The no-nonsense guide for people who think they might have an eating disorder
This guide is intended for people who think they might have a problem with exercise addiction and/or food restriction. If you’re not sure whether this applies to you, read the “Do I have a problem?” section below.
None of this is intended to be medical, legal, or financial advice. I am just some guy on the Internet. If you are dangerously ill with an eating disorder, please seek medical treatment.
Do I have a problem?
Food restriction rules
If you have rigid rules about what you eat, when you eat, or how you eat: you might have a problem. Here are some examples:
- Avoiding whole categories of food (without some medical, ethical, or religious reason)
- Skipping meals regularly
- Keeping a time-based schedule for meals
- Compensating for even small excesses at one meal with cutbacks during another meal
- Consuming lots of low-calorie foods or drinks in order to feel full
For example: I was vegetarian (without a good reason), never ate lunch, refused to eat dinner before 6:00 PM, would plan for days in advance how to compensate for a scheduled meal, and would drink lots of coffee every day to stay full.
Exercise and movement rules
Similarly, if you have inflexible rules about exercise and movement: you might have a problem. These rules can be obvious, like having a strict workout routine. They can also be subtle, like refusing to take an elevator. Here are some examples:
- Sticking to a grueling workout schedule without rest days
- Refusing to skip workouts, even when you’re sick, injured, or when the weather is bad
- Walking everywhere, even taking an unnecessarily long routes
- Being unable to sit still or relax - having to stand, pace, or fidget
- Feeling compelled to match or exceed others’ activity levels
For example: I would run a minimum of 5 miles per day, even if I was sick, even if the weather was terrible. I would walk past the Starbucks close to my office and go to one farther away to get extra walking in. I loathed driving places because it meant having to sit still.
Other warning signs
Any one of the food and exercise rules above might apply to somebody without a problem. But if you recognize more than one of them in yourself: you likely have a problem. If you’re not sure, consider these questions:
- Are you underweight / do you have a very low bodyfat percentage?
- Do you not experience normal physical hunger?
- Do you think obsessively about food-related activities, like grocery shopping; cooking; or past meals you’ve eaten?
- Do you have an obsession with metrics like calorie counts or your scale’s reading?
- If you have exercise rules like the ones above, would you be embarrassed to state them to someone else?
For example: I was underweight by most measures. I didn’t experience a normal appetite; I only ate when the clock said it was mealtime. I had weird OCD-sounding exercise rules like “match the number of flights of stairs taken yesterday.” I knew the calorie counts for everything in my kitchen.
If you answered yes to any of the questions above, and you recognize some of the food or exercise rules above: you probably have a problem. It doesn’t matter if you’re male or female, an athlete or not an athlete, at an “underweight” BMI or not.
What caused my problem?
Fortunately, it probably doesn’t matter. You can likely fix your problem without having to understand the cause – see the “How do I fix my problem?” section below.
In the popular imagination, eating disorders have psychological causes - they’re a desire to be thin, a desire to be in control, or a means of coping with trauma or abuse. This idea is at worst totally wrong and at best incomplete.
An explanation that better fits the facts is: the food restriction and exercise compulsions are an out-of-control starvation response. Experiments show that both the mental abnormalities and physical behaviors listed above can be induced in the laboratory (even in animals). Evidence suggests that humans have a built-in “reduce food / increase activity” mode that can be activated in a subset of the population.
Why is your brain perceiving starvation, even if you’re maintaining your weight? The most plausible theories involve a “bodyfat set point.” That is, your brain expects you to have some amount of bodyfat. If you wind up with less for some reason, your brain perceives starvation.
Most people’s brains react to insufficient bodyfat by activating an “increase food / decrease activity” mode. That is, most people eat more and rest when they perceive starvation. However, some people’s brains activate the “reduce food / increase activity” mode. This mode is hard to shift out of.
This story explains why most people think that wanting to be thin, coping with trauma, etc. cause eating disorders. If one of those things causes a person to lose weight, that person might lose enough bodyfat to trigger a starvation response. If they’re the type of person who goes into “reduce food / increase activity” mode, they develop a problem.
