Questions asked of us

 

 
 

Can you recommend any practitioners to help with my recovery?

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Support Links provide various organizations and associations in different countries that are hopefully a good starting point for finding appropriate care for your needs. In all likelihood you will simply have to shop around.

There have been community members who have happened upon very receptive doctors and dieticians to help them apply the Homeodynamic Recovery Method (HDRM) guidelines to achieve complete remission from an eating disorder. There have been many more community members who have had very resistant health care providers, although all of them are unable to provide the patient with evidence-based reasons for their reticence.

We are currently working on a health care provider approved list.

 

Have you personally had an eating disorder?

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The answer is no.

Did I try diets as a teenager? Of course, because I grew up in a fat-obsessed culture just like most of you.

The only difference between me and most of the folks visiting here is that I just happened not to have a genetic predisposition to develop harmful eating behaviors once I attempted to restrict calories. That's luck.

There are extremely successful and powerful women out there in the world who will tell you that their greatest achievement was losing weight (albeit not permanent weight loss). How on earth can we find a space for being more than two or three numbers on a scale when we are bombarded with that being the sum total of our value?

For some of you, it will be important to seek support from those who specifically have the same chronic condition as you, for others you might want the perspective of those who live completely outside that reality.

 

What are your credentials?

We get this a lot. There is a reason why we don't go into the stripes, badges and certificates and it is that they are absolutely and completely irrelevant to anyone in relation to seeking any information in an online setting.

 Credentials don't confirm competence or skill. Credentials are designed to ensure you have legal recourse when seeking health care guidance within a geographically-limited area. Therefore credentials that are much touted in online settings are disingenuous and misleading.

The upshot is that you, along with your family and in-person health care providers, need to review the material on this site and then make determinations on how you wish to proceed with your recovery efforts.

 
These are the common questions that include those with active eating disorders worried about mounting health concerns as well as those navigating recovery worried about new symptoms associated with re-feeding and resting.
 
 

I am weight restored but don't have a menstrual cycle. Is it ever coming back?

You are not weight restored if your menstrual cycle has not returned.

The absence of menstruation is called functional hypothalamic amenorrhea and the primary cause of this condition is being underweight relative to your body's optimal weight set point.

Continue to re-feed, allow your body to return to its optimal weight set point, and menstruation will return along with it.

However, the return of menstruation does not always indicate that you are at your body's optimal weight set point. The most telling marker of being at your body's optimal weight set point is that you can dependably eat in a completely unrestricted fashion and your weight remains stable.

 

Why do I feel worse now I'm eating more?

You may find yourself sleeping a lot more now that you are at the minimum guideline intake. You may find your hair is falling out in clumps. You may find you are struggling with quite a bit of gastrointestinal distress (gas, bloating, mild abdominal pain, acid reflux, constipation or diarrhea). You may develop acne or rashes. You may find you are dealing with night sweats, or hot flashes.

All these symptoms are occurring now because the body is working hard on repairing a lot of major physical and systems damage. Respond to your need to sleep more (but never in place of eating enough food). The hair is simply regenerating. The gastrointestinal issues subside as your body gets up to speed at producing adequate digestive enzymes and the bacterial colonies return to normal. The acne, rashes, night sweats an hot flashes are all the reproductive hormones getting back up to speed.

If you have any concerns about particular symptoms that are bothersome or don't seem to be improving over time, then see your doctor.

 

Is it normal to gain this much?

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It is normal to see an increase of 8-16 lbs. (3.6 to 7.3 kg) within days of starting to eat to the minimum guidelines every day. It is equally common to see 20-40 lbs. (9-18 kg) within 1-2 weeks. 

The increase is almost entirely attributable to water retention and it is necessary for cellular repair. Somewhere in the 4-6 week range the water retention starts to dissipate. That does not mean you lose weight (you are not looking to lose weight), it means that the water starts to be replaced by real weight restoration.

It takes 18 months to recover although you will not likely gain weight throughout that entire time period. From the time at which you begin weight restoration to the time at which your body weight stabilizes, the average per week weight gain is around 1-2 lbs (0.5 to 1 kg).

It is not a linear process and some weeks will be more and some less.

You stop gaining when you reach your body's optimal weight set point while eating more than minimum intake (because hunger should take you beyond minimum intake). You should stop weighing yourself and focus on getting the energy in that you need instead because stepping on the scales usually precipitates a relapse.

You may also experience a lot of bloating after meals and, to you, your stomach or abdomen region will appear huge. Again, this lessens as the weeks progress and you get further along in recovery.

 

What's with all the hair loss/brittleness/dryness/thinness?

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So here's how the hair loss thing works. There is a natural cycle of cell death and new cell production throughout our bodies and that includes the hair follicles.

The condition of telogen effluvium is when a large amount of hair loss is noticeable and it can be traced to a severe stressful condition about 3 months prior. In those conditions the patient's hair cycle is essentially fast-forwarded to early follicle death, rather than experiencing the usual prolonged growth phase and resting phase.

This is one way in which patients may experience hair loss while they are in fact in recovery -- it is a delayed response to starvation because the normal follicle growth and renewal process is running about 3 months after the stressful starvation period occurred.

