At the recent ANZAED conference on the Gold Coast there was a plenary session that focused on whether we should weigh patients. The gist of the discussion was that weight (and by extension BMI) is not a good measure for health and so we shouldn't use it as one. More accurate ways to assess health were discussed, which may be great if you work in a large hospital and have access to the appropriate equipment. The lack of data as to whether actually weighing patients adds to positive outcomes was pointed out and is concerning. However, weighing a patient is a key component in the therapies that have the most promising outcomes, which may tell us something. My understanding is that there is also pretty strong data in obesity treatment that weighing a patient leads to better outcome.
When weighing patients is being discussed there are many black and white statements expressed - we must weigh all patients, we should not weigh any patients, we should tell every patient their weight or we should never tell patients their weight as they would become distressed.
People seem to miss the point of why it seems really helpful to weigh patients.
I agree that weight may (or may not) be a good measure of health. I get that health is more complicated than any single measure. That is why when a patient is first seen at The Redleaf Practice we typically take a weight and ask a medical practitioner to perform a range of medical investigations, including blood test, ECG and temperature.
The point that seems to get lost is that I don't weigh patients to see if they are healthy. I weigh my patients because they are suffering and are plagued by thoughts about their weight and the importance of it. Their weight makes them anxious and they engage in destructive behaviours to reduce this anxiety. I can't help people with their thoughts and emotions about weight unless the number on the scale is in the room. This is like trying to help someone with anxiety around heights but not getting them to climb a ladder. It's just not how you treat anxiety. I weigh patients so that they can experience the anxiety and learn how to cope with it. At one level it is a chance for a patient to experience anxiety and distress and then practice the skills that we have discussed to manage their distress. This is particularly the case early in treatment.
Another way I might help a patient manage anxiety around weight is to have a patient stand on the scales and look at “the number on the scales” (i.e. let’s move away from the meaning ascribed to a weight and observe and describe the number on the scales). We might describe what the number on the scales looks like (it’s a digital scale so pretty much like lines in different directions) and describe the scale. I’ll ask the patient what their level of distress is. Then we keep doing this - sometimes for the whole session. Anxiety about that number and standing on the scale will always decrease. That is what exposure is. When asked what they learnt, patients will almost always say anxiety came and went and that they got bored (and a little frustrated with their therapist). They learn that anxiety, as distressing as it can be, does not kill you and it, like a wave, goes away.
When weighing patients is being discussed there are many black and white statements expressed - we must weigh all patients, we should not weigh any patients, we should tell every patient their weight or we should never tell patients their weight as they would become distressed.
People seem to miss the point of why it seems really helpful to weigh patients.
I agree that weight may (or may not) be a good measure of health. I get that health is more complicated than any single measure. That is why when a patient is first seen at The Redleaf Practice we typically take a weight and ask a medical practitioner to perform a range of medical investigations, including blood test, ECG and temperature.
The point that seems to get lost is that I don't weigh patients to see if they are healthy. I weigh my patients because they are suffering and are plagued by thoughts about their weight and the importance of it. Their weight makes them anxious and they engage in destructive behaviours to reduce this anxiety. I can't help people with their thoughts and emotions about weight unless the number on the scale is in the room. This is like trying to help someone with anxiety around heights but not getting them to climb a ladder. It's just not how you treat anxiety. I weigh patients so that they can experience the anxiety and learn how to cope with it. At one level it is a chance for a patient to experience anxiety and distress and then practice the skills that we have discussed to manage their distress. This is particularly the case early in treatment.
Another way I might help a patient manage anxiety around weight is to have a patient stand on the scales and look at “the number on the scales” (i.e. let’s move away from the meaning ascribed to a weight and observe and describe the number on the scales). We might describe what the number on the scales looks like (it’s a digital scale so pretty much like lines in different directions) and describe the scale. I’ll ask the patient what their level of distress is. Then we keep doing this - sometimes for the whole session. Anxiety about that number and standing on the scale will always decrease. That is what exposure is. When asked what they learnt, patients will almost always say anxiety came and went and that they got bored (and a little frustrated with their therapist). They learn that anxiety, as distressing as it can be, does not kill you and it, like a wave, goes away.
We also might look at how inaccurate scales are as a way of measuring your worth as a human being. We might take multiple weights in different spots and see if being weighed in a certain corner of the room makes us more worthwhile than if we are weighed in the middle of the room. We can then have a conversation as to how this makes sense and if there is maybe a different way we might evaluate ourselves.
We might also stand on the scales and just practice our defusion skills. When you do anything anxiety provoking the little voice inside your head will tell you to stop it. When we learn defusion we can practice recognising what our mind (or the eating disordered mind) says to us and to practice holding this lightly under the really ‘thought provoking’ conditions of being weighed. We might do this walking to the scales, on the scales and after being weighed. It’s hard but you can learn to defuse from what the eating disordered mindset tells you about the meaning of the weight.
Not surprisingly, patients have many beliefs about weight and weight change. “If I eat an extra fruit my weight will go up by a kilo… etc. etc. or, “if I eat regularly I will gain weight”. You gain information about these beliefs from being weighed. A mistake that we make however, is to look at each individual weight. This is a problem because weight varies from moment to moment and making conclusions week to week is not very useful. It feels much better to wait and draw conclusions after a series of about 4 weeks to make a decision if weight is changing (which doesn’t really fit into a twenty session therapy if you are evaluating the impact of a piece of fruit). I have found dietitians know more about what should happen to weight when you eat a certain amount and this is where I often have a dietitian involved in treatment.
