Once a single blog post, this is now a multi-part series on what to expect as you wend your way towards remission from an eating disorder. The series includes the following:

Part 1: Understanding an eating disorder
Part 2: Telltale dozen to uncover an eating disorder
Part 3: Some risks, complications and misdiagnoses

Part 4: Applying the Homeodynamic Recovery Method (HDRM) to get to remission

Part 5: Phases of recovery

Part 4: Applying the HDRM to get to remission

The calorie intake guidelines for the HDRM get a lot of copy on this site and elsewhere too. While these guidelines are discussed in a standalone post on this site, I will include them here as well.

Calorie needs for everyone else

We lie about what we eat. Yes, in health survey after health survey, adult women report eating on average just under 2000 kcal/day and men around 2500 kcal/day. 1, 2, 3 Yet when we actually measure the intake and expenditure in laboratory settings rather than relying on self-generated food journals or survey responses, then subjects eat about one-quarter to one-third more than the surveys would suggest they are eating.

Dr. Dale Schoeller, a professor emeritus with the department of nutritional sciences at the Institute on Aging, University of Wisconsin, specializes in the area of physical activity and obesity, and he has this to say on the validity of doubly labeled water method when compared to our traditional dependence on self-reports for determining energy needs in human beings:

The measurement of dietary intake by self-report has played a central role in nutritional science for decades... Recently, the doubly-labeled water method has been validated for the measurement of total energy expenditure in free-living subjects, and this method can serve as a reference for validating the accuracy of self-reported energy intake. Such comparisons have been made in nine recent studies, and considerable inaccuracy in self-reports of energy intake has been documented. Reported intakes tend to be lower than expenditure and thus are often underestimates of true habitual energy intake. Because the degree of underreporting increases with intake, it is speculated that individuals tend to report intakes that are closer to perceived norms than to actual intake. 4 [emphasis mine]

Dr. James Hébert, professor at the University of South Carolina, and his colleagues specifically investigated how social desirability and approval might impact reporting errors on food frequency questionnaires, seven-day dietary recall and seven 24-hour dietary recall interviews:

Social desirability and social approval distort energy intake estimates from structured questionnaires, in a manner that appears to vary by educational status. For college-educated women with an average social desirability score (~17 points) this would equal an underestimate of 507 kcal/day. 5

Both 7-day and 14-day self-report trials are all over the map in the actual underreporting that occurs and many researchers will classify trial subjects as failed dieters, obese, average-weighted, etc., which likely removes validity from the trial data, as an inherent bias stands that obese individuals are more prone to underreport food intake—a bias that does not stand up in clinical trial scrutiny. 6 And that bias fails to address other valid influences such as social desirability and approval that are strong motivators for the underreporting of food intake, as highlighted by Dr. Hebert and colleagues (quoted above).

The underreporting for both men and women can range from 2% to 58%. However, in the one and only doubly labeled water trial where two groups of women were identified as either non-restrictors or restrictors of food intake, and all were weight stable, the non-restricting group ate on average 2400 kcal/day and the restricting group ate just shy of 2000 kcal/day. 7 Admittedly this is a small study, but I use it because it identifies a clear non-dieting control group.

If we average the studies reviewed by Dr. Hebert and his colleagues, then people eat on average 25% more than they think they do (or report that they do). As most adult women say they eat just shy of 2000 kcal/day, then on average they actually eat 2500 kcal/day to maintain their health and weight.

But the fact that we eat much more than we say we do does not have any correlation to obesity. It only demonstrates the fact that our actual intakes match our energy expenditures. Doubly labeled water trials are measuring actual energy expenditure. A non-dieting subject, regardless of BMI, will naturally match her energy intake to her energy expenditure.

As a common research bias, we end up knowing more about male energy requirements under all manner of situations when compared to female energy requirements. We know that an 11-man sailing crew traveling around the world averaged 4700 kcal/day; six mountain climbers ascending above 19,000 ft. (6000 m) also required 4700 kcal/day; a short-term space flight equaled similar average intake as found on Earth (2800 kcal/day); soldiers in Zimbabwe required 5600 kcal/day; and yet more soldiers on field operations in extreme cold and heat required 4300 and 3900 kcal/day. 8

As a complete mind bender, consider the fact that the astronauts were eating 2800 kcal/day and they all weighed 0 lbs. (0 kg)—in space you are weightless.

