A Hunger Artist

Winning the battle against anorexia.

The Physical Effects of Weight Gain after Starvation

I describe the physical changes that often occur when someone severely malnourished begins to regain weight. The more one knows when setting out on the journey of recovery, the less likely one is to be deterred from carrying on by physical difficulties that are to some extent unavoidable but also explicable and temporary. Read More

Recovery, but not so close to the start

Where to begin? First, thank you for this post, and all your posts. I've read your blog over and over since I started my own recovery journey almost 15 months ago. Of all the blogs I've read in that time, yours is the only one I now follow and is the most 'recovered' of all the so-called recovery blogs I've seen.

But I have a question and I'd really appreciate your take on it. So, I'm not so early in recovery and have gained (to me) a lot of weight as well as increasing my intake from a three figure daily amount plus exericse to four figures (1500kcal<) and limited activity. I'm still in an underweight BMI but very much struggling with the concept of increasing my intake back to the higher places it's been over the 15 months I've been trying to beat this thing.

I can't seem to get over the fear of gaining weight, and the symptoms that go along with it - still very much those you've described above. I've been for ED assessments to access councelling and nutritional support but I've been denied it because I am a)adult (age 30) and b) now no longer a critial BMI. I'm abandoned to get on with it and I feel quite alone in knowing what the right thing to do now is. I'm struggling too with hunger. I might feel hungry, but mostly I feel ill. I can regularly feel hungry but at the same time painfully full without necessarily eating anything at all let alone a full meal. I am still dependant on kcal counting because my so-called treatment plan (help via GP) has been compeltely fixated on kcal counting. I'm not sure if that's made as much of a problem as it's helped. And on and on, you can probbly guess most of the rest!

I know that I risk being in decline again very soon, and I also know from reading your blog that my present is similar (in terms of daily intake, but not behaviour patterns) to your past. This scares me too.

I thought I had a question, but maybe I'm just asking for an opinion on where and what are good next steps, bearing in mind I'm on my own and my last rejections for help are very, very recent.
Any observations, thoughts, ideas so very much apprecaited.

Anne.

Mid-term recovery

Dear Anne,

Thank you for writing. I'm glad to hear you've been finding the blog worth reading (and rereading). It seems to me, too, though I still don't understand fully why it should be, that I've managed to recover more fully than many anorexics ever do. Although of course there's probably some self-selection going on in the realm of eating-disorder blogs, in that people who are still not quite as recovered as they might be are more likely to want to keep on thinking and writing about ED-related issues. I do sometimes wonder whether I still have anything useful left to say, given that my everyday life is now affected barely at all by my history of anorexia, but I suppose simply providing a properly 'recovered' blog might be reason enough in itself.

It seems that often the most difficult part of recovery is not the critical starting-to-eat-again phase, where change is rapid and help is at hand, but the later stages, between nine months and a year and a half or so into the process; this is certainly the period during which relapse is most common. I suppose the first thing it might be helpful to reflect upon is the simple fact that this is to be expected, and that without ongoing professional support it's a great challenge not only to maintain a programme of nutrition that keeps the weight going up when motivation might be wavering, but also to initiate more varied and flexible habits more generally, to prevent the urge to revert to starvation from gaining ground again. Not that you necessarily are criticising yourself for finding it difficult - but a realistic assessment of one's situation is always a good thing. You should also not let yourself forget the significant, measurable progress you've already made, and which you now owe it to yourself to build upon rather than letting slip away from you.

In practical terms, it seems perhaps a callous thing to say, but there really is one thing that matters above all else: following a dietary plan that is adequate to induce steady weight gain, and which, crucially, doesn't depend on the vacillations of your appetite, your mood, or any other uncontrollable factor. It may seem impossible to eat when you already feel nauseous, but in those moments where food seems the last thing you want because you feel physically so uncomfortable, you have to tell yourself that eating is the only thing which will ultimately bring that discomfort to an end.

Only by eating more will the necessary physical adjustments to increased intake - increased stomach capacity and digestion speed, muscle repair, hormonal balance and hence a more regular appetite, tolerance of a variety of foods, and so on - be completed. These processes of physical regeneration will have come on a long way in the months that you've been regaining weight, but of course while you remain in the not-quite-recovered state that so many anorexics fail ever to get beyond - eating a little more, getting scared, restricting again - you'll continue to experience some of that pain every time you restrict and then attempt to improve things again. For me, the desire not to be one of the majority who remain forever in that limbo state somewhere between emaciation and health was a powerful motivating factor in keeping going past the in-between point, anxious as it made me to begin with.

It really will get easier, if you persevere. I appreciate that it may seem as though you've been enduring it for an awful long time, and that your significant weight gain should have meant an end to it before now, but until you've reached a BMI of about 20 you probably won't ever be free of it completely. The sooner you do that, the sooner all this distress will stop overshadowing your life. As I mention in the post about the 'Minnesota Starvation Study', the regaining of weight, when it happens in starved people who didn't have eating disorders prior to starvation, tends to 'overshoot' temporarily, presumably as the body seeks to provide a 'safety net' in case of future famine, but within a year or so it then normalises. Of course lots of anorexics refuse to let this overshoot happen, or let it happen and then panic, but it happened with me, exactly as that study suggests it would: as I've described elsewhere, my BMI went up to over 25, and then with gentle dietary adjustments dropped off just a little to where I felt more comfortable. (Now it's about 26, but that's because I have a lot more muscle than before...)

