Anorexia support - Several questions regarding anorexia recovery

[AnonP216]

Hello,
Ive got several questions that I need to ask on behalf of my brother (19 year old male, 5'9.5" (176-177cm)) who is a recovering anorexic. He's too embarrassed to post them online, so I've decided to help him out.

In 2015, he used to weigh about 159lbs (72kg) at roughly the same height.

Not sure when the disorder really started, probably around April 2017 (so roughly 1 year now). Right before this, he wasn't muscular, but was pretty sporty (a lot of soccer and running).. His case is mostly anorexia of the restrictive type.

Between Sep 17 and Dec 17 he lost went from 123lbs (56kg) to 90lbs (41kg) (BMI = 13.2).
During the final two months of this period, he was committed to intermittent fasting everyday as well (15:9 I think). At the end of Dec 17, he suffered gastric perforation (which was likely a complication of the restrictive Anorexia), was hospitalized, died for about 3 minutes due to heart failure during the gastric surgery, but made it through.

When he left the hospital a week later, he was 90lbs.
After about another 12 days of refeeding, he was 99lbs
After another 10 days. he was 103 lbs (46.5kg). His highest was a week after this at 105lbs (47.5kg).
So he gained about 15lbs (6-7kg) in about 4 weeks. He could've potentially gained an extra 2lbs I think, as he only followed 90% of his meal plan.

He relapsed though, and now is back at 91.5 (41.5kg) lbs again. This time, he seems quite determined, and everyone around him is also helping him out. After doing a fair bit of self-research, we have the following q's about his recovery:

1/ Given how he used to be able to gain weight pretty easily between 2014 and 2016, and during the first months of refeeding, will he be able to quickly regain weight again (assuming no mental barriers)?

2/ Does he seem to be suffering from hypermetabolism, considering how he gained weight pretty easily after refeeding? Or is his metabolism super slow right now, as he has been mostly fasting+restricting for 5 months before the surgery and in the past 2 months?

3/ How many calories does he need per day right now to put on 1kg (2.2 lbs) in 1 week? Is it his maintenance calorie level (91.5*14.5)+(7700/7))=2434? (I used the activity level 14.5 because his daily activity includes biking for 30 mins or walking for 40mins and walking to and from classes. He runs 3 times a week, 2.75 miles each time for 20 mins (so about 1hr a week).

4/ How signficant will the water weight retention be if he continues to eat so that he puts on 1kg (2.2 lbs) a week consistently? Will this level of water weight eventually stop increasing?

5/ Would he need to proportionately (and I think this is quite important) increase his calorie intake as his weight increases so that it continues to increase.

Thank you so much, and sorry for the long post.

[Heisman2]

If his weight is that low he almost certainly needs to be hospitalized urgently for treatment. Has he seen a doctor for this recently?

To answer your other questions:
1. He clearly has lots of mental barriers so this isn't really relevant but typically people in recovery need to dramatically increase calories to continue to put on weight. So no, he likely will not put on weight easily.
2. Right now while restricting his metabolism is probably very slow.
3. He cannot safely do this at home. There is a very real risk of refeeding syndrome. This has to be done inpatient with close monitoring. Inpatient typically a safe amount of calories are started and this is increased daily until weight gain on average of 1 kg/week is obtained.
4. Eventually the water weight will stop increasing.
5. Yes, often by several thousand calories.

[AnonP216]

If his weight is that low he almost certainly needs to be hospitalized urgently for treatment. Has he seen a doctor for this recently?

To answer your other questions:
1. He clearly has lots of mental barriers so this isn't really relevant but typically people in recovery need to dramatically increase calories to continue to put on weight. So no, he likely will not put on weight easily.
2. Right now while restricting his metabolism is probably very slow.
3. He cannot safely do this at home. There is a very real risk of refeeding syndrome. This has to be done inpatient with close monitoring. Inpatient typically a safe amount of calories are started and this is increased daily until weight gain on average of 1 kg/week is obtained.
4. Eventually the water weight will stop increasing.
5. Yes, often by several thousand calories.

