What happens when the weight comes back?
In the next few blogs I am going to excerpt a few relevant parts from my upcoming book about eating disorder treatment called Give Food A Chance, to be published this year by PSI Press. Once the book becomes available, we will notify readers of my blog where it can be purchased.
This excerpt deals with “weight redistribution” or the shifting of weight in patients with anorexia who have become weight restored during their eating disorder treatment:
One of the more distressing things about weight gain following semi-starvation due to anorexia is the distribution of fat that follows.
We confront this issue directly in the outpatient clinic; there is no point trying to hide from the elephant in the room: The human body stores initial weight gain around the face and stomach. Some children may appear to be “chubby” to their parents once they reach their weight goal. Of course they are not “chubby,” but at this point it is essential to continue the frank discussion (begun in the DTU) about weight redistribution.
We do not know why it happens or understand the mechanism involved, but we have consistently observed that the extra weight gained initially around the face and stomach will redistribute over time. How soon? Boy, would I be popular if I could accurately predict that! It usually takes several months to happen, but when it does, it is fairly sudden and rather dramatic.
In the outpatient clinic I sometimes think a child has lost weight, but when I check their chart, I see that this is not so; the puffiness and extra fat has merely “left the face” with the tummy to follow. Really. The kids are very pleased, the parents are relieved, and the doctors are happy, too.
Excerpted from "Give Food a Chance," PSI Press, 2010 (anticipated). All rights reserved.
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I am 18 yrs old, 5 feet 2 inches and recovering from anorexia. At my lowest, which was less than a month ago, I weighed 89 pounds. My parents decided to deal with my problem themselves and have me on a 3000 or more calorie diet. So far I have gained 8 pounds in about a week. Am I gaining weight too fast? My parents want me to reach 108 pounds, but once I am there I'm afraid that I will continue to gain weight. I'm not very active and since regaining weight I haven't done any exercise. To maintain 108 pounds, how many calories should I eat? I'm afraid my parents will make me eat more than necessary. Also, since I lost weight very, very gradually over 2 years, will this impact how long it will take for the weight I have gained around my stomach to redistribute? It makes it tricky for me to know when I've never actually weighed 108 pounds before.
These questions are too important and too individualized to address on a blog. And while I applaud you and your parents for taking charge of this, you absolutely must have the help of someone who knows what they are doing in order to avoid the very circumstances you fear.
I've gone into treatment in mid march I'm 5 feet and I've gone from 80 lbs. to 96 in 2 months but its already 3 months since then and I'm eating according to a meal plan I'm eating anormal amount of calories yet I'm still gaining in these past 3 months of gained an additional 7 lbs. and its totaly freaking me out why am I still gaining if I'm already at a healthy weight and I'm eating according to plan?
Are you a male or female? How old are you? What did you weigh before your eating disorder? What are the heights and weights of your first degree relatives? Are you Caucasian? What is your meal plan like? Have you (if female) had a return of your periods without (important!) oral contraceptives? How active are you?
You see there are a lot of details that go into assessing a person's weight status, not just their height and weight.
Also: you are still quite slender, maybe too slender, at 96 # and 5 feet--hard to know without the details.
Thanks for your quick reply I'm 22 years old I'm a white female and I'm on a 1600-1700 calorie meal plan I'm not 96 lbs anymore because since leaving treatment 3 months ago I gained and now I'm 103 lbs I'm pretty active and I do abou 45 minutes of excersize at least 4 times a week If I'm eating the same amount of calories and basically the same types of food daily why am I still gaining weight I'm just so worried that it wont stop and also I never lost my period and I dont know what weight I was before because I started my eating disorder as at 13 years old is it normal to continue gaining even if I haven't changed my eating habits in the past 3 months I'm kinda triggered to want to restrict again
You did not answer the question about the hts and wts of your first degree relatives, which is necessary to get a full picture of your individual biology.
You have been sick a very long time (nine years) and your body is struggling to find its level. It seems to me that, with your youth and the fact that you are eating 1600-1700 kcals/day you ARE restricting, or perhaps more accurately, practicing restrained eating, which can induce cravings.
You desperately need experienced outpatient follow-up to help you sort this out. But in the meatime: stop weighing yourself. Ideal weight should be a STATE rather than a WEIGHT: normal periods, normal heart rate,normal blood pressure, good moods, normal social life, reasonably active and able to think about things besides weight, food, etc.
