Phases of Recovery From A Restrictive Eating Disorder

Whether you are contemplating or well underway towards remission from a restrictive eating disorder, knowing what to expect is what this blog post is about.

The recovery process laid out on this website is called the MinnieMaud guidelines or treatment program. There isn’t too much that is startling about the guidelines for any of you who have been in inpatient treatment before. I discuss the science behind the guidelines here and I explain more about how you are to interpret the information available on this site here.

How To Interpret Symptoms Associated With Phases of Recovery

I can remember when I had pneumonia and the doctor said, for my age, I should expect to be back to normal in six weeks’ time. I should know better than to treat such a pronouncement as inviolate, but when I was still flaked out and exhausted two months in, I most certainly considered the possibility that something “was not normal”.

Our bodies are not machines. There are no mechanisms and no binary concepts of working or not working (with the exception of alive and dead of course). Think of your body more as an ecosystem.

Imagine you are a forest, or a desert, or tundra, or a bog (alright, maybe not a bog, although they are fascinating despite their pungency). The absolute health and resilience of a forest or a desert are not measurable because these ecosystems are multivariate systems. I can count the number of species; I can count the number of invasive species; I can measure temperatures, water levels, humidity, air pressure; I can identify which species seem healthy and which seem stressed; and I can even study these items over seasons and times to see if trends emerge. But none of that will tell me the state of health and resiliency of the entire system.

When Mount St. Helen’s in Washington State (US) erupted in 1980 generating spectacular vertical and lateral explosions, a deadly pyroclastic flow and subsequent landslides, it flattened an area of about 35 km by 20 km (22 by 12 miles). Jimmy Carter, the U.S. president at the time, was said to have described it as a moonscape when he flew over to inspect the damage. Scientific predictions initially suggested the area would take generations to recover.

However, within just three years, 90% of the original species were found to be growing within the blast zone [JF Franklin et al., 1985]. For the curious, here’s a great site on the recovery after the eruption: After devastation, the recovery.

I use Mount St. Helen’s as an analogy for understanding two things about your body:

  1. Symptoms and screening tests will never accurately identify overall resilience, or lack thereof.
  2. What seems catastrophic may merely be a blip towards a new level of resilience.

Do not read the Phases of Recovery as though you are reading a recipe or following scientific steps that will realize unequivocal and successful results. Think of it as “individual mileage may vary.”

Do not panic if you find some symptoms are not present, or seem to appear, disappear and re-appear. Your entire recovery process may take you into full remission in as little as 3 months or as long as 24 months. Three months is very, very rare and 18 months is the median time to remission, so be prepared to be patient.

Pay attention to the small markers of progress along the way and celebrate them.

Like the post-eruption world around Mount St. Helens, your foundational goal in entering remission is to embrace a “new normal”. If you maintain an ED-generated focus on eating the right foods at the right time; hitting and maintaining a certain weight; just getting your fertility back; restoring enough weight to get people off your back; or restoring enough weight to lessen symptoms of starvation, then you will have ultimately missed the forest for the trees.

You mission to attain a resilient remission is to relish your new resilience and to live your life beyond an identity that has been narrowed to numbers on a scale, or mileage on a pedometer, or shape in a mirror.

The Telltale Dozen

How do you identify a restrictive eating disorder? Because it is a neurobiological condition, it is the mindset you are forced to adopt towards food that is most telling.

  1. Family and friends have shifted from congratulating you on your weight loss and/or your healthier choices to making either careful or even blunt comments that you look too thin, sick, or generally don’t seem to eat enough.
  2. You are cold when others are not. You’ve started wearing sweaters when others are in short-sleeves. Sometimes you feel light-headed, dizzy. Other times you feel foggy-headed – like you are listening to others through cotton wool.
  3. You are tired and find your mind wanders. You struggle to focus in class or at work. You cannot remember things that others remember easily.
  4. You are prone to crying spells and/or explosive bouts of anger (more so than what might be usual). You alternate between wanting to be alone, snapping at family and then finding you are clingy and needy, seeking reassurance from loved ones.
  5. Not only do you find it hard to concentrate, but also you find you are absolutely consumed with thoughts of food. When you will eat. What you will eat. What you won’t eat. 
  6. Facing social circumstances that involve food creates panic: family celebrations, lunches with friends at school, holiday times…in the days leading up to such events you feel extremely anxious and spend a lot of time trying to figure out how to avoid it altogether.
  7. The number of rules you assign to when and how will eat keeps getting longer. You have become ritualistic to the point where any deviance causes massive anxiety (the wrong plate, the fork in the wrong place…).
  8. You have longer and longer lists of forbidden foods that you will not touch.
  9. If you indulge in any food that you consider unacceptable, you are wracked with shame, self-hatred, loathing and usually ‘punish’ yourself for the transgression (exercising to exhaustion, skipping yet another meal)
  10. As a woman, your regular menstrual cycle is irregular or has disappeared completely. Whether you are a woman or man you notice your skin appears dull and dry. Your hair and nails are brittle and perhaps your hair loss seems more pronounced than usual (clumps in the bathtub drains or on your brush).
  11. You find yourself promising yourself and others more and more that “tomorrow” will be different. But it isn’t.
  12. You lie to loved ones about what you ate that day, or about how much you actually exercised and make excuses for why you cannot eat now. If they are friends, you often fabricate food allergies, intolerances or other reasons why you cannot have the particular item being offered.

If the Telltale Dozen seem to ring true, then your next step is to determine whether these behaviors are impinging on your quality of life. If you feel you are missing out and are suffering, then it is time to seriously consider a recovery effort.