However, patients may also experience an elongated catagen phase (the regressive phase of the follicle) during their starvation period. In this situation, the hair is not aging and falling out as it should normally (about 100 odd hairs a day). And in these cases the apoptosis (natural cell death) that the catagen phase is supposed to induce is halted. The body simply doesn't have enough energy to have the cells go through their natural process.

As soon as you begin refeeding, then the process of having the follicle die and the hair fall out can now proceed and there is a back log. In these cases you may have noticed your hair was becoming increasingly brittle and opaque during the restriction phase of your condition, but did not really note much increased hair loss (if any).

While of course it is distressing, it is not a permanent state and new healthy hair will replace the old in fairly short order.

The condition of hair is directly attributable to nutritional status and that is likely why "healthy-looking" hair is important in most societies as it reflects the evolutionary value of the individual as a mate.

If you want healthy-looking hair, then pursue your health with adequate re-feeding and rest.

 

What is a quasi-recovered state and why is it bad? Or not?

Quasi-recovery is a term I invented to describe the situation when a patient is no longer actively trying to eat less, lose weight, reach a target shape of some sort but they continue to create sub-clinical levels of energy deficits every day in their bodies.

A patient in quasi-recovery will have reduced the frequency or stopped compensatory behaviors (purging, extreme exertion, laxative abuse etc. etc.). He or she will have also increased food intake. For many non-scientific treatment programs for eating disorders these attributes are actually considered a process of full recovery. The patient is able to restore weight and once that weight is within 85% to 90% of an expected weight, then the patient will be discharged often to an outpatient program to continue "maintaining" that state.

When a patient eats only what someone with no energy deficit will require (or less) it's possible to restore weight, but not to repair damage. Metabolism remains suppressed because there is not enough energy coming in to reverse the energy deficit within the body.

A woman under the age of 25 needs at least 3000 calories a day on average to maintain her weight

The longer that a patient stays at a quasi-recovered state, the more efficient the body will become at shutting down non-essential biological functions to try to minimize the amount of catabolism (destroying cells to release energy into the blood stream) that has to occur to try to make up the energy deficit. Everybody's metabolic efficiency varies, but it is not unusual for a patient (after 20 years in a quasi-recovered state) to find herself gaining weight while eating 1200 calories a day. That is not a sign that she needs to cut back on her energy intake, but rather she needs to up her intake to allow her body to take the brakes off of all the biological functions that have had to be suppressed to keep going under energy deficit circumstances.

Fat is the largest hormone producing organ in the body. It is not a storage unit. Under stress (energy deficits are stressful to our body) stress hormones are released and while they have value for short-term survival, they cause damage when they flow more persistently and over months and years. That your fat organ gets larger when you are under stress. Your fat organ is having to get larger to produce more hormones to maintain some balance within a skewed metabolic state in the body.

For a body to maintain its natural optimal weight set point it has to be at its optimal metabolic state as well. For a patient with an eating disorder, to arrive at that state he or she has to take all the clamps off of eating and rest so that body can not just restore weight, but can actually heal and return to an optimal run rate as well.

"Quasi-recovery" is a comparatively better state to be in for the body than active restriction. However, physical damage is ongoing and still accumulating unless and until a patient decides to provide enough energy to reverse damage and return to an optimal state.

 

I can't eat this much! Is it normal to feel this full and nauseous?

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Yes it's normal. Not fun, but normal.

Quoting myself from Phases of Recovery from an Eating Disorder:

"For many patients in this phase they also have to overcome gastroparesis. [RW McCallum et. al., 1990]. Gastroparesis is a survival mechanism whereby the stomach doubles its emptying time to the small intestine, meaning the food is churned in the stomach for longer to try to allow for the small intestine to maximize the too-little energy coming in to the body.
Gastroparesis begins easing within a few days of doggedly staying at or above the minimum intake and it resolves quickly if you persist in eating the recovery guideline amounts, usually within a couple of weeks to a month. In fact the motility of the entire gut is slowed to try to extract as much energy as possible during starvation [M Hirakawa et. al., 1990] and this resolves during dedicated refeeding efforts.
Don't be tempted to lower the calorie intake because of the discomfort—just space the food out throughout the day. Yogurt with active cultures will be your best friend [C Coker Ross, 2008; E Nova et. al., 2006]"

The nausea will pass. Use heating pads or ice packs (whatever feels right) around the abdomen or cool cloths around the neck. Lie down and rest. Nibble on seeds and nuts to keep your intake up to minimum guidelines and then go back to eat more when the nausea, bloating and sensation of physical abdominal fullness eases just a bit.

It gets better as you persist with re-feeding.

 

Insomnia and I'm exhausted, what should I do?

Insomnia is common if you are not reaching the minimum guideline intake and/or if you are clamping down (restricting) when it comes to extreme hunger.

Either struggling to get to sleep or finding you are waking up and unable to get back to sleep are often indicators, when you are recovering from an eating disorder, of hunger.

As you up your daily intake you are liable to find your anxiety about food is ratcheting up as well. Eating disorders are inherently the misidentification of food as a threat. As a result you may be treating the minimum guidelines as your maximum and preventing your body from receiving the energy levels it actually requires during the recovery process.

Respond to insomnia with more food: up your daily intake until you find you are able to fall asleep and stay asleep, and if you find you are awake in the night, then get up and have a substantial snack (followed by upping the intake the next day).

