Edema

The Bane and Blessing of the Recovery Process

Water retention. Massive water retention. Water retention that hurts. Water retention that aches. Water retention that makes you look pregnant. Water retention that looks like it might be real weight. Water retention that adds 16 lbs. (7.3 kg) or more on the scale after only 2-3 days of eating recovery guideline amounts of food. Water retention that scares you. Water retention that sends you scurrying back into full-blown relapse.

After being immersed in all things eating disorders for coming up on three years now, I would have to say this is likely the number one source of anxiety for those in recovery. In this post I will synthesize the things you do and don’t do to manage this tough symptom of recovery and repair.

Number One: Be Prepared

The best way to handle the experience of edema is to know ahead of time what to expect. 

In this section we will look at sub-optimal food intake, upping the intake to optimal amounts, your relationship to the scale and measuring tape (hint: there is no relationship), and tips for easing the discomfort without extending the period of time needed for water retention.

Sub-Optimal Intake and Getting Stuck

If you have been slowly increasing your calorie intake to get to the minimum required intake guidelines*, you may already be experiencing some water retention and weight gain.

Often, patients panic and assume that if they are gaining on a less than the optimal amount for recovery, then they cannot increase their calories further because they will gain more/faster/too much.

The reason you can begin to retain water and gain real flesh and bone on less than optimal amounts of food intake is because your metabolism remains suppressed.

Your metabolism is not broken.

Your metabolism is doing exactly what it needs to do to keep you alive. As already mentioned in the previous post on Extreme Hunger One, when you restrict either through eating too little and/or exercising too much your body does two things to keep you going:1) stops whatever biological functions it can to save energy, and 2) takes energy from fat tissue, bones, muscles, organs and nerves to fill the void. The way it stops running non-critical biological functions is to drop the metabolic rate.

The body likes to be conservative and so it will not raise the metabolic rate when you are eating between 1000-2000 calories a day but it will take whatever extra energy that would normally go to biological functions and replenish the fat organ with it instead. Being conservative in this way the body protects you from organ failure in cold weather (due to hypothermia) and the fat organ is able to begin producing more hormones to support bringing back on line more metabolic functions should the food intake continue to be increase to real recovery levels.

You will not gain real flesh and bone faster at higher food intakes. You need higher food intakes to provide energy for physical repair and not just for restoring your weight. The recommended intake guidelines with HDRM are below what used in inpatient and outpatient settings for recovery from eating disorders around the world because they specifically reflect average intake those who don’t have eating disorders. That is why these guidelines are clearly marked as “minimum” amounts. You are expected never to go below the guidelines, but expected to respond to extreme hunger that will take you thousands of calories above those minimums.

The issue is not whether you are clinically underweight or not. The issues are: 1) whether you are underweight relative to what your body deems is your optimal weight set point, and/or 2) whether you have unseen internal damage and suppressed metabolic function due to restriction of intake relative to your body’s actual energy needs.

While you can restore your weight at sub-optimal intakes, you cannot repair all the damage and enter a robust and hopefully permanent remission that way.

But before you go any further in your efforts, you need to know about refeeding syndrome.

Refeeding Syndrome: Risks and Symptoms

First of all, refeeding syndrome is rare. It’s rare even with the most severely emaciated and ill patients in hospital settings. However when it happens, it is life-threatening and requires immediate medical attention. It is easily resolved in a hospital setting, but you need to get there fast.

Please review Phases of Recovery Part Three for further details and reference on refeeding syndrome

Refeeding syndrome is not subtle and you will feel very, very ill. You will want to stay in bed. You will be feverish, clammy and nauseous. You may likely vomit and you will experience severe swelling of the hands and feet. If you have these symptoms, call for immediate emergency help. As I mentioned, it is quickly rectified but you need immediate intervention.

The Scales and Measuring Tape: Loyal Friends to the Eating Disorder

The scales and the measuring tape are two of the eating disorder’s most favoured torture implements to get you to cower right back into a relapse.

There will be all manner of reasons you will come up with why you think your situation is the exception and why you need to monitor your weight or measure the changes in your waist or thighs. These are all reasons that have been dreamed up by your eating disorder and have been applied by thousands before you (unsuccessfully) and will be applied by thousands more after you as well.

And while of course I hope to spare you the panic and terror you will experience when you step on the scales and see 16 lbs/7 kg have magically shown up in just three days from the start of your recovery effort, sadly I cannot.

But I can tell you, when you invariably do step on the scales or weigh yourself, that it is not physically possible to gain ____ (fill in your amount here) amount of weight (flesh, organ and bone recovery) in ____ (fill in time span here) and that you need to get rid of the scales altogether.