The Three-Legged Stool of Successful Recovery

If you knew that there is actually a mathematical equation attributed to why a three-legged stool cannot wobble and yet a four-legged stool can, then you are my personal hero. It was news to me: Math Forum Explanation. And rather conveniently there are three facets to a successful recovery that should ensure a stable remission as well.

1. Weight restoration

2.Repair of physical damage

3. Developing new non-restrictive neural patterns in response to usual anxiety triggers.

And you work on developing your three-legged stool of remission in that order as well. Because starvation impacts brain function so severely, it is nearly impossible to make any headway on Item 3 unless you are sufficiently energy-balanced to think straight.

As you attempt to recover, you will feel an increase in the anxieties around food intake, weight increases and body shape changes. It is one of the major reasons why going “low and slow” outside of an inpatient setting, is almost always unsuccessful. “Low and slow” is the terminology used for taking a patient slowly up from her current restrictive intake up to recovery intake amounts. As we now know, this approach is not evidence-based and appears to have weaker outcomes both for reaching remission and maintaining it even within inpatient settings. [A. Garber et al., 2012]

Fundamentally you cannot sit on a stool that has two legs, so the sooner you are eating recovery amounts of food then the sooner you can work with a therapist to address the increased anxiety that food intake generates for all those on the restrictive eating disorder spectrum.

NOTE: Never attempt to up your calorie intake without medical supervision.

You have done hundreds of thousands of calories' worth of damage to your body. A calorie is an energy unit. You don't need to burn off food because food is used as energy for all your body's vital functions. If you burn it all off in excessive exercise, then your body literally has no more energy to keep your heart beating.

Whether you have starved at clinical or subclinical levels (less than 1000, or 1000-2000 calories a day respectively); whether you are still in the healthy BMI range or below it; and whether you have starved for just a few months or much, much longer, you are on the restrictive eating disorder spectrum if those Telltale Dozen apply and your quality of life is impaired because of the presence of those behaviors in your life.

So assuming the Telltale Dozen ring true for you, let’s look at the following:

  1. Why do you have an eating disorder?
  2. Math of energy requirements and intake guidelines based on age and sex.
  3. What to expect in the phases of recovery.
  4. What kind of help you need now to improve the chances of recovery.

1. Restrictive Eating Disorder Spectrum

What follows is the reference-heavy portion of this post.


A restrictive eating disorder is best described as the misidentification in the brain of food as a threat. It is currently defined as mental illness within the Diagnostic and Statistical Manual of Mental Illness (DSM) and psychiatrists are the only health care professionals tasked with the clinical diagnosis that will be accepted by either private or national health insurance providers.


The DSM splits out the restrictive eating disorder spectrum into three main classifications with several sub-type definitions: anorexia nervosa, bulimia nervosa and EDNOS (eating disorder not otherwise specified). 

EDNOS also includes eating disorders unrelated to restriction: binge eating disorder and night eating syndrome. BED and NES are not considered standalone eating disorders by expert researchers in the field and they are not neurobiologically related to restrictive eating disorders. [AJ Stunkard, TA Wadden [eds], 2004] 

Currently the fifth edition of the DSM is scheduled for release in 2013 and there has been a push to pursue a transdiagnostic approach to merge the currently distinct classifications into one broad classification of eating disorder. Were that to happen, and I doubt it will, then it would accurately reflect the clinical evidence that anorexia and bulimia are not two distinct conditions and that several other restrictive facets are all part of the same neurobiological condition as well. [DH Gleaves, 2000; KT Eddy et. al., 2002 and 2008]


“…extreme dietary restraint and restriction, binge eating, self-induced vomiting and the misuse of laxatives, driven exercising, body checking and avoidance, and the over-evaluation of control over eating, shape and weight.”[CG Fairburn, K Bohn, 2005]

Transdiagnosis recognizes the fact that those with restrictive eating disorders can shift from one symptom to another or express several symptoms at once and that these symptoms can also change over time as well.

The terminology I prefer to use for symptomatology is as follows:

  • Avoiding food intake
  • Avoiding food intake and experiencing reactive eating sessions in response to starvation*
  • Abuse of laxatives, diuretics and purging to try to redress a reactive eating session
  • Using exercise to alleviate anxiety associated with eating
  • Applying rigid adherence to eating ‘healthy’ or ‘clean’ to alleviate anxiety associated with eating

* “binge eating”: it is a term I will not use because bingeing does not occur in the absence of overall energy deficiency within the body for those with restrictive eating disorders.


A restrictive eating disorder is an inherited neurobiological condition. [K Nunn et. al. 2011; CM Bulik et. al., 2006; M Strober et. al., 2000]

The genetic markers are not fully identified, but the condition usually lies dormant and is triggered by environmental factor(s). [B Devlin et al., 2002; WH Kaye et. al. 2000; T Wade et al., 1998; P Slade, 2011] The condition is present in all human populations and even exists in some animals.  [JL Treasure et. al., 1995; LEA Symons et al., 1981] In fact, in sheep anorexia is caused by a parasite. Restrictive eating disorders are thought to have persisted within our gene pool because it had survival advantage. [P Slade, 2011; S Guisinger; 2003] 

There is all manner of fancy research work that has been investigating the tantalizing suggestion that the dopaminergic reward systems in the brains of those with restrictive eating disorders are different than healthy controls. [WH Kaye et. al., April and September 2005] And there is also plenty of fascinating stuff on the brain structures that may or may not be involved in miscasting food as the enemy. [A Wagner et. al., 2007; K Nunn et. al., 2008] However there are far better sites and books on the topic than this post. I’ll provide instead a layperson’s view of the cascade from the time that a restrictive eating disorder is activated.