A persuasive explanation of how the “reduce food / increase activity” mode works suggests that some people’s hormones don’t react properly when the brain perceives starvation. Different hormones control appetite and the feeling of fullness (“satiety”), and for some people they get out of step when not enough bodyfat is available.
Other theories describe the “reduce food / increase activity” response as an evolutionary adaptation. One plausible story suggests that when humans perceive food scarcity, a migratory instinct kicks in: there’s no food here, so let’s conserve what we have and get moving to somewhere else.
Biological origins are mostly irrelevant for fixing your problem, so I won’t dwell on them here. The point is: your brain is reacting to starvation, and this is what’s causing your food restriction and exercise compulsions. We need to fix that.
If you actually do have body image issues, a history of trauma or abuse, etc.: you should deal with those things for their own sake. But you should fix your starvation-induced behaviors first. Doing so will make it much easier to resolve your other problems.
How do I fix my problem?
The good news is that the fix is simple. To turn off the starvation response, you’ll need to:
- Eat more food.
- Exercise (and generally move around) less.
- Gain weight (bodyfat).
The bad news is that this is really difficult. Yeah, yeah – normal people will say “Eat more, exercise less, and gain weight? That sounds like the opposite of difficult.” Normal people don’t have an out-of-control starvation response hijacking their brains; ignore them.
Rehabilitation and fear
You will likely experience genuine fear trying to eat more, move less, and gain weight. Your brain is convinced that you’re starving and that you need to conserve food. Going against this will feel wrong.
The really good news is that the order of operations here is not (1) overcome fear, (2) gain the needed amount of weight. It’s (1) gain the needed amount of weight, (2) the fear will stop.
This bears repeating – this realization is what made all the difference to me. If you go to a therapist or counselor, they might spend years trying to motivate you to overcome the fear of breaking your food and exercise rules. This is backward; fixing the starvation response will fix the fear.
Do what you can to manage fear that comes up. I found it helpful to remind myself that if “not starving” sucks after a year, I can always go back to “having insane food and exercise rituals.” Your mileage may vary.
Rehabilitation and weight
How much weight do you need to gain? Monitor your mental state to find out. As you gain weight, the desire to do food restriction will fade. Once you’re physically hungry at sensible times, don’t have any aversion to eating at those times, and find your old rules to be foreign and off-putting, you’re probably close.
Controlled experiments suggest that the weight at which a your restriction urges fade away might be higher than your “steady state” weight. (Note that this higher weight isn’t necessarily what anyone would call “overweight.”) You should maintain this higher weight for a while - at least 12 months. After that it, you might find that your weight goes down a bit without conscious effort from you.
For example: suppose your restrictive behaviors are gone at 170 lbs. You might find that after a year of maintaining this weight, you gradually drop down to 155 lbs without dieting, as your appetite naturally adjusts.
Don’t screw around with this process; it will only drag out your problem. You have to gain bodyfat; putting on muscle won’t fix your problem. Don’t try to drop below your “recovery” weight by dieting – your problem will come back with a vengeance.
You need to gain weight in order to rehabilitate, even if you’re not underweight by the usual standards. The usual standards aren’t for people whose brains get hijacked by starvation. Being perpetually starved is much less healthy than exceeding some arbitrary point on the BMI chart.
Rehabilitation and eating
What should you eat during rehabilitation? Whatever you can to gain weight. Seriously, this is the key to fixing the problem. Not eating enough to gain weight only makes the problem last longer.
I’m not going to tell you it’s just as good to eat donuts and potato chips as it is to eat according to a healthy-weight-gain meal plan designed by a dietitian. But if your choice is between the donuts and potato chips and not gaining weight: go with the donuts and potato chips. Long-term starvation is more unhealthy than short-term junk food consumption.
If you can power through the fear of violating your food rules: do it.
If you can't: eat as much of what your rules allow today. Then try breaking the rules and eating more tomorrow. The mental resistance may lessen as you gain weight. The goal is to eat without restrictions; you have to convince your brain that imminent starvation is not at hand.
