Western medicine today, like much of science, prioritizes objectivity and quantitative research (what can be empirically investigated and either verified or falsified using mathematical, statistical or computational techniques.) The goal of such research is to yield unbiased results that can then be repeated and eventually generalized to larger populations. This is an important process in scientific fields and reflects Western society's high esteem for reason, which is not problematic in and of itself (in fact it has many benefits!) However, what I would like to explore in this particular blog post are the ways in which the prioritization of objectivity and the focus on what is measurable, plays out in healthcare and the treatment of people with eating disorders (as well as other mental health conditions).
Of course I have my own biases, but as with all my reflective posts, all I really want to do is ask questions and encourage awareness around prioritizing objectivity as a main measure of progress in the treatment of eating disorders (and other mental health conditions).
Measuring the Hard to Measure:
How do you determine progress in healthcare? In physical disease you can look to the resolution of signs and symptoms, you can assess blood work and the normalization of laboratory values, you can biopsy diseased tissues, and assess medical imaging or electro-physiologic studies. Essentially you can look and you can measure (for the most part, of course there are exceptions).
But how do you measure progress in mental illness? In some cases, you can do similar things: you look to the resolution of signs and symptoms; sometimes blood work and other studies can also inform you of progress. In the case of eating disorders, weight is often looked to as a benchmark for progress. This is understandable as eating disorders can affect a person's weight (although they don't necessarily), but in other ways, focusing on weight is limited and reinforces disordered beliefs in patients.
Weight is certainly a tool and I am not implying it does not have a place in the assessment and treatment of eating disorders. However, the focus on weight can reinforce the belief of patients that their weight is in fact their worth, and they are not "sick enough" to deserve help unless they can provide clinicians with visible and disturbing illness. This focus on weight is one of the reasons why patient's often speak about a kind of "hierarchy of eating disorders." This idea of a hierarchy is problematic as it leads patients to actively attempt to "get worse" in order to feel "valid."
The thing is, eating disorders are both about weight and not about weight. Some eating disorders will be reflected in a person's weight, but many patient's appear to be of entirely normal weight regardless of the suffering they are experiencing. Take a second to consider two examples of theoretical patients. Patient #1 is of a normal weight and loses weight due to their eating disorder. People become concerned quite quickly. Patient #2 is of a "higher weight" (whatever that means) and loses weight due to their eating disorder. People praise them. Both people are suffering, but receive entirely different responses. When you only look at weight, something fairly easily measured, you miss a lot.
What we need to understand about BMI as a tool of measurement is that it is an incredibly outdated, inaccurate, and racially-biased tool. It was developed in the 1800s by a mathematician and based on a European males who lived in a vastly different time period who lived different lifestyles and faced different health challenges. It is important to note that the formula itself it mathematically flawed. Finally, "in 1998, the National Institutes of Health lowered the overweight threshold to match international guidelines. But critics noted that those guidelines were drafted in part by the International Obesity Task Force, whose two principal funders were companies making weight loss drugs."
All of that said, it would be extremely difficult to step away from using weight and BMI as at least one measure of "health" entirely in eating disorder treatment programs. This is because much of the research and standards of treatment are based around these measures (whether or not we agree with them). It is encouraging to see some programs stretching themselves to try and include a wider variety of different measures of progress. All of this still raises the question, do we have to wait for the overall system to change its reliance on BMI (an outdated, biased, and inaccurate tool)? Or can we push for change from the bottom up (i.e. in individual treatment settings)? How could this look if we adapted this to more acute care settings such as emergency rooms (and the guidelines they operate by)? How could this support individuals who are struggling, help to build trust between patients and providers, and dismantle harmful stereotypes?
If we are trying to support patients in recovery we need to understand that eating disorders are about far more than food and weight: they are complex coping mechanisms. There desperately needs to be more education for healthcare providers that allow them to explore their own biases around weight. You cannot adequately support patients without unpacking your own fatphobia and diet culture influences. You cannot adequately support patients without understanding eating disorders as complex coping mechanisms - illnesses that are not choices and have nothing to do with vanity. You cannot adequately support patients without reflecting on the epistemological frameworks by which we operate.
If we are going to tell people that their weight is not their worth (and have that be more than an empty statement), we need to be transparent about the other ways we determine progress and keep exploring new ways of measuring it.
Are you up to the task of trying to change a system from the bottom up? I hope so, because your patients need you to. Food for thought (pun intended.)
- S.
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