Nutritional restoration and weight normalization are imperative steps on the road to eating disorder recovery. The process of renourishing the body is difficult, but necessary to prevent severe physical complications and improve cognitive function [1].

There is a common consensus among medical professionals that eating disorders cannot be effectively treated without first restoring weight [2]. This is because without weight restoration no meaningful psychotherapy can be completed due to starvation-induced cognitive deficits [2].

Where to Start?

Build a Recovery Team

Recovering alone can be an overwhelming process to navigate. Recovery with a team is still a challenging journey but provides support, understanding, and accountability when the road gets tough.

A recovery team should involve a dietitian, primary care physician, therapist, and psychiatrist who all specialize or have backgrounds in treating eating disorders.

Have a Dietitian at the Center of Nutrition

Registered Dietitians are nutrition experts. They will support individuals at all levels of care by providing compassion and structure.

The dietitian will work with each patient to determine individual nutritional needs and what meal plan will be most suitable. Meal plans can shift over time, but initially the more structure the better.

Dietitians can help in supporting gradual meal plan increases to restore weight safely and in a maintainable fashion. For patients at high risk of refeeding syndrome close monitoring is recommended.

Throughout the process of restoring weight, the dietitian and recovery team will monitor laboratory values and vitals. These can be monitored at all levels of care, but again for those at the highest risk, the team may recommend completing the process of refeeding in a hospital setting.

Be a Part of Your Recovery Team

Recovery doesn’t just mean restoring weight and nutritional status. Recovery is an upwards spiral of progressing forward, taking steps backward, and learning or practicing what can aid in continuing along this journey.

It is normal to fear the unknown. For example, not knowing or fearing what a restored body will look like. The challenge here is to keep in sight what you do know.

The fact is the eating disorder has a grip that needs to be broken free of. It will try to pull you back in, but your life depends on continuing the road to recovery. This means continuing the road to renourishment and weight restoration.

Related Reading

What Does Restoring Weight & Nutritional Status Entail?

Restoring weight during ED recovery can be uncomfortable physically and emotionally. However, it can be supportive knowing what to expect.

The process of renourishing the body should be discussed as an open conversation. Patients can often feel crazy, wondering if what they are feeling or experiencing is normal?

When patients start to feel and recognize their bodies are changing, behaviors can return or worsen as an attempt to combat emotions and weight gain. This is an imperative time to have a team established for support.

The team’s job is to support patients through this process and provide an understanding that what the patient is going through is normal and temporary.

Physical and Emotional Battle

When physical changes are recognized as a result of renourishing the body it is normal for patients to turn to behaviors. Behaviors are second nature to patients, they know when using these behaviors emotions and discomfort go away temporarily.

Challenging irregular behaviors around food such as slow eating, restriction, purging, excessive exercise and more are uncomfortable, but key components to overcoming an eating disorder. Noted that low energy-dense foods and limited variety have been associated with poor treatment outcomes [1].

Patients will work with their team to expand food variety beyond their view of safe or acceptable foods in order to meet energy and nutrient needs. This is called exposure-based therapy and is necessary to overcome fears and adequately restore macro and micronutrients.

Hydration

Initial weight gain is often related to rehydration of the body. Dehydration can be the result of behaviors including purging, water restriction, laxative or diuretic abuse, over-exercise, inadequate nourishment, etc.

Patients can fear drinking water due to knowing they will gain weight in the process of rehydration. Practitioners and patients again need to have open conversations about what is happening in the body and why adequate hydration is necessary for optimal functioning of the body.

Metabolism changes

When the body starts to heal the metabolic rate will increase. A symptom of this is often waking up sweating, sheets often soaked [1]. This is a result of the body releasing energy or calories in the form of heat [1].

As patients start to refeed the body is gradually transitioning from a hypometabolic state to a hypermetabolic state often requiring energy or calories beyond maintenance of homeostatic level. This is where dietitians will work to support patients through meal plan increases.

With a dietitian, the goal will be to eat all macronutrients including carbohydrates, proteins, and fats in the recommended amounts at all meals and snacks. Energy-dense foods will also be incorporated here to not only meet caloric needs but to continue to heal a patient relationship with food.

Tissue Restoration

In a state of restriction and malnutrition, all organ systems are affected including cardiovascular, gastrointestinal, endocrine disorders (osteopenia, amenorrhea), and other metabolic alternations [1].

Restoring tissue in the body includes gaining fat, brain tissue, cardiac muscle, skeletal muscle, smooth muscle, bone, cartilage, etc. Providing patients education as to how tissue gain serves the body is important.

Initial weight gain is often seen in the abdomen. This can be scary and at that moment many patients worst fear. Explaining that this is the body restoring fat tissue needed to protect its vital organs can help patients maybe not accept, but initially understand.

Long-term malnutrition impacts all systems as the body tries to compensate to survive. The gastrointestinal (GI) system is especially important to discuss since patients will experience GI discomfort. This is due to the body relearning how to digest increased amounts and variety of food.

Patients can experience acid reflux, bloating, constipation due to slowed gastric emptying and gastroparesis, or slowed GI movement [2]. Again, as with all symptoms reiterating that these are temporary.

How Long Does Weight Restoration Take?

The journey towards recovery isn’t over when a “normal” weight has been reached. Even in weigh-restored bodies, abnormal eating patterns can persist. Long-term recovery is not sustainable if returning to limited diet and food variety [1].

This is a pivotal time in the healing process. Without careful consideration, patients can quickly relapse if returning to old behaviors. Relapse rates are reported to be up to 50% [1].

Follow-up studies looking at food intake 1 year after hospital discharge showed that individuals returned to restrictive eating [1]. After leaving treatment it is imperative patients continue to meet with a team including a registered dietitian for continued follow-up and accountability.

After the refeeding process is over patients’ metabolic rates will still be elevated. This means, for at least 3-6 months, if not longer, patients will need to be on a higher than maintenance meal plan until their body returns to baseline. Again a recovery team is pivotal in guiding this process.

Citations:

[1] Marzola, E., Nasser, J. A., Hashim, S. A., Shih, P. A. B., & Kaye, W. H. (2013). Nutritional rehabilitation in anorexia nervosa: review of the literature and implications for treatment. BMC Psychiatry, 13(1). https://doi.org/10.1186/1471-244x-13-290

[2] Mehler, P. S., Winkelman, A. B., Andersen, D. M., & Gaudiani, J. L. (2010). Nutritional Rehabilitation: Practical Guidelines for Refeeding the Anorectic Patient. Journal of Nutrition and Metabolism, 2010, 1–7. https://doi.org/10.1155/2010/625782

Author: Raylene Hungate, RDN,LD/N
Page Last Reviewed and Updated on October 12, 2021 by Jacquelyn Ekern MS, LPC

How to Regain Weight During ED Recovery