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Calculation of Expected Body Weight in Adolescents With Eating Disorders

Daniel Le Grange, Peter M. Doyle, Sonja A. Swanson, Kali Ludwig, Catherine Glunz and Richard E. KreipePediatrics; originally published online January 4, 2012;DOI: 10.1542/peds.2011-1676

The online version of this article, along with updated information and services, islocated on the World Wide Web at:

http://pediatrics.aappublications.org/content/early/2012/01/02/peds.2011-1676

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthlypublication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 NorthwestPointBoulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy

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ARTICLEARTICLECalculationofExpectedBodyWeightinAdolescentsWithEatingDisorders

AUTHORS:DanielLeGrange,PhD,aPeterM.Doyle,PhD,aSonja

A.Swanson,ScM,bKaliLudwig,BA,aCatherineGlunz,MD,candRichardE.Kreipe,

aDepartmentofPsychiatryandBehavioralNeuroscience,andcDepartmentofPediatrics

andInternalMedicine,TheUniversityofChicago,Chicago,Illinois;bDepartment

ofEpidemiology,HarvardSchoolofPublicHealth,Boston,Massachusetts;anddDivisionofAdolescentMedicine,DepartmentofPediatrics,UniversityofRochesterMedicalCenter,Rochester,New

KEYWORDS

adolescence,bodyweight,eatingdisorders

ABBREVIATIONS

ANanorexianervosaCDCCentersforDiseaseControlandPreventionCIconfidence

intervalDSM-IVTRDiagnosticandStatisticalManualofMentalDisorders,FourthEdition,

TextRevision

EBWexpectedbodyweight%EBWpercentexpectedbodyweight

Allauthorsmadesubstantialcontributionstoconceptionanddesign,acquisitionof

data,oranalysisandinterpretationofdata;draftingofthearticleorrevising

itcriticallyforimportantintellectualcontent;andfinalapprovaloftheversionto

bepublished.

www.pediatrics.org/cgi/doi/10.1542/peds.2011-1676

doi:10.1542/peds.2011-1676

AcceptedforpublicationSep26,2011

AddresscorrespondencetoDanielLeGrange,PhD,DepartmentofPsychiatryandBehavioralNeuroscience,TheUniversityof

Chicago,5841S.MarylandAve.,MC3077,Chicago,IL60637.E-mail:legrange@uchicago.edu

PEDIATRICS(ISSNNumbers:Print,0031-4005;Online,1098-4275).

theAmericanAcademyofPediatrics

FINANCIALDISCLOSURE:Dr

LeGrangereceivesroyaltiesfromGuilfordPressandhonorariafromtheTrainingInstituteforChildandAdolescentEatingDisorders,LLC.Theotherauthorshave

indicatedtheyhavenofinancialrelationshipsrelevanttothisarticletodisclose.

FundedbytheNationalInstitutesofHealth(NIH).

KNOWNONTHISSUBJECT:Eatingdisordersare

characterized

bypreoccupationwithweightandshape,whichis

manifestedbyarefusaltomaintainanormalweight.Anexact

determination

ofexpectedbodyweight(EBW)iscriticalfor

diagnosisandclinical

managementofthesedisorders.

WHATTHISSTUDYADDS:TheMcLarenand

MooremethodspresentwithseverallimitationswhencalculatingEBWfor

adolescentswitheatingdisorders.AcommonlyagreeduponmethodforEBWcalculationsuchastheBMIpercentilemethodisrecommendedforclinicalandresearch

purposes.

abstract

OBJECTIVE:Toexaminetheagreement

betweenthreemethodstocalculateexpectedbodyweight(EBW)foradolescentswitheating

disorders:(1)BMIpercentile,(2)McLaren,and(2)Mooremethods.

METHODS:Theauthorsconductedacross-sectionalanalysisofbaselineinformationfromadolescentsseekingtreatmentofdisorderedeatingatTheUniversityofChicago.

