Weight Suppression and Bulimia Nervosa
Weight suppression (WS) is defined as highest ever historical weight minus current weight. It represents a measure of the level of weight lost since being at the highest ever weight achieved over a lifetime. Although the psychological and behavioral symptoms of bulimia nervosa (BN) are undoubtedly the major focus in this eating disorder, it has been argued that the magnitude of weight suppression may play an important role. Credit for identifying the importance of weight suppression goes to Professor Gerald Russell who coined the term “bulimia nervosa” (BN) in his classic 1979 paper (1) that described the syndrome as an “ominous variant of anorexia nervosa.” His formulation emphasized the fact that many BN patients had either a history of frank anorexia nervosa (AN) or that they had lost to below a “heathy weight defined as the weight reached before the onset of the eating disorder” (p. 429). He explained that the determined efforts of these patients to suppress body weight below a self-imposed weight threshold set in motion biological mechanisms designed to return the person to this “healthy weight.”
The theoretical significance of weight suppression in bulimia nervosa was advanced more than twenty years ago by research showing that even BN patients with no history of AN had experienced dramatic weight loss during the course of their eating disorder (2, 3, 4). Garner and colleagues (3) observed that binge eating, “whether it occurs in obese, normal weight or anorexic subjects, occurs within the context of weight suppression” (p. 586) and it was recommended that treatment goal weights may need to be higher to ameliorate bulimic symptoms (5).
More recent research has shown that higher levels of WS predict frequency of bingeing and purging, amount of weight gain during and following treatment, and poorer outcome in treatment. Butryn et al. (6) investigated the impact of WS on treatment outcome in BN and found that patients who dropped out of treatment had a significantly higher levels of WS compared to those who completed treatment. Another more recent study by this group indicated that WS predicted the time to full remission from BN over a follow-up period of 8 years (7).
However, there is some controversy regarding the significance and the treatment implications of weight suppression in BN since several subsequent studies have failed to find any relationship between WS and treatment outcome (8). Regardless of the inconsistencies in the results of WS as a predictor of treatment outcome, the clinical implications of this variable must be considered.
It is well-established that BN patients have a higher premorbid BMI than age-matched peers and have generally lost significant weight in connection with their disorder. If BN patients are indeed “weight suppressed,” given what has been well-known about the set-point concept, it stands to reason that they will have no more long-term success in maintaining a lower weight than obese patients who have been shown to regain weight lost during a diet. Indeed, WS has been shown to predict long-term weight gain in numerous studies (9, 10, 11, 12).
Of course, these findings present a clinical dilemma since BN patients typically approach treatment with incredible fears of weight gain. The suggestion that they may have to accept a higher weight than others matched for age and height is understandably difficult to accept. This is particularly true since it is common for health practitioners to use population-based weight norms or BMI norms to inform BN patients regarding “ideal weights.” Rather than relying on these misleading standards, it important to gradually introduce the idea in treatment that there are biological-hereditary individual differences in body weight, like most all other human attributes. Self-acceptance means growing to accept YOU, and not deferring to unrealistic and inappropriate cultural norms or media-created “ideals” that are both impractical and personally damaging. This appeal to altruism and rationality may not always be persuasive and may have to be augmented with another compelling argument for relaxing weight control efforts as part of treatment. There is good evidence that continued WS, bingeing and purging indeed may lead to an all-time high weight during the course of an unremitting battle with BN (11, 13). Therefore, the bottom line is that it makes sense to learn to accept body weight, even if it is higher than a particular set of weight norms that happen to have nothing to do with the weight that a particular person can expect given their genetics and personal weight history.
