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Figure 1 – The BMI Chart above (click to view larger image) displays a range of BMI values for various heights and weights. The BMI, or Body Mass Index, is a number calculated by taking your weight in kilograms and dividing it by height in meters squared. For reference, according to BMI, male who is around 5’8” should weigh between 130 and 165 pounds.
Although the BMI calculation has been around since the 1800s, it gained popularity after a study published in the July 1972 issue of the Journal of Chronic Diseases concluded BMI to be the best proxy for body fat percentage among ratios of weight and height.2 Epidemiological studies (studies of large populations) often use the BMI to predict likelihood of a number of diseases. Note: Some studies have shown that being underweight is also a risk for premature death, sometimes even more so than being overweight. Many doctors calculate the BMI of patients and make recommendation simply based on that number, which is a flawed approach for the reasons given above. 1) Body fat measurement: While BMI is used as proxy for body fat, it is a much better idea to just measure body fat.
As always, it is important to look at the “big picture” rather than focusing on a particular calculation to evaluate your chances of developing an obesity-related illness. Exercise Capacity and Body Composition as Predictors of Mortality Among Men With Diabetes Diabetes Care. Changes in Body Weight and Body Fat Distribution as Risk Factors for Clinical Diabetes in US Men American Journal of Epidemiology.
Folsom AR, Prineas RJ, Kaye SA, and Munger RG- Incidence of hypertension and stroke in relation to body fat distribution and other risk factors in older women. I think Waist to Hip Circumference is definitely interesting, and I’ve seen some research more recently showing waist to height may also be a useful indicator.
The BMI (Body Mass Index) CHART is considered the most common measurement for identifying the obesity and the stage of obesity. You can use BMI to see whether you are underweight, normal weight, overweight, obese or extreme obese. I announced in my last blog post that this one would be about bad meta-analyses of weak data used to secure insurance reimbursement for long-term psychotherapy. Hands down, CBT did better than psychoanalytic therapy in reducing binging and purging, despite there being only five months of cognitive therapy and two years of psychoanalysis.
Zipfel, Stephan, Beate Wild, Gaby Gro?, Hans-Christoph Friederich, Martin Teufel, Dieter Schellberg, Katrin E. The abstract of the Lancet article is available here, but the full text is behind a pay wall. Or an example of a thorough uncritical churnalling of this press release in the media here. Media portrayals of anorexia often show the extreme self-starvation associated with the severe disorder, but this study recruited women with mild to moderate anorexia.
Anorexia nervosa is associated with serious medical morbidity and pronounced psychosocial comorbidity. Overall, the two new types of therapy demonstrated advantages compared to the optimized therapy as usual,” said Prof. You can find out more about BMI [body mass index] here and you can calculate your own here. These patients had to have been quite underweight to be diagnosed with anorexia, and so how much weight did they gain as result of treatment?  The authors should have given us the results in numbers that make sense to most people. Four months after beginning the 10 month treatment, the women had gained an average of 5 pounds and at 12 months after the end of treatment (so 22 months after beginning treatment), they had gained another 3 pounds.
On average, the women participating in the trial were still underweight 22 months after the trial’s start and would have still qualified for entering the trial, at least according to the weight criterion. Optimised treatment as usual, combining psychotherapy and structured care from a family doctor, should be regarded as solid baseline treatment for adult outpatients with anorexia nervosa.
Anorexia was treated with two therapies, each compared to an unusual control condition termed “optimized” treatment as usual. In interpreting these results, note that the study involved a sample of young women with mostly only mild to moderate anorexia. In post hoc “exploratory analyses,” the authors emphasized a single measure at a single time point that favored focal psychodynamic therapy, despite null findings with most other standard measures at all time points. Put another way, results of the trial were very likely spun, starting with the abstract, and continuing in the results and press release. The optimized routine care condition involved ill-described, uncontrolled  psychotherapeutic and medical interventions.
