Anorexia is about eating as little as possible. What counts as "possible" varies from sufferer to sufferer: It may be next to nothing, a few calories a day, to induce rapid weight loss and rapid hospitalisation, or it may be enough to keep the disorder perpetuated for years or decades, eating just too little every day to sustain a stable body weight, but enough to avoid hospital and other crises, so that advanced malnutrition and emaciation are very gradual "achievements." As I've described in a previous post, there are ultimately only three options for the anorexic: death, the transition to a related eating disorder such as binge-eating disorder or bulimia, and recovery.

For many anorexics, the first two options don't appeal. Suicidal tendencies are relatively common in anorexia sufferers—suicide is an even more common cause of death in anorexics than starvation itself—yet there are many anorexics who do not wish to die. Many find themselves trapped in the vicious circles of self-starvation, the "hunger high", the illusion of self-control, the obsessiveness, mental inflexibility, and depression of malnutrition, and simply can't find a way out.

One day, these anorexics—of whom I was one—have to confront the necessity of starting to eat more, and translate that necessity into practice. In my posts on 'The day I started eating again' and 'How it feels to eat again' I described the psychological changes that took place as I abandoned the mantra of my own personal "as little as possible", and told of the extreme hunger that accompanied the increase in intake. In 'Eating, continued', I mentioned some of the stomach pain and the diarrhoea that I experienced in the months after the dietary change. This time I want to set out in a little more detail the physical changes that often occur when anyone 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 unexpected and unexplained difficulties. The early stages of a shift in eating habits may well be frightening anyway, not only psychologically but also physically—but apprehension at specific possibilities is better than a fear of the limitless unknown.

One of the most common fears about beginning to eat more concerns the risk of "refeeding syndrome", which can occur in the very early stages (the first week or so) of refeeding. The syndrome consists of metabolic and biochemical disturbances that occur when severely malnourished patients begin to take in more nutrients. Insulin secretion (which lowers blood-sugar levels) is suppressed during fasting, and increases again once blood-sugar levels rise in response to increased nutrient intake. This results in increased synthesis of glycogen, fat, and protein, which requires phosphates, magnesium, and potassium, reserves of which are depleted in the malnourished. The uptake into the body's cells of much of the blood's electrolyte content leads to a low level of blood phosphate, which in turn can cause muscle weakness, confusion or delirium, convulsions, and other symptoms, and can lead to death through cardiac failure unless phosphorous supplements are given, either intravenously or orally. Those most at risk are those who are extremely emaciated, have gone for at least five days with negligible food, or have been vomiting or abusing laxatives (see Abraham, 2008: 137). The risk is reduced by ensuring very gradual refeeding to begin with, by avoidance of foods high in refined sugar, and ideally by continual monitoring of blood electrolyte levels, fluid balance, and organ function, including cardiovascular health (see Gunarathne et al., 2010). In one study (Ornstein et al, 2003) involving 69 patients with anorexia, aged between 8 and 22, who were hospitalised for nutritional rehabilitation, low phosphate levels (hypophosphatemia) was observed in 27.5% of patients: in four patients this was moderate, and in 15 it was mild. Supplementation was given, and the only severe complication was one instance of ventricular tachycardia. These effects are much less likely in someone whose weight is stable or only gradually dropping, and who eats every day without vomiting.

And crucially, as is the case for all the physical complications that may arise during refeeding, the risks have to be weighed up against the risks of remaining malnourished. The greater the malnutrition, the greater the risk of complications during recovery—but also, of course, the greater the risks of remaining ill. Starvation can cause (amongst other things) low blood pressure and poor circulation; osteoporosis leading to possible fractures, deformities, and pain; anaemia; stomach shrinkage, leading to uncomfortable stretching and feelings of fullness when more than a small amount is eaten; increased blood cholesterol levels due to lack of oestrogen; nerve and muscle damage; low glucose levels, which may lead to coma; kidney failure; and death through heart failure (see Treasure, 1997: 106-7).

