Weight restoration eating disorder anorexia - what weight target?

Weight-restoration: why and how much weight gain?

If your child has an eating disorder, especially one that has caused weight loss, you're probably wondering how much weight they should regain.

❓ What's the weight target? What will 'weight-restoration' mean for your child? And will that fix the eating disorder?

Some other frequent questions I'll address in this post:

❓ How is a weight goal worked out? How accurate is it?

❓ Would it be better to allow my child to stay rather thin, to protect them from restricting again?

❓ If their body went from high to average weight, is it true they need to regain — and to the highest peak they ever had?

❓ Their mood, beliefs and behaviours improved as they got renourished, but progress has stalled. Is that a sign they need more weight?

❓ Should they see their weight? Should they be told a target weight, when even now they feel they're fat?

My overall message:

Table of Contents

➡️ Get weight regain moving now, without waiting for a precise number.

➡️ Accept that the range that will eventually suit your child can only be discovered along the way — not predicted with certainty in advance.

➡️ Once your child reaches a likely healthy weight, focus on the behavioural and psychological work of recovery.

➡️ And after all that, if your child is still 'stuck', be ready to experiment with all variables: more weight, more of the behavioral and psychological inputs, and more time.

I'll also help you with these:

➡️ Weight has to increase to match a young person's need for growth.

➡️ If a recovery weight or weight range is announced (and I give pros and cons), it can only be a rough estimate.

➡️ I explain the methods most often used by clinicians to predict a recovery weight, and the uncertainties.

Note: I use terms like ‘target / goal / recovery / healthy / expected / ideal weight’ / ‘weight-restored’ interchangeably to refer to a state conducive to full physical and mental health. Check with your therapist what they mean, though.

Weight regain: necessary but not sufficient

I want to help you see nuance, and to work wisely with uncertainty.

My azalea lost its leaves when I forgot to water it and let the soil get completely dry. Obviously, it needed water, urgently. I've given it a soak. Within a few hours, it's already looking more vigorous. Water is magic! Yet clearly, water is not its only need, and more water won't provide more magic.

A recovery weight can be like the water my azalea needs

Likewise, after weight loss your child needs renourishing and weight regain without delay. That is absolutely necessary. It brings many physical and mental improvements — what a relief!

💡 Weight is, in part, of proxy — an indicator — for physiological recovery. The return of nutrients and physiological processes. The brain and other organs having what they need to function well. Weight is also a need: bodies need muscle and fat mass for metabolic and endocrine functions.

Like other medical indices (blood pressure, heart rate, etc), weights are medical indices.
NICE guideline for eating disorders (National Institute for Health and Care Excellence)

On this page I'll also stress that to recover from an eating disorder, other work is needed. Weight isn't the whole cure. Beyond a point — a point that is subject to uncertainty — more is not automatically better. Indeed the danger of focusing on more weight is that you might miss the other work.

Restoring to a healthy weight is non-negotiable

All good treatment providers now aim for full weight restoration:

If you don’t get weight restoration, you will get nothing.
Dr Julie O'Toole in YouTube "What constitutes good medical care"

A healthy body provides the foundations for the wellbeing of the brain and the mind:

"Behavioral recovery follows physical recovery, and psychological recovery follows behavioral recovery"
Dr Alix Timko in the excellent webinar 'Challenging Parent Perceptions on Weight, Fat, and Food'

Worldwide, professional bodies state the need for weight regain in a restrictive eating disorder:

Weight gain is key in supporting other psychological, physical and quality of life changes that are needed for improvement or recovery.
NICE guideline for eating disorders (National Institute for Health and Care Excellence)

The need for body fat

Why the focus on weight? Because we're trying to meet the body's needs. Two major needs are muscle and body fat. Both diminish with weight loss.

Your child may be scared of fat and see it as just padding, but they're at greater risk of relapse without enough of it:

"[Insufficiently high] BMI or measures of body fat and leptin levels at discharge were the strongest predictors of relapse with an approximate relapse rate of 50% at 12 months.
Frostad et al (2022) – from review of almost 1400 anorexia patients

That may be because fat has an active role in metabolism and produces essential hormones, including reproductive hormones, and leptin.

Some young people want weight regain to be done by 'toning' at the gym: the weight gain will be purely muscle. The problem is twofold:

The person needs nutrition and body fat, not just muscle — a normal or even high weight can hide a serious health issue if body fat is too low, since fat drives so many biological processes.
An exercise compulsion or a hyperfocus on reshaping the body are eating-disorder issues, not solutions.

Fat deficiency has long been recognised in sport, under the name Relative Energy Deficiency in Sport (RED-S), previously called the ‘female athlete triad’. One sign is the loss of periods.

Body-builders describe feeling terrible, physically and mentally, while ‘cutting’ body fat before a competition. And with boys and young men, an over-emphasis on lean muscularity should raise just as many alarm bells as weight loss or emaciation does — it’s easy to miss because it doesn’t look like the stereotype of an eating disorder.

Regain weight now — worry about the target later

During the early stages it is generally entirely appropriate to be focused on the need for weight gain.
Ivan Eisler, Maudsley’s Child and Adolescent Eating Disorders Service, personal communication, 2019

It’s a no-brainer. If your child has been restricting and lost weight, they need to gain weight. The same applies if their weight hasn't increased in line with their age and height. A short way of saying this is: has your child dropped off their growth curve?

➡️ Don’t waste time wondering ‘how much’ weight to gain — you can work that out later. Right now, their body is in famine mode and needs nutrition and weight gain without delay.

If your child has kept tracking, more or less, on their growth curve — as is often the case with bulimia or binge-eating disorder — then much of this page may not apply: the work is likely to be on regular, structured meals and snacks, rather than weight gain. Note that if your child has gained additional weight, relative to their growth curve — as can happen with binge-eating disorder — regular nourishment is part of the treatment, not weight loss.

I'll discuss later the pros and cons of being given a target weight. Either way, predicting healthy weight is no better than a weather forecast. It will have to be tweaked. Don't waste time on numbers now — start renourishing.

As with everything in my resources, do seek professional advice targeted to your child.

How fast should the weight gain be?

While your instinct might be to go 'slow and low', a lot of research indicates best results come with rapid gain, all the way to weight recovery.

➡️ What's 'rapid'? The rate that's commonly recommended is half a kilo to one kilo a week at home, and perhaps twice as fast in an inpatient setting.

"It is well established in outpatient and higher levels of care that early and steady weight gain is associated with good prognosis"
AED Guidebook for Nutrition Treatment of Eating Disorders (2020)

"Early weight gain (4–5 pounds by session 4, typically correlating with 4 weeks of treatment) is predictive of better outcomes in adolescents."
American Academy of Pediatrics (2021)

More [Click]

The only reason not to renourish fast now is where there's a risk of refeeding syndrome. Clinicians monitor for this with blood tests.

Note: parents of autistic children have contradictory experiences: some report great progress with rapid weight gain, while others are certain their child can only cope with slow gain. See my page: 'Autism and eating disorders: individualising treatment for your autistic child or teen'. The picture is complicated as many parents have had very little support.

What does the science say?

Adolescents who gain about 3–4 lbs by around week four of treatment are considerably more likely to reach full remission with FBT (Doyle et al, 2010). A later study recommended 3.20kg in the first 3 weeks (Le Grange et al, 2014).
A gain of at least 0.8 kg per week during inpatient treatment predicted a better outcome at one year (Lund et al, 2009).
Refeeding used to be slow in hospitals because of fear of refeeding syndrome. Modern protocols go faster (while monitoring), following studies like Madden et al, 2015, where adolescents safely regained medical stability with a mean gain of 5 kg in 2.5 weeks.
There used to be a belief that rapid gains are traumatic, or that ‘the mental has to catch up with the physical’). This has now been overturned. For instance Guarda et al, 2020.

"The importance of early weight gain for long-term recovery has been demonstrated by several studies in both outpatient and inpatient setting. Recent studies have also provided evidence to support a switch in current care practices for refeeding from a conservative approach to higher calorie refeeding."
Bargiacchi et al (2019): Refeeding in anorexia nervosa

More sources

Start with an excellent talk, backed up by data, to help you understand the benefits of rapid, full weight restoration: Alix Timko, in ‘Challenging Parent Perceptions on Weight, Fat, and Food’, youtube.com/watch?v=1Fzjx0VO438 She references studies, including some I quote on this page.

Anything by Dr Jennifer Gaudiani on the subject of weight and body fat is fascinating. Hear her in this podcast episode and there's more in her book ‘Sick enough’.

A healthy weight is individual — not one-size-fits-all

Weight is a bit like shoe size: there’s a size that fits your child, and often it's different from their friends’.

The major determinant of body weight is genetic.
AED Guidebook for Nutrition Treatment of Eating Disorders (2020)

Different dogs - different healthy BMIs — The BMI that suits your child isn't determined by a calculator

Of course, there’s more flexibility with weight than shoe size — we function well within a range and don't need to obsess over a single number.

Still for both weight and shoe size, there is no one-size-fits-all.

Weight has to be determined on an individual basis.
Daniel Le Grange, co-author of the FBT manual, in this webinar

This is what makes a weight target just a temporary prediction of what might suit your child.

And it's what brings uncertainty to the question, 'Are we there yet?'

Experts' recommendations for a weight target to be individualized

Studies have stressed the need to abandon a one-size-fits-all, median BMI target, for a long time. Professionals have, likewise, embraced it. I collected quotes on this page. Still, I hear of many clinicians who continue to use a 'one hundred percent weight-for-height' calculator.

How mood and behaviour improve with weight

As weight is restored, mood and eating-disorder symptoms typically improve fast — often faster than seems intuitive, and before any direct psychological work has started.

As her weight increased, her mental and emotional health grew stronger.
A parent

Paradoxically, the fear of weight gain, the "I'm so fat!", usually reduces as weight increases.

It’s very counterintuitive but as weight goes up these things [measures of shape and weight concerns, and eating-disorder thoughts, beliefs and behaviours] go down, and super fast… Even though we are not directly targeting these cognitions.
Dr Alix Timko in the excellent webinar 'Challenging Parent Perceptions on Weight, Fat, and Food'

How mood, eating disorder beliefs and behaviours usually improve with weight gain and other treatment aspects — How mood, eating disorder beliefs and behaviours usually improve with weight gain, then with the other tasks of treatment.

So while it's easy to grasp how weight gain is associated with physical repair, remember it also helps the mind. Perhaps that's because the body's famine alarm gets deactivated — all that anxiety-raising and constant thoughts of food ease off as the body feels the threat of famine is over.

For a paper on this effect [click]

See for instance Accurso et al's study 'Is weight gain really a catalyst for broader recovery?' and Dr Sarah Ravin's plain English summary.

That said, this improvement has a ceiling. Full mental recovery takes more than raising weight.

