Weight-restoration: why and how much weight gain?

"There is considerable evidence that our weight is genetically influenced. Research suggests that our minimum weight cannot be significantly altered over the long term. This hypothesis is called 'set-point theory'[….] The aim of any treatment has to be to help [patients] to live and eat more healthily. This means helping them to eat regular healthy meals (which might or might not lead them to put on weight) and, if they do gain some weight, helping them to accept this weight as the one that they are 'meant to be' (wherever it may be within the healthy BMI range)"

Glenn Waller et al in the CBT Manual 'Cognitive behavioural therapy for eating disorders'

You can read more on set-point theory here. In general, from what we see of adult dieters, the body seems to push to regain its highest weight. With our children, regaining lost weight is an absolute minimum, and more is needed for growth. Plus, the body may require more for healing.

Consider a healthy or normal weight as one that is conducive to physical and mental health. In adults that have stopped growing it's also a weight that is effortlessly stable when people eat flexibly to their appetite, without restricting or bingeing.

During the early stages it is generally entirely appropriate to be focused on the need for weight gain.

It's a no-brainer. If your child has been restricting, they need to gain weight. Don't waste time wondering 'how much'. Their body is in famine mode. It needs nutrition and weight gain. Start regaining what was lost. If you have no idea how much was lost, a good eating disorder clinician will still prioritise weight gain.

Weight gain is, obviously, needed for physical repair, but is also essential for the mind (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 of it.)

While it might seem sensible to go 'slow and low', a lot of research indicates best results come with rapid gains, reaching full weight recovery. (See references at the bottom of this page.)

"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)

So, start refeeding.

This isn't just for anorexia, and this isn't just for low-weight individuals. With an eating disorder, including bulimia or binge-eating disorder, there is usually a component of restriction. If someone has lost weight, or failed to grow, they need weight gain. Also, all eating-disorder sufferers need regular renourishment, whatever their weight or body shape.

The only reason not to refeed fast now is if your child is at risk of refeeding syndrome. Check with a professional. (What's normally meant by 'fast' is half a kilo to one kilo a week at home, and usually twice as fast in an inpatient setting — more on this in Chapter 6 of my book.)

If your child used to be labelled as 'overweight', or still is, it makes no difference: their health needs to be checked and if they lost weight they now need to increase it.

"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

Some treatment providers like to estimate a goal weight very early on. I'll discuss pros and cons of you and your child being given any kind of number. What is sure is that a goal weight is no better than a weather forecast, and must not be a criterion for treatment ending. When your child reaches the predicted number, they may be well, or they might need more gain.

Indeed, there are three main elements to eating disorder recovery, and weight restoration is just one of them. It's necessary, but not sufficient. Here are the three elements, as I see them:

• Biological: weight restoration, good nutrition, rest etc. Too many people think that's all FBT is about.
• Behavioural: phasing out eating-disorder behaviours, replacing them with 'normal' ones, and through exposure and repetition and brain rewiring, fading out fears and changing beliefs. Part of bringing back normality is the often-mishandled 'Phase 2' work of FBT, where we guide our children back to age-appropriate independence.
• Psychological: addressing any prior anxieties, depression, trauma, bringing back self-esteem/self-compassion, good emotional management and returning to a full, enjoyable life. Part of this is 'Phase 3' of FBT.

All three components take work, and most importantly, time is a key ingredient in all this. If your child's mental state is poor, it could be that one, two or three of those components need more work or more time. This means there is always a level of uncertainty on whether a person needs more weight to reach complete recovery.

"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

Weight is a bit like shoe size: there's a size that fits your child, and it's probably different from their friends' shoe size. It could be smaller than average, or larger. Sure, there's a little more flexibility with weight than with shoe size, but every respected expert I can think of will tell you one can't beat an eating disorder with 'too small'.

And just as we don't expect our shoe size to go down, we don't expect people with an eating disorder to function well when weight-suppressed.

"There are certainly people who get stuck in the recovery process at a weight that is too low for them."

Ivan Eisler, Maudsley's Child and Adolescent Eating Disorders Service, personal communication, 2019

Therapist Lauren Muhlheim  asks 'Are we setting recovery weights too low?' here (and pretty much answers, 'yes'). Likewise:

"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'

With a family-based model, we don't need buy-in from our children. We support them to eat, meal after meal, in spite of their fear. With time and weight gain, their resistance to weight gain usually reduces as they experience that they look and feel fine.

