RECOVERY REVOLUTION

TEMPORARY AND LONG TERM PHYSICAL CHANGES TO EXPECT IN YOUR RECOVERY; 

 THE PHASES OF RECOVERY

There are three distinct phases and one critical final phase for complete weight recovery and here's a bit of what to expect.

Yes, you can experience symptoms of multiple phases at once and you can seem to progress from one phase to the next and then, for no apparent reason, seem to back track. That’s all normal and not cause for concern.

Remember the body is not a machine but it knows what it is doing as long as you are providing the energy and resting.

And finally, please keep in mind that no one (absolutely no one) sails through this process with no slips or problems. Whenever you slip back into more restrictive behaviors you have not failed. Instead you must treat the experience as an opportunity to learn more about what are your specific triggers that cause relapse—that will make for a far more resilient remission in the end.

KATELYN FAY: FLICKR.COM

Phase I—edema.

Water Onboard

The body seems to gain 7-16 lbs. (sometimes more than that) in the first couple of days or weeks when you get to re-feeding amounts for your age/sex/height.

Someone not prepared for this will panic and restrict before she gets too far along. The "weight" almost exclusively water retention (edema). The body needs the water for cellular repair and the normalization of both liver and kidney functions [WB Salt, 2004; GFM Russell, JT Bruce, 1990].

The water retention dissipates past the second month, but only if the patient is reliably eating to the minimum guidelines or more every single day.

Very rarely, extreme edema (most pronounced on hands and feet) is one of several symptoms of refeeding syndrome. It is one of the many important reasons why medical supervision is a necessity in the early phases of refeeding.

Further details on water retention are available in this blog post: Edema: The Bane (and Blessing) of the Recovery Process. 

One of the tenets of the MinnieMaud treatment approach is to stop weighing yourself at all. You will find the Your Eatopia Forums strewn with panicked ED-driven meltdowns after someone in recovery has succumbed to stepping on a scale.

The scales are one of the eating disorder’s most favorite of torture implements that it gets to use on you to generate an easy relapse. Do not give it the satisfaction.

Digestive Distress

Digestive distress is common in this first phase: bloating, gas, pain and abdominal distention, diarrhea or constipation. You can alleviate this a bit by eating smaller amounts more constantly throughout the day: 200-250 calorie increments from the moment you get up until you go to bed.

This digestive distress occurs because starvation has drastically reduced all the critical bacteria in your gut as well as all your digestive enzyme levels. In order for the bacteria to recolonize to acceptable levels they need the energy in. [MD McCue, 2012; PD Cani et. al. 2007]

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]

If you could tolerate lactose before the restrictive eating disorder took hold, then you will again once recovered. However, many patients in recovery can experience transient, otherwise known as secondary, lactose intolerance. This is because the system is so stressed that it can no longer reliably produce lactase to break down the lactose. If you find having milk, cream and ice cream cause bloating and diarrhea, then replace them with soy and rice options or ideally use a lactase supplement (such as Lactaid). Do not have any low-fat or non-fat options for any foods in your home.

Also, while dehydrated in the early phases, resist the urge to drink lots of water. You will get adequate hydration if you eat to the recovery guidelines. If you do have drinks, make sure they are full of calories. So instead of sodas, it's ice cream shakes and fruit smoothies with full fat yogurts and extra oil and nut butters too.

Coffee tends to increase gut motility (that means moving things faster through the colon) [SR Brown et. al., 1990; PJ Boekema et. al., 2000] and this is usually not an issue as most have very slow gut motility due to starvation. However, do limit coffee intake to one or two cups a day and make sure they are loaded with creams and sugars to focus on getting food in the system.

Pain

Edema, water retention, causes a considerable amount of aching throughout the body. You may feel very sore all over.

When you twist your ankle and it swells with fluid, heats up and hurts, that is the healing process at work. In recovery, the process is happening on a body-wide scale. Pain forces us to stop and rest. That subsequently allows for the body to deal with whisking away all the damaged cells and providing energy for the development of new, healthy cells without having to deal with new damage all the time as you “push through the pain”.