🔅 The other tasks of recovery🔅

Although weight restoration is a goal for FBT, it is not sufficient. If weight restoration was sufficient for treatment of anorexia we would have cured it a long ago.
James Lock, co-author of the FBT treatment manual, personal communication, 2019

Food and weight are essential medicine in a first phase of treatment

Think of weight regain like an antibiotic you take after surgery: essential to get over the worst of it, but treatment and rehabilitation continue afterwards.

Or think back to my azalea. It needs water urgently, but it will also need the right soil, lighting, as well as time to fully recover.

Another analogy: a house needs a good foundation, on which you build everything else.

weight restoration is the foundation of the house

To recover our children need to:

✅ Recover their full physical health — 'metabolic' or biological recovery through weight restoration, good nutrition and rest. This also helps mood and thoughts but rarely provides a complete fix. The blue band in the diagram below.

✅ Re-learn 'normal' behaviours — phasing out eating-disorder behaviours and replacing them with ‘normal’ ones, through exposure, repetition and brain rewiring. The purple band — my book's chapter 9 and many Bitesize audios help you with this.

✅ A careful return to independence: containment, guidance and supervision for the things they can't yet handle wisely, and coaching and experimentation for age-appropriate freedoms they seem ready for. This is the often-mishandled ‘Phase 2’ of FBT. The yellow band — more in Chapter 10 of my book and many Bitesize audios.

✅ Heal from psychological issues — addressing prior anxieties, depression or trauma, rebuilding self-esteem and emotional management. For some, this requires individual psychotherapy. For others, it's simply a matter of returning to a full life. Part of this is ‘Phase 3’ of FBT.

✅ Time is part of the treatment — as long as it's used to consolidate improvements, not for stagnation

The four elements of eating disorder recovery: biological, behavioural, independence, psychological

More [click]

A full physiological recovery

Whereas an eating disorder like anorexia used to be seen as mostly psychological, a metabolic component was revealed in genome research (ANGI: The Anorexia Nervosa Genetics Initiative) led by Dr Cynthia Bulik:

One very important message is how critical it is to adequately renourish people with anorexia nervosa — especially in the United States, we often see that insurance companies will de-authorize treatment prematurely. So people will be discharged from the hospital before their bodies have had an opportunity to sort of re-equilibrate or stabilize at a healthy weight. And so this suggests that getting the metabolism stabilized again might be a very important — in fact core component — to recovery from anorexia nervosa.
Dr Cynthia Bulik, ANGI study leader

We're aiming for all biological processes to be back on track, and this lays the groundwork for psychological work.

Full recovery from eating disorder thoughts, beliefs and behaviours

Remember that big Frostad study that found a high risk of relapse if patients are discharged with insufficient BMI and body fat? It also found that people need help to transform their eating disorder thoughts, beliefs and behaviours:

"In addition, the presence of ED symptoms at the end of treatment indicated a higher risk of relapse"
Frostad et al (2022) – from review of almost 1400 anorexia patients

Treatment that only improves BMI while leaving other symptoms and signs of the disorder unaddressed is associated with a substantial risk of relapse.

More on making a full recovery — not just weight — and what to do if your child seems 'stuck', further down here.

How is an optimal weight range worked out?

Let's see how therapists decide on a weight goal.

First, a disappointment: there is no precise ‘working out’ of optimal weight. Human beings are complex, and the science can’t predict exactly what will suit each of us. Predicting a recovery weight is rather like a weather forecast — an expert does their best with the variables available, but you’ll only know it’s sunny tomorrow when tomorrow comes.

Tomorrow’s weather is uncertain, whatever the forecast — the same with goal weight — Setting a recovery weight is as uncertain as weather forecasting.

So plenty of good clinicians don't set a goal weight, and tell you that the signs that your child is weight-restored will unfold as they get close.

But what are those signs?

A “biologically appropriate weight” is a weight that is easily maintained without need for dieting or inappropriate food and exercise behaviors, and reflects pre-morbid weight, normal physical and psychological function, genetic predisposition ethnicity, gender, and family history.
AED Guidebook for Nutrition Treatment of Eating Disorders (2020)

Specialists have a range of tools they may use

if they want to predict a goal weight,
or when trying to work out if optimal weight has been reached

Tools to predict a healthy weight [click]

These include:

height and weight before disordered eating began
the extent of weight loss, or failure to gain weight or height
growth history (height, weight, BMI) plotted on a percentile growth chart — a useful but imperfect tool (more below)
menstrual history
current pubertal stage (to help factor in growth spurts)
lab tests (such as leptin or estrogen) to indicate if the body's biological functions are fully restored
bone age (e.g. via X-ray)
photographs
genetics (based on family members’ build)
skeletal frame
muscle bulk (muscle weighs a lot, and health requires body fat too)
and mental state — whether the eating-disorder mindset is still strong, or easing off (more on this below)

A person’s healthy weight is highly individual to their genetics, their medical history, their experiences with food and dieting/caloric restriction throughout their life, and their body’s unique responses to inadequate fueling and to nutritional rehabilitation.
Dr Jennifer Gaudiani, in ‘Weight goals in anorexia nervosa treatment’

For adolescents and young adults and adults, we are really trying to think about their lifetime growth trajectory and not just some standard norm, off a chart. So we’re looking at their growth patterns throughout their own lives, considering what pubertal stage they’re at, considering if catchup height is needed.
Rebecka Peebles, FEAST of Knowledge 2024 conference

One-size-fits-all? the median BMI / percent weight-for-height method

Goal weight used to be determined with a one-size-fits-all tool. In some places it still is, though I have heaps of quotes from studies and specialists who do not recommend it.

That tool is median BMI. It's the same as ‘100 percent weight-for-height’. Because a neat weight in kilos or pounds is delivered by a calculator, it can give a sense of accuracy. I'll explain how it's a poor tool for any particular individual.

How '100% weight-for-height' may not even give you a ballpark [click]

Imagine lining up 100 children the same age and sex as your child, in order of their BMI. Naturally, many healthy kids are on either side of the middle (median) point.

What is Median BMI or 100 percent weight for height

If your child is given a goal weight of 100 percent weight-for-height, it means we're aiming for that middle point. But statistically, half of those patients would naturally be at a higher weight, and half at a lower weight. Just like half of 15-year-old girls have a shoe size above the median, and half, below.

* What do BMI and Weight-For-Height mean? *

There are studies where every child was given a goal weight of median BMI or similar (as in the main Family-Based Treatment studies). It makes research convenient, given the uncertainty about the weight that will eventually suit each child. When the result is that only half or fewer made a full recovery, I wonder if that's because, statistically, half of those children were genetically programmed for a higher BMI.

🌤️ Using median BMI is a bit like giving all girls of the same age the same shoe size, or predicting today's weather near you from the average rainfall worldwide. It’s good at flagging that someone is dangerously thin — it has a place in the toolbox for that. But it’s very bad at estimating an individual’s goal weight.

To further understand the BMI method, and how far it can be from yielding even a ballpark healthy weight for any individual, see my YouTube and my post 'Is your child's target weight a gift to the eating disorder?'

My child has a 'weight-for-height' target

When a clinician declares a child weight-recovered based on median BMI, with no consultation with parents, without any careful assessment of their physical and mental state, we parents have to jump into damage limitation mode.

You might have to tell your child, as I once did, 'I'm sorry darling, I've studied this and I know better'. Or from another parent:

"When my daughter, still quite ill, came home from an individual therapy session saying, 'She told me I'm at 100 percent and that's my perfect weight', I replied, 'I'm sorry you heard that. Nothing is changing before all the adults review this together."

I know of a few parents who did ask for a review, and the best result they could achieve was to 'agree to disagree'. The parents continued to feed for some incremental weight gain, and the therapists agreed not to block this.

The growth charts method: part of the picture

Plotting growth history on a percentile growth chart, and assuming your child should track along the same percentile, is a far better tool — but still very approximate when used in isolation.

I created this YouTube to show you how to use one, and if you prefer reading, here's my post on it.

I want to stress that a growth chart only provides part of the picture, and you should be ready to ditch its prediction.

That's because your child's growth is unlikely to track neatly along those statistically smoothed out percentile lines. They may grow in fits and starts, including a big growth spurt between their tweens and teens. A chart can’t predict that in advance.

* Weight centile growth charts: why they can’t predict your child’s recovery weight *

🌤️ Using a growth chart alone is a bit like predicting your town’s weather today from previous years, without looking at current weather fronts.

‘My child has always been slight’

Perhaps your child has been light, or slight, compared to their peers, ever since they were a toddler. They tracked along a low percentile for years, and this has been their ‘normal’. But is that the percentile they need now?

More [click]

It’s worth reviewing what kept your child at the lowest end of the weight spectrum. Did this appear in their early years? We know that children who drop off their weight trajectory at an early age are more likely to be diagnosed with anorexia in their teens. Maybe their low weight really is where they’re meant to be. Or maybe they started under-eating young for various reasons — like they heard diet advice very young, or they had anxiety starting nursery school, or there were too many foods that felt wrong, as can happen with ARFID.

Whatever the reason for an early drop, the more useful question now is whether that low weight actually suits your child today.

Here’s an example from Dr Peebles, of a child born at a normal weight who dropped off and then stayed on the 3rd percentile for BMI:

"and if there appears to be no reason for them to always have been so small, we're often pushing for the 15th to 25th percentile BMI-for-age so that we can give them a robust chance at not having difficulty with eating."
Rebecka Peebles, Children's Hospital of Philadelphia, 46mn into podcast 'State Not Weight'

Weight targets vary hugely from one clinician to the next

The weights or BMIs presumed to be 'healthy' and conducive to eating disorder recovery vary greatly from one treatment provider to another.

I explain these wide variations in my post 'Is your child's target weight a gift to the eating disorder?', where I compare the two most common methods — median BMI versus growth chart.

In places where discharge depends on hitting a weight goal, these inconsistencies lead to some people leaving treatment too soon and others perhaps staying weeks beyond what they need. Do keep in mind:

➡️ a weight goal will always be subject to uncertainty

➡️ reaching a healthy weight provides the foundation for further work — it should not be the end of treatment

We need better physical markers of weight restoration

Given the uncertainties about whether a body is weight-restored, I'm intrigued by how seldom lab tests are used.

With many of our children, we don't feel a need for those because a picture emerges that they are indeed back to a healthy weight. It can be as simple as 'they look well again'.

But for those who seem 'stuck' with eating disorder thoughts and urges, we need more clues to help us decide:

❓ if they need more weight or nutrition

❓ or more of the 'other work' I listed earlier

It makes sense to me to take some of the guesswork out and rule out deficiencies with a thorough assessment of a person's physical state. Most often, from what I hear, the only physical measures used are heart rate, blood pressure and the return of periods in females.