It can also be helpful to have patients make predictions of what will happen to their weight each week. When we have a graph of actual weight, cumulative predicted weight and weekly weight prediction (sometimes what you think the weight will do and what you feel your weight will do) you have a pretty messy graph that will lead to an eventual conclusion that my predictions about weight are not that accurate and maybe I shouldn’t follow them.
I’m often asked who should weigh the patient. My answer is whomever has a rationale that you can explain whilst you look the patient in the eye. If weight change (or weight stabilisation) is the point of treatment, weight can be used to see if that goal is being met. That makes sense. If the goals are not being met you may need to make a decision about the direction of treatment. Weighing to see if a patient is healthy makes less sense, as it may not be a particularly good measure of health. Although, if you also take into account blood results, ECG results, etc. you are on safer ground. Weighing a patient because “I’m a … insert profession..” or “It is in the manual” are pretty lame reasons if you ask me.
One of the reasons I will weigh a patient is to elicit the thoughts about the number on the scale when they are "hot" and come with all the attached emotion. This is why the clinician helping the patient with their distress needs to be weighing the patient and not just receiving the weight from a dietitian or practice nurse (which was how weight was gathered in the original incarnations of CBT). A story - I once weighed a patient and they lost a few hundred grams. Anorexia was initially very happy and my patient smiled. As we walked back to my office my patient’s mood changed and she began to beat her hand against the wall as we walked down the corridor. Anorexia had begun to tell her how hopeless she was because she should have eaten less and lost even more weight. This led to a really productive discussion of how the pleasure of anorexia can be so short lived. I wouldn’t have had that conversation if I hadn’t weighed the patient. I wouldn’t have experienced how distressing a weight loss was for this patient.
There is no one reason to weigh a patient. I think it is also useful to think through the idea that weighing a patient may have different rationales at different points in therapy. Initially, weighing a patient may be an important part of the assessment process and can be useful in setting goals. During treatment, weight is usually used to review the outcome of a behavioural experiment (does eating more lead to as much weight gain as I predict), and later in treatment can be used to help a patient decrease distress around the number on the scale and shift the attachment between the number on the scales and the sense of our worth as a person.
I can think of lots of reasons to weigh a patient with an eating disorder. There may be some reasons not to. I am happy to hear about them.
Not surprisingly, patients have many beliefs about weight and weight change. “If I eat an extra fruit my weight will go up by a kilo… etc. etc. or, “if I eat regularly I will gain weight”. You gain information about these beliefs from being weighed. A mistake that we make however, is to look at each individual weight. This is a problem because weight varies from moment to moment and making conclusions week to week is not very useful. It feels much better to wait and draw conclusions after a series of about 4 weeks to make a decision if weight is changing (which doesn’t really fit into a twenty session therapy if you are evaluating the impact of a piece of fruit). I have found dietitians know more about what should happen to weight when you eat a certain amount and this is where I often have a dietitian involved in treatment.
It can also be helpful to have patients make predictions of what will happen to their weight each week. When we have a graph of actual weight, cumulative predicted weight and weekly weight prediction (sometimes what you think the weight will do and what you feel your weight will do) you have a pretty messy graph that will lead to an eventual conclusion that my predictions about weight are not that accurate and maybe I shouldn’t follow them.
I’m often asked who should weigh the patient. My answer is whomever has a rationale that you can explain whilst you look the patient in the eye. If weight change (or weight stabilisation) is the point of treatment, weight can be used to see if that goal is being met. That makes sense. If the goals are not being met you may need to make a decision about the direction of treatment. Weighing to see if a patient is healthy makes less sense, as it may not be a particularly good measure of health. Although, if you also take into account blood results, ECG results, etc. you are on safer ground. Weighing a patient because “I’m a … insert profession..” or “It is in the manual” are pretty lame reasons if you ask me.
One of the reasons I will weigh a patient is to elicit the thoughts about the number on the scale when they are "hot" and come with all the attached emotion. This is why the clinician helping the patient with their distress needs to be weighing the patient and not just receiving the weight from a dietitian or practice nurse (which was how weight was gathered in the original incarnations of CBT). A story - I once weighed a patient and they lost a few hundred grams. Anorexia was initially very happy and my patient smiled. As we walked back to my office my patient’s mood changed and she began to beat her hand against the wall as we walked down the corridor. Anorexia had begun to tell her how hopeless she was because she should have eaten less and lost even more weight. This led to a really productive discussion of how the pleasure of anorexia can be so short lived. I wouldn’t have had that conversation if I hadn’t weighed the patient. I wouldn’t have experienced how distressing a weight loss was for this patient.
There is no one reason to weigh a patient. I think it is also useful to think through the idea that weighing a patient may have different rationales at different points in therapy. Initially, weighing a patient may be an important part of the assessment process and can be useful in setting goals. During treatment, weight is usually used to review the outcome of a behavioural experiment (does eating more lead to as much weight gain as I predict), and later in treatment can be used to help a patient decrease distress around the number on the scale and shift the attachment between the number on the scales and the sense of our worth as a person.
I can think of lots of reasons to weigh a patient with an eating disorder. There may be some reasons not to. I am happy to hear about them.
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