Those of you who applied excessive exercise, purging, diuretic or laxative abuse when you were actively restricting, will likely experience more swelling and pain in this phase of recovery.

Rest

Many of you will feel like you have been hit by a freight train’s worth of exhaustion and tiredness. You will find this confusing because you were “so energetic” during active restriction and now that you are really working on recovery you just want to flop and sleep.

As mentioned in the previous section, there is marked hyperactivity during active starvation for those on the restrictive eating disorder spectrum.

In the throes of restriction, you have a very effective "signal jammer". Basically your brain is not able to really receive and interpret all the distress signals from your body. This is why non-ED people feel horrible when they starve and yet eating-disordered people initially feel energized, calm, dissociated from bad feelings etc. There are marked neurotransmitter anomalies that appear to have something to do with it and they occur in various emotional centers in the brain, specifically those responsible for threat identification.

It is a good sign if you are exhausted because it suggests your body is finally able to communicate its needs for recuperation and energy in a way that was not happening during active restriction.

No Exercise

Removing workouts and exercise from your regime tend to be more difficult than increasing food intake for many. It is a common question as to why it is necessary and can’t one just consume enough energy to support the expenditure of energy.

Most will profess that their exercise regime has nothing to do with restriction and that it is merely for all the mood-modulating benefits that exercise will provide.

Yah, no. Mood-modulating benefits can be achieved through simply sitting outside and the mood-modulating benefits of exercise are far from scientifically definitive as well.

Furthermore, because you do not have a mechanistic body you cannot actually magically consume enough energy to necessarily support expenditures because the body is conservative and cautious when it comes to how it chooses to use energy intake. In other words, even if you doubled your intake that may not result in your body being comfortable assigning energy to repairs and weight restoration because the cortisol levels suggest the body is under stress and therefore the energy should be socked away in case.

Just stopping exercise will be highly anxiety-provoking and that is why an approach of “replace and distract” is recommended by experts in the field of exercise dependency:

There is plenty of clinical evidence that there seems to be no way to return a woman who is on the Female Athlete Triad (inadequate energy intake, amenorrhea (lack of a regular menstrual cycle) and bone density de-mineralization) back to a regular menstrual cycle with adequate bone re-mineralization without having her cease all activity. No matter how much we increase the intake, or change the timing to try to negate any energy deficit, nothing happens until she is usually injured out and the forced rest reverses the situation [DL Wiggins et.al., 1997; R Olyai et. al. 2009; NH Golden 2007].

I also have my own direct experience with patients with this condition. One in particular spent 5 months trying to increase her intake to have her period return regularly (she was weight restored after a long intermittent history with anorexia, then bulimia, then anorexia athletica). Within one month of finally hanging up the running shoes, her period returned with no additional weight gain at that point (she was already BMI 23).

There is nothing wrong with taking this in steps, but essentially you have to keep focused on replace and distract while getting to the minimum daily intake every single day. Once you get there, then you have actually started a full recovery process.

So, replace and distract.

If you workout in the morning, that is easily replaced with sleep. If you set your alarm to do those aerobics sessions, then set the alarm later and then continue with your morning routine minus the workout.

For some, that morning session provides some grounding—in that case, still set the alarm, but do slow yoga stretching, or mindfulness exercises, breathing exercises, or just sitting quietly in the kitchen with a nice mug of something hot (and ideally full of calories too!).

Others have to also include distraction because the eating disorder ratchets up the anxiety when you don't follow through on restrictive behaviours. Have family breakfasts. Set up mid-morning get-togethers with a friend for a coffee and a muffin.

Enroll in activities (non-exertion) that you may have had some interest in in the past. Crafts, languages, learning new software packages—flip through what's on offer at a local community center to get inspired.