There is one trial that did include female cross-country skiers along with their male counterparts. The energy requirements for the female skiers were 3585 to 4827 kcal/day. 9

Urban Chinese adult women (age ranges 35–49) had energy intake levels confirmed at 2300 kcal/day. That their intake was somewhat lower than averages found in North America is not due to racial differences but rather a discrepancy in average height (lower in China for that age range). 10

Pregnant adult women require on average 2854 kcal/day in the first trimester, 3070 kcal/day in the second trimester, and 3092 kcal/day in the final trimester. 11

The compilation of 22 studies indicates that adult women have an average confirmed intake of 2500 kcal/day, using the doubly labeled water method. The average confirmed intake for the adult men was 3400 kcal/day. However, the age range in this compilation for the females was 25 and older, whereas for the males it was 22 and older. Because males younger than 25 will consume more (for developmental reasons), the average intake is a bit higher than for fully matured male adults (approximately 3000 kcal/day). 12

Those Between Approximately Ages 12-24

What does all the data in the previous section mean for those between the ages of 12 and 24? One lone doubly labeled water trial confirms that 14-year-old males and females appear to have energy intake requirements that average out at 3072 kcal/day. 13

In the absence of actual data, we have to use studies of underreporting on this age group to extract likely energy intake requirements. It’s worth noting is that in an additional analysis of a representative cross-section of those who completed the French Étude Individuelle National des Consommations Alimentaires dietary survey, 40% of the children ages 11 to 17 had attempted to lose weight in the past year and 41% wanted to weigh less, out of a total of 881 males and females assessed. In the same study, children ages 3 to 10 underreported food intake by 4.8%, and those between ages 11 to 17 underreported by 26%. No significant differences were found between males and females in underreporting values, and no incidences of overreporting occurred for those aged 11 to 17. 14

In one UK study where the survey results of 16- to 17-year-old female dieters and non-dieters were compared, self-reported intake for dieters was 1604 kcal/day and 2460 kcal/day for non-dieters. 15 Given that underreporting appears to occur at the same rate for 11- to 17-year-olds as it does for their adult counterparts, we can extrapolate that non-dieting teenage girls actually eat 3075 kcal/day to support all their metabolic and developmental needs to arrive at biological adulthood at age 25.

Rather conveniently, 16- to 17-year-old dieting and non-dieting males were also assessed for their self-reported intakes, and male dieters stated they consumed 2190 kcal/day whereas non-dieters stated they consumed 3066 kcal/day. 16 As we know there are no distinctions between rates of underreporting for males and females in this age group, 16- to 17-year-old non-dieting males actually eat 3833 kcal/day to support development to age 25.

And there you have it. Note that none of the above solid data on actual required energy intake for various age and sex-matched subgroups applies to you if you have an eating disorder. This data applies only to energy-balanced individuals, and those with eating disorders are energy deficient.

Homeodynamic Recovery Method food intake guidelines

The Homeodynamic Recovery Method minimum intake guidelines are age-, height-, and sex-matched based on energy intake requirements for equivalent healthy controls. They are based on all the amassed hard data listed above. Of course this is confusing as I have just stated that these intake levels are for energy-balanced individuals and when you have an eating disorder, you are energy depleted. The reason the minimum intakes are set to these levels is that it is a reasonable way to get you started. You will need more than minimum intake to reach remission (see section “Hyperphagia” below).

Adult female

You are a 25+ year-old female between 5’0” and 5’8” (152.4 to 173 cm): minimum 2500 kcal/day.

Adult male

You are a 25+ year-old male between 5’4” and 6’0” (162.5 and 183 cm): minimum 3000 kcal/day.

Adolescent female

You are an under 25-year-old female between 5’0” and 5’8” (152.4 to 173 cm): minimum 3000 kcal/day.

Adolescent male

You are an under 25-year-old male between 5’4” and 6’0” (162.5 and 183 cm): minimum 3500 kcal/day.

Outside the height ranges listed above

If you are taller than the height guidelines listed above, then expect to add approximately 200 kcal/day to the minimum intake amounts listed for your shorter counterparts (age and sex matched).

If you are shorter than the height guidelines listed above, then you may eat 200 kcal/day less than the minimum intake listed for your taller age and sex matched counterparts; however, keep in mind that these are average intake guidelines for those without an eating disorder—you should find yourself wanting to eat far more than these intake guidelines during your recovery process as hyperphagia will kick in to help you replenish the energy deficit in the body.