Adolescents(N=373)aged12to18years(mean=15.84,SD=1.72),

withanorexianervosa(n=130),bulimianervosa(n=59),oreating

disordernototherwisespecified(n=184).ConcurrencebetweentheBMI

percentile,McLaren,andMooremethodswasassessedforagreementaboveorbelowarbitrarycutpointsusedinrelationtohospitalization(75%),diagnosis(85%),and

healthyweight(100%).Patternsofabsolutediscrepancieswereexaminedbyheight,age,gender,

andmenstrualstatus.Limitationstosomeofthesemethodsallowedcomparisonbetweenall

3methodsinonly204participants.

RESULTS:Moderate

agreementwasseenbetweenthe3methods(kvalues,0.480.74),withpairwisetotalclassificationaccuracyateachcutpointrangingfrom84%to98%.

Themostdiscrepantcalculationswereobservedamongthetallest(.75thpercentile)andshortest

(,20thpercentile)casesandolderages(.16years).Manyofthemostdiscrepant

casesfellaboveandbelow85%EBWwhencomparingthe

BMIpercentileandMooremethods,indicatingdisagreementonpossiblediagnosisofanorexianervosa.

CONCLUSIONS:ThesemethodslargelyagreeonpercentEBWin

termsofclinicallysignificantcutpoints.However,theMcLarenandMooremethodspresent

withlimitations,andacommonlyagreed-uponmethodforEBWcalculationsuchasthe

BMIpercentilemethodisrecommendedforclinicalandresearchpurposes.

Pediatrics2012;129:19

PEDIATRICSVolume129,Number2,February2012

Eatingdisordersarecharacterizedbydisturbancesiningestivebehaviorandareusuallyaccompaniedbypreoccupationwithweightandshape.1Thispreoccupationisoften

manifestedbyaninabilitytomaintainanormalweightforageandheight

andistheprimarydiagnosticcriterionforanorexianervosa(AN).Determiningthedeviation

fromexpectedbodyweight(EBW)(oftenreferredtoasideal

bodyweight)isthereforeimportantinthediagnosisofAN(,85%EBW)andthedifferentialdiagnosisofbulimianervosa(.85%EBW)andeatingdisorder

nototherwisespecified(deviationfromEBWlessclearlydemarcated).

Inaddition

todiagnosis,EBWisusedasanindicatorofmedicalstability,asjustification

forhospitalization,tosetappropriatetargetweights,2,3andtotrack

progressintreatmentandassessrecovery.4,5Yet,thereisnoconsensusonhowbesttocalculateEBWforthepediatricandadolescenteatingdisorders

population.AlthoughabsoluteBMI(weightinkilograms/heightinmeters;seeref2)has

gainedattentioninbothclinicalandresearchsettings,itismostcommonlyused

toscreenforobesityandismostapplicabletothe

adultpopulation.6,7Moreover,BMIisbasedonheightandweightonlyanddoesnotaccountforuniquephenomenonsuchasshortstatureorstunted

lineargrowthduetomalnutrition.8Therefore,itisnotanoptimalmethodto

reflectnutritionalstatus,especiallyforadolescents.Forpediatricandadolescentpopulations,age-andgender-

adjustedBMIpercentilesaremoreappropriateasweightandheight

normallyincreaseuntil20yearsofage(CentersforDiseaseControlandPrevention[CDC]BMI-for-agegrowthcharts;www.cdc.gov/growthcharts).9

Examinationofanadolescents

weightinrelationtothe50thBMIpercentile,alsoknownastheBMI

percentilemethod,orBMImethod,isperhapsthe

mostfrequentlyused

methodtodeterminetheweightcriterionforaneatingdisorder

diagnosis.10,11InadditiontotheBMImethod,9othermethodsareusedtocalculateEBW;forexample,theMcLaren12andMoore13methods.TheBMI,McLaren,

andMooremethodsareallpediatricspecificandusethechildoradolescents

gender,age,andheighttocalculateEBWbutdonottakeothermeasures

ofanthropometry(eg,bodycompositionandbodyframe)intoaccount.

