Why not 100%

Why don't we shoot for 100% of "ideal body weight?"
Why does the definition of anorexia start at <85%?
Why are target weight set at minimums and hospital discharge set at minimums?

A lot of it has to do with patient "tolerance."

This is like setting chemo at one dose short because they've been through enough. Or only removing most of the tumor to prevent a larger scar. Or setting insulin amounts a bit low to stunt growth to save future insulin.

This short-sheeting of treatment is a factor in relapse rates. In chronicity. In lack of response to psychotherapy. In a loss of family resources and social supports.

If I could wave a wand and only change one thing wholesale, it would be this: 100%.


  1. A lot of it has to do with insurance companies. They pull the plug on paying for treatment before 100% weight is achieved. That's why parents and other caregivers need to keep going, even without reimbursement from insurers.

  2. You ask some good questions, Laura.

    By "ideal body weight," do you mean a BMI greater than 17.5? That's what the Steinhausen et al. article suggests as being the optimal BMI for recovery. Or is there some other "ideal" body weight that might be a gold standard for people recovering from an eating disorder?

    I wonder about the use of the word "ideal" to describe a certain weight. By appropriating an everyday term such as "ideal" to describe a medical parameter, we may contribute to further confusion and even stigmatization of the person with an eating disorder. To someone with an eating disorder, his or her idea of the "ideal body weight" is likely very different from the medical establishment's. This ideal may be a mixture of what the media considers beautiful or powerful, and the individual's internal, somewhat distorted, ideals. Yet, once that person is in treatment for an ED, he or she is told that he or she can no longer pursue *that* ideal, that it must be exchanged for another one, i.e. BMI > 17.5. What demoralization for the patient, to be told that you not only fail to live up to your own ideal, but to someone else's ideal, as well!

    I think that we should reconsider the use of the term "ideal body weight" in reference to patients with eating disorders. What about "healthy body weight"? Or "optimal"? Or "functional"? Aren't these really more accurate descriptions, anyway? What may be the ideal body weight for me may not be for you; our genes, our diets, our lifestyles are different, and so are our bodies.

    It's ironic to see how the research community often reflects back the same rigidity regarding "ideals" as the patients themselves. Coincidence? I think not. This is a disorder that is being defined and constructed by the patients and doctors alike, in a dialectic struggle over bodies and weights and ideals and myths. I think that it can do some good to step outside of such polarized battles and see BMI > 17.5 for what it really is: healthy, real, whole, functional, human, imperfect.

  3. I have been thinking some more about your post and my reaction to it. After I read the other person's comment, I realized that I may have misinterpreted what you were actually writing about, and we're really more on the same page than I might have conveyed in my last comment.

    I think that you make very good points about how patients may not be getting as much treatment as they need, because there is a lack of accountability in terms of making sure that the patient has actually reached a healthy weight before stopping treatment. These criteria are also harmful to the extent to which they discriminate against people with eating disorders who may not be below 85% of a healthy body weight, but still need treatment.

    In the interest of full disclosure, I recovered from an eating disorder three years ago and have a blog about food and eating disorders. I think that these issues are more complex than meets the eye, and I am grateful to other bloggers, such as yourself, who are willing to tackle these complex, emotional topics.

    Ai Lu

  4. Anonymous - yes, the insurance companies' standards are at issue - but they're following the DSM. We need to change both, right?

    Ai Lu, I don't think you and I disagree. The supposedly technical term "Ideal Body Weight" is used as a scientific thing but it turns out all clinicians have their own definition.

    And clearly, meeting a weight requirement is NOT a cure. You can be at a "normal" BMI and still be very ill mentally.

    My problem, though, is that the standards and expectations are set low - consigning countless people to permanent illness.

    We need better medical measurements, and better science all around!

  5. I think part of the reason I hate being at my "ideal body weight" is because I was always told I only needed to reach 90% of it. Now that I'm at 100%...I hate it, and I'm not sure how not to fight it.

  6. Laura,
    I hate all of the talk by providers about numbers, because if it isn't supposed to be about the number then why are they always making it about the number?
    Gain this amount this week. Oops, 1/8thlb under-sorry out of tx. Oh you are 1/8 lb over your IBW-you can be discharged! It is so-I can't stand it.
    My therapist and I were talking today and she has been spouting about how she has been seeing me for three years and throwing weights at me and I said "BUT in that time" and she cut me off and said "I just want to see X per week from here on until X weight."-I am not bashing her because, well I am not BUT I said something to her on my way out of her office about IBW and she said "I don't CARE what your IBW is, I just want you to gain SOMETHING." I walked away and thought two things-she has no idea what I am going through.

  7. Laura -- Yes, we need to change both the DSM and insurance coverage. Change DSM so that if someone suffers from an eating disorder they can still receive a diagnosis that entitles them to treatment regardless of whether or not their body weight happens to be above or below 85%. The 85% figure is arbitrary and isn't necessarily related to what is happening in their brain/thinking process and therefore whether they need treatment. Second, change insurance policies and laws so that "medical necessity" is determined on the basis of best clinical judgment and scientific knowledge, not on whether the patient's condition happens to fit into an arbitrary DSM classification. I hear the DSM is in the process of being revised. Does anyone know whether the broader community of sufferers, family members, and the general public will be given an opportunity to participate in the process of revision? As for insurance, parity would be a good start, although not the solution to the "medical necessity" problem.

  8. Elaine, you were ill-served. I wish it had not been that way, and I continue to hope you will come to peace in your healthy body.

    Labyrinth, I wish you could hear your thoughts the way I do. I hear your ED resisting numbers as a way of avoiding certain numbers, not a freedom from contraint. The emphasis on the numbers you are hearing isn't about constraining you: it is about getting you anywhere near brain health. Kind of like someone who is quite drunk accusing those trying to take the bottle away of being obsessed with alcohol?

    Anon, I know that some people at AED are involved with the DSM revision. But the things they seem to be working on tweaking are far, far from the concerns you and I might want to discuss. I believe the things under debate are whether there should be different standards for children/adolescents/adults, and whether or not to add BED, and how to parse anorexia with purging from bulimia. I want them to go back to basics and question the whole classification... but no one there has asked my opinion!

  9. Hi Laura,

    Just curious... what do you consider to be 100%?

    100lbs for 5'0" + 5 lbs per inch?
    a BMI of 18.5+ ?
    Some weight based on your growth chart percentile?

    I think that there can be a pretty large difference between all three.

  10. Me, I think they are all flawed and except for the last one are downright dangerous. But the reason for my post is that we don't even get 100% of THESE. Most treatment falls short of even these minimums.

    I prefer the last one, certainly, but it seems clear that people's brains clear when they find THEIR optimum body composition and it will almost NEVER be the minimum.

    I believe low-balling treatment goal weights is a major reason for low recovery rates and high relapse rates. And it isn't for medical reasons - if it was then they'd set the goals at the highest range of "normal." It is for "tolerance reasons" and that's just wrong.


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