Getting out in the nature is mentally valuable, but put the breaks on the exertion and duration. So again, a bit of replace and distract. How slowly can you go around the block? Make that your task. See if you can get it to 15-20 minutes for one block. Take in absolutely everything in your surroundings. Note every change. Bring a camera and take a picture of the same view each day so you can then compare after your walk whether you actually missed a detail from one day to the next or not.

Consider pot gardening (as in plants in pots!) on a patio or deck. This will allow you to be outside and connected to some of the benefits of gardening without the more strenuous aspects of hauling mounds of dirt etc. Set up a bird feeder (I have a hummingbird feeder I love). Sit out and admire your handiwork growing in the pots and watch the birds.

If one kind of replacement strategy doesn't work, then try another. Basically enter the process with curiosity about what things you could include in your life to broaden your horizons, rather than entering the process with trepidation assuming you will simply be pacing the floors with nothing better to do.

KDINURAJ: FLICKR.COM

Honeymoon

Despite all the physical discomfort of these early days, many experience a tremendous sense of relief and initial joy at eating in an unrestrictive way. Understandably, you have many, many distributed and ingrained systems that ensure you eat because your survival depends upon it.

However, the restrictive eating disorder will not allow that relief to stand for very long. Soon you will find yourself starting to feel edgy and anxious. For many the fast physical shifts in the body will become a focal point for allowing the eating disorder to suggest that the process is not going “according to plan” and that somehow trusting your body cannot apply to you as it does to everyone else.

Despite all the noise and anxiety that the eating disorder will create, these truths hold for everyone:

• Your body has an optimal weight set point that it can and will defend. [RE Keesey et al., 1997; RE Keesey, 1988] Your body can manage without your conscious interference. Your set point is managed and distributed throughout brain structures that are far more mature, evolutionarily speaking, than your late-to-the-party conscious thought. Think of this as your prime directive: do not interfere in a process that your body can manage.

• No one keeps gaining and gaining.

• Extreme hunger is a normal progression in recovery. It does not last. You do not ‘habituate’ to 6000-10,000 calories a day, but you need that energy during refeeding.

Menstruation

For women, it is important to remember that the return of menstruation is not a definitive marker that you have reached your optimal weight set point. It is the case for some and not others. Nonetheless, we can say that if you are amenorrheic or oligomenorrheic (absent or irregular periods) then you are definitively not at your body’s optimal weight set point.

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Phase II—vital organ insulation

If you get here, then the body is now focused on protecting your vital organs. It assumes you will starve it again soon enough and without insulation around your mid-section, your organs are in grave danger.

The body preferentially lays down fat around the mid-section to insulate vital organs from hypothermia. [L Mayer et. al., 2005] Again, someone in recovery who is not prepared for this will freak. You can feel huge (a combination of fat around the middle and the residual bloating and gas of a digestive system struggling to get up to speed again). Unfortunately, many relapse here.

The redistribution of all that fat around the mid-section to the rest of the body only occurs if you persist right the final phase. [LES Mayer et. al., 2009]

Phase II is a neither/nor phase that is difficult for many to navigate. The body is focused on conservative maneuvers to ensure your safety should you starve again. For many this tends to be a phase of extreme impatience—following all the guidelines day and day out and yet still wearing floaty and stretchy clothes and feeling like an alien in your own body seems unfair.

You may still be restoring weight and that will bother your eating disorder-generated anxiety. Your ingrained sense of an acceptable weight may not be your body’s optimal weight set point. Your body may additionally need to temporarily overshoot its optimal weight set point in this process in order to return to a correct fat mass to fat-free mass ratio. [A Dulloo et. al., 1996, 1999]

This phase will test you. It requires that you double-down in your trust of your own body. It requires that you work to identify your value beyond weight, shape or ideals found in our cultures and society. It is a phase that lays the groundwork for your ultimate ability to maintain a resilient remission.

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Phase III—bones, muscles, almost there

Assuming you have been purposefully eating to your minimum guidelines and responding to extreme hunger without compensatory restriction up to this phase, then you start to get rewarded for all your hard work.

