Phases of Recovery From A Restrictive Eating Disorder

The math of the calories

If you eat 3000 calories every day and stay completely sedentary, then that's 21,000 calories that go into
you for one week. That may sound like a lot however we have to subtract the 7,000 needed for the actual
fat and muscle rebuilding that has to happen each week. Fat is not an energy storage unit, it is the largest
and most critical hormone-producing organ in your body. That leaves 14,000. But then there is the amount
just to keep you breathing, heart beatingthat basal metabolic rate thing that just keeps you alive.
Estimating, that assigns another 7,000 or so.
To repair damaged heart, skin, nails, hair, kidneys, digestive system, brain areas, bone and blood formation
systems...you are actually giving your body only 1,000 calories a day to go to that effort. That's if you
dependably eat 3,000 calories each day.
The less you eat, the longer it takes to recover as the harder it is for your body to find any excess energy
to repair the damage.
Here are the MinnieMaud Recovery Guidelines for calorie intake based on age/height and sex:
Here are the guidelines for when 2500 calories applies as a minimum daily intake for recovery:

You are a 25+ year old female between 50 and 58 (152.4 to 173 cm) and,
The regular menstrual cycle has stopped and/or,
You have other symptoms of starvation: feeling the cold, fatigued, foggy headed, hair loss, brittle
nails, dull skin and/or,
Even if you were only underweight/dieted for a very short space of time (a few months), these
guidelines apply.

Here are the guidelines for when 3000 calories applies as a minimum daily intake for recovery:

You are an under 25 year old female between 50 and 58 (152.4 to 173 cm) or an over 25 year
old male between 54 and 60 (162.5 and 183 cm) and,
The regular menstrual cycle has stopped and/or,
You have other symptoms of starvation: feeling the cold, fatigued, foggy headed, hair loss, brittle
nails, dull skin and/or,
Even if you were only underweight/dieted for a very short space of time (a few months), these
guidelines apply.

Here are the guidelines for when 3500 calories applies as a minimum daily intake for recovery:

You are an under 25 year old male between 54 and 60 (162.5 and 183 cm) or female with young
children or an equivalent and unavoidable level of activity.
The regular menstrual cycle has stopped and/or,
You have other symptoms of starvation: feeling the cold, fatigued, foggy headed, hair loss, brittle
nails, dull skin and/or,
Even if you were only underweight/dieted for a very short space of time (a few months), these
guidelines apply.

Exceptions:
If you are taller than the guidelines listed above, then add 200 calories to the guidelines that match your age
and sex. If you are shorter than the guidelines listed above, then you may eat 200 calories less than what is
suggested for your age and sex, however these are all minimum guidelines and everyone is expected to eat well
above them for a good portion of the recovery process in any case. Please see this these blog posts for more
details: Extreme Hunger I: What Is It? and Extreme Hunger II: Very Disturbing
If you want the scientific references behind why these intakes are defined as they are, please see I Need How
Many Calories?!! and MinnieMaud Method & Temperament-Based Treatment.

Everyone in recovery should cease all exercise and workouts and any discretionary activities. The energy you
take in is required for weight restoration and repairs.

The Phases of Recovery

There are three distinct phases and one critical final phase for complete weight recovery and here's a bit of what
to expect.
Yes, you can experience symptoms of multiple phases at once and you can seem to progress from one phase to
the next and then, for no apparent reason, seem to back track. Thats all normal and not cause for concern.
Remember the body is not a machine but it knows what it is doing as long as you are providing the energy and
resting.
And finally, please keep in mind that no one (absolutely no one) sails through this process with no slips or
problems. Whenever you slip back into more restrictive behaviors you have not failed. Instead you must treat
the experience as an opportunity to learn more about what are your specific triggers that cause relapsethat
will make for a far more resilient remission in the end.

