If you missed the introductory page, click here. The set up of the pages on this wordpress theme makes it a little difficult to navigate sometimes!
Because I get questions about the physical aspects of recovery so often, I did feel like it might be useful to include numbers in the discussions of meal plans and target weights. I have not referred to numbers around weight or intake on any other page in the DIY section, so if you don’t feel that it will help your recovery to read this, please feel free to move on to the next page.
On this page:
Issues around target weight
Meal plans and calories
Recovering from a low weight without going IP is risky. You NEED medical supervision – at the very least see your GP for frequent blood tests, because eating disorders can cause very serious health problems and have the highest fatality rate of any mental illness. Having said this, it is still often possible to recover at home – I gained almost 40lbs under my own steam. Other friends of mine started at even lower weights than I but still regained their health without going IP. This isn’t justification for losing another 5/10/15/etc pounds before you start trying to get better though, because the longer you leave it and the more unwell you are, the harder it gets physically and mentally. You can be malnourished at any weight – even overweight people can end up with dangerous nutritional deficiencies if they go on very low calorie diets. As well as decimating your immune system, causing osteoporosis and eventually leading to organ failure, eating disorders affect your cognitive function. At a certain degree of weight loss or intensity of behaviours it will become virtually impossible for you to turn things around by yourself, because you won’t be able to think clearly enough. The brains of anorexics literally shrink – not surprising, considering that brains are 60-70% fat. Even a year after starting to gain weight my memory is full of holes and I find it very hard to concentrate when reading or studying. Most damage caused by eating disorders is reversible though. I know women who have gotten their period back after years without them, others whose bone density has returned to normal after being in the osteopenic or even osteoporotic range – bodies are wonderful at healing if they are allowed to. This is the way I started trying to heal mine.
Issues around target weight
Everyone seems to want a definite target weight in their mind when they start recovering. I based mine on research I had read that suggested that recovering anorexics who get to a BMI of 20+ have much lower relapse rates than those who stop gaining before then. If you are a Caucasian woman over the age of 18 is it very unlikely that your set point weight would be lower than a BMI of 20, however much you would like it to be! Stopping right on the border of the underweight range also means that every time you got a stomach bug or had a couple of stressful weeks, you would be at risk for slipping back into an anorexic weight range. I know it seems counterintuitive – you would think that stopping at a lower weight would make you feel safer and less likely to relapse, right? Wrong. Stopping at a lower weight means you are most likely listening to your anorexia rather than doing what’s genuinely in your best interests, and hanging on to your eating disorder is mutually exclusive with full recovery.
Research studies have also shown that getting to a healthy weight can DECREASE the intensity of eating disordered thoughts and behavioural urges. This is because of how eating disorders affect the brain. Your fear of being a normal weight is, in part, a biological symptom of the eating disorder. Once you are weight restored your brain chemistry and hormones start getting back to normal (this can take a couple of years) and all of the difficulties caused by the biological effects of malnutrition start to dissipate. Obviously most people with eating disorders have emotional triggers as well, but you can’t work on them until you are healthy enough for the biological symptoms to have abated. For example, when I was underweight I couldn’t see what I looked like at all. I didn’t think I looked fat, but I couldn’t see how ill I was either. Now I can see myself quite accurately most of the time. I don’t look much different in my eyes to how I thought I looked at my lowest! My perception was warped at lower weights and I couldn’t see myself properly. I haven’t worked on this in therapy, it’s just sorted itself out naturally.
The other big change is that I don’t obsess about food anymore. When I was very ill I thought about food all the time. I collected recipes, watched cookery programmes, counted down the minutes until I could eat next, panicked if I wasn’t at home when I usually ate. There was no room for anything in my head other than food. This is a biological symptom, caused by malnutrition. It continued until I got my periods back at a BMI of 18. These days I enjoy eating, but you couldn’t get me to sit through an episode of Masterchef if you paid me 😛 and I have started to rediscover my old interests, like music and art as well. It’s wonderful to be able to concentrate on and enjoy things that are entirely unrelated to food again. Again, I did no work on this in therapy, it just stopped like magic when my periods came back. It doesn’t work like that for everyone – it takes more time for some people and less for others – but regardless, being at a healthy weight is the starting point for changing this. Reading about the Minnesota Study is a good basis for understanding the biological effects of malnutrition.