ResearchershavedemonstratedconsiderableagreementforEBWcalculationsacrossthese3methodsforhealthyadolescents.14However,suchcalculationsarewidelydiscrepantforolderhealthy

adolescentsatthelowestandhighestpercentiles.14

Instudiesofpatients

witheatingdisorders,authorsrarelydescribetheirmethodforcalculatingEBW.Therefore,the

primarygoalofthecurrentstudywastoexaminethe

agreementand/ordiscrepancybetweentheBMI,McLaren,andMooremethodswhencalculatingEBWforadolescentswitheatingdisorders.Asecondarygoalwastodetermine

whetherourfindingswouldallowforclearerguidelinesregardingthemostappropriatemethod(s)

tocalculateEBWforthepediatricandadolescenteatingdisorderspopulation.

METHODSSubjects

Subjectswere373treatment-seekingadolescents,including

researchparticipants,evaluatedatanoutpatienteatingdisordersclinicfromOctober1998throughDecember2009.Thesamplewascomposedof342(91.7%)femalesand

31(8.3%)males,aged12to18years(mean=15.84,SD=

1.72),whometDiagnosticandStatisticalManualofMentalDisorders,FourthEdition,Text

Revision(DSM-IVTR)1criteriaforAN(n=130),bulimianervosa

(n=59),oreatingdisordernototherwisespecified(n=184).Themajoritywerewhite

(74.1%),and13.2%wereHispanic,7.6%

black,1.9%Asian/PacificIslander,and3.2%identifiedasOther. Inadditiontoweight

andheightmeasures,participantsprovideddemographicinformationandcompletedstructureddiagnosticinterviews(ie,

theEatingDisorderExamination15andasetofpaper-and-pencilquestionnaires).

Forthepurposesofthisreport,weonlyusedweight,height,age,gender,menstrualstatus,ethnicity,anddiagnosis.Writteninformedconsentforpatientsaged

18yearsorparental/guardianconsentandadolescentassentforpatients,18years

ofagewereobtained.TheUniversityofChicagoInstitutionalReviewBoardapprovedthe

researchprotocol.

EBWCalculations

EBWwas

calculatedforeachsubjectlimitedtothreeindependentmethodsdescribedinthefollowingtext:BMI,9McLaren,12andMoore13methods.

IntheBMI

method,tocalculatepercentexpectedbodyweight(%EBW)foragivenparticipantbased

onhisorherheight,age,andgender,the50thpercentileBMIfor

exactageandheightatpresentationontheCDCBMI-for-age

percentileschart4wasused(%EBW=BMI/50thpercentileBMIforageandheight3100).ABMIatthe50thpercentilewouldbetheexpectedmedianina

groupofnormallydevelopingadolescents,orEBW.

TheMcLarenmethod12uses

agrowthchartbasedonheight-andweight-forageandforgender(eg,CDC).First,

theparticipantsheightisplottedonthechart.Aline

isextendedhorizontallytothe50thpercentileheight-for-ageofthatparticipant.Asecondlineisthenextendedverticallyfromthe50thpercentileheight-for-ageto

thecorresponding50thpercentileweight.This50thpercentileweightisdeemedtheparticipantsEBW.

TheMooremethod13alsousesagrowthchartbasedonheight-and

weight-forageandgender(eg,CDC),albeitinaslightlydifferent

way.Theparticipants

LEGRANGEetal

ARTICLEARTICLEheight-for-agepercentileisdetermined,andtheEBWistheweightthatcorrespondstothatweightpercentile(eg,aparticipantinthe30th

percentileheight-for-ageandgenderwouldhaveanEBWthatcorrespondstothe

30thpercentileweight-for-ageandgender).

Ofnote,becauseoftheasymptotic

natureoftheheightcurvesasadolescentscompletegrowth,the

McLarenmethodcannotcalculateEBWforgirls.163cmorforboys.176cm.Inaddition,theMooremethodcannotbeusedeasilyfor

children.97thor,3rdpercentileforheightorweightontheCDCgrowth

charts,asthesearethelimitsofwhatarepicturedonthecharts,

andmostpractitionersdonotreadilyaccesstherawCDC

dataforextremesofheightandweightpercentiles.Assuch,directcomparisonbetweenall3methodscouldonlybemadefor204(55%)participants

inourstudy.