Does the return of period indicate 'We're nearly there'? [click]

The absence of periods is a warning the body is in deficit:

"Inadequate caloric intake in comparison to energy expenditure is the catalyst for endocrine changes and leads to decreased bone density and menstrual irregularities. Body weight may be stable."
Hornberger, Lane, Committee on adolescence (2021): Identification and Management of Eating Disorders in Children and Adolescents

The return of several regular periods is a welcome sign that some — though not all — biological systems are working again. The return of periods shouldn't be used alone to judge whether your child is weight-restored. More likely, menses resume on average at a point below pre-illness weight (Swenne, 2004).

In some people, periods continue despite the illness:

"In some cases, individuals exhibit all other symptoms and signs of anorexia nervosa but still report some menstrual activity"
American Psychiatric Association: Highlights of Changes from DSM-IV to DSM-5: Feeding and Eating Diso r ders

Note that bleeds on the contraceptive pill are not an indicator of the return of hormonal function.

⚠️ And here's an example of how inconsistent this field can get. Some clinicians require, say, three regular periods before considering a girl weight-restored. Meanwhile others are ready to discharge your daughter before menstruation ever resumes, assuring you she's weight restored, and that periods take a few months to catch up.

You may hear that periods usually return at about 95% of 'ideal weight', and that this can be used to re-assess the weight goal. I wonder if that comes from studies like Faust et al, where periods returned on average at about 95% of median BMI.

Be careful. 95% of median BMI is not 95% of your daughter's own healthy weight. If her growth history points above the median, the two can be far apart. The figure also describes when periods happened to return, not what she needs in order to be well. Also, other studies report different averages. Finally, in real life, the variations between girls matter more than the mean.

What to measure? [click]

On my page on exercise, I refer you to more resources on physical measures. Briefly:

"At Kartini clinic, we try to focus on 'state', not 'weight'. That is, the state of good health as opposed to a given weight. As measures of this state of health, we use our metabolic labs, including measurements of thyroid health, sex hormones, leptin, glucose, insulin, cortisol and others. We also look at the return of menstrual cycles (related to those same labs), return of energy and normal socialization.

What we don’t look at is BMI."
Julie O'Toole, Chief Medical Officer of Kartini Clinic 'The Misuse o f BMI in Diagnosis of Pediatric Eating Disorders'

But there's no consensus on which markers of physical health are relevant, and that's partly because various functions come back on line at different times for different people. For example, periods usually return on average a little above the weight at which they'd stopped, but still before pre-illness weight. Leptin may or may not be slow to recover. And Dulloo (2021), reviewing the Minnesota starvation study, describes a theory that body fat recovers faster than lean tissue (muscle, mainly), and that the body will drive hunger until lean tissue is regained. Can you see how it's complicated?

An analogy for the physiology of weight loss and regain

imagine you gradually lose money. You let go of a succession of things — first the Starbucks takeaway coffee, then the avocados, then the heating, the car, and finally, you lose your house. When you start making money again, you might not get things back in reverse order.You might go for the avocados first, then the heating, then the Starbucks. A house and car may come much later. You and I may be similar regarding the house and car, but differ with respect to the heating and avocados.

Here's how that's expressed in this perspective piece:

"Physiological normalization during refeeding is not uniform across biological systems, with cardiovascular parameters correcting more rapidly than gonadal and skeletal systems.

In AN, weight restoration improves most physiological indices, but the time course of biological recovery remains unclear.

In atypical AN, data characterizing how biological indices of starvation change with refeeding are sparse.

These observations underscore the utility of moving beyond approaches based exclusively on BMI. We propose the identification of biomarkers of physiological recovery as a necessary foundation for improved guidance regarding the renourishment of patients with AN and atypical AN.
Uniacke et al (2026): Moving Beyond BMI: The Need for Biomarkers of Physiological Recovery in Anorexia Nervosa and Atypical Anorexia Nervosa

As the above quote indicates, we still don't know enough. All the more reason to have a careful, open conversation with your treatment team.

"We do not have enough information about the process of nutrition rehabilitation to know if it is weight restoration alone, or the restoration of other nutrients, such as the many micronutrients involved in physical and mental health, that cause mental changes that are beneficial.

Certainly, in the process of gaining weight , other nutritionally important things are happening, but we have not tracked those in a precise, quantitative way.

We need to look at what is being eaten during weight restoration, as someone can gain weight on a very micronutrient poor diet or they can gain weight on a very nutrient dense diet, and this may make a big difference in how they present during the process of recovery.
Therese Waterhous, co-author of the Academy for Eating Disorders Guidebook for Nutrition Treatment of Eating Disorders, personal communication 2026

Mental state offers clues

Remember how I explained that mental state — I mean mood and behaviour — improve as weight is regained?

➡️ That means that if mood and behaviours are still extreme, chances are the person is still underweight. That certainly ties in with my experience in talking with hundreds of parents.

➡️ But remember also, that weight regain doesn't fix all of a person's mental state. So if mental state is somewhat poor, there's no certainty that it's due to insufficient weight, and that more weight will bring a fix.

Still, mental state does provide clues.

The strongest demonstration of the weight-state relationship is when someone loses weight. Perhaps you can look back and see how your child's thoughts and anxieties spiralled down as they lost weight.

Some people who have experiences of recovery and relapse say they noticed a tipping point (I haven't seen any research on this — for some it may be more like a steep slope). Below that weight, eating disorder thoughts are activated and become hard to shift.

Tipping point where weight loss seems to trigger an eating disorder — Many observe a tipping point: below this weight, the eating disorder is (re-)triggered.

"I’ve found that the single most important variable—the safeguard that separates the valley of recovery from the valley of illness—is maintaining the weight range that’s right for me[…] A few pounds [down], it suddenly felt more comfortable to be hungry than full. A meal that seemed normal two weeks ago looked huge and daunting."
Emily Boring, in an enlightening piece 'When in doubt, aim higher: What I wish I'd known about target weights in recovery'. Listen also on this podcast

More [click]

My understanding is that each of us has a rough weight threshold or zone below which the body raises a famine alarm. The alarm is also activated when food supply is sporadic. The body urges us to prioritise survival by making us anxious and driving us to think of food all the time (dieters call it 'food noise' and want to turn it off).

The alarm threshold or zone differs from person to person. That's one reason optimum weight is highly individual.

Does this potential tipping point reveal itself in the other direction, as people regain weight? Not really. I've never heard of a miracle switch from eating-disordered to recovered.

What you do get is incremental improvements, leading to some 'My kid is back!' rejoicing. With my daughter I noticed several time/weight points where recovery took a clear step forward.

I'll keep repeating this: full mental recovery takes more work than just raising weight. Once someone has an eating disorder, usually they need weight recovery plus other work, as discussed here.

➡️ Still, we expect a healthy weight to bring significant mental improvements. So if your child is still highly distressed by food, desperately trying to exercise, very delusional, showing big levels of resistance or aggression, then a clinician may sensibly guess that they are still significantly underweight.

⚠️ Set up to fail with a low weight goal

A dietitian once tried to reassure my daughter she'd be kept 'on the thin side of normal'.

Indeed, for a long time, clinicians thought a low weight would do the job, aiming only at medical stability (e.g. heart rate, blood pressure). Often, they gave every patient the same (rather low) BMI target. This seems to still be common in adult treatment.

A patient may be declared weight-restored at a low BMI without lab tests to check for physiological restoration, and with the mental side only slightly improved. Treatment ends with the person momentarily out of danger, but not recovered.

If your remember that physical restoration is like the foundations of a house, having a low target is like building a house on sand.

It is clear that under-nutrition cannot be good — yet as practitioners, many of us contribute unintentionally to this mistake every day. How so? By allowing patients to remain slightly below a weight that represents real physiologic restoration for fear that they will not be able to tolerate the anxiety of returning to a “non-skinny” weight/BMI.
Julie O’Toole, Chief Medical Officer of Kartini Clinic, in 'The dangers of staying slightly below weight'

While the intention of keeping a person 'on the thin side of normal' might be to prevent them from restricting and relapsing, sadly we have strong evidence that the opposite happens.

⚠️ A low BMI at the end of treatment is one of the strongest known predictors of relapse.

Here's from the Frostad review I quoted earlier:

"this systematic review finds that not reaching a sufficiently high BMI, within the normal range, at the end of treatment will increase the risk of relapse. This finding is informative as it will help to set a target for the patient and therapists in their common ambition to reach remission"
Frostad et al (2022) – from review of almost 1400 anorexia patients

In other words, people who left treatment at the lower end of the 'normal BMI' band (a statistical, not individual 'normal') were more likely to relapse.

Crucially, a person who isn't helped to reach full weight recovery is unlikely to recover in the first place.

"If a treatment goal weight is inappropriately low, there is an inherent risk of offering only partial weight restoration and insufficient treatment."
Hornberger, Lane, Committee on adolescence (2021): Identification and Management of Eating Disorders in Children and Adolescents

If weight dropped from 'overweight' to 'normal'

If your child was ever labelled ‘overweight’, or still is, you may find a range of opinions on whether they should regain weight, and how much.

(I am sorry that so many words related to weight have become judgemental and offensive. I hope you can see my intention to bring clarity, so your child gets the help they need).

"I do not know how many times I have been told by a parent that their pediatrician dismissed their concerns about their child’s weight loss as 'not a problem' because they were 'still on the normal BMI chart.’"
Julie O'Toole, Chief Medical Officer of Kartini Clinic in The misuse of BMI in diagnosis of pediatric eating disorders

It's likely that your child is physically and mentally unwell because of the extent and speed of the weight loss. The fact their BMI is now 'normal', or even 'high', is a distraction.

The mental and behavioural signs you see are evidence of malnutrition, even though today a calculator would categorise their BMI as 'healthy'. Often there are signs of severe physical deficit: low heart rate and blood pressure, and in girls, periods may have stopped. Some children faint. Some are rushed to hospital. All this at a weight that is now labelled 'normal'.

➡️ So make sure your child gets just as much care as if they were considered 'underweight'. Make sure the extent and speed of weight loss is taken into account.

Your child needs regular nourishment, and it's likely they will need some weight regain urgently. So get started with that. Don't waste time wondering how much weight regain they need.

More [click]

Make sure you don't praise the weight loss. Even among professionals, there can be an assumption that a person improved their health by losing weight — even when, objectively, they're currently in poor health, physically and mentally.

Get a second opinion. Get yourself informed:

In individuals who lived in higher weight bodies before the onset of their ED, such as those with atypical anorexia, refeeding and weight restoration should proceed with premorbid usual weight taken into account in determining weight restoration goals.
AED Guidebook for Nutrition Treatment of Eating Disorders (2020)

Notice the wording: premorbid usual weight is ‘taken into account’, not automatically the target.

What's the target? Just like with any BMI, there is uncertainty

It's a heated topic… Here's a range of views from clinicians [click]

We're talking about a child whose BMI has dropped to 'normal' after being 'high'.

