What happens in eating disorder recovery when you are trying to heal yourself from an illness in which you are weight suppressed (at any BMI) because of ongoing restrictive eating and compensatory behaviours (such as compulsive exercise, movement, purging or laxatives etc) and you have very low or even no perceived appetite? Do you really have to push yourself to eat, even when doing so not only feels very wrong mentally (which eating disorder recovery will until it doesn't) but also very uncomfortable and even distressing on a physical level too?
Well... the answer to that in a nutshell is yes, you DO have to eat anyway but this post covers the topic in a bit more depth.
Before going on, just as a side note, this post is written about perceived appetite in eating disorder recovery, as experienced by the person going through it. This episode therefore is predominantly related to the commonly thought of signs of hunger (the physical signs that are widely accepted and more common signs of mental hunger) rather than the more insidious signs of hunger (which I will discuss in a future post).
Low Appetite in Eating Disorder Recovery
When it comes to eating disorder recovery, we talk a lot more today about the phenomenon of extreme hunger and that insatiable drive to eat that many people experience as they eat more and begin to come out of the energy deficit that they have been forcing on their body, perhaps for years or even decades.
We talk about extreme hunger a lot because it is frightening for people going through it, especially when people around them have never experienced it and they themselves understand very little about what is happening or why their hunger is taking them to levels that they feel no human in the world ever, not even the most extreme of all extreme eaters, could or would ever eat. This drive to eat with extreme hunger is also all the more terrifying because of the restrictive eating that preceded it, making any higher level of appetite and food intake feel extreme by comparison and it all feels so very wrong to a brain that is really not used to breaking those old restrictive habits that it knows so very well and finds comfort in.
Therefore, I understand why we talk so much about extreme hunger. It is a phenomenon that is largely unique to people coming out of long periods of energy deficit which most commonly occurs through eating disorders, making it generally unknown as a concept to the public or even to health professionals and therefore more frightening and lonely to go through. This means that we need to talk about it as an eating disorder community so people feel less alone and know they are not broken when they want to eat everything and more and still feel hungry.
However, we talk a lot less about the other end of the spectrum when it comes to hunger in eating disorder recovery and that is low appetite or even zero perceived appetite. We don't talk as much about lack of hunger in recovery and yet it is something that, in my experience, most people in recovery go through at some point (often at more than one stage) and I would argue that it is just as terrifying and confusing to go through as when you have insatiable hunger.
Low appetite in eating disorder recovery is hard because this is when the need sets in to make yourself eat, even with low appetite, no appetite or when you feel physically unwell or completely turned off by food.
How do you allow yourself to eat all the foods that you understand you 'should' eat or that you need to eat when you feel physically stuffed full, bloated or even nauseous?
Low appetite is common at the early stage of recovery as the stomach is getting used to more food but it can also show up at other stages in the process and each time it hits, it can be equally uncomfortable, not just physically but mentally and emotionally too as it makes recovery and eating feel even more anxiety provoking than it did already.
For those in the later stages of recovery, another common feature can be not just feeling a lack of physical hunger but also finding they reach a point of finding food much less interesting and unexciting.
Let's then take a closer look at the ways in which low appetite can appear at various stages in recovery and some of the common reasons for this.
Appetite in The Early Stages of Recovery
For many people (not all!) at the start of the recovery process, when they have been eating restrictively for some time, hunger signals can be significantly blunted and they need to be pushed into life (with food) in order to get the appetite going.
This is for a number of reasons:
If you have been eating restrictively for some time it is likely that your stomach capacity has shrunk, you will have what they call slow gastric emptying (it takes longer than it should for food to leave your stomach and process through your intestinal system), you may have constipation and then eating more can lead to cramps and stomach spasms as your stomach also adjusts to new food types. All of this creates a perfect blend of early satiation, bloating, gas and low physical appetite.... but of course it does not mean your body is not very very hungry!
When you started to eat restrictively at the beginning of the illness, it is very likely that your body tried desperately for a time to keep sending you hunger signals and use all the weapons it could to drive you to eat more food. As you went on eating restrictively though despite your body sending those hunger signals, your body will have decided that sending those signals was futile and so it will have given up trying. Creating and sending hunger signals is a process in itself that takes energy and a body that is living under a restrictive intake needs to preserve all the energy it can so won't waste precious resources if it doesn't lead to beneficial results.
Blunted hunger signals as a response to prolonged energy deficit is also thought to be a survival mechanism of the body. In our ancestor's hunter gatherer times, when being hungry was common if food was scarce in the environment, it was important that those affected could focus on finding food and on their baseline survival. If the hunger they were experiencing was creating symptoms of feeling constantly famished and what we call 'hangry' (anger created by being overly hungry), then those ancestors of ours would have been too distracted by their hunger to actually get on with finding the food they so desperately needed. Of course in our ancestor's case, the hunger would be blunted for a time, they would (hopefully) find and gather food, feast on it and reawaken their natural hunger cues and so this survival mechanism was a short term measure and useful to them... It is not something that evolved for people today, restricting their food intake despite having abundant food in their environment, as is the case in restrictive eating from an eating disorder.