ConcurrencebetweentheBMI,McLaren,andMooremethods

wasassessedprimarilyforagreementaboveorbelowEBWthresholdsof75%(hospitalization),

85%(ANdiagnosis),and100%(healthygoalweight).Patternsof

absolutediscrepancieswereexaminedbyheight,age,gender,andmenstrualstatus.Table1demonstratesthechallengesaroundthese3methodsbycalculating%EBWfor

a14-year-oldgirlstanding165.1cm(65in.)tall.

StatisticalAnalysis

StatisticalanalyseswerecompletedinRversion2.10.Usingcategoriesas

describedearlier(above/belowcutpoints

TABLE1Example

CalculationFor14-Year-

OldGirlMeasuring165.1cm(65

in.)and45.4kg(100lb)

MethodEstimatedEBWSubjects

%EBWBMI52.68kg(116.15lb)86.1Moore57.13kg(125.95lb)79.4

McLarenIncalculableaIncalculablea

Subjectsexpectedbodyweightand

percentexpectedbodyweightcouldnotbecalculatedusingthe

McLarenmethodbecausesheistallerthan163cm.

forhospitalization,diagnosisof

AN,orahealthygoalweight),totalclassificationaccuracyandunweightedandquadratically

weightedkvalueswerecalculatedforpairwisecomparisonsofthe3methodsfor

EBWcalculation.Althoughbothtypesofkstatisticsreflectoverall

measuresofconcordance,quadraticallyweightedkvaluesgivemorepenaltytothelargerdiscrepancies(eg,asubjectinthe,75%EBWcategoryusingone

methodand.100%EBWcategoryusinganother)comparedwiththeunweightedkvalues.

Totalclassificationaccuracywasfurthercalculatedforthe3waycomparison.Inaddition,the

actualvaluesof%EBW(asopposedtothecategoriesmentioned

earlier)wereplottedaspairwisecomparisonsofthe3methods.Linearmodelswerefitforeachofthesecomparisons,andintraclasscorrelationswerecalculated.

Finally,thesepairwisedifferenceswereevaluatedacrosslevelsofthefollowingcovariates:age,

gender,heightpercentile,andmenstrualstatus.

RESULTSAgreement

2presentsthepairwiseand3-wayagreementofeachof

thesemethodsbythe3predeterminedcutpoints.Lookingfirstatpairwiseagreement,all3possiblepairsperformmoderatelywellateachthreshold,with

totalclassificationagreementrangingfrom84.2%to97.5%.TheBMIandMooremethods

tendedtohavethelowestclassificationagreement(84.2%87.7%),followedbytheBMIand

McLarenmethods(87.7% 96.1%)andthentheMooreandMcLaren

methods(90.2%97.5%).Agreementtendedtoperformbestonthelowerextremecutpoints;thatis,betteragreementwasseenwhenpredictingwhetheradolescentswere

aboveorbelow75%EBW(87.7%97.5%)comparedwiththatforthe85%EBW

cutpoint(84.2%95.1%)andthe100%EBWcutpoint(85.8%90.2%).kvaluesindicate

moderate-to-goodagreement

overall,withtheunweightedkvalues

rangingfrom0.49to0.74andquadraticallyweightedkvaluesrangingfrom0.72to0.89.Thesuperiorityofthequadraticallyweightedkvaluesto

theunweightedkvaluesindicatesthatwhendisagreementoccurs,itmostoftenoccurs

onecellover(eg,onemeasureindicates,75%EBWwhereasanotherindicates75%

to85%EBW).

Three-wayagreementpatternsindicatethat

abouthalfofthetime,all3measuresagreeonclassificationaboveorbelow75%EBW(51.5%),85%EBW(46.9%),and100%EBW(46.6%).