Perhaps you could tell me what sort of BMI you have now, and what the 'higher places' were which it reached earlier in recovery? And what exactly happened that caused your weight to drop again from those high points?

For now, I assume you have a meal plan that was allowing you to continue to regain weight, so the first thing to do is to revert to that and abandon whatever pruned-down version you may currently be following. 1,500 kcal a day is really not very much as compared to a healthy person's diet, as presumably you know, but what matters is that you achieve a steady weight gain of about 0.5 kg a week or so. I was eating around 2,200-2,300 per day at the start of recovery, and more after that as I gradually let go of my controlled anorexic foods and started to eat real food with other people again.

You might also try making a list of your reasons for wanting to continue recovery till you reach a healthy weight, and have that to hand whenever the nausea or fullness/bloatedness make things difficult - as well as, if it seems useful, a clear sentence or two about why those symptoms must be just symptoms of your still undernourished state, and why they will therefore fade if you do keep eating.

The calorie-counting is bound to make you feel as though you're still ill mentally as well as physically, but at the moment it may be a necessary evil. As my therapist put it to me on many an occasion: you don't have the privilege that healthy people have, of eating when and what you feel like it. You have to earn that privilege back by eating to plan, for as long as it takes to reach a healthy weight. Only then, in any case, will it be possible for you to start eating more flexibly in terms of times, amounts, and so on, because only then will your mental state no longer be that of the half-starved person and your bodily state no longer be disrupted by the aftermath of starvation.

I hope this reply gets to you before your anticipated decline does, and that you don't lose faith (or can regain your faith) in the restorative power of food.

Emily

I'm also a long-time reader

I'm also a long-time reader of your blog and find it to be amazingly informative yet accessible, something that is both rare and delightful to find.

What isn't delightful is that I've struggled with an ED--overexercising and OCD that led to being underweight--for 10 plus years now. While I've had inpatient treatment before, insurance never covers more than a week and to be honest, it never helped. I have a clear idea of what I need to do, but getting myself to do it on a consistent basis is the issue. I eat around 2,200 calories a day, but at 5'8" and 91 lbs, I realize that's not enough.

The problem is that I have a hard time convincing myself to eat more or eat "different" things when I can be satisfied with the routine I've set up for myself. If I can't exercise, I feel like I can't increase. But even when I do exercise, I still like to play it safe. I feel like my body is used to where I am, and I don't know if this is simply my "normal."

I guess my point is that the physical effects of being underweight are more familiar than the physical effects of increasing that food and the physical/mental stress that causes. I don't know how to get past that point, so I'm just living with it...

Living with the familiar

I suppose everyone has the right to say that they can't or won't improve things any more: that here is as far as I'm going to get. In your case, given that your BMI is so very low, I would think that such a 'decision' couldn't be sustainable for long in any case, but assuming for the sake of argument that you could live like this for the rest of a long life if you so chose, that decision needs exploring a little further. The terms of the decision (or the inability to decide otherwise) can usefully be interrogated: what does it mean to you to be 'satisfied', to 'play it safe', to be physically 'used to' a particular state, and are all those assessments put together enough to make the decision an informed and lasting one?

The fact that you're thinking and writing about it in this context implies that you're not sure you do want to live forever like this, and the confidence with which you mention the 'physical effects of being underweight' suggests you don't really believe that they are your physical 'normality', any more than the point you're at now is what you really envisage as your ideal - or perhaps even your acceptable - state or destination.

Perhaps the single question all this comes down to is: does my fear of change outweigh my frustration with staying the same, or not? Even if it does today, and tomorrow, it may not always. The sheer tedium of anorexia was for me, with hindsight, one of the important factors that ultimately hung in the balance. Combined with the nastier symptoms of long-term under-eating, it was one chronic flaw in my life, which in my more honest moments I was able to recognise.

Once you do admit fully to yourself that you feel frustrated (/bored, trapped, weak, obsessed, lonely...) and you do acknowledge that you feel like that because you're consistently under-eating and over-exercising, it will become possible for you to do consistently what you can't do now: eat enough more than 2,200 kcal a day to bring your weight up away from the dangerously low level it's currently at, and to keep it there.

And given that you do already know what's needed, and given that you do seem dissatisfied with life as it is, it seems to me as an outsider that there is only a small step left to take. You may have to deal with the difficulties of taking that step on your own without the support of inpatient care - or at least with brief inpatient treatment as only one short stage in a much longer journey. But wouldn't it be lovely to be able to exercise for the sake of it, rather than just to earn your food - and indeed not even to 'exercise', but to do sport, or do something sociable or something skilful that enhances your body and your mind rather than diminishing it?

Just 'living with it' is a sad way to watch life slip past, I know, and ten years feels and is a significant chunk of time to do that for. Really living may cost that short period of physical upheaval, but in my view, and from my experience, that is negligible in comparison with what it makes possible.

All best wishes,

Emily

Weight gain after being illl

I dropped to 40kg after being exposed to heavy metals. Now I gain weight if I eat anything. Perhaps insulin resistance? I didn't eat for at all really for 2 years.