Keep in mind that extreme hunger will take you far beyond minimum guideline intakes and that is normal and desired. Please read: 

Extreme Hunger I: What Is It?

Extreme Hunger II: Extremely Disturbing.

As you re-feed you are going to likely experience a heightened level of anxiety precisely because you are eating food rather than avoiding it. To alleviate this agitation somewhat, consider applying relaxation exercises, meditation and very slow yoga stretches throughout the day to help lower your stress levels and make sleep a bit easier to bring on as well.

 

Is this symptom (see list below) to be expected during recovery?

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Here are the usual suspects:

  1. Bloating (‘huge’ stomach), edema (water retention), swelling.
  2. Gastric and intestinal problems: gas, diarrhea, constipation, undigested food, abdominal pain, acid reflux, indigestion.
  3. Extreme fatigue: sleeping much more than usual, loss of energy.
  4. Brain fog: hard to remember or follow trains of thought.
  5. Skin sensations: tingling, burning, prickliness, numbness, itching, rashes. 
  6. Anxiety, paranoia, fear, depression, crying a lot.
  7. Hair falling out, dry and flaky skin, nail breakage.
  8. Orange colored skin (particularly palms of hands).
  9. Dizziness/heart beat issues: slow resting heart rate (bradycardia) or speeding heart rate while resting (tachycardia) or dizziness when going from lying to sitting or sitting to standing (orthostatic hypotension)*
  10. Cold when others are not, hot flushes, sweating and night sweats (drenching night attire and bedding).
  11. Aching joints, hips or leg pain.
  12. Fidgeting, restlessness, general agitation.
  13. Aching muscles (as if you had completed a strenuous workout).

* Damage to the heart muscle due to restrictive eating behaviors is reversible. However, if you have any of these symptoms at the start of recovery, then do not reintroduce exercise until cleared to do so by your medical advisor.

If any symptom causes you any concern, appears to be steadily worsening despite continued re-feeding and rest, or does not seem to be easing steadily as the weeks progress, then consult your physician.

However, the above list is a fairly comprehensive list of the common symptoms you can experience in the early phases of recovery from an eating disorder. All these symptoms are indicative of either damage that was done while restricting and/or signs that healing is underway. All these symptoms should steadily improve throughout the recovery process.

Please remember that you should never attempt refeeding from an eating disorder without medical supervision.

 

Is my metabolism permanently broken or damaged?

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No. No matter how you have restricted, in what ways you have restricted, for how long or how severely you have restricted, how many times you have reactively eaten, purged, abused laxatives, diuretics, compulsively exercised through injuries and exhaustion...your metabolism will return to normal if you pursue complete weight restoration.

Obviously if there are complex additional medical problems involved, then it will be for your physician to make the final determination on your metabolic state, but restrictive behaviors in and of themselves do not break metabolic function.

You need to eat no less than minimum guidelines every day to provide enough energy for weight restoration, physical repair, (maturation as applicable -- if under age 25) and then the metabolism returns to its optimal state.

Metabolic rate drops to keep you alive when you are not bringing in enough energy to support all the biological functions in your body. In fact, your metabolism is the opposite of broken -- it is doing exactly what it needs to do to keep you alive over the short term. If you restore the energy balance in your body, your metabolism restores to its optimal state along with that process.

 

Doesn't an overshoot in weight prove that these intake guidelines are too high?

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Although we cannot predict which patient will or will not temporarily overshoot his or her optimal weight set point during a recovery process from an eating disorder, we do seem to have some scientific evidence that an overshoot is necessary so that the body might eventually return to its optimal fat mass to fat-free mass ratio.

Abdul Dulloo and his colleagues carefully assessed the comprehensive data from the Minnesota Starvation Experiment [AG Dulloo et al., 1990, 1996, 1997 and 1998], and found that in re-feeding the body preferentially restores fat relative to lean tissue, contributed by reduced thermogenesis, to support further adipose organ restoration; that there appear to be distinct signalling mechanisms in re-feeding from both fat mass and fat-free mass to trigger hyperphagia (extreme eating); and that we can surmise from these findings that the return to an optimal fat mass to fat-free mass ratio will be curtailed should a patient fail to refeed fully and allow for a possible temporary overshoot in weight to occur.

Because a recovered state from self-imposed starvation in clinical trials often refers merely to a return to BMI 18.5 (rather than a cessation of all weight gain and weight stabilization as a result of unrestricted eating), we see a large body of literature that indicates many 'recovered' patients that fit the clinical criterion of BMI 18.5 have disproportionately high levels of visceral fat compared to lean (fat-free) mass [L Scalfi et al., 2002; M Helba et al., 2009; J Hebebrand et al., 2007; MT García de Álvaro et al., 2007].

All that science is important.

If you just restore to a specific weight either by half-restricting throughout the recovery process or as soon as you reach a "target weight", then you set yourself up for disproportionate layers of visceral fat. That is known to correlate with negative health implications for you over your lifetime. [MI Goran et al., 1999; T Cascella et al., 2002; JL Kuk et al., 2006]

Conversely, in the very few trials where recovery was identified with both extended inpatient and outpatient review and a criterion of "achieved maximum weight gain", then patients achieved average fat mass to fat-free mass ratios and returned to average gynoid (female) shape [CI Orphanidou et al., 1997].