Inaboutone-thirdofcases(35.1%35.9%),theMooreandBMImethodsagreeon

theclassification,whereastheMcLarencannotbecalculated(ie,aformofdisagreement).

Theremainingcasesrepresentmeasureddisagreement.

Figure1

plotsthepairwisecomparisonsofthe3methodscontinuously.Althoughtheindividualcomparisonsclusternearthelineofoptimalagreement,significantnoiseanddiscrepancies

canbeseen,especiallywhencomparingtheBMIandMooremethods.Intraclasscorrelation

fortheBMIandMooremethodswas0.88(95%confidenceinterval[95%CI],

0.85 0.90),fortheBMIandMcLarenmethodswas0.90

(95%CI,0.870.92),andfortheMooreandMcLarenmethodswas0.96(95%CI,0.950.97).

MostDiscrepantCases

Althoughagreement

atthecategoricallevelwasrelativelyhigh,someadolescentshadextremelydifferentcalculations

of%EBWforthevariousmethods,withthebiggestdiscrepancybeingnearly60%

EBW.Table3presentsthefivemostdiscrepantcasesfor

eachpairwisecomparison.Mostofthesediscrepancieswillbeclinicallyrelevantforeatingdisorderassessment.Forinstance,oneadolescentwasmeasuredas143.2%with

theBMImethodand196.0%intheMcLarenmethod.As

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on Jan

uary 27, 2012

both are above 85% EBW, they wouldnot distinguish AN from other eatingdisorders. Others crossed boundariesbetween characterizing the adolescentas severely underweight versus abovetheir ideal weight. For instance, oneadolescent was measured as 107.1%EBW with the BMI method and 55.4%EBW with the Moore method. Generally,these severely discrepant calculationsoccurred in females and older ages(primarily 1618 years). The 5 mostdiscrepant cases between the BMI andMoore methods tended to be tall,whereas the discrepant cases in theother comparisons ranged in height.Discrepancy by CovariatesPairwise discrepancies (eg, BMI methodestimate minus Moore method estimate)werecomparedacrosstherangeofheightTABLE 2 Total Classification Agreement and Overall k-Value Estimates for Pairwise and 3-Way ComparisonsAgreement 75% EBW Agreement 85% EBW Agreement 100% EBW Agreement, k

Comparison Na % Na % Na % Unweighted Quadratic WeightsBMIMoore comparison 0.487 0.721Agreement 327 87.7 314 84.2 320 85.8Disagreement 46 12.3 59 15.8 53 14.2BMIMcLaren comparison 0.592 0.824Agreement 196 96.1 180 88.2 179 87.7Disagreement 8 3.9 24 11.8 25 12.3MooreMcLaren comparison 0.737 0.888Agreement 199 97.5 194 95.1 184 90.2Disagreement 5 2.5 10 4.9 20 9.83-Way comparison NC NC3-Way agreement 192 51.5 175 46.9 174 46.6Disagreement (all methods measurable) 12 3.2 29 7.8 30 8.0

Disagreement (McLaren unmeasured) 35 9.4 35 9.4 38 10.2Moore/BMI agreement, McLaren unmeasured 134 35.9 134 35.9 131 35.1a When comparing BMI with Moore, N = 373. When comparing BMI with McLaren or Moore with McLaren, the McLaren method is unable to be calculated for several cases and thus the N = 204.NC, not calculable.FIGURE 1Pairwise comparisons of the 3 methods to calculate %EBWat the continuous level.Intraclass correlations associated with these 3 graphs were 0.879, 0.902, and0.960, respectively.4 LE GRANGE et alDownloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on January 27, 2012

ARTICLE ARTICLETABLE3Characteristicsofthe5MostDiscrepantPairwiseDisagreements

ComparisonDiscrepancyofInterestaBMIWeight(kg)Height(cm)Age

(mo)Gender%EBWBMI%EBWMoore%EBWMcLarenBMIMoore51.72271.6180.3

195F107.155.4NC35.925.780.1176.5216F120.985

NC35.225.478175.3188F125.390.1NC

32.224.775.7175.3197F119.587.3NC30.523.271.2175.3196F112.682.1NCBMIMcLaren52.8b29.941.3117.5204