If you’re on some restrictive diet without a medical or serious ethical reason: pause it for now. You can pick it back up later. If you can tolerate gluten, eat gluten. If you’re not epileptic, you don’t need to be in ketosis. If you’re not overwhelmed by guilt at eating meat, stop being vegetarian or vegan for a while. The starvation response latches onto these diets and their justifications; don’t give it more fuel. Diets for the general public don’t apply to people whose brains get hijacked by starvation responses.
Some people experience very intense hunger during rehabilitation, and may binge eat. This is OK - it’s not a reason to go back to restricting. This is a well-documented phenomenon in starvation recovery; it won’t persist once you’ve broken the starvation cycle.
Rehabilitation and exercise
Can you exercise during rehabilitation? Unless you have some serious obligation to do so, you probably shouldn’t.
If you’re a college athlete, and your scholarship depends on you continuing to perform: OK, but you have to cut back relative to what you were doing before.
If you’re somebody who works out for your health: take a break. You can go back to it later. Long-term starvation is more unhealthy than short-term sedentary-ness.
If you’re not breaking your exercise rules, you’re slowing down your rehabilitation. If you couldn't stand not exercising yesterday: do less today. Again, the mental resistance may lessen as you gain weight.
If your exercise and movement compulsions have a ritualistic or “OCD” quality: you need to work on stopping these entirely. They might lead to relapse later.
I found it helpful to fill in this template when I wasn’t sitting still:
Hey, I’ll be back in ____ minutes. I’m going to ____ because ____.
If you would be embarrassed to say the result aloud, then sit down until the urge to do the thing passes. Some examples:
- 10 / walk the dog / she’s whining at the door: OK.
- 30 / mow the lawn / it’s going to rain later this afternoon: No problem.
- 15 / shovel the driveway / it snowed another quarter inch since I did it last: Stop.
- 2 / run up and down the stairs / I have to take the same number of stairs as yesterday: Stop!
These habits are insidious – watch out for them. If you always take the stairs because using the elevator feels wrong: take the elevator. If you walk places that are more than 15 minutes away: drive. If you absently pace while on the phone: sit down. Not breaking these habits will make your rehabilitation take longer.
Dealing with contributing factors
If your food restriction and exercise compulsions started in response to some identifiable cause – trauma, abuse, or introduction of some other stress: you should work on processing that after you’ve gained the needed amount of weight. Dealing with anxieties and stresses will help prevent a relapse.
You can work with a counselor, religious advisor, etc. on these things – they are probably important to resolve for their own sake. Fortunately, you’ll have more capacity to work on them once your brain doesn’t think you’re starving.
Being fully recovered means that your food restriction and exercise compulsions have faded to the point that they don’t seem like rules. Your mind isn’t preoccupied with food and exercise anymore, and you get physically hungry when you haven’t eaten for a few hours. You don’t feel anxiety when you eat meals, eat certain foods, or have your eating/exercise routines interrupted.
This happens once you’ve gained enough weight for your starvation response to turn off. If you find that your mind is still obsessed with food and/or exercise, keep going with the rehabilitation program.
Freedom from perpetual starvation is great - you might remember what it’s like! That said, I’m not going to tell you that everything will magically be perfect after you’ve gained enough weight. The food and exercise obsessions have likely carved deep pathways in your brain - they might not be gone, but they’ll be more ignore-able.
I'm not promoting the idea that a higher weight is a silver bullet. You’re not going to suddenly “love your body.” Anything that was wrong with your life before will probably still be wrong with your life after. If you’re insecure about how you look, dissatisfied with your career, or whatever - those things aren’t going to go away magically.
Fortunately, you’ll have much more capacity to deal with your real problems once you’re not starving. You’ll have more time, more patience, and more space for rational thought.
Personally, the realization that relief from even half of the crazy rules and rituals was enough to get me started with rehabilitation. The benefits I didn't initially realize would happen - having more time and patience for family, friends, and career - have kept me going with it.
Frequently asked questions
Q. What eating disorder do I have?
A. I don’t know. The taxonomy of psychiatric disorders changes from decade to decade. This guide is my interpretation of what treatment professionals with a modern understanding are doing.