One of the unfortunate aspects of recovery from an eating disorder (ED) is that some things have changed in your body in ways that do not occur for non-ED people. So I'll first explain a bit about the shifts that happen when ED-genetic mutations are activated with starvation.

When a non-ED and ED person both starve their leptin levels plummet in their systems. Leptin is a gating hormone that manages metabolism, appetite, bone formation and reproductive hormone function. When we are at a healthy weight and taking in adequate energy, then our leptin levels are at an optimal level. When they plummet, two things happen: the metabolism is suppressed and the appetite increases.

For the ED person, the starvation activates genes that shift the normal function of neurotransmitters in the brain. It is these neurotransmitters that generate the anxious and compulsive thoughts, feelings and behaviors surrounding food and weight gain [WH Kaye et. al., 2005; F Fumeron et. al., 2001].

A non-ED person will say she feels irritated, fatigued, hungry and moody when starving. The leptin levels dropping are creating unpleasant moods and extreme hunger to signal to the brain that it is time to go find more food/energy to eat.

An ED person will say she is not hungry. Although experts dispute whether she actually does feel hunger or not, it is clear she feels calmer, energized and dissociated from negative feelings (emotionally blunted) as a result of suppressing her hunger [S. Guisinger, 2003; M. Duclos et al., 2012]. The ED-skewed neurotransmitters are able to override what the leptin levels should be triggering: unpleasant moods and the desire to eat more.

One third of all people who diet end up on the restrictive eating disorder spectrum. [J Jones et. al., 2001; CM Shisslak, M Crago, 1995]. While not all of them develop clinical cases, they all experience lifelong anxieties and compulsions around food and weight gain (if left untreated). They can develop clinical cases at any point due to life stressors (anything from a cold to a break-up) and they can slide up and down the spectrum or express multiple facets of the same spectrum at once (anorexia, restrict/reactive eating cycles, bulimia, orthorexia (extreme focus on healthy foods) and anorexia athletica (over-exercise)).

If the non-ED person and ED person are both of the same age/weight/height (pre-starvation) and we ensure they both return to that pre-starvation weight, the non-ED person returns to optimal leptin levels, but there are several studies suggesting attenuation of abnormalities in leptin levels for the ED patient. Steven Grinspoon and his colleagues discovered in their study that leptin levels appeared to remain sup-optimal for anorexic patients despite full weight restoration [S Grinspoon et. al., 1996] whereas Christos Mantzoros and his colleagues found in their sample that leptin levels appeared to normalize abnormally quickly for anorexic patients. These contrary results may have much more to do with the conclusions drawn by Abdul Dulloo and his colleagues when re-analysing the data from the Minnesota Starvation Experiment that the body has two distinct autoregulatory feedback mechanisms that trigger hyperphagia after a period of starvation and these mechanisms originate separately from both fat and lean tissue within the body [A. Dulloo et. al., 1996]. The translation of all that is that patients in recovery from restrictive eating have normal metabolic responses within the variation we see with non-eating-disordered subjects as witnessed in the Minnesota Starvation Experiment [A. Keys et. al., 1945].

As leptin acts as a gating hormone for the normal functioning of reproductive hormones, a weight-recovered ED patient needs sufficient leptin in her system to normalize reproductive function, bone formation function and neurotransmitter function.

In weight-recovered female patients where their periods have not returned, we know that further weight gain will be needed to return to normal resumption of reproductive hormone cycles, bone formation and neurotransmitter function. [GA Laughlin et. al., 1998; CK Welt et. al., 2004; JD Vescovi et. al. 2008]

Evidence-based Treatment

Most people don’t know or are unaware that treatments for restrictive eating disorders are largely not evidence-based.

Evidence-based treatment means that there have been clinical trials where the treatment in question is measured against a control group and other researchers have duplicated the results. Ideally, the treatment has also been measured over a long period of time to ensure the outcomes are not short-lived as well.

There is only one treatment protocol out there that fits that definition today: Maudsley Family-Based Treatment. It has controlled and duplicated trials as well as published and confirmed 5-year remission rates.

Two other protocols, Kartini (a family-based approach) and Mandometer (a technology-based approach), have self-published data but no independent corroboration of their findings as yet.

Problematically, Maudsley is specifically designed for child and adolescent sufferers of restrictive eating disorders. And its design is usually difficult to translate into the adult sufferer’s environment.

MinnieMaud Treatment

The MinnieMaud is the set of guidelines for recovery that are published on this site. There have been no controlled trials or independent corroboration and therefore MinnieMaud cannot be identified as evidence-based treatment at this point. However, the guidelines are based on clinical trial data from Maudsley and the Minnesota Starvation Experiment, among other trial results, rather than merely empirical observation or practitioner philosophy.

The MinnieMaud guidelines include the following key facets:

  1. Unrestricted eating with minimum intakes that are set to reflect actual average consumption of non-restricting equivalents. [I Need How Many Calories?!! and MinnieMaud Method & Temperament-Based Treatment references embedded in those posts]
  2. No workouts or exercise. [C Zunker et. al., 2011; S Bratland-Sanda et. al., 2010]
  3. No weighing or taking measurements of self*.

*Numerous inpatient environments resort to “blind weigh-ins” so that they can monitor the patient’s progress while ensuring the patient isn’t triggered to relapse by knowing his or her weight (standing on the scale backwards). But the larger issue of why we must know our weight is overlooked in this approach. Weighing oneself is counterproductive to accepting that optimal weight set points are maintained without cognitive interference.

