Written by Lucy Walton & Talia Cecchele
For many individuals recovering from an eating disorder or overcoming years of dieting, weight restoration is part of their journey. Weight restoration means that an individual returns to a weight that is:
healthy for them
able to maintain long-term
supports their physical and psychological health.
A goal weight range is often discussed in treatment and while it is a sensitive element of recovery, it is an important one to have a deeper understanding of especially as we live in a world that idealises a thinner body.
What can get in the way of achieving a healthy weight?
On paper, achieving a healthy weight in recovery seems straightforward. Nourish your body, move for enjoyment and let your body settle at a weight that it was genetically determined to be at. Unfortunately, it's not always that straightforward. Due to the nature of the illness, there are many factors which complicate reaching a healthy weight in recovery and impact treatment teams or loved ones who are supporting them. Let’s take a closer look:
Weight Bias
Unconscious weight bias is something that almost all of us have been taught since childhood. The message that being thinner is better and that we need to be thin to be ‘healthy’. Our environment is weight and diet-obsessed which perpetuates our internalised weight stigma.
Internalised weight stigma (IWS) is where individuals judge themselves through the lens of false or harmful stereotypes about individuals in larger bodies (1) for example, believing that they are personally responsible for their weight, are greedy, lazy or out of control. Research has suggested that IWS involves a component of negative appearance evaluation and a strong element of self-blame, leading to a drive for thinness (2). We must recognise and challenge internalised weight bias to ensure weight is gained in a healthy way, and weight restoration isn't stopped early because of this.
Fear of Uncontrolled Weight Gain
Many people recovering from an eating disorder experience an intense fear of gaining weight, body image distortions (seeing oneself or certain body parts as larger than they are), and a fear that weight gain won't stop. This fear can hinder a person from taking the leap of faith to start and continue weight restoration. If you're struggling with weight restoration, we share tips on how to manage weight gain on our blog.
In the first few weeks of eating disorder recovery, if weight gain is required, an individual might gain up to 3kg per week, and the eating disorder brain will try to convince you that this is all body fat. It isn't. The change in the number on the scale can reflect glycogen (the storage form of carbohydrate) being replenished, hormonal shifts, rehydration, increased content in the gut, muscle, bone and fat gain. After the initial change, the rate of weight restoration will usually ease and generally the aim is to restore at a rate of 500g to 1kg per week. It is not healthy or recommended to weight restore above 1-1.5kg/week and is physically near impossible to achieve.
Body distress
An individual’s body shape and size will change throughout the weight restoration process and can look and feel different even up to a year (or more) after weight has been restored (3). We have evolved to survive starvation and adjust to energy deficiency. During the early stages of nutritional rehabilitation, weight is usually gained around the abdomen and face to protect internal organs and to allow the body to quickly utilise this energy should it need it again. Once weight restoration is achieved, this weight will redistribute according to an individual’s genetics. The initial weight change can hinder progress for some people as this can be very distressing and negatively impact body image. If this is something you struggle with, checking out our 7 ways to improve body image is a great place to start.
Body image distress can be challenging for family members, friends and professionals to witness, which can make supporting a lower target weight appealing. However, in the long run, this is not helpful and can reinforce the eating disorder belief that thin = healthier. Loved ones must receive support to challenge the belief that gaining weight is worse than the eating disorder remaining, and health professionals remain firm in recommendations for restoring weight to help support the individual through their recovery.
Set-Point Theory
Set-point theory is the idea that there is a genetic weight range that our bodies are determined to be at (if not influenced by lifestyle, dietary or exercise behaviours) (4). The theory proposes a proportional feedback control system designed to regulate body weight to a constant ‘body-inherent’ weight (5). In ED recovery, many people believe that they will not be happy returning to a weight they were previously at or fear the weight genetically determined for them, especially if this does not meet the thin ideal imposed by society. In reality, everyone’s set-point weight will be different. Just like their height has been genetically determined, the healthy weight for a 5’5 female will be much different from the healthy weight for a 6 foot male.
Menstruation
Getting your period back is just one sign that the body is healing and the body is receiving enough energy for body functions to return. The weight at which your period returns for most people is not a healthy weight as if you were to suddenly turn ill, you would likely lose your period again. Menstruation re-starts at different times for different people and should not be used as a target to stop weight restoration.
Target Weight
Setting a target weight or weight range can have its downfalls. Remember that an estimated recovery weight is just that, the best estimate of where physical and psychological health will flourish. This might hinder the weight restoration process when a target weight (or weight range) is given and taken as gospel (not used as a guide), especially if an individual naturally surpasses this. It is also unhelpful if a lower target weight or weight range is negotiated due to the strength of an eating disorder, distress or lack of understanding of weight restoration or a person's medical and weight history.
Weight history
The target weight range should be determined based on appropriate medical and weight history and will vary from individual to individual. Some people have never experienced a healthy body weight during adulthood, especially if an eating disorder developed in childhood or teenage years and full weight restoration wasn't achieved. Weight history is important to consider in order to fully support an individual through recovery, and guide a minimum healthy weight.