Hi,
I am recovering from anorexia, and I am finally at a healthy weight now. I am experiencing the same issue that you described with the bloating around the face and stomach. I was hospitalized and went from being 70 pounds to 95 in just 2 months, I'm 5'0 by the way. Although I've reached a healthy weight, I'm continuing to gain and I'm getting worried. I keep getting cravings for food that I had restricted for so long, and I'm finally allowing myself to eat them. However, the stuff I'm craving tends to be stuff that is not the healthiest, like trail mix, pretzels, cookies, chocolate ... etc. When I eat this stuff it tends to be in pretty large quantities and I often go back for more because I enjoy the taste so much! Is this normal? I don't know if I should stop myself or how to stop myself without restricting again?
You describe something which we have tried to help our patients avoid and which is described very well in the Minnesota Semi-starvation Study (MSSS). People who have been starved (whether or not they denied themselves "forbidden foods") went through a period of craving (and eating) sweets and high carbohydrate, hyper-palatable foods, basically delicious foods and treats. In the MSSS this eating drove their weight up for a while.
We avoid this by having our patients eat on our meal plan for the first year after diagnosis and weight restoration. Then this disturbing brain chemistry- driven behavior abates.
Our recommendation would be not to restrict (of course) but to follow our meal plan and not eat hyper-palatable foods for a while. You must also eat enough fat in your diet to achieve a sense of satiety and diminish craving and hunger.
Although not everyone understands our approach, it was developed to relieve patients of the very distress you are reporting. For more evidence-based information on our approach, please consider reading Chapter 9, pages 223-233 and pages 258-259 in my book Give Food A Chance, recently released on PerfScipress.com.
I am currently going through treatment and I find this very frustrating. I have been in treatment for 8 weeks now. I went into treatment 80lbs (5 foot 3 inches tall) and I am currently 104. I have a couple questions that relate to this subject, too. I was wondering if you ever have people who get extremely bloated and constipated. Do you ever have people who never get rid of the bloating after treatment? This is the biggest trigger of mine and it really concerns me that it might never go away. I know it is bad to compare, but I look at the other girls in treatment and it seems like they never get severely bloated or constipated like I do. This really distresses me.
Your complaint is one we frequently hear-- and yes, it seems to resolve over time. Is there a physician on your team? Can you speak to them? Everyone's bowel flora is unique to them, so have you tried any probiotics? I hear they can work wonders. And make sure your diet is full of whole grains, prunes, plums, raisins, adequate fat and fluids and that --if you are constipated-- you avoid apples, bananas and guava.
Im currently recovering from anorexia.. My bmi was 13 and is now 19! I have to keep gaining until my period returns and i am noticing a bulge in my stomach! Its very triggering, but i feel a bit better after reading this. I researched that lack of estrogen may cause the weight to end up there? And that we need our female hormones to work normally in order to even this out? Also, when should my period return? Im about the weight i was when i had it regularly..
Dear Anonymous,
Resumption of menses (the return of menstruation) is complex. Dr Neville Golden and colleagues (now of Stanford University) published a seminal article on this subject called: "Resumption of Menses in Anorexia Nervosa" (Arch Pediatr Adolesc Med. 1997 Jan;151(1):16-21). He made several useful observations:
1. the patients he studied required a weight of 2.05 kg more than the weight at which menses were lost in order to have their periods return and
2. a serum estradiol of 30 pg/ml was predictive of the body being ready to resume menstruation and
3. resumption of menses required restoration of hypothalamic-pituitary-ovarian function, which did not depend on the amount of body fat
To translate:
1. in order to get their periods back, patients may very well need to weigh about 4 1/2 pounds MORE than they weighed when they first lost their periods
2. serum estradiol can be measured by your doctor and has proven to be a help in seeing "where your body is at" in menstrual recovery
3. the brain "trusting" that starvation is truly over and releasing normal female hormones again is what matters in the return of menstruation, not actually how much body fat you have (a surprise finding).
I hope this helps.
I'm so happy to see that the clinic has confronted this issue and is being honest with patients about what to expect!!! You have no idea how relieved I am to read that this is a typical occurrence. Until I just now read this post, I thought that I could NEVER return to the weight I was after my last hospitalization (7 years ago) because of how "chubby" I looked. I remember seeing my face and stomach puff up before me but nobody around me at the time would admit that what I saw was true. I realize now that they were afraid (rightly so) that bringing up the "elephant in the room" would have sent me back into my eating disorder. However, I remember feeling lied to and betrayed. To this day, I still show my friends pictures of me immediately after being released from the hospital as evidence that I was once "chubby". People who don't know about what I have been through are honest about what I looked like then, which is why I vowed to myself that I would never return to that weight. I didn't know that this was a typical part of the weight restoration process and never gave my body a chance to redistribute. I have spent the past several years comfortably hovering slightly below that weight thinking that by getting to that point my appearance would change dramatically. I am so grateful and relieved to know that a few pounds is not going to dramatically change the way I look right now.Thank you for your willingness to explore this issue and to work with patients to better understand how their bodies will change. It could save them 7 years of worry!