Statistics & Prognosis

Between the ages of 15-24 restrictive eating disorders are 12 times more deadly than all other leading causes of death combined for that age group (including car accidents). [PF Sullivan, 1995]

The rates of remission range from 3% to 96% [J Couturier, J Lock, 2006] and relapse rates range from 35-50%. [JC Carter et. al., 2004; ED Eckert et. al., 1995] Remission rates for Maudsley Family-Based Treatment at 12 and 36-month follow-ups are 75%. [D leGrange et. al., 2007; J Lock et. al., 2010; J Arcelus et. al., 2011] 

Standardized mortality ratios (SMRs) for restrictive eating disorders range from 1.92 to 10.5. [G Pauslen-Karlsson et. al., 2008; FC Papadopoulos et. al., 2009; CL Birmingham et. al., 2005] A standardized mortality ratio is a scientific way of identifying the increased risk of death associated with a particular condition when compared to a random healthy group of human beings. The standardized mortality ratio for a random healthy group is set at 1.00.

Because causes of death for those with restrictive eating disorders can range from heart failure to suicide, it is not always possible to extract accurate data if their underlying contributing condition (namely an eating disorder) is not identified on a death certificate. That is why SMRs vary from one trial to the next.

Re-framing the SMR ranges, restrictive eating disorders have approximately a 1 in 4 to 1 in 5 fatality rate over a 20-year period.

The prognosis is generally accepted as 50% achieve full remission and generally maintain that remission and the remaining 50% struggle with chronicity, social decline, progressive ill-health and early death. [K Tolstrup et. al., 1985]

It is a very serious and deadly neurobiological condition. And that ends the reference-heavy portion of this post. Phew!

2. The math of the calories

If you eat 3000 calories every day and stay completely sedentary, then that's 21,000 calories that go into you for one week.

That may sound like a lot however we have to subtract the 7,000 needed for the actual fat and muscle rebuilding that has to happen each week. Fat is not an energy storage unit, it is the largest and most critical hormone-producing organ in your body.

That leaves 14,000. But then there is the amount just to keep you breathing, heart beating—that basal metabolic rate thing that just keeps you alive. Estimating, that assigns another 7,000 or so.

To repair damaged heart, skin, nails, hair, kidneys, digestive system, brain areas, bone and blood formation are actually giving your body only 1,000 calories a day to go to that effort. That's if you dependably eat 3,000 calories each day.

The less you eat, the longer it takes to recover as the harder it is for your body to find any excess energy to repair the damage.

Here are the MinnieMaud Recovery Guidelines for calorie intake based on age/height and sex:

Here are the guidelines for when 2500 calories applies as a minimum daily intake for recovery:

You are a 25+ year old female between 5’0” and 5’8” (152.4 to 173 cm) and,

The regular menstrual cycle has stopped and/or,

You have other symptoms of starvation: feeling the cold, fatigued, foggy headed, hair loss, brittle nails, dull skin and/or,

Even if you were only underweight/dieted for a very short space of time (a few months), these guidelines apply.

Here are the guidelines for when 3000 calories applies as a minimum daily intake for recovery:

You are an under 25 year old female between 5’0” and 5’8” (152.4 to 173 cm) or an over 25 year old male between 5’4” and 6’0” (162.5 and 183 cm) and,

The regular menstrual cycle has stopped and/or,

You have other symptoms of starvation: feeling the cold, fatigued, foggy headed, hair loss, brittle nails, dull skin and/or,

Even if you were only underweight/dieted for a very short space of time (a few months), these guidelines apply.

Here are the guidelines for when 3500 calories applies as a minimum daily intake for recovery:

You are an under 25 year old male between 5’4” and 6’0” (162.5 and 183 cm) or female with young children or an equivalent and unavoidable level of activity.

The regular menstrual cycle has stopped and/or,

You have other symptoms of starvation: feeling the cold, fatigued, foggy headed, hair loss, brittle nails, dull skin and/or,

Even if you were only underweight/dieted for a very short space of time (a few months), these guidelines apply.


If you are taller than the guidelines listed above, then add 200 calories to the guidelines that match your age and sex. If you are shorter than the guidelines listed above, then you may eat 200 calories less than what is suggested for your age and sex, however these are all minimum guidelines and everyone is expected to eat well above them for a good portion of the recovery process in any case. Please see this these blog posts for more details: Extreme Hunger I: What Is It? and Extreme Hunger II: Very Disturbing

If you want the scientific references behind why these intakes are defined as they are, please see I Need How Many Calories?!! and MinnieMaud Method & Temperament-Based Treatment.

Everyone in recovery should cease all exercise and workouts and any discretionary activities. The energy you take in is required for weight restoration and repairs.

3. The Phases of Recovery

There are three distinct phases and one critical final phase for complete weight recovery and here's a bit of what to expect.

Yes, you can experience symptoms of multiple phases at once and you can seem to progress from one phase to the next and then, for no apparent reason, seem to back track. That’s all normal and not cause for concern.

Remember the body is not a machine but it knows what it is doing as long as you are providing the energy and resting.

And finally, please keep in mind that no one (absolutely no one) sails through this process with no slips or problems. Whenever you slip back into more restrictive behaviors you have not failed. Instead you must treat the experience as an opportunity to learn more about what are your specific triggers that cause relapse—that will make for a far more resilient remission in the end.

Phase I—edema.

Water Onboard

The body seems to gain 7-16 lbs. (sometimes more than that) in the first couple of days or weeks when you get to re-feeding amounts for your age/sex/height.

Someone not prepared for this will panic and restrict before she gets too far along. The "weight" almost exclusively water retention (edema). The body needs the water for cellular repair and the normalization of both liver and kidney functions [WB Salt, 2004; GFM Russell, JT Bruce, 1990].

The water retention dissipates past the second month, but only if the patient is reliably eating to the minimum guidelines or more every single day.