I can also tell you that you do not need to weigh yourself at all in recovery. You have nothing to monitor because your weight will stop increasing when it’s good and ready to do so. Yep. No exceptions.

I can also assure you that when you tell me ____ (fill in the weight gain here) seems too much, too fast, unique, unusual, never seen before—it is indeed water retention.

And finally, I am so phenomenally omniscient that I can predict that none of the past six paragraphs will mean a thing to you and you will still feel compelled to keep asking:

1) Am I almost done in my recovery process (because I am almost at a normal weight)? or

2) So scared—is this weight gain going to slow down? or

3) This can’t all be real weight, right?

And the answers are again: 1) No 2) Yes 3) Right. The best way to manage this constant anxiety that does not respond to the repeated answers above is to review the post: Anxiety One

Why Does Edema Happen in Recovery?

When you twist your ankle badly it swells up and it hurts. These are symptoms of healing. The swelling is water retention and the pain is the reaction of the tissues to that swelling that signals you to stay off the ankle and rest.

The water retention in recovery is fluid being retained in areas where a whole mess of damage is being cleaned up and removed by all those fabulous cells dedicated to the task. The fluid actually speeds up the process because things travel faster in and out that way.

Think of it as your own personal City of Venice and all the damaged, overworked, cells that have been on shift for months (because restriction means no back-up cells are available to takeover) are now hopping on the gondola and heading out for retirement (finally).

And the sore is the body's way of trying to keep you immobile—it’s a bit harder for the gondolas to do their job if you either flush all the water away with diuretics or you decide to ignore the pain and slosh everything all over the place instead.

Sore is the signal to rest.

That swelling is a badge of healing honour.

You do not want to try to make the water retention go away because with it will go the healing process as well.

Tips To Manage Edema

The first thing to accept is that the body needs you to rest. You have to chill. Relax.

Ideally spend most of your time sitting with your feet up, lounging or lying down.

Eat a lot. Snack constantly. The more energy you provide, the faster those gondolas move nutrients into the area for repairs and damaged cells away from the area as well.

Put nothing on that doesn’t have some elastic and lycra. Stretchy and floaty clothes are also your best friends.

Don’t use diuretics. Ever. If the swelling is very painful and you still have things you have to do, then (with a doctor’s okay) consider compression socks, hose and garments to ease the pain while still allowing the healing to continue.

Nap and sleep as much as you possibly can.

Donate your clothes. Never try on clothes that once fit you. There are several really good reasons for this approach. First of all, if they fit then you are not recovering. Secondly, if they don’t fit you will get upset despite the fact that it is a clear indicator you are recovering. Thirdly, only weighing yourself or measuring your dimensions is worse than trying on old clothes when it comes to handing a relapse on a silver platter to the eating disorder.

Remember how I mentioned that you to get rid of the scales and the tape measure? Well, it’s worth repeating. Do not weigh yourself or measure yourself. If you are being supported through recovery with a treatment team, then make it very clear you want blind weigh-ins—that means that you do not face the scales and only your treatment team is aware of exact progress.

They are also not to comment on, show facial responses to, or otherwise "accidentally" let you know your weight either.

Use this time to journal. Investigate all the aspects of yourself that have gone by the wayside, or perhaps never even had a chance to flourish.

If you can afford it, have regular massage therapy sessions as they are especially useful for easing some of the edema-related pain while not interfering with the healing progression. Furthermore, massage therapy is clinically proven to help those with eating disorders have less anxiety about body image, weight gain and food intake and less desire to practice restrictive behaviours when the anxiety strikes as well.

If you do experience mini-relapses throughout recovery, and almost everyone does, then be prepared for a few rebound days of water retention—obviously restriction causes damage and the body has to fix it. But you will return to where you were in your recovery process within a few days of getting back onto your recommended food intake guidelines*.

The edema will end. The water, bloating and swelling will all dissipate. Of course it won’t mark the end of the recovery process, but it does mark the beginning of the end. 

One important note on edema: swelling that is one-sided in the body (one leg, one foot or one hand) is not a common form of edema associated with refeeding and needs immediate medical attention.

*MINIMUM Recommended Intake Guidelines for Recovery:

a) Females under the age of 25: 3000 calories and sedentary.

b) Females 5’0”-5’8” over the age of 25: 2500 calories and sedentary.

c) Males under the age of 25: 3500 calories and sedentary.

d) Males over the age of 25: 3000 calories and sedentary.

e) Females over 5’8” over age 25: 2700 calories; under age 25: 3200 calories.

f) Females over age 25 and under 5’0” as well as post-menopausal women can lower the minimum intake to 2300, but more is always better.