Life hack: you may not want to attach the “eating disorder” label to yourself - too many connotations. Tell people you have a “metabolic disorder.” It's probably more accurate.
I’m convinced that in a few generations that most eating disorders will be treated more like Type I diabetes than clinical depression. That is, like a physiological illness that has psychiatric effects; not like a psychiatric illness with physiological effects.
I think that athletes who develop the restrictions/compulsions get better treatment than the stereotypical “underweight adolescent girl.” If you seek professional treatment, try to steer the discussion toward “Relative Energy Deficiency in Sport” (if you’re male) or “Female Athlete Triad” (if you’re female).
There are eating disorders with characteristics other than those I’ve described in this guide (which basically constitute anorexia). You probably know of bulimia and binge eating disorder, but professionals (depending on their vintage and specialization) also have recognized ARFID, orthorexia, “eating disorder, not otherwise specified,” and others.
Q. What other symptoms are there?
A. Reading through catalogs of eating disorder symptoms can be surreal. There are a lot of them, and you’ll find things you thought were just innocent quirks about yourself. Things that you think you’ve chosen consciously (and maybe you have). Things that you might not want to change (see below).
I didn’t mention “body dysmorphia” above. In the popular imagination it’s “being thin but hallucinating that you’re not,” but that’s a bit fanciful. It’s more “being distressed about your body for reasons nobody else would understand”. There are various theories for why starvation might cause this, but I don’t find any of them terribly convincing.
For women, amenorrhea is another well-recognized symptom. Many women stop menstruating when they have low bodyfat. This can be a wake-up call that men don’t get.
Lack of bodyfat produces a lot of strange food obsessions. The well-known Minnesota Starvation Experiment documents a number of them. Some people hoard food, and get very distressed if something their supply of some particular thing runs low. Some people eat their food very slowly, or chew it excessively, or are horrified by other people wasting food.
The focus on conservation sometimes spills into other areas, particularly finance. This can be benign - keeping a careful budget, avoiding debt. But it can also go wrong - refusing to spend any money, even being compelled to steal.
Some of the OCD-like movement rules are hard to spot. For example, you might walk through the grocery store in a really inefficient pattern. You might have chosen an apartment on a high floor because it has stairs. You might clean your dishes very thoroughly by hand (even when you have a dishwasher) so you can stand up. You might carry your kid long distances when you have a perfectly good stroller (or they can walk).
Most of these things should go away after gaining an appropriate amount of weight. However, the compulsive habits might take more effort - you’ll want to break those to prevent relapse!
Q. What happens if I don’t fix my problem?
A. I could give a litany of the terrible things that long-term malnutrition causes. But the starvation response that’s hijacking your brain probably won’t care; it’s focused on the short-term. My message here is that first you solve your problem, then you’ll have motivation; not the other way around.
That said: You are risking injuries - anything from stress fractures to broken hips. You are risking nutrient deficiencies that can cause your hair and teeth to fall out. You are risking your life - people with eating disorders commit suicide at disturbingly high rates.
Also: you’re currently suffering, and suffering is bad!
Q. What is “re-feeding?”
A. This is the “eat more and gain weight” part of fixing your problem. You have to do this even if you’re not underweight by normal standards.
This was confusing to me when I started researching this; I thought if I wasn’t dangerously thin then I didn’t need to “re-feed.” That was wrong.
The same process is also called “weight restoration.” This name seems to imply that you need to get back to a certain previous weight, but that’s also wrong. You have to gain enough weight that your mental state improves.
It can be dangerous for extremely underweight people to re-feed without medical supervision. This is not an excuse for you not to weight restore - this guide is not for dangerously underweight people.
Q. What is “mental hunger?”
A. This is a preoccupation with food, or things related to food, that some people have.
Some people continually go over the things they’ve eaten, the nutritional content of those things, what to eat next.
Some people get obsessed with cookbooks, recipes, or grocery shopping. They might spend hours planning meals they won’t actually eat, staring at food they won’t actually buy.
Other people focus on what other people are eating, or how much they weigh. Some worry neurotically about their family members getting enough food. Others are attracted to feeding their romantic partners.