Phase Iedema.
Water Onboard
The body seems to gain 7-16 lbs. (sometimes more than that) in the first couple of days or weeks when you get
to re-feeding amounts for your age/sex/height.
Someone not prepared for this will panic and restrict before she gets too far along. The "weight" almost
exclusively water retention (edema). The body needs the water for cellular repair and the normalization of both
liver and kidney functions [WB Salt, 2004; GFM Russell, JT Bruce, 1990].
The water retention dissipates past the second month, but only if the patient is reliably eating to the minimum
guidelines or more every single day.
Very rarely, extreme edema (most pronounced on hands and feet) is one of several symptoms of refeeding
syndrome. It is one of the many important reasons why medical supervision is a necessity in the early phases of
refeeding.
One of the tenets of the MinnieMaud treatment approach is to stop weighing yourself at all. You will find
the forums strewn with panicked ED-driven meltdowns after someone in recovery has succumbed to stepping on
a scale.
The scales are one of the eating disorders most favorite of torture implements that it gets to use on you to
generate an easy relapse. Do not give it the satisfaction.
Digestive Distress
Digestive distress is common in this first phase: bloating, gas, pain and abdominal distention, diarrhea or
constipation. You can alleviate this a bit by eating smaller amounts more constantly throughout the day: 200250 calorie increments from the moment you get up until you go to bed.
This digestive distress occurs because starvation has drastically reduced all the critical bacteria in your gut as
well as all your digestive enzyme levels. In order for the bacteria to recolonize to acceptable levels they need
the energy in. [MD McCue, 2012; PD Cani et. al. 2007]
For many patients in this phase they also have to overcome gastroparesis. [RW McCallum et. al., 1990].
Gastroparesis is a survival mechanism whereby the stomach doubles its emptying time to the small intestine,
meaning the food is churned in the stomach for longer to try to allow for the small intestine to maximize the toolittle energy coming in to the body. Gastroparesis begins easing within a few days of doggedly staying at or
above the minimum intake and it resolves quickly if you persist in eating the recovery guideline amounts,
usually within a couple of weeks to a month. In fact the motility of the entire gut is slowed to try to extract as
much energy as possible during starvation [M Hirakawa et. al., 1990] and this resolves during dedicated
refeeding efforts.

Don't be tempted to lower the calorie intake because of the discomfortjust space the food out throughout the
day. Yogurt with active cultures will be your best friend [C Coker Ross, 2008; E Nova et. al., 2006]
If you could tolerate lactose before the restrictive eating disorder took hold, then you will again once recovered.
However, many patients in recovery can experience transient, otherwise known as secondary, lactose
intolerance. This is because the system is so stressed that it can no longer reliably produce lactase to break
down the lactose. If you find having milk, cream and ice cream cause bloating and diarrhea, then replace them
with soy and rice options or ideally use a lactase supplement (such as Lactaid). Do not have any low-fat or nonfat options for any foods in your home.
Also, while dehydrated in the early phases, resist the urge to drink lots of water. You will get adequate hydration
if you eat to the recovery guidelines. If you do have drinks, make sure they are full of calories. So instead of
sodas, it's ice cream shakes and fruit smoothies with full fat yogurts and extra oil and nut butters too.
Coffee tends to increase gut motility (that means moving things faster through the colon) [SR Brown et. al.,
1990; PJ Boekema et. al., 2000] and this is usually not an issue as most have very slow gut motility due to
starvation. However, do limit coffee intake to one or two cups a day and make sure they are loaded with creams
and sugars to focus on getting food in the system.
Pain
Edema, water retention, causes a considerable amount of aching throughout the body. You may feel very sore all
over.
When you twist your ankle and it swells with fluid, heats up and hurts, that is the healing process at work. In
recovery, the process is happening on a body-wide scale. Pain forces us to stop and rest. That subsequently
allows for the body to deal with whisking away all the damaged cells and providing energy for the development
of new, healthy cells without having to deal with new damage all the time as you push through the pain.
Those of you who applied excessive exercise, purging, diuretic or laxative abuse when you were actively
restricting, will likely experience more swelling and pain in this phase of recovery.
Rest
Many of you will feel like you have been hit by a freight trains worth of exhaustion and tiredness. You will find
this confusing because you were so energetic during active restriction and now that you are really working on
recovery you just want to flop and sleep.
As mentioned in the previous section, there is marked hyperactivity during active starvation for those on the
restrictive eating disorder spectrum.
In the throes of restriction, you have a very effective "signal jammer". Basically your brain is not able to really
receive and interpret all the distress signals from your body. This is why non-ED people feel horrible when they
starve and yet eating-disordered people initially feel energized, calm, dissociated from bad feelings etc. There
are marked neurotransmitter anomalies that appear to have something to do with it and they occur in various
emotional centers in the brain, specifically those responsible for threat identification.
It is a good sign if you are exhausted because it suggests your body is finally able to communicate its needs for
recuperation and energy in a way that was not happening during active restriction.
No Exercise
Removing workouts and exercise from your regime tend to be more difficult than increasing food intake for
many. It is a common question as to why it is necessary and cant one just consume enough energy to support
the expenditure of energy.
Most will profess that their exercise regime has nothing to do with restriction and that it is merely for all the
mood-modulating benefits that exercise will provide.
Yah, no. Mood-modulating benefits can be achieved through simply sitting outside and the mood-modulating
benefits of exercise are far from scientifically definitive as well.