The study is best understood as testing the effectiveness of treating anorexia in some highly unusual circumstances in Germany, not an efficacy trial testing the strength of the two treatments. The study probably demonstrates that  meaningful RCTs of the treatment of anorexia cannot be conducted in Germany with generalizable results. Maybe this trial is just another demonstration that we do not know enough to undertake a randomized study of the treatment of anorexia that would yield readily interpretable findings. On average, the women were still underweight at follow up, despite having had only mildly to moderate anorexia at the start of the study.  The sample was quite heterogeneous at baseline.
Any discussion of outcomes has to take into account the substantial number of women not completing treatment and lost to follow up. We certainly cannot assume that failures to complete treatment, loss to follow up and the necessity of inpatient stays are randomly distributed between groups. The preregistration of the trial listed BMI at the end of treatment as the primary outcome. The authors’ failure to designate one or two of these variables a priori (ahead of time) sets them up to pick-the-best hypothesizing after results are known or HARKING. We should in general be highly skeptical about post hoc exploratory analyses of variables that were not pre-designated as outcomes for a clinical trial, in either primary or secondary analyses.
In table 3 of their article, the investigators present within-group effect sizes that portray the manualized treatments as doing impressively well.
Yet, as I will discuss in forthcoming blogs, within-group effect sizes are highly misleading compared to the usually reported between-group effect sizes. The conventional strategy is to provide between-group effect sizes comparing a treatment to what was obtained the other groups. As an example, we do not pay much attention to the within-group effect size for antidepressants in a particular study, because these numbers do not take into account how the antidepressants did relative to a pill placebo condition. Take a look at weight gain by the end of the 12 month follow-up among patients receiving focal psychodynamic therapy. Descriptions in the preregistered study protocol, press releases, and methods section of the article do not do justice to the “optimized” treatment as usual.
Under close guidance from their family doctor—eg, regular weight monitoring and essential blood testing—and with close supervision of their respective study centre, patients allocated optimised treatment as usual were able to choose their favourite treatment approach and setting (intensity, inpatient, day patient, or outpatient treatment) and their therapist, in accordance with German national treatment guidelines for anorexia nervosa.11 Moreover, comparisons of applied dosage and intensity of treatment showed that all patients— irrespective of treatment allocation—averaged a similar number of outpatient sessions over the course of the treatment and follow-up periods (about 40 sessions).
In a more typical trial, patients assigned to treatment as usual are provided with a list of referrals.
Overall, no matter what condition patients were assigned, all received about the same amount of outpatient psychotherapy, about 40 sessions.
Alot of attention and support is provided in 40 sessions of such psychotherapy, making it difficult to detect the specific effects provided by the manualized therapies, above and beyond the attention support they provide.. In short, the manualized treatments were doomed to null findings in comparison to treatment as usual.
Most evidence-based treatments earned their status by proving superior in a clinical trial to a control group such as wait list or no treatment at all.
Some investigators, however, are less interested in establishing the efficacy of treatments, then in demonstrating the effectiveness of particular treatments over what is already being done in the community. But even if their intention is to conduct an effectiveness study, investigators need to better describe the nature of of treatment as usual, if they are to make reasonable generalizations to other clinical and health system contexts.
We know that the optimized treatment as usual was exceptionally intensive, but we have no idea from the published article what it entailed, except lots of treatment, as much as what was provided provided in the active treatment conditions. Again, if all of the conditions had done well in terms of improved patient outcomes, then we could have concluded that introducing manualized treatment does not accomplish much in Germany at least. The ready availability of free, intensive treatment prevents recruitment of a large, representative sample of women with anorexia to a potentially burdensome clinical trial. There is less incentive for women to remain in the study once they are enrolled because they can always drop out and get the same intensity of treatment elsewhere. Treatment as usual available to everyone is not necessarily effective, but it precludes detecting incremental improvements obtained by less intensive, but focused treatments.