Very rarely, extreme edema (most pronounced on hands and feet) is one of several symptoms of refeeding syndrome. It is one of the many important reasons why medical supervision is a necessity in the early phases of refeeding.

Further details on water retention are available in this blog post: Edema: The Bane (and Blessing) of the Recovery Process.

One of the tenets of the MinnieMaud treatment approach is to stop weighing yourself at all. You will find the forums strewn with panicked ED-driven meltdowns after someone in recovery has succumbed to stepping on a scale.

The scales are one of the eating disorder’s most favorite of torture implements that it gets to use on you to generate an easy relapse. Do not give it the satisfaction.

Digestive Distress

Digestive distress is common in this first phase: bloating, gas, pain and abdominal distention, diarrhea or constipation. You can alleviate this a bit by eating smaller amounts more constantly throughout the day: 200-250 calorie increments from the moment you get up until you go to bed.

This digestive distress occurs because starvation has drastically reduced all the critical bacteria in your gut as well as all your digestive enzyme levels. In order for the bacteria to recolonize to acceptable levels they need the energy in. [MD McCue, 2012; PD Cani et. al. 2007]

For many patients in this phase they also have to overcome gastroparesis. [RW McCallum et. al., 1990]. Gastroparesis is a survival mechanism whereby the stomach doubles its emptying time to the small intestine, meaning the food is churned in the stomach for longer to try to allow for the small intestine to maximize the too-little energy coming in to the body. Gastroparesis begins easing within a few days of doggedly staying at or above the minimum intake and it resolves quickly if you persist in eating the recovery guideline amounts, usually within a couple of weeks to a month. In fact the motility of the entire gut is slowed to try to extract as much energy as possible during starvation [M Hirakawa et. al., 1990] and this resolves during dedicated refeeding efforts.

Don't be tempted to lower the calorie intake because of the discomfort—just space the food out throughout the day. Yogurt with active cultures will be your best friend [C Coker Ross, 2008; E Nova et. al., 2006]

If you could tolerate lactose before the restrictive eating disorder took hold, then you will again once recovered. However, many patients in recovery can experience transient, otherwise known as secondary, lactose intolerance. This is because the system is so stressed that it can no longer reliably produce lactase to break down the lactose. If you find having milk, cream and ice cream cause bloating and diarrhea, then replace them with soy and rice options or ideally use a lactase supplement (such as Lactaid). Do not have any low-fat or non-fat options for any foods in your home.

Also, while dehydrated in the early phases, resist the urge to drink lots of water. You will get adequate hydration if you eat to the recovery guidelines. If you do have drinks, make sure they are full of calories. So instead of sodas, it's ice cream shakes and fruit smoothies with full fat yogurts and extra oil and nut butters too.

Coffee tends to increase gut motility (that means moving things faster through the colon) [SR Brown et. al., 1990; PJ Boekema et. al., 2000] and this is usually not an issue as most have very slow gut motility due to starvation. However, do limit coffee intake to one or two cups a day and make sure they are loaded with creams and sugars to focus on getting food in the system.


Edema, water retention, causes a considerable amount of aching throughout the body. You may feel very sore all over.

When you twist your ankle and it swells with fluid, heats up and hurts, that is the healing process at work. In recovery, the process is happening on a body-wide scale. Pain forces us to stop and rest. That subsequently allows for the body to deal with whisking away all the damaged cells and providing energy for the development of new, healthy cells without having to deal with new damage all the time as you “push through the pain”.

Those of you who applied excessive exercise, purging, diuretic or laxative abuse when you were actively restricting, will likely experience more swelling and pain in this phase of recovery.


Many of you will feel like you have been hit by a freight train’s worth of exhaustion and tiredness. You will find this confusing because you were “so energetic” during active restriction and now that you are really working on recovery you just want to flop and sleep.

As mentioned in the previous section, there is marked hyperactivity during active starvation for those on the restrictive eating disorder spectrum.

In the throes of restriction, you have a very effective "signal jammer". Basically your brain is not able to really receive and interpret all the distress signals from your body. This is why non-ED people feel horrible when they starve and yet eating-disordered people initially feel energized, calm, dissociated from bad feelings etc. There are marked neurotransmitter anomalies that appear to have something to do with it and they occur in various emotional centers in the brain, specifically those responsible for threat identification.

It is a good sign if you are exhausted because it suggests your body is finally able to communicate its needs for recuperation and energy in a way that was not happening during active restriction.

No Exercise

Removing workouts and exercise from your regime tend to be more difficult than increasing food intake for many. It is a common question as to why it is necessary and can’t one just consume enough energy to support the expenditure of energy.

Most will profess that their exercise regime has nothing to do with restriction and that it is merely for all the mood-modulating benefits that exercise will provide.

Yah, no. Mood-modulating benefits can be achieved through simply sitting outside and the mood-modulating benefits of exercise are far from scientifically definitive as well.

Furthermore, because you do not have a mechanistic body you cannot actually magically consume enough energy to necessarily support expenditures because the body is conservative and cautious when it comes to how it chooses to use energy intake. In other words, even if you doubled your intake that may not result in your body being comfortable assigning energy to repairs and weight restoration because the cortisol levels suggest the body is under stress and therefore the energy should be socked away in case.

Just stopping exercise will be highly anxiety-provoking and that is why an approach of “replace and distract” is recommended by experts in the field of exercise dependency:

There is plenty of clinical evidence that there seems to be no way to return a woman who is on the Female Athlete Triad (inadequate energy intake, amenorrhea (lack of a regular menstrual cycle) and bone density de-mineralization) back to a regular menstrual cycle with adequate bone re-mineralization without having her cease all activity. No matter how much we increase the intake, or change the timing to try to negate any energy deficit, nothing happens until she is usually injured out and the forced rest reverses the situation [DL Wiggins, 1997; R Olyai et. al. 2009; NH Golden 2007].