Here's the deal: No one can predict your final optimal weight set point. It's unwise to assume anything about the process of recovery. While overshooting your optimal weight set point may occur, it may not. And it's probably even unwise to hope that, if you don't like the weight at which your body decides to settle in after several months of dedicated rest and re-feeding, you can simply await tapering to a weight you find acceptable, because that can simply keep you locked into eating disorder focus on your weight defining your very existence.

It's not the food intake or extreme hunger that causes a temporary overshoot in weight, it is the need for the body to restore its optimal fat mass to fat-free mass ratio that causes food intake and extreme hunger when recovering from persistent energy deficits in the body. 

 

But I have PCOS (polycystic ovarian syndrome)?

Misdiagnosis of polycystic ovarian syndrome (PCOS), which can include increased facial hair, weight gain and a lack of a regular menstrual cycle, is common in those with eating disorders.

PCOS should not be diagnosed in a patient with a co-existing eating disorder unless and until the patient is in a full remission.

If a patient is diagnosed with PCOS prior to the onset of an eating disorder, then she would need to have been older than about 21 or so at the time of the PCOS diagnosis because immature ovaries can lead to misdiagnosis prior to that age.

Clinical studies also suggest about a 50% rate of misdiagnosis for PCOS for a variety of clinical reasons. There is both a level of over-diagnosis and lack of reproducibility in the screening and clinical criteria used that suggest the entire condition is hard to identify and has many phenotypic variables.

"The data suggest that there is considerable uncertainty of all measurements and lack of clarity of the definition of the term 'hyperandrogenaemia' which can lead to misdiagnosis. The current diagnostic strategies for PCOS are defined too vaguely to ascertain that individuals fit the definition of the syndrome." [JH Barth et al., 2007]

These are all fancy ways of saying an "official" PCOS diagnosis should be approached with extreme skepticism.

Polycystic ovaries occur in several circumstances and do not require treatment. They are present quite naturally as the reproductive system matures in young girls from the ages of 12-18. They are also present for those with eating disorders as the reproductive system has atrophied. 

The facial hair growth indicates hyperandrogenism which, in the case of eating disorders, has more to do with the low levels of estradiol and other female reproductive hormone levels relative to androgen levels, rather than actual elevated levels of androgens.

These symptoms, when they are the result of restrictive eating behaviors, will resolve with rest and re-feeding.

 

What about bulimia or binge eating disorder?

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Bulimia? Yes you too.

Binges Are Not Binges

Binge Eating Disorder Part 1 and 2

Because the eating intake guidelines are set for energy-balanced folk who have never had an eating disorder, then they apply to everyone as a baseline. Bulimia is reinforced with restriction, not eating.

The more you attempt to restrict in response to "binges" the more you reinforce the cycle. Work on not restricting and use a counselor or therapist to help you address how panicked that might make you feel. Restriction is always the enemy for everyone. Even those who have no eating disorder at all.

 

Is the Eating Disorder Institute just for those with Anorexia Nervosa?

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No.

While the Diagnostic and Statistical Manual of Mental Illness distinguishes between anorexia, bulimia and binge eating disorder (not to mention all the various subtypes as well as ARFID and OSFED) the biological underpinnings are all one lone eating disorder spectrum.

Most commonly those who undergo cycles of restriction/reactive eating and or restriction/reactive eating and purging (bulimia) assume that because they are average or above average weight that the guidelines for recovery found on this site do not apply to them.

Unfortunately the reason that bulimics suffer lower remission rates than those with anorexia is two-fold: firstly there is usually a latent (hidden) period of restriction that may or may not have been identified by either the patient or her loved ones at the time, and secondly the health care communities have become as focused on the 'evils' of binges as their patients such that all focus on recovery is exclusive to the efforts to cease the binges and eat in a structured and patterned way (usually at an energy deficit level using non-scientific calorie intake guidelines for healthy adults).

62% of those who have anorexia develop bulimia within 8 years of the onset of the eating disorder if a full remisison eludes them in that time.

In cases where a patient has had a latent and long onset of an eating disorder: "Oh she was just a very athletic girl, but I didn't see her restrict food at all." (anorexia athletica onset), "Well, I became concerned with eating very healthy in my teens and cut out sugars and junk food, but I wasn't really dieting at all." (sub-clinical levels of restriction/orthorexia), the body is dealing with a cumulative deficit of energy perhaps for years before it gets to a point of desperation.

The onset of "binges" is actually the onset of reactive eating in all these cases. The body starts to push a lot harder to try to get you to eat sufficient amounts of food to try to rectify the damage and energy deficits. However, having practiced years of restrictive behaviors, that drive to eat enough triggers massive panic. At first the patient attempts to get back on her restrictive path after a reactive eating event. From there, when the reactive eating appears to be unstoppable and happens no matter what every few days, the patient will likely then resort to further anxiety modulation: laxative and diuretic abuse and purging in all its forms.

The enemy is restriction, not reactive eating. Eating to the Homeodynamic Recovery Method minimum guidelines provides clinically-confirmed food intakes that are needed to support total energy expenditure in people are energy balanced (age/height and sex matched variations are included in the guidelines). Just because you may be "weight restored", your body is still dealing with energy deficits and damage associated with those deficits as much when you cycle through restriction/reactive eating, as when you burn the energy away with excessive exercise, or when remove so many food groups from your diet that you are in both total energy and nutritional deficit.