More detail, please

Hello, I need a bit more detail to be able to respond meaningfully here. What kind of exposure was it? What does 'not really eating at all' mean, exactly? Why do you suspect insulin resistance in connection with the heavy-metals incident? And what precisely is the problem you want advice about? Presumably gaining weight once you start eating is a good thing - and even if you can't currently accept it as such, it's at least a completely predictable and normal thing.

Emily

Post anorexia bingeing

Hi Emily,

Quick question - did you ever find yourself binge eating at all during 'recovery'? If so, how did you mentally cope with it?

Oops, that's two questions.... LOL

Thanks,

Kate

Recovering without binge-eating

Dear Kate,

No, I never did. That is to say, I never ate more than planned in a way that felt uncontrollable. But after the first four or five months of following my plan very carefully I did increasingly eat a lot, no longer counting calories at all, with large portions at most meals, and a lot of meat, sugar, and fat. But by the time this was the case, I had adjusted to my continual hunger and to the conviction that the best thing I could do was to respond to it and, for the most part, enjoy doing so.

The development of that period of substantially increased intake was determined by the fact of getting together with my then new boyfriend, who liked (and still likes) to cook for me, and I don't know quite how things would have progressed if it hadn't been for him and the deeply pleasurable novelty of eating with someone I cared about romantically. His being there and sharing everything with me certainly made the whole thing mentally much easier than it would otherwise have been, although I hope that if I hadn't had him I would have found related pleasures with family and (my few remaining) friends, and certainly kept on with the plan such that my thoughts and habits would have loosened up of their own accord as my weight continued to increase. I suspect it would have taken a good deal longer, though.

The key point here, as in my post on the relation between anorexia and binge-eating disorder, is that binge-eating rarely happens without restriction, and that if eating a lot is required to become healthy again, and if it isn't mentally evaluated as something that should be stopped but can't be, it isn't binge-eating, it's just eating. It's much better to do the mental adjustment before the fact rather than after, so that it's no longer a question of coping in retrospect, but becomes one of accepting, and anticipating, and, eventually, being glad.

Emily

Still Here ... Still Struggling

Hi Emily - I have read through all of your posts - beginning to end - again. After scanning a couple other ED blogs, I fully appreciate your topic choices and point of view. Thank you, again, for modeling how to overcome an eating disorder. I look forward to reading more from you when you have time! - karin

Thanks, Karin; I'm glad

Thanks, Karin; I'm glad you're still finding them helpful. I seem to have settled into the pattern of posting once a month, around the end of the month, and so will be writing something new in the next few days.

Emily

Still Here ... Still Struggling

Hi Emily - I have read through all of your posts - beginning to end - again. After scanning a couple other ED blogs, I fully appreciate your topic choices and point of view. Thank you, again, for modeling how to overcome an eating disorder. I look forward to reading more from you when you have time! - karin

Hi Emily, Thank you so much

Hi Emily,
Thank you so much for all your posts - it is helpful and refreshing to read about anorexia nervosa recovery from an intelligent and informative perspective.

I am just in the first month or so of recovery and Im finding it extremely difficult. Although I recognise that weight gain is crucial to get better I am wondering if it is possible to avoid the '10% overshoot' - This concept terrifies me as I would like to gain weight but remain 'slim.'

If you dont mind, can I ask you about what point you got your periods back and did regaining this hormonal cycle help aid recovery? Also did you have any long term physical complications for anorexia.

Anna

The '10% overshoot', and long-term complications

Dear Anna,

I'm glad you find the blog helpful.

Of course, every single anorexic would like to avoid the overshoot, every anorexic would like to remain 'slim', every anorexic is terrified of anything else happening. And, crucially, giving in to all these fears is why so few ever fully recover.

We don't have as much choice as we might like to think about our body shape and weight, which is significantly genetically determined, and for the recovering anorexic it is more important than for anyone else to find and accept not the weight which one's eating disorder dictates as desirable, but the weight at which one's own particular body can thrive. Whether or not that weight is one which you would currently categorise as 'slim' will come to matter less and less if you can find the courage not to let that preconception determine how you go about recovering.

As for your question about my periods, what was going on was obscured by the fact that from very early on I'd been taking the contraceptive pill as a hormonal regulator and inducer of menstruation. Then as I recovered I kept taking it for contraceptive purposes, so I'm still not actually sure when and to what extent my hormonal cycle normalised. I'm just starting an experiment of not taking it for six months and seeing what happens, but I'll have to report back on that one...

As far as I know, I did no long-term damage to myself. I had a bone-density scan about five years in, and there was no significant damage then. And although my bones would have continued to get weaker, I suppose that the past three years of eating well, combined with the density-increasing effects of strength training, will have reversed most if not all of that damage. My blood sugar and cholesterol are at healthy levels, and I feel well and strong and resilient. The very gradual nature of my decline, and the fact that I never got into the unstable and destructive cycle of bingeing and purging, probably spared me from some of the worst effects of anorexia, but many complications can be reversed by the introduction and maintenance of appropriate nutrition.

The first weeks are the very hardest, and if you persevere and don't succumb to those worries you express - which all amount to not wanting to let your body get fully better - it will all get much easier, easier than you can at present imagine.

Best wishes,

Emily

Actively recovering, in pain

I can't believe I only discovered today all of the helpful articles on this website about eating disorders.