Furthermore, because you do not have a mechanistic body you cannot actually magically consume enough
energy to necessarily support expenditures because the body is conservative and cautious when it comes to
how it chooses to use energy intake. In other words, even if you doubled your intake that may not result in your
body being comfortable assigning energy to repairs and weight restoration because the cortisol levels suggest
the body is under stress and therefore the energy should be socked away in case.
Just stopping exercise will be highly anxiety-provoking and that is why an approach of replace and distract is
recommended by experts in the field of exercise dependency:
There is plenty of clinical evidence that there seems to be no way to return a woman who is on the Female
Athlete Triad (inadequate energy intake, amenorrhea (lack of a regular menstrual cycle) and bone density demineralization) back to a regular menstrual cycle with adequate bone re-mineralization without having her cease
all activity. No matter how much we increase the intake, or change the timing to try to negate any energy
deficit, nothing happens until she is usually injured out and the forced rest reverses the situation [DL Wiggins
et.al., 1997; R Olyai et. al. 2009; NH Golden 2007].
I also have my own direct experience with patients with this condition. One in particular spent 5 months trying to
increase her intake to have her period return regularly (she was weight restored after a long intermittent history
with anorexia, then bulimia, then anorexia athletica). Within one month of finally hanging up the running shoes,
her period returned with no additional weight gain at that point (she was already BMI 23).
There is nothing wrong with taking this in steps, but essentially you have to keep focused on replace and distract
while getting to the minimum daily intake every single day. Once you get there, then you have actually started a
full recovery process.
So, replace and distract.
If you workout in the morning, that is easily replaced with sleep. If you set your alarm to do those aerobics
sessions, then set the alarm later and then continue with your morning routine minus the workout.
For some, that morning session provides some groundingin that case, still set the alarm, but do slow yoga
stretching, or mindfulness exercises, breathing exercises, or just sitting quietly in the kitchen with a nice mug of
something hot (and ideally full of calories too!).
Others have to also include distraction because the eating disorder ratchets up the anxiety when you don't
follow through on restrictive behaviors. Have family breakfasts. Set up mid-morning get-togethers with a friend
for a coffee and a muffin.
Enroll in activities (non-exertion) that you may have had some interest in in the past. Crafts, languages, learning
new software packagesflip through what's on offer at a local community center to get inspired.
Getting out in the nature is mentally valuable, but put the breaks on the exertion and duration. So again, a bit of
replace and distract. How slowly can you go around the block? Make that your task. See if you can get it to 1520 minutes for one block. Take in absolutely everything in your surroundings. Note every change. Bring a
camera and take a picture of the same view each day so you can then compare after your walk whether you
actually missed a detail from one day to the next or not.
Consider pot gardening (as in plants in pots!) on a patio or deck. This will allow you to be outside and connected
to some of the benefits of gardening without the more strenuous aspects of hauling mounds of dirt etc. Set up a
bird feeder (I have a hummingbird feeder I love). Sit out and admire your handiwork growing in the pots and
watch the birds.
If one kind of replacement strategy doesn't work, then try another. Basically enter the process with curiosity
about what things you could include in your life to broaden your horizons, rather than entering the process with
trepidation assuming you will simply be pacing the floors with nothing better to do.
Honeymoon
Despite all the physical discomfort of these early days, many experience a tremendous sense of relief and initial
joy at eating in an unrestricted way. Understandably, you have many, many distributed and ingrained systems
that ensure you eat because your survival depends upon it.

