Ovideo Bermudez, MD, FAAP, FSAHM, F.iaedp, CEDS
Jocelyn Lebow, Leslie A. Sim & Erin C. Accurso
To cite this article: Jocelyn Lebow, Leslie A. Sim & Erin C. Accurso (2017): Is there clinical consensus in defining weight restoration for adolescents with anorexia nervosa?, Eating Disorders, DOI: 10.1080/10640266.2017.1388664 To link to this article: http://dx.doi.org/10.1080/10640266.2017.1388664
Advances in the treatment of adolescents with Anorexia Nervosa (AN) have included, for example, building a body of evidence to support family involvement as in Family-Based Therapy (FBT). At the core of any treatment modality have been weight restoration and weight normalization as important markers of treatment success and positive treatment outcome. However, the field has struggled with a lack of consensus in both terminology (ideal body weight, expected body weight, target weight in treatment, etc.) and methodology for establishing optimal weight. The lack of consensus in methodology is particularly important because it has implications for treatment variability and contributes to the research-practice gap. This study is the first to point out the absence of “evidence-based methods to establish weight targets” and the need for “empirical attention” to this matter.
Although the study had limitations, it provides an interesting review of the variety of methods used by clinicians to establish expected body weight (EBW) in treatment. Of the 113 clinicians surveyed, 82% reported that they use a measure of EBW in their practice. Forty percent (40%) of the respondents reported using individual growth curves to establish EBW. The remaining 60% reported using a variety of approaches including about 17% that outsourced the establishment of EBW to dieticians or physicians. A minority of clinicians included patient preference to determine EBW. Clinicians who practiced FBT were statistically least likely to include patient preference in their approach to establishing EBW. In addition to a lack of consensus in the method used in clinical practice, the use of data from individual growth curves has not been used in adolescent AN treatment studies. The current published practice recommendation to use an idiographic approach (based on an individual’s own historical growth pattern) does not meet the need in research studies of objectively operationalizing EBW. So the current state of affairs in establishing EBW in treatment demonstrates a significant gap between research and practice. The authors also point to the fact that without a standardized approach to EBW, assessing severity of illness, adequate level of care, adequate length of treatment and treatment progress may be impaired. This may also have implications for clinician’s ability to advocate for optimal care with third party payers.
Why is this important?
The methodological variability in establishing EBW in clinical practice was significant among the clinicians who participated in the study which implies that in different treatment settings or with different providers, patients and families may hear an inconsistent message about what an optimal weight to support sustained recovery may be for any given patient. This can be confusing at best and for some patients may provide fertile ground to cave in to their fear of weight gain. Weight recovery in the treatment of AN is difficult for patients to tolerate and accept even under ideal circumstances. Inconsistencies in weight expectations can only add to this difficulty.
The ability to have an evidenced-based approach to consistently establish EBW in treatment would be an important contribution to treatment advances, especially in children and adolescents in whom variables such as the impact of the malnutrition state on growth patterns or periods of stunted linear growth can make predicting an optimal weight to be achieved in a treatment episode particularly challenging. The authors did not make recommendations as to a best approach but did call for attention to this matter both from the research and clinical practice perspectives. This may be one of the holy grails in the treatment of children and adolescents with AN and should be an important part of the future research in the field of eating disorders.