I have to say, I'm particularly interested in hearing more about the physical effects of weight gain after starvation and during restriction. I've been actively recovering for half a year, and I'm halfway to achieving my given "goal weight" which will give me a BMI of 20 - safely and comfortably above the bare minimum BMI of 18.5 for being in the "healthy" range, at least in terms of BMI. However, I'm still experiencing a lot of discomfort when and after eating. Not mentally, but physically. Numerous times I have attempted to eat heartier meats with my family and by myself, only for to experience diarrhea (sorry, TMI I know!) shortly thereafter. I know you don't HAVE to eat red meat to recover, but I liked the occasional burger pre-ED, so I'd like to know I can still eat one without the paralysing intestinal pain and leaky GI tract afterwards. Also, is it common to experience so much flatulence in recovery? I love going out to eat with my family, but I'm sometimes embarrassed by how stinky it is to be around me. :\ We are good at joking about it, but I still wish I didn't have to put my family members (and myself, to be honest - I can smell it just fine and it's not pretty) through it...

Are there other common physical symptoms and signs of recovery that are off-putting? Will they go away with full recovery?

All the best and thank you so much for your great posts and insight,

Jenny

More on physical side-effects

Dear Jenny,

I'm glad you find some of my posts helpful.

I've talked in previous posts about the emotional volatility that often accompanies recovery (as starvation-induced depression recedes), and I described in some early posts my own experience of physical difficulties related to those you mention, so you might look over those, if you haven't already, to reassure yourself that your problems aren't unusual.

As for your particular difficulties at the moment, red meat is relatively hard to digest (compared, say, with white meat or fish), so might be more likely to cause diarrhoea, and the sulphur it contains might be conducive to flatulence. But red meat is also, of course, an excellent source of vitamins such as B12, and of protein, which is crucial when recovering from malnutrition, in restoring muscle and other tissues and (in combination with adequate calcium) in improving bone density. And it's almost certainly much healthier in the long term than more easily digestible foods such as refined carbohydrates.

At the moment, however, your highest priority must be to keep eating enough food that is calorific enough to sustain your weight-gain and restore your weight to a safe and healthy level. If the side-effects of eating burgers and so on are in danger of seriously compromising that aim, it might therefore be as well to do without them for a month or two, to give your digestive system more time to adjust. On the other hand, if the pain is rare, and you're happy joking about all the rest with your family, that's probably a good way of connecting with them in a light-hearted way - very different, I imagine, from how things were between you before you began to recover.

It is highly probable that these and any other difficulties you may currently be experiencing will come to an end as recovery proceeds and a healthy weight is reached and maintained. (Though of course everyone farts, and some naturally more than others!) I can't immediately think of any other physical effects beyond those mentioned here and in my post, but let me know if there's anything else in particular you want to ask about.

Finally, I'd just like to say how admirable your attitude to recovery seems: the combination of pragmatism and humour is an excellent armour against the humourless essence of anorexia and the (surmountable) obstacles that recovery always involves.

Emily

hi Dr Emily... i'm not

hi Dr Emily...
i'm not anorexic and havn't ever really been but i went through a "rough patch" and lost alot of weight! i'm currently with a dietition who has just pushed me into this hectic weight gaining diet and i feel like i'm DYING but i'm only on day 3!!! thank you soooooo much for explaining all the problems i'm having like stomach issues etc. and explaining how weight gain will work as my doctor just gave me the diet and a tub of Ensure with a good luck sticker...grr...
anyway, your blog is amazing, thankyou!!!
take care ;D

I'm really glad to have been

I'm really glad to have been of help! I hope knowing a bit more will make it easier to persist well beyond day 3! On the disproportionately rapid weight gain at the start, and why cellular rehydration is so important, you might like to look at another ED blog post by 'Roxy', http://adverseuniverse.wordpress.com/2012/05/26/rapid-weight-gain-in-ear..., and one of the sources she links to: http://www.justinowings.com/understanding-bodyweight-and-glycogen-de/.

Initial quick weight gain...

Hi
First I have to say that your posts have always been a very guiding light to me. So inspirational and they resonate so much for me. I am beginning an earnest recovery since about three/four weeks ago. I have only increased my calories from about 1500 -1750 a day and have already gained near 4 pounds. I am trying not to revert to my previous 1500/day, however I feel like I have been given a crappy deal because I am gaining so rapidly whilst still feeling completely restricted. Is this 4 pounds the water weight you refer to? Will it continue to go on this quickly with such a small increase? I was expecting/hoping it would take me far more calories to gain weight this quickly, and I was hoping that with small increases I could gain 0.5 pound a week so I could cope with it better. I feel so lost and disgusted with myself, each time I reach 1700 again, knowing it is all just piling on me. I would really appreciate your experience in how weight can fluctuate, is this all real weight? Will the speed with which I am gaining subside?
Thank you

Weight gain now and later

Thanks for this; I'm happy that you've found my posts helpful, inspiring even. Your experience - down to the fact of feeling you've ended up with a raw deal, that you're gaining faster than you should, and faster than other people - is completely normal.

On weight gain and water, I suggest you check out the links I posted in response to the previous reader's comment on this page. As for your calorific intake, you really haven't increased it by enough. If you were maintaining a steady weight at 1500 a day, you should now be on at least 2000. I was treated according to the 'additional 500 calorie' principle, which is of course relative to pre-recovery intake; others (e.g. http://www.gwynetholwyn.com/blog/2011/9/14/do-i-need-2500-calories.html) argue that a blanket 2500 kcal/day (at least) is necessary for pretty much everyone. In any case, you've added too little.