F143.2138.419649.9c38.9d34.331.359.953.1132.1130.2220

188FF160.6154.5171.2171.8210.5193.428.423.333.2119.4

156F124.5150.9152.927.1e37.993.9157.5213

F178.8189.9205.9MooreMcLaren57.6b29.941.3117.5204F143.2138.419639.3c21.6d34.331.359.953.1132.1130.2220188

FF160.6154.5171.2171.8210.5193.416e37.993.9157.5213

F178.8189.9205.912.329.372.6157.5217F137.5146.1158.4

aDiscrepancymeasuredastheabsolutedifferencebetween

the2referencemethodsofcalculating%EBW.beIndicatesthesamecaseappearingundermultiplepairwisediscrepancies.NC,notcalculable.

percentiles(Fig2),

age(Fig3),gender(Fig

4),andmenstrualstatus(Fig5).

Regardingheightpercentiles,anear-cubicrelationshipbetweenheightpercentileandtheBMIMoorediscrepancy

wasseen,withtheMooremethodyielding

largerestimatesfor%EBWatlowerheightpercentiles(eg,,20thpercentile)andtheBMImethodgivinglargerestimatesatthehigherheightpercentiles(eg,

.75thpercentile).IncomparingboththeBMIandMooremethodsagainstthe

McLarenmethod,thediscrepanciesweremostpronouncedforlowerheightpercentiles.

Intermsofage,theBMIandMooremethods

haveconsistentdisagreementacrossthisagerange(1218yearsold).

FIGURE2

Pairwisediscrepancyaccordingtoheightpercentile.

FIGURE3

Pairwisediscrepancyaccordingtoage.

FIGURE4

Pairwisediscrepancyaccordingtogender.

LEGRANGEetal

ARTICLEARTICLEFIGURE5

Pairwisediscrepancyaccordingtomenstruationstatus.PA,primaryamenorrhea;SA,secondaryamenorrhea;oligo,oligomenorrhea;BC,birthcontrol.

WhencomparingtheBMIandMooremethodsagainsttheMcLarenmethod,the

discrepanciesincreasewithage.TheMooremethodtendstoestimatehighervaluesof

%EBWamongolderagescomparedwithbothothermethods,particularly

aboveage16years.

Withrespecttogender,theMcLarenmethodprovideslargerestimatesof%EBWthaneithertheMooreor

BMImethodsforgirls,butthisbiaswaslessforboys.Thereseems

tobemorevariabilityforgirlsthanforboys,whichcouldbea

functionofthefactthatoursamplewasmostlygirls.

Intermsofmenstrualstatus,forthoseonbirthcontroland/orwithregularmenses,theMcLarenmethodprovideslargerestimatesof%EBWthaneither

theMooreorBMImethods,butthisfindingcouldbeconfoundedbyage.

DISCUSSION

Theprimaryobjectivewastotest3methods

usedtocalculateEBWforadolescentswitheatingdisorders:BMI,

McLaren,andMoore.Specifically,wewereinterestedintheextenttowhichthesemethodsbroughtaboutagreementordisagreementoncutpoints

forhospitalization(75%EBW),diagnosis(85%EBW),andhealthyweight(100%EBW).Our

secondarygoalwastodeterminewhetherourfindingswouldallowforclearerguidelines

regardingthedeterminationofEBWforthispatientpopulation.

Overall,therewasmoderateagreementbetweenthe3methods,withpairwisetotalclassificationaccuracyateachcutpointrangingfrom84%to98%.