Prasad and Ioannidis have recently called attention to the pervasiveness of non-evidence-based medical treatments and practice guidelines that are not either cost-effective, ensuring good patient outcomes, or avoiding unnecessary risks. Surely, that would be the case in any effort to de-implement guidelines the treatment of anorexia in Germany.
The potentially life-threatening nature of anorexia may discourage any temporary suspension of treatment guidelines until evidence can be obtained. It would be unethical to assigned women with anorexia to waitlist control or no treatment when free treatment is readily available in the community.


This may well be, as the investigators proclaim in their press release, the largest ever RCT of treatment for anorexia. For me, this study highlights the anonymous barriers to conducting a well-controlled RCT for anorexia with patients representative of the kinds that would seek treatment in real-world clinical context. There are unsolved issues of patient dropout and retention for follow-up that seriously threaten the integrity of any results. I am not sure how we would otherwise get this understanding without involving women with anorexia in the design of treatment in future clinical trials. Before we undertake massive randomized trials such as ANTOP, we need to get information to set basic parameters from nonrandomized but nonetheless informative small-scale studies. All views that Professor Coyne expresses are his own and do not necessarily reflect those of PLOS or other institutional affiliations. I am disappointed to hear this, particularly because this is not the way the situation was described in the discussion section of the Lancet article. I still think that the availability of psychotherapy in Germany is better than most of the world and has fewer health disparities.
I’m not sure, they were referring mostly to the therapy of anorexia nervosa, which, around here, happens in psychiatric wards, aka inpatient a lot (so not necessarily CBT, medical doctors often much more inclined towards psychodynamic stuff). Thanks, and excellent points, but apparently this is now in Google and so I cannot change it on the web or its appearance in Google searches. One of the reasons such poor results were had is that psychotherapy cannot be fully effective (if at all) while someone with an eating disorder is still restricting calories whether by food restriction, or by intensive exercise, use of laxatives or other medications (including alcohol), or some combination of those.
There is far too much focus on psychotherapy and its intended effects on the consciousness of the individual, with far too little focus on the state of the actual, physical brain.
We MUST move past the model where people are urged to recover to a certain point, where weight and body size are seen to be reliable markers of weight restoration (and thus also by inference, of being in a fit state to receive psychotherapeutic care), which keeps many, if not the majority, in an ongoing state of restriction – which perpetuates the cycle of a restrictive eating disorder. In order to psychotherapy to be effective, the person needs to be in a nourished state for long enough to enable the physical brain to be fully restored. Ancel Keys Minnesota Starvation Experiment showed clearly that there are stages to recovery from starvation – and one of these is a prolonged period of eating at well above maintenance calories. The unrelenting focus on the subjects’ BMI and weight gain hampers psychotherapeutic efforts. Calculadora Del Indice De Masa Corporal (imc) Para Que Los PapA?s Puedan Chequear El Peso Saludable De Sus Hijos. Calculates Bmi, Waist-to-height Ratio, Percent Body Fat, Lean Body Mass And Gives Personal Suggestions For Protein Intake.
Find your height on the side (in metres on the left and in feet on the right) and draw a horizontal line across the chart. Find your weight (in kilograms across the bottom of in pounds across the top) and draw a vertical line across the chart.
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To find your BMI, identify your height on the left column, then use the top row to find your weight, then meet the two points in the graph. These studies, however, did not exclude “sick” people, like those with cancer or emphysema, or people who smoke or use dangerous drugs, which often can cause weight loss.
Using that data and applying it to an individual without looking at the person’s overall health is a bad idea. Health is generally better with lower body fat percentages regardless of the BMI, and this includes populations with documented diseases like diabetes.10 I recommend striving for maximum muscle mass and a body fat below 15% for men and 23% for women.
Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies The Lancet, V. The Diabetes Risk Score: A practical tool to predict type 2 diabetes risk Diabetes Journals. In general the obesity occurs when a person consumes more calories than they need for the energy they use.