WS also has important implications for the delivery of care to the BN patient population. We are very often caught up in battle with insurance companies over the appropriate weight for discharge from partial hospitalization or residential care. The insurers insist on using body weight norms tables or BMI and seem impervious to the argument that “90% of average weight” is completely inappropriate for a person who is highly weight-suppressed and likely needs to be at a higher body weight in order for symptoms to subside. When the insurer denies care claiming that the patient has met the weight restoration criterion, it seriously undermines treatment recommendations. It can be disheartening for a BN patient who has begun to accept the concept that they may have to accept a bit higher weight to hear that insurance no longer deems them deserving of treatment. They report feeling like “second class citizens” among their peers with AN. Fortunately, there has been a steady accumulation of research indicating that WS plays an important role in the development of bulimic symptoms and that a truly “healthy weight” for some can be tied more closely to their personal weight history than to population norms.
1) Russell, G. (1979). Bulimia nervosa- An ominous variant of anorexia nervosa. Psychological Medicine 9: 429-488.
2) Garner, D. M. & Fairburn, C. G. (1988). Relationship between anorexia nervosa and bulimia nervosa: Diagnostic implications. In D. M. Garner and P. E. Garfinkel (Eds.), Diagnostic issues in anorexia nervosa and bulimia nervosa (pp. 56-79). New York, NY: Brunner/Mazel.
3) Garner, D., P. Garfinkel, et al. (1985). “The validity of the distinction between bulimia with and without anorexia nervosa.” American Journal of Psychiatry 142: 581-587.
4) Garner, D., M. Olmsted, et al. (1985). Similarities among bulimic groups selected by different weights and weight histories. Journal of Psychiatric Research 19: 129-134.
5) Garner, D. M., Rockert, W., Olmsted, M.P., Johnson, C. Coscina,D. (1885). Psychoeducational principles in the treatment of bulimia and anorexia nervosa. Handbook of Psychotherapy for Anorexia Nervosa and Bulimia. D. M. G. a. P. E. Garfinkel. New York, Guilford Press: 513-572.
6) Butryn, M. L., A., Lowe, M.R., Safer, D.L. & Agras, W.S. (2006). Weight suppression is a robust predictor of outcome in the cognitive-behavioral treatment of bulimia nervosa. Journal of Abnormal Psychology, 115, 62-67.
7) Lowe, M. R., L. A. Berner, et al. (2011). “Weight Suppression Predicts Time to Remission From Bulimia Nervosa.” Journal of Consulting and Clinical Psychology 79: 772-776.
8) Dawkins, H., H. J. Watson, et al. (2013). “Weight Suppression in Bulimia Nervosa: Relationship with Cognitive Behavioral Therapy Outcome.” International Journal of Eating Disorders 46: 586-593.
9) Herzog, D. B., J. G. Thomas, et al. (2010). “Weight suppression predicts weight change over 5 years in bulimia nervosa.” Psychiatry Research 177: 330-334.
10) Keel, P. K. and T. F. Heatherton (2010). “Weight Suppression Predicts Maintenance and Onset of Bulimic Syndromes at 10-Year Follow-Up.” Journal of Abnormal Psychology 119: 268-275.
11) Stice, E., S. Durant, et al. (2011). “Weight suppression and risk of future increases in body mass: effects of suppressed resting metabolic rate and energy expenditure.” American Journal of Clinical Nutrition 94: 7-11.
12) Wildes, J. E. and M. D. Marcus (2012). “Weight suppression as a predictor of weight gain and response to intensive behavioral treatment in patients with anorexia nervosa.” Behaviour Research and Therapy 50: 266-274.
13) Shaw, J. A., Herzog, D.B., Clark, V.L. et al. (2012) Elevated Pre-morbid Weights in Bulimic Individuals are Usually Surpassed Post-Morbidly: Implications for Perpetuation of the Disorder. International Journal of Eating Disorders 45: 512-523.
David M. Garner, Ph.D., Founder and Administrative Director, River Centre Clinic (RCC)
Julie Desai, M.A., Director, Adult Partial Hospitalization Program, RCC
Meggan Desmond, LISW, Director, Adolescent Residential Program, RCC
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