Bodyweight then and now

I got back from a couple of conferences and a ski trip a little while ago and weighed myself, as I occasionally do, and found I’d lost a few kilos. I was surprised, because my weight has been pretty stable for the past few years, and I hadn’t been aware of eating differently while I was away. It made me reflect on how six or seven years ago a change of this size, whether up or down, would have been as unthinkable as it would have been unbearable, since bodyweight was such a constant preoccupation, treated like a crutch even though I knew it was crippling me:

‘I’ve eaten so much today – after dinner I felt completely sick, but I’ve just weighed myself and I don’t seem to have put on any weight. [...] It’s ridiculous how much time I spend thinking, worrying, about my weight, how many better things I could use my brain power for.’ (21.09.98)

It also made me wonder about the connection between bodily experience and bodyweight: I hadn’t noticed that anything about my body had changed, but had I been tracking it with weekly weighing, the change would have seemed significant, because in numerical terms it was (around 5% of my total bodyweight). Regular weighing would have made me experience those weeks as a period of weight loss, as a process – instead of just living, and becoming aware of an objective change retrospectively. The simple fact of knowing the number or not really can change how you feel your body, and how you feel about it.

Anorexia on the weighing scales

Emily T. Troscianko
Source: Emily T. Troscianko

This is one thing that makes the question of whether or not to weigh yourself during recovery matter. For me now, the slight surprise of seeing numbers different from the ones I expected is just that: slight, and brief. I wondered for a little while about possible reasons, from eating different food abroad, to using up more energy skiing, to losing muscle from not being at the gym. (I’ll come back in a moment to the question of how much bodyweight alone actually tells you.) Six or seven years ago, though, the idea of my weight changing by this much and not particularly caring would have been just as incomprehensible and implausible to me as loving driving a convertible, or having fun being not particularly good at golf. Certain sets of numbers demarcated my existence, just as they do for so many people with eating disorders; numbers representing calories ingested, calories expended, money spent, hours worked, can easily come to dominate life. Dress size and waist size and other markers of body size or body fat are more fundamental for some, but for many, me included, bodyweight is one of the most oppressive of all the numerical prisons. Over and over, in my diary from those days, I record how weighing myself in the morning set the mood for the whole day:

‘Terrible how depressed I was made by my increase in weight this morning, even as I keep up the regime whose aim is meant to be precisely that’ (26.04.04); ‘Most of the morning I wondered how I’d stay awake…, wondered why my weight was still so high…’ (27.04.04); ‘Surprised and relieved by my weight this morning. But trying not to hope for tomorrow’ (10.05.04); ‘Waking up to pouring rain, then seeing my weight on the scales, I dressed with hot dry tears of a lack of will to carry on’ (03.05.04).

It goes on and on. Now happier kinds of numbers – like how many kilos I can squat, or where my football team is in the league – are part of my life, but only because I want them there, because they enrich it. I care about them without them consuming me as the numbers on the scales did back then. The momentousness of minutiae in anorexia is something I’ve talked about in different contexts in other posts, but bodyweight was one of the most interminably tortuous of the mental traps. In the labyrinthine ‘autobiography’ I wrote compulsively from the depths of illness in 2004, I reflected:

‘For me, the weighing lets me forget. Or it lets me know, and keeps reassuringly murmuring in the back of my mind, that today was little different from yesterday, and that if I eat this thing that I ate then but am still scared of eating it will be little different tomorrow. I worry what the numbers will be, but worrying about seeing them is better than worrying because I can’t see them. It makes my mood a puppet of my known weight – a few hundred grams more ushers in a day more subdued and more fixatedly glancing at tummy in mirror; but other things pull the strings too, and better the knowledge of weight than the ignorance of it, which wouldn’t let me eat at all. For this is the second marionette in the scales’ hands: intake that would otherwise be controlled only by appetite – and although this otherwise remains the ideal, for now to aspire in practice to the ideal would I think drive dangerously further from it a body whose mind doesn’t yet fully aspire to the ideal in concept. As long as the conflicting ideal of restriction wherever possible holds sway, that of obedience to appetite has to wait: I’d only ever feel nausea, refuse to feel hunger or believe in it. For now, as long as the numbers are always more or less what are expected, painful, tedious thought is minimized. Though such thought – no, the painful but the frightening flight from the tedious –, is the only thing that will one day make the numbers themselves unnecessary.’

