel I went into recovery not realizing I'd end up with a body that looks so much different than the last time I was at this weight.

Yes, it will adjust. Maybe you could talk to your team about adding some light hand weight exercises to start building up muscle mass- it's good for your bones, too. An ED totally cannibalizes your muscles, and it will take time to build them back up. Much of it will happen as your body adjusts to being fed regularly.

If we focus on body fat percentage intead of BMI, then what %age would be considered healthy?

I am in recovery and also struggling to figure out what weight I should aim for - since the weight I was before I had any ED behaviours was when I was 12 years old, 22 years ago!