Outside the assumed weight ranges

The intake values are confirmed averages for those of average height and weight. The vast majority of the population is of average height and of average weight—almost all of us are sitting on or near that peak of the bell-shaped curve. The absolute peak is BMI 27ish, with the range in which approximately 70% of the population will reside between BMI 21 to 30. 17

Only 4% of the adult population is naturally meant to be between BMI 18.5 to 20.9. There is a steep slope up from the x-axis to the peak of the bell curve on the left-hand size and a shallow slope down from the peak of the curve to the x-axis on the right-hand side. Human beings cannot survive being exceedingly tall or exceedingly thin as well as they can survive being exceedingly short or exceedingly fat (see Figure 1).

During the re-feeding phase of recovery, no matter your current BMI, use your age-, sex-, current weight- and height-matched minimum intake amounts and respond fully to the extreme hunger that will likely occur (as per the re-feeding experience for those who were part of the Minnesota Starvation Experiment). If you share an inherited optimal weight set point with the 26% of our population who is naturally above BMI 30, then your daily intake requirements will be higher than average as well. Expect to add an additional 200 to 300 calories to create your daily minimum intake in recovery if you are between BMI 30 and 48.

I realize that this concept will be absolutely horrifying to most people, but as Drs. Philip Mehler and Arnold Anderson pointed out: “someone has to hold down the upper standard deviation from the average, although few women accept this fact…” 19 And as we saw in the Étude Individuelle National des Consommations Alimentaires mentioned in a previous section, both boys and girls between ages 11 and 17 are equally under reporting food intake, suggesting that social acceptability of weight impacts both sexes today.

Parents of young children and/or unavoidable work-based activity

Resting is a critical component of the recovery process, so it is understood that no discretionary activity will be undertaken during recovery: no exercise and workouts.

However much it might be ideal for a patient to convalesce fully during the recovery process, both financial and familial obligations mean that many patients have to face unavoidable activity. In these cases, patients should consider assigning themselves a minimum intake that is 500–1000 kcal more than the intake assigned for their age and sex. But it is very important to recognize that it is not a linear equation in that physical activity is not fully compensated during recovery merely by upping food intake. We know that an energy-depleted body makes conservative metabolic choices that can lead to weight gain in the presence of ongoing energy intake deficits. 20 We also know that women with restriction-induced functional hypothalamic amenorrhea (absence of a regular menstrual cycle due to energy depletion in the body) are rarely able to restore menstruation with increased food intake alone, and they must also stop athletic endeavors at the same time to be successful. 21

When your financial means depend upon a job where you are active (standing, walking or something with significant exertion), consider some these possible options that other patients have used to try to help their recovery efforts:

Coincide the first few weeks of recovery with using up your holiday allotment (if you have that privilege).
Seek a doctor’s note for sick leave for the initial six weeks where the worst of the exhaustion tends to hit.
Investigate any possibility of a temporary work-share with another employee to drop your hours (if you can take the financial hit).

Many patients I have interacted with are unable to entertain the above options and in those cases remission might still be achieved by unabashedly transferring all nonessential activity to loved ones (family and/or friends). Such activities will include household cleaning, general chores and errands, and anything that does not pertain to income-based obligations.

For parents who are primary caregivers (i.e., not an income-based obligation, but most certainly an obligatory effort), make every attempt to transfer as much of the caregiving duties as possible and shift responsibilities elsewhere to ensure sleep duration and quality are improved as much as is feasible.

Try to keep in mind that the ability you have now to place your recovery effort first will greatly enhance your ability to continue to earn a living over the long term as well as to give you the opportunity to be there for your children as they grow.

You will be tempted to classify many things as “unavoidable activity” because you are compelled to do so as part of an active eating disorder. So involve a family member, trusted friend, or therapist in helping you push back on what you might deem unavoidable when compared to what someone who doesn’t deal with an eating disorder might deem unavoidable.

A note on counting calories

Someone with an active eating disorder cannot “eat intuitively” or depend on hunger cues to provide sufficient energy to the body. Anxiety responses create a strong and constant pressure to avoid food. As such, a patient should ensure she eats the minimum intake guidelines within each 24-hour period.

However, counting calories can be anxiety provoking in itself and lead to obsessive compulsivity associated with weighing and measuring food portions. In those cases, patients should involve a dietician or nutritionist to help develop a meal plan. The meal plan should be designed to meet and exceed the minimum intake guidelines. The patient can then focus her attention on merely ticking off the items on the daily intake list, thereby minimizing the anxiety of counting calories for each food item.

