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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
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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ARTICLEARTICLECalculationofExpectedBodyWeightinAdolescentsWithEatingDisorders
AUTHORS:DanielLeGrange,PhD,aPeterM.Doyle,PhD,aSonja
A.Swanson,ScM,bKaliLudwig,BA,aCatherineGlunz,MD,candRichardE.Kreipe,
MDd
aDepartmentofPsychiatryandBehavioralNeuroscience,andcDepartmentofPediatrics
andInternalMedicine,TheUniversityofChicago,Chicago,Illinois;bDepartment
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ofEpidemiology,HarvardSchoolofPublicHealth,Boston,Massachusetts;anddDivisionofAdolescentMedicine,DepartmentofPediatrics,UniversityofRochesterMedicalCenter,Rochester,New
York
KEYWORDS
adolescence,bodyweight,eatingdisorders
ABBREVIATIONS
ANanorexianervosaCDCCentersforDiseaseControlandPreventionCIconfidence
intervalDSM-IVTRDiagnosticandStatisticalManualofMentalDisorders,FourthEdition,
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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
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AcceptedforpublicationSep26,2011
AddresscorrespondencetoDanielLeGrange,PhD,DepartmentofPsychiatryandBehavioralNeuroscience,TheUniversityof
Chicago,5841S.MarylandAve.,MC3077,Chicago,IL60637.E-mail:[email protected]
PEDIATRICS(ISSNNumbers:Print,0031-4005;Online,1098-4275).
Copyright©2012by
theAmericanAcademyofPediatrics
FINANCIALDISCLOSURE:Dr
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LeGrangereceivesroyaltiesfromGuilfordPressandhonorariafromtheTrainingInstituteforChildandAdolescentEatingDisorders,LLC.Theotherauthorshave
indicatedtheyhavenofinancialrelationshipsrelevanttothisarticletodisclose.
FundedbytheNationalInstitutesofHealth(NIH).
WHATS
KNOWNONTHISSUBJECT:Eatingdisordersare
characterized
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bypreoccupationwithweightandshape,whichis
manifestedbyarefusaltomaintainanormalweight.Anexact
determination
ofexpectedbodyweight(EBW)iscriticalfor
diagnosisandclinical
managementofthesedisorders.
WHATTHISSTUDYADDS:TheMcLarenand
MooremethodspresentwithseverallimitationswhencalculatingEBWfor
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adolescentswitheatingdisorders.AcommonlyagreeduponmethodforEBWcalculationsuchastheBMIpercentilemethodisrecommendedforclinicalandresearch
purposes.
abstract
OBJECTIVE:Toexaminetheagreement
betweenthreemethodstocalculateexpectedbodyweight(EBW)foradolescentswitheating
disorders:(1)BMIpercentile,(2)McLaren,and(2)Mooremethods.
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METHODS:Theauthorsconductedacross-sectionalanalysisofbaselineinformationfromadolescentsseekingtreatmentofdisorderedeatingatTheUniversityofChicago.
Adolescents(N=373)aged12to18years(mean=15.84,SD=1.72),
withanorexianervosa(n=130),bulimianervosa(n=59),oreating
disordernototherwisespecified(n=184).ConcurrencebetweentheBMI
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percentile,McLaren,andMooremethodswasassessedforagreementaboveorbelowarbitrarycutpointsusedinrelationtohospitalization(75%),diagnosis(85%),and
healthyweight(100%).Patternsofabsolutediscrepancieswereexaminedbyheight,age,gender,
andmenstrualstatus.Limitationstosomeofthesemethodsallowedcomparisonbetweenall
3methodsinonly204participants.
RESULTS:Moderate
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agreementwasseenbetweenthe3methods(kvalues,0.480.74),withpairwisetotalclassificationaccuracyateachcutpointrangingfrom84%to98%.
Themostdiscrepantcalculationswereobservedamongthetallest(.75thpercentile)andshortest
(,20thpercentile)casesandolderages(.16years).Manyofthemostdiscrepant
casesfellaboveandbelow85%EBWwhencomparingthe
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BMIpercentileandMooremethods,indicatingdisagreementonpossiblediagnosisofanorexianervosa.