I also have my own direct experience with patients with this condition. One in particular spent 5 months trying to increase her intake to have her period return regularly (she was weight restored after a long intermittent history with anorexia, then bulimia, then anorexia athletica). Within one month of finally hanging up the running shoes, her period returned with no additional weight gain at that point (she was already BMI 23).

There is nothing wrong with taking this in steps, but essentially you have to keep focused on replace and distract while getting to the minimum daily intake every single day. Once you get there, then you have actually started a full recovery process.

So, replace and distract.

If you workout in the morning, that is easily replaced with sleep. If you set your alarm to do those aerobics sessions, then set the alarm later and then continue with your morning routine minus the workout.

For some, that morning session provides some grounding—in that case, still set the alarm, but do slow yoga stretching, or mindfulness exercises, breathing exercises, or just sitting quietly in the kitchen with a nice mug of something hot (and ideally full of calories too!).

Others have to also include distraction because the eating disorder ratchets up the anxiety when you don't follow through on restrictive behaviors. Have family breakfasts. Set up mid-morning get-togethers with a friend for a coffee and a muffin.

Enroll in activities (non-exertion) that you may have had some interest in in the past. Crafts, languages, learning new software packages—flip through what's on offer at a local community center to get inspired.

Getting out in the nature is mentally valuable, but put the breaks on the exertion and duration. So again, a bit of replace and distract. How slowly can you go around the block? Make that your task. See if you can get it to 15-20 minutes for one block. Take in absolutely everything in your surroundings. Note every change. Bring a camera and take a picture of the same view each day so you can then compare after your walk whether you actually missed a detail from one day to the next or not.

Consider pot gardening (as in plants in pots!) on a patio or deck. This will allow you to be outside and connected to some of the benefits of gardening without the more strenuous aspects of hauling mounds of dirt etc. Set up a bird feeder (I have a hummingbird feeder I love). Sit out and admire your handiwork growing in the pots and watch the birds.

If one kind of replacement strategy doesn't work, then try another. Basically enter the process with curiosity about what things you could include in your life to broaden your horizons, rather than entering the process with trepidation assuming you will simply be pacing the floors with nothing better to do.


Despite all the physical discomfort of these early days, many experience a tremendous sense of relief and initial joy at eating in an unrestricted way. Understandably, you have many, many distributed and ingrained systems that ensure you eat because your survival depends upon it.

However, the restrictive eating disorder will not allow that relief to stand for very long. Soon you will find yourself starting to feel edgy and anxious. For many the fast physical shifts in the body will become a focal point for allowing the eating disorder to suggest that the process is not going “according to plan” and that somehow trusting your body cannot apply to you as it does to everyone else.

Despite all the noise and anxiety that the eating disorder will create, these truths hold for everyone:

  1. Your body has an optimal weight set point that it can and will defend. [RE Keesey et al., 1997; RE Keesey, 1988] Your body can manage without your conscious interference. Your set point is managed and distributed throughout brain structures that are far more mature, evolutionarily speaking, than your late-to-the-party conscious thought. Think of this as your prime directive: do not interfere in a process that your body can manage.
  2. No one keeps gaining and gaining.
  3. Extreme hunger is a normal progression in recovery. It does not last. You do not ‘habituate’ to 6000-10,000 calories a day, but you need that energy during refeeding.


For women, it is important to remember that the return of menstruation is not a definitive marker that you have reached your optimal weight set point. It is the case for some and not others. Nonetheless, we can say that if you are amenorrheic or oligomenorrheic (absent or irregular periods) then you are definitively not at your body’s optimal weight set point.

Phase II—vital organ insulation

If you get here, then the body is now focused on protecting your vital organs. It assumes you will starve it again soon enough and without insulation around your mid-section, your organs are in grave danger.

The body preferentially lays down fat around the mid-section to insulate vital organs from hypothermia. [L Mayer et. al., 2005] Again, someone in recovery who is not prepared for this will freak. You can feel huge (a combination of fat around the middle and the residual bloating and gas of a digestive system struggling to get up to speed again). Unfortunately, many relapse here.

The redistribution of all that fat around the mid-section to the rest of the body only occurs if you persist right the final phase. [LES Mayer et. al., 2009]

Phase II is a neither/nor phase that is difficult for many to navigate. The body is focused on conservative maneuvers to ensure your safety should you starve again. For many this tends to be a phase of extreme impatience—following all the guidelines day and day out and yet still wearing floaty and stretchy clothes and feeling like an alien in your own body seems unfair.

You may still be restoring weight and that will bother your eating disorder-generated anxiety. Your ingrained sense of an acceptable weight may not be your body’s optimal weight set point. Your body may additionally need to temporarily overshoot its optimal weight set point in this process in order to return to a correct fat mass to fat-free mass ratio. [A Dulloo et. al., 1996, 1999]

This phase will test you. It requires that you double-down in your trust of your own body. It requires that you work to identify your value beyond weight, shape or ideals found in our cultures and society. It is a phase that lays the groundwork for your ultimate ability to maintain a resilient remission.

Phase III—bones, muscles, almost there

Assuming you have been purposefully eating to your minimum guidelines and responding to extreme hunger without compensatory restriction up to this phase, then you start to get rewarded for all your hard work.

Osteopenia and osteoporosis begin to reverse (the completion of that may take up to 7 years, but it begins to reverse in this phase).

The fat deposited around the mid-section is now beginning to be redistributed throughout the body.

Hair, nails and skin begin to have increased pliability and suppleness.

You also start to feel more connected and self-imposed isolation diminishes. You feel less emotional blunting and start to want things for your life.