It is just fine to ask a family member or friend for help in designing the meal plan as well. Whether it is a meal plan or a calorie-counting exercise, the goal is to relinquish all control to hunger and accept the onslaught of extreme hunger.

Many patients are keen to move to “intuitive eating” very early in the process of recovery. Resist the urge to do so until well beyond phase two; otherwise relapse can occur.

Minnesota Starvation Experiment

In 1944, as the ravages of starvation due to World War II were at their peak across Europe, a researcher sought to gain an understanding of the physiological impacts of starvation and re-feeding in the hopes that it might be possible to help survivors restore their health.

Dr. Ancel Keys, responsible for the development of the US army’s K rations and head of the laboratory of physiological hygiene at the University of Minnesota, believed that a study on starvation might have important humanitarian and practical benefits. Keys enlisted 36 volunteers for his starvation experiment. They were all young male volunteers who formed part of the Civilian Public Service as conscientious objectors.

The first 12 weeks involved standardizing the men on 3200 kilocalories per day (kcal/day) while assessing all their biological and psychological markers as a baseline prior to the semi-starvation period of the study. Three months in, the calorie intake was cut to 1570 kcal/day. The diet was carbohydrate rich and protein poor to simulate the conditions faced by many in war-ravaged Europe. During this six-month semi-starvation period the physical and psychological impacts of the restriction were astounding to Keys and his fellow researchers.

There are numerous online sources that provide a comprehensive outline of the experiment and its outcomes, and a good book on the topic is The Great Starvation Experiment: Ancel Keys and the men who starved for science, by Todd Tucker [University Minnesota Press, 2006].

For the purpose of the development of the Homeodynamic Recovery Method for treating an eating disorder, there are two critical outcomes from the Minnesota Starvation Experiment that form self-evident yet nonetheless greatly overlooked requirements for reaching remission after self-imposed restriction of food intake: 1) a starved brain works very poorly; and 2) excess food intake will be required beyond pre-starvation amounts to restore weight, health, and ultimately sanity.

Dr. Emily Troscianko, a researcher in the field of eating disorders, had the following analysis to offer on how the Minnesota starvation experiment informs the recovery process from an eating disorder:

1. If you regain weight, not only the physical effects of your current state — being constantly cold and weak, . 22sleeping and concentrating poorly, bad hair and skin — will disappear, but so will the ways in which you currently think and feel. Your body is starved, and your character and your thoughts are dominated by this starvation, and will cease to be so once you allow yourself to regain weight.
2. There is no point in waiting for the magical moment at which you decide, once and for all, that you want to start eating more again, or to regain weight. Your starved state is making you unable to think flexibly enough to fully comprehend the possibility of eating or living differently, or even the possibility of wanting to think about and enjoy things other than food; it has hidden from you who you really are, and made you believe you are nothing but the anorexia; it is making the smallest piece of food feel like too much. For these reasons you will never truly want to recover, but you have to seize all your feelings of despair, desperation, hope, recklessness, and curiosity in order to make yourself plunge into that first day and first meal of recovery. As long as you keep yourself going, keep eating, through the first difficult weeks, it will get easier and easier

As with a patient suffering from suboptimal blood oxygen levels (hypoxia), or a patient suffering from diabetic-induced combativeness (in need of insulin), or even a patient who has head trauma that involves potentially fatal injury and yet he assures the paramedics he is fine, the brain is not designed to identify its own impairment. There is a reason that anti–drinking-and-driving campaigns urge you to make plans to have an alternate way of getting home before you head out for a night on the town: by the time you have had a couple of drinks you will not be able to correctly assess the fact that you are too impaired to drive safely.

There are still recalcitrant and dogmatic old-school format treatments for eating disorders that emphasize the need for neutralizing the influence of supposedly cold and distant mothers, for psychodynamic analysis, and for insisting that self-imposed starvation is not about the food. However, fortunately most modern and science-based treatments have recognized that, until a patient is re-feeding and redressing the energy deficits, the brain cannot function. Therefore, expressions of psychological distress may well be present entirely due to the starvation-induced impairment of the brain—exactly as was seen in the Minnesota starvation subjects.

No one takes too much issue with the rather self-evident necessity of re-feeding after a period of self-imposed starvation. Where things get awfully sticky is that excess food intake is actually required to redress the energy deficit in the body. The research chasm 23 reflects the serious delay from the time at which there is sufficient clinical trial data to change practice behaviors, to the actual point at which those behaviors are dependably and broadly in place in practitioner settings. The research chasm is at work for the treatment of eating disorders precisely because the research data confirm excess energy will be required to reverse the impacts of starvation and yet many treatment programs still apply food intake guidelines that are only relevant for those without eating disorders.