CONCLUSIONS:ThesemethodslargelyagreeonpercentEBWin
termsofclinicallysignificantcutpoints.However,theMcLarenandMooremethodspresent
withlimitations,andacommonlyagreed-uponmethodforEBWcalculationsuchasthe
BMIpercentilemethodisrecommendedforclinicalandresearchpurposes.
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Pediatrics2012;129:19
PEDIATRICSVolume129,Number2,February2012
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Eatingdisordersarecharacterizedbydisturbancesiningestivebehaviorandareusuallyaccompaniedbypreoccupationwithweightandshape.1Thispreoccupationisoften
manifestedbyaninabilitytomaintainanormalweightforageandheight
andistheprimarydiagnosticcriterionforanorexianervosa(AN).Determiningthedeviation
fromexpectedbodyweight(EBW)(oftenreferredtoasideal
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bodyweight)isthereforeimportantinthediagnosisofAN(,85%EBW)andthedifferentialdiagnosisofbulimianervosa(.85%EBW)andeatingdisorder
nototherwisespecified(deviationfromEBWlessclearlydemarcated).
Inaddition
todiagnosis,EBWisusedasanindicatorofmedicalstability,asjustification
forhospitalization,tosetappropriatetargetweights,2,3andtotrack
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progressintreatmentandassessrecovery.4,5Yet,thereisnoconsensusonhowbesttocalculateEBWforthepediatricandadolescenteatingdisorders
population.AlthoughabsoluteBMI(weightinkilograms/heightinmeters;seeref2)has
gainedattentioninbothclinicalandresearchsettings,itismostcommonlyused
toscreenforobesityandismostapplicabletothe
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adultpopulation.6,7Moreover,BMIisbasedonheightandweightonlyanddoesnotaccountforuniquephenomenonsuchasshortstatureorstunted
lineargrowthduetomalnutrition.8Therefore,itisnotanoptimalmethodto
reflectnutritionalstatus,especiallyforadolescents.Forpediatricandadolescentpopulations,age-andgender-
adjustedBMIpercentilesaremoreappropriateasweightandheight
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normallyincreaseuntil20yearsofage(CentersforDiseaseControlandPrevention[CDC]BMI-for-agegrowthcharts;www.cdc.gov/growthcharts).9
Examinationofanadolescents
weightinrelationtothe50thBMIpercentile,alsoknownastheBMI
percentilemethod,orBMImethod,isperhapsthe
mostfrequentlyused
methodtodeterminetheweightcriterionforaneatingdisorder
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diagnosis.10,11InadditiontotheBMImethod,9othermethodsareusedtocalculateEBW;forexample,theMcLaren12andMoore13methods.TheBMI,McLaren,
andMooremethodsareallpediatricspecificandusethechildoradolescents
gender,age,andheighttocalculateEBWbutdonottakeothermeasures
ofanthropometry(eg,bodycompositionandbodyframe)intoaccount.
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ResearchershavedemonstratedconsiderableagreementforEBWcalculationsacrossthese3methodsforhealthyadolescents.14However,suchcalculationsarewidelydiscrepantforolderhealthy
adolescentsatthelowestandhighestpercentiles.14
Instudiesofpatients
witheatingdisorders,authorsrarelydescribetheirmethodforcalculatingEBW.Therefore,the
primarygoalofthecurrentstudywastoexaminethe
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agreementand/ordiscrepancybetweentheBMI,McLaren,andMooremethodswhencalculatingEBWforadolescentswitheatingdisorders.Asecondarygoalwastodetermine
whetherourfindingswouldallowforclearerguidelinesregardingthemostappropriatemethod(s)
tocalculateEBWforthepediatricandadolescenteatingdisorderspopulation.
METHODSSubjects
Subjectswere373treatment-seekingadolescents,including
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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
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(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).
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Forthepurposesofthisreport,weonlyusedweight,height,age,gender,menstrualstatus,ethnicity,anddiagnosis.Writteninformedconsentforpatientsaged
18yearsorparental/guardianconsentandadolescentassentforpatients,18years
ofagewereobtained.TheUniversityofChicagoInstitutionalReviewBoardapprovedthe
researchprotocol.