This is a lovely example of the paralysed combination of insight and inability to act on it that I discussed in my post on how and why to start recovery. I understood perfectly well what was happening and what would be needed to change things, but that had no effect: my everyday anorexic routines, my thoughts, my moods were nonetheless all punctuated by self-weighing. Most of the crisis points of my illness were also precipitated by it too: one session with the child psychiatrist when my weight had gone down again and he made me genuinely scared, scared enough to go and eat curry and drink Smirnoff Ice with my father and brother that evening; ski trips when I weighed myself every morning with one of my parents peering over my shoulder, being forbidden to ski if my weight had gone down, and not even knowing whether I wanted it to have or not; agreements about greater freedoms I could preserve if the scales marked adequate weekly increases; the granting of said freedoms after the scales said the right thing; and, not least, moments of private revelation that my half-hearted efforts to eat more were really not enough:

‘I’ve eaten more, slept less, talked more today than I remember ever doing in Dresden at least. The day began at 4am, when after going to the loo I couldn’t sleep, I felt vaguely hungry, was worried about my weight, head full of feverish thoughts of being forced home at Easter – about five I got up and weighed myself – and the result made me upset and shocked and even angry – having thought I’d eaten so much I weighed [less] than ever before; I could hardly believe it, but it spurred me to the bold step of going into the kitchen and making hot chocolate, sweet and piping and frothy, to drink with a few pages of Donna Tartt. By six I fell asleep, but was by seven again in the bathroom and wide awake. Got up and put on a dressing gown and collected all my random bits of variously acquired chocolate and ate them as I began to work (more Grass criticism) – it felt really weird, like Easter Sunday or something.’ (05.04.03)

That morning, far away from home with my parents waiting anxiously for signs of progress or relapse, marked the time when I stopped playing games, and finally started taking my body at its word. I didn’t compensate, later that day, for the extra food and drink, and after that I kept on eating. I got quite a long way, that time I tried to recover, and the numbers on the scales that morning were one of the many big and little things that galvanised me to get better.

What weighing tells you

The strength of the effect of knowing the numbers is particularly strange because weighing yourself doesn’t really give you much knowledge about anything. Knowing how many pounds or kilos your body weighs tells you only your total weight at a given place and a given moment. (And, to make a brief detour into physics – talking about ‘weight’ in terms of kilos is in fact a confusion of terms, since what we measure in kilos is mass. Mass describes the amount of matter in an object, and is an absolute measure, independent of gravity. By contrast, any measurement of bodyweight should strictly speaking be given in Newtons, and is gravity-dependent, so someone whose bodyweight meant they were diagnosed with EDNOS on earth might be classified as anorexic on the moon. So everything gets more and more relative the deeper you probe. For convenience’s sake, though, we tend to refer to mass and weight interchangeably.) Knowing your weight doesn’t tell you anything about your body composition, or your body size or shape, all of which are more meaningful measures of physical state than weight alone: the relative proportions of fluid to fat to muscle to other fat-free mass, and the distribution of fat around the midsection or elsewhere, are much more useful health markers than total weight or even BMI (which is nothing more than mass (in kg) divided by height (in metres) squared) (e.g. Després 2012). Weighing yourself also gives you no information about the present moment as connected to past and present, so the number on the scale in isolation tells you nothing about the possible contributions of factors as diverse as whether you have a full bladder or stomach, what the ambient humidity is, or what stage of your menstrual cycle you’re at.

So, is weighing yourself always fairly meaningless? Well, no. It’s more meaningful the fewer other factors may be at play – so simple strategies like always weighing yourself at the same time of day can take some of the variation out of it. More profoundly, prolonged anorexia removes some of the variation: because in severe malnutrition muscle and other lean tissue will be used as alternative energy source after the fat supplies have been exhausted, the ambiguity arising from unknown body composition tends to be less significant – you’re very unlikely to have minimal fat but lots of muscle after years of starvation. And of course the larger the changes at issue, the less likely any given non-essential factor is to make a significant difference. These two considerations combined help to explain how it is that, in the weight-gain phase of recovery from anorexia, fairly accurate predictions can be made about the cognitive-behavioural changes that will result from progressive increases in bodyweight: depending on the length and severity of illness, the anorexic body is likely to be quite systemically depleted in fluids and tissues, such that weight gain can be a relatively good marker of overall physical regeneration. I’ll never forget the graph of projected weight gain that the clinician who’d done my initial assessment showed me and my mother before I started my final course of treatment, and how she said confidently that when my weight got to a certain line on the graph my OCD symptoms would abate, and at another my thinking would become more flexible, and how I didn’t believe a word of it – and how it all ultimately came true, more or less exactly as she’d predicted.