The3methodslargelyagreeon%EBWintermsofclinicallysignificantcut

pointswiththeexceptionofthediscrepantcalculationsforarelativelysmallnumber

ofcases(2.5%-15.8%).CorrelationswerelowestforBMIand

Moore(0.88)andhighestforMooreandMcLaren(0.96).Themostdiscrepantcalculationswereobservedamongthetallerpatients(.75thpercentile),shorterpatients(,20th

percentile),andthose.16

yearsofage.Manyofthesemost

discrepantcases,whencomparingtheBMIandMooremethods,fellaboveandbelow

85%EBW.Forinstance,thisdiscrepancynotonlyindicateddisagreement

ontheweightcriterionforpossiblediagnosisofAN,butalsothesameindividual(seeTable3,firstcase)wouldwarranthospitalizationgiventhe

Mooremethod(ie,55%EBW)whilesimultaneouslybeingconsideredclosetonormalweight

giventheBMImethod(ie,107%EBW).Theevidenceforagreementwasnot

asstrikingforgenderandmenstrualstatusasitwas

forheightandage.TheMcLarenmethodpresentedwiththemostsignificantlimitationinthatitcannotbeusedforboys.176cmor

girls.163cm(medianheightforgirlsaged$14years),whichlimitedour

originalsampleby.40%.Inaddition,theMooremethodischallengingatextremes

ofheightandweight.Therefore,ourstudydemonstrates,evenprior

totheanalyses,theimportanceoftheBMImethod

asamethodologythatcanapplytochildrenandadolescentsatallages,heights,andweights.

Thesediscrepantcalculationsunderscorethe

implicationswhenusingonemethodratherthananotherfortheassessmentofadolescents

witheatingdisorderswhoareoutsidethenormforheightor.16years

ofage.Thisconsiderationisespeciallyimportantforresearchendeavors

whenstudyinclusioniscontingentuponadiagnosisthatisarrivedatviaEBWcalculations.Forexample,itisfairtosaythatfor

verytalladolescents,theBMImethodwillcalculatehigher%EBWthantheMoore

method.IfcliniciansareuncertainaboutthediagnosisofAN,theyshouldconsider

thetrade-offsofmakingafalse-positiveversusafalse-negative

diagnosiswhenchoosingonemethodoveranother.However,intheinterestofadvancingasharedlanguageamongcliniciansandresearchers,wesuggestthatthe

BMImethodbeusedasitmayposethefewestobstacles(easeof

calculation)orexceptions(heightandage).Weacknowledgethatinsomeinstancesclinical

decision-makingwillbecomplexandrequireamoreflexibleapproach.

However,auniformadherenceto1methodtocalculateEBWwillstrengthenclinicalandresearchpractice.

Somelimitationsandstrengthstoour

studyshouldbeconsidered.Wedidnotknowapriorithattheshortcomings

fortheMcLarenandMooremethodswouldresultinthesemethodsnotbeing

feasibleforEBWcalculationsinasubsetofoursample.

However,onlyuponattemptingcomparisonsofthesemethodsdidwelearnthat.40%ofoursamplecouldnotbecomparedinthisway.To

date,ithasnotbeenwellestablishedthateatingdisorderpatientswouldpresent

thismanyoutliers,norhassuchafindingbeenpresentedin

anempiricalmanner.Thus,ourstudyshowsthatthereis

littleutilityfortheMcLarenmethodinanadolescenteatingdisordersample.Alimitationofall3methodsinvolvestheinabilitytoaccountfor

stuntedgrowthinpediatricsubjectswitheatingdisorders(ie,heightstuntingwillaffect

calculationofEBWandwillunderestimateitinalllikelihood).Itisfor

practitionerstotakethislimitationintoconsiderationwhengrowthstunting

issuspectedclinically,basedongeneticpotentialasevidencedbyparentalheight,oronpriorgrowthrecordsshowingaclearslowingoflineargrowth.