Another thing to consider when setting a target weight is that weight fluctuates – having a target weight RANGE is less stressful than heading for a specific number. I chose to maintain between BMI 20-21. BMI is a flawed system, yes, but I have been ill since I was 13 so I have no other way of working out what a healthy weight would be for me. Don’t make the mistake of thinking that your pre-ED weight has to be a good target either. People are not supposed to weigh the same as they did during their adolescence for their entire lives. The BMI associated with lowest mortality at the age of 20 is about 20, but by the age of 70 those with the least risk of dying have BMIs around 26-27. Also, although getting your periods back is essential, menstruation is not necessarily a good indicator of health. I have friends who get their periods at anywhere down to a BMI of 14, which is clearly not their set point!
Meal plans and calories
It is quite common for someone in recovery from an eating disorder to need anywhere from 2500-6000kcals a day to gain weight consistently. I increased slowly at first – my original plan was to increase by a couple of hundred calories once a week – but that wasn’t quick enough. My metabolism sped up quicker than I increased! Having gained nothing by the time I’d got up to 1200kcals a day I doubled my intake and gained 3.5lbs in a week. This is normal if you increase by a lot, but if you see weight jumps after an increase of a few hundred it’s more likely to be the replenishment of glycogen stores (water weight, as glycogen binds to water) and only one or two of those pounds will be permanent. Be aware of the existence of refeeding syndrome, but it’s unlikely that you will develop it from increasing by a few hundred every few days. After the first week or two, I gained about a pound a week on 2600-3000kcals a day, and I was almost entirely sedentary. I am 5’5, but I know people a few inches shorter than me who needed upwards of 4000kcals a day to gain on bedrest, so my metabolism was not exactly hardcore! I ate six times a day, three meals and three snacks, and stuck to roughly the same amounts at the same times. A typical day would have gone something like this (note – I’m allergic to milk, not scared of dairy!):
8am: rice porridge with rice milk and nut butter (400kcals)
10am: cereal bar (200kcals)
12pm: jacket potato, baked beans, vegan margarine, salad, chocolate bar (700kcals)
3pm: banana and peanut butter (200kcals)
5pm: gluten free wrap, tofu, red pepper, mushrooms, pumpkin seed butter and tomato puree, gluten free chocolate muffin (800kcals)
8pm: bowl of cereal and rice milk (300kcals)
Before bed: a couple of biscuits or another cereal bar (200kcals)
I kept breakfasts quite light (I love that my ‘light’ breakfast is 400kcals, considering what I used to exist on when I was ill…) because I have digestive problems and often feel quite sick in the mornings, but I’ve known others to eat upwards of 1000kcals when they get up, so it’s entirely down to personal preference how you organise things.
Now, I maintain my weight through intuitive eating, but when I do tally up the calories they might be anywhere between 2000-3000kcals a day, and again, I’m not very active. For example, yesterday I sat on my butt all day working on a physics assignment, and I ate:
9am: pancake with vegan chocolate spread! It was Shrove Tuesday 😉 (450kcals)
12.30pm: gluten free pasta with beans and veg, piece of millionnaire’s shortbread (600kcals)
3pm: gluten free biscuit, blood orange (200kcals)
5pm: sweet potato fries, homemade bean burger, sweetcorn, dark chocolate (800kcals)
9.30pm: rice cakes with cashew butter (200kcals)
I base the composition of my meals around the structure of the day programme I attended a couple of years ago. A serving of carbohydrate was something like 200g potatoes, two slices of bread or 60-70g dry weight rice/pasta. A serving of protein containing food was also about 200g and had to provide 10-14g protein, so in my case that would be 200g beans/chickpeas/tofu or 2 eggs. Our meals also had to contain fat, for example some olive oil in a pasta bake, spread on bread or nuts/seeds for fat and something else for protein. Then we could have one or two different types of vegetables and dessert afterwards. We were encouraged NOT to eat high fibre, high volume, low calorie density foods. If you haven’t been eating much for months or years and suddenly start trying to eat 2500kcals a day worth of whole grains and vegetables you will be in a lot of pain! In particular, getting enough fat is essential to restoring hormonal balance and cognitive function. Beware of developing orthorexia, an obsession with eating as healthily as possible. Although that doesn’t sound like it could possibly be dangerous, people can take ‘healthy’ eating to extremes and end up dangerously underweight and malnourished. I really didn’t want to switch from one disorder to another so I made myself face foods that scared me from day one. And starting to eating desserts again did not make my blood sugar fluctuate wildly or leave me hungry before my next meal/snack as long as I ate them after meals.