EBWCalculations
EBWwas
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calculatedforeachsubjectlimitedtothreeindependentmethodsdescribedinthefollowingtext:BMI,9McLaren,12andMoore13methods.
IntheBMI
method,tocalculatepercentexpectedbodyweight(%EBW)foragivenparticipantbased
onhisorherheight,age,andgender,the50thpercentileBMIfor
exactageandheightatpresentationontheCDCBMI-for-age
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percentileschart4wasused(%EBW=BMI/50thpercentileBMIforageandheight3100).ABMIatthe50thpercentilewouldbetheexpectedmedianina
groupofnormallydevelopingadolescents,orEBW.
TheMcLarenmethod12uses
agrowthchartbasedonheight-andweight-forageandforgender(eg,CDC).First,
theparticipantsheightisplottedonthechart.Aline
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isextendedhorizontallytothe50thpercentileheight-for-ageofthatparticipant.Asecondlineisthenextendedverticallyfromthe50thpercentileheight-for-ageto
thecorresponding50thpercentileweight.This50thpercentileweightisdeemedtheparticipantsEBW.
TheMooremethod13alsousesagrowthchartbasedonheight-and
weight-forageandgender(eg,CDC),albeitinaslightlydifferent
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way.Theparticipants
LEGRANGEetal
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ARTICLEARTICLEheight-for-agepercentileisdetermined,andtheEBWistheweightthatcorrespondstothatweightpercentile(eg,aparticipantinthe30th
percentileheight-for-ageandgenderwouldhaveanEBWthatcorrespondstothe
30thpercentileweight-for-ageandgender).
Ofnote,becauseoftheasymptotic
natureoftheheightcurvesasadolescentscompletegrowth,the
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McLarenmethodcannotcalculateEBWforgirls.163cmorforboys.176cm.Inaddition,theMooremethodcannotbeusedeasilyfor
children.97thor,3rdpercentileforheightorweightontheCDCgrowth
charts,asthesearethelimitsofwhatarepicturedonthecharts,
andmostpractitionersdonotreadilyaccesstherawCDC
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dataforextremesofheightandweightpercentiles.Assuch,directcomparisonbetweenall3methodscouldonlybemadefor204(55%)participants
inourstudy.
ConcurrencebetweentheBMI,McLaren,andMooremethods
wasassessedprimarilyforagreementaboveorbelowEBWthresholdsof75%(hospitalization),
85%(ANdiagnosis),and100%(healthygoalweight).Patternsof
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absolutediscrepancieswereexaminedbyheight,age,gender,andmenstrualstatus.Table1demonstratesthechallengesaroundthese3methodsbycalculating%EBWfor
a14-year-oldgirlstanding165.1cm(65in.)tall.
StatisticalAnalysis
StatisticalanalyseswerecompletedinRversion2.10.Usingcategoriesas
describedearlier(above/belowcutpoints
TABLE1Example
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CalculationFor14-Year-
OldGirlMeasuring165.1cm(65
in.)and45.4kg(100lb)
MethodEstimatedEBWSubjects
%EBWBMI52.68kg(116.15lb)86.1Moore57.13kg(125.95lb)79.4
McLarenIncalculableaIncalculablea
a
Subjectsexpectedbodyweightand
percentexpectedbodyweightcouldnotbecalculatedusingthe
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McLarenmethodbecausesheistallerthan163cm.
PEDIATRICSVolume129,Number2,February2012
forhospitalization,diagnosisof
AN,orahealthygoalweight),totalclassificationaccuracyandunweightedandquadratically
weightedkvalueswerecalculatedforpairwisecomparisonsofthe3methodsfor
EBWcalculation.Althoughbothtypesofkstatisticsreflectoverall
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measuresofconcordance,quadraticallyweightedkvaluesgivemorepenaltytothelargerdiscrepancies(eg,asubjectinthe,75%EBWcategoryusingone
methodand.100%EBWcategoryusinganother)comparedwiththeunweightedkvalues.