The field is polarized. There are clinicians who believe the child just needs 'weight maintenance'. They prescribe a corresponding, ungenerous meal plan. Their next patient might have lost the same amount of weight, and show similar physical and mental problems, but be put on a high-calorie regime because their BMI is currently low.

Contradicting this, there are clinicians who believe that all lost weight must be regained. For those at the most polarized end of the debate, that means regaining to the highest ever percentile the patient was ever on – even if it was only a brief, uncharacteristic peak. They may further believe that everyone needs an additional ten percent.

Among those clinicians, I know of some who threatened to discharge the child if the parents queried the weight goal. Parents can be accused of fat-phobia by both clinicians and parent groups when they seek to understand and learn.

I hope your team can hold a measured, respectful discussion, remembering that weight targets are subject to much uncertainty.

We often encounter patients and families who say “but they looked better when they were a few pounds less” and want to use the eating disorder as an opportunity to keep a person’s weight suppressed.
We believe that using an eating disorder as an opportunity to avoid returning to a previous higher weight could hinder the individual from reaching full recovery.
Lauren Muhlheim, ‘How we set recovery weights’

Julie O'Toole approaches the topic in 'Determining ideal body weight' and in 'Coming to terms with my daughter's genetically programmed body size'.

More on patients with a higher-weight history from Dr Peebles, 47 mn into her podcast with Laura Collins Lyster-Mensh: Episode 21 'State Not Weight'. Also her webinar on YouTube.

What does the science say?

Should your child regain to their highest previous point?

Does research prove that people must return to their highest-ever BMI? In parent groups, I see many claims in favour of this — accompanied by a long list of studies.

I’ve patiently been through the list and found that none of those studies addresses the question. Research (as I edit this in 2026) looks at bringing underweight people back up to a middle-ish BMI. It doesn’t look at the recovery weight people needed if their pre-illness BMI was high.

Given the lack of research, we're left with just opinions — ranging from passionate to dogmatic.

I conclude that, just like for people with a 'low' BMI, we can't predict what a suitable weight will be until the person gets close to it. And let's remember there are other aspects and tasks to recovery.

It makes sense to me to restore some weight, proceeding in increments. This gives a chance for time, and all the other tasks of recovery, to take effect. From there, there'll be more clues regarding whether weight must be further raised.

At the same time as proceeding in increments, we can reflect on the weight that once suited our child, and in particular, what were they like at their highest weight:

were they healthy?
did they feel well within themselves?
did they have relaxed, 'normal' eating behaviours?

Whatever your child’s current BMI, there’s uncertainty about what weight might be conducive to recovery. It needs discussing as a team, collaboratively — nobody should be accused of being fat-phobic. A child’s wellbeing matters more than proving a belief right.

➡️ Start regaining, and worry about 'how much' later.

Note that the official diagnostic name for anorexia with a 'normal' or 'high' BMI is 'atypical anorexia'. I've written two pages on this for you: 'Atypical anorexia diagnosis? Handle with care!' and 'How much weight did your child lose? Weight suppression is critical in eating disorder diagnosis and treatment'.

Why are we even talking about a weight target?

'There's no need for a target'

Some clinicians I respect say there’s no need for a target weight at all. When they first see a child, it’s usually obvious weight gain is needed. Later, weight becomes only one of many indicators of health — and of course, a healthy weight is a range, not a single figure.

Restoring physical health (which includes being at a weight that is healthy for that particular person) is a necessary condition of recovering from anorexia. However, that does not mean that we need to identify a particular weight to aim for as a target for recovery.
Ivan Eisler, Maudsley’s Child and Adolescent Eating Disorders Service, personal communication, 2019

More expert views on this [Click]

"The focus should be not on weight per se but health. This would include absence of signs of malnutrition (such as amenorrhoea, pubertal delay, feeling cold, bradycardia etc.) as well as presence of indicators of healthy functioning (e.g. expected growth velocity for age/stage of puberty, resumption of periods etc.). There will be also psychological indicators such improvements in mood, reduction in ED cognitions etc., etc. In this broader context weight is also relevant as long as we recognize the limitations of the information it provides."
Ivan Eisler, Maudsley's Child and Adolescent Eating Disorders Service, personal communication

"We focus on using the body's response to nutrition rather than a weight goal"
Lock and Le Grange, in FBT treatment manual

"While weight is one measure to use for judging clinical progress it is helpful to think of weight as reflective of a state of health rather than an end goal in and of itself. The healthy weight becomes that weight where a person is physically and mentally healthy."
Therese Waterhous and Melanie Jacob, Practice Paper of the American Dietetic Association (now the Academy of Nutrition and Dietetics)

In other words, you'll know when you get there. (I know, you were wishing for something more predictable!)

Perhaps talking about target weight reinforces eating disorder beliefs:

"Reliance on targets is often a mark of the illness' need for 'certainty'. Later on in treatment everyone understands that it is other areas of life that will determine when someone has reached a weight that is good for them."
Esther Blessitt,Principal Family Therapist at Maudsley's Child and Adolescent Eating Disorders Service, personal communication, 2019

In other words, we don't engage in the eating-disorder's demands. Our poor children have an anxious focus on weight and they kid themselves that numbers will reassure them. Instead, we talk about health and wellbeing, and we help them to tolerate uncertainty. As they get well, they appreciate feeling good, they see that they haven't turned into a blob, and they loosen their attachment to a number.

It makes a lot of sense not to discuss target weight while someone is very underweight:

"It's not a topic that should even be discussed until well into the refeeding process. With a starved, paranoid cave person brain and a critical fear of even one pound of weight gain, no one should be tormented early in recovery by the idea of some number range they are supposed to reach, weeks or months hence."
Jennifer Gaudiani in her highly recommended book, 'Sick enough'

'It's helpful to have a target'

Now I'll give you a different view, from reputable therapists. They say that weight goals have their usefulness. And that it's useful to discuss target weight in therapy.

More [click]

First, knowing a target is part of exposure treatment for your child's fears around weight:

"By NOT saying the weight range target to the kid we would reinforce the idea that it is too scary or bad for them to handle."
Rebecka Peebles, Children's Hospital of Philadelphia, personal communication, 2019

And then it helps focus the parents too, and we owe it to them as they are doing all the hard work of renourishing:

"We also have so many parents who really think their kid maybe has only 10-20 lbs to gain but actually they have 30-50, and it dramatically alters their concept of the work ahead to get an accurate number."
Rebecka Peebles, Children's Hospital of Philadelphia, personal communication, 2019

And it may help parents and clinicians be on the same page:

"Some parents set lower thresholds for weight targets than clinicians believe are healthy. They may do this because they believe their child is constitutionally thin, to make it easier to re-feed, or because of their own weight concerns."
James Lock, co-author of the FBT treatment manual, personal communication

James Lock added that "Of course this is not most parents, but it is an ongoing clinical issue I hear about frequently." I mostly see the opposite on parent groups: they're upset that a clinician announced a low goal, without any consultation, and that their child is now 'stuck' there.

A target will need to be adjusted — or let go of

Even with a proper, individualised weight target, don’t get attached to a number. As your child’s weight goes up, there’ll be more clarity on what they need.

"In adolescents, target weight will be adjusted upward to correspond to increases in the patient’s height, and it can be helpful to discuss this with them from the initiation of treatment. During a period of growth, the target weight should be reassessed every 3–6 months.
The American Psychiatric Association (APA) Practice Guideline For The Treatment Of Patients With Eating Disorders 2023 Section 10

"The treatment goal weight is reassessed at regular intervals (eg, every 3–6 months) to account for changes in physical growth and development (in particular, age, height, and sexual maturity)
Hornberger, Lane, Committee on adolescence (2021): Identification and Management of Eating Disorders in Children and Adolescents

"A range of 1-2 kgs on either side of the "target" allows for professional and parental judgment to contribute on whether weight gain is sufficient for health and growth, and based on the changes in THINKING and BEHAVIOR, which are really what need to change to recover from AN even if weight-restored by any definition."
James Lock, co-author of the FBT treatment manual, personal communication

Note that if you mention "1-2 kgs on either side" to your child, it may be very hard to keep raising weight if, as often happens, it turns out they need quite a bit more. I recommend you either set higher expectations, or take the focus off numbers.

We're looking for a weight corresponding to physical recovery — so lab tests may be helpful, even though they're not commonly offered. As for recovery in terms of thoughts, beliefs and behaviours, remember that weight is only a foundation. The house itself must be built.

"Before you consider someone recovered, you're not just saying, 'Oh, have they got to the original target weight that I set 6 months ago', but 'Are they really fully physically, pubertally, and cognitively recovered? And if they are, OK, you're in the goal weight range. And if they're not, you might need more weight."

"You'll have a goal weight range and we need to aim for the upper end of that range, and if they're not doing well we need to keep going."
Rebecka Peebles, FEAST of Knowledge conference 2024

Beyond a knife-edge: build a buffer

Tipping point: below this weight, eating disorder symptoms return — Don’t stay on a knife-edge: have a weight buffer.

Many people find their weight has a tipping point: drop even a little below it, and eating-disorder thoughts and behaviours come roaring back.

As soon as she would hit 1 pound [0.5 kg] under [xxx weight] the ‘voices’ and behaviours would come back with a vengeance. So now during exams she ups her fat intake a lot. She doesn’t weight herself but she just knows because of the thoughts.
The mother of a 20-year old

The threshold for mental wellbeing is almost always higher than the bare minimum needed for physical health.

➡️ To avoid living on a knife edge, wise clinicians help you build in a buffer.

"My relapse taught me that for my own body, the difference between health and illness can be quite a narrow margin, just a handful of pounds. The simplest solution? Don’t live so close to the boundary."
Emily Boring, in an enlightening piece 'When in doubt, aim higher: What I wish I'd known about target weights in recovery' Listen also on this podcast

A person may resist even a small buffer, having fixated on one magic number and fearing anything above it. As a parent, you can continue to be compassionately firm about the need to continue the work. This means you should resist giving too many freedoms (Phase 2 of FBT) and be cautious if your child is discharged from treatment before this work is done.

Weight-restored but still eating-disordered? What's next?

I often see parents asking this on support groups:

'My child is weight-restored. But they're still counting calories, refusing many foods they used to love, avoiding restaurants, over-exercising and body-checking. They're stuck. What more can I do?'

Treatment used to aim for 'the thin side of normal'. Now, in places, the pendulum has swung to a view that weight-restoration fixes everything, and that if you still have eating-disorder symptoms, you need more weight.

The reply on parent groups is often, "Your child needs more weight. If they were truly weight-restored they wouldn't have all those ED signs. Keep raising weight until thoughts and behaviours have normalised".

