Toss the scales and shred the BMI charts... well, unless you are a boy

Just yesterday I was gnashing teeth and venting spleen on two successive phone conversations on the recurrent problem families have with their own health care providers who declare little Susie quite well and ready for independent living based on charted weight measurements while Susie's parents cower in deference to medical advice with rising alarm. The parents know all is not well, but have nothing to base it on but parental intuition - a measurement that ranks with astrology charts and "I heard it on a commercial" as far as credibility.

I truly believe we are consigning another generation of eating disorder patients to poor outcomes, and a generation of children to misery and ill health, based on unforgivably bad science.

It is long past time that we stop using the crude and demonstrably weak measures of weight and BMI, but of course we need an alternative. One that asks the body itself "are you full yet?"

An alternative:
Predicting the weight gain required for recovery from anorexia nervosa with pelvic ultrasonography (full text available online)
Eur Eat Disord Rev. 2010 Jan 7;18(1):43-48. [Epub ahead of print]
Allan R, Sharma R, Sangani B, Hugo P, Frampton I, Mason H, Lask B.
Department of Radiology, St Georges Healthcare NHS Trust, UK.

Target weights are an arbitrary means of determining return to physical health in patients with anorexia nervosa (AN) and lack reliability and validity.... In our sample was a wide variation of WfH ratios and BMI percentiles at each grade of maturity. This supports the view that arbitrary targets for weight, WfH ratio or BMI percentile are likely to be unnecessarily high for some patients and too low for others. We recommend that targets be based upon baseline pelvic U/S grading and follow-up scanning.

No, can't use it for boys. But maybe we can, by using reproductive maturity instead of weight, learn useful things about diagnosis and early intervention and other recovery markers that will help us better serve male patients as well.


  1. may I ask a silly question? I thought Pelvic US are usually done transvaginally. Were these abdominal I hope?
    Does it correlate with menses? Meaning, does the sexual maturity seen on the pelvic scan correlate with menses? Would not a history be less invasive and costly? Is the history of menses not to be trusted?

  2. This is interesting, but would it really be a good predictor of health? I have friends who get their periods at BMIs right down to 13. They are clearly nowhere near healthy, but reproductively everything looks fine. I wonder what a pelvic ultrasound scan would show in people who get their periods at dangerously low weights. Forgive me if this is a really stupid comment, I'm not even sure what pelvic ultrasound scans show in healthy people, it just seems that if it's to do with reproductive health it might have the same difficulties as using the return of periods as a sign of health.

  3. A friend just pointed out that the full text is available online - I edited the link.

    The scans are abdominal, not vaginal. The measures are not of periods but of true reproductive maturity. Since self-reports of periods are notoriously faulty, and this measure is less arbitrary, I believe it could be a wonderful tool in wider use.

    Perhaps most important is the knowledge that the "90%" restoraton recommendation that is so widely given leaves 17% of patients (!!!!!) short of healthy restoration. That means we're overshooting for some people as well - we're just using very crude and faulty tools!

  4. forgive me if I'm missing the point but reading the beginning of the abstract gives me the impression that the scan is meant to find the level of reproductive maturity needed to start menstruating, so it IS basically about periods. I've actually been in a treatment programme where they used these but was very confused by it. honestly I don't know where that data comes from but I don't understand how 'misreporting' of menstrual function from patients would happen because having experienced having periods at a bmi of 13 myself it is really pretty much impossible not to notice!

  5. Menstruation is obvious to the person, yes, but self-reporting of menstruation is notoriously poor. (People sometimes say they are when they are not, and have trouble remembering details)

    And having a period doesn't mean you have regained or reached healthy reproductive status. Periods can happen without ovulation, or just be the fits and starts of borderline health.

    Ultrasound is a way to get some deeper knowledge of the trend toward restoration. Your ovaries know whether you're getting enough food to get back to work doing their job.

  6. I am all for adjunctive clinical measures, however...

    -It concerns me that almost half of the enrolled patients were excluded (72/155) due to inability to visualize, inability to classify them into an appropriate grade, or confounding medical condition. With these limitations it is hard to herald this as a new gold standard.
    -Of the kids who were perhaps weight restored but hadn't achieved pelvic maturity it would be interesting to know at least age and the duration of time at target weight. Since their sample included ages 11-17 it is possible that some of these children hadn't reached pelvic maturity due to age not nutrtitional status. I have many patients in my pediatric practice age 11-13 (without history of ED or nutritional compromise) who are still premenarche.

  7. I'd like to know the answers to the questions you pose as well. I think the greatest value here is in establishing that weight and BMI don't correlate well with reproductive maturity, something that has been assumed.

    I'd like to see this tool further refined and see what data this yields in larger use.

    You might want to pose these questions to the authors, and I'd love to hear the response, and whether others are doing research on this.

  8. This study is early and therefore flawed in some ways as noted above, but the critical issues are these:

    1. we need another biophysical parameter (or several) in order to free ourselves from the tyranny of weight.

    2. target weights are at best an educated guess and are shown by this study to correlate poorly with actual reproductive maturity

    As mentioned, a serious flaw to using these ultrasounds is that they do not pertain to males or the very young patient and also the numbers are still too small to be sure what "presence of a dominant follicle " means in re complete physical restoration, for example. An experienced sonographer who knows what is being looked for is also important.

    In re: intravaginal probes. No! We do pelvic ultrasounds as does Dr Lask et al. and they are never done transvaginally.

    In re: unpredictable reporting of periods. I do not think the issue is that the reporting is unreliable (although recall of "regularity" can be flawed), but it's more that just bleeding does not prove ovulation. The immature uterus can bleed (even a lot) and yet the cycles can be anovulatory.

    This is an important piece of research, even if not yet a perfect one.

  9. My earlier comment was not to disregard the potential utility of pelvic U/S but merely to suggest it isn't quite time to jump on the toss out the scales bandwagon as suggested by the blog author.

    In my clinical experience, anovulatory bleeding tends to be heavier than ovulatory bleeding so I usually include additional nutritional screening in my standard menorrhagia workup. Additionally ovulation and even fertility may continue in spite of quite compromised nutritional state so I have some reservations about relying on even ovulatory cycles as evidence of nutritional adequacy universally.

  10. The blog author was being puckish. She does not really think people will throw out the scales or shred the charts.

    But she also believes that even a good tool will take decades to get into practice and that the current treatment environment is using poor methods and getting poor results.

    I'm delighted at any clinical support that presses for full health - medical, emotional, cognitive.

  11. I am sorry for jumping back on this topic but I only remembered this when I was replying to Carrie's review of this research. One of my good friends fell pregnant at a BMI of 14.5. She carried the baby to full term, although throughout the first six months of her pregnancy her BMI was only around 16 and her health suffered a lot. Also, when I was in treatment in 2008 my therapist asked me about partners/birth control because two of their day patients had become pregnant at BMIs of 15-16 the previous year despite apparent amenorrhea. I'm not disagreeing for the sake of it, I believe that full weight restoration is essential for relapse prevention and I am a weight restored recovering anorexic myself, but I really don't think that being reproductively intact is as rare at low weights as people seem to think it is.

  12. That seems to be true. The key here is that weight/BMI are not reliable in measuring health (on either end). They have been the cheapest, easiest proxy but we need to do better. Using BMI/weight will leave a percentage of people under and a percentage of people over on estimating nutritional recovery. In reality, however, because of the psychological barriers, it leaves more patients underweight and chronically ill than the reverse.

    I'm also troubled because the lack of clarity on this issue offers encouragement to those who want to say "it's not about the food" and that medical recovery is only of importance after a person has reached very low weights.

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