Check the word above your BMI to see whether you are normal weight, overweight, obese or extreme obese.
But that is postponed so that I can give timely coverage to the report in Lancet of results of the Anorexia Nervosa Treatment of OutPatients (ANTOP) randomized clinical trial (RCT).
I had expressed a lot of enthusiasm for a RCT comparing cognitive behavior therapy (CBT) to psychoanalytic therapy for bulimia.
This difference seems to be a matter of psychoanalysis doing quite poorly, and not that the cognitive behavior CBT doing so well.
The combination of high dropout and low treatment acceptability has led some researchers to suggest that we pause large-scale clinical trials for anorexia nervosa until we resolve these fundamental obstacles.
But note that BMI is a controversial measure, does not directly assess body fat, and is not particularly accurate for people who are large- or small-framed or fit or athletic. I had to do some calculations to translate the changes in BMI reported by these authors with the assumption that they were an average height of 5’6”, like other German women. Focal psychodynamic therapy proved advantageous in terms of recovery at 12-month follow-up, and enhanced cognitive behaviour therapy was more effective with respect to speed of weight gain and improvements in eating disorder psychopathology.
This is an unusual way that exaggerated results, particularly when comparisons are made to the effect sizes reported for other studies. Little sense can be made of this clinical trial except that availability of manualized treatment proved no better (or no worse), and none of the treatments, including routine care, did particularly well. Results are not generalizable to either of the psychotherapies administered by themselves in other contexts. We don’t know how much of the modest weight gain and the minority of women who were considered “fully recovered” represents small improvements in women starting with higher BMI and milder, subsyndromal anorexia at baseline.
But they are not magic, and involve some assumptions that cannot be tested with loss of patients to follow up in such small treatment groups. We cannot convincingly rule out that some combination of these factors are decisive for the results that were obtained. That means the investigators staked any claims about the trial on this outcome at this time point.
Not all of these outcomes are reported in the article, and for the ones that are reported, almost all are not significantly different at any timepoint.
These within-group effect sizes attribute all changes that occurred in a particular group to the effects of the intervention. Presumably the pill placebo is chemically inert, but it is provided with the same attention from clinicians, positive expectations, and support that come with the antidepressant. These data partly reflect an important achievement of the German health-care system: that access to psychotherapy treatment is covered by insurance. Although a desire to contribute to science is sometimes a factor, the main reason for patients entering clinical trials are because they think they will get better treatment and maybe because they think they can get a preferred treatment which they cannot get it elsewhere.
Dropping out of the clinical trial would still give them access to free treatment–without the hassle of remaining in the trial. Often few bother to complete a referral or remain in treatment, and so we can assume that the treatment-as-usual condition usually represents minimal treatment, providing a suitable comparison  with a positive outcome for more active, free treatment. How could these authors have expected to find a substantial difference between the two manualized treatments and this intensity of routine care? Differences between groups of the magnitude they assumed in calculating sample sizes under these conditions would be truly extraordinary. The only thing really unexpected about this trial is that all three conditions did so poorly. Such comparisons provide the backbone to claims of evidence-based treatments, but are not particularly informative.
Effectiveness studies typically find small effects been obtained in straw-man comparisons between treatments and the weak effects observed in control groups. It may even be that some of the women assigned to optimized treatment obtained therapists providing much the same treatment. In my last blog post, we viewed a situation in which less treatment proved better than more. Maybe the availability of intensive and extensive treatment discourages women from taking responsibility for their health threatening condition. But these standards are not evidence-based and appear to have produced mediocre outcomes in at least this trial. They propose de-implementing such unproven practices, but acknowledge the likelihood that cultural values, vested interests, and politics can interfere with efforts to subject established but unproven practices to empirical test. But we need only to look to the example of similarly life-threatening cancers where improved treatments only came about only when investigators were able to suspend well-established but unproven treatments and conduct randomized trials.