Arguments for weighing, and how to weigh well: ‘Trying to get over your eating problem without knowing your weight is like having your hands tied behind your back’ (Fairburn 2008, 55)

This brings me to my first argument in favour of carrying on (or initiating) regular weighing during recovery. (The only strong argument against which I could come up with follows a few paragraphs below.) Anorexia is in equal parts a physical and a mental illness, so recovery involves equal parts physical and psychological repair and regeneration and rebalance. Monitoring weight gain can be a useful way of tracking these combined processes week by week; for me, certainly, adding points to the graph with my therapist every session gave me a reassuring sense that things were happening as they were meant to, and that recovery wasn’t some mysteriously opaque transformation, but a comprehensible set of embodied changes for which food was the fuel.

My therapist helped me achieve the right attitude to those regular weighings, most importantly by impressing on me the impossibility of drawing conclusions from a single data point. Given that natural variation in bodyweight due to the kinds of ‘extraneous’ factors I mentioned before can easily be as much as a kilo or two more or less, it’s impossible to say anything confidently about real, lasting weight gain with less information than three results provide. This is also an important reason not to weigh too often: daily weighing is common in anorexia, but weekly weighing (or twice-weekly at most) makes more sense as recovery begins. This helps reduce the anxiety over day-to-day fluctuations in weight that seem momentous with daily weighing, but can otherwise go happily unnoticed.

Fairburn 2008, 71
Why two data points are never enough.
Source: Fairburn 2008, 71

It’s also crucial to bear in mind, right at the start of the weight-gain period, that the weight apparently gained will represent primarily water weight, and not the start of an unstoppably rapid upward trajectory. A rapid initial increase can be traumatic, as it seems to confirm that most paralysing of anorexic fears at the cruellest of moments: that eating the littlest bit more will send your bodyweight spiralling up out of control. (The real danger at this point, of course, is just the opposite: that weight gain will stall because the effort and courage required to keep eating consistently more are too difficult to sustain.) What makes things even harder at the start of weight gain is that you know you’re meant to want to be successful, so if you feel pleasure when the numbers stay the same or go down, you might also feel guilt at the pleasure, maybe combined with a little disappointment or even shame at not managing to bring about an increase. And when they do go up, you may not know what to feel:

‘I’ve eaten so much today… I just weighed myself – I’m [...] about half a kilo more than before – I don’t know whether to be pleased or not. I’m so confused. I never know what I think or feel any more. Like before, putting on weight was bad, now it’s good – my whole world, my little comforting rules, have been torn apart, and I’m lost.’ (25.11.98).

Or, you know what you feel, and wish you hadn’t committed to the changes that mean you’ll keep on feeling it; wish you could make the grand gesture of starting recovery without the bleak clarity of those numbers telling you it’s working:

‘The continuing weight gain’s oppressing me – and yet I fear to break the routine in case it falls and falls again… I promised myself I’d keep it up – it’s just I didn’t think it’d have this much of an effect. I suppose it’s just the warm weather making the difference, but I don’t really know. Just hope it’ll stop somewhere’ (04.05.04)

Marshalling all the relevant facts, together with all your personal motivations, for embarking on this journey, and holding them up as defences against the fear that nearly stopped you starting at all, is probably the best way of staying calm at this critical stage. And one helpful way of taking up a more impartial perspective on the numbers themselves could also be to practise imagining, at least in the early days, that they represent something other than what’s become so existentially fraught: ‘If patients are struggling to be objective about the interpretation of their weight graph, ask them to imagine that the graph is of something with less personal significance (e.g., weekly rainfall over several weeks) as this can help’ (Fairburn 2008, 65). Whether weekly rainfall is likely to do the trick for you, I’m not sure (have fun thinking of your own stupidly neutral examples!); but I remember a few times when I was finding it hard to interpret my line on the graph, and my therapist encouraged me to think of it at least as someone else’s. As recovery proceeds it should then get easier to confront the graph on its own terms, as yours, as what it really represents: your body growing back to a size at which it can be healthy.

Because of the inextricable connections between the processes of mental and physical recovery, then, weekly or twice-weekly weighing may be an effective way of monitoring progress and becoming reconciled to its simplicity: if I eat such and such an amount more than before, I will gain this much weight, and this will lead in time to the improvements I want from recovery. Witnessing that magically natural process run its course might be an important element in the profound shift from exerting pathological control over your body to allowing it the freedom to repair itself, and ultimately to living in greater harmony with it. If numbers have been the form the tyranny has taken, reinstating freedom by means of those same numbers could be a quite profound kind of liberation.