Totalclassificationaccuracywasfurthercalculatedforthe3waycomparison.Inaddition,the
actualvaluesof%EBW(asopposedtothecategoriesmentioned
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earlier)wereplottedaspairwisecomparisonsofthe3methods.Linearmodelswerefitforeachofthesecomparisons,andintraclasscorrelationswerecalculated.
Finally,thesepairwisedifferenceswereevaluatedacrosslevelsofthefollowingcovariates:age,
gender,heightpercentile,andmenstrualstatus.
RESULTSAgreement
Table
2presentsthepairwiseand3-wayagreementofeachof
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thesemethodsbythe3predeterminedcutpoints.Lookingfirstatpairwiseagreement,all3possiblepairsperformmoderatelywellateachthreshold,with
totalclassificationagreementrangingfrom84.2%to97.5%.TheBMIandMooremethods
tendedtohavethelowestclassificationagreement(84.2%87.7%),followedbytheBMIand
McLarenmethods(87.7% 96.1%)andthentheMooreandMcLaren
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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
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rangingfrom0.49to0.74andquadraticallyweightedkvaluesrangingfrom0.72to0.89.Thesuperiorityofthequadraticallyweightedkvaluesto
theunweightedkvaluesindicatesthatwhendisagreementoccurs,itmostoftenoccurs
onecellover(eg,onemeasureindicates,75%EBWwhereasanotherindicates75%
to85%EBW).
Three-wayagreementpatternsindicatethat
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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
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plotsthepairwisecomparisonsofthe3methodscontinuously.Althoughtheindividualcomparisonsclusternearthelineofoptimalagreement,significantnoiseanddiscrepancies
canbeseen,especiallywhencomparingtheBMIandMooremethods.Intraclasscorrelation
fortheBMIandMooremethodswas0.88(95%confidenceinterval[95%CI],
0.85 0.90),fortheBMIandMcLarenmethodswas0.90
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(95%CI,0.870.92),andfortheMooreandMcLarenmethodswas0.96(95%CI,0.950.97).
MostDiscrepantCases
Althoughagreement
atthecategoricallevelwasrelativelyhigh,someadolescentshadextremelydifferentcalculations
of%EBWforthevariousmethods,withthebiggestdiscrepancybeingnearly60%
EBW.Table3presentsthefivemostdiscrepantcasesfor
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eachpairwisecomparison.Mostofthesediscrepancieswillbeclinicallyrelevantforeatingdisorderassessment.Forinstance,oneadolescentwasmeasuredas143.2%with
theBMImethodand196.0%intheMcLarenmethod.As
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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
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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
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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
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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
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the2referencemethodsofcalculating%EBW.beIndicatesthesamecaseappearingundermultiplepairwisediscrepancies.NC,notcalculable.
percentiles(Fig2),
age(Fig3),gender(Fig
4),andmenstrualstatus(Fig5).
Regardingheightpercentiles,anear-cubicrelationshipbetweenheightpercentileandtheBMIMoorediscrepancy
wasseen,withtheMooremethodyielding
much
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largerestimatesfor%EBWatlowerheightpercentiles(eg,,20thpercentile)andtheBMImethodgivinglargerestimatesatthehigherheightpercentiles(eg,
.75thpercentile).IncomparingboththeBMIandMooremethodsagainstthe
McLarenmethod,thediscrepanciesweremostpronouncedforlowerheightpercentiles.
Intermsofage,theBMIandMooremethods
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haveconsistentdisagreementacrossthisagerange(1218yearsold).
FIGURE2
Pairwisediscrepancyaccordingtoheightpercentile.
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FIGURE3
Pairwisediscrepancyaccordingtoage.
FIGURE4
Pairwisediscrepancyaccordingtogender.
LEGRANGEetal
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ARTICLEARTICLEFIGURE5
Pairwisediscrepancyaccordingtomenstruationstatus.PA,primaryamenorrhea;SA,secondaryamenorrhea;oligo,oligomenorrhea;BC,birthcontrol.
WhencomparingtheBMIandMooremethodsagainsttheMcLarenmethod,the
discrepanciesincreasewithage.TheMooremethodtendstoestimatehighervaluesof
%EBWamongolderagescomparedwithbothothermethods,particularly
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aboveage16years.