And given the poor performance of routine care observed in this study, such results were not represent the familiar Dodo Bird Verdict for comparisons between psychotherapies in which all of the treatments were winners in all get prizes. But it is very difficult to make sense of it, other than to conclude that no treatments, including treatment as usual, had particularly impressive results.
We just do not know how to recruit a representative sample of patients with anorexia and keep them in therapy and around for follow-up. Obviously the investigators in this study could not even estimate effect sizes in order to set sample sizes.


Coyne, PhD is Professor of Health Psychology at University Medical Center, Groningen, the Netherlands where he teaches scientific writing and critical thinking. Coyne is Emeritus Professor of Psychology in Psychiatry, where he was also Director of Behavioral Oncology, Abramson Cancer Center and Senior Fellow Leonard Davis Institute of Health Economics. The photo was certainly not an accurate depiction of the kinds of patients with anorexia that were recruited to this file. Insurances, however, restrict the number of therapy places based on off numbers AND German insurance still pays for LTPP, so lots of time and money is wasted there. As best as I could gather from the Lancet article, these women in the study were mostly treated outpatient, but a substantial proportion required inpatient stay during the study and follow up. Looking at so much wasted work presented in this study (spinned results, possible harking, results misinterpretation, dropouts) makes me feel sad.
The calorie deficit drives further restriction, and it enables disordered thoughts and behaviour, so until that primary issue is addressed, it will be almost impossible to change thought patterns and behaviours. If you dig around, you will see that relapse rates for this disorder, in all its permutations, are HUGE, with people often limping from on subtype to another over the course of many years. This means that the practice of refeeding somone at a calorie surplus until they are a socially acceptable weight and size, and then cutting calories again and adding in exercise as a means of weight control, must change.
His subjects were not men with a history of a restrictive eating disorder, so their recovery from the period of starvation was for the most part linear, and uncomplicated, and cannot be fully comparable to the recovery of a person who has what we know to be the genetic makeup involved in eating disorders. In attempting to exert and maintain external control over their bodies, treatment teams are enabling the disorder to remain active. Use These 10 Tips To Lower Your Body Mass Index (bmi) Naturally, Supporting Sound Health And Avoiding Chemicals. There are no studies to my knowledge which show healthy people with desirable body compositions die sooner than overweight people. BMI calculations do not consider age, gender, frame size, muscle mass, or fat distribution.
Despite having a 33 inch waist, 11% body fat and perfect cholesterol and blood sugar, his primary care doctor told him he must lose 25 pounds if he didn’t want to get diabetes and heart disease! These numbers are within the “fitness range” of recommended body fat according to the American Council on Exercise. You should watch all measurements, as BMI alone can be misleading, but other things should be considered especially in the young healthy, athletic individual.
Relation of body fat distribution in men and degree of coronary narrowings in coronary artery disease. Women could be considered overweight if their BMI is between 25 and 29.9 and women could be considered obese if their BMI is over 30. The trial, proclaimed the largest ever of its kind, compared cognitive behavior therapy, focal psychodynamic therapy, and “optimized” routine care for the treatment of anorexia. I was impressed with its design and execution and the balanced competing investigator allegiances. Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomised controlled trial. You can at least get the details of what the authors said they were going to do, ahead of doing it. No serious adverse events attributable to weight loss or trial participation were recorded. Long-term outcome data will be helpful to further adapt and improve these novel manual-based treatment approaches.
And yet, we need some way to account for all patients initially entering a clinical trial (termed an intent-to-treat analysis) for valid, generalizable results. That includes claiming credit for nonspecific effects common across conditions, as well as any improvement due to positive expectations or patients bouncing back after having enrolled in the study at a particular bad time.
Once these factors shared by both the antidepressant and pill placebo conditions are taken into account, the effect size for antidepressant decreases. It described patients assigned to the treatment as usual being provided with a list of psychotherapists specializing in the treatment of eating disorders and their family physicians assuming an active role in monitoring and providing actual treatment. However, patients allocated optimised treatment as usual needed additional inpatient treatment more frequently (41%) than either those assigned focal psychodynamic therapy (23%) or enhanced cognitive behaviour therapy (35%). I doubt anything like this treatment would be available elsewhere in the world as standard care.