On the other hand, it’s easy to see how continuing to focus on bodyweight during recovery could feel like a perpetuation of one of the most dysfunctional aspects of illness. If you’re in treatment, and your therapist is taking care of the measuring and recording, why should you need to know at all, when knowing risks plunging you into unnecessary turmoil at the sight of a number on the scale you haven’t seen for some time? If weighing yourself, unlike, say, weighing your food, doesn’t give you any information you can’t do without, then why not let the physical changes happen as they will, and learn to trust your body from the start to do what it needs to in the absence of rigid numerical forms of control?

This logic is attractive, but it neglects two important factors. Firstly, if recovery is being undertaken without professional support, weighing is by far the easiest way of ensuring that progress is being made at a reasonable rate and with reasonable consistency; otherwise it can be easy to feel some psychological improvement and assume the physical process is occurring as it should be too, or conversely to frantically exaggerate every small bodily change as evidence that weight gain is happening when it isn’t. Of course, without a therapist to monitor the frequency and process of the weighing, it’s crucial that self-discipline in limiting it to once or twice a week be developed and maintained. If that proves impossible, complete abstinence may seem the lesser danger – but then of course you forfeit that objective marker of progress.

In this regard, there’s a little bit of research that suggests self-weighing can have significant benefits as a progress marker the context of weight loss among obese participants (see Welsh et al. 2009 for a brief overview). (I’m unaware of equivalent research focused specifically on bodyweight monitoring, independent or therapist-led, as a variable in recovery from eating disorders.) Many of the studies are only observational (and therefore can’t distinguish between causation and mere correlation) or have pretty small sample sizes, so the existing results are far from conclusive, but the larger and more rigorous of the experiments conducted on self-weighing as a factor in deliberate weight loss for health reasons (e.g. Wing et al. 2007) suggest that achievement of the desired outcome (weight loss and/or maintenance of weight loss) tends to be aided by self-weighing, and that the adverse psychological effects you might expect to be the price of this benefit – like greater preoccupation with weight, low mood, and low body satisfaction – aren’t actually observed. But of course, whether it’s weight gain or weight loss that’s at issue may make a significant difference, so these findings should be interpreted with a double pinch of salt.

The second thing missing from the ‘why bother weighing?’ argument is a consideration important in any recovery process, or in any process at all that takes time: nothing happens all at once, and expecting it to causes trouble. So if weekly or daily or even more frequent weighing has been part of your illness, expecting to be able to do without it immediately and completely may be as unrealistic as expecting to be able to eat flexibly and according to appetite from the very beginning. Learning to listen to appetite – even having a reliable appetite to be listened to at all – takes time, and so, perhaps, does weaning oneself off the scales. There are always pros and cons to be weighed up for acute withdrawal (cold turkey) versus gradual dehabituation from any given addictive substance or behaviour, but maybe in this case there’s an extra argument in favour of the gradual approach – and this was the main one my therapist made to me when we discussed the issue of weighing early on.

What to me seems the most persuasive argument of all in favour of weighing is that if you ‘protect yourself (or someone else does) from knowing what your weight is, not knowing will probably become much more significant to you than it should be:

‘[Some patients] actively avoid knowing their weight while remaining highly concerned about it. Generally these patients weighed themselves frequently in the past but switched to avoidance because they found frequent weight checking too aversive. However, avoidance of weighing is as problematic as frequent weighing since it results in patients having no data to confirm or disconfirm their fears about their weight’ (Fairburn 2008, 63).

In the CBT context, the solution is regular ‘collaborative weighing’ at the start of every session, with the number being agreed on by therapist and patient, calmly spoken out loud, and plotted together on an individualised weight graph – and, crucially, no weighing at all outside those sessions. (I know less about what the attitude is to bodyweight monitoring in other types of treatment; if anyone has any experience of this I’d be very interested to know.)

Emily T. Troscianko
Source: Emily T. Troscianko

In this sense, regular planned weighing could be seen as a kind of exposure therapy: a positive means of coming to accept that the feared outcome (weight gain, or being ‘heavier’) doesn’t have the feared effects (making you instantly obese-looking, say). Without this source of information, the fears and their unspoken logic survive unchallenged, and may grow and grow in the absence of counterevidence. Ironically, then, it’s those anorexic fears that are really protected by your refusal to know those numbers. A few years ago, I was in touch with someone I’d known during her recovery, and I was delighted to hear her describe herself as well again. But when she said that she didn’t know her bodyweight because she never weighed herself, and asked her therapist at follow-up sessions not to tell her her weight, my immediate (unspoken) reaction was, ‘so you aren’t fully recovered yet, then’. My reasoning wasn’t very profound; just that if you can’t cope with knowing something that the majority of other people are comfortable knowing, that means you’re still not quite there yet.