This occurs for many at around the 4-6 month mark, but for others it takes shape between months 8-12.

Unfortunately this is often when an almost-fully recovered patient makes a series of mistakes (often also due to misguided advice even from her own medical and professional team). She assumes she can now maintain her weight and that she is recovered.

Instead, she relapses again within the year. Why?

Final Critical Phase—remission or relapse

Only 2-4% of the population is naturally at BMI 18.5-20—i.e. naturally thin [Statistics Canada, 1978] Despite this fact, many are encouraged by their treatment teams to stop gaining weight and ‘maintain’ as soon as they reach this arbitrary lowest so-called healthy range.

In fact 70% of all women are naturally going to fall between BMI 21-27 [ibid.], with half of those at BMI 23, 24 or 25.

I get into a lot of detail on the fallacies associated with the “healthy weight range” set at BMI 18.5-24.9 in the Fat Series with all the accompanying scientific fact to confirm the falsehoods. Fundamentally, the optimal weight range for lowest incidence of ill health and death is actually BMI 25-30 [KM Flegal et. al., 2005].

However, you don’t maintain your weight, your body does. The minimum guidelines for recovery are, on average, what non-restricting weight-stable individuals in your category consume to maintain their weight and health.

Once your body reaches its own optimal weight set point (and only your body decides what that is) then it just stops gaining weight and starts maintaining the optimal set point it has reached. It does this seamlessly because the metabolic rate moves back into the optimal range at that same time and biological functions that were on hold are now back on line.

You gain weight through all those phases of recovery because the metabolism is suppressed—that energy went to weight gain and repair. But now you are recovered, the energy now goes to day-to-day functions (all the neuroendocrine systems that had been on hold up to that point).

You gain on recovery amounts and then you maintain on right about the same amount. And once you stop gaining weight then you can also depend on your hunger cues to keep you eating what your body needs to maintain your health and weight for the rest of your life.

Unfortunately many of you will be encouraged to restrict under the auspices of maintenance of your weight and health. Restriction of food intake will always precipitate relapse.

Restrictive eating disorders are chronic conditions and you are never cured of the condition. You can enjoy a complete and even permanent remission, but it requires of you that you never restrict your intake.

Our society suffers such severe anxiety over obesity and believes, wrongly, that both food intake and exercise determine the appearance and onset of obesity (they do not), that many health care providers will encourage patients to be careful about their intake and get back to exercising in this phase for all the wrong reasons. [W. Kulesza, 1982; JA Baecke et al., 1983; RJ Myers et al., 1988; ML Johnson et al., 1956*; L Lissner et al., 1989; AM Prentice et al., 1986; H Pontzer et. al., 2012].*Can I just say that we've known this a long time?

Reverse Honeymoon

If you relapse at this point, there will be an initial phase of comfort and ease as your restrictive eating disorder begins to take hold. I liken this situation to that of returning to an abusive partner—they are full of care, concern and apologetic pronouncements that this time will be different.

It’s trickery. There is no love or peace to be had within a restrictive eating disorder. If at any time you experience a relapse, then return to your minimum intake immediately and seek out support to keep working on applying non-restrictive behaviors instead of restrictive ones in response to anxieties.

You cannot bargain with a restrictive eating disorder and it always plays for keeps.

If you discover that your treatment team that has been so supportive and helpful to now starts to show signs of its own anxiety and issues around weight and body image, then switch them out.

Your body can only be healthy at its optimal weight set point whether our society can accept that or not is its problem and not yours.

4. What kind of help improves the chance of recovery?

Food Is Not Fuel It’s So Much More

No calorie restriction for the rest of your life. Do not use calorie-counting sites that have underlying calculations that depend upon basal metabolic rate x activity level. These are clinically proven to underestimate your actual energy requirements. [LE Bratteby et. al., 1998; JJ Cuningham, 1980]

Beyond that, you will not count calories or follow a meal plan in remission. Quoting myself from another blog post:

When you struggle with a restrictive eating disorder, so much of the social/emotional connections with food consumption have been hijacked by eating disorder-related anxieties. This disconnect is also heavily reinforced by our society’s current preoccupation with the presumed superiority of what I once called autistic eating (referencing parallel nomenclature used in economics, namely autistic economics). However, it is an incorrect term to use because autism is not a condition lacking in an emotional landscape, rather it is a variation on the usual development of theory of mind.

So, I’m going to rename this issue in our society: the reverence attributed to consciousness eating (sometimes misattributed as mindful eating).

Consciousness eating presumes that having our emotions active and interacting with our hunger and satiation cues is inferior to the process of applying our conscious, or logical mind, to the assessment of whether the desire we feel to eat is in fact something that must be addressed for logical reasons.

We cannot eat logically. Our logical minds are too late to the evolutionary party, by millennia, to actually offer any value to how we pursue and stay optimally energized.

This reverence of the logical mind and twinned disdain of the emotional mind is, from an evolutionary perspective, ludicrous. The structures within your brain that support your emotional landscape are robust, distributed and ensure your survival to a level that your logical mind couldn’t even hope to achieve on its best coffee-upped day!

I often mention the patients with lesions and trauma to the emotional centers of the brain (you’ll find one in particular who is referenced by multiple neuroscientists and neurologists in their bestseller books) who are institutionalized despite the fact that they have fabulous and intact IQs; have completely intact memory, retention and retrieval faculties; and can sustain a conversation on any topic pertaining to the past (historical and personal) to the present and future (current affairs, debate, analyses etc.). Ask them what they would like to have for lunch and then you see why they need the 24/7 oversight and care. Without emotional salience, their logical mind is completely stymied by what might be the better option: lasagna or burger and fries.