The extra 250 calories are enough to initiate the processes of cellular rehydration but not to drive sustained weight gain in the medium term. And as you say yourself, you feel at the moment as though you're gaining rapidly while still feeling 'completely restricted'. This is a psychological issue as well as a physiological one, and it is important to get the balance between the potential for weight gain and the inevitable side-effects (mental and physical) of eating (even a little bit) more, so that you don't get all the 'pain' of increasing and its effects without the lasting 'gain' of actually healing your body.

It's very easy to lose motivation if 1) you're hardly eating any more than before, but see your body weight increasing rapidly, and then 2) you see the weight gain level off while still dealing with all the traumatic feelings associated with eating more, or even 3) the 0.5 pound a week increase does continue, and it takes you years to get back to a healthy weight. You really shouldn't be aiming for as minimal an increase as that; double that (1 pound, or 0.5 kg, a week) is a much more reasonable rate of increase, for all the reasons above. If you are determined to recover in earnest, you need to make your goals both more ambitious and more realistic; adding at least another 250 kcal per day is the way to do both.

Finally, yes, the weight you've already gained is 'real weight' in the sense that it is vital to your body's healthy functioning, and a positive sign of regeneration. What it isn't is fat. It probably isn't much else 'real' except water right now either: the regeneration of bone, cartilage, skin, etc. etc. is mostly still to come.

Be strong and keep reminding yourself why you're doing this,

Emily

rapid weight gain after ED

I as well am freaking out over the extra weight I've seemed to have added. I was 5'8" and 86 lbs. at the thinnest. Now I've gained weight and I am not eating too much more, but I'm always hungry. I injured myself working out and no exercise for six weeks. My clothes are tight and I look in the mirror and see the enormous person. I won't weigh or measure myself because those numbers will freak me out. I'm back to exercise now, and want to know when this will even out? people say I look a lot better but, I just see a blob. Coping with this weight is more than I can handle.

Issues with weight gain

You don't say how much weight you've regained, or how quickly, or in what sense it's 'extra' weight, but starting from a low-point BMI of around 13, you had an awful lot of weight to regain to reach a healthy level. This process is bound to be difficult, both physically and psychologically, but there are certain things to bear in mind to reduce the trauma.

An important one in your case is the finding that, as I noted in response to another reader, bodyfat takes time to redistribute after weight gain; in particular, it seems to take around a year for the initial disproportionate deposits of fat round the midsection to even out (Mayer et al. 2009: http://www.ncbi.nlm.nih.gov/pubmed/19793856). It also takes time for muscle mass to be rebuilt (the body restores fat first), and for you to get used to being a healthy(/healthier) size and shape again. These things will all happen, but only once you're fully weight-restored.

Until your weight is at a healthy level again you also shouldn't be exercising; there's no point risking repeated injury when your body is already working flat out to repair all the damage done to it by extreme malnutrition. Furthermore, increased levels of cortisol caused by exercise seem to discourage the body from directing the available energy into those necessary long-term repairs. So anything more than gentle walking should be avoided during the weight-gain phase.

Extreme hunger is your body's way of signalling that it requires a significant nutritional surplus beyond the intake that would maintain a stable weight, to carry out all the restoration of fat reserves and repair of organs etc. that are necessary to becoming healthy again. Your hunger will probably not abate until the weight-gain phase approaches an end, and you should capitalise on that hunger to make and follow a daily food plan that involves at least three decent-sized meals and three snacks. This is the only way you're going to get well and be in a position to do sport again without injuring yourself or compromising your long-term health.

Finally, completely avoiding weighing yourself can be as psychologically problematic as doing so to excess, since the numbers you don't know but are constantly making guesses about can take on more and more cognitive significance. So if you can build fortnightly or monthly weighing into your recovery process, with someone else there to help you if need be, and chart your progress with you, that would be ideal.

Starting from such a low weight, I hope that you've sought professional - therapeutic and possibly also dietary - advice; if not, you should definitely do so, and the question of regular weighing might be something you'd want to raise with your therapist.

When people say you look a lot better, they mean it, and you will come to agree with them in time. Certainly anyone with a BMI of 13 can look like nothing other than an emaciated husk of a person, and although the distribution of fluid and fat won't yet have evened out, just bear in mind that continuing on the path of weight gain is the only way to achieve a body that looks and feels good.

Emily

in recovery

What types of foods would you reccomend? I am looking to eat about 3000 calories if I can. I work a full day and want to do it relatively cheap. Is it bad if I go to Mcdonalds or something like that or is it better to eat that than a really small lunch just because its easy?

What to eat

Basically, eating enough is far more important than the details of food types. So McDonalds is infinitely better than a 'really small lunch'. Enjoy it if you can!

More generally, you should ideally aim for decent quantities of fat and protein in addition to carbs, so meat is good (and fattier cuts are generally cheaper than lean ones), as are eggs (nice and cheap too) and milk (full fat). But of course if chocolate and other 'junk foods' are convenient and you find them easy (/easier) to eat, you absolutely shouldn't shy away from them.