Therefore as you start the recovery process and begin to eat with much less restriction, it is likely you will have to do so despite low or no appetite (certainly physically, but very possibly mentally too).
This is when you have to eat in order to stimulate your appetite!
When you do start to eat at the beginning of the recovery process, despite little or no appetite, it will have the effect of giving that much needed hunger a little poke and help it switch on. For some people that reawakening of the appetite can happen gradually and for others it can happen suddenly and dramatically once they begin to eat more, but either way eating can bring on the hunger.
When you do start to eat more, it has the effect of allowing your body to begin to trust that food is more abundantly available in your environment and so sending you signals to keep on eating might actually get results, as in you might actually respond and eat even more of the good foods it so desperately needs to heal.
Basically then, all of this is to say that most people in recovery, especially at the beginning but later on in the process too (particularly those of you who have been 'doing recovery' in a less restrictive but still restrictive way), need to eat more in order to get your hunger and appetite to its true (high) level.
Appetite During Recovery
Recovery is of course a lengthy process, which takes a good year or more to really and truly fully heal mentally and physically.
Over that time it is natural that your hunger will be up and down and that's for a number of reasons, some of which you might be able to identify at the time and others that will be a simple result of whatever your body happens to be doing internally at that moment, which you don't need to know about, other than responding to the hunger signals!
Extreme hunger is very likely to hit at various points in your recovery process. Don't question it when it does, just let it drive you to where you need to be! There will also be times though that the extreme hunger levels are not quite so extreme and at these times you are responsible still to eat good amounts of food and ensure your intake does not drop to a restrictive level again.
And, there will also be periods in recovery when you are likely to experience symptoms that make eating a lot more difficult. This might be days of feeling nauseous, days of acid reflux, severe bloating, cramps, spasms, constipation or diarrhoea... all things that can make the thought of putting more food in your belly feel physically very uncomfortable (which will also make it more mentally uncomfortable too).
For recovery though, despite physical symptoms making your physical (and possibly mental) appetite much lower, you will still have to make yourself keep eating a high baseline amount of food as not doing so will risk further energy deficit and a reawakening of disordered urges and thoughts.
Appetite Towards The End of Your Recovery Process
For those who have made it towards the end of their recovery process (huge congratulations!!), you are likely to also experience more fluctuations in your appetite and find it naturally reducing over time from the extreme hunger levels you have experienced.
As your body reaches it's set point weight or even goes into overshoot in order to complete all the internal physical repairs needed, your hunger levels will naturally reduce slightly. However, this is a really dangerous time for most people as it is at this point that recognising true hunger cues and trusting your body is a skill that you are still very much developing and one that can still be led astray by lingering disordered thoughts which are not overly happy with your new found bigger body.
Therefore, at the point in recovery at which your hunger really and truly is starting to level off slightly because you really have achieved full physical restoration (and that is not a target weight on a BMI chart by the way!), you are going to need to be really vigilant to ensure that you continue to eat enough (and by enough I mean really quite a lot!) and you will need to keep your eating disorder radar switched on strongly to ensure that you recognise if the drive to restrict or use compensatory behaviours because of your recent weight gain doesn't sneak back in, while you happily justify it to yourself and those around you as being reduced appetite because you are 'recovered' when actually deep down, you know this isn't quite true.
Having now explored some of the ways in which low appetite can materialise in the different stages of recovery and why, surely we now need to ask the question...
What Do You Do With No Appetite in Recovery?
Most people with eating disorders who have learnt enough about recovery and what it takes will understand that if you are thinking about food or have any signs of hunger at all then you should be eating, responding to all signs of mental or physical hunger wherever and whenever possible. And many now advocate that if you keep following all your hunger signals (mental and physical) that these alone will drive you to eat a significant amount of food, help you to break your disordered and restrictive habits and guide you to mental and physical recovery.
But what if you don't feel that you do have any mental or physical hunger signs? Does this mean that you just don't eat until you do?
I think everyone reading this is intelligent enough to understand that eating disorder recovery won’t get very far if you stop eating for long periods because you don’t ‘feel’ hungry. In fact, your recovery probably won’t even get off the ground if you do only eat when hunger signals strike.
So, yes, you do have to eat in eating disorder recovery, even if you have a low appetite or no appetite and even if you are feeling sick and unwell... Sorry!
In the next post, I will provide 11 tips to help you keep eating in eating disorder recovery despite having a low appetite so stay tuned!
**This post is a transcript of a podcast episode on my series, 'Feck it, Fun, Fabulous and Free in Eating Disorder Recovery', which you can access for free here or wherever you usually listen to podcasts!**