Working Through the Weight Restoration Phase of Anorexia Nervosa

Why is Weight Gain so Hard?

Many people who struggle with anorexia nervosa (AN) ask this exact question of their dietitians. In order for an anorexia sufferer to regain a medically recommended amount of weight, he/she needs to consume over 500 extra calories per day, in addition to the calories someone that age and height would normally require. Most people with severe AN need to consume an additional 1,000+ calories per day to gain just one pound per week. If someone with AN needs to gain over thirty pounds, weight restoration can take many months. On a daily basis, the hardest part for many people is eating every two to three hours. Most weight restoration meal plans include three meals, three snacks, and sometimes supplements in between, per day because of hypermetabolism, discussed below. The patient’s dietitian will also have to be careful not to increase the meal plan too quickly for fear of refeeding syndrome.

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What is Refeeding Syndrome?

Refeeding syndrome is a potentially fatal complication of increasing food intake too quickly. The body needs time to adjust to processing more food than it is used to. As the individual increases his/her nutrient intake, the body starts processing food again, but since the individual has had a long period of starvation, electrolytes like phosphate, magnesium, and potassium are in low supply. The body tries to make more of these electrolytes to process the increased food intake, but the cells in the body start to shut down from overwork. This causes the electrolytes to be in low supply. This is dangerous because low potassium causes heart arrhythmia if it is untreated. Heart arrhythmias can be serious and can even cause a heart attack or sudden death. Symptoms of low potassium are weakness, cramping in the arm/leg muscles, paralysis, tingling/numbness, nausea/vomiting, abdominal cramping/bloating, constipation, and heart palpitations.

If a person is beginning the refeeding process, he/she needs to be monitored every few days by a physician and dietitian so that he/she can help ease the body into being able to process the amount of food needed for weight restoration. Refeeding syndrome is a concern for sufferers of AN, and while the syndrome is rare, the medical team must monitor for it. It is always best to see professionals specializing in eating disorders to avoid any adverse consequences related to refeeding syndrome.

What is Hypermetabolism?

When a person reaches a point in his/her illness at which he/she wants to work towards eating disorder recovery, the individual’s dietitian must increase meals and snacks to a level that supports weight gain. During starvation, muscle and fat are lost, which lowers the metabolic rate. The body will also use muscle and fat as fuel for bodily processes (such as movement, digestion, creation of hormones, proteins, and energy, running the brain, etc.), and therefore, a person with AN typically will have lost quite a bit of body tissue and potentially heart muscle by the time he/she decides to seek treatment. Heart rate is typically quite low and needs time to slowly increase as the metabolic rate increases. When food is reintroduced and the body is given adequate nutrition, metabolism will improve, and the body will require more energy.

When a person with anorexia nervosa is weight restoring, the meal plans are high (usually between 3000-5000 calories a day) because the body must use the food first to reconstruct body tissue lost during starvation. The extra calories go toward repairing the heart, brain, cells, bones, hair, nails, blood, muscles, joints, intestines, hormones, and skin. After restoring its tissues to a healthy state, the body will put the remaining fuel in storage, which will promote weight gain. This is a difficult and long process because, like any time a person wants to gain weight, the energy requirements must be surpassed each day for weight gain to continue.

How Long Does Weight Restoration Take?

Weight restoration can take weeks to months. It depends on the amount of weight the person needs to gain and how compliant the person is with the prescribed meal plan. Often, the person will start out with a meal plan and periodically need caloric increases as the body starts to respond to increased energy requirements. Metabolism slowly increases so more energy is needed to repair body processes as well as increase body weight. Dietitians will typically not increase a meal plan if the patient is not fully following the current plan.

To parents and loved ones, it may seem as though the person with AN is following his/her meal plan, but he/she could be cutting corners such as avoiding added oils/fat or skipping snacks. These are small infractions, but over time, they can stall the weight restoration process because of the precise nature of prescribed diets.

What are the Difficulties With Following a Weight Restoration Plan?