For now, your single priority is to regain weight to a healthy level. Once you've achieved that, you can make decisions about the details of what kind of diet will be most sustainable for you, physically, psychologically, and financially. By then your tastes may well change in any case - I certainly found my cravings for salty and sweet foods gradually waned of their own accord as my body came out of starvation mode.

Hope that helps, and good luck with it,
Emily

weight gain

Hi,
I'm currently in my 4th month of recovering from and E.D (for about a year and a half i was really restricting my cals and lost over 3 stone). I have experienced all the things you spoke about- disproportionate weight gain etc etc. I have now gained about a stone and my bmi has gone just from the edge of being underweight to being 21. But i'm really freaking out because it seems as if the weight gain isn't stopping its just going up and up. I use to be overweight and i really dont want that, as it may trigger me to stat starving again. And i would hate to be a yo yo dieter cos to me thats just as unhealthy- i just want to eat normally and not make food run my whole life. i have a healthy bmi so i just want the gaining to stop. I have read SO many forums of girls gaining excessive amounts of weight and then NEVER being able to loose it. I understand i have to gain weight but im at healthy weight and size now i just really do want to become overweight again and then never be able to loose it. Is this a common thing for people in recovery- to gain too much weight and not be able to loose it? or is this just a small minority and most just maintain a normal healthy weight? do you know roughly how far into recovery does the weight gain steady and stop so that a normal healthy weight can be maintained?- i was only restricting for about a year and half so i was hoping i havent damaged my body too much and maybe the recovery process would be quicker- i already have normal periods again and my nails are no longer yellow etc. Sorry for all the questions but i just want to move on from this and get on with my life without worrying if im gaining more and more.
Thankyou

Where weight gain stops

No one wants to 'gain too much weight', but it does seem to be a relatively common thing in the short term, followed by a gradual return to pre-illness levels in most cases (see e.g. my discussion of the Minnesota Starvation Study: http://www.psychologytoday.com/blog/hunger-artist/201011/starvation-stud...). Certainly it happened in my own case: my BMI went up to about 26 and only then stabilised and gradually decreased to where it is now, a very stable 24ish. I was eating really a lot by that stage, and made only very minor changes to my diet to help bring about the end of the gain (fruit instead of dessert at lunch most days, for example).

In my case, I'm convinced that allowing my weight to reach that level was key to a full recovery: it was only then that the extreme hunger which was a feature of most of the weight-gain phase finally came to an end. You may have read stories of people recovering from anorexia only to end up overweight, but there are far more cases of people never recovering from anorexia at all because they're too scared to let their BMI go above 19, or 20, or 21, or some other arbitrarily chosen figure.

Every body has a different optimum weight, so that while 21 may be healthy for one person, it won't be for another. In general, weight maintenance shouldn't require a reduction in daily intake from what was being consumed during the weight-gain phase (see e.g. http://www.gwynetholwyn.com/blog/2011/9/14/do-i-need-2500-calories.html). Do you know what sort of amount (in kcal) you're eating at the moment? It's a good sign that your periods are back to normal, and that other things seem improved too, but even though your illness was relatively short, there will still be all kinds of longer-term and less conspicuous repair (e.g. of bone density) that haven't happened yet and require a reliable supply of energy, and your metabolic rate will probably not yet have fully normalised from its suppressed anorexic state.

At the moment, the greatest danger you face is probably not continuing to gain weight, but relapsing into weight loss again. The best way of ensuring that food doesn't keep controlling your life is therefore probably to keep eating as you are doing until the weight gain naturally slows and stops. Yo-yo dieting is a very destructive habit to get into, but constant 'successful' restrictive dieting isn't a great way to live either, since for someone who used to have anorexia it basically means resigning yourself having a low-level (or not so low-level) eating disorder for the rest of your life.

So, anyway, a bit more detail on what your current diet looks like would be helpful. Could you also tell me what your appetite / hunger levels are like at the moment? Finally, is there any way you could talk to a doctor or other professional about this? I'd definitely advise it if at all possible.

Well done, anyway, for managing to get this far. It's a really significant achievement.

Emily

thankyou

Thankyou i really appreciate the time taken to write all of that it was really helpful. One of the biggest stresses is not the weight gain itself but the idea that maybe it wont stop. But the fact that you said it does normalize again really brings me a bit of piece of mind. I also worry about my mental hunger- i know a lot of the time i would be physically full but mentally starved and would binge and crave this would make me feel so upset and angry with myself. But just about 3 months in and im finding these cravings are subsiding and the binging stopping- which is actually making me feel positive about recovery and wanting to continue.
You say in the other article you gain your pre-ed weight plus about 10%. But before i was restricting i had other problems with food.
Just to explain myself a little more: So when i was about 16 i got really bad stomach problems and turned out i had quite bad IBS. bread, pasta, fried food and generally things that were difficult for the body to digested cause me problems. There was nothing the dr could do so i managed it myself through regular exercise and healthy eating at regular intervals. I was really happy with my body, weight wasn't a stress for me and neither was food, and it was probably the healthiest i had ever been (i wasn't counting calories but just eating well). But naturally because i was moving more and the IBS bloating went down, some weight came off- but my dad would always comment, 'don't you loose any more weight' (but for me then it wasn't about the weight, it was about going out without worrying about my stomach or needing the toilet! im so jealous of how i was then and how i thought and felt about myself).
But because i felt bad that dad didn't like it i would make a conscious effort to eat around him. But because it as food that i didn't want to eat due to it causing me problems. So i would eat it and then leave the room and spit it out. This soon escalated and i started doing this ALOT it became like a habit; i wanted these foods but didn't want them in my body as it would cause me problems (ironically the c/s caused me the same problems as IBS!) so i would chew and not spit my food out (not just like a little bit either but i could get through entire boxes of cereal, massive choc bars, ice cream, even sugar- anything really).
I was 16 when that started (i am 20 now) but i managed to stop that- but its like i replaced one habit with another with restriction, which i done for about just under 2 years. because im a lot older now and there is a big difference between the body of a 16 yr old to a 20 yr old, i didn't know if the weight gain you talked about would still be the same with me. My chewing and spiting actually made me gain weight; i went from about 8 and half-9st to over 11st. so will my weight go back to over 11stone!?! or is it more likely to go back to what i was when i had a healthy normal diet (about 8 and half stone- 9stone). At the moment i weight 8st 10lb/12lb- but it has stayed that was for a fair few weeks now and the weight is no longer on just my stomach but seems to be spread out a bit more.

