Expert: Leigh-Anne Persing, PA-C - 10/18/2008

Question
QUESTION: I'm a 21 year who is 5 feet and currently weigh 88 pounds. I've engaged in anorexic behaviours to reach this weight. I was 121 pounds and began sever restricting of food (under 300 calories most of the time) everyday along with one to one and a half hour of moderate strength training sometime around May of last year. Last month and this month I even did a seven day water fast and did heavier strength training. Yesterday, I binged badly. My stomach ached really really bad all night long. I finally noticed that my muscles aren't there. I don't know how I didn't notice, but I didn't. I have no real definition in my body. So, I decided to stop what I was doing and try and salvage what I can. today, I'm attempting to eat normaly, but I can't. When I look at my stomach, it feels like I have no abdominal muscles, and any amount of food makes me feel bloated. Did my stomach shrink? How can I go back to eating normaly? When can I strength train again? I'm not from a first world counrty, I'm from the Middle East and I live there and things like disordered eating are not understood here, so I have to absolutely do it on my own. Directions, please?

ANSWER: Anorexia causes muscle wasting due to the lack of protein intake. When you starve your body, yes, your stomach itself will shrink. You need to slowly introduce foods back into your diet. If you try going straight from nothing to normal meals you will develop abdominal discomfort, and there is something called refeeding syndrome as well which results when an anorexic individual starts eating again (electrolyte abnormalities). So, I would suggest you start slowly and over a period of several months bring yourself back up to at LEAST 1200 calories per day. At that point you can start strength training again, but when you train you need to add more calories to your diet to support those activities (mainly protein sources to help rebuild muscle).

---------- FOLLOW-UP ----------

QUESTION: I did not check my email in ages. Anyway, I already developed refeeding syndrome. I have awful water retention and almost chronic edema. It started the day I sent you the e-mail. that day, I was still attempting to eat normally. I developed very sever swelling in my legs (they became enormous) and was taken to the hospital where they took a blood test and a urine test and sent me home. The results were satisfactary (but my urine contained "crystals" which they didn't care about) which is insane since I have been practically starving myself. The next day I was given another blood test and the doctor said it was satisfactary but that I was eating too much salt (which I think I was). I did an ultra sound and it was discovered that I developed ascites in the pelvic area. But the kidneys and liver appeared "normal", according to the ultrasound, and levels of phosphorous and albumin (the albumin were slightly high)were satisfactory. I explained about my anorexic behaviour but they didn't really understand. I was given a vitamin and mineral supplement (formula centrum) and Aldoctine duritic and Ensure milk and told to come after two weeks. During these two weeks I ate small meals every hour and a half. Caloric intake throughout the day was about 1500-2000, though. Bowel movements normal. I was at the university , moving and sweating and I was a bit in denial. On the weekend, because I was sitting around, my edema got a bit worse and I panicked. I researched all day long and discovered the refeeding syndrome. The second week I attempted to be more moderate, but frankly I think I still ate much because the water retention and edema were still there although milder. The thing is that I would wake up in the morning empty of water, would eat a breakfast that is no more that 100-80 calories (Is that too much?) and take maybe four small sips and I could immediately feel the water. I went to my appointment today, did a blood test for levels of phosphorus which turned out normal, did an ultra sound which revealed that the ascites is gone.I asked for an ECG, but the doctor laughed at me and told me I didn't need it and that I was obbsessing. He also said that I should stop using the duritics and he didn't give me any supplements and basically told me to eat normally until my body gets used to food. I have bought the vitamin supplements (formula centrum) regardless, but am at a loss of what the next step is. I also want to say that my edema is generalized. My hands and legs swell, and I think my breasts do that too sometimes. Also, my weight is less than what I thought. I was using my home's scale which is old, and thought that I was 88 pounds. Electronic scales show the same result. But I was able to gain access to a scale in an upscale place for diet related issues, and I was assured that their scale is very accurate (this was a little before my last appointment), and I was more or less dehydrated from the duritics and the scale said that I was 79.2 pounds. I am utterly devestated now. Now that I have refeeding syndrome, what do I do? How do I eat? I don't know whether or not I have right-heart failure (my cardiac silhoutte was normal in one of the tests), the water retention and edema are my only clues. Going to the doctor is not an option anymore, I have no money of my own and my family is angry with me for inconveniencing them with the hospital visits (we are Middle Eastern, girls live with their families till they get married, usually, so I don't make money, I'm given an allowance). What I have right now are vitamin and mineral supplements, Ensure milk and support socks for the edema that aren't doing anything for me, frankly. I don't even have duritics. What do I do? Will the continous edema affect my veins? What do I eat? I need an eating plan. What's a number of calories to start at? Do I drink water normally? (I've kept a 500 ml water that I've restricted myself to because I'me so scared of making the water retention worse). My veins are starting to hurt and burn and I'm desperate. Please tell me what a good number of calories would be, foods that I should avoid, and please tell me if the water retention is supposed to be there all the time or not. I'm so tired and it's only been two weeks. I alternate between feeling very depressed and very positive and elevated. Today I was seriously thinking about killing myself. I'm very tired, mentally. Please help me with an eating plan and please answer my questions. Please.

Answer
Your questions are very indepth. I know you are confused and want answers, and I will do my best, although I may not be able to answer everything. I don't know much about refeeding syndrome, only that it occurs in anorexic individuals who try to start eating a normal diet all of a sudden. The edema may persist for some time, but that does not mean that you should stop drinking fluids. Fluid pushed fluids. The more you drink the more you'll pee off. Diuretics can have effects on your electrolytes, which combined with your eating disorder could be potentially dangerous and may be the reason your doctor did not want you to continue taking them. They pull fluid off quickly and may be why you saw such a dramatic decrease in your weight. As I said previously, the best way to go about eating is to start small and slow and work your way up. So, take what you were eating before and add 100 calories/day every week until you are up to goal (at least 1400 calories/day). Food items should not include junk foods and should not be heavy laden with sodium. Vitamin supplements are always a good idea and I encourage you to continue taking them. STOP SEARCHING THE INTERNET!!!! Many symptoms accompany many different diseases and while your concern may be justified your doctor has taken an oath that says "do no harm" and if he thought further testing/medicines were advised then he would have ordered them.