Osteopenia and osteoporosis begin to reverse (the completion of that may take up to 7 years, but it begins to reverse in this phase).

The fat deposited around the mid-section is now beginning to be redistributed throughout the body.

Hair, nails and skin begin to have increased pliability and suppleness.

You also start to feel more connected and self-imposed isolation diminishes. You feel less emotional blunting and start to want things for your life.

This occurs for many at around the 4-6 month mark, but for others it takes shape between months 8-12.

Unfortunately this is often when an almost-fully recovered patient makes a series of mistakes (often also due to misguided advice even from her own medical and professional team). She assumes she can now maintain her weight and that she is recovered.

Instead, she relapses again within the year. Why?

FIMILYMWR: FLICKR.COM

Final Critical Phase—remission or relapse

Only 2-4% of the population is naturally at BMI 18.5-20—i.e. naturally thin [Statistics Canada, 1978] Despite this fact, many are encouraged by their treatment teams to stop gaining weight and ‘maintain’ as soon as they reach this arbitrary lowest so-called healthy range.

In fact 70% of all women are naturally going to fall between BMI 21-27 [ibid.], with half of those at BMI 23, 24 or 25.

I get into a lot of detail on the fallacies associated with the “healthy weight range” set at BMI 18.5-24.9 in the Fat Series with all the accompanying scientific fact to confirm the falsehoods. Fundamentally, the optimal weight range for lowest incidence of ill health and death is actually BMI 25-30 [KM Flegal et. al., 2005].

However, you don’t maintain your weight, your body does. The minimum guidelines for recovery are, on average, what non-restricting weight-stable individuals in your category consume to maintain their weight and health.

Once your body reaches its own optimal weight set point (and only your body decides what that is) then it just stops gaining weight and starts maintaining the optimal set point it has reached. It does this seamlessly because the metabolic rate moves back into the optimal range at that same time and biological functions that were on hold are now back on line.

You gain weight through all those phases of recovery because the metabolism is suppressed—that energy went to weight gain and repair. But now you are recovered, the energy now goes to day-to-day functions (all the neuroendocrine systems that had been on hold up to that point).

You gain on recovery amounts and then you maintain on right about the same amount. And once you stop gaining weight then you can also depend on your hunger cues to keep you eating what your body needs to maintain your health and weight for the rest of your life.

Unfortunately many of you will be encouraged to restrict under the auspices of maintenance of your weight and health. Restriction of food intake will always precipitate relapse.

Restrictive eating disorders are chronic conditions and you are never cured of the condition. You can enjoy a complete and even permanent remission, but it requires of you that you never restrict your intake.

Our society suffers such severe anxiety over obesity and believes, wrongly, that both food intake and exercise determine the appearance and onset of obesity (they do not), that many health care providers will encourage patients to be careful about their intake and get back to exercising in this phase for all the wrong reasons. [W. Kulesza, 1982; JA Baecke et al., 1983; RJ Myers et al., 1988; ML Johnson et al., 1956*; L Lissner et al., 1989; AM Prentice et al., 1986; H Pontzer et. al., 2012]. *Can I just say that we've known this a long time?

ZORAH OLIVIA: FLICKR.COM

Reverse Honeymoon

If you relapse at this point, there will be an initial phase of comfort and ease as your restrictive eating disorder begins to take hold. I liken this situation to that of returning to an abusive partner—they are full of care, concern and apologetic pronouncements that this time will be different.

It’s trickery. There is no love or peace to be had within a restrictive eating disorder. If at any time you experience a relapse, then return to your minimum intake immediately and seek out support to keep working on applying non-restrictive behaviors instead of restrictive ones in response to anxieties.

You cannot bargain with a restrictive eating disorder and it always plays for keeps.

If you discover that your treatment team that has been so supportive and helpful to now starts to show signs of its own anxiety and issues around weight and body image, then switch them out.

