I can’t quite believe I haven’t already written a post on this. It’s at the heart of a large proportion of the comments and questions I receive, and it’s something I’ve thought about countless times in the context of what has come to seem like the relative anomaly that is complete recovery from anorexia. How do you get past the in-between stage of having regained some weight but probably not enough, of not being sure whether it’s enough, of finding it awful enough already and not believing you can bear any more, of knowing this isn’t being well again but fearing going any further? Some of what I say here will reflect my experience and motivations at the time of recovery, and some represents my thinking on it since. Some of my thoughts address the physiological side of things and some the cognitive aspects. I hope this combination might be helpful if you’re looking for a way to renew your motivation to achieve full recovery.
Partial recovery is such a common outcome in anorexia – anecdotally, at least, it seems the norm – that many people assume it’s the best possible outcome. Gwyneth Olwyn, a well-known patient advocate and blogger on eating disorders, refuses even to use the term ‘recovery’ as a state rather than a process, insisting that the most we can ever hope for is a full, resilient, or stable remission. But given that there’s no clear evidence for irreversible neurological or cognitive damage post-recovery, to me this seems an unnecessarily pessimistic way of thinking about the possibilities for life after anorexia. My life now is not remission; it’s health. Indeed, I think I’m now less susceptible to relapse than many women around me are to disordered eating.
I’ll start with the physiology of full recovery, then. One obvious though often neglected truth is that a minimally healthy BMI (say around 20) is usually an inadequate basis for full recovery from a severely underweight state (i.e. a BMI of 17.5 or below). This is something you need to bear in mind when you find yourself wondering whether you really need to regain more weight; if you’re just within the 20-25 ‘healthy range’ BMI, but many anorexic symptoms still seem to be in place, the answer is probably going to be to regain more weight. The fact that this is the last thing you want to do is also a sign that you probably ought to.
I’ve mentioned the temporary ‘overshoot’ phenomenon in previous posts, but it’s worth reiterating here: if recovery from a malnourished state is allowed to proceed naturally (i.e. without any negative impact of restricting behaviours), bodyweight, and specifically bodyfat, increases beyond the level at which it was stable before weight loss, but gradually drops back again to pre-starvation levels within a year or so. Abdul Dulloo and colleagues’ (1997) reanalysis of the Minnesota Starvation Study data shows some crucial things about the structures of weight restoration. First, that extreme hunger (known as hyperphagia) in the weight-gain phase is driven by signalling mechanisms from both fat mass and fat-free mass; that is, you carry on feeling hungrier than usual until both types of tissue are fully restored. Second, that full refeeding, allowing for a possible temporary overshoot in bodyweight, is necessary if an optimal ratio of fat mass to fat-free mass (FFM, e.g. muscle, bone, water) is to be restored. This is because systematic metabolic suppression of thermogenesis (production of heat) allows fat tissues to be restored before fat-free tissue, and the final stage of lean-tissue restoration can take place only if more body fat is deposited.
This is what leads to the frequently observed (but rarely discussed) phenomenon of overshoot. As the authors put it,
This explains why when fat recovery in the Minnesota men reached 100%, FFM recovery was incomplete. […] [A] consequence of the delay in achieving 100% FFM recovery (relative to 100% fat recovery) is that the hyperphagia is prolonged until FFM is fully recovered. Because the proportion of extra energy store as protein (energy partitioning) is relatively constant for an individual, 100% FFM recovery can only be achieved if more body fat is deposited, hence accentuating the phenomenon of fat overshooting. (p. 723)
In a nutshell: fat is restored first, but extreme hunger will continue until fat-free mass is restored. And because your body has a basic fixed proportion of fat to fat-free mass, this means you have to let your body gain more fat to finish off the process. The size of the overshoot may increase the more severe the preceding starvation was (Dulloo et al., 2017).