One final point on meal plans is intuitive eating. A lot of people seem to want to try this very early on in recovery, and it’s just not a good idea if you’re trying to gain weight. Eating disorders mess up natural hunger signals, and it can take years after recovery for them to return. If you try to move to intuitive eating too soon you will probably find yourself restricting, because a lot of people with anorexia forget what stomach hunger feels like. If I only ate when I was hungry from the start I would never have gotten to my target weight! Following a meal plan now does not mean that you will never be able to eat intuitively, it actually helps you get to that point in the long term, but you need to be thinking in terms of years rather than months. You didn’t get sick in a week and you won’t recover in a week, but you CAN recover, and with any luck one day you will be back in touch with your body to enough of an extent that you will be able to forget about calories or exchanges and eat intuitively. I can do this now, but it took me a full year to get to that point.
It is generally advised that you DON’T exercise until you are at a healthy weight. Seriously. It does far more harm than good – your body won’t build muscle or strength while you are underweight, exercising will just cause further damage. Overstressing your body weakens your immune system, can lead to organ damage and heart problems and if you are unwell you will also be at far more risk of serious musculoskeletal injuries. I’ve included more about exercising in the behavioural section.
A lot of people with eating disorders say that moving to maintaining their weight is harder than losing or gaining, because they have a lot of experience with the latter two but can’t get their head around the concept that it is possible to be at one weight without using eating disordered behaviours to stay there. Many people with anorexia worry that they will need to restrict to maintain their target weight. Long term, if your target weight is too low, you might need to eat less than you would at a healthy weight, but to begin with people gaining from a low weight often need more than the ‘average’ person when they start to maintain. As I mentioned, my weight remains the same on a daily intake of anywhere between 2000-3000kcals, and I don’t do much in the way of exercise – I walk for purpose (to work) and pleasure (along the coast), but that’s about it.
Theoretically speaking, it takes about 500kcals extra every DAY to gain one pound a WEEK – a grand total of 3500kcals over maintenence. So in my case, I gained on 2700-2800 and began to maintain on around 2200-2400 a day. I didn’t cut all of that out in one go or I would have been very hungry and at risk of relapse – drastic intake changes are not a good idea in recovery. I cut maybe 300kcals out of my daily intake over a period of about a month after I got my period back, and continued to gain more slowly at about half a pound a week. A month or so later I got depressed, lost another couple of hundred calories a day by accident and started maintaining at a BMI of 19-19.5, then didn’t bother pushing it when I started feeling better again. Around Christmas I decided I’d had enough messing around, put those 2-300kcals back in for about six weeks, and gained the last 3lbs to my target. Then I reversed the process again slowly, back down to my former intake. Later on I gave up on calorie counting and moved to intuitive eating – more is included on this in the post-weight restoration section.
One thing that seems quite common is that people have a really hard time coping with weight fluctuations when maintaining. In 2008 when I was trying to recover I stopped gaining at too low a weight, began trying to maintain, and every time my weight fluctuated by as much as half a pound upwards I would panic and cut my calories. Of course, when I lost weight I wouldn’t add them back in, and I relapsed really quickly. This time around I set myself a target weight range rather than a target weight, the lower end of which was 10lbs higher than in 2008. I got there in January 2010 and at first I freaked out when my weight bounced around a bit. But I was determined to think of the long term, not what was happening week by week. If my weight went up, usually it was something hormone related and it would be back where it was the week after. The thing I kept forcing into my head is that the bottom of my target weight range is not an upwards limit, it’s a downwards limit. I need to stay above it to give myself the best chance of staying recovered, but I would still be at a perfectly healthy weight for my height if I weighed 20lbs more than I do now. I don’t intend on purposefully gaining more weight, but if my set point turns out to be another 5 or 10lbs higher than I am now, that is just something I will have to deal with. Eighteen months after reaching weight restoration, I weigh myself once every 6 weeks or so.