Withrespecttogender,theMcLarenmethodprovideslargerestimatesof%EBWthaneithertheMooreor
BMImethodsforgirls,butthisbiaswaslessforboys.Thereseems
tobemorevariabilityforgirlsthanforboys,whichcouldbea
functionofthefactthatoursamplewasmostlygirls.
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Intermsofmenstrualstatus,forthoseonbirthcontroland/orwithregularmenses,theMcLarenmethodprovideslargerestimatesof%EBWthaneither
theMooreorBMImethods,butthisfindingcouldbeconfoundedbyage.
DISCUSSION
Theprimaryobjectivewastotest3methods
usedtocalculateEBWforadolescentswitheatingdisorders:BMI,
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McLaren,andMoore.Specifically,wewereinterestedintheextenttowhichthesemethodsbroughtaboutagreementordisagreementoncutpoints
forhospitalization(75%EBW),diagnosis(85%EBW),andhealthyweight(100%EBW).Our
secondarygoalwastodeterminewhetherourfindingswouldallowforclearerguidelines
regardingthedeterminationofEBWforthispatientpopulation.
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Overall,therewasmoderateagreementbetweenthe3methods,withpairwisetotalclassificationaccuracyateachcutpointrangingfrom84%to98%.
The3methodslargelyagreeon%EBWintermsofclinicallysignificantcut
pointswiththeexceptionofthediscrepantcalculationsforarelativelysmallnumber
ofcases(2.5%-15.8%).CorrelationswerelowestforBMIand
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Moore(0.88)andhighestforMooreandMcLaren(0.96).Themostdiscrepantcalculationswereobservedamongthetallerpatients(.75thpercentile),shorterpatients(,20th
percentile),andthose.16
yearsofage.Manyofthesemost
discrepantcases,whencomparingtheBMIandMooremethods,fellaboveandbelow
85%EBW.Forinstance,thisdiscrepancynotonlyindicateddisagreement
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ontheweightcriterionforpossiblediagnosisofAN,butalsothesameindividual(seeTable3,firstcase)wouldwarranthospitalizationgiventhe
Mooremethod(ie,55%EBW)whilesimultaneouslybeingconsideredclosetonormalweight
giventheBMImethod(ie,107%EBW).Theevidenceforagreementwasnot
asstrikingforgenderandmenstrualstatusasitwas
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forheightandage.TheMcLarenmethodpresentedwiththemostsignificantlimitationinthatitcannotbeusedforboys.176cmor
girls.163cm(medianheightforgirlsaged$14years),whichlimitedour
originalsampleby.40%.Inaddition,theMooremethodischallengingatextremes
ofheightandweight.Therefore,ourstudydemonstrates,evenprior
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totheanalyses,theimportanceoftheBMImethod
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asamethodologythatcanapplytochildrenandadolescentsatallages,heights,andweights.
Thesediscrepantcalculationsunderscorethe
implicationswhenusingonemethodratherthananotherfortheassessmentofadolescents
witheatingdisorderswhoareoutsidethenormforheightor.16years
ofage.Thisconsiderationisespeciallyimportantforresearchendeavors
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whenstudyinclusioniscontingentuponadiagnosisthatisarrivedatviaEBWcalculations.Forexample,itisfairtosaythatfor
verytalladolescents,theBMImethodwillcalculatehigher%EBWthantheMoore
method.IfcliniciansareuncertainaboutthediagnosisofAN,theyshouldconsider
thetrade-offsofmakingafalse-positiveversusafalse-negative
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diagnosiswhenchoosingonemethodoveranother.However,intheinterestofadvancingasharedlanguageamongcliniciansandresearchers,wesuggestthatthe
BMImethodbeusedasitmayposethefewestobstacles(easeof
calculation)orexceptions(heightandage).Weacknowledgethatinsomeinstancesclinical
decision-makingwillbecomplexandrequireamoreflexibleapproach.
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However,auniformadherenceto1methodtocalculateEBWwillstrengthenclinicalandresearchpractice.
Somelimitationsandstrengthstoour
studyshouldbeconsidered.Wedidnotknowapriorithattheshortcomings
fortheMcLarenandMooremethodswouldresultinthesemethodsnotbeing
feasibleforEBWcalculationsinasubsetofoursample.