"The problem is, there is a cohort of people out there who believe that weight restoration will solve all of the problems associated with this terrible brain disorder. It does not always do so — in fact, in my experience, although weight gain is the foundation of the house we are building, it is not the house."
Julie O'Toole, Chief Medical Officer of Kartini Clinic Kartini Clinic, in The treatment of pediatric anorexia nervosa

Remember, weight restoration is necessary but not sufficient. All of the following need to be considered:

➡️ More weight might indeed be needed (the original target may simply have been inaccurate, or a growth spurt or hormonal process — like restoring oestrogen — needs it)

➡️ Or more exposure work is needed to change behaviours and beliefs

➡️ Or the person needs more containment and monitoring — they're not ready for 'Phase 2' independence or they need more guidance and coaching to regain competence around eating or exercise issues

➡️ Or they need more psychological input — psychotherapy or a fuller life

➡️ Or simply their body, brain and mind need more time to heal, adjust, consolidate

Here's an illustration for a child who'd lost a lot of weight. I show which interventions had an effect on their OCD handwashing issue, on fear foods, their compulsion to move, and body image.

eating disorder recovery: weight, exposure, time

Weight is the foundation, but it won't fix everything.

If you're not sure if your child needs more weight, you can ask for physical checks, you can experiment with small incremental raises, you can review what further exposure or psychotherapy work could be done, and you can also give life and time a chance.

Body image is particularly slow to return to normal

Before you make big decisions on adding to treatment, or switching, or further weight gain, you need to know that of all the signs that make up an eating disorder, body image is usually the slowest to return to normal.

There is general agreement among clinicians that distorted attitudes about weight and body shape are the least likely to improve with weight restoration and typically lag changes in weight and eating behavior.
The American Psychiatric Association (APA) Practice Guideline For The Treatment Of Patients With Eating Disorders 2023, Statement 10

So don’t read a lingering ‘I feel fat’, or discomfort in the mirror, as proof that treatment hasn’t worked, or that the body is still in deficit. It’s common for body image to trail well behind improvements in physical health and in behaviours — sometimes by months.

How does body image eventually get fixed?

For some, it's just time — time is a healer when used to lead a full and interesting life, while consolidating helpful ('normal') behaviours. There is therapy for body image (it's one of the modules of CBT-E). It doesn't seem to be widely on offer and I'm not sure why. Of course we can all improve how we talk with our child, helping counteract our culture's weight bias.

Overshoot

Have you been told your child can only fully recover if you keep feeding them for 'overshoot'? I’m not talking about the sensible aim of having a moderate buffer (see above). Overshoot usually means going well above a weight target — temporarily or permanently.

This advice comes mostly from parents whose child recovered at a higher weight than the initial goal . Some therapists also recommend it.

If you're grappling with this issue, scroll back up to the section: 'Weight-restored but still eating-disordered? What's next?'

Is overshoot for everybody? [Click]

Let's check: is overshoot helpful? Is it necessary? And should it be recommended to everyone?

Overshoot by how much?

You'll want to know, ‘Overshooting by how much, and relative to what?’

We’ve already seen how uncertain weight‑target estimation is. When someone is given an arbitrarily low target and later discovers they feel better at a higher weight, that isn’t overshoot — that’s correcting an under‑estimate. This might explain some (not all) of the positive overshoot stories.

Some prescribe overshoot like this: take the number a person needs to get back on their growth curve and add ten percent. Before you rejoice that finally, you have a simple formula, remember that growth curves lack precision for any individual. Also, the ten percent isn't universally endorsed. It could be more, less, or 'Keep going until the eating disorder is gone'.

There’s no harm in a safety margin. My concern is that focusing too much on weight may mean missing the other tasks of recovery — a point I also make when discussing 'extreme hunger'.

More theories related to overshoot

I've come across the instruction to continue weight gain until you like your body:

"When my daughter got back to her growth curve, we'd already done a lot of exposure work and her behaviours and thoughts were mostly back to normal. What remained was some body dislike. The therapist insisted we continue feeding for rapid weight gain until she started liking her body. This went on for months. Eventually we got better expertise."

Another theory is that parents should keep driving weight up until they see it flattening out:

"The therapist said, keep feeding for weight gain. Her weight will naturally settle, and that will tell us she's reached recovery weight."

Related to this: keep feeding high calories, and if weight keeps rising it's proof the body needs it.

I've not found research sources for these theories. Perhaps they're extrapolated from set-point theory. Set‑point theory suggests that each body tends to defend a certain weight range by adjusting appetite and metabolism. This works reasonably well to guard against weight loss: metabolism slows and hunger increases to put the brakes on. But the same mechanism doesn't work well in reverse. When weight is rising, there’s little evidence that metabolism applies brakes. Appetite cues only provide stability if other factors don't stand in their way. If you're the one deciding on portions, your child's appetite and psychosocial cues are not the ones leading the process.

If you're confused because you're being told to feed until weight plateaus, know you're not alone. Clinicians — who fully support getting someone back on their growth curve and even having a moderate overshoot — express concern when they inherit a discouraged, depressed patient who has complied with ongoing high calorie intake and been taken significantly beyond their historical weight percentile, e.g from 50th to 90th. Sometimes the only physical monitoring has been weight, and a growing insulin resistance has been missed.

Overshoot: what's the evidence?

Overshoot polarises people. Some parents are accused of fat‑phobia for questioning it. Some are told their child will be discharged unless they agree to indefinite weight gain.

On the other hand, when overshoot coincides with recovery, parents naturally want to recommend it.

I’ve reviewed the scientific studies often cited as evidence that overshoot is universally necessary. They’re excellent studies — but they’re not about overshoot. I’ve searched further and found no research supporting the theory.

The most-quoted evidence is the Minnesota Starvation Study, where young men without an eating disorder experienced extreme hunger and overshoot once they were allowed to eat. It's useful for insights into the physiology and psychology of starvation and hunger. But it's not a study where you take people with an eating disorder, raise their weight to overshoot, and this results in psychological and behavioural recovery.

The study does raise the possibility that some bodies need to overshoot, and that frustrating this could be counterproductive. But in my view it doesn't justify blanket advice.

There is plenty of published research that indicates that overshoot is not necessary for everyone. Studies where roughly half of patients recovered at median BMI. And we have many ordinary-life examples of full, lasting recovery without overshoot.

So we can't say overshoot is necessary for everybody.

Why not try overshoot anyway?

Some say that questioning overshoot is fat-phobic. What's wrong with more weight, if there's a chance it will fix this vile illness?

I think that's a good question, within limits. If a child is stuck, labs show full physical health, and the other work of recovery has been done, then trying some additional weight makes sense. Do it in increments, so you can see whether more psychological work is still needed, and give time and a rich life a chance to take effect.

But what happens when overshoot doesn't work? Families may become disheartened after huge efforts to keep raising weight, yet the eating disorder remains. They may have focused so much on one theory that they’ve neglected the other parts of recovery. I’ve seen parents become hopeless, and adults expressing despair on blogs that promote overshoot.

Overshoot: the success stories

Overshoot has success stories. Many people recover after going significantly higher than their initial target.

The scientist in me queries whether the active factors were the exposure, the time, the rich life happening alongside the weight gain.

Still, overshoot may be relevant for some — perhaps your child's body truly needs more weight than they ever had before. Some parents are very certain that overshoot was the sole, direct reason for recovery:

Her voices and behaviors stopped. It was absolutely the magic wand.
A parent

Is it OK to lose weight after overshoot?

Some who overshoot stay at the higher centile; others drift down months or years later.

Weight loss can be a relapse risk, so it’s understandable to feel anxious. Here are two positive experiences:

When she was losing, at first I thought it was due to relapse, but I see her eat 5 of her 6 meals, she is eating the same way, snacks freely, no exercising, not vomiting. There are none of the telltale signs I’ve learned to identify: she’s not striving for perfect grades, she has friends over all the time, her room is messy, she can wear non-baggy clothes, there’s no drama or odd behaviors around meals, and the non-stop negative self-talk has gone.
A parent

Her hunger cues normalised and she began to lose weight gradually. Those around her noticed it before she did. Weight loss occurred over the course of a year and then stabilized. This was a scary time as we tried to figure out if this could be a relapse, but no clear signs of relapse emerged. She ate freely and exercised very minimally. Her mental and emotional health remain strong and she is excelling in school, work, and relationships. She honestly is functioning at her best, including pre-eating disorder.
A parent

While your child is losing the overshoot weight, check it's different from relapse: are they still eating freely and flexibly, still socialising, free of rituals and compulsive exercise?

If warning signs appear, treat it as a relapse signal and get help.

Ravenous after weight restoration – a sign more weight is needed?

Some people (once considered weight-restored, and once they can choose what and how much to eat) experience extreme hunger and find themselves eating more than seems needed (hyperphagia). It can feel confusing, out of control, discouraging.

It makes complete sense that the body should drive hunger when it's underweight. Is the reverse always true? Could the drive to eat and gain weight be evidence the body is still underweight?

Or could the hyperphagia be driven by other forces that your child needs help with?

More [click]

What usually happens with hunger and weight

Let's remind ourselves of what usually happens for most people as they get closer to recovery from anorexia.

When your child has lost weight it's normal and biologically right that food occupies most of their thoughts. This is how the human race survived.

Many months of feeding later, our children usually get mildly, pleasantly hungry around mealtimes. There's some re-learning and confidence-building to do around food choices and portion sizes. Phase 2 of FBT should include coaching and practice to re-learn normal eating. We parents monitor how competent they are, and give them back choices accordingly.

We know that hunger and fullness cues can take many months to come back on track (this is shown when testing for leptin, for instance). So at first it may be appropriate to guide our children with some kind of structured (rule-based) eating because they don't (yet) have the biological or psychological tools for intuitive eating. Eventually, it all works out.

We parents have some re-learning to do too: for a long time it was right to be hyperfocused on getting our child to eat lots, limit physical activity and increase their weight. We had to be determined. Eventually the time comes to re-orient ourselves towards the 'normal' lifestyle we've been aiming for all along. To move towards nuance. More and more food, more and more weight, isn't appropriate any more. 'Moderation', 'balance' and 'healthy' stop being dirty words.

So is hyperphagia a sign your child needs more weight?

It might be. It's so hard to be sure about weight recovery, it would be careless to ignore a big flashing sign like hyperphagia. And for some, the proof is in personal experience: embracing hunger and additional weight led to their full recovery.

Among those, there's a view that any desire for food — even a passing thought of ice cream — should be read as a genuine hunger cue. If you hold back — if you reason that you've already eaten plenty — that's the eating disorder making a resurgence. Overshoot isn't just expected, it's necessary. Hunger and weight will eventually naturally settle back to pre-illness levels. To read more on this from reputable author/bloggers for adults, see Emily Troscianko, Tabitha Farrar, Amazonia-Love, Helly Barnes.