It is very difficult for a person with anorexia nervosa to eat in general, let alone to adhere to a meal plan that requires eating every 2-3 hours. It is quite common for someone going through the weight restoration process to report feeling full often and not wanting to eat again. The patient may not feel hungry for every meal and snack and might struggle with completing the meal plan, given mealtime anxiety. People with AN generally report feeling emotionally full and refuse to eat despite their physical need. It is important for a person with AN to not only see a doctor and dietitian but also a therapist to help the person deal with difficult emotions while continuing to follow the meal plan.

On a physical level, many people following a weight restoration meal plan report gastrointestinal issues, such as severe bloating, constipation, diarrhea, headaches, night sweats, low blood sugar, and increased anxiety. All of these are common with weight restoration as the body becomes accustomed to processing regular nutrition once again. Bloating, constipation, diarrhea, low blood sugar are direct results of the gastrointestinal tract getting accustomed to processing a greater volume of food and more balanced meals. The old saying, “If you don’t use it, you lose it,” applies here as the gastrointestinal tract slows down during starvation to ensure nutrition lasts longer to meet the body’s needs. Night sweats are a direct result of the metabolism increasing, and the recovering patient might also experience headaches and increased anxiety. These symptoms usually go away within the first few weeks of weight restoration. A doctor will monitor these symptoms and can prescribe medication to ease these symptoms if needed.

How Can Families and Loved Ones Help?

Families and loved ones can help by making the mealtime experience pleasant and taking the focus away from calories, weight, and size topics. People with eating disorders report wanting to be treated like anyone else and have a pleasant meal. Discussing neutral topics such as TV shows, movies, music, hopes, dreams, passions, travel, art, and any other interests the person has can help the person see that there is so much more to life than the eating disorder. This could vary depending on the family’s involvement in treatment and the modality of treatment. Families can help by providing encouragement and support.

It is easy to become concerned about a loved one with anorexia nervosa; however, it is best to express concerns to the person in a calm way using “I feel” statements. It is not helpful to harp on the person about any lack of progress, as people with AN report feeling as though any correction is pointing out where the individual has failed, no matter the good intentions of the person giving feedback. This is emblematic of the black-and-white thinking of those with an eating disorder, but it is best to be honest with the loved one about feelings on both sides so a productive, caring conversation can ensue. There are different modalities of treatment for anorexia nervosa. Some involve the family more, especially with adolescents. Expressing feelings in a family group or with the family therapist can elicit helpful discussions. Even though it can be difficult for people with anorexia nervosa to ask for help, it is important to involve the family, friends, and significant others in the discussion of progress, signs of relapse, and ways they can help support the patient.

Is Full Weight Restoration and Recovery Possible?

With treatment, Steinhausen showed that only “46% of patients fully recover from anorexia nervosa, a third improved with only partial or residual features of the disorder, and 20% remained chronically ill for the long-term. A low body mass index (BMI), a greater severity of social and psychological problems, self-induced vomiting, and purgative abuse have been identified as predictors of a poor outcome in this disorder.” Full recovery means full weight restoration, successful relationships, and letting go of the focus on weight, calories, and types of foods. They have careers and families and report feeling a sense of strength within themselves after overcoming an eating disorder. The “risk of death was highest for those with anorexia nervosa, with a weighted annual mortality rate of 5 per 1000 person-years (slightly higher in studies of females only)”. These numbers change as the incidence of anorexia nervosa continues to be studied.

Anorexia nervosa affects about 1 in every 200 women in the United States. The actual percentage may be higher as not all people with AN present for treatment. In general, treatment is helpful for most people, and research, treatment, and outcomes have improved over the years. Since people who recover are more vocal about their experiences now than ever before, they may inspire others to seek treatment. Thus, the incidence of recovery in the future may be higher than we currently see.

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1. Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality Rates in Patients With Anorexia Nervosa and Other Eating Disorders: A Meta-analysis of 36 Studies. Arch Gen Psychiatry. 2011;68(7):724-731.
2. signs and symptoms of eating disorders-ERC handout

About The Author:

Hayley Miller, MS, LPC, RD is a registered dietitian and licensed therapist. She has been working with clients with eating disorders as a dietitian and therapist since 2011. She has a private nutrition practice called Hayley Miller Nutrition in Manhattan, NY and is working on becoming dually credentialed as a Certified Eating Disorder Registered Dietitian (CEDRD) and Certified Eating Disorder Specialist (CEDS).

Written – 2017