IT’S ALL ABOUT PERSPECTIVE

To add a little context, this is raw post from the perspective of a person named Jane that I am working with to explain her perspective of the struggles she has with consuming energy. I will be adding my thoughts in shortly, or if you’re reading this at a later date, they may be already there and highlighted.

We felt that many may share certain aspects and it would be good to remove the secretive nature of disordered eating to allow Jane and others to realise they may not be as alone as they once felt. A post on perspective will also follow as it was a topic I had already started to cover. Comments welcomed!

Hello. My name is Jane. With Billy’s assistance, I would like to share my story with you. The purpose of this seeming solipsistic endeavour is two-fold (and hopefully not wholly solipsistic). One: by writing about it, by setting it down in words, the rationale is that I will be able to take a step back from myself and in so doing discern a way forward. At the moment, I am stuck. Completely and utterly. My size-fours are glued to the ground and I am going nowhere. Moving forward by stepping back sounds like a paradox. It is a paradox. But the truth often resides in this contradictory space. Stepping back opens up a bigger space in front of you. Stepping back makes a bigger perspective – a more objective perspective – possible. Two: someone reading this might relate to it. It might chime with their own story. It might make them feel less alone. At our root, my own included, we all want to feel less alone. It would be wonderful if my sharing this has that effect on someone.

The individual perspective refers to the unique way in which each person perceives and experiences the world. It encompasses an individual's thoughts, beliefs, emotions, and subjective understanding of their own existence. One common aspect of the individual perspective is the tendency for people to perceive themselves as the central character in their own story, often referred to as the "narrative self" or the "egocentric bias."

As human beings, we navigate through life primarily from our own point of view. Our thoughts, feelings, and experiences shape our understanding of the world, and we interpret events and interactions based on how they impact us personally. This subjective lens creates a sense of self-importance and a natural inclination to prioritise our own needs, desires, and perspectives.

This self-centred perspective can lead to a limited awareness of the wider outlook. We tend to focus on our own beliefs, goals, interests, and challenges, often disregarding or overlooking the experiences and perspectives of others. This doesn't mean that we are completely oblivious to others or lack empathy, but rather that our own thoughts and concerns occupy a central position in our consciousness.

This egocentric bias is deeply rooted in our psychology. From early childhood, we develop a sense of self and personal identity, and we constantly construct narratives that shape our understanding of who we are and how we fit into the world. These narratives can reinforce the belief that our experiences and perspectives are unique and central, leading us to perceive others as supporting characters or background figures in our personal story.

However, it is important to recognise that this individual perspective is not absolute. While we may be naturally inclined to focus on ourselves, we are capable of empathy and understanding. Through social interactions, education, and exposure to different cultures and perspectives, we can broaden our outlook and develop a more nuanced understanding of the world.

By actively seeking out diverse perspectives, listening to others, and practicing empathy, we can overcome our inherent egocentric bias. This broader awareness allows us to recognise that everyone has their own story, their own desires, and their own struggles. It fosters understanding, compassion, and a more comprehensive view of the world beyond our individual narrative. Having spoken with Jane I am well aware of her broad world view in all areas aside from a nagging doubt that upsets her belief in her own bodies needs.

So, allow me to step back. Allow me to present my story. ‘Story’. I cringe when I write it: it sets me up as a character in a novel. But, in a way, I am. We all are. We are all conditioned by that which surrounds us – what we hear, what we see, what we read. In this way, our thoughts are not our own – and who are we, at least in the egoic sense, if not our thoughts? I’ll leave the issue of Universal Consciousness and our fundamental nature to Jung. Our surroundings are the novelist and we the protagonist, adhering to their subliminal nudges without even realising it.   

I have an eating disorder. Or should that be ‘had’? No, have. Definitely have. I’m not as ‘bad’ as I have been. I’ve been more underweight than I am now. Physically, I’ve felt weaker than I do now. I’ve been more fixated on food than I am now. But things are still not good. I’m still underweight – and actively keeping myself so by controlling my food intake. In a physical sense, I’m still FAR from thriving. I still spend more time than I should thinking about food. ‘Have’ it is, then. I have an eating disorder. Saying this still feels surreal; part of me thinks that I have fabricated the whole thing.