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However,onlyuponattemptingcomparisonsofthesemethodsdidwelearnthat.40%ofoursamplecouldnotbecomparedinthisway.To
date,ithasnotbeenwellestablishedthateatingdisorderpatientswouldpresent
thismanyoutliers,norhassuchafindingbeenpresentedin
anempiricalmanner.Thus,ourstudyshowsthatthereis
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littleutilityfortheMcLarenmethodinanadolescenteatingdisordersample.Alimitationofall3methodsinvolvestheinabilitytoaccountfor
stuntedgrowthinpediatricsubjectswitheatingdisorders(ie,heightstuntingwillaffect
calculationofEBWandwillunderestimateitinalllikelihood).Itisfor
practitionerstotakethislimitationintoconsiderationwhengrowthstunting
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issuspectedclinically,basedongeneticpotentialasevidencedbyparentalheight,oronpriorgrowthrecordsshowingaclearslowingoflineargrowth.
Asaresult,cliniciansshouldanticipateperhapshavingtoaimforhighertreatment
goalweightsoradjustingEBWoncelineargrowthreturnstonormal.Second,it
iscrucialtoacknowledgethatthecutpointsstudiedhere,
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althoughcommonlyusedinclinicalpractice,arearbitraryandshouldnotbeseenasabsoluteindicatorsofillnessorhealth.Forexample,hospitalizationis
notindicatedonlywhenweightisbelow75%EBW,andtheDSM-IVTRcut
pointof85%EBWwasinitiallyintendedasanexamplebutisoften
mistakenlyreifiedintoaconcretecutpoint.TheDSM-5Eating
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DisorderWorkgroupspecificallynotedthatforclinicalpurposes,itwouldbeundesirabletosettleonaspecificnumericalstandard forweightforAN.16Finally,
weconsidered3methodsforEBWcalculation,whereasothersstillinuse(see,
eg,refs17and18)werenotincludedinthiscomparison.
CONCLUSIONS
Thisstudyrepresentsafirststepto
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examinethelevelofagreementand/ordisagreementbetweentheBMI,McLaren,andMooremethods,andfutureresearchshouldinvestigatetheirperformance;thatis,
canthesemethodsbedelineatedonwhetheroneis
morepredictive
ofknownbiologicalmeasuresoflowweight,suchasbloodpressureorbody
temperature.Ourfindingswarrantsomeclosingconsiderations.First,cliniciansshould
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refrainfromtalkingaboutideal weightorexpressingthistargetwithunrealisticaccuracy(eg,2decimalpoints).Itismoreinformativetousethe
termsaverage ormedian, ashasbeensuggestedbyothers,19orexpected as
weindicatehere,whenreferringtoreferenceweight.Second,itisimperativethat
theresearchandclinicalcommunitiesattemptacommonlanguageby
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statingtheirmethodforEBWcalculationandstandardizingunitsofmeasurement(eg,kilogramsratherthanpounds).Basedonthisstudy,wewouldrecommendthe
BMImethodwhenassessingthepediatricandadolescenteatingdisorderspopulation.Third,the
useofanelectronicmedicalrecordthatincludesBMIchartsaspartof
pediatricsoftwarepackagesshouldbeencouraged.20Removingthebarrierof
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calculatingBMIbyhandistimeandcostefficientinpediatricpractice.Finally,andinreferencetoarecentreportfromtheAmericanAcademy
ofPediatrics,21pediatriciansareattheforefrontintermsofdiagnosingeatingdisorders
andshouldthereforeroutinelycalculateandplotpatients weight,height,andBMIon
appropriateageandgendercharts.Pediatriciansshouldpaycloseattention
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todeviationsfromanindividualchildsgrowthcurve(ie,fallingoffpersonaltrajectory)assuchpersonalizedgrowthcurvesprovideconsiderablesupportinthedetermination
ofhealthytargetandpotentiallyimproveearlyidentificationofeatingdisorders.
ACKNOWLEDGMENT
ThisstudywassupportedbygrantNRSAT32MH082761
fromtheNationalInstitutesofHealth.
LEGRANGE
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etal
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2012
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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
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