But, if this is the situation of routine care in Germany, why would eligible women not just remain in routine care without the complications of being in a clinical trial?
Yet, they were only able to randomize 242 patients, despite a massive two-year effort to recruit patients involving 10 German departments of psychotherapy and psychosomatic medicine. In the United States, patients enrolling in clinical trials often either do not have health insurance or can find only providers who will not accept what health insurance they have for the treatment they want. It may simply be that many manualized, structured treatments are no better than other active treatments patients have similar intensity of treatment, positive expectations, and attention and support. But we do not have evidence-based protocols in place for standardizing surveillance and decision-making. He is also Visiting Professor, Institute for Health, Health Care Policy & Aging Research, Rutgers, the State University of New Jersey. He has served as External Scientific Advisor to a decade of European Commission funded community based programs to improve care for depression in the community. As a matter of fact, while there is, in theory, free choice, in practice, you end up with whoever happens to have a free slot by chance, even if that means travelling to the next town.
Lancet also reports that Germany has ten specialized settings for treating eating disorders, proportionately more than in most countries.
As well, current treatment tends to focus on weight, with people being graded as to the severity of their condition according to their level of emaciation. Many therapeutic efforts focus on the person’s history, familial and other, while ignoring the fact that their physical brain is still suffering the effects of starvation, and that that starvation is likely the major cause of disordered and maladaptive functioning.
What is missed is that as long as they stay in a state of restriction, by any means, and with any rationale as to ideal weights and body sizes being applied, they will still be in an active eating disorder state. All of Keys subjects ate well above their normal intake, for varying periods of time, and gained well above their normal weight.
Subcutaneous fat (under the skin) does not appear to strongly predispose to disease, whereas visceral fat (in and between the organs) does.
The article’s reporting was transparent, substantially reducing risk of bias and allowing a clear message. So, we cannot ignore these problems and simply concentrate just on the women completing treatment and remaining available. We cannot determine if the inpatient stays contributed to the results that were observed or maybe interfered with the outpatient treatment.
It appears that a very small minority of the available patients were recruited, raising questions about the representativeness of the sample. Patients in the United States enter a clinical trial just to get the possibility of treatment, very different circumstances than in Germany.
That is simply a hypothesis, but Germany is spending lots of money assuming that it is incorrect. He has written over 350 articles and chapters, including systematic reviews of screening for distress and depression in medical settings and classic articles about stress and coping, couples research, and interpersonal aspects of depression.
The psychological problems that had emerged during the period of starvation were resolved ONLY once food restrictions were lifted, and had been for some time. Therefore, someone can have a normal BMI but a high percentage of visceral fat and be at high risk for diabetes and heart disease but a sumo wrestler, with a high BMI but little visceral fat, will be metabolically healthy.9 Additionally, as most people know, essentially all NFL running backs, most of whom sport 6-packs and sub-10% body fat would be classified as obese under this system.
You will not see me very often being so positive about a piece of research in this blog, although I did note some limitations.
After all, it would be unethical to leave women with such a threatening, serious disorder on a waiting list just to allow a comparison.
He has been designated by ISI Web of Science as one of the most impactful psychologists and psychiatrists in the world. The metabolic changes that occur as a result of restriction can see someone cycling up to a far higher weight than their genetic setpoint, while still restricting severely, and being as psychologically unwell as someone who is emaciated. Even a recreational athlete with slightly above average muscle mass could be considered overweight. He also blogs and is a regular contributor to the blog Science Based Medicine and to the PLOS One Blog, Mind the Brain.
He is known for giving lively, controversial lectures using scientific evidence to challenge assumptions about the optimal way of providing psychosocial care and care for depression to medical patients.



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