The biggest fear for those with anorexia nervosa is gaining weight. The perception is that weight gain will be unstoppable. Since this fear is so great, weight loss in any amount is never enough. In fact, losing more is sometimes the only signal that convinces a person with anorexia that there's no weight gain.
When a person chooses recovery, on the other hand, gaining weight is the first item on the agenda. Restoring body weight helps the body to recover (moving away from death by starvation, in some cases) and also supports the brain's functioning, a necessary asset for treatment of other noneating issues to be effective.
So what can a person with anorexia expect when the process of weight gain begins?
Weight Gain Strategies for Anorexia
There are two main types of refeeding strategies for a person who is severely malnourished. Most patients are candidates for a staged oral refeeding plan that encourages them to eat, increasing amounts of food over time as their bodies adjust to eating again. Some, however, are unable or unwilling to eat. These patients require parenteral nutrition (calories given intravenously or by nasogastric tube) to help them gain weight.
Weight Gain for Anorexia Should Move Slowly
For someone with anorexia, refeeding is going to be uncomfortable no matter what, but moving too quickly can create side effects that are unhelpful. Here are some common side effects that refeeding is too aggressive:
- Edema (swelling due to fluids): Even though edema is temporary and will subside as recovery continues, it is unsettling because it reinforces a person's faulty belief that she (or he) will "get fat" immediately.
- Bloating: As with edema, looking or feeling bloated is often frightening for the person in recovery. It seems to be visible evidence of "getting bigger" in a short time.
Research indicates that a good target for a person who is severely underweight is an initial intake of 800 to 1000 calories per day, with a steady increase of 200 to 300 calories/day every two or three days.
Even with a reasonable intake, some patients will experience edema and bloating. While psychologically stressful, these are temporary circumstances that can be navigated with consistent reminders that they will pass.
In rare cases, adding calories too quickly results in a phenomenon called "refeeding syndrome," in which phosphorus and electrolyte levels become dangerously out of balance. These imbalances can cause heart failure.
In short, it took a while to lose all that weight, and it's going to take a while to gain it back as well.
Close Supervision Enables Healthful Weight Gain
Anorexia doesn't just fade quietly. The disorder puts up a stiff fight and that can mean ramping up secretive weight-loss practices behind the backs of doctors, therapists and family members. For example, hospitalized patients often try to exercise silently in their bathrooms to burn extra calories.
Clinicians know this, so most anorexia patients receive constant monitoring. Sometimes it means confining a patient to her (or his) room to take away the temptation of climbing stairs or walking hallways. This can feel patronizing and invasive, especially to a teenager. Those with this eating disorder, though, are generally too sneaky to be allowed freedom at this point. In fact, freedom is a common incentive offered to hospital patients in exchange for weight gain.
Watching the Scale Move -- Three High-Stress Zones
Those with anorexia are often obsessed with numbers -- the number of calories in three carrots, how many miles must be walked to burn off a cup of yogurt and so forth. The biggest number of them all, though, is the one the scale reports, and when it goes up, there is often resistance.
Consider that in many cases, anorexia has become the person's identity. It takes up huge amounts of time and energy, because life must be organized, for example, around scheduling exercise and avoiding places where eating is a must. Weight gain challenges the identity of anorexia, and the eating disorder fights back.
Some clinicians plan to see their patients resist further weight gain at three points: after the first 5 pounds, at 80 to 85% of the target weight and when approaching the target weight.
All of these are significant points. The first 5 pounds say that something is changing, and anorexia resists any sort of change. Upon reaching 85% of "ideal weight," the person does not meet the definition of anorexia anymore. And while the goal weight is in sight, so is the end of the weight-gain portion of treatment. It's a signal that reentering the world as a whole person is coming soon.
Surviving the Comeback
With all these stressors, it might be hard to imagine that gaining weight to a healthful level can be rewarding. Yet the rewards are there. Moving away from starvation leads to increases in mental and physical strength. As these attributes take hold, a person can shed the identity of anorexia and become a person who is free to engage in healthful activities and relationships.
Sources:
Bogden JD, Goldstein DJ, Klevay LM. The Management of Eating Disorders and Obesity. Totowa, New Jersey: Humana Press; 1999.
Mehler PS, Weiner KL. Use of total parenteral nutrition in the refeeding of selected patients with severe anorexia nervosa. International Journal of Eating Disorders 40 (2007): 285-287.
Salisbury JJ, Levine AS, Crow SJ, Mitchell JE. Refeeding, metabolic rate, and weight gain in anorexia nervosa: a review. International Journal of Eating Disorders 17 (1995): 337-45.