Note that it's normal for anxiety over body shape to spike every now and again, but it abates as people are supported to push through. In particular, there may be anxiety a few kilos before weight-restoration (see Dr Anna Vinter's article about this phenomenon, which some refer to as the 'extinction burst') where it's particularly important 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'

Further down, in 'The abandoned underweight', I'll talk of the outdated practice of deliberately setting low weight targets.

"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

"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 the excellent piece Insights from relapse to recovery: what I’ve learned from falling and getting back up again

Clinician and researcher Alix Timko has a great graph in this excellent YouTube, where she says:

'It's very counterintuitive but as weight goes up these things [measures of shape and weight concerns and of various eating disorder thoughts, beliefs and behaviours] go down, and super fast… [Even though] we are not directly targeting these cognitions.'

It's natural that you should want to know what weight you're working towards. Yet there is no way of predicting this with any precision. The only certainty for almost everyone is, regain lost weight as an absolute minimum, then keep assessing how much more is needed.

Use any weight goal a bit like a weather forecast. An expert has done their best with the many variables, but ultimately, you'll only know it's sunny tomorrow… when tomorrow comes.

If tomorrow turns out to be wet, then you'll cancel the beach trip. It is poor treatment indeed when a clinician decides your child ought to be well now, just because they've reached a goal weight.

What's recommended

To predict healthy weight, or to estimate that weight may now be healthy, many factors must be considered. Here are a few from the APA Guidelines (2023):

• height and weight before the illness
• growth history plotted on a growth chart
• menstrual history
• current pubertal stage (which will help factor in growth spurts)
• bone age (e.g. through X-rays)
• assessment of skeletal frame
• the height of the parents

• Also crucial to any assessment of healthy weight are your child's mental state and their behaviours.

In the real world, I don't think many clinicians are equipped to use all of the above factors. And it might be a waste of resources anyway, as the result will still be… just an estimate. Only the experience of being well, mentally and physically, can provide the confidence that weight is now healthy.

Yet pronouncing on a goal weight is common. If most clinicians can't or won't use all of the above recommended factors, then how do they set goal weight? I'll give you an overview of the two main methods they use. (More detail in this other post.)

The median BMI / percent weight-for-height method

Using median BMI is a bit like giving all girls of the same age the same shoe size. Or predicting the weather near you today based on the average rainfall worldwide.

The median BMI method doesn't feature in any of the reputable guidelines, yet it's still commonly in use. I think some clinicians don't realise that it's just a 'middle-size fits all' calculation, and that humans can't all be well in the middle. You'll know this method is in use if you're told your child should be at '100 percent weight-for-height' (or some other percentage). What that corresponds to is the median (or middle) BMI of a whole population of girls or boys of your child's age. Being the middle, it's going to under-predict healthy weight for half the patients, sometimes by a huge amount. Apart from your child's sex and age, there is nothing individual about it. I take you through this sorry method in this post and in this YouTube.

Using a growth chart

The other tool that is commonly used is far better (but is still very approximate when used in isolation): plotting growth history on a growth chart. It uses your son or daughter's childhood growth history to predict current and future needs. Past weight and height data are plotted on a percentile growth chart, and the assumption is that your child should track along the same percentile. I explain here how this can be wrong. For instance, as I say here, you can expect your child to have a growth spurt some time between their tweens and teens, and it could be big.

Using a growth chart in isolation is a bit like predicting your town's weather today based on previous years — without looking a current weather fronts.

Huge differences in predicted healthy weight

Overall, the weights or BMIs presumed to be 'healthy' and conducive to eating disorder recovery vary mightily from one treatment provider to another (as shown in this study by Roots et al, described in plain English by Tetyana in 'Setting a target weight: an arbitrary exercise?)

So what to do, if there's no way of predicting healthy weight? Well, we could let go of weight targets.