However, the restrictive eating disorder will not allow that relief to stand for very long. Soon you will find
yourself starting to feel edgy and anxious. For many the fast physical shifts in the body will become a focal point
for allowing the eating disorder to suggest that the process is not going according to plan and that somehow
trusting your body cannot apply to you as it does to everyone else.
Despite all the noise and anxiety that the eating disorder will create, these truths hold for everyone:
1.

2.
3.

Your body has an optimal weight set point that it can and will defend. [RE Keesey et al., 1997; RE Keesey,
1988] Your body can manage without your conscious interference. Your set point is managed and distributed
throughout brain structures that are far more mature, evolutionarily speaking, than your late-to-the-party
conscious thought. Think of this as your prime directive: do not interfere in a process that your body can manage.
No one keeps gaining and gaining.
Extreme hunger is a normal progression in recovery. It does not last. You do not habituate to 600010,000 calories a day, but you need that energy during refeeding.
Menstruation
For women, it is important to remember that the return of menstruation is not a definitive marker that you have
reached your optimal weight set point. It is the case for some and not others. Nonetheless, we can say that if
you are amenorrheic or oligomenorrheic (absent or irregular periods) then you are definitively not at your bodys
optimal weight set point.

Phase IIvital organ insulation

If you get here, then the body is now focused on protecting your vital organs. It assumes you will starve it again
soon enough and without insulation around your mid-section, your organs are in grave danger.
The body preferentially lays down fat around the mid-section to insulate vital organs from hypothermia. [L Mayer
et. al., 2005] Again, someone in recovery who is not prepared for this will freak. You can feel huge (a
combination of fat around the middle and the residual bloating and gas of a digestive system struggling to get
up to speed again). Unfortunately, many relapse here.
The redistribution of all that fat around the mid-section to the rest of the body only occurs if you persist right the
final phase. [LES Mayer et. al., 2009]
Phase II is a neither/nor phase that is difficult for many to navigate. The body is focused on conservative
maneuvers to ensure your safety should you starve again. For many this tends to be a phase of extreme
impatiencefollowing all the guidelines day and day out and yet still wearing floaty and stretchy clothes and
feeling like an alien in your own body seems unfair.
You may still be restoring weight and that will bother your eating disorder-generated anxiety. Your ingrained
sense of an acceptable weight may not be your bodys optimal weight set point. Your body may additionally
need to temporarily overshoot its optimal weight set point in this process in order to return to a correct fat
mass to fat-free mass ratio. [A Dulloo et. al., 1996, 1999]
This phase will test you. It requires that you double-down in your trust of your own body. It requires that you
work to identify your value beyond weight, shape or ideals found in our cultures and society. It is a phase that
lays the groundwork for your ultimate ability to maintain a resilient remission.
Phase IIIbones, muscles, almost there

Assuming you have been purposefully eating to your minimum guidelines and responding to extreme hunger
without compensatory restriction up to this phase, then you start to get rewarded for all your hard work.
Osteopenia and osteoporosis begin to reverse (the completion of that may take up to 7 years, but it begins to
reverse in this phase).
The fat deposited around the mid-section is now beginning to be redistributed throughout the body.
Hair, nails and skin begin to have increased pliability and suppleness.

You also start to feel more connected and self-imposed isolation diminishes. You feel less emotional blunting and
start to want things for your life.
This occurs for many at around the 4-6 month mark, but for others it takes shape between months 8-12.
Unfortunately this is often when an almost-fully recovered patient makes a series of mistakes (often also due to
misguided advice even from her own medical and professional team). She assumes she can now maintain her
weight and that she is recovered.
Instead, she relapses again within the year. Why?