Your body can only be healthy at its optimal weight set point whether our society can accept that or not is its problem and not yours.

JOE HOUGHTON: FLICKR.COM

4. WHAT KIND OF HELP IMPROVES THE CHANCE OF RECOVERY?

Food Is Not Fuel It’s So Much More

No calorie restriction for the rest of your life. Do not use calorie-counting sites that have underlying calculations that depend upon basal metabolic rate x activity level. These are clinically proven to underestimate your actual energy requirements. [LE Bratteby et. al., 1998; JJ Cuningham, 1980]

Beyond that, you will not count calories or follow a meal plan in remission. Quoting myself from another blog post:

When you struggle with a restrictive eating disorder, so much of the social/emotional connections with food consumption have been hijacked by eating disorder-related anxieties. This disconnect is also heavily reinforced by our society’s current preoccupation with the presumed superiority of what I once called autistic eating (referencing parallel nomenclature used in economics, namely autistic economics). However, it is an incorrect term to use because autism is not a condition lacking in an emotional landscape, rather it is a variation on the usual development of theory of mind.

So, I’m going to rename this issue in our society: the reverence attributed to consciousness eating (sometimes misattributed as mindful eating).

Consciousness eating presumes that having our emotions active and interacting with our hunger and satiation cues is inferior to the process of applying our conscious, or logical mind, to the assessment of whether the desire we feel to eat is in fact something that must be addressed for logical reasons.

We cannot eat logically. Our logical minds are too late to the evolutionary party, by millennia, to actually offer any value to how we pursue and stay optimally energized.

This reverence of the logical mind and twinned disdain of the emotional mind is, from an evolutionary perspective, ludicrous. The structures within your brain that support your emotional landscape are robust, distributed and ensure your survival to a level that your logical mind couldn’t even hope to achieve on its best coffee-upped day!

I often mention the patients with lesions and trauma to the emotional centers of the brain (you’ll find one in particular who is referenced by multiple neuroscientists and neurologists in their bestseller books) who are institutionalized despite the fact that they have fabulous and intact IQs; have completely intact memory, retention and retrieval faculties; and can sustain a conversation on any topic pertaining to the past (historical and personal) to the present and future (current affairs, debate, analyses etc.). Ask them what they would like to have for lunch and then you see why they need the 24/7 oversight and care. Without emotional salience, their logical mind is completely stymied by what might be the better option: lasagna or burger and fries.

How you feel about your food is how you not only survive, but also thrive. 

Treatment Team

You need a recovery team around you that you see pretty-much weekly to ensure some accountability and support. That can include family.

While your GP is there for the physical check-ups and confirmation that your re-feeding is going as planned, she is not going to be up on a lot of the research on recovery from EDs unless it happens to be a personal interest of hers.

Dieticians or nutritionists can be a great addition to your team—helping you with food ideas and perhaps meal plans if you find counting calories is creating too much initial anxiety and reactive restriction.

However, keep in mind that a disproportionate number of those in the nutritional sciences are also on the restrictive eating disorder spectrum. [M.C. Teixeira Martins et al., 2011] Keep their input to meal plans that follow your recommended minimum intake and you can avoid receiving advice that will actually lessen the chance of success for your recovery.

A counselor, therapist or psychologist that you like and trust who will offer you cognitive behavioral therapy (CBT) is the single most effective way of ensuring you have a complete and permanent recovery. [DM Garner et. al., 1997; CG Fairburn et. al., 1999; WS Agras et. al., 2000]

If you see one and don't like him or her, move on to the next one. But the accountability of the process will help generate new neuronal pathways that will initially sidestep the ED-skewed neurotransmitter pathways and eventually weaken them and override them.

Remember: all the damage, as monstrously serious and severe as it is, is completely reversible at this point.

Keep a tight rein (with therapist support) on letting the anxieties and your goals become one and the same, because they are not:

Try not to focus on what the recovery weight is going to be.