"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)

Here's a reason for not talking about target weight:

"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'

• the extent of weight loss, or failure to gain weight or height prior to diagnosis
• plots on the percentile growth chart (but remember this is still a poor tool)
• photographs
• genetics (based on the build of family members)
• skeletal frame
• muscle bulk (muscle weighs a lot, and health requires body fat too)

Most usefully, a good clinician will guide you, based on:

• mental state (so keep updating professionals on your child's behaviours or beliefs)
• and physical state (using more or less sophisticated measures, like return of menses)

"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, internist and expert on the medical complications of eating disorders, in 'Weight goals in anorexia nervosa treatment'

"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)

"Weight has to be determined on an individual basis"

Daniel Le Grange, co-author of the FBT manual, in this webinar

"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

Dr Rebecka Peebles points out that at first, physiology is normalised, then more weight is needed to restore hormonal function (e.g. periods return), and then in her experience (and experiences gathered from parents) another 6 to 10 pounds are needed before cognitions (the mental side, the beliefs, the behaviours) return to the person's old normal.

"[The return of periods] is a good marker of pubertal recovery BUT it's not a marker of cognitive recovery."

Rebecka Peebles, FEAST of Knowledge 2024 conference

You're looking for mental recovery, not just physical:

"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

"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 a lot more. I recommend you set higher expectations, or take the focus off numbers:

"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

Here's from one of several blogs on the subject by Julie O'Toole:

"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

Clinicians use more or less sophisticated tests for physical health. Note that the return of several regular periods is a common indicator (necessary, but not sufficient) for girls.

But your child should not be deemed to be weight-restored just because their physical signs are normal again. You absolutely must update the professionals about your child's behaviours and mental symptoms.

Tell the clinicians if you see signs of extreme hunger in your son or daughter. The eating disorder will complicate all this, but is your child hinting they want more? Are their eyes lingering on the bakery's window display? Does your child have binges (real or imagined)? Many consider this as an indication that the body needs more nutrition, more weight, and that the eating disorder won't go until it gets it.

You may have heard people in the field saying it's got to be about 'State, not Weight'. What does this mean? How can this mantra help or confuse?

The expression 'State, not weight' probably grew as a protest to the shocking practice of discharging patients as soon as they'd reached a set BMI. Irrespective of weight, when beliefs and behaviours continued to be eating-disordered, we want treatment to continue to restore the person's mental state.

'State, not weight' can also mean that we're not going to obsess over predicting a weight number. When your child keeps asking about a weight target, when they ask 'How many more kilos before I'm allowed to eat and live as I choose', we remember that we're aiming for complete recovery, physical and mental. That's what will govern our decisions around weight and around how we conduct treatment.

It might be better to say we're aiming for wellbeing in 'State and Weight'. All we really care about is a person's state, but we know that one of the necessary factors to get there is weight.

A deficiency in fat has long been recognised as 'Relative Energy Deficiency in Sports (RED-S), previously named the 'female athlete triad'. In female athletes, one sign is absence of menstruation. Body-builders know how terrible they feel mentally and physically as they work on cutting body fat ahead of a competition. With males, an over-emphasis on lean muscularity should raise alarm bells just as much as weight loss or emaciation.

Clearly, the emphasis must go to gaining body fat and halting the muscle-building efforts. This is difficult when exercise is compulsive — a common issue with eating disorders.

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

* One minute YouTube from Dr Jennifer Gaudiani: Body fat *

* 'Should you be concerned about your son?' by Scott Griffiths *

Perhaps they've needed to be on a higher percentile for a long time. We know for instance that when kids drop off their weight trajectory at an early age, they are more likely to be diagnosed with anorexia in their teens (see the paper here and a layman's summary here).

Why did they drop? Maybe it was 'normal' for them, but could they possibly have started under-eating because of anxiety — for instance as they started nursery school? Or because there were too many foods that they felt wrong, as can happen with ARFID?

"Anxious kids may manage primary school tummy aches with restricted eating during the school day. Even 3-year-olds learn that thinner is better. I have had multiple teen girls disclose restriction on and off since kindergarten before they fell off the cliff.

JD Ouelette, parent expert-by-experience, personal communication, 2023

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

"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'

This is yet another example of how we must be cautious with percentile growth charts — we should not assume that a child must track along a centile curve.

I feel the AED guide (quoted above) is being cautiously vague with the phrase "taken into account". Some therapists and parents are ambivalent about bringing youngsters back up to the higher end of the weight range.

We should reflect on whether a high weight suited our child: were they healthy, did they feel well within themselves, were their eating behaviours well balanced, and so on. When we reflect on their psychological wellbeing, can we disentangle the effects of any body-shaming from peers, in our harsh, fat-phobic society? How can we apply the limited evidence available to get to the weight necessary to beat the greatest health risk to health of all: the eating disorder?