Overshooting fat mass in weight restoration

The model predicted that the fat mass overshoot was not permanent… however, recovery of the original body composition was predicted to take more than a year. The predicted mechanism of the fat mass overshoot was an enhanced rate of de novo lipogenesis in the early re-feeding period, followed by a dramatic increase of fat intake during ad libitum feeding. 24

In its original published form, the Minnesota Starvation Experiment comprises two volumes. The above quote is from an in-depth computational analysis of the masses of data provided by that starvation experiment. Another similar computational review of the same starvation data restated the same outcome as “the original body weight and composition was eventually recovered but body fat mass was predicted to take more than one additional year to return to within 5% of its original value.” 25

If there is one phrase that strikes cold, icy fear into the heart of any ‘self-respecting’, weight-conscious person today it is “fat mass overshoot…”

But what is this dreaded overshoot really all about? And maybe it appeared for a bunch of hapless volunteers in a starvation study that would be too unethical to replicate today, but surely it is different when it comes to re-feeding from a period of self-imposed starvation due to an eating disorder?

It is the curse of the research chasm that “recover, but not too much” prevails in too many treatment programs ostensibly designed to help patients with an eating disorder reach remission. Treatment decisions such as assigning specific weight targets or body mass index points, indicating that there is a risk of developing binge eating, and/or suggesting that the overshoot of fat mass is dangerous or unhealthy all contradict solid evidence that re-feeding after a period of semi-starvation involves eating to excess for a period of time. And for many, the recovery process will naturally involve a temporary, and needed, overshoot of fat mass for perhaps a year to several years before that fat mass naturally returns to its optimal point.

And it’s important to recognize that the temporary overshoot can happen no matter where you are expected to be (from a hereditary point of view) on the bell-shaped curve of healthy, natural incidence of body mass index (as per Figure 1 above).

While these facts are not news within the research community, you can be sure that many practitioners will raise a skeptical eyebrow at the concept. To reach remission you must allow the body its process of energy replenishment as it sees fit.

Restriction is the enemy.

Restorative eating is designed to redress deficits

Drs. David M. Garner and Paul E. Garfinkel, researchers in the field of eating disorders responsible for developing numerous psychometric tests for the identification of eating disorder behaviors in individuals, had the following to say on the topic of the kind of reactive eating that was witnessed in the ad libitum (freely, without restraint) re-feeding period that occurred after the initial slow stepped re-feeding period in the Minnesota Starvation Experiment:

During the weekends in particular, some of the men found it difficult to stop eating. Their daily intake commonly ranged between 8,000 and 10,000 calories…

After about 5 months of refeeding, the majority of the men reported some normalization of their eating patterns, but for some the extreme overconsumption persisted: “No. 108 would eat and eat until he could hardly swallow any more and then he felt like eating half an hour later” (p. 847). More than 8 months after renourishment began, most men had returned to normal eating patterns; however, a few were still eating abnormal amounts: “No. 9 ate about 25 percent more than his pre-starvation amount; once he started to reduce but got so hungry he could not stand it” (p. 847)… Serious binge eating developed in a subgroup of men, and this tendency persisted in some cases for months after free access to food was reintroduced; however, the majority of men reported gradually returning to eating normal amounts of food after about 5 months of refeeding. Thus, the fact that binge eating was experimentally produced in some of these normal young men should temper speculations about primary psychological disturbances as the cause of binge eating in patients with eating disorders. These findings are supported by a large body of research indicating that habitual dieters display marked overcompensation in eating behavior that is similar to the binge eating observed in eating disorders (Polivy & Herman, 1985, 1987; Wardle & Beinart, 1981). [emphasis mine]. 26

Abdul Dulloo and his colleagues in 1997 postulated that the fat mass to fat-free mass data collected from the Minnesota Starvation Experiment during the ad libitum re-feeding period suggests “that poststarvation hyperphagia [excess eating] is determined to a large extent by the autoregulatory feedback mechanisms from both fat and lean tissues.” 27 The subjects all returned to pre-starvation fat mass to fat-free mass ratios, although, as mentioned above, it could take beyond a year for that to occur.