The other key physiological point to bear in mind is that natural or ideal bodyweight varies between individuals. There are powerful mechanisms by which the body maintains stability in weight: on the energy intake side, if bodyweight increases or decreases, intake of food will adjust down or up accordingly; on the energy expenditure side, an increase or decrease in bodyweight triggers a corresponding increase or decrease in resting metabolic rate. The concept of a ‘bodyweight set point’ (e.g. Keesey and Hirvonen, 1997) isn’t quite as straightforward as it may seem, since environmental factors can clearly contribute to the original set point being adjusted (to a medically problematic extent in obesity, for example), but broadly speaking this concept is highly relevant to our concerns when we’re thinking about recovery from anorexia, in two respects.
First, there is absolutely no reason to assume that your natural bodyweight is going to correspond to a BMI of exactly 20. Very few people's weight falls precisely on this numerical boundary, and because of the overshoot phenomenon, even if your natural BMI did happen to be exactly 20, that doesn’t mean you should force your weight gain to stop there - for the physiological reasons just set out, and for the obvious psychological reason (which I'll come back to in a moment) that dieting will never help recovery from anorexia. Because anorexia so often develops during the teenage years, there’s often no reliable benchmark available for pre-anorexia bodyweight, and in that case the only solution is to wait and see.
Anorexia doesn’t much like ‘wait and see’, least of all when it comes to food- and body-related things, but recovering fully requires that, at some point, we start accepting that we can’t predict or control everything. This may as well begin with one of the most important things in illness and recovery: how much you weigh. There is absolutely no way you will ever recover fully if you decide on a (for your body) arbitrary BMI like 20 and, once you reach it, start restricting again to make sure you stay there. Dieting is incompatible with recovery from anorexia, both physically and psychologically. This should be trivially obvious, but with all your anorexic instincts screaming at you not to lose control and let yourself get fat and ugly, it can be easy to forget.
Secondly, your metabolism won’t normalise until you reach your natural bodyweight (see my two detailed posts on this here and here). This means that when you get there (building in the overshoot factor), your metabolic rate will be ramped up to normal levels again, which will mean that you will be able to keep eating the same amount as was supporting weight gain, and you will not keep gaining forever. Your bodyweight will stabilise without restriction – but only if you let your weight increase to where it’s meant to be. Otherwise, your still lowered metabolism will force you to keep restricting to stabilise your weight. This is your choice to make. Either you diet indefinitely to keep your BMI at, say, 20, or you let it increase to, say, 26 in the short term without restricting, and stabilise at 26 then drop back down to, say 22 or 23 (as I did) over the following months and years. Which seems like the better option?
Even assuming you do the sensible thing and choose option 2 here, however, that of course doesn’t make everything automatically easy. One of anorexia’s most fundamental characteristics seems to be the combination of a high degree of insight and the complete inability to act on it. I explore it in the companion to this post, here, and it is is one of the main things that allow the illness to continue long after it’s been recognised, diagnosed, and accepted as destructive. The paralysis as regards action comes from the many physiological and psychological effects of starvation that act in concert to make weight gain seem impossible, from the shrunk stomach to the rigidly obsessive thought patterns, from the diminished self-esteem to the slowed metabolism. Even objectively positive things like the return of your period or your breasts, signs of a re-emergence of life and fertility, can induce panic because they seem to signal a loss of control, when in fact they denote the opposite: a brave and powerful wresting back of control from anorexia.
In any case, all the consequences of starvation, in combination with the specifically anorexic valuations of hunger, thinness, and deprivation as positive, mean that even tiny forays into eating more can be painful. I’ve described in my post on the physical effects of weight gain the kinds of challenges that are to be expected in the weight-gain phase, and they’re physically excruciating for some people, and mentally and emotionally frightening for everyone. But remember: 1) this pain is temporary, both the physical aspects of it and the psychosomatic and psychological aspects, and 2) every aspect of the pain is evidence of just how damaged your body and mind have been, and therefore how profound are these processes of repair and regeneration. Knowledge is power here, because it lets you know what to expect and how to interpret what’s happening, and above all, it reassures you that everything will pass. Life simply will not keep on being this bad forever, and in many cases, as for me, the improvements will be imminent, rapid, and profound.