Apart from personal experiences, the study usually quoted in support of this view is the Minnesota Starvation Study. The study validates that post-starvation hyperphagia and weight and fat overshoot, followed by a natural setting, is a normal physiological response. That's reassuring for anyone who's finding hyperphagia upsetting.

What's tricky is that the study isn't directly testing methods to overcome an eating disorder. Anorexia isn't purely a starved body seeking calories; it's that plus thoughts, beliefs, emotions and habits that don't necessarily resolve just because hunger is honoured, just because weight is restored.

Look at the whole picture

Maybe your child really does need more weight. Some say that this 'maybe' is a good enough reason to support your child's urge to have large amounts of food. Indeed, some say that parents should insist on continued weight gain.

If your child is enjoying their big meals, the freedom to eat without care after a long period of rules and restriction, and if they're comfortable in their body, then all is well — no need to read any further.

But I also know of some very unhappy, depressed people in this situation. Their eating shows no sign of stabilising. Treatment has stopped, yet it doesn't feel like recovery. The parents say nothing because they fear triggering a new cycle of restriction. They stop asking for help on peer support groups because when they mention the ongoing weight gain, they're quickly accused of fat phobia.

After discussing this with some eating disorder dieticians, here's what I've come to understand.

Eating is complex! It's not just 'If you think of pizza it means your body needs it'. The biology is way more intricate. So much so that it's easily disrupted: not everybody is blessed with well-regulated hunger and fullness biochemicals. In addition, a person recovering from an eating disorder has to find their way through all the psychological and social factors of eating and weight.

Hop over to a flowchart on this YouTube by Cara Bohon to eyeball the numerous, interrelated factors that shape our eating behaviour.

After that, you may agree with me that a person who thinks of food all the time needs help with the whole picture. Maybe they need more weight, and maybe the issue is something else.

So what to do?

Here's how I see it: look for a registered dietitian specialising in eating disorders, ideally one who works with both anorexia and binge-eating disorder. Words like ‘weight neutral’, ‘weight inclusive’, ‘Health At Every Size’ and 'Intuitive Eating' are usually good signs, but check what the person really means by it.

Check they'll address the physiological, psychological and social aspects. Will they use physiological indicators that your child's body has now met its needs? Will they investigate whether your child has reliable biological hunger and fullness cues? And will they take the time to know all the other factors shaping your child as an individual — their wishes, distress, emotions, habits and environment?

When we start eating disorder treatment, our implicit contract with our child is to guide them to full recovery. That means a relaxed, balanced attitude to food and to healthy living. We all deserve professionals to help our children get there.

Your child's feelings about their weight

It's one thing for clinicians and parents to know that a child needs to restore to a healthy weight, and quite another for the child to bear the fear, distress and horror that this can evoke.

Should your child be told a target weight?

Some therapists insist on patients knowing a target, while others don't see a need.

Typically, the target weight will be discussed explicitly with the patient, but this can require considerable sensitivity. On occasion it may be judicious to delay this discussion until the patient is less fearful of their ultimate weight.
The American Psychiatric Association (APA) Practice Guideline For The Treatment Of Patients With Eating Disorders 2023 Statement 10

Either way, the need for weight gain usually must be out in the open. You'll tie yourself in knots if you try to protect your child from that knowledge.

Hopefully, the clinician announcing a target also pays attention to the patient's reaction. If they don't, your child's upset may manifest not in the treatment room, but in the car on the way home.

Parents need all their parently skills to weather the storm (see chapter 14 of my book) and make sure the next meal is eaten (chapters 6, 7 and 8 and my Bitesize audio collection). Parents can do this a lot more confidently when there's teamwork with clinicians.

Bitesize audio collection - help for parents of a child with an eating disorder

Kindle ebook Eva Musby - anorexia and other eating disorders - help your child

Book Anorexia and other eating disorders - help your child eat well and be well

How clinicians explain a target [Click]

"As long as this message comes across as caring and an expression of a wish to promote long term well being (rather than being controlling and unwilling to listen) most young people with anorexia go along with the need to gain weight, albeit grudgingly and with perhaps (unpredictable) meltdowns. We have argued that, as long as the message about the need for weight gain is experienced as an expression of care, the young person, in spite of being scared, finds it at some level reassuring."
Ivan Eisler, Maudsley's Child and Adolescent Eating Disorders Service, personal communication. 2019

Be really careful with any numbers you say aloud. Our children can fixate on a target as their maximum. Giving a range can be just as problematic while eating disorder thinking is strong: our children hear the top number as a limit.

"As a HAES provider, I have moved toward setting a minimum weight rather than a weight range for my patients […] A weight range implies that there’s a weight above which they’ve gone 'too high.’"
Dr Jennifer Gaudiani, internist and expert on the medical complications of eating disorders, in 'Weight goals in anorexia nervosa treatment' (HAES is 'Health At Every Size')

I believe that the way we talk about optimum weight or weight range evolves as our children recover. While they're deep in the eating disorder, they anxiously distort our words and it makes everything harder. Our priority is lots of good nutrition and rapid weight gain, not education. After they're weight-recovered, surely the conversations need to change, so that they can learn or re-learn how balance works in normal life. More on this further down.

As we saw, for some therapists, talking about a weight gain goal is part of the therapy. Parents, you can ask for an appointment without your child in order to learn more:

"We walk the parents through a step by step explanation, with their kids' historical curves. We then let them know it is our recommendation to only tell their kid the highest number in the range, as the kid cannot ‘unhear‘ the lowest number."
Rebecka Peebles, Children's Hospital of Philadelphia, personal communication, 2019

Parents and youngsters need different conversations:

"We then tell the kid the highest number – with phrasing like, ‘A goal weight is just our best estimate of where your body and brain will work best. It's also going to move up as you get older and/or taller, so the goal is a moving target and will go up. It’s based on where you were healthy long before this illness. Because kids grow all the time, any number we say is going to probably be the highest you’ve heard and it will probably feel upsetting, but it’s important we go over it so that you’ve heard it and the numbers seem less scary over time. Keep in mind that we are flexible on your goal weight and if your brain and your body are completely better earlier than we think, that’s fine. Likewise if you’re not totally better or not thinking clearly at the number we say now you may need more. We are fine as long as you are really truly fine and your eating disorder is gone.'

Then we tell the kid the highest number in the range. Watch the meltdown. And then keep going."
Rebecka Peebles, Children's Hospital of Philadelphia, personal communication, 2019

Note that Rebecka Peebles, quoted above, is not dogmatic about telling all kids their target weight: "If I see a 7 year old who has no concept of weight at all, then we won’t. If parents refuse permission we won’t. But it’s really hard to do good work without being transparent."

"If parents indicate their child cannot tolerate it, then I'm willing to wait. […] It's a question of when is best. I want to talk with the kids and the parents and see what makes the most sense. If patients are saying, 'I have to know, I have to know!' but it's clear, they're very honest, that if they hear a number that they can't handle then they're going to stop eating, then that's probably not a time to talk to them about it."
Rebecka Peebles, FEAST of knowledge 2024 conference

It's paradoxical: the fear of weight reduces as weight increases

With a family-based approach, we don’t need our children’s buy-in. We support them to eat, meal after meal, despite their fear. With regular nourishment, time and weight gain, resistance to weight gain usually, paradoxically, reduces.

As I said earlier, mental state improves with weight gain.

It’s normal for anxiety over body shape to spike now and again, but it abates as people are supported to push through. Some report a renewed spike of anxiety and resistance a few kilos before weight restoration. My experience of supporting parents is that this can happen at any point along the weight-gain process. Perhaps it's an ‘extinction burst’ — the unconscious mind testing whether an old pattern might still work. When that happens, the main thing is to keep going.

"The anxiety over being fat is more likely to significantly improve with recovery, more regular eating patterns, and — ironically — weight gain than it is with appeasement."
Lauren Muhlheim in 'When your teen has an eating disorder'

"There is another powerful belief that makes some parents wary of 'too much weight gain' — the belief that their child will become distressed, more depressed and 'worse psychologically' if they 'gain too much'. There are some providers out there who share this belief as well, setting weight gain goals 'their clients can accept'. The fallacy to this argument is that we are not talking about the average child or teen, we are talking about the one with anorexia nervosa. There is quite literally no weight, however low, that will placate an eating disorder."
Julie O'Toole, Chief Medical Officer of Kartini Clinic, in 'Setting goal weights'

Paradoxically, I became freer from preoccupation with weight and food when I allowed my weight to climb higher … I can eat and move on with my life much more easily than even just a handful of pounds lower, and I don’t constantly have thoughts of food and weight and exercise on my mind.
Hannah, in 'Insights from relapse to recovery: what I’ve learned from falling and getting back up again'

Remember: although body image tends to improve with weight gain, it's often the last thing to fully resolve.

Should your child see their weight? Blind versus open weighing

A scale, illustrating the choice between blind and open weighing

Blind weighing is where your child is weighed with their back to the scales, or using a blind scale (no dial — results are sent to the parents' phone via bluetooth or wifi). With open weighing, your child sees their weight.

Blind versus open? It's hotly debated [Click]

Let's take a step back and remember why we are weighing — often weekly. It's mainly for the adults to track progress and check they're feeding adequately. But therapists also view weighing as part of the therapy.

Open weighing was used in the studies validating Family-Based Treatment (FBT)and also Cognitive Behavioural Therapy (CBT). Therapists following the manuals should be using each weight reading as a therapeutic intervention, discussing fears, challenging beliefs, giving psychoeducation. Daniel Le Grange also explains in this webinar how knowing the direction of the weight is essential in FBT and how weight "sets the tone of the meeting".

The good news is that plenty of young people get used to seeing the numbers rise. For them, open weighing brings potential benefits, and no harm.

However, for others, each weekly weighing brings a meltdown, which the parents are left to deal with alone. Contrary to principles, the therapist have not done any therapeutic work around the child's reaction to their weight. They've just weighed, displayed the number — that's it. The consequence can be that for a day or two after each reading, parents struggle to feed their child adequately. Given that rapid weight gain is a priority in a first phase of treatment, it seems obvious that open weighing should be put on hold.

From my discussions with parents, I note that many therapists who do open weighing don't do any therapeutic work around it. The parents deal with the meltdown in the car on the way home. Open weighing is surely counterproductive if each time it leads to missed meals.

Some people worry that with blind weighing, a person will spiral down in a panic the day they happen to see their weight. From lots of personal accounts, what actually happens is… nothing very much. Presumably, by the time our children are exposed to a number, their brain is functioning better and they lead a more interesting life.

The FBT and CBT methods' recommendation for open weighing come from principles of openness and exposure. There are no studies comparing open and blind. Bring your observations of what currently works for your child to the clinical team.

