Navigating Weight Checking and Avoidance in Eating Disorder Recovery

Written by Paulina Syracuse

The number on the scale. This one number can have a large impact on how someone with an eating disorder (or someone without this diagnosis but struggling with negative body image) feels about and views themselves. It can have the power to potentially make or break one’s sense of self-worth and elicit intense emotions, like anxiety, guilt, and shame. As a result, people may interact with the scale in a way that aims to help protect their sense of self-worth and avoid feeling these hard emotions. Specifically, they may weigh themselves frequently and adjust their eating behaviors accordingly to “compensate” for the number  they see. In doing so, weight checking may produce a sense of control. Conversely, others may avoid weighing themselves out of fear of what the number may be and, consequently, how they will feel about themselves. This behavior (or lack thereof) has the effect of shielding oneself from self-criticism and strong emotion. It’s also not uncommon for people to vacillate between frequent weight checking and weight avoidance. However, there are two major downsides with both methods.First, incorrect beliefs about weight and how it fluctuates are maintained. Second, weight continues to be a large factor importance in how one evaluates themselves. Basically, the act of frequent weight checking and/or weight avoidance sends messages to the brain that the number on the scale is very important and can either be “good” or “bad.” In the following paragraphs, I’ll discuss these biased beliefs, how they are maintained, and an effective intervention that can be used to dispel them.

Let’s start exploring what thoughts and feelings come up when a person checks their weight daily or multiple times throughout the day. There are a number of flawed beliefs that remain intact when one engages in frequent weight checking. For example, they may have misconceptions about the extent to which food and eating impacts their weight, specifically that eating certain foods or in certain ways will have a large and immediate effect on one’s weight. People may also have an expectation that their weight should remain the same (or less) each time they step on the scale without an awareness of the extent to which various factors impact one’s weight outside of food, like water intake, digestive functioning, hormones (particularly for women and people whose biological sex is female), genetics, and medications. They may experience stress and even panic when a totally normal and temporary increase on the scale pops up. Frequent weight checking often results in significant concern about normal or inconsequential fluctuations in weight and can also be used as a way to manage distressing emotions. If the scale is at the “right” number or lower, they may experience relief or feel a sense of  control. If the scale is higher than the “right” number, they may experience increased distress which results in their need to engage in disordered and unhealthy behaviors to “fix” it. Further, frequent weight checking preserves disordered eating behaviors, such as dietary restraint, purging, and excessive exercise, to either sustain the current weight or lose weight.

Weight avoidance might be thought of as a double-edged sword. On one side, misconceptions about weight and how it fluctuates are unchecked because there are no opportunities to gather contradictory information. They may have predictions or fears about what their weight might be in general or how it has changed after eating a certain meal, for instance, but never step on the scale to test these predictions. On the other side, one is left with low confidence in their ability to tolerate strong emotion or urges to engage in compensatory behaviors, like dieting, purging, or intense exercise. By never seeing the number on the scale, they may believe that they will be overwhelmed with intense feelings and not be able to cope and are unable to gain counter evidence. Many providers still do what is known as “blind weighing,” in which the client faces or looks away from the scale  and the provider does not share their weight. They will also often recommend that the client asks not to see their weight at appointments in other scenarios. While blind weighing  can be helpful in the short term, it gives full power to the number on the scale and does not empower the individual to practice seeing and knowing the number, and tolerating the emotions that it may elicit. . This practice can fuel weight-fear and weight-stigma in ways that may hinder progress in treatment. Ultimately, we want all of our clients to be completely  free of the power of the scale and have the distress tolerance skills to tolerate difficult emotions.  We believe that these goals cannot be fully achieved without seeing the number on the scale.

This is all to say that the ultimate consequence of both frequent weight checking and weight avoidance is that they both maintain the importance of the number on the scale on how one evaluates themselves. These behaviors create a feedback loop in concern about weight is reduced by weight checking or avoidance which reinforces the behaviors and the significance of the number on the scale. A main aim of evidence-based eating disorder treatment, therefore, is to reduce this over-importance of weight in one’s self-evaluation system. This aim can be achieved by addressing these scale-related behaviors in a standardized and systematic way using an exposure-based technique called in-session weighing. This technique is used in the gold-standard treatments for adults with an eating disorder (i.e., Cognitive Behavior Therapy – Enhanced; Fairburn, 2008) as well as adolescents (i.e., Family-Based Treatment, Lock & Le Grange, 2001).  There are on-going conversations regarding seeing weight in different diagnoses, in particulary atypical anorexia. We will update as research becomes more available.

So, why do we do in-session weighing at our practice and how do we do it? In-session weighing is done collaboratively on a weekly basis with a patient and trained therapist. It can be scary and hard at first, especially if a patient  has  not seen the scale themselves in weeks, months, or years OR if they weigh themselves daily/hourly and depend on this for their emotional management. Logistically-speaking, in-session weighing involves the patient weighing themselves at the beginning of each session, reading the weight out loud, and plotting the weight on a graph with the therapist. Clients  are asked to refrain from weighing themselves outside of session. Importantly, weight is interpreted using multiple weeks’ weights rather than on a week-to-week basis (Note: Patients are also supported in eating regularly outside of session to address dietary restraint/restriction and refrain from other disordered eating behaviors. This is no small thing!). The goals of weekly, in-session weighing serves to provide corrective education about weight and normal fluctuations in it as well as misconceptions about the effect of food and eating on weight.

Importantly, in-session weighing also serves to increase an individual’s sense of mastery and self-efficacy as they learn that they are capable of handling strong emotions and that the number on the scale does not need to determine their future food choices, what they wear, and what they do. It  can take weeks or months for patients to become more comfortable knowing their weight/not checking their weight frequently while also resisting other eating disorder-related urges. Weight has been immensely stigmatized, and unlearning thoughts and behaviors of the thin ideal without an eating disorder is hard enough! At the Center for Hope and Health, we strive to encourage and support patients to make these challenging and meaningful decisions to take the power back from their weight.