Eating disorders in athletes: how can we tackle them?
How to gain weight after having an eating disorder
If you're in recovery from a restrictive eating disorder, weight gain might be a crucial part of that process. However, this can be a real challenge and often a painful process, even if you understand that it's right for your body. Gaining weight can be especially difficult if you've lived with an eating disorder for a long time and have a lot of aggressive, ingrained thoughts about what weight gain means.
An initial reminder
Before we start talking about weight gain, we should remember that not all people with eating disorders have to gain weight in order to recover. Perpetuating the misconception that all people with eating disorders (ED) are underweight and must gain weight in order to get better, feeds into harmful myths around EDs. In reality, fewer than 6% of people with eating disorders are medically diagnosed as underweight. Many people who seek professional help for a suspected eating disorder will be considered a 'normal' or 'healthy' weight, or 'overweight'.
Why can weight gain be important for people with eating disorders?
It cannot be ignored that gaining weight after restricting food intake for an extended period - and losing weight as a result - can be crucial to saving a life. This process is also known as weight restoration as it allows the body to reach a point of body weight stability and a weight that is healthy and maintainable for the individual. This might follow an ED such as anorexia nervosa, bulimia nervosa, or binge eating disorder (BED).
Specialist eating disorder dietitian Lisa Waldron explains that there's evidence showing low weight can have a range of effects on physical and mental health, such as:
- Low mood.
- Increased anxiety.
- Brain shrinkage - which can impact cognitive flexibility.
- Reduced hormone production - which can impact fertility.
- Weakened bone health.
- Struggles making decisions and being spontaneous.
- Irritability or trouble managing emotions.
Gaining weight as you pursue treatment and tackle the root of your struggles can also improve your relationship with food. As you gain weight and become less controlling and restrictive over your calorie intake, the rest of your life can flourish as a result. Successful recovery can help you to eat without micromanaging every bite and no longer giving food choices a moral value - viewing low-calorie foods as 'good' and high-calorie foods as 'bad'.
Why might gaining weight be difficult if you’ve had an eating disorder?
At the root of the majority of eating disorders is a penchant for control - whether that’s control over food intake or implementing rigid routines in other aspects of life, like exercise. Therefore, the reality of having to gain weight and giving up this control can be scary.
Other difficulties you might encounter include:
- Fear that weight restoration may not stop.
- Fear that restoring weight will result in others thinking you are recovered when you are still struggling.
- Struggles maintaining a meal plan and regular eating habits.
- Increased feelings of self-loathing and insecurity as you settle into a growing body.
- Trouble finding healthier coping mechanisms for challenging situations that don’t involve food.
- Early satiety - feeling full halfway through meals.
- Gut issues - bloating, pain, constipation/diarrhoea.
- Weight restoration occurring around the middle - stomach area - with no control over where it will sit on the body.
- Menstruation restarting if it stopped, which is not always welcome.
Waldron adds that an eating disorder can be aggravated by the need to gain weight if the illness has consistently reinforced the idea that you need to do the opposite for so long.
"It’s understandable why people become distressed during weight restoration, since they are challenging their eating disorder. Therefore, it’s important to work with a therapist and dietitian to understand how to manage difficult emotions. Professionals may work on developing skills to manage anxiety, challenge intrusive thoughts, and focus on the reasons for recovery."
Eating alongside a family member or friend for support in the early stages can help, as can writing in a journal to reflect on your feelings.
What might a weight restoration plan look like?
"Everyone's weight restoration plan will be unique since it is designed around the individual and their needs. This plan should be agreed with a dietitian, with the input of a therapist, as they are often required to work through mental and emotional barriers," says Waldron.
She explains that a dietitian will do a nutritional assessment and agree on a plan based on their patient’s needs. To ensure you restore weight safely, you should follow the advice of a dietitian who can monitor and review appropriately.
While the mere thought of a weight restoration process can feel daunting, you should remember that an eating plan will likely increase in stages. This can help you to adjust and is also due to the risk of refeeding syndrome, a serious condition caused by introducing nutrition to a malnourished person. There’s a risk of a fatal shift in fluids and electrolytes, which may lead to clinical complications. Calories need to be increased incrementally under a doctor’s supervision.
"Dietitians typically encourage people to use food for weight gain by increasing portion size or increasing the frequency of meals or snacks, or increasing the nutrient density of food eaten," says Waldron, adding that shakes are not typically recommended, as:
"We like people to use food because it offers the experience of the whole eating process, including chewing and swallowing."
However, oral nutritional supplements can occasionally be used in the refeeding process, since many people with eating disorders can be malnourished. Therefore, along with the guidance of a professional, in some cases, shakes and supplements can be invaluable. This might be especially true in early recovery, where a person struggles to get enough calories from food alone.
How can you maintain your weight gain?
While gaining weight initially can be taxing, maintaining that weight can be even more so. This can be due to the physical discomfort of having a larger body, or the emotional hardship of moving on from a mental illness. Therefore, it’s important to remind yourself consistently of the benefits of recovery, working closely with your eating disorder treatment team.
Waldron adds: "Weight restoration does not mean the person is recovered and may only be the beginning of their journey. You will need continuous support to work on dismantling the eating disorder until you reach a point where you are confident in managing your eating and urges independently."
A personal story of what weight gain offers
Victoria English, 53, is a mental health campaigner who developed anorexia in the late 1980s. She says her ED stemmed from comments about her weight from family members, as well as watching her mother diet throughout her lifetime. Victoria learned to equate gaining weight with sadness and losing weight with joy.
As time went on, Victoria felt "horribly out of control" in all aspects of life and fulfilling the desires of her ED became her whole focus, enjoying a hit of dopamine when she saw the scales dip lower.
In her late twenties, Victoria developed generalised anxiety disorder. This added to her struggle with her mental health and it wasn't until her forties that she sought treatment and eventually acquired a toolkit of coping mechanisms beyond her ED behaviours.
"The weight gain was difficult, but I aided the process by filling my life with activities other than eating and weighing myself obsessively. I threw away the scales and built up my self-esteem and confidence through my successful career lecturing. I had a real purpose," she says.
"The ever-present need for control was diminished by the fact that I now had a full and active life that I was in charge of, not the cruel eating disorder."
While her story is personal and weight gain isn't pivotal for everyone's recovery, it's important to highlight how pursuing recovery can transform your life. Victoria also altered her mindset to a more optimistic one and feels able to openly discuss her mental health to access information and support.
Now, Victoria has healthier relationships with exercise and diet, and can see that weight gain saved her life.
"You can recover and lead a healthy, happy life after an eating disorder, and everyone should feel empowered to access the tools they need to help them get better."
If you suspect an eating disorder, you can contact Beat, the UK's eating disorder charity, 365 days a year on 0808 801 0677 or beateatingdisorders.org.uk. You should also book a GP appointment, as support from perinatal mental health services is available via the NHS.