Human evolution is driven by the process of survival rather than the concept go thriving or longevity that is promoted by many, but it is important to recognise that thriving and survival are not mutually exclusive concepts. In fact, the ability to thrive often enhances an organism's chances of survival and reproduction.

Throughout our evolutionary history, humans have faced numerous challenges and pressures that have shaped our biology and behaviour. The primary driving force behind these changes has been the need to survive and adapt to changing environments. Traits that confer survival advantages, such as the ability to find food, avoid predators, and reproduce successfully, are more likely to be passed on to future generations.

However, thriving goes beyond mere survival. It encompasses not only meeting basic needs but also achieving a higher level of well-being, growth, and flourishing. While survival is a fundamental aspect of evolution, thriving allows individuals to maximise their potential and create conditions for future generations to thrive as well.

Thriving can be seen as an extension of survival. The traits and behaviours that contribute to thriving, such as intelligence, cooperation, adaptability (especially metabolism), and innovation, can provide significant advantages in terms of survival. For example, our cognitive abilities have allowed us to develop tools, technology, dense foods, and social structures that have improved our chances of survival and provided opportunities for flourishing. Equally some may view the same factors as being responsible for ill health.

Moreover, as societies have developed, our understanding of thriving has expanded. We recognise that factors such as education, healthcare, social support, and mental well-being are crucial for individuals and communities to thrive. By promoting these aspects, we not only enhance our individual lives but also create conditions for the long-term survival and success of our species. As Jane will discuss, these aspects are critical but the commodities available to us, such as eating disorder services may not enhance conditions as intended.

In summary, while survival is the foundational principle of evolution, human evolution has not been solely driven by survival. Thriving, encompassing both survival and the pursuit of well-being, has played a significant role in shaping our biology, behaviour, and societies. By striving for thriving, we continue to push the boundaries of what it means to be human and create opportunities for future generations to flourish.

I am thirty-four. I stumbled into a restrictive eating disorder when I was twenty – though I only realised years later that this was what I had done. Fourteen years. Wow. That number saddens and disappoints me. It makes me feel a bit hopeless: fourteen years is a chunky chunk of my life. I won’t focus too heavily on why I found myself in this position. Let’s just say that in many ways I was ripe for it, though at the time I thought myself the least likely candidate. I see now that I was an eating disorder waiting to happen. I have all the classic traits. Perfectionism (to a RIDICULOUS degree). OCD (to a RIDICULOUS degree). Low self-worth (again, to a RIDICULOUS degree).

Perfectionism refers to a personality trait or mindset characterised by an individual's striving for flawlessness and setting extremely high standards for themselves or others. People with perfectionistic tendencies often have an intense desire to achieve excellence in all areas of their lives and may feel a strong need to avoid making mistakes or falling short of their ideals.

Perfectionism can manifest in various aspects of life, including work or academic performance, relationships, personal appearance, and even hobbies or creative pursuits. It involves a relentless pursuit of perfection, often at the expense of one's well-being and mental health.

There are two main types of perfectionism:

• Adaptive Perfectionism: This type of perfectionism is considered healthy and functional. Individuals with adaptive perfectionism set high standards for themselves but also maintain a realistic perspective. They strive for excellence, take pride in their accomplishments, and are motivated to improve. However, they are more flexible, able to accept their mistakes, and understand that perfection is unattainable.

• Maladaptive Perfectionism: This type of perfectionism is characterised by unrealistic expectations, excessive self-criticism, and a chronic fear of making mistakes. Individuals with maladaptive perfectionism often experience high levels of anxiety, self-doubt, and self-criticism. They may have an intense fear of failure and often engage in excessive checking, reassurance-seeking, or repetitive behaviours to ensure their work or performance is flawless. This type of perfectionism can lead to negative consequences such as burnout, low self-esteem, procrastination, and difficulty coping with setbacks.

Perfectionism can stem from various factors, including personal traits, upbringing, societal pressures, or a combination of these. Some people may develop perfectionistic tendencies as a response to high expectations from their family, peers, or society, while others may have innate personality traits that make them prone to perfectionistic thinking.