Thank you so much for your response. I'll make sure he reads it.
The thing is that he has begin to learn to enjoy eating again, and is more determined than ever. He's also considering a gym membership when he is near full recovery to avoid being skinny fat. With this in mind, don't you think he will easily put on weight and also because, as you mentioned, his metabolism is very slow? He used to be able to eat a lot before developing the illness, and I remember him putting on a lot of weight in 2015-16.

Also, even though he has been restricting for most of the past 4-7 months, he has never really eaten <1100 cals/day, and showed no signs of refeeding syndrome during his first refeeding month after the surgery. He has increased his intake dramatically in the past 4 days without any major signs of this syndrome, although his real weight hasn't started to budge yet. Do you still think he'll get refeeding syndrome if he tries to gain more than 3lbs a week?

As for the last question, given the data I've given, can you give a vaguely realistic approximation of what you mean by "by several thousand calories", and whether you mean in total or in excess?

Thank you so much again for the response; this will help him tremendously.

[Heisman2]

Yes, he is still at a severe risk of refeeding syndrome (even though he did not get it the first time). Chances are when he was inpatient initially his caloric intake was slowly increased daily. At my hospital we do 300 kcal daily. We also check labs daily to ensure we are not causing refeeding syndrome.

If he's learned to enjoy eating and is determined that is great and perhaps he is getting past the mental aspects, but that doesn't make the process of regaining the weight and refeeding syndrome less dangerous. I would still have him see his doctor ASAP to discuss this.

Think about it another way; it's common to develop delayed gastric transit time with anorexia. Your brother actually suffered a gastric perforation. Now he is eating a lot more but quite possibly still has delayed gastric transit; he is at significant risk of suffering another gastric perforation.

While restricting metabolism is slow. When food intake is increase people with anorexia nervosa typically become hypermetabolic so it can be hard to gain weight. Given their normal TDEE, they may need to eat thousands of calories above this to actually put on weight at a desired rate. This is one reason why he hasn't gained any weight the last 4 days although he has increased his intake dramatically. In general it's advised to try to gain 1kg a week while inpatient (2 pounds), not >3 pounds per week.

Even if he isn't hospitalized for this he should definitely be doing it under a doctor's supervision.

[fluidZ]

The dude literally died. How was he released without having explicit instructions concerning eating in the future, or with strict orders to see a doc weekly / monthly for updates?

Get the hell off the internet and go to the office man. And then chew whoever released him's ass out for not giving better instructions and supervision.

[AnonP216]

Thank you for your valuable replies; I've shown them to him and he feels a lot clearer about his situation now

Yes, he is still at a severe risk of refeeding syndrome (even though he did not get it the first time). Chances are when he was inpatient initially his caloric intake was slowly increased daily. At my hospital we do 300 kcal daily. We also check labs daily to ensure we are not causing refeeding syndrome.

During the 8 days he was hospitalised, he had no physical food but some of that liquid food through a bottle into his veins for the first 4 days. He had porridge for the next 2.5 days, and began eating rice and bread on the 8th day, where he consumed about 1/2 cup of white rice, 3 oz beef, 1/2 cup bean soup, and 1/2 cup spinach in one meal.

Think about it another way; it's common to develop delayed gastric transit time with anorexia. Your brother actually suffered a gastric perforation. Now he is eating a lot more but quite possibly still has delayed gastric transit; he is at significant risk of suffering another gastric perforation.

As for his gastric perforation, he has obeyed all the medication prescriptions in the two months after hospitalisation (the prescription amount ended after 2 months), and has not experienced any discomfort in the two months since. He's due for a check-up soon (can't remember when). Do you still think his chances of developing refeeding syndrome is significant if he puts on weight really quickly?

While restricting metabolism is slow. When food intake is increase people with anorexia nervosa typically become hypermetabolic so it can be hard to gain weight. Given their normal TDEE, they may need to eat thousands of calories above this to actually put on weight at a desired rate. This is one reason why he hasn't gained any weight the last 4 days although he has increased his intake dramatically. In general it's advised to try to gain 1kg a week while inpatient (2 pounds), not >3 pounds per week.