 
Very specific common doubts and concerns associated with a recovery process.
 
 

It's just not normal to eat this much!

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Well, in fact the minimum recovery intake guidelines for the Homeodynamic Recovery Method are normal for everyone who doesn't have any history of an eating disorder. "Normal" for recovery is actually to eat more than the intake guidelines posted for HDRM.

You'll find explanations and references here:

Homeodynamic Recovery Method, Doubly-Labeled Water Method Trials and Temperament-Based Treatment

Binges Are Not Binges

I Need How Many Calories?!!

The amount of food needed to recover is not normal because the damage and energy deficit in your body is not normal. If you get by on two hours’ sleep every day this week, do you think you’ll just have a normal 8 hours on Saturday? Sleep deprivation is cumulative as is food deprivation.

 

Why hasn't my healthcare professional provided me with the guidelines you offer on this site?

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When this question gets asked, the person asking usually means one of 3 things to varying levels:

1) I don't trust or I question your sources;

2) I am uncomfortable with what your sources would recommend and/or

3) I have a trusting and personal relationship with my existing health care provider.

I don't have the answer to the overall question as to why your health care provider has not provided the same data and information, but I hope I can guide you through the process whereby you could arrive at an answer that most suits your needs and requirements.

Firstly, you are right to question all sources, in particular those you cannot verify in some way. You will find on this site a comprehensive, but by no means exhaustive, set of research references and books on which I have attempted to base all the assertions that I make regarding recovery from restrictive eating behaviors. I encourage you to review them and to take them to your health care professionals if you have more questions and want clarification.

Your health care practitioner may or may not have any specific education in the process of recovery and even if they are specifically offering services to support recovery, they may have been schooled in programs and processes that research has now proven are less effective than perhaps more recent approaches.

Tread carefully if you hope to educate your health care practitioner: some may be open to information provided by patients; others will not. On the other hand, do not remain with a practitioner that is not willing to partner with you in developing a recovery program that suits your needs and your understanding of your particular circumstance.

It is also true that your in-person professional health providers have the benefit of knowing your situation and circumstances in ways we cannot. They may be fully aware of all the relevant data and research but have decided to tread carefully with you to allow you to focus on your recovery in doable steps and stages. Just as all patients have distinct approaches, so too do health care providers. I know of many caring and highly skilled health care practitioners who prefer to maintain the role of "leader" in the care process because they have found it alleviates the patient's anxiety levels to do so.

Which brings me to the second reason behind asking me the above question: being uncomfortable with the actual recommendations within the research and information provided. If you sense that the information is correct, and you subsequently confirm it by doing your own research, then you can still be unwilling to accept it because it pushes too hard against all the reasons why you continue to apply eating behaviors that are self-harming.

It is alright to choose your own path and find health practitioners that can work with where you are at right now. These are complex, extremely complex, conditions and there is no one path to the end goal of replacing harmful eating behaviors with nurturing ones.

Finally, you may feel more of a personal relationship conflict when faced with data that you have confirmed is correct, want to embrace fully because you sense it is the path for you, and yet find your health care practitioner will not support the new direction at all.

Not wanting to "hurt" your health care provider is a common feeling. Wanting to trust them despite knowing their advice is not going to be right for you comes from an empathetic soul. You know that your health care provider has your best interests at heart and that s/he is well-trained and means to do the right thing. However, you have to come first.

In this case I encourage you to adopt a mindset that you might apply to health care providers taking care of a loved one: your child, parent or spouse (as examples). In those cases, you find it much less conflicting to apply a clear delineation that the health care provider is offering professional services. Should those services not suit the needs of your child or spouse, then you would be the first to seek second and third opinions.

Ask your own loved ones to support you in ensuring you do not continue to see any health care professional simply because you do not want to hurt his or her feelings.

The systemic aspects of metabolism, optimal weight set points, energy requirements, hunger and satiety are not understood fully by any of us, so it is more likely than not that your health care professional cannot provide you with all the data and information because no one has all the information yet.

If the information and data on this site is different than what you have received from your health care providers then that is likely because we are all the proverbial blind people describing the part of the elephant we happen to be touching. I hope the additional information serves you well in your pursuit of recovery working with the health care practitioners that are best at supporting your goals.

 

But I've heard you can permanently lower your body's set point?

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So yes it is possible, but not doable. The procedure is a parallel process to a lobotomy. About the only way in which a weight set point might permanently be changed is to create lesions in the hypothalamus (destroy brain tissue). 1 Such procedures have only be done on mice and rats in laboratory research.