It's important to note that while striving for excellence can be positive, excessive perfectionism can be detrimental to one's mental health and overall well-being. Seeking a balance between setting high standards and accepting imperfections is crucial for personal growth, resilience, and maintaining a healthy self-image.

• "Typical American Male and Female" (1893): Commissioned by Dudley Allen Sargent for the Chicago World Fair in 1893, this set of statues aimed to depict the average measurements of young white American college men and women. The intention was to create a representation of what was considered typical for that demographic during that era.

• "Average Young American Male" (1921): Created by Jane Davenport in 1921, this statue was based on the anthropometrics collection of soldiers mobilised and demobilised during World War I. The purpose was to capture the average physical characteristics of American soldiers at that time. The statue was initially exhibited as part of the 1922 International Congress on Eugenics, a controversial movement that sought to apply principles of genetic selection to human populations.

• "Norma and Normann" (1945): This set of composite statues was created by gynaecologist Robert Latou Dickinson in collaboration with artist Abram Belskie. The statues became the central exhibit at America's first permanent health museum, which opened in 1945. The names "Norma" and "Normann" were given to these statues. However, it's important to note that the information you provided does not specify whether these statues were specifically related to the "normal" body or if they represented the statistically average body.

These sets of composite statues played a role in popularising the concept of the normal or average body during the first half of the twentieth century. They aimed to provide a representation of what was considered typical or average for specific groups based on the collected data. However, it is worth considering the social and cultural context in which these statues were created, as societal norms and ideals of physicality can change over time.

The Cleveland Health Museum, after acquiring the statues named Norma and Normann in 1945, sponsored a contest to find an Ohio woman whose body measurements closely matched those of the Norma statue.

The contest, advertised in the Cleveland Plain Dealer, offered a $100 US War Bond and the title of "Norma, Typical Woman" to the winner. Women were instructed on how to measure various body parts such as hips, bust, neck width, and wrist circumference to determine their resemblance to the Norma statue's dimensions.

Interestingly, only a small percentage of the 3,863 entries came close to the average dimensions represented by the statue, no body was able to match the perfection of NORMA. This suggests that the concept of true normality or achieving the exact average measurements was elusive. Nonetheless, a 23-year-old theatre cashier ultimately won the contest and claimed the title of "Norma, Typical Woman."

This contest and its outcome reflect the museum's attempt to engage the public and highlight the concept of the average or typical body during that time period. It also underscores the fact that individuals' body measurements often deviate from statistical averages, highlighting the natural variation in human physiology.

The attitudes and perceptions toward body weight and appearance can vary across different societies and cultures. However, it is true that many societies tend to favour and promote thinness as an ideal, while often stigmatising and criticising individuals who are obese or overweight. There are several factors that contribute to this phenomenon:

• Cultural ideals and media influence: In many societies, the media, fashion industry, and popular culture often portray thinness as the standard of beauty and attractiveness. These images can create unrealistic and unattainable ideals, leading to the marginalisation of those who do not fit these standards.

• Health concerns: Society's preference for thinness is often linked to the perception that being thin is healthier than being overweight or obese. While there are legitimate health risks associated with obesity, obesity is not always a road to ill heath and can indeed be protective in some diseases. Equally, being underweight is just as risky for health.

• Stereotypes and biases: Negative stereotypes and biases against overweight individuals exist in society. These biases can stem from assumptions that overweight people lack discipline, willpower, or self-control, despite the fact that weight is influenced by various factors including genetics, environment, and socio-economic conditions.

• Internalised beliefs: Individuals within society may internalise these ideals and biases, leading them to hold prejudiced views towards overweight individuals and to praise those who are thin. These beliefs can be deeply ingrained and perpetuated over time.

It's important to challenge these societal norms and promote body positivity and acceptance for people of all body types. Recognising that beauty comes in diverse forms and that a person's worth should not be solely determined by their appearance is crucial in fostering a more inclusive and compassionate society.