Here are the views of some experts:
Julie O'Toole, who covers the topic in 'Determining ideal body weight' and in 'Coming to terms with my daughter's genetically programmed body size'.

There's a good illustration from Rebecka Peebles's conference talk (FEAST of Knowledge 2024): a girl who hovered around the 90th percentile for weight in her childhood, then went much higher age 10 to 13 when she got her first period. Then anorexia took hold and she shot down to the 50th percentile. It took a while for people to acknowledge how sick she was at that weight and to begin treatment and insist on weight gain. She got her periods back around the 75th. But to get well mentally she had to settle around the 90th percentile.

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'. She also gives a super-informative webinar on YouTube.

"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'

It's important that all parties can have respectful conversations to work out the best path for an individual. I have heard of parents being accused of being fatphobic for asking questions. The truth is we all want to work out what's best for this person. The most detrimental factor in their life is the eating disorder. And it's also valid for parents to seek to understand the whole risk assessment picture. To help you with these questions I recommend you head over to this excellent video from therapists Kiera Buchanan and Audrey Raffelt, 'Atypical anorexia or weight stigmatised anorexia?', relating to their ICED 2022 presentation. The whole lecture is brilliant, but for questions like, 'Won't it be unhealthy to bring weight all the way back up, and in any case my child won't cope', jump to 30 mn in.

I say a lot more on these pages:

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

* Atypical anorexia diagnosis? Handle with care! *

* How to overcome weight bias and fat phobia *

"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 any given target as their maximum. Giving a range can be just as problematic:

"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')

As we saw, some therapists consider that talking about weight 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

Often, the meltdowns happen not in the therapist's office, but in the car on the way home. The parents need all their parently skills to weather the storm (see chapter 14 of my book) and make sure the next meal is eaten (in particular chapters 6, 7 and 8 — there's also loads in my Bitesize audio collection). parents can do this a lot more confidently when there's teamwork with clinicians.

Note that Rebecka Peebles, whom I 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."

And at any age, it's "not a one-size-fits-all" and "there's a time and a place":

"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

When a child is declared 'weight-recovered', with no consultation with parents, without any careful assessment of their physical and mental state, usually using a middle-size-fits-all figure, we parents have to jump into damage limitation mode.

"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."

Eventually, if a therapist will not engage in discussion and insists that the weight given by their calculator is what your child needs, you might have to tell your child, as I once did to mine, 'I'm sorry darling, I've studied this and I know better'.

Blind weighing is where your child is weighed with their back to the scales. Its purpose is mainly for the adults to check on progress. Usually, as the young person gets better, they stop caring so much about their weight, and when eventually they see the number on the scales, they shrug and get on with their lives. Sure, there's a risk that they'll have a meltdown and try restricting again because that part of the eating disorder was never addressed. But by then their brain function is probably greatly improved, and they may better be able to take in some psychoeducation about weight.

On the other side of the debate, is open weighing. The studies by Lock, Le Grange and others, which test out the effectiveness of Family-Based Treatment (FBT), used open weighing. Likewise for Cognitive Behavioural Therapy (CBT). The studies didn't compare open and blind, but if you think of open weighing as a form of exposure therapy, it makes sense that therapists working to the FBT or CBT manuals view it as an essential component. These therapists use 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".

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 therapeutic value of open weighing:

From my discussions with parents, I note that many therapists who do open weighing do not do any therapeutic work around it. They weigh and let the parents deal with the meltdown in the car on the way home. The parents are unable to feed properly for several days (or worse), and weight gain is slowed down or reversed.

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, whereas 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.

It's particularly common for body image issues to require more time:

"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 2023

You are dealing with uncertainty, and that's normal and it will help if you make peace with that. Does your child need more weight? More time? More freedoms to engage with a richer life? There is no science to tell you which. So you'll need to try things out, then review. I wish you great clinicians to support you through this process.

One of the variables to experiment with is more weight. We have a big number of first-hand accounts of youngsters who were 'stuck', until they were supported to get more nourishment and increase their weight by a few more kilos, or another 10 percent. Or by more than that. We hear that wonderful phrase, 'My kid is back'. (See for instance Katie Maki's account of the years supporting her child on 6000 calories a day).