Excerpt from Shields Up post on the topic:
“When we restrict calorie intake the body has a way to manage it, but it costs.
The energy deficit has to be addressed by filling the deficit from within the body itself. Most biological systems are run to an overdrive level with certain key clamps put on the system to keep it at an optimal state.
It is biologically more energy-intensive and risky to try to run a system right to 100% all the time than to run the system to 200% and just use a few hormones or enzymes to clamp it down to 100%. 
Our bodies are probably quite literally built to burn off excess energy in our sleep if there are any unneeded excesses.
But restrict your calories and now all of the limiting hormones like leptin, ghrelin and insulin and others are left scrambling because you have just dumped the entire metabolic system to well below its 100% functional level. Leptin is a clamping hormone. With nothing to clamp down on, it plummets in our blood streams and this creates a cascade of shut downs throughout the body.
We have evolved to overeat and maintain weight easily, in our sleep no less. We have evolved to survive some environmentally imposed under-eating as well, but not with the same ease and not without some heavy-duty damage for which we must account.
Some lizards can indeed drop their tails, when threatened, as a way to avoid a predator. “The loss of the tail (called autotomy)…is stressful to the lizard, especially if that lizard stores critical fat deposits in the tail, such as leopard geckos. Not only do they need to spend energy healing the stump and regrowing the tail, but the loss of fat may occur at a critical time, such as during gestation or a period of low food availability.” [M. Kaplan, 2002]
Think of dieting as autotomy for humans.”

1. Sjöström, Lars, Aila Rissanen, Teis Andersen, Mark Boldrin, Alain Golay, Hans PF Koppeschaar, Michel Krempf, and European Multicentre Orlistat Study Group. "Randomised placebo-controlled trial of orlistat for weight loss and prevention of weight regain in obese patients." The Lancet 352, no. 9123 (1998): 167-172.

 

I don't count calories so how can I be sure I'm eating enough?

Some find counting calories in recovery stressful and counterproductive to the whole recovery effort.

That's fine, but you still have to be sure you are getting the minimum intake because those with eating disorders are very prone to greatly overestimate their actual intake and you could be sliding back into progressive restriction and relapse if you rely entirely on "what I am hungry for".

The best alternative in recovery, when calorie counting is not suitable, is to create a meal plan and follow it. Ideally have a dietician or nutritionist draw up a meal plan that ensures you are getting the minimum+ intake recommended for your height, age and sex (Homeodynamic Recovery Method Guidelines).

Michelle is a Canadian accredited dietitian familiar with the Homeodynamic Recovery Method guidelines and she offers her services on line, for those of you interested.

You can also ask a family member or friend to help you come up with a suitable meal plan to follow. Then all you have to do is ensure you eat and check off everything on your daily meal plan to feel confident that you are not inadvertently restricting while attempting to recover.

However, "intuitive eating" is not an option for those pursing recovery.

 

Why should I believe in the intake guidelines listed on this site?

You shouldn't because it's not a matter of belief.

If you are dealing with the eating disorder spectrum (anorexia nervosa, restriction/reactive eating cycles, bulimia nervosa, orthorexia nervosa, binge eating disorder and/or anorexia athletica ) then you can also take a step back and think about what in the guidelines for recovery is really at issue from your own perspective.

Certainly there will be a lot of a noise and chatter in your mind from the anxiety over weight restoration, and you may even be very cognitively compromised due to starvation, but nonetheless there is a part of you that will sense that the guidelines are not set out to undermine your recovery, but to facilitate it.

The information provided here is set out to help guide your decisions and it is not meant to dictate solutions. No one here will compel you to do anything that simply does not sit right for you.

So review the references listed across the site and see what you think.

 

But I'm already at a 'healthy' BMI (and all things BMI).

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No one can assign you a specific goal weight, not even you.

Your body has an optimal weight set point and we all sit on a bell-shaped curve of a natural human weight range. You are only healthy at your body's specific optimal weight.

There is no such thing as a healthy body mass index range, although we have all been told it is 18.5 to 24.9. Sadly, there is absolutely no science behind suggesting that that range offers maximum health benefits.

In fact the science suggests it is actually BMI 25-30 that offers the lowest incidence of illness and death.

For clinical data on this topic, please review Obesity under Skrifa.

 

 

But do I really have an eating disorder?

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Check out the Telltale Dozen in Phases of Recovery from an Eating Disorder.

Usually I am asked this question because the person asking is not clinically underweight. However, 2/3 of those with active eating disorders are not clinically underweight, nor have they ever been.

There is also a common theme of "not being sick enough" that those with eating disorders seem to think delineates whether they need to recover or not.

You need to recover when the Telltale Dozen rings true for you.

 

What is the Homeodynamic Recovery Method (formerly MinnieMaud Guidelines)?

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Originally, MinnieMaud was the name chosen to reflect the basic elements of the recovery guidelines are set out as they are here on this site. "Minnie" is in reference to the Minnesota Starvation Experiment and "Maud" is in reference to family-based treatment protocols, often referred to as the Maudsley treatment program.

From there, we have decided to rename the program to be the Homeodynamic Recovery Method as it better reflects the 360° approach embedded within this model for achieving remission from an active eating disorder.

It is science-based because it stands on experimental data and not merely on empirical observation of individual practitioners.

The guidelines for daily food intake are based on doubly-labeled water method trials that confirm actual energy intake for both males and females of various ages with absolutely no history of eating disorders. In other words, the minimum amounts assigned for recovery are actually what non-restricting, non-eating-disordered people consume on average every day to maintain their weight and health. For more details please look out Papers under the heading Skrifa in the main menu above.

 
Food is where the misidentification of threat resides and so many questions around food are
common to all in recovery.
 
 

Is any kind of food addictive?

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No.