My diet now:
I have actually tried to eat different foods but have found that bread, fried food like chips of heavily oily food like roast potatoes does really make my IBS flair up. I was worried that all carbs would upset me but i have no problem with rice, mash, boiled so just incase you thought, I'm NOT using it as an excuse not to eat carbs :).
So for breakfast: either cornflakes or porridge with either raisins or banana in.
lunch: omelet and cottage cheese with salad. or il have a salad with something like tuna,chicken or goats cheese- and i make sure i put high kcl veg in like corn, advacado. and then a yoghurt.
dinner: usually fish or chicken with veg and then something like potatoes or rice or lentils or bulgarwheat/ stir-fry/ fish pie/ jacket potato with beans.
snacks: apple (sometimes with peanut butter), yoghurt coated raisins,fruit like mango or banana, something like a club bar.
drinks: water/squash/different teas/ milk/hot chocolate.
I know im probably not reaching as much as what i should be i find it physically really hard to do so. But i do ensure i eat at least 1200 and i'm actually eating what i enjoy and what i fancy.
You asked about my hunger-Well i did feel pretty much constantly hungry, but over the past week this hunger seems to have leveled out and i'm getting hungry at meal times and im not constantly craving. Iv been trying not to deny myself anything which has actually really helped- when i 1st started in recovery i would still feel bad about eating stuff like chocolate and it would make me crave and binge it. but im telling myself not to feel guilty about what i eat and this has actually subsided my cravings and iv been finding if i fancy some chocolate i will have it but im not eating it for the sake of it or because im craving it (and i haven't binged in a couple of weeks now).

Many Thanks Again, the info your given me is making me gain a lot more perspective and rationality :)
Emily

Daily intake and bodyweight

My pleasure; I’m happy if it was helpful. It’s great news that the craving and bingeing are becoming less frequent. The absolutely key issue here is eating regularly and frequently, as well as in sufficient quantities, of course. The details you give of your diet sound very good, with a nice balance and variety, and a decent amount of protein – but then you say that you ensure you’re eating a minimum of only 1,200 kcal a day. This is absolutely not sufficient to sustain a healthy or near-healthy weight. It’s less than half the minimum you should probably be eating, and if you eat that little, even just one day a week, you’re significantly increasing the risk of the crave/binge cycle being reinitiated. I appreciate that the inevitable difficulties with feelings of fullness will seem all the more acute given your history of having been overweight for a while, but it’s very important to accept that (calorie) restriction increases rather than reduces the danger of returning to a higher than optimum bodyweight. It’s of course nice to be able to eat what you enjoy and what you fancy, but for now you still have to get yourself back to a place where that’s fully possible, and that may often involve eating when you think you’re not hungry and don’t ‘fancy’ anything, just for the sake of consistency and to prevent hunger building up and culminating in binge-eating. All the improvements in the stability of your appetites do suggest that in general you’re probably managing to eat well over 1,200 a day, but if not, you really need to address this as a matter of urgency.

As for whether your weight will revert to its original 8.5 stone or its more recent 11 stone level – I see no reason why, as long as you don’t return to the disordered chewing and spitting habits, your weight shouldn’t normalise at its previously stable level. Your weight gain due to bingeing in the chewing and spitting phase makes perfect sense as a result of the self-imposed restriction, which won’t now be an issue. You’ve set out very clearly the sequence of events that led to your dysfunctional eating followed by the sustained two years of restriction, and as long as there weren’t also other psychological factors that are still causing you problems, there’s no reason why you shouldn’t easily maintain a weight close to what it was aged 16 or so. It may be a bit more now you’re a little older, and we’ve already discussed the temporary ‘overshoot’ phenomenon which probably shouldn’t be resisted, but it sounds as though, with the convergence of a stabilisation in weight and a reduction in hunger, you might naturally be nearing the end of the weight-gain phase anyway. In which case, well done for getting to this stage!

From what you say here, I think you’ve really got the worst of it behind you now. The redistribution of bodyfat will continue over the coming months, till that slightly bloated look is completely gone, and your appetite will carry on becoming more predictable, and eventually you’ll be able to allow yourself more leeway as regards eating according to appetite. For now, though, I’d just reiterate that you need to be very careful not to jeopardise what you’ve achieved and keep eating around 2,000-2,500 kcal a day, well spaced out.