For some, mental hunger takes the place of actual physical hunger. My (unsupported) theory for this is that ignoring hunger pangs leads the body to try other means of getting you to eat. Other (better-supported) theories involve a signal filtering mechanism in the brain.
It was a revelation to me that the mental preoccupation with food was a manifestation of hunger; this is one of the things that made me realize I really had a problem. If you don’t get physical hunger, try eating when you notice mental hunger.
Q. What is “energy deficit?”
A. This is the thing that “eating more, exercising less, and gaining weight” fixes.
If you expend more calories than you take in for a day, we might say you were in “energy deficit” for the day. All else equal, you’ll lose some amount of bodyweight.
But one day is arbitrary. If you fast one week but feast the next, on net you won’t be in energy deficit for the two-week period. Ceteris paribus, your bodyweight won’t be different from the beginning of day 0 to the end of day 14. We can extend this to months, years, decades.
This means you can simultaneously be in long-term “energy deficit” and short-term “energy surplus.” For example, suppose you were 150 lbs. on January 1st. On July 1st you were 135 lbs. On December 31st you were 140 lbs. We could say you are in “energy deficit” for the year (because you lost 10 lbs.), even though you were in “energy surplus” for the last six months.
I’d like it if people used “bodyfat debt” to refer to longer periods and reserved “energy deficit” for shorter periods. But alas, outside of economics, few people get level vs. rate distinctions right.
Q. What if my mental state gets worse before it gets better?
A. This is a valid concern (it was one of mine). The goal is to fix your mental state, such that the food and exercise rules no longer have a hold over you, the preoccupations with food or your body fade away, etc. But will the starvation response torture you for ignoring it?
For some people the answer is no: getting to a higher weight makes things easier, not harder. The food and exercise rules start seeming more optional, the preoccupations lessen a bit. This makes it less difficult to continue gaining weight until those things fade out almost entirely.
For other people the answer is yes: the starvation response fights back, and causes mental distress. This can be triggered by eating, by noticing weight gain, by other people’s comments, and more. It is not fun.
If you’re afraid of this, you’re right to be - it’s scary. Fortunately, you don’t have to overcome the fear - you just have to eat more, exercise less, and gain weight. That’s what fixes the fear.
Q. Is recovery all sunshine and rainbows?
A. As the answer to the last question suggests: no.
In addition to potential mental distress about additional weight, there are other unpleasant things to deal with in recovery. I'll mention a few that I contended with.
One big one is gastrointestinal difficulties - eating a lot more food than you're accustomed to can be very uncomfortable. Chronic starvation and semi-starvation slow down digestion, and it can take a while to catch up. People try eating smaller meals, easily-digestible nutrition shakes, etc. to deal with this.
Another is unexplained pains. For some people this is a set of minor aches that start, for others it's more intense muscle and joint pain. I had leg cramps that lasted several days; others have these symptoms for weeks. This phenomenon doesn't seem to be very well-studied (except for pain caused by edema), but probably the best advice to rest (really rest) a lot.
Sleep disturbance happens for some people. This can be a side effect of not exercising as much, reducing caffeine intake, general distress, and others. It contributes to irritability and anxiety, so it's good to try to fix. I had to cut my caffeine intake by more than expected to try to normalize my sleep.
Despite all the short-term unpleasantness, I was feeling a lot better (and feeling that all the unpleasantness was worth it) after a couple months. There is much more information on this topic in the books Rehabilitate, Rewire, Recover! and Sick Enough; see the "Where to find more information" section below.
Q. Will fixing my problem destroy [some trait I value]?
A. No, probably not. And if it does, you can go back to starving.
I had this concern that the discipline and willpower I’d developed to keep such a strict diet and exercise regimen was the key to my professional and personal well-being. That I might become be a worse parent, a worse spouse, a worse employee.
The good news is that you can re-purpose the 20% of your mental energy that’s currently going toward meeting your crazy food and exercise rules and dedicate them to pursuits you actually endorse. You can probably be a better parent/spouse/employee.