Food is not a drug and does not have a drug-effect on our bodies or minds -- not sugars, not ultra-processed foods, not fats, not carbohydrates, not any food you can name.

The concept that any type of food is addictive has no good science grounding that statement at all. Some neurological imaging has indicated that we release endocannabinoids when we consume ultra-processed foods, but we release those natural opioids when we eat pretty much anything we enjoy. I explain this fact usually using this example:

Referring to the natural release of endocannabinoids in our system as an addiction (because addictive substances bind to the same receptors) is like saying:

All babies drink some form of milk

Mrs. Jones nextdoor drinks some form of milk

Therefore Mrs. Jones is a baby.

It's called a faulty syllogism: If A=B and B=C then A must also equal C.

Drugs and alcohol are addictive in very specific neuro-chemical ways. They interfere with natural endocannabinoid release and reception. That sex can be classified as an addiction is contested within the neuroscientific communities for good reason—it is likely more biochemically related to OCD than to chemical dependencies that arise from the interference with natural opioid systems.

 

Are dietary fats and/or saturated fats bad?

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No.

Dietary fats are critical in recovery and shooting for 45% percent of your daily intake coming from fats (saturated equally critical) helps with specific healing requirements.

Myelin is a fatty covering on nerves that allows for fast and accurate conductance of electric signals. Not all nerves in our nervous system are myelinated, but those that are need to be for us to function well.

During starvation your body uses the myelin on your nerves as fuel to make up the energy deficit created by not eating enough to meet all your biological requirements. As the researcher Janice Russell has said, this is akin to throwing your antique furniture on the fire to keep the house warm -- it's going to work short term, but it has long term negative implications.

Not only does this de-myelination affect brain function, but it also impacts motor function, the dependable contraction of the heart muscle, etc. etc. It can mimic the symptoms of multiple sclerosis but it is not MS (I have seen patients misdiagnosed with MS who are on the eating disorder spectrum).

De-myelinated nerves due to restriction will be re-myelinated with adequate re-feeding and dietary fats play a critical role in that process. 

Under age 25 there is additional first-time myelination that needs to happen in the frontal lobes of the brain. If you starved between the ages of 16-25 then the natural myelination process in that area of the brain did not happen. And yes it happens at whatever time you are finally able to recover fully.

Dietary fats (saturated and unsaturated) are critical for helping your body to re-myelinate all the nerves.

Beyond recovery, dietary fats are critical for maintaining nerve health and supporting reproductive cycles (particularly in women).

 

But if I eat more I'll get fat.

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It's a possibility. However, if you eat more it's also a possibility that you might find you think more clearly; have more energy; stop thinking about food every waking moment; feel like smiling again; and generally might be able to pursue things that have real meaning and purpose to you.

Fatness is not correlated to eating more or inactivity. You'll need to review the posts found under Obesity for all the solid systematic review data that prove those points. But your fat organ needs to be whatever size it needs to be to support your metabolic functions. It's not in your control and part of pursuing remission will be working with a therapist or counselor who can help you address the fact that fearing getting fat is very likely getting in the way of your desire to live a fulfilling and meaningful life (however you define that meaning and purpose).

 

What about supplements?

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I address supplements in the Phases of Recovery from an Eating Disorder Part 3, 4 and 5

Food Fears 1: Food, Family and Fear

Zinc Supplementation for Eating Disorders

Extreme Hunger Part 2: The Experience and Science

Supplementation fundamentally means that 1) you are supplementing an otherwise unrestricted and average food intake and 2) your medical doctor has confirmed through screening that you are dealing with a specific deficit that will not be supported with average food intake alone. Supplementation doesn't mean replacement: i.e. supplements cannot replace food intake.

 

Still wanting 'junk' food/ultra-processed foods?

You will hear lots of things about others in recovery that will generate anxiety that you are somehow not trending as you should.

Quoting myself from Phases of Recovery from an Eating Disorder:

“Do not read the Phases of Recovery as though you are reading a recipe or following scientific steps that will realize unequivocal and successful results. Think of it as “individual mileage may vary.” 
Do not panic if you find some symptoms are not present, or seem to appear, disappear and re-appear. Your entire recovery process may take you into full remission in as little as 3 months or as long as 24 months. Three months is very, very rare and 18 months is the median time to remission, so be prepared to be patient.”

I sympathize with the impatience that everyone experiences through the recovery process, but try to remain realistic about how long the body really needs to repair all the damage.

Food, Family and Fear and I Need How Many Calories?!! can help reaffirm the fact that you need a lot of energy to re-balance the huge energy deficit you have in your body. A preference for ultra-processed foods is explained in the former blog post and the latter blog post provides the clinical data for why the minimum intakes are set as they are. 

What about liquid intake and thirst during recovery?

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As you up your caloric intake to re-feeding guideline amounts for your age, sex and height (keeping in mind that there should be medical oversight as you up your food intake of course), you may find you are quite thirsty.

Some of this thirst will be genuine and some of it might be anxiety-based responses to actual hunger cues. Either way, try to make your liquid intake always an energy dense choice.

Avoid drinking water, sodas, or fruit juices as these can fill you up and make getting to your intake guideline amounts difficult.