(Incidentally, would you mind just telling me your height, so I can work out your BMI?)

Congratulations again on your excellent progress, and best wishes,

Emily

reply

phew! Thankyou so much its nice to know what will happen- i dont think my dr had had much experince with eating disorders and when i 1st went to him simply said eat more; so to begin with i just didnt want to change i was only going to the dr because my family wanted me to. But now even though a bit selfconcious due to the change in my body and the full feeling i get i am actually so smuch happier with more energy, actually able to concentrate on uni work and nice to have my periods back to how they should be! so am now really positive about recovery and want to be better. So thankyou for the reasurance and honesty, its nice to know that as long as i address my eating habbits and not slip back into the restriction or chewing and spitting, that i can maintain a normal comfrotable weight. Im making more of a concious effort to addres these issues by writting them down in a diary; its strange I seem to be very rational about my irrationalities so im hoping this way i can reflect on what im thinking and feeling a bit more and work through what my troubles are. Feels like iv wasted so much time worrying about food, im just really looking forward to moving on with my life.
I've taken on board what you said and have been trying to consume more- found it hard to physically eat more beacuse it cn feel just so fillin, so been trying so have food with higher cal content, like peanut butter and milk.
My height is about 5ft 3'/ 5ft 4'.

Emily

Diary-writing

It's really great that you're feeling so positive and so aware of all the benefits weight gain has already had. I should think you'll soon get used to how your new healthier body looks and feels, and also to what it feels like to be eating enough again, especially if you keep reminding yourself of all that these feelings signify in terms of your health and your future.

The diary could be very helpful. Many sufferers from eating disorders are highly lucid about their situation, and the inconsistencies and paradoxes that maintain it, and it can be useful to document these, disentangle them, and use that analytical process to work at altering how one thinks and behaves. My own experiences with diary-writing would suggest that two points are key, though:

1) Set limits on what you write. Whether you do this by limiting your entries to feelings that arise specifically around food (as in the standard 'food diary' model, with one column for what you've eaten/drunk and another for your comments about any difficult thoughts/feelings that arise), or by just writing once a day, or by writing only one page, I think it's important not to let the writing get out of control. It very much did with me - though primarily in the illness rather than the recovery stage -, to the point that I was stopping in between almost every mouthful while I ate, to write about how amazing it tasted and analyse that delight and then analyse the fact that I needed to analyse it thus... I kept writing some way into recovery, but then I found I simply wanted and needed to stop, to give myself space simply to live and eat rather than constantly writing about living and eating. But your own situation, not having written much before, will obviously be very different. Just be careful not to let it get out of hand and become more a trap than a tool.

2) On that note, I think it's probably also important to keep what you write directed towards practical goals of changing patterns of thought and behaviour, i.e. make sure that you keep focused on what you've learnt from each 'irrationality' and how you're going to use what you've learnt to challenge your thoughts, or act differently, in the near future. Despite the frequent high degree of 'intellectual' understanding manifested in anorexia, the key skill of transferring insight into action is usually what's missing, and it's usually the hardest - but always the most important - thing to achieve.

For example, you might find that you eat less one day, and find your concentration on your work suffers but that you nonetheless feel some pleasure in having eaten too little. You then write down and analyse that irrationality, and conclude that the pleasure was a mixture of predictable factors like the addictiveness of the 'hunger high', the illusion of control that comes from the return to old restrictive habits, and so on. You also note that it had noticeably detrimental effects on things that matter to you (like your academic work). Then you should highlight the key elements of this insight and deliberately use them the next time you're tempted to skip a meal, or the next time that for some reason you eat less than planned, to stop the not-eating continuing or the feeling of pleasure from going unchallenged.

I think these considerations ought to help ensure that the writing becomes a way of moving on and spending less time worrying about food, rather than risking contributing to the overwhelming sense that food dominates your life.

Based on the figures you've given me, your BMI is between 20.9 (assuming 8 st 10 and 5'4) and 22 (if 8 st 12 and 5'3) - and actually I've just seen that you actually told me it was around 21 when you first wrote; sorry about forgetting that! As you say, it is within the healthy range now, but as I also said, some amount of further gain may well still be necessary, in the context of the consistent healthy eating habits (around 2,500 calories a day) that we've already discussed.

Well done again,

Emily

Another unexpected jump...still trapped.

Hi Emily,
I wrote to you in August last year when I had just begun my recovery journey in earnest. My head is still completely caught up in calories and weight. It's been so difficult to continue. At the beginning, I upped my calories from 1500-1750/1800. From July to the end of September I gained 7 pounds from doing that. During October, November and December I continued to eat 1750/1800 calories a day and my weight stayed the same. I have continued eating that amount into the new year but for some reason I have put on 4 pounds since the end of December. I didn't increase my calories and all of my activity is the same. I feel extremely out of control and frustrated. Any idea what could be at play here? It makes me scared to ever eat more. Can you maybe give me some logic here? My ED is screaming at me that I just need to cut back to 1500 again.
Can you help me lay out the negative of going back to 1500 and can you help me see why I should increase further than 1750/1800 if I seem to gain randomly on it?

Thanks,
Susy

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Emily T. Troscianko, Ph.D. is a research fellow at the University of Oxford, investigating what happens when we read fiction.

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