Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

It’s Not About Weight


Approaches employed by eating disorder specialists can be applied to support all patients. This includes emphasizing healthy behaviors and acknowledging your own assumptions about weight.

A 15-year-old girl and her parents sit in my office after completing an urgent assessment for concerns of malnutrition. I give a diagnosis of restrictive anorexia nervosa, which is common in my field of adolescent medicine. The words regarding the diagnosis come out of my mouth in a familiar cadence, while my patient and her parents are wide-eyed.


“But my weight is normal!” my new patient protests passionately.


“While your weight is technically in the ‘normal’ range, what your body is experiencing isn’t normal or safe,” I respond gently. I show her parents her growth curve, which demonstrates the dramatic weight loss from the 85th percentile to the 25th in a period of months, and explain the abnormalities I’m concerned about on her physical exam.


This is a common clinical scenario encountered in eating disorder treatment. Many patients start at a higher weight, then after a period of restricting nutritional intake end up at a “normal” BMI. We know now that although their weight and BMI may not have an extremely low value, the rapid weight loss places them at similar risks for symptoms and complications of malnutrition as those who are very underweight. To reflect this, the most recent diagnostic criteria for anorexia nervosa does not include a specific weight threshold for diagnosis.


One of my mentors in the eating disorder field taught me early on that “as a clinician, your first responsibility in caring for a patient is to stamp their ticket of entry.” I think of this often when caring for patients with eating disorders, as the mentality of not being “sick enough” is incredibly pervasive. No matter what a patient’s weight is, their eating disorder will often manipulate their thinking into not believing their disease is serious. This is a known facet of these diseases. Our culture contributes to this with the inescapable pursuit of thinness and normalization of dieting and disordered eating behaviors. In some cases, especially in patients that don’t have an “underweight” BMI, the medical community can contribute to their disbelief that they deserve treatment.


Oftentimes my colleagues will ask for tips on how they can talk to patients of all weights in a manner that isn’t stigmatizing or unintentionally promoting of unhealthy weight loss. Here are some techniques I’ve learned throughout the years in treating patients with eating disorders that may be helpful when caring for any patient:


1. Discuss health behaviors instead of focusing on weight.

For example, movement and exercise are healthy behaviors in the absolute sense, not because they may lead to weight loss.


2. Avoid blindly applauding weight loss without knowing how it occurred.


3. Acknowledge your own assumptions.

Many clinicians have the mindset that individuals need to be emaciated to have an eating disorder or need treatment, which we know to be untrue.


4. “Stamp your patient’s ticket of entry.”

This validates the suffering they’re experiencing and will help get them the treatment they need and deserve.



This piece expresses the views solely of the author. It does not represent the views of any organization, including Johns Hopkins Medicine.