The point of enumerating these risks both of recovery and of remaining ill is not to induce a paralysed sense of fear or hopelessness. On the contrary, when confronting the daunting idea of recovery, it's important to bear in mind not just what might happen if you go ahead with it, but what might happen if you don't. Many anorexics never experience any of the extreme symptoms listed above, but all will experience some of the milder ones: over-sensitivity to cold, muscular wastage and weakness, sleep disturbances, a weak bladder and constipation, excess hair growth on the body, amenorrhea (cessation of the menstrual cycle), and so on—not to mention the psychological effects like obsessive thought patterns and a fixation on weight and body shape.

For most sufferers undertaking recovery without in-patient treatment, the complications will be unpleasant but not life-threatening. Many of them may seem to confirm the worst fears of the anorexic, since they involve visible bloating that can look like fat deposits. Fluid retention, for example, may be an issue, with oedema around the ankles (during the day) and around the eyes (at night), and the sensation of bloating, seeming to realise all one's worst fears about regaining weight as nothing but 'getting fat' (although oedema can be a feature of starvation as well). As with all the problems that can arise, it can be reduced by ensuring very gradual refeeding. The stomach is also likely to become bigger disproportionately to other body parts, which also taps into typical anorexic fears, but this is to be expected given the slowing of digestion (food can take four or five hours to pass through the stomach in a starved person, as opposed to about 1.5 in a healthy person) and the wastage of abdominal muscles during starvation. Bloating and wind, abdominal discomfort, and stomach cramps are likely as the digestive system adapts to larger amounts of food and the muscles involved stretch and strengthen. Avoiding too much insoluble fibre may help at this stage. It's important to remember that all of these things will pass, and are not reliable indicators of what the recovered state will be.

Another frightening consequence of fluid retention can be disproportionately rapid weight gain in the first days or weeks of eating even a small amount more, as fluid in the tissues between the body's cells and glycogen stores in the liver and muscles are replenished. (This mirrors the rapid weight loss that can be expected when first embarking on a restrictive diet, which is due mainly to dehydration.) This rapid weight gain (of around 1-1.5 kilos, or 2-3 pounds) soon drops off, and thereafter the rough formula applies of a gain of 0.5 kilos (approx. 1 pound) per week for an additional 500 calories per day above maintenance levels. During the early days it is important not to weigh oneself too often (once a week is plenty), because fluctuations in weight can lead to unnecessary anxiety and distress. In general, weight fluctuations over the course of the day, and from day to day, aren't negligible, so it's important not to attribute significance to a single reading, but to assess at least three readings, taken across three weeks, in order to draw a conclusion about whether weight gain (or loss) is a trend or just an anomaly. After about three weeks of a consistently followed refeeding plan, fat will start to be deposited, in a thin layer all over the body, serving as insulation and protective padding, and helping restore hormonal balance. Then, gradually, sunken cheeks and the hollows between bones are filled in; later, in women, the buttocks, hips, thighs, and breasts will begin to fill out too (see Lucas, 2008: ch. 9). Fat distribution may be a little uneven for the first months, but gradually it will even out. Then the once-skeletal sufferer can start to rediscover what his or her healthy body looks and feels like.

It can be hard to distinguish between the physiological and the psychosomatic effects of eating more. Sensations of nausea can be heightened by the knowledge of eating more than was once 'allowed', or eating foods that were once 'forbidden'. Keeping one's mind focused on the reasons that contributed to the decision to embark on recovery can help in this regard. But many of the symptoms are simply physical consequences of malnutrition, and will pass with time, just as the psychological trauma will pass, in tandem with, and thanks to, physical recovery.

Perhaps the most crucial thing to bear in mind is that the discomfort of these complications is a sign of how damaged the starved body is. The discomfort of fluid retention during refeeding, for instance, is proportional to the extent to which the body is dehydrated, and is a consequence of its being rehydrated again. There is no way round these physical difficulties, just as there is no way round those of starvation, but the key difference is that the former are a step on the road towards health, whereas the latter only mark the progress deeper into sickness. This certain knowledge makes it all bearable.

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