Final Critical Phaseremission or relapse

Only 2-4% of the population is naturally at BMI 18.5-20i.e. naturally thin [Statistics Canada, 1978] Despite this
fact, many are encouraged by their treatment teams to stop gaining weight and maintain as soon as they
reach this arbitrary lowest so-called healthy range.
In fact 70% of all women are naturally going to fall between BMI 21-27 [ibid.], with half of those at BMI 23, 24 or
25.
I get into a lot of detail on the fallacies associated with the healthy weight range set at BMI 18.5-24.9 in
the Fat Series with all the accompanying scientific fact to confirm the falsehoods. Fundamentally, the optimal
weight range for lowest incidence of ill health and death is actually BMI 25-30 [KM Flegal et. al., 2005].
However, you dont maintain your weight, your body does. The minimum guidelines for recovery are, on
average, what non-restricting weight-stable individuals in your category consume to maintain their weight and
health.
Once your body reaches its own optimal weight set point (and only your body decides what that is) then it just
stops gaining weight and starts maintaining the optimal set point it has reached. It does this seamlessly because
the metabolic rate moves back into the optimal range at that same time and biological functions that were on
hold are now back on line.
You gain weight through all those phases of recovery because the metabolism is suppressedthat energy went
to weight gain and repair. But now you are recovered, the energy now goes to day-to-day functions (all the
neuroendocrine systems that had been on hold up to that point).
You gain on recovery amounts and then you maintain on right about the same amount. And once you stop
gaining weight then you can also depend on your hunger cues to keep you eating what your body needs to
maintain your health and weight for the rest of your life.
Unfortunately many of you will be encouraged to restrict under the auspices of maintenance of your weight and
health. Restriction of food intake will always precipitate relapse.
Restrictive eating disorders are chronic conditions and you are never cured of the condition. You can enjoy a
complete and even permanent remission, but it requires of you that you never restrict your intake.
Our society suffers such severe anxiety over obesity and believes, wrongly, that both food intake and exercise
determine the appearance and onset of obesity (they do not), that many health care providers will encourage
patients to be careful about their intake and get back to exercising in this phase for all the wrong reasons. [W.
Kulesza, 1982; JA Baecke et al., 1983; RJ Myers et al., 1988; ML Johnson et al., 1956*; L Lissner et al., 1989; AM
Prentice et al., 1986; H Pontzer et. al., 2012].*Can I just say that we've known this a long time?
Reverse Honeymoon

If you relapse at this point, there will be an initial phase of comfort and ease as your restrictive eating disorder
begins to take hold. I liken this situation to that of returning to an abusive partnerthey are full of care, concern
and apologetic pronouncements that this time will be different.
Its trickery. There is no love or peace to be had within a restrictive eating disorder. If at any time you experience
a relapse, then return to your minimum intake immediately and seek out support to keep working on applying
non-restrictive behaviors instead of restrictive ones in response to anxieties.
You cannot bargain with a restrictive eating disorder and it always plays for keeps.

If you discover that your treatment team that has been so supportive and helpful to now starts to show signs of
its own anxiety and issues around weight and body image, then switch them out.
Your body can only be healthy at its optimal weight set point whether our society can accept that or not is its
problem and not yours.

Knowing When You Can Trust Your Hunger Cues

Almost everyone tries to rush the process of recovery. Despite the fact that they may have massive damage
over years of steady restriction, they still believe that a few months in they are ready to just move on and be
normal.
Here is how you know you are ready to attempt eating to your hunger cues:
1.
2.

Your weight appears stable. (weighing yourself is not necessary to determine that).

in a row.

3.
4.

If you have dealt with amenorrhea during your restriction, then you have achieved 3 consecutive periods

You are continuing to eat minimum amounts and it is comfortable to do so.

Other lingering signs of repair seem complete (no longer cold, tired, achey, dealing with water retention,
no brittle hair or nails etc.)

5.

You think you may need to start eating to hunger cues and are a bit anxious that you can trust those
cues.
Note Item 5if you are feeling extremely confident about eating to hunger cues then chances are you are a
ways away from remission still.
You move from meal plans or counting calories to eating to hunger cues by attempting a 3-day experiment. Eat
to your hunger cues but jot down everything you eat. At the end of those three days you should discover that
your hunger has taken you to approximately the recovery guidelines you have been following thus far. If so, then
you can likely trust your hunger cues and move into your remission with some confidence.
Keep in mind that remission is not a permanent state for most. Life stressors and changes can precipitate slips
that lead to relapses. I encourage you to develop your Relapse Reversal Intervention Kit, which I touch upon in
the Recovery Journal. It is fairly straightforward to avoid a full blown relapse if you are prepared and have
identified likely warning signs well in advance of them actually showing up.