An expert will see how patients do at their best estimate of a healthy weight, and if symptoms continue to be strong, they will bring the weight up. They'll then assess the person's physical and mental state over a short period, and if necessary, keep going.

You might think of this as a series of steps and thresholds, experimenting to see what suits the person. Do you have medication that's been dosed that way? (For me, thyroxine and estrogen).

Some parents and clinicians are really nervous about bringing weight up. They're scared it will drive their child to rebel and restrict. But what's new? They've already proved they can support their child even through these 'I feel fat' crises. Perhaps they share their child's resistance to a less thin body, because our society privileges those who are thin. So ask yourself: if there was a chance of saving a life using a medicine that caused weight-gain, would you have any hesitation? We must all do a little self-awareness and detect if we are suffering from a whiff of fat-bias. In this society, it would be strange if we were immune.

"Even treatment providers may be susceptible to weight stigma encouraged by society's war on obesity. Consequently they may err on the side of under-restoring a teen in recovery."

Lauren Muhlheim in 'When your teen has an eating disorder'

"Unfortunately, many medical professionals, nutritionists, life coaches, and therapists have not yet done vital work on understanding their internalized thin biases, and they end up subscribing to and recommending practices that are grounded in diet culture. This is very harmful for everyone, but particularly so for those recovering from eating disorders."

Dr Jennifer Gaudiani, internist and expert on the medical complications of eating disorders, in 'Weight goals in anorexia nervosa treatment'

The idea is that the body needs 'extra' to complete various bits of mending and to know it's safe to return to normal functioning — the famine really is over.

With tweens and teens, the body may also be busy driving a growth spurt.

Some adults report that their overshoot was a biological drive, as they experienced 'extreme hunger' after years of restriction and underweight. They describe 'mental hunger', where there's a drive to think about food and to keep eating even though they've eaten lots and feel full. They recommend that people honor this hunger, rather than fear it.

When people talk of 'overshoot' I see two different things being described:

• Going above your pre-illness level and staying there.
• Or going above your pre-illness level, then after a while finding that your body naturally dips back down to pre-illness level… without any deliberate restriction: you're just less hungry.

You'll find numerous personal accounts of both types of overshoot, where people achieved total freedom from an eating disorder.

With teens, many parents say how 'overshoot' was instrumental in their child's recovery. What happened after the overshoot? Some youngsters stayed happily on a higher weight percentile. Others gradually dipped back down to a pre-eating-disorder level (in terms of weight percentile, rather than in actual kilos). I suspect there are many varied experiences, and that in any case, when it comes to expected growth trajectories and weight percentiles, we are dealing with a lot of variability.

Is a dip a welcome sign that the body now has all it needs and is stabilising to pre-illness levels? That would be fanstastic.

But we do have to be on the alert. Is our child covertly restricting again? Or perhaps they are not eating enough because they don't yet have reliable appetite, hunger and fullness cues (because of their time being underweight, because of anorexia, and maybe because they were not born with a well-regulated system)?

Here's an example of overshoot, leading to lasting recovery — the overshoot was followed by gradual dips in weight which were not linked to restriction:

"While she was having growth spurts, her predicted recovery weight (RW) was not enough. We took her to RW plus 30lbs, and there her voices and behaviors stopped. It was absolutely the magic wand.

Around age 17 the growth spurts stopped, and even though she was eating the same, her weight slowly dropped by 10lbs. She stabilised there for two years. Then at age 20, she slowly lost another 10 lbs, still without restricting. So now, at almost 21, her weight for wellbeing is stabilised at RW plus 10 lbs.

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.

I have to add that when she first naturally started losing the weight I freaked out and severely and secretly upper her calories, and watched her like a hawk. She still lost. Then my own mother reminded me that as a teen, I was large and I naturally lost in my early 20s."

A mother

While some, like this mother, are sure that overshoot was essential to them, is that the case for everyone? For those who needed it, was the 'extra' the factor that got them 'unstuck'? Or did the magic happen because while gaining more weight, they were also getting essential ingredients of treatment: it takes time to work on reduce fears, to normalise behaviours through exposure and repetition, and to rebuild a life worth living. It's normal for mental healing to lag behind physical healing. The answer is probably different for different people.