One thing to note: the starvation response latches onto socially-acceptable justifications to perpetuate itself. If your food rules included being vegan or vegetarian, and you value that: consider supporting animal rights in a different way. If your exercise rules dictated that you walk instead of drive, and you value that: consider supporting the environment in a different way.
Nobody expects somebody with an autoimmune disease to ignore their doctors and be vegan. Nobody wants somebody with a broken leg to walk to the grocery store. If you’ve got a broken starvation detector, you are hereby excused and forgiven for not being able to participate fully.
Q. Isn’t being obese really unhealthy?
A. Of course it is. Fixing your food and exercise issues doesn’t mean you can’t avoid becoming really obese. Many well-meaning people say that full recovery means not having any concern about weight; I think this is a noble lie: It’s OK to keep nutrition and fitness in mind after you’ve fixed your problem.
That said, avoiding obesity is not an excuse to not gain weight during recovery. If your food and exercise issues faded out at a higher weight than you’re used to, that’s to be expected. You’ll probably lose some of that weight without needing to diet (see above). This is a well-documented phenomenon. Being temporarily at BMI 25 is not the same as being permanently at BMI 40.
The BMI guidelines are not for people who have a broken starvation response. It is healthier to be at BMI 25 (“overweight”) and not have your life consumed by an eating disorder than it is to yo-yo between 18 (“underweight”) and 23 (“normal weight”), never fully rehabilitating.
Q. Isn't body mass index (BMI) a pack of lies?
A. Yes. I only mention it because it gets used a lot by professionals. The units don't make sense, it's not physically meaningful, it works poorly for short / tall / athletic people, etc. It's dumb.
BMI 18.5 (the low end for “normal weight”) is not the target for rehabilitation; the target is mental state improvement - the fading out of food and exercise rules. If that's too vague for you, pretend like your target is BMI 22.
Q. Who are you and why are you writing this?
A. I'm some guy on the Internet. I knew that I had a problem with weird food and exercise rules - I'd had them since childhood. But I didn't have anorexia, did I? That's what teenage ballerinas get, right?
Most of what I found about eating disorders over the years was unhelpful. It was aimed at teenage girls (I'm an adult man), it assumed some history of abuse or trauma (I didn't have those), it focused on "body positivity" (I wasn't body negative), it was for dangerously underweight people (I usually had a low-but-"healthy" BMI), etc.
My perspective got flipped around after reading about one of the proposed biological explanations for anorexia. These weird food and movement compulsions can be induced in the lab? They stop after weight restoration? Why did no one tell me this!
The first draft of this guide was written several weeks into my rehabilitation project. It was my summary of the things I found helpful to get me started, and what I had gleaned from experts so far. I got lots of help with my recovery from an Internet stranger, and want to pay that kindness forward.
Where to find more information
Tabitha Farrar's book, blog, and podcast
The most helpful resource I know of is Tabitha Farrar’s book, Rehabilitate, Rewire, Recover!. It has a very thorough catalog of food restriction and exercise rules, and goes into detail on how to identify and stop compulsive movement habits. In addition, it outlines obstacles one might face in recovery, and offers a step-by-step recovery plan.
Farrar’s website and podcast are also excellent. I recommend these posts:
- Anorexia is a Obsessive Compulsive Spectrum Disorder and should be treated as such
- Anorexia and Exercise 2: The lower-level movement trap
- Lower-level movement and why it is scary to be still
and these podcasts:
- Anorexia as an evolved genetic response to famine (with Shan Guisinger)
- Genetics of Anorexia Nervosa (with Cynthia Bulik)
- Energy deficit, energy debt, target weights, weight vs. state restoration
- Variants in neuropeptide signaling are associated with disordered eating behaviors (with Michael Lutter)
- Recovering when you’re a no-nonsense guy who totally doesn’t have anorexia but has some sort of problem (with me)
Farrar also offers a coaching service and support services that I am sure are excellent.
Emily Troscianko's articles
Emily Troscianko has been writing a blog at Psychology Today for the last several years, which I recommend. Some particularly fantastic posts:
- Anorexia Is a Physical Illness of Starvation
- Recovering from Anorexia: How and Why Not to Stop Halfway
- Q&A on what makes eating and the rest of recovery seem impossible in anorexia
Troscianko also offers a coaching service.