For me, what let me keep going as my BMI crept up to 20 and beyond, and finally even beyond 25, was the conviction, now I’d come this far, that I wasn't going to do things by halves. By then I knew that there were no unanswered questions for me about anorexia any more: it had given me all the answers it could, and there was nothing left that I didn’t know about how life (and death) would be if I kept starving. And gradually I realised that I wanted now to get all the answers about getting better. I didn’t want to stop halfway and be forever wondering what might have happened if I hadn’t. I wanted to do this thing properly. This kind of determination may be quite potent, especially when combined with the defiance that comes from the fact that no one seems to think you could ever do it.
One day, exactly six months into recovery, I went to the eating-disorders clinic for my weekly appointment and weigh-in. My weight had gone up 3 kilos since the previous week, taking it well beyond the boundary of 20 BMI. My therapist and I talked through all the reasons why this couldn’t be ‘actual’ weight gain but must be due to fluid fluctuations caused by a recent cold and my period and so on, and I accepted those reasons, although that didn’t make the fear instantly subside. So that evening I wrote in an email to my soon-to-be partner of my ‘shock, fear, and disbelief’ at the numbers on the scales, but I also wrote about how ‘it is really remarkably wonderful to be safely within the healthy range, both in immediate terms and for the sake of my future’ and of how ‘even a month ago there were so many more rules and rigidities so firmly in place. I won’t let them come back now.’
This kind of ambivalence is absolutely natural; it’ll never feel unequivocally great to regain weight, but if you keep in mind the reasons why it’s a good thing, and the reasons why you don’t want to be ill any more (not even semi-ill), it will be bearable. And then at some point you’ll realise that it has stopped being just about bearable – and has stopped mattering. A diary entry five months later, in which I recorded a new weigh-in result that took my BMI to about 24, was full of a night out clubbing and my hangover and how ‘I use exclamation marks these days!’, and how ‘I have curves, and breasts, and I love them!’ (maybe I was actually still drunk). Right after that I stopped keeping a diary, and didn’t write another entry until a year later, because I felt I needed to stop recording for a while, and start experiencing. Life had crept back in, and so had my ability to love it, and things about myself.
I’m not saying it will definitely be like this for you, but I am saying that it’s much more likely to be than you think. And that there’s no reason why it shouldn’t be. Everyone thinks they must be the one person to be an exception to the rule, but the point is that it is a rule, and the exceptions are just that: rarities. Accepting this can be hard in itself: the illusion of specialness is one of anorexia’s most addictive deceits. And this illusion is doubly problematic: not only does the person with anorexia often assume that he or she won’t be able to adjust metabolically and in other ways to weight gain, he or she often also dreads, despises, and/or believes inaccessible the normality of having achieved a healthy weight. But the thing about normality is that it never feels as banal as it looks from the outside. The person recovering from anorexia sees, at least some of the time, the oversized people stuffing themselves in restaurants, or the lazy people watching TV in the evening instead of working; sees sheer ordinariness as an undifferentiated mass. But that vision is a misperception, and a failure of imagination. When you get there, normality doesn’t feel normal.
What is the ‘normality’ of being physically healthy again? It’s the secure and forgiving setting for unimagined pleasures great and small: the pleasures of idle daydreaming and focused thought, total relaxation and physical exploit, sensory exploration and social learning, undirected conversation and erotic intimacy. ‘Normality’ seems quite the wrong word for all this; maybe ‘health’ intimates it more easily. That isn’t to say it’s like this all the time: it’s difficult, boring, upsetting, scary some of the time too, of course. But then anorexia is those things most of the time, statically. The transition from anorexia to health is a privileged time: the excitements of normality can get lost in all the fear and uncertainty, but if you manage to let yourself enjoy them, they can delight you with all the intensity of their novelty, and help make the progress to full recovery self-sustaining.