Choose ice-cream shakes, or fruit smoothies with whole-fat yogurt. Add nut or seed butters, bananas, and oils as well. One former member found freezing the bananas and then adding them into the blender with the rest of the fruit, whole fat yogurt and Nutella made for a really tasty blended drink.

If you notice symptoms of extreme thirst along with frequent urination and any accompanying changes in vision, then please see your doctor immediately. Insulin regulation in the early phases of re-feeding can sometimes be problematic, although it will almost always resolve with continued monitored re-feeding. 

Food intolerance? Likely Not.

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Food intolerances are huge topic which I will cover off in Tummy Troubles. A food intolerance does not involve an immune-mediated response to the food in question.

The most common food intolerance is of course lactose intolerance. Primary lactose intolerance is genetically determined and by the age of four, the body switches off lactase production (the enzyme that breaks down and digests lactose).

For most of Northern European decent, they have a genetic mutation that keeps lactase production switched on for life. These individuals can develop secondary lactose intolerance due to illness -- where the body is so stressed it cannot produce enough lactase to digest the lactose.

Secondary lactose intolerance is common for many who have eating disorders because, of course, starving creates tremendous stress on the body and eventually the organs responsible for producing all manner of digestive enzymes are too depleted of energy to pump out the necessary enzymes.

Secondary lactose intolerance resolves quickly with re-feeding. Lactose is present in creams, milks, ice-cream. However it is not present in most cheese and yogurts have enough lactase within them that most with secondary lactose intolerance have no issues consuming yogurt either. You can use digestive enzyme supplements such as Lactaid for the first couple of weeks in recovery until your body is able to produce its own lactase.

Many of the food "sensitivities" and "intolerances" that you either have determined you have (due to physical symptoms after consumption), or have been diagnosed in you by various questionable screening tests, are most likely a reflection of a stressed digestive system unable to produce sufficient digestive enzymes to support comfortable digestion.

So the catch-22 is that in order to resolve the difficulty you may have digesting certain foods, you must eat more food to provide the energy to digest the food.

 

Common misunderstandings and issues around what signifies "remission" from an eating disorder.

 
 

When can I start exercising again?

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The resumption of a regular period or returning to a pre-eating disorder weight in no way tells us that someone is energy balanced just yet. While they are great signs that things are moving in the right direction, remission is actually a lifelong practice and not an end-state.

You are liable to simply shift your eating disorder from to anorexia athletica if you reintroduce exercise. Please re-read Phases of Recovery from an Eating Disorder as well as Exercise II: Insidious Activity to understand why the resumption of exercise has tremendous pitfalls and problems for those with eating disorders.

Many with a history of an eating disorder will rationalize that exercise had "nothing to do with the eating disorder" and that it's not about "restriction," plus it's so health protective and is a necessary addition to longevity and health. The health protective benefits of regular exercise are largely cultural platitudes and the science doesn't really support the construct.

Another post on the topic: Exercise III: Athletes, the Picture of Health

 

When can I start eating to hunger cues again?

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Be careful on this one. Many attempt to eat to their hunger cues as soon as they have had three consecutive periods (women obviously) and often it is far too soon to trust hunger cues.

Your hunger cues are always accurate, but those with an eating disorder have what I call a "signal jamming" issue in their brain such that they are torn between responding to hunger and avoiding the perceived threat (namely eating). It takes a lot of non-restrictive practice before you can be sure your hunger cues are coming through to you loud and clear.

Here is how you know you are ready to attempt eating to your hunger cues:

  1. Your weight appears stable. (weighing yourself is not necessary to determine that).
  2. If you have dealt with amenorrhea during your restriction, then you have achieved 3 consecutive periods in a row.
  3. You are continuing to eat minimum amounts and it is comfortable to do so.
  4. Other lingering signs of repair seem complete (no longer cold, tired, achy, dealing with water retention, no brittle hair or nails etc.)
  5. You think you may need to start eating to hunger cues and are a bit anxious that you can trust those cues.

Note Item 5—if you are feeling extremely confident about eating to hunger cues then chances are you are a ways away from remission still.

[from Phases of Recovery from an Eating Disorder]

You should really be comfortable that you have covered off all 5 items on that list, not just item 2, before you attempt to eat to hunger cues.

When you think you might be ready, you log your food intake for 3 days while eating entirely to your hunger. After the 3 days, you tally up the calorie intake for each of those days. If you are averaging the minimum guideline amounts for your age, sex and height, then you can feel fairly confident that you will be able to use your hunger cues to stay in remission from that point forward.

 

I am weight restored by my period hasn't returned, is it ever coming back?

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Menstrual cycles feature prominently in recovery programs despite the fact that their presence or absence is a) irrelevant for males and post-menopausal women and b) has been removed from any Diagnostic and Statistical Manual of Mental Disorders classifications of eating disorders precisely because menstruation is a poor marker of health (although its absence signifies ill health; its presence doesn't signify health).

The second problem is that "weight restored" has no significance because weight restoration is only reflected when unrestricted eating is occurring all the time and weight has stabilized as a result. Usually "weight restored" for those with a history of eating disorders continues to involve food restriction and/or energy deficits through exertion relative to food intake (exercise and other compensatory behaviors).

The first line of resolution is to eat without restriction and seek out psychotherapeutic support to address anxiety for doing so and the second line of investigation would be to discuss the situation further with your medical doctor.