There are no clinical studies on overshoot, and it looks like many clinicians don't believe there's a need for it, though they may also be open to having research done:

"It has not been our experience that further weight gain helps, except in the case where the recovered weight has been set too low"

Julie O'Toole, Kartini clinic, in her blog

Adults describing their 'overshoot' process say that the dip and downwards stabilisation happened naturally. They were not making any deliberate attempt to reduce food intake or weight. Simply, their period of extreme hunger ended.

We try to infer lessons from the Minnesota starvation study where adult men (without an eating disorder) overshot their previous healthy weight when their imposed starvation was ended. Once they were allowed to eat, it looks like their copious eating and their overshoot was 'natural'. Does that mean it's the only way to regain health? I ask because I see adults describing overshoot and 'extreme hunger' as a miserable and confusing time. Is it possible that things are different for our children, given that we have been supporting regular weight gain for weeks or months?

I think we don't know enough to make universal overshoot recommendations. Clearly, it's been necessary for many. And at the same time, many youngsters have recovered without overshoot. Maybe we can't define 'overshoot' when there is so much uncertainty in what weight any child needs at any time.

We need studies that better reflect our children's situations. Alternatively, as I previously suggested, we can let go of all that, accept uncertainty, and keep bringing weight up in increments while attending to all the other work of recovery.

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 of these:

A good predictor of success with FBT is adolescents gaining 3 or 4 lbs by week four. Doyle, P., Le Grange, D., Loeb, K., et al, ‘Early response to family-based treatment for adolescent anorexia nervosa’ in J Eat Disord (2010) 43: 659-662. https://doi.org/10.1002/eat.20764

A later study recommended a gain of at least 3.20 kg in the first 3 weeks: Le Grange, D., Accurso, E. C., Lock, J., Agras, S. and Bryson, S. W., ‘Early weight gain predicts outcome in two treatments for adolescent anorexia nervosa’ in International Journal of Eating Disorders (2014), 47(2), 124–129 https://doi.org/10.1002/eat.22221

Rapid refeeding of adolescents, 2400-3000kcal/day, mean gain of 5kg at 2.5 weeks: Madden, S., Miskovic-Wheatley, J., Clarke, S. et al. Outcomes of a rapid refeeding protocol in Adolescent Anorexia Nervosa. J Eat Disord (2015), 3(8) https://doi.org/10.1186/s40337-015-0047-1

An inpatient study showed that a gain of at least 0.8 kg per week predicted a better year-1 outcome: Lund, B. C., Hernandez, E.R., Yates, W.R., Mitchell, J.R., McKee, P. A. and Johnson C. L., ‘Rate of inpatient weight restoration predicts outcome in anorexia nervosa’ in Int. J. Eat. Disord (2009), 42(4) https://doi.org/10.1002/eat.20634

Another study found that a shorter duration of illness prior to treatment beginning was a predictor of successful weight gain: Agras, S. W., Lock, J., Brandt, H., Bryson, S. W., Dodge, E., Halmi, K.A., Jo, B., Johnson, C., Kaye, W., Wilfley, D., Woodside, B., ‘Comparison of 2 Family Therapies for Adolescent Anorexia Nervosa. A Randomized Parallel Trial.’ In JAMA Psychiatry (2014), 71(11) https://doi.org/10.1001/jamapsychiatry.2014.1025 Contradicting other findindings, this study showed there was no difference at end of treatment, and a year on, between those who had gained weight fast with FBT, or more slowly with systemic family therapy. There were fewer hospitalisations with the FBT patients, though.

Nowadays, inpatient units often raise weight faster than 1 kg a week. This is a welcome turnaround from previous slow gains which kept people in hospital for many months.

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, e.g. in Guarda, AS, Cooper, M, Pletch, A, Laddaran, L, Redgrave, GW, Schreyer, CC. Acceptability and tolerability of a meal-based, rapid refeeding, behavioral weight restoration protocol for anorexia nervosa. Int J Eat Disord (2020), 53 https://doi.org/10.1002/eat.23386 For a summary, see medicalxpress.com/news/2020-12-anorexia-patients-tolerate-rapid-weight.html

Anything by Dr Jennifer Gaudiani on the subject of weight and body fat is fascinating. eatingdisorderrecoverypodcast.podbean.com/e/dr-g-metabolism and her book ‘Sick enough’.

Note that 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.