Weight-restoration: why and how much weight gain?

Why does weight matter?

A healthy weight is necessary for recovery from an eating disorder. Without a healthy weight, the eating disorder will stay. A healthy weight is necessary for the wellbeing of the body, the brain, and the mind.

"Attainment of appropriate body weight in anorexia nervosa is a critical element of full recovery. A person can be insightful, motivated, successful, and doing better than they were before, but unless they have achieved full weight restoration, they remain at medical and psychological risk and aren’t well. This is pretty well accepted."

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

A healthy weight is not a designer choice but a biological imperative.

"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)

"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)

If your child has been restricting (whether because of anorexia or another eating disorder — or indeed, any illness), their weight is not where nature intended. They must recover lost weight, plus catch up with lost growth, plus keep growing. A child or adolescent’s weight has to go up.

The weight nature seeks

"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.

Weight restoration - growth

Regain weight… now!

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

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.

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.)

So, start refeeding.

This isn't just for anorexia. With an eating disorder, including bulimia or binge-eating disorder, there is usually a component of restriction. If they lost weight they need weight gain. And 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

Weight restoration: essential but not sufficient for 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 along ago."

James Lock, co-author of the FBT treatment manual, personal communication

Indeed, with a family-based approach you're doing a lot more than weight gain, even if you're not conscious of it — and that's even before whatever psychotherapeutic interventions the clinician does or does not do (note that individual psychotherapy is not required for many kids doing FBT). You're doing exposure to fears, you're stretching your child to tolerate uncertainty and to be more flexible. You're giving them unconditional acceptance and compassion, which means your son or daughter is developing self-compassion and learning what to do with their emotions. You're installing new habits and bringing back the pull of a good life, so that they feel secure in the world. 

All this takes time and work. The brain needs to heal. Improvements in mental state tend to lag after physical restoration.

"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

When weight is too low

There is no such thing as a universal minimum target weight. People vary dramatically in terms of body build, muscle mass, bone structure, body shape, and natural weight […]Many patients are left to struggle with ongoing depression, fatigue, anxiety, and preoccupation with food and weight because they haven’t reached their optimal body weight.

Dr Sarah Ravin, in 10 Common Mistakes in Eating Disorder Treatment

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'.

"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

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.

New indicators from genetics

"The major determinant of body weight is genetic"

AED Guidebook for Nutrition Treatment of Eating Disorders (2020)

We are now seeing anorexia through a new lens, thanks to ground-breaking research into the genome, first reported on in 2019 . The Anorexia Nervosa Genetics Initiative (ANGI) found that the illness has a metabolic component. The study leader Dr Cynthia Bulik reported on this:

"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."

Weight isn't a designer item

When females in China were tortured to make their feet small, I imagine the shoe shops only stocked torturously tiny shoes…

Weight is not like shoe size

I have used shoe size as an analogy for healthy weight, and of course, weight is a little more adaptable than shoe size. Most of us are comfortable within a range of a few kilos. Within this zone, we eat freely and our body has stability and health.

But we're not that adaptable. Diet companies have told us for years that we can manipulate our weight to enjoy a fashion-driven body shape. We know people can get there, but in spite of willpower, rarely does their body let them stay there.

How clinicians work out target weight and why there are huge differences

In this other post I explain two methods which are commonly used. The one that is recommended by the top experts produces an individualised goal, much of it based on your son or daughter's childhood growth history. This goal is used to focus parents (and often also the patient) on the work ahead. There are also clinicians I respect who don't set a target weight. All this in 8mn on my video below:

The other method, which for about half of patients gives an under-estimate (and it could be wrong by a huge amount), is to quote a BMI that your child should reach or to give a weight target that corresponds to, say, '100 percent weight-for-height'. There are huge variations between treatment centres in the BMI or percentage weight-for-height which they set for their patients (as shown in this study by Roots et al, described in plain English by Tetyana in 'Setting a target weight: an arbitrary exercise?)

I explain the problem with this second method in the video below:

Often we don't have our child's growth history, so we can't use the first method. That doesn't justify using the second method. Instead, you and the clinicians will evaluate your child's needs as treatment progresses.

Why are we even talking about weight targets?

Some clinicians I respect say there's no need for a target weight. When they first see a child, it's usually obvious that weight gain is needed. Later, weight will only be one of many indicators of health. And of course a healthy weight is not a single figure but a range.

"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

"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

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'

An argument in favour of a weight target

Now I'll give you a different view, from therapists I also respect, which is that weight goals have their usefulness. These therapists find it useful to discuss target weight in therapy.

First, it 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

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

"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

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." On parents' forums I mostly read from parents who are very upset that their child is now 'stuck' at a low number, often announced by one clinician without consulting parents or the rest of the team.

