Friday, November 2, 2012

Opinions on weighing

A recent discussion on a professional listserv was regarding whether or not providers weigh patients and communicate their weight to them. At about the same time, a normal weight patient in the process of learning Intuitive Eating commented to me that she felt that being weighed by her dietitian went counter to learning IE, which I thought was an interesting point, so I brought this question to the listserv.

Everywhere I have ever worked has not shown the weights to patients, instead making the treatment team responsible for weights and encouraging patients to not focus on weight, but to instead focus on becoming healthy. Which is what still makes the most sense to me. Weight has recently been such a topic of debate within the field, with of course the "old school way" being to focus likely too much on weight, which has resulted in many problems getting appropriate insurance coverage for EDs. The insurance industry took the height/weight numbers identified in the DSM, and used these to justify terminating treatment ridiculously early. As a result, I believe the weight criteria will be removed for the DSM-V, but don't quote me on that. But then the "new school" seems to, in my opinion, go a little overboard in saying we shouldn't care about patient weights at all, and instead focus solely on physical signs of starvation.

Personally, I think it is more realistic to be in the middle ground. Reality is that weight is one of the more concrete indicators we have to work with in treating eating disorders. But, it certainly is not the be all and end all, since reality is nobody can ever know what is the "right" weight for someone. So, I both track patient weights, through a dietitian or physician, but also ask patients questions that assess for cognitive and physical effects of starvation. I don't think you can do just one or the other because, in my experience, sometimes the cognitive effects don't necessarily change immediately upon the patient seeming to get to a healthy weight, but instead develop over the next little while, while they maintain that healthy weight.

I think most everyone agrees we need to weigh patients who need to gain weight; I saw no debate of that point. But then there's the debate of whether the weight should be shown to the patient. I can see benefits to showing the weight, especially for patients who dramatically overestimate what they weigh or how quickly they are gaining. But I guess I'm not sure why we would show weights for any other reason. To show weights seems, to me, like it perhaps reinforces the message that the weight is important. Though, again, I'm sure there's a middle ground wherein the weight is shown, but also discussed as being not nearly as important as physical and emotional health. I guess I'm just concerned that showing weights could end up taking up more therapeutic time than if the individual just learns to not focus on weight without seeing and reacting to it.

To address my question of weighing in those of normal weight and learning Intuitive Eating, Elyse Resch, one of the authors of Intuitive Eating, did confirm what my patient  had said, and argued that patients who are learning IE, should not ever be weighed, as this does propagate the focus on weight and number. But then, we have had patients who want to turn over weighing to us for fear that if their weight is not tracked, they will gain weight and nobody will know. But then others feel shame and guilt even stepping on the scale, perhaps due to things like weigh-ins at Weight Watchers.

So, as you can see, this is proving to be a bit of a confusing topic! As far as I heard on the listserv, nobody has ever actually researched the effect of doing blind vs non-blind weights. So, I thought we should do our own, terribly informal, qualitative research here, and ask for your thoughts on blind vs non-blind weights. Please, comment away!!


  1. I like being weighed backwards, and not knowing but knowing that some one I can trust is observing it for me. But the thing I do not like is being weighed multiple places when it is already being constantly monitored, because then I feel like it's a little to much. I think for me if I knew my weight it would become an obsession but having an idea of the range I am in. I also enjoyed being taught about how weight varies it brings a lot of perspective. I also wanted to comment on something I have read on here where food labels have a 20% leeway and I have to say it has made me careless about voiding and obsessing.

  2. Way back when I was very sick and deep into behaviors I definitely appreciated and needed blind weights from dietitian and questions like you mentioned from my therapist to help me and because knowing my weight would have only perpetuated my Ed further. However, as I got stronger and healthier I hated getting blind weights as I felt worse about myself and got more depressed and wanted to go back to Ed. Finally towards one of my stays at a treatment center I finally was able to start being ready to focus on IE and then I was able to convince my team to let me try knowing my weights and it was hard at first but I don't think it took up to much time in therapy as I was then able to process more behind the symptoms etc. Knowing my weight now when going to doctors as I know longer get weighed regularly and haven't engaged in any behaviors for over a year lets me know that I am doing the right thing and staying healthy. My weight is a number not who I am.Ed isn't an option.