I think it's about time someone addressed this issue of uneven weight distribution following re-feeding in anorexic patients! I began to recover in an ED ward in Mountainview, CA in 2004 and was devastated to experience the immediate weight gain to my stomach, the part of my body with which I've been most uncomfortable. The doctors told me that the weight would eventually redistribute, but no one could tell me even an estimate of how long it would take for "my body to start trusting me again", as they put it. I can tell you from personal experience that it took 5 months to get my period back after I was discharged at a healthy weight and continued to gain, and that my body began to become more evenly distributed with body fat 4-5 months after that. I know that everyone's different. I know that the doctors cannot tell you or your child that this will be the case. But I really would have appreciated it if someone who had been through it had attempted to describe their (physical) recovery process to me.
Thank you for your response Elsa. Let me see if I can tell you what we have seen. Of course any parents out there who wish to chime in with their child's experience, please do so!
The disproportionate (and very annoying) weight gain in the stomach and face that happens when a body gains weight after an episode of semi-starvation, is experienced by almost everyone. Parents are at least as disconcerted as their child or young adult is when they see it. We tell them that it ALWAYS re-distributes, and it ALWAYS does.
The timing of this weight re-distribution is variable, but once the person is weight restored it usually happens within a few months of normal living. Strenuous exercise is not necessary and does not help.
Hi, Dr. O'Toole. I'm sorry that this comment is in the wrong place. It's in response to your older post called "Determining Ideal Body Weight," and I wanted to make sure you would see it.
[editor's note: It does not matter if you post questions to previous blogs; we receive email alerts for any comment left to any previous blog post. Also one can always find past blog posts using the Google Custom Search field, located on the right-hand column of every page on this site. Simply type in key words such as "ideal body weight" and the blog entry should appear.]
What do you do in the case of a child in Group D (at her full adult height, had two years of menstruation prior to amenorrhea) whose highest healthy, pre-illness BMI fell below the minimum standard of 18.5? A BMI of 18.5 would place her well outside her historical growth curve. Thank you so much for your answer.
You bring up a good question: "when did the eating disorder actually start?" I have seen young people whose insufficient eating suppressed their weight long before anyone realized they had an actual eating disorder, so returning them to their "pre-morbid weight" would not be enough. But whether or not this applies to your daughter (you do mention that this low BMI places her outsider her historical growth curve), you need to return her to a "state" rather than a "weight". Aim for the historical growth curve weight and wait for resumption of menstruation, a marker for normalcy. Most women are unlikely to menstruate regularly until they have a BMI of 20.
Wow, this totally happened to my daughter when we re-fed her! I had heard from Laura Collins that it would eventually re-settle, but my husband and I found it a little concerning, yet hoped desperately she wouldn't notice....she had quite a protruding belly and very round cheeks that she had never had before! Thankfully, it eventually evened itself out (in maybe 10 months?)and she looks wonderfully proportioned at her healthy weight..
Weight redistribution is an underreported phenomenon in recovery from anorexia nervosa and you can imagine that we spend a lot of time talking to our patients and parents about it. The initial gain around the stomach and face is very distressing for many parents who feel it could re-trigger their child's eating disordered behaviors. But it goes away! Shout it out so everyone knows: it goes away!
my weight got down to a low of 95 pounds and im 5'5, is there a high chance that this will happen? i didnt get that skinny, however i did develope the lenugo and stopped my period...and lost alot of hair... im eating like 3000 calories a day now, so far i havnt even gained hardly any weight but if i dont soon ill boost it up to 3500, feeling alot more energized and mentally "here" . my metablism is still fairly high and all this has happened in the last 8 months so it hasnt been going on that long i dont think. is it all really going to go to my face and tummy?? or have i stopped in time for my body to recover a bit more quickly
I cannot, of course, give you medical advice via this forum. There are too many things I don't know, for example your age, how long you have been ill, what you are eating, drinking, etc. I do hope you have a physician monitoring your recovery.
The point of my blog about weight re-distribution was that any unwanted gain on the face and tummy disappears. For a person who has gone through what you have, any temporary weight to the face or tummy should be the least of our concerns. Do NOT stop your weight restoration because of it.
If you are eating 3000 calories a day and not gaining weight, chances are you need to stop whatever exercise you are doing.
But the main thing I cannot tell from your post is whether or not you are getting help in your quest to get better. Please get help.