Interestingly, a few clinical trials assessing the body fat composition of weight-restored patients with an eating disorder suggest that fat mass levels were higher than healthy controls and they remained unevenly distributed at the abdominal and tricep regions after re-feeding. 28, 29 However, I suggest that this data is the result of incomplete recovery processes whereby a specific weight target was applied as a faulty marker of remission. If ad libitum re-feeding and longitudinal assessment are applied beyond the one-year period of weight readjustment, then in fact the clinical findings support my assessment: namely those with eating disorders also return to optimal fat mass to fat-free mass ratios assuming they mimic the re-feeding process seen within the Minnesota Starvation Experiment (i.e., they respond fully to hyperphagia). 30

Restriction of food intake is very similar to restriction of sleep. The impacts of doing so are cumulative in nature. If you stayed up for 36 hours straight and then went to sleep, would you be concerned if your sleep lasted more than 8 hours? Would you be surprised if you were still tired when you awoke and the subsequent night you found you still required perhaps more sleep than was usual to feel really “caught up” the next morning?

Hyperphagia in recovery

August 2, 2012
Kimberly

Not too long ago, I put some hash browns in the oven and decided to have some toast while I waited. While the toast was in the toaster, I had some cashews and poured myself a bowl of yoghurt—so, essentially, I was having a snack while I waited for the second snack that I was preparing while I waited for the first snack. SNACKCEPTION.

Patients find extreme hunger very upsetting and disturbing in recovery, so I will examine this in some detail before moving onto the phases of recovery as a whole. So pervasive are the misconceptions regarding binge eating and so-called emotional eating as dangerous and unacceptable behaviors that lead to ill health and obesity, it takes herculean focus to maintain respectful responsiveness to the demands for energy that the body is making.

In simplified terms, several hormones including leptin and adiponectin can activate adenosine monophosphate-activated protein kinase (AMPK) and that in turn regulates metabolic choices between anabolism (resulting in the building up of tissue) and catabolism (resulting in the breaking down of tissue). 31 These same hormones also act on the brain and specifically interact with the hypothalamus, which is responsible for identifying whether energy balance is present or absent throughout the entire body. 32 Leptin and adiponectin, as well as resistin and several others, are all generated by cells within the fat organ of your body.

In our current understanding of the cycle of these adipocytokines (as these fat-generated hormones are called as a group), their serum levels are affected by restriction of energy intake (even before catabolism occurs); they “inform” the hypothalamus of an energy deficit; and they activate AMPK to begin the process of catabolism of existing body tissue (made up of cells, obviously) to release energy to support ongoing biological functions.

One of the reasons that those with an active eating disorder often do not appear deficient in many minerals and vitamins may not actually be due to their heavy use of vitamin and mineral supplements, but rather the release of these minerals and vitamins through catabolism of their own body tissue. 33 Catabolism (the destruction of cells and tissue) releases the energy necessary to try to remediate the drop in serum adipocytokine levels while at the same time those levels are signaling the hypothalamus that energy intake is a necessity to reverse the process of catabolism. When you see the word “catabolism,” think cannibalization of your own being.

It is rather obvious to point out that, in the aftermath of restriction, the catabolism (breakdown of tissue) has to be reversed with anabolism (the buildup of tissue).

Nonetheless, this process is complicated further as the gastrointestinal tract has its own nervous system—the enteric nervous system—and specific peptide hormones are released by the gastrointestinal tract in response to the presence of food as well: peptide YY, pancreatic polypeptide, glucagon-like peptide-1, and oxyntomodulin. And these peptides are all presumed to act as postprandial (after a meal) satiety signals. 34

Your gut and your mind

When a person is energy balanced, then hunger, fullness, and satiation are all synchronized. But after just a few weeks (let alone months or years) of catabolizing your own body, these things will be asynchronous when you begin to reverse the damage.

In the earlier phases of recovery, you experience significant sensory dissonance because physical fullness, as identified by your enteric nervous system, and extreme absence of satiation, as experienced by your central nervous system are confirming you are both full and hungry at the same time.

Your enteric nervous system is receiving information that the physical aspects of energy absorption are at peak levels, yet the central nervous system continues to receive information that more anabolism (building up of tissue) is required to return to an energy-balanced state. You are gut-full, body-empty.

Try not to get too caught up in what descriptions your conscious mind generates to try to make sense of the nonsensical as you move through these phases of recovery. Your job is to eat. The anxieties about whether it is “normal,” “emotional,” or “the stomach has adapted to more food” are just that: anxieties.

If you feel the need to eat more, then it doesn’t matter how your mind describes that need; the drive to eat is fundamentally sound and all about energy restoration, or anabolism.