The restrictive eating disorder spectrum does not include binge eating disorder or night eating syndrome. Those sit on a completely different ED spectrum and have completely different genotypes involved.

On the restrictive eating disorder spectrum, your system responds to leptin in your body correctly and that system not broken.

Once your leptin levels get back to optimal levels (which will happen when you hit your natural weight set-point) then you will stop gaining weight. Leptin runs your appetite and metabolism—when it is optimal then everything is in balance. You maintain your weight naturally and eat when you are hungry when you get to that point.

So, every time the ED-skewed thoughts get you all panicked about gaining weight and not stopping, remind yourself that it is not biologically possible for that to happen to you.

So your focus has to be on eating enough food to restore weight and trust that your body and your entire leptin response system will work exactly as it is supposed to. It will.

Respond to the hunger as much as you possibly can.

You can respond to extreme hunger and it will not trigger any kind of binge-eating disorder. Remind yourself of this frequently. Bingeing is not bingeing for you—it is just eating the amount of energy that your body desperately requires. 

The critical thing is no restriction—you must eat no less than the minimum guidelines no matter how much you consumed the previous day.

Restrict/reactive eating cycles are on the same ED spectrum as anorexia and many shift into restrict/reactive eating cycles and bulimia when trying to recover if they and their treatment teams are not really, really vigilant about allowing absolutely no restriction.

You don't sit at 1200 calories for more than a couple of days before you move it up -- and you keep moving it up until it's dependably at the minimum guideline. If you are hungry for far more than that, then it is normal and respond to that hunger.

Whatever craving you have respond to it, but ensure that you are getting some psychological support to short-circuit any fear or anxiety that may tempt you to restrict afterwards. Restriction is your enemy at all times, so don't give it even a toehold in your life.

You cannot depend on eating intuitively because the eating disorder will always veer towards under-eating. So if you are finding counting calories creates anxiety then work with either a dietician or a family member to create meal plans—then you know that as long as you eat everything on the list that day, then you've reached your target.

Nuts and seeds are your best friends—100 calories a handful they should be constantly nearby and you should snack on them as many times throughout the day as possible. They are also usually well tolerated for the healing digestive tract.

Eat any time of the day or night. It is always good for your body to eat. But again, don't restrict through the day in anticipation of eating at night.

While it's good to cry and connect with the reality of how dangerous things have become for you and your health, it's equally important to focus on how reversible all the damage really is. Every time you eat chocolate or have a lunch that isn't just a salad, you are one real step further away from kidney failure and all the other catastrophic aspects of restrictive eating disorders.

Praise yourself for every piece of food/energy you give to yourself. You can do this and you will succeed. You will get your life back.

 

KNOWING WHEN YOU CAN TRUST YOUR HUNGER CUES

 

Almost everyone tries to rush the process of recovery. Despite the fact that they may have massive damage over years of steady restriction, they still believe that a few months in they are ready to just “move on” and “be normal”.

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

• Your weight appears stable. (weighing yourself is not necessary to determine that).

• If you have dealt with amenorrhea during your restriction, then you have achieved 3 consecutive periods in a row.

• You are continuing to eat minimum amounts and it is comfortable to do so.

• Other lingering signs of repair seem complete (no longer cold, tired, achey, dealing with water retention, no brittle hair or nails etc.)

• 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.

You move from meal plans or counting calories to eating to hunger cues by attempting a 3-day experiment. Eat to your hunger cues but jot down everything you eat. At the end of those three days you should discover that your hunger has taken you to approximately the recovery guidelines you have been following thus far. If so, then you can likely trust your hunger cues and move into your remission with some confidence.

Keep in mind that remission is not a permanent state for most. Life stressors and changes can precipitate slips that lead to relapses. I encourage you to develop your Relapse Reversal Intervention Kit, which I touch upon in the Recovery Journal. It is fairly straightforward to avoid a full blown relapse if you are prepared and have identified likely warning signs well in advance of them actually showing up.