Understanding the Significance of Weight Gain or
Loss in ED Diagnosis and Recovery
What Patients and Parents need to Know

By Abigail Natenshon, MA, LCSW, CGFP

A young man with OCD is a compulsive runner who had been in recovery for anorexic for two years when I first saw him. After several months of working with him both individually and in family therapy with his parents, he became able to recognize and accept the existence of his disease and to decide to heal. During that time, he had increased his caloric intake significantly and agreed to supplement his intake with Ensures; he'd improved substantially in the realm of friendships and sociability having shed his oppositional attitudes and defensive demeanor as he began to restore weight. As he became more trusting of me, the treatment process and himself, he was able to listen and integrate information more readily. Best of all, he had become able to take responsibility for setting his own goals and becoming accountable for reaching them, even while developing practicable coping tools to deal with his anxiety that became exacerbated by his weight gain. This young man was able to continue his running during his recovery, having vowed to make up the burned calories as part of his daily intake.

As summer drew near, his parents began to think deeply about speeding up the pace of his recovery through considering a more intensive outpatient milieu as his primary form of care. However, his significant recovery progress through out-patient care rendered him an unlikely candidate for such a program at this point. As the patient remained eager and determined to do whatever was necessary to avoid any deterrent to his running, he agreed to sign a contract promising that he would gain a pound a week (even while continuing to run) for the next four weeks, in working closely with a nutritionist. The contract stipulated that if he did not meet that goal, he would need to stop running.

Though he continued to recover well, he failed to gain any weight during the critical weeks of his contract. At this point he and his parents, now convinced that he didn't need a hospital program after all, and happy that he was feeling happier, failed to understand my continuing motivation to "push" him to begin to accrue weight systematically and predictably as part of his recovery learning curve. "But it's not about weight!" they threw my own famous line back at me, though now in a distorted vein.

Weight significance for this young man at this point, and at every point in recovery, needs to be clearly understood, particularly as it changes from stage to stage of the recovery process. Because of the weight he had already restored, the role of weight gain was less significant as a diagnostic tool to determine his physiological status; it was clear that he was no longer "at risk." He was on the 40th percentile on his pediatrician's weight chart which his doctor clearly saw as a sign of "normalcy," disregarding the fact that a person may be in the 90th, or in the 5th, percentile for height and weight and be perfectly fine. Using the growth charts effectively requires taking into consideration such genetic factors as parents' builds, developmental stage, whether or not puberty has been reached, etc. Studies show that regaining lost weight is not sufficient: it is not adequate to restore a child to his normal weight for the fact that had he not acquired an eating disorder, he would have weighed more.

The significance of continuing weight gain at this stage of recovery is pivotal for a complete and sustainable recovery.

• The capacity to gain weight is diagnostic of the quality and degree of his recovery, providing a measure of his motivation and capacity to keep a pace moving forward. Eating disorders are never stagnant. If they are not getting better, they are surely getter worse.

• The process of weight gain is more significant than pounds gained, as a metaphor for the individual's ever-increasing capacity to regulate and care for the self. In order to gain weight, the patient is required to begin to develop and maintain a healthy eating lifestyle, a critical life tool in moving forward.

• Discussions of issues of eating and weight disclose underlying fears of becoming fat, feelings of being out of control or unpopular; black and white thinking; body image disturbances; compulsivity and mood issues; problem-solving skills and efforts towards self-determinism. The therapist needs to extrapolate "food talk" to discussions that include deeper and co-occurring issues.

• Weight gain during recovery for an anorexic becomes a metaphor for a healthy approach to problem solving. Achieving weight stability requires problem solving, self acceptance, sound judgment, accuracy of self-perception and responsiveness to feelings and personal needs.

• Without a complete weight restoration to set point, no recovery can be a complete recovery and "relapse" becomes inevitable.

This young man had the right to pace his own recovery and weight gain; however, it was my responsibility as his therapist not to permit him to fall between the cracks of a complete and timely recovery by stagnating in within a realm of eating marked by a lack of motivation. It is a realm in which the "readiness window," with all of its opportunities for growth, may be missed. I spoke opening with him about that being my agenda., as I felt he was capable of accepting and running with these challenges at this point in his recovery. Was I right? According to him I was.

We spoke about his wish and need to become liberated from his over-self reliance on his parents to run his life and his food. As we discussed his new food plan and his plans to execute it himself, we realized together that once his parents bowed out of the role of micro-management and he was on his own, weight alone (the numbers on the scale) will become his measure of accountability. Ultimately, the process would launch him into the independence of his imminent adulthood.

Recovery is about the development of the self, and its re-integration into core functioning. Recovery is about the learned capacity self-determination, self regulation and self care, following self-awareness. In this regard, food, eating and resulting weight gain may also be considered an aspect of the development of the self.


Points to remember about the importance of weight in the eating disordered individual

• Weight restoration is not what defines recovery from an eating disorder. Even so, recovery cannot happen in the absence of an eating disorder.

• The rapid loss of weight with anorexia is an indicator that eating behaviors are out of control or erratic and potentially dangerous.

• The process and dynamic around eating, which ultimately affects a person's weight, is what is significant. Healthy eating, a learned process, can stave off what might otherwise become dire health problems, preserving life and life quality, reinstating the brain's capacity to learn and the body's capacity to grow and mature.

• Weight restoration makes possible a person's ability to benefit optimally from the therapy process.

• Recovery from an eating disorder lies in the person's thinking and attitudes; in the freedom to eat without guilt or fear; the capacity to live life fully, to solve problems effectively, to make choices freely, and to moderate oneself. Incidentally, it is marked by a restoration to one's set point (not target) weight as determined by the human body.

• The most critical fact to keep in mind is that weight is less important than the return of normal function.

Abigail Natenshon, MA LCSW, GCFP is a psychotherapist who has specialized in the treatment of eating disorders with individuals and families for the past 36 years. The author of When Your Child Has An Eating Disorder: A Step-by-Step Workbook for Parents and Other Caregivers, Ms. Natenshon is the founder and director of Eating Disorder Specialists of Illinois and a Guild Certified Feldenkrais Practitioner; she and uses this hands-on body-centered technique in conjunction with traditional psychotherapy to augment and promote body image awareness, acceptance and healing.

Abbie consults professionally and speaks nationally on the topics of eating disorders… their prevention and treatment, body image, and healthy eating and weight management.  An advocate for parents of afflicted children, she has published widely in books, magazines, journals and newspapers, and has appeared on the Oprah Winfrey Show, the John Walsh Show, and MSNBC News. The creator and host of www.empoweredparents.com, www.empoweredkidZ.com, and www.treatingeatingdisorders.com, she conducts a private practice in psychotherapy in Highland Park Illinois where she resides with her husband.