Asaresult,cliniciansshouldanticipateperhapshavingtoaimforhighertreatment

goalweightsoradjustingEBWoncelineargrowthreturnstonormal.Second,it

iscrucialtoacknowledgethatthecutpointsstudiedhere,

althoughcommonlyusedinclinicalpractice,arearbitraryandshouldnotbeseenasabsoluteindicatorsofillnessorhealth.Forexample,hospitalizationis

notindicatedonlywhenweightisbelow75%EBW,andtheDSM-IVTRcut

pointof85%EBWwasinitiallyintendedasanexamplebutisoften

mistakenlyreifiedintoaconcretecutpoint.TheDSM-5Eating

DisorderWorkgroupspecificallynotedthatforclinicalpurposes,itwouldbeundesirabletosettleonaspecificnumericalstandard forweightforAN.16Finally,

weconsidered3methodsforEBWcalculation,whereasothersstillinuse(see,

eg,refs17and18)werenotincludedinthiscomparison.

CONCLUSIONS

Thisstudyrepresentsafirststepto

examinethelevelofagreementand/ordisagreementbetweentheBMI,McLaren,andMooremethods,andfutureresearchshouldinvestigatetheirperformance;thatis,

canthesemethodsbedelineatedonwhetheroneis

morepredictive

ofknownbiologicalmeasuresoflowweight,suchasbloodpressureorbody

temperature.Ourfindingswarrantsomeclosingconsiderations.First,cliniciansshould

refrainfromtalkingaboutideal weightorexpressingthistargetwithunrealisticaccuracy(eg,2decimalpoints).Itismoreinformativetousethe

termsaverage ormedian, ashasbeensuggestedbyothers,19orexpected as

weindicatehere,whenreferringtoreferenceweight.Second,itisimperativethat

theresearchandclinicalcommunitiesattemptacommonlanguageby

statingtheirmethodforEBWcalculationandstandardizingunitsofmeasurement(eg,kilogramsratherthanpounds).Basedonthisstudy,wewouldrecommendthe

BMImethodwhenassessingthepediatricandadolescenteatingdisorderspopulation.Third,the

useofanelectronicmedicalrecordthatincludesBMIchartsaspartof

pediatricsoftwarepackagesshouldbeencouraged.20Removingthebarrierof

calculatingBMIbyhandistimeandcostefficientinpediatricpractice.Finally,andinreferencetoarecentreportfromtheAmericanAcademy

ofPediatrics,21pediatriciansareattheforefrontintermsofdiagnosingeatingdisorders

andshouldthereforeroutinelycalculateandplotpatients weight,height,andBMIon

appropriateageandgendercharts.Pediatriciansshouldpaycloseattention

todeviationsfromanindividualchildsgrowthcurve(ie,fallingoffpersonaltrajectory)assuchpersonalizedgrowthcurvesprovideconsiderablesupportinthedetermination

ofhealthytargetandpotentiallyimproveearlyidentificationofeatingdisorders.

ACKNOWLEDGMENT

ThisstudywassupportedbygrantNRSAT32MH082761

fromtheNationalInstitutesofHealth.

LEGRANGE

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1.AmericanPsychiatricAssociation.DiagnosticandStatisticalManualofMentalDisorders,Revised4thed.Washington,DC:AmericanPsychiatricAssociation;

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adolescents.Pediatrics.2010;126(6):12401253PEDIATRICSVolume129,Number2,February

Calculation of Expected Body Weight in Adolescents With Eating Disorders

Daniel Le Grange, Peter M. Doyle, Sonja A. Swanson, Kali Ludwig, Catherine Glunz and Richard E. KreipePediatrics; originally published online January 4, 2012;DOI: 10.1542/peds.2011-1676

ServicesUpdated Information &/peds.2011-1676http://pediatrics.aappublications.org/content/early/2012/01/02including high resolution figures, can be found at:Subspecialty Collections

_medicinehttp://pediatrics.aappublications.org/cgi/collection/adolescentAdolescent Medicinethe following collection(s):This article, along with others on similar topics, appears inPermissions & Licensingtmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xh

tables) or in its entirety can be found online at:Information about reproducing this article in parts (figures,Reprintshttp://pediatrics.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthlypublication, it has been published continuously since 1948. PEDIATRICS is owned, published,and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, ElkGrove Village, Illinois, 60007. Copyright © 2012 by the American Academy of Pediat

rics. Allrights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

pediatrics 2012 le grange peds.2011 1676

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