How a target weight is individualised

In another post and in this video I show how your child's height and weight history can be plotted on a growth chart to help predict the weight they'll be healthy at in the future. But a growth chart only provides an estimate for prediction, and it is never the only tool used to declare someone 'weight-restored'. There's also:

  • photographs: when you have no height or weight data to plot
  • accounting for recent weight loss, or failure to gain weight or height prior to diagnosis
  • genetics (based on the build of family members)
  • skeletal frame
  • muscle bulk (muscle weighs a lot, and health requires body fat too)
  • mental state (keep updating professionals on your child's behaviours or beliefs)
  • and physical state (using more or less sophisticated measures)

"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)

Aim for higher

When you use a growth chart — which is so much better than using a one-size-fits-all — you may still be underestimating a person's needs. There are many first-hand accounts of people needing a few kilos above the predicted weight – some say 10 percent more. More on this further down this page.

Cynthia Bulik, who researches the genetics of eating disorders, explains in a conference talk:

"Does adequate renourishment need to be done in order to reset metabolism? One of the things we have anecdotal evidence in is that re-admission to many programs is lower if you can get a person's weight up even higher than their projected weight based on their growth charts […] We definitely need adequate renourishment to reset that perhaps […] poorly-wired metabolism."

A weight target will need to be adjusted… or let go of

Even with a really good individualised weight target, nobody should get attached to a number. As your child's weight goes up, there will be more clarity on what he or she needs for a healthy physical and mental state.

physical and mental state for recovery from anorexia /eating disorder

"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

and this:

"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.

Fitness-lovers who are all muscle and no body fat

People who are into body building or fitness or who do top-level sport can become extremely ill, even while looking fit and muscular and having an average or above-average BMI. Body fat is key to biological processes, and these people don't have enough of it. This issue has long been recognised in the 'female athlete triad' where a clear sign of malnourishment in a muscular body is the 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.

In these situations, people may need weight gain with an emphasis on gaining body fat and halting the muscle-building exercise. Do look for guidance elsewhere, as to my knowledge when we increase nutrition, we tend to gain both fat and muscle.

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

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

Youngsters who were 'always' at the low weight end

As I explain in more detail in this post, a growth chart is a pretty good tool to work out a rough weight target. Clinicians may have good reason to deviate from this if your child was 'always' very light — before any eating-disorder-related restricting — especially if they dropped off their weight trajectory at an early age (something we now know provides an early warning sign of anorexia — see the paper here and a layman's summary here). For instance if your son or daughter was born at a normal weight but 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'

Youngsters at the higher end of the weight range

Weight loss in youngsters is automatically a red flag and our children must get the support to bring their weight back up. This applies to any kid, and any eating disorder — not just anorexia. While emaciated kids get medical attention, those who started off at a high weight sometimes do not. In the wrong hands, they get praised for now being at a 'healthy' weight, and are encouraged to stay that way. It's awful, and it's one of so many reasons why eating disorders need specialist treatment.

"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)

Some therapists or parents are nervous about bringing these youngsters back up. So I wanted to share the views of two 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', and Rebecka Peebles:

"Prior larger bodies kids get a minimum of 75th percentile BMI for age and a max of wherever they lived before"

Rebecka Peebles, Children's Hospital of Philadelphia, personal communication

More on this from Dr Peebles, 47 mn into her podcast with Laura Collins Lyster-Mensh: State Not Weight and this 16mn conference video with Dr Peebles is super-informative:

Should your child be told about target weight?

Some clinicians explain to the child the weight they're aiming at, and some don't. What's for sure is that the child needs to know that the whole team is focused on the need for weight gain. That can't be a secret:

"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

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. It starts with educating the parents:

"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

Note that the young person isn't hearing the above. Parents, ask for an appointment without your child if you need to discuss weight.

And then there's a careful explanation for the young person:

"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

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). They 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."

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'.

Should your child see their weight?

The question of blind weighing versus open weighing is hotly debated. I'll keep it brief here.

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 go crazy because that part of the eating disorder was never addressed, and they'll start restricting again. 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.

From my discussions with parents, there are many therapists who do open weighing but don't 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.

Is your child 'stuck' even though 'weight-recovered'? Perhaps they need more weight.

 When the body is fine and the mind isn't even close, it may be a sign that:

  • more weight is required because your child was given a poor target weight — see my other post in which I warn of how very wrong some targets can be
  • or that more time is needed for brain healing to catch up with body healing
  • or that other aspects of treatment still need to be addressed (because weight-restoration is necessary but rarely sufficient)

Regarding this last point, review if all aspects of treatment have been done well and given the time to work. It's crazy how often children are discharged from treatment as soon as they've reached a target weight. None of the work of normalising behaviours — of learning to 'do' normal life — has been done. The children still have a long list of fear foods and fear situations, and they've never had guidance to practice small, safe doses of autonomy.