So this is another argument to be made in favour of regular planned weighing, then: an appeal to normality. Knowing roughly what you weigh is the norm: I had to enter it on the ski hire booking form, for instance; lots of sports involve weight classes; it occasionally just comes up in conversation, or at the doctor’s surgery in other health contexts. If you don’t know it, you aren’t, in that particular sense, normal. You may decide that for you, that specific measure of normality isn’t significant for you, or it is but it needs to be set against the ability to live relatively healthily with the calm that comes from not knowing. Those are quite reasonable conclusions to come to. But maybe it’s still worth bearing this little marker of normality in mind as a goal that might be achieved, some day in the future when other things have become a little easier.

The body politic

If we’re thinking about normality, maybe it’s also worth briefly considering bodyweight from a political perspective. At a staff dinner dance last month, someone who had worked for the college for several decades was being given a little retirement presentation, and the person making the speech started to tell the story of her first coming to work at the college: ‘...when she arrived in 1978, at the tender age of –’. And he stopped himself, fluffed the line, mumbled something that was meant to make not saying her age into a joke. He assumed that she wouldn’t want us all to be able to do the calculation. This assumption is perfectly normal, but it’s also nonsensical: people retire at a pretty standard age, we can look at her and see roughly how old she is, etc. The withholding of the number withheld no information we couldn’t easily work out, with a decent degree of accuracy, via other means. And the withholding made me sad. Her arriving at the place where she was to work for most of her adult life must have been a significant thing for her at the age of, say, 25, and it’s a shame that as her colleagues and friends we couldn’t honour the years of that journey from her then to her now, without shying awkwardly away from the basic fact of how long it is since she was born.

Bodyweight isn’t only a female issue, of course, any more than anorexia is, but the feminist connection here seems quite striking. I’m always puzzled by the acuteness of women’s embarrassment about revealing their age, since it seems to reveal nothing except itself: it tells you how long someone has been alive. Looking at a woman if you already know her age tells you a little more: how her appearance relates to her age. But that means if you lie about your age, as so many women routinely do, that makes you look older than you actually do for your age, and if you look younger than you do for your age, i.e. your age is greater than the person looking at you expected, isn’t that meant to be a good thing? In a way, of course, I’m being deliberately obtuse here, but I think the parallel with bodyweight is quite a close one: normally one wouldn’t dream of asking a woman how much she weighs, but what intimately revealing information is knowing her weight going to give you about a woman standing in front of you? And why is the positive-negative polarity the way it is? If her weight is higher than you expected from looking at her, that probably means she has more muscle and/or less fat than you thought, which presumably is generally thought to be a good thing, whereas if it’s lower, she probably has very little muscle. Yet we’re meant to want not to weigh much. It’s weird.

This may seem a long way from the ins and outs of weighing during recovery, but I think it can be helpful to take the broader view. Eating disorders can’t be understood in a vacuum that excludes sociocultural factors, and questions of gender are part of those. When women reject anorexia, we also – deliberately or by default – reject one crippling but widespread belief about what women should be: thin, frail, physically vulnerable. Even if that rejection doesn’t seem significant to begin with, even if it seems an unbearable burden to begin with, it is part of any successful recovery and the healthy life that follows it. Some kinds of normality are things to be aimed for, others are best tacitly accepted, and others again need to be challenged and overthrown where possible; everyone makes their own choices about which are which for them, and those decisions change yearly, monthly, even daily.

I was very happy when at the same work party another woman asked me how old I was quite directly and without awkwardness because it was relevant to our conversation, and I told her ‘33’ just as straightforwardly. I don’t think anyone’s ever asked me how much I weigh except in the context of powerlifting competitions, but if they do, I’ll be happy to tell them, and happy, very probably, that they asked. They’re numbers, but they don’t have more power over me now than the more subjective markers of where I am now, and how I am in my own skin. Being OK with all kinds of stuff about your body is a good way to be. Maybe it’s as simple as that.

You are reading

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Questioning the evidence base for the efficacy of early intervention in anorexia

Christmas in Recovery

Tackling a few of the trickiest questions about anorexia recovery

Lose Your Phone, Find Your Body

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