At Kartini Clinic we have been embarking on something we call “weight restoration 2.0”. In other words we are trying to move beyond mere weight restoration (as critical as that is) towards a deeper assessment of each patient’s full physical recovery. We have noticed, over the years of faithfully weight restoring each and every patient, that people respond differently to recovery from starvation, depending no doubt on their genetics and on the duration of their illness. Just one more reason why early recognition is so important.
Weight restoration is a complex topic, one I will try to cover over the course of several blogs; but it’s not something for which there is a simple “recipe”. Even our own understanding of these issues continues to evolve.
One of the first things we noticed -- and something that is commonly reported among clinicians -- is that a small number of patients never recover their menstrual cycles (or it isn’t initiated) despite apparent weight restoration. In the past, we have had nothing to offer except to say “gain more weight”. But it became clear to us that this was not the whole story. One day I discussed this issue with our colleague in Seattle, Dr. Emily Cooper, of Seattle Performance Medicine. She was able to give us some insights into the metabolic derangements that can occur with recovery from starvation of any origin, including restrictive dieting. These insights have lead us to the concept of weight restoration 2.0.
It has also lead us to a more sophisticated understanding of “state not weight”.
State (of health) parameters:
normal heart rate and pulse differentials
normal resting heart rate and temperature
return to or initiation of menses in females who are Tanner 3-4
normal sex steroids (males and females)
return to school
return to a social life that was normal for them before their illness
return to a sense of humor and play
normal metabolic labs: thyroid, leptin, insulin, glucose, etc.
return to normal growth trajectory/pubertal advancement for that child
An assessment of this state begins with what we like to call “metabolic fingerprinting”, a series of lab tests done on each of our patients to define their individual biology at the time of initial presentation and then followed throughout refeeding and recovery.
Let’s consider just one one aspect of a patient’s metabolic fingerprinting: thyroid functioning.
What happens when a mammal (as we all are) is starved or chooses to restrict their energy intake below an optimal level, or increases their output (exercise) without adequately fueling to meet this increased demand? Weight will drop. And that’s usually the idea behind energy restriction, of course -- but, oh, beware of what you wish for!
Our brains are very well defended against starvation and famine. They’ve had to be, since surviving famines of prehistory was essential to our survival as a species. So remember that however much you may care about your weight, your brain considers your weight goals to be nearly irrelevant in comparison to your survival during times of food scarcity! And the brain is extremely conservative in its ongoing assessment of famine conditions, meaning it will only very reluctantly and slowly “change its mind” about the conservation measures it puts in place to protect you against weight loss.
When the brain perceives inadequate fueling it sets many systems into motion. One of the first things it does is “turn down the thyroid” to conserve fuel, as the thyroid controls our metabolic furnace. Makes sense, right? If you thought you were going to run out of fuel for your furnace, you’d probably turn the thermostat down to make your fuel last longer. And along with thyroid function, our brain also shuts down our reproductive hormones, as it doesn’t want us to reproduce in the middle of a famine. But more about that later.
The brain can also alter insulin production in order to “hog all the glucose for itself”, and its “conviction” that it must act emergently to save you, is reinforced by the low leptin signals it is getting from vanishing fat cells (which generate leptin) as one’s weight continues to go down. Alterations in one or all of these various hormones will have profound implications for prompt and adequate weight restoration and -- for those with anorexia nervosa, at least -- lasting recovery.
But the first thing to understand is that it can take frustratingly long period of good nutrition and adequate refueling for the brain to be convinced to turn hormonal systems - thyroid, reproductive hormones, insulin, etc. - back on. How fast this happens is very individual, depending on our individual genetics and related to diabetes or insulin management, and to duration of the illness… and, no doubt, to other factors yet to be discovered.
So there you have it, the beginnings of a discussion about to a return of good “state”. This is is the first in a series on weight restoration 2.0, with more to follow. Stay tuned.