There's a lot more to treatment than weight gain (more in Chapter 10 of my book).

But let's say you've worked at all that, and your child is still 'stuck' and the clinicians are hinting they might as well discharge your kid, since nothing more is working (yes, it happens — sometimes combined with 'It's time they took responsibility for their recovery')

This might be a good time to experiment with a little more weight. We have such 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. 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 push the weight up. They'll then assess the person's physical and mental state over a short period, and if necessary, keep going.

Was the 'extra' weight necessary for those who were 'stuck', or did the magic happen because of the additional time it took to gain more weight, providing more exposure to fears, more normalisation of behaviours? Remember that it's normal for mental healing to lag behind physical healing. But the Minnesota starvation study indicates that people do naturally 'go over' their previous healthy weight after a period of deficit. And here's a significant observation from some parents: if for some reason their son or daughters' weight drops back a little, the symptoms return in all their glory. 

For that reason you could discuss with your clinician the idea of building in a bit of buffer, so that your child, once well, isn't constantly on the edge of relapse.

Teens may fight the idea of a small buffer because they've made their 'weight-recovered' number their psychological maximum. This stops their recovery because they get back into controlling their eating and exercise, for fear of going into the feared zone above their magic number. To me that sounds like a good reason to use principles of exposure therapy and let them experience that nothing bad happens one or two kilos above. I believe they need that flexibility because it's normal for weight to vary by plus-or-minus 1.5 kg or so in any given month or day.

If there was a chance of saving a life using a medicine that caused weight-gain, it would be a no-brainer, so why not here too? 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'

There's plenty more on the importance of sufficient weight gain in this fantastic podcast with Dr Peebles talking to Laura Collins Lyster-Mensh: State Not Weight

The theory of overshoot

A person's growth chart indicates a likely target weight for long-term wellbeing (a moving target for growing youngsters). 'Overshoot' means that for a while the person's weight goes above that, and then goes back down.

Among adults in recovery from anorexia or another eating disorder, there's a theory that to recover you need to overshoot (see for instance Emily TrosciankoTabitha Farrar, Amazonia-Love).

The idea is that for a while, people experience extreme hunger, driven by the body's needs for extra weight or nutrition, and if they honor this hunger, this helps the body mend. With kids, maybe this would also correspond to a growth spurt.

There are numerous first-hand accounts of people who needed 'extra' weight to truly recover. But I'd like to be a little cautious with the concept of 'overshoot' if it means dipping back down. That might not suit everyone.

Although parents of teens talk of their successes with 'overshoot', their child stayed on a higher weight percentile. That makes sense to me. I would be nervous that any drop off that percentile might precipitate (or be a symptom of) relapse.

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.

The rationale for overshoot is that this is what happened to the men in the Minnesota starvation study. Researchers Dulloo et al, after analysing the men's weight data, hypothesized that the great hunger and overshoot are autoregulation mechanisms to recover both fat and lean tissues (Emily Troscianko translates this in layman's terms).

The abandoned underweight

When you think of the dismal recovery rate quoted for various eating disorders, bear in mind that traditionally, patients were often allowed to stay underweight. Their weight target was based on a low BMI figure, or a low weight-for-height percentage. This still goes on in places. I've heard of growing children being told they only need to recover some of the weight they lost.

With adults who voluntarily attend treatment, there can be a fear that the patient will walk away, or will step up their restricting, if required to gain more weight. The clinician may also believe that a low weight is good enough for recovery. As a result people can live with not-too-bad a physical state — but their weight is too low, and their anxious control over food too high, for the eating disorder to ever be beaten. With anorexia, these people get the tragic label of 'functioning anorexic'.

Our sons and daughters need empathy and food, not a lower weight target.

Experiment and review

"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


Parents, you have been your child's life-support machine as you've taken charge of the things your child could not safely do for themselves. Don't suddenly back off just because your child has reached a number on a scale. The work continues (this is Phase 2 and 3 of family-based treatment). You will guide your child to practice bits of independence and experiment with manageable bits of age-appropriate autonomy. More on this in Chapter 10 of my book.

Where to next?

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

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

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

* This topic is beautifully covered by Dr Peebles talking to Laura Collins Lyster-Mensh in podcast 'State Not Weight' *

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

11 Replies to “Weight-restoration: why and how much weight gain?”

  1. 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 🙂

  2. 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.

    1. 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

  3. 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 .

    1. 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.

  4. 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.

    1. 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

  5. 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?

    1. 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.

  6. 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.

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