  3. hmmm, i read this a few days ago but didn't comment because i wasn't sure what my opinion was. i've thought about it a little bit, and here is my somewhat jumbled response:

    i can only speak from the perspective of someone who has AN, so for those who suffer from BN or other disorders, i can't really say what is best. but for me, the first time i went to IP treatment 10 years ago, they told me my goal weight. i FREAKED out, because of course i knew how much i weighed going in, and so doing the math and realizing how much i had to gain made me agonize and stress over that number. it was a huge mistake, in telling me.

    so, for those who have to gain weight, i think it is very necessary for the patient to not know their weight, and to not know their goal weight. i think maybe them knowing a range is okay, but i think a concrete number is ineffective because 1) what if that number doesn't end up being the "magic" number, and heaven forbid they need to get a little higher, and then if the patient does end up gaining a bit of weight, they freak out and think they're overweight and that they did something wrong, etc. 2) for me, i started to obsess about the number. about how i couldn't get any higher, etc, and instead of focusing on my health and how i was feeling, i disregarded all that an only focused on the number. i felt like a failure if i got above what they told me was my goal weight.


    with IE, i think it's different. for the few months that i was actively working on IE and maintaining a stable weight, i feel like getting weighed every week was not helpful. i think getting weighed every 2-4 weeks (depending on the patient) would have been more beneficial. i started to get freaked out knowing i was about to get weighed, and in my head, if i went up or down, that meant i sucked and obviously couldn't do IE and was doing something wrong and was never going to get it right blah blah. when in reality, especially at first, IE is all about feeling things out and testing the waters, and in reality, your weight is going to fluctuate. i think that if the patient is in a good place and honest and if they are not engaging in ED behaviors, then i think that if they are working on IE, they shouldn't be weighed weekly. we're always told in treatment that weight isn't important, and i see the need for it (like you said) in patients who need to gain weight, but when they are stable, i think that the importance of being weighed weekly should be put on the back burner in favor of letting them really explore IE without having to constantly worry if the number on the scale is going to go up or down.

    just my thoughts.

  4. For me, it was really helpful to know that I COULD eat and NOT gain weight (eventually). It honestly drove me crazy in treatment to not know my weight, so much so that I honestly turned it into a game of trying to guess the WHOLE 4 months. I realize that's my problem in part, but I honestly think it would have been better to just tell me and let me DEAL with it. I do believe that it's something we need to deal with. If you look at it objectively, it's like height. It's a measurement that doesn't have anything to do with WHO you are. It's really impractical to not have any idea about size, weight, etc, in my opinion. At some point, most patients will step on a scale. At some point, all patieients will have to buy clothes. Most of of remember what weights we were at certain sizes.

    I guess I just believe that it's important to DEAL with it. Not hide from it. I'm at a healthy weight and I am OKAY with it. That was a huge step! And it was a big moment in my life where I could say, I'm healthy, and that's okay, and I am proud of that. I do realize we are all different here, but that was my experience.

    Fwiw, I still work with people from a treatment center that is VERY STRICT about not letting weights be known, but my therapist and dr have agreed that for me, I seem to handle it okay and it might be best for me. I also am pretty good about setting a "range" instead of a number, which I think is important.

  5. I feel that unless there is a weight gain need, that a patient should not be weighed. For me being weighed even backwards was anxiety ridden. There were always a million thoughts going through my head every time I had to get on the scale for someone else. Do they think I'm too fat? Did I lose weight? Did I gain weight? Will they think I'm not sick enough? Will they think I eat too much or not enough? These questions became so overwhelming that it really interfered with my ability to do dietary work for a long time.

    On the flip side of that, it's true that it's hard to keep a patient's weight a secret from them forever. What's going to happen when they do find out? Will they be able to handle it? I LOATHED being weighed altogether when I was in treatment, but if I had to be weighed, I would have preferred they just tell me so that I could deal with it.

  6. I was similar Krista. SO worried about pleasing the dietitian and making her proud of me that weigh-ins made me crazy. Is the number too big? Is the number too small? Is she proud of me? Is she mad at me? What if I do everything right, and the scale doesn't show it? She won't believe me - she'll only believe the scale.

    I was also trying to do a lot of trauma work. I wasn't sleeping. I was barely functioning, and I finally told her I couldn't be weighed every week. I understood that avoiding the scale wouldn't change anything, but I just couldn't handle one more thing to worry about right then. My therapist agreed, and I stopped doing weigh-ins. It was nice that he listened to me when I told him what I needed. His trust in me made a world of difference. It helped give me the courage to face into all of the crapwork I needed to do.

    Eventually, I got through the worst of the trauma work. And then found that I didn't need to do dietary work, because the eating disorder just... went away. I'm not afraid of the scale. I know how much I weigh (generally), and I also know it has stayed pretty close to the same for more than four years.

    I think the most powerful thing is if a treatment provider can look at the individual and the individual's needs. I also recognize that is a tall order to fill.

  7. I really appreciate all your comments here. And, in the end, your comments confirm the stance of probably the majority of the profession: take it patient by patient and decide on an individual basis. I am happy to be in an environment (does your own practice count as an environment?) where I can totally individualize treatment, and not be held to mass decisions. I still lean towards not showing weights, but can be convinced otherwise when needed.