Three-legged stool for success

The HDRM for attempting to achieve remission from an eating disorder is built upon a sturdy three-legged stool where each leg is described as follows:

Weight restoration (re-feeding)
Repair of physical damage (resting)
Developing new non-restrictive neural patterns in response to usual anxiety triggers (brain re-training)

An easier way to remember the method is as the three “R”s to remission: re-feeding, resting, and re-training.

It is best to develop your three-legged stool toward remission by attending to the above facets in order. However, you cannot sit on a two-legged stool, so the sooner you are consuming the minimum intake, the sooner you will have enough energy for the brain to be able to handle the work you will undertake (with a suitable counselor or therapist) to develop the new non-restrictive neural patterns.

Remember to involve your medical advisor before you begin upping calorie intake.

In part 5 we’ll look at what to expect in the phases of recovery to remission.

1. Health Canada, Statistic Canada. “Canadian community health survey cycle 2.2, nutrition intakes from food (provincial, regional and national summary data tables)”, Vol.1, Revised March 31, 2008 and February 2009.

2. Public Health England, Food Standards Agency. “National diet and nutrition survey: results from years 1-4 (combined) of the rolling programme (2008/2009 – 2011/12)”, Executive summary, 2014: 11.

3. Wright, Jacqueline D., Chia-Yih Wang, Jocelyn Kennedy-Stephenson, R. Bethene Ervin. “Dietary intake of ten key nutrients for public health, United States, 1999-2000.” CDC Advance Data from Vital and Health Statistics, no. 334 (2003).

4. Schoeller, Dale A. "How accurate is self-reported dietary energy intake?" Nutrition Reviews 48, no. 10 (1990): 373-379.

5. Hebert, James R., Cara B. Ebbeling, Charles E. Matthews, Thomas G. Hurley, M. A. Yunsheng, Susan Druker, and Lynn Clemow. "Systematic errors in middle-aged women's estimates of energy intake: comparing three self-report measures to total energy expenditure from doubly labeled water." Annals of Epidemiology 12, no. 8 (2002): 577-586.

6. Asbeck, I., M. Mast, A. Bierwag, J. Westenhöfer, K. J. Acheson, and M. J. Müller. "Severe underreporting of energy intake in normal weight subjects: use of an appropriate standard and relation to restrained eating." Public Health Nutrition 5, no. 05 (2002): 683-690.

7. Tuschl, Reinhard J., Petra Platte, Reinhold G. Laessle, Willibald Stichler, and Karl-Martin Pirke. "Energy expenditure and everyday eating behavior in healthy young women." The American Journal of Clinical Nutrition 52, no. 1 (1990): 81-86.

8. Schoeller, Dale A. "Recent advances from application of doubly labeled water to measurement of human energy expenditure." The Journal of Nutrition 129, no. 10 (1999): 1765-1768.

9. Sjoedin, ANDERS M., AGNETA B. Andersson, JEANETTE M. Hoegberg, and KLAAS R. Westerterp. "Energy balance in cross-country skiers: a study using doubly labeled water." Medicine and Science in Sports and Exercise 26, no. 6 (1994): 720-724.

10. Yao, M., M. A. McCrory, G. Ma, Y. Li, G. G. Dolnikowski, and S. B. Roberts. "Energy requirements of urban Chinese adults with manual or sedentary occupations, determined using the doubly labeled water method." European Journal of Clinical Nutrition 56, no. 7 (2002): 575-584.

11. Butte, Nancy F., William W. Wong, Margarita S. Treuth, Kenneth J. Ellis, and E. O’Brian Smith. "Energy requirements during pregnancy based on total energy expenditure and energy deposition." The American Journal of Clinical Nutrition 79, no. 6 (2004): 1078-1087.

12. Schulz, Leslie O., and Dale A. Schoeller. "A compilation of total daily energy expenditures and body weights in healthy adults." The American Journal of Clinical Nutrition 60, no. 5 (1994): 676-681.

13. Bandini, Linda G., Dale A. Schoeller, Helen N. Cyr, and William H. Dietz. "Validity of reported energy intake in obese and nonobese adolescents." The American Journal of Clinical Nutrition 52, no. 3 (1990): 421-425.

14. Lioret, Sandrine, Mathilde Touvier, Morgan Balin, Inge Huybrechts, Carine Dubuisson, Ariane Dufour, Mélanie Bertin, Bernard Maire, and Lionel Lafay. "Characteristics of energy under-reporting in children and adolescents." British Journal of Nutrition 105, no. 11 (2011): 1671-1680.