How you feel about your food is how you not only survive, but also thrive.

Treatment Team

You need a recovery team around you that you see pretty-much weekly to ensure some accountability and support. That can include family.

While your GP is there for the physical check-ups and confirmation that your re-feeding is going as planned, she is not going to be up on a lot of the research on recovery from EDs unless it happens to be a personal interest of hers.

Dieticians or nutritionists can be a great addition to your team—helping you with food ideas and perhaps meal plans if you find counting calories is creating too much initial anxiety and reactive restriction.

However, keep in mind that a disproportionate number of those in the nutritional sciences are also on the restrictive eating disorder spectrum. [M.C. Teixeira Martins et al., 2011] Keep their input to meal plans that follow your recommended minimum intake and you can avoid receiving advice that will actually lessen the chance of success for your recovery.

A counselor, therapist or psychologist that you like and trust who will offer you cognitive behavioral therapy (CBT) is the single most effective way of ensuring you have a complete and permanent recovery. [DM Garner et. al., 1997; CG Fairburn et. al., 1999; WS Agras et. al., 2000]

If you see one and don't like him or her, move on to the next one. But the accountability of the process will help generate new neuronal pathways that will initially sidestep the ED-skewed neurotransmitter pathways and eventually weaken them and override them.

Remember: all the damage, as monstrously serious and severe as it is, is completely reversible at this point.

Keep a tight rein (with therapist support) on letting the anxieties and your goals become one and the same, because they are not:

Try not to focus on what the recovery weight is going to be.

The restrictive eating disorder spectrum does not include binge eating disorder or night eating syndrome. Those sit on a completely different ED spectrum and have completely different genotypes involved.

On the restrictive eating disorder spectrum, your system responds to leptin in your body correctly and that system not broken.

Once your leptin levels get back to optimal levels (which will happen when you hit your natural weight set-point) then you will stop gaining weight. Leptin runs your appetite and metabolism—when it is optimal then everything is in balance. You maintain your weight naturally and eat when you are hungry when you get to that point.

So, every time the ED-skewed thoughts get you all panicked about gaining weight and not stopping, remind yourself that it is not biologically possible for that to happen to you.

So your focus has to be on eating enough food to restore weight and trust that your body and your entire leptin response system will work exactly as it is supposed to. It will.

Respond to the hunger as much as you possibly can.

You can respond to extreme hunger and it will not trigger any kind of binge-eating disorder. Remind yourself of this frequently. Bingeing is not bingeing for you—it is just eating the amount of energy that your body desperately requires. 

The critical thing is no restriction—you must eat no less than the minimum guidelines no matter how much you consumed the previous day.

Restrict/reactive eating cycles are on the same ED spectrum as anorexia and many shift into restrict/reactive eating cycles and bulimia when trying to recover if they and their treatment teams are not really, really vigilant about allowing absolutely no restriction.

You don't sit at 1200 calories for more than a couple of days before you move it up -- and you keep moving it up until it's dependably at the minimum guideline. If you are hungry for far more than that, then it is normal and respond to that hunger.

Whatever craving you have respond to it, but ensure that you are getting some psychological support to short-circuit any fear or anxiety that may tempt you to restrict afterwards. Restriction is your enemy at all times, so don't give it even a toehold in your life.

You cannot depend on eating intuitively because the eating disorder will always veer towards under-eating. So if you are finding counting calories creates anxiety then work with either a dietician or a family member to create meal plans—then you know that as long as you eat everything on the list that day, then you've reached your target.

Nuts and seeds are your best friends—100 calories a handful they should be constantly nearby and you should snack on them as many times throughout the day as possible. They are also usually well tolerated for the healing digestive tract.

Eat any time of the day or night. It is always good for your body to eat. But again, don't restrict through the day in anticipation of eating at night.

While it's good to cry and connect with the reality of how dangerous things have become for you and your health, it's equally important to focus on how reversible all the damage really is. Every time you eat chocolate or have a lunch that isn't just a salad, you are one real step further away from kidney failure and all the other catastrophic aspects of restrictive eating disorders.

Praise yourself for every piece of food/energy you give to yourself. You can do this and you will succeed. You will get your life back.

Knowing When You Can Trust Your Hunger Cues

Almost everyone tries to rush the process of recovery. Despite the fact that they may have massive damage over years of steady restriction, they still believe that a few months in they are ready to just “move on” and “be normal”.

Here is how you know you are ready to attempt eating to your hunger cues:

  1. Your weight appears stable. (weighing yourself is not necessary to determine that).
  2. If you have dealt with amenorrhea during your restriction, then you have achieved 3 consecutive periods in a row.
  3. You are continuing to eat minimum amounts and it is comfortable to do so.
  4. Other lingering signs of repair seem complete (no longer cold, tired, achey, dealing with water retention, no brittle hair or nails etc.)
  5. You think you may need to start eating to hunger cues and are a bit anxious that you can trust those cues.

Note Item 5—if you are feeling extremely confident about eating to hunger cues then chances are you are a ways away from remission still.

You move from meal plans or counting calories to eating to hunger cues by attempting a 3-day experiment. Eat to your hunger cues but jot down everything you eat. At the end of those three days you should discover that your hunger has taken you to approximately the recovery guidelines you have been following thus far. If so, then you can likely trust your hunger cues and move into your remission with some confidence.

Keep in mind that remission is not a permanent state for most. Life stressors and changes can precipitate slips that lead to relapses. I encourage you to develop your Relapse Reversal Intervention Kit, which I touch upon in the Recovery Journal. It is fairly straightforward to avoid a full blown relapse if you are prepared and have identified likely warning signs well in advance of them actually showing up.

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