If there's chaos and trauma when your child knows their weight, watch below (at 44:20) how "rules are made so that you know when to set them aside". He also explains the therapeutic value of open weighing:

My opinion is that, on the basis of 'First do no harm', you can't go wrong doing blind weighing at first, especially in the first visit to a generalist. This gives you time to find a good therapist who is skilled at open weighing, and ready to discuss with you the pros and cons based on your child's mental state at this particular time. The principle, as always, is that you are an expert in your child, and the therapist is an expert in the treatment method.

For more on 'The Pros and Cons of Blind Weighing', I recommend this podcast with Karin Kaplan Grumet.

Feelings about weight after a goal is reached

All that hard work to beat an eating disorder! We owe it to our children to help them build a relaxed relationship with food, exercise and weight afterwards. Think of the weight-gaining phase as tough medicine, and time-limited — not ‘normal’ life. We serve big amounts, impose rest, and focus on rapid weight gain. Once our children are weight-recovered, they need guidance to learn, or re-learn, stability — and that’s not going to happen overnight.

One of the tasks of this later stage is loosening the attachment to a magic number. Often, our children turn a target weight into a personal ceiling. They easily regain weight if it dips a little, but control eating and exercise to avoid going above. This is, of course, still eating-disordered. And if they're stuck on a number at a time they need to grow, they're at risk of relapse.

The problem when a young person hears a recovery weight as a magic number to never go over — When a recovery weight becomes a magic number never to be crossed.

➡️ To give your child a chance to learn that their weight doesn't need micromanaging, one option is to give them some scaffolding with structured (rule-based) eating. Intuitive eating tends to come later.

➡️Some might benefit from more exposure work — to food, or to a weight a little higher than their ‘magic’ number.

Each person finds their own route to freedom and stability, and deserves professional guidance. This means your child probably shouldn’t be discharged the moment they’re weight-recovered — or if they must be, the work needs to continue within the family. It also means some freedoms (Phase 2 of FBT) may need to wait a little longer, while you hold and guide them through learning how food, exercise and weight settle in ordinary life: that weight can vary by a kilo or more from day to day or month to month without meaning anything has gone wrong, and that a happy weight is a flexible range, not one number.

What to do with all the uncertainty? Experiment, proceed in increments, review

With all these uncertainties, how might an expert proceed?

➡️ They might take a patient to their best individualised recovery-weight estimate, stabilise them there, and step up work on the other tasks of recovery.

➡️ If the person continues to be stuck, after a short while they might proceed in increments — a little more weight, alongside renewed attention to exposure work, psychological work, and enriching the person’s life.

Focusing on a target weight, given all the uncertainties, can create anxiety, confusion, and spawn unhelpful theories. I can relate to an incremental, experimental process. It's how my daily HRT and thyroxine doses have been worked out. To the extent that weight represents a biological need, the same process makes sense to me.

An important part of the later stages of the process of recovery is to accept that one needs to learn to tolerate uncertainty. This is a difficult piece not just for the recovering young person but also for the parent — and in different ways for the clinician. It would be wonderful to be able to have something specific and measurable that would tell us when it is safe to back off and let the young person get on with their life – if only.
Ivan Eisler, Maudsley’s Child and Adolescent Eating Disorders Service, personal communication, 2019

The bottom line

➡️ Get weight gain moving now, without waiting for a perfect number. Expect the target to be an estimate, revised as you go.

➡️ Keep doing the other work of recovery.

➡️ Watch the whole person — body and mind — not the scale alone.

➡️ Accept that you’ll only really know your child has found their healthy weight once they’re living well in it.

➡️ Build in a buffer rather than living on a knife-edge.

More help from me related to weight [click]

* Experts say, "Recovery weight must be individualized" *

Quotes from eating disorder experts on weight targets: researchers, professional bodies, and the clinicians who may well have trained your clinicians!

* Is your child's target weight a gift to the eating disorder? *

Comparing two methods therapists use to determine a weight target: growth chart + adjustments, versus the one-size-fits-all BMI approach. The difference can be huge!

* What do BMI and Weight-For-Height mean? *

What BMI and Weight-for-height (WFH) and BMI z-scores mean, and how they cannot be used for advice. Read this if your child’s therapist uses BMI or WFH.

* Weight gain in growth spurts *

To help you let go of weight targets, I remind you that youngsters' growth is unpredictable and can go in spurts.

* Weight centile growth charts: why they can’t predict your child’s recovery weight *

How growth charts cannot predict a healthy weight for your child: I show you how they fail to show normal variations in healthy individuals and remind you that you won't know your child is weight-recovered until they get there.

* How much weight did your child lose? Weight suppression is critical in eating disorder diagnosis and treatment *

If your child has failed to gain weight with age, or has lost weight, that's weight suppression. Make sure your clinicians aren't only looking at your child's current weight: here's evidence that the amount and speed of weight loss matter at least as much.

* Atypical anorexia diagnosis? Handle with care! *

What's 'atypical anorexia', the issue with weight being declared 'normal' or high, the risk from malnourishment and the need to regain lost weight.

* Autism and eating disorders: individualising treatment for your autistic child or teen *

* More on weight and feeding in Chapter 6 of my book *

* Exercise compulsion with an eating disorder – what can we learn from others? *

Are you wondering how to help your child with weight gain and the other tasks of recovery? Lots of help in my resources:

Thank you to James Lock, Daniel Le Grange, Ivan Eisler, Esther Blessitt, Rebecka Peebles, Therese Waterhous, and a whole lot of well-informed parents, for helping me write this post.

Comments

Anonymous

Thank you very much , I will start to communicate with my parents more and fill them in as much as I can. I also talked with my parents about the feeling and we’re working through it
Have a beautiful Christmas !
-The 13 year old

Reply
1. Eva Musby
  
  Ah, you've done exactly the right thing! I'm delighted!
  Eva
Anonymous

Hey,This is the 13 year old again What should I do? Today I faced a trigger by one of my parents which makes me want to restrict so much tomorrow and I know in my case when I restrict It becomes very severe very fast What should I say to these thoughts and voices?

Reply
1. Eva Musby
  
  Dear Anonymous, I am so sorry you are experiencing these difficult triggers. One day, you will stable and nothing will trigger you! For now, please know I help parents to help their child, I don't help the young people themselves. So I would encourage you to keep up the communication with your parents so they can best help you through these difficult times, rather than be asking ME. And of course I can help your parents if they want to come for example to one of my workshops, or to read my materials. Love, Eva
Meg

What about hair falling out ? I have a 13 year old at home who is dealing with strands of hair falling out at a time. Is this a sign she should gain more weight even if she is apparently weight restored?

Reply
1. Meg
  
  Your opinion would be greatly appreciated
2. Eva Musby
  
  Hi Meg, a doctor will have the expertise for all the reasons hair may be falling out. However, "when you hear hooves, think horse, not zebra". The most obvious one in this context is indeed, malnutrition, which could indeed mean nowhere close to weight-restored (if periods are not back that would be another sign) or maybe there are restrictions of particular food group so essential nutrients for hair are lacking. I hope this helps you with the courage to keep going.
Sam

Hi, concerned parent here what if my child is supposedly weight restored but yesterday morning nearly started to skip breakfast again does this mean she still needs to gain some more weight?

Reply
1. Eva Musby
  
  Hello Sam, almost everyone will relate to your question, because it's normal that worrying behaviours or signs pop up for a while, and then we wonder if our child is going to sink all the way back down, or if we're missing some crucial element. Here's what I think.
  Yes, maybe it's a sign she needs more weight. Always bear that one in mind.
  However weight recovery on its own rarely fixes the eating disorder, as I explain in the heading above "Weight restoration: essential but not sufficient for recovery"
  
  So if for now you're pretty sure your daughter is weight-restored (and that her current meals will keep her on that growth curve, i.e. the weight keeps going up, her nutrition needs are being met) then you could focus your attention on all the work of exposure (chapter 9of my book) and of Phase 2 (chapter 110 of my book). I do a 'Phase 2' workshop covering both those aspects.
  That work is necessary, but not sufficient: if it's not done, chances are high that a person will keep suffering from an eating-disorder
  And weight restoration is also necessary, but not sufficient: without complete weight restoration, chances are high that a person will continue being anxious and resistant to progress, with a mind that continues to be beset by distortions.
  So we parents live with some level of uncertainty when we see symptoms: is it that my child needs more weight, or more exposure and 'Phase 2' work, or is it both.
  Given the uncertainty, we try and make wise decisions, experiments, small steps, and review from that.
  I hope this helps. Love, Eva
Lilly

What if my daughter is weight restored will she still need to be in taking a high amount of nutrients per day or can she go back to a persons ideal amount of nutrients per day?Your content has helped my family very much over this tough period Many thanks

Reply
Anonymous

Hey
I'm a 13 year old who is 3 months into recovery. Yay! I'm really proud of myself but how many calories should I be eating? I read I should be eating xxx calories per day and so far I'm doing it! But is this the right amount for me I would ask my doctor but my mom and dad are trying to help me without professional help I'm just wondering what you think:)

Reply
1. Eva Musby
  
  Hi darling, you're using great courage and determination to get well – exactly what's needed, and yes, you sure can be proud of yourself! I've deleted some of your comment so as to avoid anything that might 'trigger' others.
  So, you're 13, your parents are supporting you, and you'd like to know if you're eating the right amount, and you're getting taller. So it sounds like your parents are guiding you super-well and you can trust them! I imagine it's a bit nerve-racking to know where to put your trust… You say your parents are not getting professional help, but if they're guiding you to eat as you describe, I'm guessing they're very well informed – fantastic!
  The standard rule is that the amount of food you need is whatever is bringing you back to your weight and height growth curves, plus a bit more to make sure your body really has what it needs, as explained on this page. And your parents will be able to give you the feedback about what your body needs, because you want both body and mind to feel great! You're aiming for a rapid rate of progress, even if that is stressful, so keep calling upon your courage.
  Also, if your body is sending hunger signals, and you eat more than the numbers you've given me, that's great AS LONG AS you still eat the next meal or snack. (Missing meals or restricting on any meal, even if you ate plenty before, would set your body and mind back). If you don't feel hunger, that's normal too for now, and so keep up the good work in eating to plan.
  You ask if I can hep you some more: direct your parents over my way, as I help parents to help their child.
  Keep going and here's to your beautiful free life ahead!
2. Anonymous
  
  This is the 13 year old again I really appreciate that you replied also I'm sorry that I wrote with some words that may be triggering to others I will take better care in the future:)
3. Eva Musby
  
  You are very sweet! No worries at all — I'm super cautious about these things, and what you wrote for mild compared to much that is written elsewhere 🙂
Kat

My daughter is 13 and has worked diligently on her recovery. Her mood, her academics, her medical stats, her peer relationships are all improved. However, she has lost weight over the past several weeks and her dietician is stating that my daughter regain the weight she lost. Her growth chart has always had her in the 75th percentile as her "normal". When she entered treatment she was at the 50th percentile. She returned to the 75th, but now is back at the 50th. My daughter insists she is emotionally and physically much much better. Her pediatrician also says she is healthy. My daughter says she is happy at the weight she is and that she is not necessarily opposed to regaining the weight if she understands why the weight specifically is important. I am thinking I am over identified with her since I see her point. Weight is "just a number" and "only one indicator of recovery". I'd welcome your thoughts and input.