So hypermetabolism only manifests when refeeding starts/increases dramatically (I suppose the first couple of pounds he gained after refeeding may've come from water retention)?

Even if he isn't hospitalized for this he should definitely be doing it under a doctor's supervision.

To be honest, when I said dramatic caloric intake in the past 4 days, it was more like an extra 400-600 calories in the first two days, then 800-900 calories in the past two days. Admittedly, this is not that much yet, but he really seems to have overcome that mental wall, and I predict he'll be able to on average eat 900 calories in surplus in the next week. Are you unable to give a more accurate level of excess calorie he needs to consume if we're trying to get him back on weight as soon as possible?

[AnonP216]

The dude literally died. How was he released without having explicit instructions concerning eating in the future, or with strict orders to see a doc weekly / monthly for updates?

Get the hell off the internet and go to the office man. And then chew whoever released him's ass out for not giving better instructions and supervision.

Thanks dude I certainly will have a word with the docs about this. The guy did get pretty explicit instruction, but some time between this january and late february he derailed from it (see my post about how he was gaining some weight, then relapsed).

Thanks again for the response. He's read it and knows this is the kind of talk he needs.

[fluidZ]

Are you unable to give a more accurate level of excess calorie he needs to consume if we're trying to get him back on weight as soon as possible?

I'm having a very difficult time conveying my shock and horror right now, that you dont have EXTREMELY explicit instructions from whoever discharged him / is supervising him

Stop. Now. Stop the internet. Unplug your router. It's against the rules to give / seek medical help on the website... especially for someone that has DIED from the subject matter!! we are random internet people!!

And go to the doctor, and get an actual SCHEDULE of kcals per week, with macro targets.

This is completely bewildering to me, how you don't already have this information from the hospital staff. It honestly reeks of malpractice to me.

The dude, LITERALLY DIED, and somehow you don't have explicit instructions on how much he should be eating while in recovery?

Madness!

[fluidZ]

Thanks dude I certainly will have a word with the docs about this. The guy did get pretty explicit instruction, but some time between this january and late february he derailed from it (see my post about how he was gaining some weight, then relapsed).

Thanks again for the response. He's read it and knows this is the kind of talk he needs.

Then you need to call the police and have him institutionalized for harming himself. It's no different than cutting / attempting to kill yourself. Not eating for him is literally the same thing. There are psychiatric holds / evaluations, and it's pretty easy to add up the math from the doctor's instructions to his actual weight...

This isn't a joke or game. Sometimes you just need professional help that friends and family can't give you.

[Heisman2]

He is without question still at risk of refeeding syndrome. There is NO way I can predict how many calories he will need. Again, we usually increase calories by 300 daily to a goal amount and then this is adjusted to ensure weight is gain at a desired rate. We ALWAYS have a registered dietitian who specializes in anorexia go over this in detail with patients and provide meal plan options.

Your brother absolutely needs to see a doctor.

I don't even understand how he was discharged after 4 days of TPN, 2.5 days of soft food, and then at most 1.5 days of actual food intake without tracking for appropriate weight gain. Seems like he was hospitalized solely for the surgery and not for the anorexia aspect (as what you describe is more standard for post-op discharge). He likely should have been transferred to a different inpatient unit to address anorexia or discharged to a facility where treatment could have been continued.

[fluidZ]

I don't even understand how he was discharged after 4 days of TPN, 2.5 days of soft food, and then at most 1.5 days of actual food intake without tracking for appropriate weight gain. Seems like he was hospitalized solely for the surgery and not for the anorexia aspect (as what you describe is more standard for post-op discharge). He likely should have been transferred to a different inpatient unit to address anorexia or discharged to a facility where treatment could have been continued.

Exactly. His brother needs psychiatric treatment. There is absolutely no excuse for him to have not been transferred somewhere. If he had died from a suicide attempt but they brought him back, he would still be in the hospital or enrolled in a mandatory rehab program.

This is ridiculous that he's still walking around with only you to ensure that he doesn't die or relapse.


After he is getting the care needed, you seriously need to chew some ass and get a lawyer.