And if all this seems a million miles away, as you battle with nausea and tummy fat and confused emotions and residual anxieties, and think to yourself ‘all this, and my BMI is still only 20!’, remember that it’s still bad because your BMI is only 20 and you’re not letting it go any further, and remember too that recovery isn’t a linear progression. Your body doesn’t start repairing the major organs or increase the metabolic rate straightaway: as I set out in this post, and as explained by Gwyneth Olwyn, fluid retention for cellular repair and the normalisation of liver and kidney function happens first, followed by fat deposits especially around the midsection to protect the vital organs, followed by major longer-term repairs and finally, as long as adequate energy remains available, by neuroendocrine and metabolic reversion to normal.
This order means that things like bloating and disproportionate sensations of fullness are bound to be bad to begin with, and that things like the extreme hunger get dramatically better only towards the very end – the end of the natural process, not the 'end' where your anorexia wants it to be. So if you feel you’ve simply lost all motivation to carry on, because still, despite all the enormous effort and trauma of getting your weight up to 19 or 20, nothing seems to be how you were told it would be, counter that apathy by reminding yourself the following.
1) You’ve experienced one or two of those shifts between the phases of recovery but not yet all of them.
2) Real recovery comes only once all those stages are completed.
And 3) they can all be completed only once bodyweight restoration with overshoot has occurred.
These truths may seem implacable, but their simplicity can be reassuring too: you know exactly what you have to do.
And what if there’s still that niggling little voice that says, well, surely this is the absolute best place to stop, isn’t it, because after all, this was what I was aiming for all along, wasn’t it, with anorexia, to be just at the nicely slim end of normal? There are a few ways of arguing that voice down.
1) Look where it got me, that ambition. That worked out brilliantly, didn’t it? I’ve just spent however many months clutching my way back from danger and misery. Why should it be any different second time round? Why shouldn't the definition of 'nice and slim' start to slip gently down to 19.5, to 19, to 18... just as it did before, till you're right back where you started?
2) The ‘low end of healthy’ (which, as I hope I’ve shown, is not a meaningful concept for an individual) may be where you always wanted to be, but it now gives you the worst of both worlds: you’re nowhere near thin enough for your anorexia, and at the same time you’re missing out on all the benefits of going all the way to what healthy actually means for you.
3) Your months or years of illness mean that you simply can’t think and act in relation to diet and weight and shape in the mildly disordered way that other people can ‘get away with’, if you want to be anything approaching healthy. This might seem a negative – now you can’t diet and control your weight as others do, because it’ll keep you ill – but actually it’s a massive positive: calorie-restricted dieting doesn’t work, and just because other people usually just don’t get quite bad enough to have to confront the reality of what constant dieting and body-dissatisfaction is doing to them mentally and physically, that doesn’t mean they’re happy or enviable. You can see through that now, and choose to do better.
You can’t predict everything about recovery, and that’s part of what makes it scary, because anorexia needs predictability. But you can predict most things, and that makes it scary too, because anorexia hates being predictable. Embrace the fear, though, and you will be rewarded, in beautiful ways both predictable and unpredictable.
Getting to EDNOS status and staying there is better than remaining trapped in anorexia, but because it is (or should be) a waystation on the journey of recovery, not the destination, it isn’t that much better. You deserve way more, whether or not you believe you do, or indeed believe that more is possible for you. You do, and it is. Looking back, you’ll kick yourself for not having called time on the limbo between sickness and health sooner, but then you’ll forget all about it, and get on with the complex business of living.
Thanks to Cheryl for requesting this post - suggestions are always welcome - and to all my readers for their consistently stimulating questions and their courageous sharing.
Dulloo, A.G., Jacquet, J., and Girardier, L. (1997). Poststarvation hyperphagia and body fat overshooting in humans: a role for feedback signals from lean and fat tissues. American Journal of Clinical Nutrition, 65(3), 717-723. Abstract here.
Dulloo, A.G., Jacquet, J., Miles-Chan, J.L, and Schutz, Y. (2017). Passive and active roles of fat-free mass in the control of energy intake and body composition regulation. European Journal of Clinical Nutrition, 71(3), 353-357. Full text here.
Kelsey, R.E., and Hirvonen, M.D. (1997). Body weight set-points: determination and adjustment. The Journal of Nutrition, 127(9), 1875S-1883S. Full text here.