Reply
1. Eva Musby
  
  Hi Kat, I know well this confusing situation where we're trying to work out if we're over-identified, when we see our child's point… Hurray, by the way, for all this lovely progress!
  Here's my instinct: you have a dietician who really knows your situation, giving you clear instructions, having presumably guided you all so far very competently. Sounds like this is a trustworthy professional. The paediatrician might (if they're not expert on eating disorders) be using more 'minimum' criteria for basic physical functioning, maybe reading a weight off a chart? Worth checking…
  Consider that at 13, a young person must grow, not lose weight. The fact she lost weight may be an indicator that while loads of indicators have improved, that particular indicator is still flagging up a difficulty, possibly a rather crucial one, to do with her mental state, her attitude to food or weight, some of her behaviours… It may be that regaining the lost weight is part of giving the body what it needs for complete recovery, or more simply, that it gives her mind the practice and permission to find stability without restriction. It's common that our children restrict, once declared weight-restored, for fear of going above the magic number.
  I hope you can have a private conversation with the dietician so that YOU really understand, which means then you can support your daughter with confidence.
Jane

I have a 15 year old who believes that she has stopped growing as her friends are all much taller but she remains not much taller than when she left primary school. She refuses to take on board that she is still growing and is very against putting on any weight since loosing around 2 stone. This is when we first realised we had a problem. The GP took too long to refer to CAMHS and we have now been on a waiting list for 5 months with only infrequent telephone calls and no sign of an actual assessment. Finding your book and this website has been a godsend. I feel like I finally have some guidance.

Reply
1. Eva Musby
  
  Dearest Jane, I am so very glad you have found some of the guidance you need. I do wish you lots of encouraging progress in helping your girl with nutrition. As for CAMHS, I believe they are currently fire-fighting and trying to prioritise, given what may be a 3 or 4-fold increase in eating disorder referrals (since Covid began). For that reason I would encourage you to a) keep telling them what you're managing and not managing; symptoms; worsening behaviours (and use Accident & Emergency if ever in doubt)
  and b) do as much as you can from all the help in my stuff and in the stuff I link to from others in the UK and worldwide.
  All my fond wishes, Eva
Danielle

I am concerned for my child now in outpatient treatment who has remained on Xyprexa for 130 days, has experienced extreme hunger for weeks, and has reached the 90th percentile on her growth chart (her normal range was close to the 50th percentile through childhood). Could this hunger be a side-effect of medication and possibly interfering with her body's cues? I am deeply concerned for how her body will return to its set-point without triggering relapse. How far is too far for overshoot?

Reply
1. Eva Musby
  
  Hi Danielle
  Yes I can see how you would want some good guidance on this. I think these are important questions to discuss with her treatment team. Both, on the management of Zyprexa, and on your questions regarding appetite cues, and weight. Sounds like you've been learning about 'overshoot'. and be aware this means different things to different people (e.g. for some it's just a little buffer). I don't feel competent to influence you on this. I'd say that as with most things with eating disorders, you get info from many sources, and then you and the clinicians discuss with care your own child's situation, as it may be different from whatever else you read about.
  I hope you get competent support very soon. Love, Eva
Eva Musby

Dear Ash, good on you to start treatment soon. That's a valid discussion to have with the therapist. I am sure you will be told the aim is to free you of ANY eating disorder, so that you will be healthy physically and will be free of both restricting and bingeing. I wish you lots of courage and swift successes.

Reply
ash

i am not new to disordered eating. at my "start weight" i used to binge eat quite regularly. my weight made it difficult for me to engage in exercise, and made me a lot more uncomfortable during the heat and sun of summer. it was an unhealthy weight for me, and i am really scared that i will be forced to return all the way there. it is not even for aesthetic reasons: at a lighter weight i can enjoy exercise and feel a lot more comfortable in daily life. will i still be forced to go back to this weight, even if it was clearly unhealthy and unpleasant, and was the result of another type of disordered eating? i understand the importance of "eating without restriction" but essentially i would have to go back to binge-eating practically every day or so to maintain the weight i was at before- this seems counterproductive, as binging has been an issue for me long before restriction began. i am really worried about this as i am starting treatment soon, if anyone can answer my question it would be greatly appreciated 🙂

Reply
Caroline

I am feeling pretty desperate with a 15 year old daughter who just will not follow the weight gain meal plan, says she can’t and won’t eat, despite our compassionate approach. She has been told by Camhs for the last six months that she is within the normal weight for height range but she is clearly too thin, has no periods and is now losing weight fast -despite an initial weight gain and despite still eating snacks and meals (albeit not enough) at each required time. She’s now below 90%. I just don’t know how we break the cycle of refusal – FBT doesn’t seem to be working at all, and I don’t know what will make things change. I have orders your book but wonder if you can point me to any particular strategies.

Reply
1. Eva Musby
  
  Dear Caroline, I feel for you as I know this horror of not being able to get your child to eat enough.
  
  Since you've ordered my book, I think you will find many strategies in there as it's a major focus of the book. Sounds like you want at least one quick tip, and for that I suggest my 'bungee jump' video on YouTube. There are also lots of quick tips (which are also in my book) in my Bitesize audios.
  
  Check also if your CAMHS has people who can help with meals at home — to break a deadlock and/or as coaching for yourselves. It's a bit rare, but worth asking for and trying.
  
  It is a no-brainer that if she didn't recover regular periods, she had not reached a healthy weight. I am sorry that your CAMHS went by some one-size-fits-all figure instead of her own health indicators, and indeed if they're now talking in terms of 90% weight-for-height, there is a worrying implication that 100% (middle-size-fits-all) is the goal.
  
  So what to do? You can make yourself super-informed so you can steer your daughter at home, and you can also — and this is more uncertain — ask for a review meeting, bringing in, say the psychiatrist at the head of the unit. I wish you good progress at this difficult time.
  Eva
Claire

How do I, as a parent begin taking control of meals when my daughter will not let me prepare any food for her and refuses to eat anything I make .

Reply
1. Eva Musby
  
  A crucial question, Claire, which I address as thoroughly and helpfully as I can on this website, in my book, in my Bitesize audios. The shortest answer is my motto "Compassionate Persitence" and the "Yes but how?" is all over my resources. I wish you swift successes.
Jaci

What a great article. Thank you. My daughter (19) is out of residential and now in PHP. We are struggling with why she is required to eat more when she “looks” restored. I feel this is creating anxiety on her part that she is now required to eat dessert everyday. I’m worried this anxiety over weight gain will cause her to go backwards in her progress. I know this is her fight but I have never dealt with something that feels like the family is left out of the process as much as it has. We are trying to support her at home but don’t feel like we have the tools even after she has been in treatment for months. Very frustrating.

Reply
1. Eva Musby
  
  Hi Jaci, it's a shame it feels like the family is left out of the process. That must feel incredibly frustrating, especially if you are worried that the clinicians are making unwise decisions. Good practice requires teamwork with parents.
  Can you ask these questions directly to the PHP staff so they can explain it all to you? From what you say, it's likely that you will then be reassured that it is indeed a wise move. In general, we should not fear our children's anxiety: the aim is to support them through whatever it is they need, including any necessary weight gain (what she 'looks' like may not be a valid measure), and she must also practice eating without restriction/fear foods (so the ability to eat dessert would come into it). With the repetition and the support, normally the anxiety goes. More in Chapter 10 of my book.
  Parents' questions and concerns are always valid, so ask your questions, raise your concerns, and show you want teamwork.
  I hope things are going to look up very soon, Love, Eva
Eve

What if a child is at 87% weight for height and looks healthy, has had periods return and is completely mentally recovered? What if she eats intuitively and a really reasonable normal amount of food? Is it okay to stop the weight gain?

Reply
1. Eva Musby
  
  Hi Eve, you're describing a child who has recovered all aspects of physical and mental health, hurray! Her BMI, for her age, is below the median, and indeed half the population, statistically is naturally below the median. She would also have to keep gaining weight to stay on her weight curve, as she gets older and taller. I don't know how many kids are genuinely recovered at 87%, as that is low, so if I was the parent I'd want to know the signs are real and it's not my child painting a rosy picture because weight gain is so very hard.
Concerned therapist

Sadly there are still many clinicians out there who hold inaccurate beliefs about healthy weight.

I recently had a discussion with a colleague who did not think a patient of ours could be unhealthy at their supposedly 'healthy weight', even though their blood tests and physical observations suggested otherwise.

I have at times even heard statements that such patients could afford to 'lose more weight' and would not need to weight restore at all. I do believe this comes from a place of ignorance, although I acknowledge how harmful it can be.

For any parent in such a situation share your concerns with your clinician. Very often you do need to educate and point out the most recent evidence (if in doubt refer to something like Jennifer Gaudiani's book 'Sick enough' which is very evidence-based).

If you are unhappy ask if there is another clinician who is more aligned with your views. People do hold different views in teams. Don't be afraid to challenge or ask for further clarification.

Reply
1. Eva Musby
  
  I know your comment will be incredibly helpful and validating to lots of readers out there. Thank you. And yes, there is so much help in Dr Jennifer Gaudiani's book 'Sick enough' and her podcasts and videos

Weight-restoration: why and how much weight gain?

My overall message:

Weight regain: necessary but not sufficient

Restoring to a healthy weight is non-negotiable

The need for body fat

Regain weight now — worry about the target later

How fast should the weight gain be?

A healthy weight is individual — not one-size-fits-all

How mood and behaviour improve with weight

🔅 The other tasks of recovery🔅

To recover our children need to:

A full physiological recovery

Full recovery from eating disorder thoughts, beliefs and behaviours

How is an optimal weight range worked out?

One-size-fits-all? the median BMI / percent weight-for-height method

The growth charts method: part of the picture

‘My child has always been slight’

Weight targets vary hugely from one clinician to the next

We need better physical markers of weight restoration

Mental state offers clues

⚠️ Set up to fail with a low weight goal

If weight dropped from 'overweight' to 'normal'

Why are we even talking about a weight target?

'There's no need for a target'

'It's helpful to have a target'

A target will need to be adjusted — or let go of

Beyond a knife-edge: build a buffer

Weight-restored but still eating-disordered? What's next?

Body image is particularly slow to return to normal

Overshoot

Ravenous after weight restoration – a sign more weight is needed?

Your child's feelings about their weight

Should your child be told a target weight?

It's paradoxical: the fear of weight reduces as weight increases

Should your child see their weight? Blind versus open weighing

Feelings about weight after a goal is reached

What to do with all the uncertainty? Experiment, proceed in increments, review

The bottom line

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