There are some papers that range from “readable by anyone” to “inscrutable to non-biochemists” that have looked into aspects of what I’ve described above.
On animal studies:
- The Stephanies (Klenotich and Dulawa) have a paper that serves as an instruction manual for how to induce anorexia symptoms in mice. The paper has a history of animal models of eating disorders. How is it that this has been well-known to researchers for decades, but is totally unkown to the general public?
- Michael Lutter, Anna Croghan, and Huxing Cui collaborated on a 2015 literature review that discusses moving beyond social explanations for eating disorders. It details how animal studies shed light on the physiological basis of human symptoms.
On evolutionary origins:
- Shan Guisinger’s 2003 paper, Adapted to Flee Famine, has a clear description of one proposed evolutionary explanation for what I called the “reduce food / increase activity” response to starvation. The paper has a number of interesting bits, including a discussion of a genetic origin of the “some people are vulnerable to developing problems when they lose bodyfat” story I’ve told above.
- This blog post (by Taylor Burbach) reviews a 2007 paper by Nicholas Gatward that outlines some additional evolutionary explanations for the persistence of eating disorders.
- Dwyer et. al. 2011 has a technical discussion of starvation responses that have been observed in species ranging from yeast to humans. It also provides details on the biochemistry of the “reduce food / increase activity” response in some individuals.
On weight improvement leading to mental state improvement:
- For a perspective that differs from mine, see Murray et. al 2018, a review article that concludes “it should not be expected that weight gain alone will ultimately confer commensurate psychological symptom remission.” See also this response, which suggests “most subjects included in this meta-analysis were never adequately weight restored.” I believe this is correct.
- Accurso et. al 2014 and Sala et. al 2014 clarify that the core eating disorder psychological symptoms (e.g. food restriction) improve with weight restoration. However, other psychological issues (e.g. depression, anxiety) follow a different trajectory.
- Glenn Waller's 2016 article on progress in eating disorder treatment supports my view unequivocally, noting that “Starvation/semi-starvation is a powerful maintaining factor in the eating disorder” and “nutritional changes appear to be necessary for psychotherapies to be effective for eating disorders.”
RED-S and Female Athlete Triad
I mentioned above that athletes probably get better treatment for the same condition than others do. If you work out, it may be easier to tell people you have “Relative Energy Deficiency in Sport” than “anorexia nervosa” (if not, go with “metabolic disorder”).
The International Olympic Committee’s 2014 article on RED-S tells basically the same story that I do:
The underlying problem of RED-S is an inadequacy of energy to support the range of body functions involved in optimal health and performance...
Low [energy availability], which occurs with a reduction in [energy intake] and/or increased exercise load, causes adjustments to body systems to reduce energy expenditure, leading to disruption of an array of hormonal, metabolic and functional characteristics.
[Disordered eating] underpins a large proportion of cases of low [energy availability]...
Essentially: some people are vulnerable to developing problems if they find themselves low in bodyfat:
Prevalence studies of low EA in male athletes have been few, however, low EA appears to occur among the same at risk sports as for female athletes: the weight sensitive sports in which leanness and/or weight are important due to their role in performance, appearance or requirement to meet a competition weight category.
It also has a pair of tables on when athletes are recommended to “return to play.”
Jennifer Gaudiani's book, Sick Enough, has very detailed information on medical complications associated with various eating disorders.
Tabitha Farrar's first book, Love Fat, is a good thing to read if you're trying to understand what a friend with an eating disorder is going through.
Stephen Guyenet has a clear summary of how starvation response works in normal people (the “increase food / decrease exercise” response) at his blog.
It's common for sufferers to characterize their eating disorder as a voice in their heads. But is that just a metaphor? Pugh, Waller, and Esposito 2018 examine the question.
I'm indebted to the community on Scott Alexander's Slate Star Codex blog for getting me to start my recovery project, and am especially grateful to one particular benefactor from somewhere around Greenland.
If someone you know might benefit from this information, please send them the link to this page. Don't hesitate to send me a note if you want to discuss this stuff with someone.