Getting off the scale: Non-weight severity markers in anorexia
One of the most common catchphrases in the eating disorder community is, “It’s Not About the Weight!” Although I’d love nothing more than to change this to “It’s About More Than Just Weight!,” the fact is that, in most cases, treatment for an eating disorder depends mostly on weight. If your BMI doesn’t fall below some sort of arbitrary cut-off, no matter how sick, demented, and symptomatic you are, it’s (to borrow a phrase from Seinfeld*) NO TREATMENT FOR YOU!!
Basically all of the treatment providers, advocates, sufferers, and family members say that this is a really, really dumb system. Not that weight is irrelevant to eating disorder risks (low BMI does increase your risk of dying, but that doesn’t mean the risks at higher BMIs are insubstantial, either), but there are plenty of other psychological and physical dangers that can and do kill and seriously harm people at higher BMIs. Insurance companies and many national health systems, however, typically won’t foot the bill (an exception is labwork, but generally that involves a few days in the hospital, followed by discharge. Lifesaving, certainly, but it’s hardly ED treatment. I’ve also heard insurance that won’t pay unless your labwork is seriously messed up, which is problematic because many times in AN, your bloods remain normal even at very low weights and high symptom use, and then crash abruptly). Which is what gave me a WTF moment when I saw that in the new DSM-5, the severity marker for anorexia was…wait for it…BMI.
Bulimia and binge eating disorder have behavioral severity markers: number of binge and/or purge episodes per week. Granted, the diagnostic criteria for these disorders doesn’t involve weight change like AN does, but still. Again, I don’t think weight and weight lost are irrelevant in AN (they’re not), but for them to be the ONLY measure of severity is rather shortsighted.
Thankfully, I’m not the only one who feels this way. A large group of scientists recently published an article in the International Journal of Eating Disorders that showed restrictive eating behaviors were a separate marker of severity in AN (De Young, et al., 2013).
The researchers recruited 115 individuals with full- or sub-threshold AN that were being treated as outpatients in the Midwest. They were divided 60/40 between the restricting and binge/purge subtypes. The researchers defined “restrictive eating behaviors” as “skipping a meal; limiting calories, carbohydrates, or fat grams; and eating as little as possible,” as well as fasting and strictly limiting overall daily intake.
Using ecological momentary assessment (EMA), which using a mobile device to ping a person randomly throughout and day and ask about current or recent use of ED behaviors, including binge eating, purging, and restrictive eating behaviors. On initial surveys, the AN-BP group had higher levels of ED thoughts and behaviors, which is consistent with what researchers found in other studies.
What the researchers found from the EMA data, however, was much more interesting. The AN-BP group, although having the same average BMI as the AN-R group, had significantly different indicators on ED severity. The group had
- more episodes of binge eating and purging for week (obvious, since this is required for the diagnosis and regular binge/purge behavior is excluded in the diagnosis of AN-R)
- more fasting
- more skipped meals
- more restrictive intake at those meals
- and more times they reported “eating as little as possible”
What’s more, these behaviors weren’t a compensatory reaction to binge eating (the authors did a statistical analysis that showed when you factored in binge eating episodes, these restrictive behaviors were just as severe). Instead, they were an independent marker of ED severity. In fact, higher BMI was associated with more fasting, though not with other behaviors.
The authors concluded:
For AN, the severity dimension is based on current BMI. Body weight is an indisputably critical marker of medical severity in AN and has been associated with risk of mortality. The results of this study further indicate that the AN subtypes may be a useful proxy for degree of ED psychopathology, providing information about severity as well as the current configuration of behavioral symptoms. Indeed, the frequency of these restrictive eating behaviors (and perhaps binge eating and purging as well) may represent a nonweight-based dimension of severity in AN independent of BMI…professionals working clinically with individuals with AN may wish to assess and monitor the variety of behaviors in which their clients engage to restrict their food intake, noting that the configuration of these behaviors may differ according to subtype and represent a nonweight-based marker of the severity of ED psychopathology.
It’s not that low body weight isn’t a potential marker of severity in AN, just that it shouldn’t be the ONLY marker. We’re judging a mental illness on medical criteria. We don’t do that for depression or anxiety. Behavioral severity is also important in that it has a tremendous effect on people’s lives and overall well-being, independent of how much they weigh. That’s what we need to focus on as well as the physical factors that are associated with EDs.
*True confession: I’ve never seen an episode of Seinfeld. Not ever. Nor most of the TV shows that “normal” people watched when I was younger. Actually, I really didn’t watch TV at all. But my friend was obsessed and shared the Soup Nazi segment with me. I can haz cultural references?References:
De Young, K. P., Lavender, J. M., Steffen, K., Wonderlich, S. A., Engel, S. G., Mitchell, J. E., Crow, S. J., Peterson, C. B., Le Grange, D., Wonderlich, J. and Crosby, R. D. (2013), Restrictive eating behaviors are a nonweight-based marker of severity in anorexia nervosa. Int. J. Eat. Disord.. doi: 10.1002/eat.22163