The concept of a set point is also quite difficult to get your head around if your weight has been dictated by eating disordered behaviours for years. I have no idea what mine should be because I’ve had an eating disorder since I was 13, well before I would have reached my adult weight. My plan over the next few years is to absolutely forbid myself to lower my calorie intake to below 2000kcals a day, even if I gain more weight on that (unlikely, but I needed to really cement this rule in my head when I started planning my maintenence). I have to point out that this is NOT the way you determine your set point if you are underweight. If you are underweight and trying to gain, you will most likely need more calories than this because your body will be using more energy to repair the damage done by the eating disorder, your hormone levels will be fluctuating and for various other unknown reasons the metabolisms of recovering anorexics are usually faster than the average person while they are gaining weight. It would be quite possible for some people to maintain a much lower than healthy weight on 2000kcals a day if they had gained up from even lower, but that does not mean that this is their natural weight. They would still be at the risk of osteoporosis (whether they get their periods or not, underweight people are more at risk of the condition) and all the other health problems associated with eating disorders, plus the cognitive, behavioural and psychological effects of being underweight like being obsessed with food, having urges to binge and purge, finding it difficult to concentrate, depression and being generally emotionally flat. Finding your natural weight will be a bit of a minefield, but in my view the starting point must be a medically healthy weight, otherwise you will be running the risk of relapse.
They definitely deserve their own topic! Not all women lose their periods when they are ill, but many do. I lost mine for two years and now have osteopenia, the precursor to osteoporosis. The best way to reverse the loss of bone density is to get to a healthy weight. However, getting your periods back can’t be taken as a sign that you are definitely at a healthy weight, because many women get them when they are very underweight, and if you stay underweight you will still be at a higher risk than the general population for osteoporosis and other related health problems, periods or not.
Hormonal changes in recovery can be very difficult to deal with. Some of that topic belongs in the page about emotional aspects of recovery, but one important issue is the biological effect that hormones have on your mood. If you did go through puberty before your eating disorder started you might remember what it was like. It’s not an awful lot different as an adult! A lot of people in recovery have a really hard time with mood swings. PMS can make the most stable woman feel crazy, so trying to deal with that when you’re already fighting a serious mental health problem is a bit of a nightmare. This varies person to person so don’t worry too much, you might not have much of a problem at all. However, it is pretty common for people whose hormones do give them a hard time to blame weight restoration for their mood swings, and to start believing that they will never cope with life at a healthy weight. I believed that myself for a long time – when I tried getting back to a healthy weight in 2008, I got my period back once and relapsed pretty much immediately because PMS made me feel so completely crazy. Part of that was just that I had been numb while I was ill, so I didn’t really have any experience of tolerating such intense emotional distress without abusing food or self harming. The other part was entirely genuine, because hormones can give you hell. The good news is that for most people this does seem to calm down. This time around in recovery I have forced myself to deal with the crazy period, and after I’d suffered the mood swings for about six months they began to even out. Eighteen months on, my hormones don’t have that big an effect on my mood 🙂
Of course, some people do have comorbid mood and anxiety disorders which spring up again when they are no longer using eating disordered behaviours. I have OCD, PTSD and I suffered from depression from the age of 11-23. However, the way I look at this now is that if I stayed ill I would only be masking these problems, and I would have no chance of genuine recovery from them because of the way eating disorders affect cognitive function, brain chemistry and emotional experience. Now I’m healthy I have a much better chance of dealing with the trauma related issues, and I have more physical and psychological resources to cope with bad days.
Brain chemistry, hormone levels and weight distribution can all take two or more years after weight restoration to get back to normal. You might gain weight unevenly at first and this can be distressing, but it is only because your body is trying to restore vital fat levels around your internal organs first to protect them. This might be a little surprising because everything you read in the media suggests that fat is the enemy, but actually some level of body fat is essential to the continuation of life. In medical terms body fat consists of two types: essential and storage. Essential body fat is the level below which health will be drastically affected, 10-12% in women and 3-5% in men. Storage body fat helps to protect organs in the chest and abdomen. Values for healthy body fat percentage vary depending on the source, but are typically quoted as 18-30% for women and 8-20% for men. Fat is a scary topic for people with eating disorders, but it’s important to realise that having fat on your body doesn’t mean you are fat – it is necessary for survival. The weight gain will become more evenly distributed after a while if you maintain a healthy weight.