BMI
A person's healthy weight is individual to their genetics, medical history and experience with food and diets. Body Mass Index (BMI) is often used as a clinical indicator of health and in the context of eating disorders both for diagnosis and to guide weight restoration. While the measure can be useful, its limitations must be considered. BMI was created in 1832 to measure body weight across different populations (6). It is important to remember that BMI does not account for medical history, an individual’s relationship with food, dieting history, psychological health, the longevity of the eating disorder and other physical factors. Learn more and read our blog The Truth About BMI
When guiding weight restoration, most eating disorder services use the BMI range of 20 – 25 as a minimum healthy weight. Emphasis on the word minimum. Human bodies come in all shapes and sizes (a beautiful thing) and focusing on the lower end of a minimum range can hinder full weight restoration and return to physical health. If you consider all the humans living on this planet, a fraction of humans would naturally have a BMI of 20. We don't all look the same, and BMI should never be used as a black and white outcome measure for weight restoration.
Unfortunately, the NHS and some health professionals continue to use and advertise the "healthy" BMI range at 18.5 – 25. This can cause a lot of confusion and distress in ED recovery. But what we know is that not many individuals naturally sit below a BMI of 20. Many people attempting to maintain below this in recovery will need to engage in some degree of restrictive eating or compensatory behaviours. To achieve full recovery, physical and psychological functions need to be fueled appropriately and for the majority, this occurs at or above a BMI of 20.
What is a Healthy Weight?
As we have recognised, there is no one size fits all when it comes to a healthy weight in eating disorder recovery. Ideally, a minimum weight will be determined at the beginning of treatment to guide full weight restoration (7). A qualified health professional should work as part of a team and with the individual to set a minimum weight range. The method for this can vary:
Minimum weight range is calculated at BMI 20 with a 2kg range to allow for day-to-day fluctuations in body weight, for example, a BMI of 20 + 2 kg i.e. 65-67kg (7).
Using just a BMI of 20
Using a previous "normal" weight or weight range i.e. the weight a person was when they ate and moved their body intuitively before developing an eating disorder or disordered eating
Using growth charts to calculate the trajectory of expected weight gain for children and adolescents
Using weight for height percentage in children and adolescents, generally, this is approximately 95%-105%
A slightly lower minimum weight range may be appropriate for persons of Asian descent for example a BMI of 18.5 or 19 and a higher range may be appropriate for males and people from the Pacific Islands (7).
At the end of the day, it is important to reinforce that these are guidelines. The only way to truly know what a healthy weight is for you is to fully recover; heal your relationship with food, exercise and your body, to eat intuitively without following a set of rules or dietary restrictions. It is learning to trust your body and allowing it to settle at a place where it thrives. It can be terrifying to leap into the unknown, but we know from helping so many individuals on their recovery journey that it is worth it. Recovery is possible and you deserve to live a life that is not dictated by a number on a scale.
If you need support in your recovery, please do enquire about how we can help you in our clinic and group program.
Lucy Walton, TCN Intern
& Talia Cecchele, Founder of TCN
Lucy is a Registered Associate Nutritionist and intern at TCN! With Lucy's background in nutrition and psychology, her aim is to help you become more confident in your food choices and enrich your mindset. You can find Lucy on instagram @lutritionw and her website here
REFERENCES
[1] Durso, L. and Latner, J., 2012. Understanding Self-directed Stigma: Development of the Weight Bias Internalization Scale. Obesity, 16(S2), pp.S80-S86.
[2] Marshall, R., Latner, J. and Masuda, A., 2020. Internalized Weight Bias and Disordered Eating: The Mediating Role of Body Image Avoidance and Drive for Thinness. Frontiers in Psychology, 10.
[3] Gaudiani Clinic. 2021. Weight Goals in Anorexia Nervosa Treatment — Gaudiani Clinic. [online] Available at: <https://www.gaudianiclinic.com/gaudiani-clinic-blog/2020/4/22/weight-goals-in-anorexia-nervosa> [Accessed 7 September 2021].
[4] Müller, M., Bosy-Westphal, A. and Heymsfield, S., 2010. Is there evidence for a set point that regulates human body weight?. F1000 Medicine Reports, 2.
[5] Leibel, R., 2008. Molecular physiology of weight regulation in mice and humans. International Journal of Obesity, 32(S7), pp.S98-S108.
[6] Euro.who.int. 2021. Body mass index - BMI. [online] Available at: <https://www.euro.who.int/en/health-topics/disease-prevention/nutrition/a-healthy-lifestyle/body-mass-index-bmi> [Accessed 7 September 2021].
[7] Cedd.org.au. 2021. [online] Available at: <http://cedd.org.au/wordpress/wp-content/uploads/2014/09/Minimum-Weight-Range-and-Achieving-Regular-Weight-Gain.pdf> [Accessed 7 September 2021].
Talia Cecchele Nutrition is a team of registered dietitians that specialise in eating disorder recovery, disordered eating, digestive issues and sports nutrition. We aim to bring balance back to nutrition, help you to break free from food rules and find food freedom. We offer virtual consultations and group programs so whether you are based in London, the United Kingdom or around the world we would love to support you. To enquire about a private consultation please fill out a contact form.