15. Crawley, Helen, and Rita Shergill‐Bonnert. "The nutrient and food intakes of 16–17 year old female dieters in the UK." Journal of Human Nutrition and Dietetics 8, no. 1 (1995): 25-34.

16. Crawley, H., and C. Summerbell. "The nutrient and food intakes of British male dieters aged 16–17 years." Journal of Human Nutrition and Dietetics 11, no. 1 (1998): 33-40.

17. Centers for Disease Control and Prevention. “National Health and Nutrition Examination Survey [NHANES] 2005-2006”, CDC.gov (data), November 2007, http://www.cdc.gov/nchs/nhanes/nhanes2005-2006/BMX_D.htm.

18. ibid.

19. Mehler, Philip S., and Arnold E. Andersen. Eating disorders: a guide to medical care and complications, 2nd edition, (Baltimore: John Hopkins University Press, 2010).

20. Olwyn, Gwyneth, “Gaining Weight Despite Calorie Restriction.” The Eating Disorder Institute (blog), June 13, 2015, http://www.youreatopia.com/blog/2015/6/13/gaining-weight-despite-calorie-restriction

21. American College of Sports Medicine. "The female athlete triad." Special Communications (2007): 1867-1882.

22. Troscianko, Emily, T. “Starvation study shows that recovery from anorexia is possible only by regaining weight”, Psychology Today (blog), November 23, 2010, https://www.psychologytoday.com/blog/hunger-artist/201011/starvation-study-shows-recovery-anorexia-is-possible-only-regaining-weight.

23. Glasgow, Russell E., and Karen M. Emmons. “How can we increase translation of research into practice? Types of evidence needed.” Annual Reviews Public Health 28 (2007): 413-433.

24. Hall, Kevin D., and Vickie E. Baracos. "Computational modeling of cancer cachexia." Current opinion in clinical nutrition and metabolic care 11, no. 3 (2008): 214.

25. Hall, Kevin D. "Computational biology of in vivo human energy metabolism during semi-starvation and re-feeding." The FASEB Journal 20, no. 5 (2006): A1300.

26. Garner, David M., and Paul E. Garfinkel, eds. “Handbook of Treatment for Eating Disorders.” (New York: Guilford Press, 1997), pp.156-157.

27. Dulloo, Abdul G., Jean Jacquet, and Lucien Girardier. "Poststarvation hyperphagia and body fat overshooting in humans: a role for feedback signals from lean and fat tissues." The American journal of Clinical Nutrition 65, no. 3 (1997): 717-723.

28. Mayer, Laurel, B. Timothy Walsh, Richard N. Pierson, Steven B. Heymsfield, Dympna Gallagher, Jack Wang, Michael K. Parides et al. "Body fat redistribution after weight gain in women with anorexia nervosa." The American Journal of Clinical Nutrition 81, no. 6 (2005): 1286-1291.

29. Scalfi, L., A. Polito, L. Bianchi, M. Marra, A. Caldara, E. Nicolai, and F. Contaldo. "Body composition changes in patients with anorexia nervosa after complete weight recovery." European Journal of Clinical Nutrition 56, no. 1 (2002): 15-20.

30. Mayer, Laurel ES, Diane A. Klein, Elizabeth Black, Evelyn Attia, Wei Shen, Xiangling Mao, Dikoma C. Shungu et al. "Adipose tissue distribution after weight restoration and weight maintenance in women with anorexia nervosa." The American Journal of Clinical Nutrition 90, no. 5 (2009): 1132-1137.

31. Hardie, D. Grahame, John W. Scott, David A. Pan, and Emma R. Hudson. "Management of cellular energy by the AMP-activated protein kinase system." FEBS letters 546, no. 1 (2003): 113-120.

32. Flier, Jeffrey S. "Regulating energy balance: the substrate strikes back." Science 312, no. 5775 (2006): 861-864.

33. Casper, Regina C., Barbara Kirschner, Harold H. Sandstead, Robert A. Jacob, and John M. Davis. "An evaluation of trace metals, vitamins, and taste function in anorexia nervosa." The American Journal of Clinical Nutrition 33, no. 8 (1980): 1801-1808.

34. Chaudhri, Owais B., B. C. T. Field, and S. R. Bloom. "Gastrointestinal satiety signals." International Journal of Obesity 32 (2008): S28-S31.

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