One of the toughest parts of eating disorder treatment may be weight restoration, or helping a person reach a healthy weight. But as an eating disorder registered dietitian in recovery, I know firsthand that the discomfort of weight restoration—the physical, the emotional, the psychological—is well worth it.
What is weight restoration, and why is it important?
In eating disorder recovery, weight restoration is the process of gaining enough weight to reach a healthy, stable, and sustainable weight for a person's body. Weight restoration can be a challenge for the person in treatment as well as for their loved ones and providers, but it’s an essential part of treatment. Without full weight restoration, full recovery isn’t possible.
Weight restoration isn’t just for people who are underweight. It’s necessary in multiple instances regardless of a person’s body size, including when a person loses weight through disordered behaviors or when they are chronically below their body’s healthy weight (which may be different than what the BMI chart says they “should” be). In the instance of a child or teen, weight restoration is usually necessary when they experience a drop on their growth chart or fail to gain appropriate weight to support their physical and cognitive growth.
The bottom line is this: in order to achieve lasting recovery, full weight restoration is crucial for most eating disorder patients. Read on to learn why this is the case, as well as common questions that both patients and their loved ones have about weight restoration.
If someone seems healthy, why do they need to gain more weight?
One of the most dangerous misconceptions about eating disorders is the belief that we can tell how sick a person is based on their weight and appearance.
“While a patient may be doing ‘better than before,’ there are often still signs that more weight restoration is needed,” says Brandy Minks, an RD specializing in eating disorders. She says some of those signs include binge eating, abnormal hunger and fullness cues, preoccupation with food, or ongoing physical symptoms that can’t be tied to another medical issue (like frequent colds or digestive issues).
Contrary to what I was taught in my (traditional) dietetics training and have now unlearned, Body Mass Index (BMI) is not a reliable predictor of a person’s health nor weight, and it’s often a faulty tool for setting an eating disorder patient’s target weight. This means that even if a person’s weight falls into the “healthy BMI range,” they can still be weight-suppressed, meaning they are below their body’s healthy weight.
Weight suppression carries significant psychological and physical health risks, including death. “The risks of being weight-suppressed can range from mental health concerns to fatal heart conditions,” says Caroline Thomason, an eating disorder registered dietitian. “Further, malnutrition can have serious consequences like decreased immune function and risk for osteoporosis.”
Minks adds that not gaining adequate weight can cause a poor quality of life due to “debilitating physical or mental symptoms.” Those symptoms can include cold intolerance, dizziness, low blood sugar, GI issues, fatigue, headaches, and anxiety, among many others.
Another significant physical risk of weight suppression is functional hypothalamic amenorrhea (FHA), or the absence of regular periods in those who should be menstruating. FHA can cause infertility, poor bone health, declining heart health, and unstable hormones. This happens because when someone is below their body’s healthy weight, their body will distribute its minimal energy to critical organs (like the heart) to ensure they stay alive; meanwhile, the reproductive system basically shuts down until it has enough energy and fat to work again.
Mentally, weight suppression helps keep an eating disorder alive by allowing the disease to maintain its grip on a person’s mind. Despite intake being largely improved, every single one of my clients who was still weight-suppressed reported being consumed with eating disorder thoughts and thoughts of food until they had achieved full weight restoration. This was true even if they “looked healthy” and were eating what seemed to be a “normal” amount.
Weight suppression can also prevent progress in other areas of treatment, like individual therapy. Without a clear connection to their body and a relatively clear mind, it can be futile for patients to attempt to do the deeper work.
What are the benefits of weight restoration?
Although it can be a hard process for both patients and their loved ones, reaching full weight restoration is well worth the struggle. In addition to avoiding all of the mental and physical risks outlined above, weight restoration also comes with many benefits for those struggling with an eating disorder.
Physically, weight restoration supports healing across several body systems, including the cardiovascular, skeletomuscular, immune and reproductive systems. For example, anemia is a typical condition I see in my clients who are malnourished and weight-suppressed. Anemia directly affects immune health—making it harder to fight off illness and infections—and heart health—putting clients at risk for developing serious cardiac complications. Thankfully, with an adequate and relatively balanced intake along with weight restoration, anemia can be reversed.
“Weight restoration allows the body to heal from macro- and micronutrient deficiencies, resulting in significant quality of life improvements in terms of both physical symptoms,” Minks says.
Not only does it help to support optimal physical health, but weight restoration is also a key factor in improving mental and emotional well-being.
Research shows adequate weight gain is one of the best predictors of psychological improvement and reduced eating disorder symptoms. Another study showed an association between weight restoration and improved mental processing speed in kids and teens with anorexia nervosa.
In my practice, one of the most common symptoms I observe in clients who are restricting (even slightly) and weight suppressed is the mind being nearly or completely consumed with thoughts of food. Weight restoration allows a patient to get rid of their scarcity mindset and eliminate this preoccupation.
Early on in our work together, I ask my clients to draw a pie chart showing the percentages of brain space that thoughts of food takes up. Their charts always show food taking up at least 75 percent, with only 25 percent left (at most) for the entire rest of their life. Once they’ve become weight-restored, their new pie chart will typically show food taking up around 10 percent of brain space, leaving most of it free for a whole life, full of family, friends, passions, education, and work.
Why is my or my loved one’s target weight so high?
In the weight restoration process, a person’s target weight (typically set by their RD and doctor) is typically at least their weight prior to eating disorder onset and sometimes higher. In the case of children, teens, and younger adults, it’s almost always higher in order to support healthy development. Sometimes, a person’s target weight is higher than what may seem to be a “healthy” or acceptable weight, according to society’s narrow standards.
“Weight stigma [or bias against larger-bodied people] is the main reason for resistance to target weights that seem too high,” says Minks. “I’ve had families and providers voice that if the patient gains ‘too much weight’ they will no longer be healthy, or will develop diseases like diabetes or heart disease, or will not be attractive or find a partner.” Thomason adds that those supporting people in treatment often carry their own weight biases, believing that those in larger bodies are less happy, successful, or attractive. “This can happen subconsciously, and loved ones may not even realize that they are projecting this onto the patient in recovery,” she says.
Not only are these beliefs untrue, but they also ignore the fact that if a patient fails to reach their true target weight, they cannot be fully rid of their eating disorder.
Like Minks, I often help clients and their loved ones gently pull back the veil on diet culture and see that recovering into a larger body is okay and often necessary. In fact, weight and health are not synonyms: it is entirely possible to live in a larger body and be a healthy, happy human, and body diversity is part of human biology.
In addition to the influence of weight stigma and diet culture, patients and their families might feel overwhelmed at the idea of reaching a higher-than-expected target weight, so it may feel more attainable or realistic to lower it. However, lowering the target weight (if it was set appropriately) will often make reaching full recovery harder, because this is exactly what the eating disorder desires. As writer and eating disorder recoveree and activist Emily Boring put it in a 2021 podcast interview, “When in doubt, aim higher.”
Recovery is all about re-establishing a life worth living, one that is aligned with a person’s needs and desires, and being weight suppressed makes it significantly more difficult to do so. It may be challenging, but weight restoration gives people the mental and emotional energy they need to live in connection with their core values and pour themselves into the parts of life that mean the most to them—like family, travel, and joy—instead of pouring everything they have into their eating disorder.
Achieving weight restoration is nearly impossible without support. If you or your loved one are struggling, reach out to our team for a consultation.
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