[Strawng]

Please listen to Heisman & Fluidz, OP. I myself have battled anorexia in the past and I almost died of complications related to refeeding at home. At your brother's weight & supposed activity level/caloric intake, he seems to be in even more dire circumstances than I was. Take him to the hospital asap.

[AnonP216]

Thank you all for the suggestions and comments. I have shown them all to him, and he is glad that I've posted his questions on this forum.

One more request: does anyone have a link to a comprehensive food log/diary that accompanies a weight gain log/diary (basically any sort of log that tracks daily calorie and food type/quantity intake with weight changes) for an anorexic patient?

Seems like he was hospitalized solely for the surgery and not for the anorexia aspect (as what you describe is more standard for post-op discharge).

^ This is true - we didn't really suspect he had anorexia - at the time the situation was so urgent that only the agony from the gastric perforation mattered at that very moment.

If only he had someone with fluidZ's no-bull**** mentality next to him at the time.

[AnonP216]

Please listen to Heisman & Fluidz, OP. I myself have battled anorexia in the past and I almost died of complications related to refeeding at home. At your brother's weight & supposed activity level/caloric intake, he seems to be in even more dire circumstances than I was. Take him to the hospital asap.

Will do Strawng. If it's not too much trouble, could you please share some of your experiences about recovering from Anorexia (starting weight, recovery meal plan sample, times and eating schedules...etc)? This will be much appreciated.

[AdamWW]

Will do Strawng. If it's not too much trouble, could you please share some of your experiences about recovering from Anorexia (starting weight, recovery meal plan sample, times and eating schedules...etc)? This will be much appreciated.

There really isn't much point given how unique each experience is. #1 priority now is ensuring nothing dire happens.

[Heisman2]

There are registered dietitians who specialize in eating disorders. That is the person your brother should go to (AFTER seeing a doctor urgently) to get advice on how to develop a meal plan and how to keep track of what he eats.

[AnonP216]

There really isn't much point given how unique each experience is. #1 priority now is ensuring nothing dire happens.

Thanks for the advice Adam. Despite this, it would still be helpful just as a comparison. After all, despite the differences of each case, there are still overlaps here and there. Therefore the more sample meal plans and diets + weight logs I can get, the more mentally reassured the boy will be.

[AnonP216]

There are registered dietitians who specialize in eating disorders. That is the person your brother should go to (AFTER seeing a doctor urgently) to get advice on how to develop a meal plan and how to keep track of what he eats.

^That is certainly going to happen. I would still like to give him as many comparative insights as possible though, so any additional links to any sample plans (food type + quantities + weight log) would also help.

[Heisman2]

^That is certainly going to happen. I would still like to give him as many comparative insights as possible though, so any additional links to any sample plans (food type + quantities + weight log) would also help.

That may not be a good idea. That can provide unrealistic expectations and trying to compare himself to others could add to any mental hang ups. He needs professional help. There is a very, very high risk of him dying if he does not seek professional help soon.

[AnonP216]

That may not be a good idea. That can provide unrealistic expectations and trying to compare himself to others could add to any mental hang ups. He needs professional help. There is a very, very high risk of him dying if he does not seek professional help soon.

Thanks for the warning Heisman2, I'll be sure to pass this along to him.

With regards to the metabolism in general for any recovering anorexic, is it correct when I said that

So hypermetabolism only manifests when refeeding starts/increases dramatically (I suppose the first couple of pounds he gained after refeeding may've come from water retention)?

?

Also, for a normal person, is my estimation of the maintenance calorie level (in my reply above), the activity level factor, and calories needed to gain weight at the specified rate correct?

3/ How many calories does he need per day right now to put on 1kg (2.2 lbs) in 1 week? Is it his maintenance calorie level (91.5*14.5)+(7700/7))=2434? (I used the activity level 14.5 because his daily activity includes biking for 30 mins or walking for 40mins and walking to and from classes. He runs 3 times a week, 2.75 miles each time for 20 mins (so about 1hr a week).

[Heisman2]

Even for people with normal metabolisms calculations can be off by several hundred calories easily; that's why the general advice is to pick any number, track progress, and adjust accordingly. Your ballpark estimate is as good as any.