For me, it was never about weight. It was never about being thin, about chasing society’s idea of the perfect body. According to societal standards, I was one of the lucky ones. I was naturally lean and had an athletic body shape. I wasn’t thin or skeletal, but I was slim and toned. I ate freely, no restriction, no thoughts of restriction. The opposite, in fact. When the evening meal was being dished up, I always had to have the biggest portion. I wanted the largest serving of mashed potato, the biggest chicken fillet, three rounds of sandwiches instead of two, the most sizeable piece of cake. If it wasn’t a doorstop, then I wasn’t interested. Oh, to have those days again. I didn’t track calories back then (why the FUDGE would I do that?!?!) but, looking back now, I easily cleared 2,500 calories daily. Yes, you read that right. 2,500. I did not exercise. Very sporty at school, I played anything and everything, but gave it all up at fourteen in order to concentrate on my academic work. OCD alive and well. All-or-nothing, tunnel-vision thinking in action.

One day, when I was twenty, the summer of my first year at university, I had the following thought: “If I eat more perfectly, then I will feel more perfect.” I actually remember having the thought. I even remember where I was. Stood in the middle of a British Heart Foundation charity shop, where I was doing some voluntary work over the summer holidays. Random, I know. My perfectionism meant that I was always coveting that ‘perfect’ feeling. Always coveting, but never finding – because an illusion. But, in the mind of a perfectionsit, a very real illusion. The realest illusion. I wanted – needed – everything to be perfect. Every aspect of life. Every aspect of myself. I didn’t feel ‘right’ if things were not so.

As I have stated before, there is no no good and bad within physiology, only adaptation to what we are exposed to. A perfect diet does not exist and nobody can achieve the perfect health diet, we can only adapt to our environment. Chemistry is not good or bad, we don’t have good or bad inflammation we just have inflammation.The fundamental approach of good and bad is not what actually what happens. We have optimisation.

We have immediate and delayed gratification of optimisation to adaptation and right now many are doing things which they perceive as optimising their longevity, such as fasting, cold shock, extreme exercise etc and utilising the belief that survival physiology (the response to short-term stress) is creating a better day today despite it potentially making it worse later (chronic stress). When I speak of consistent eating, or consistent exposure to safety this does not feed into the immediate gratification most of us seek. We desire to be slimmer now, to lose the dad bob in 6 weeks or suffer being shamed on social media posts. Delayed gratification is doing the harder things, helping your physiology to feel safe.

We don't know if we're going to live 10 or 20 or 50 more years so we maximise for this current moment until we are able to convince your brain to maximise/optimise further down the road. Create a famine and optimisation here and now is to reduce muscle mass that is expensive and takes up resources that can be used for something else. What gives us a short term survival advantage? Muscle or organ? Clearly organ failure is bad, but if your muscles get weaker you have years repair this problem, if and only if the environment changes.

The number one brain default is to keep your brain alive, second to keep your heart beating, third to keep your organs functioning as well as possible. Skeletal muscle, nervous system etc are all low priority, as is VO2 max/performance/growth and repair. You have to understand that convincing your body to make an adaptation that is expensive, using resources such as ATP and amino acids, to become inefficient takes a longterm delayed gratification in which you build a biology of trust.

Humans are the ultimate adaptation machine, we spent our entire existence trying to mitigate stress. Initially it was thermal stress so we created housing, then we faced the stress of attack so communities formed, food stress was alleviated by sustainable actions, agriculture, farming and better hunting. We created safety nets to eradicate extremes of stress and allow growth (evolution) to occur. Modern humans have been convinced to utilise stress as a response to physiological adaptions i.e. the brain creates energy stores to survive, we create stress to try and force change. Is it any wonder biology always wins.

The problem was that nothing about me or my life felt perfect. Everything felt messy and out of control. I felt inadequate, particularly academically, even though I had finished Year One with a First. My OCD was very loud. A constant companion since the age of eleven, I was accustomed to its insistent calls, but it never got any easier. Any less infuriating. I adored being at university, loved everything about it, but I did feel like an impostor. I was surrounded by middle-class, privately educated gids (they always say gid, not good); I was (am) working-class and had gone to a struggling comprehensive. I could see that the gids were not necessarily brighter than me, but they appeared to know more. They had certainly read more. TONS more. My school had been a battlefield. Lessons were full of noise and disruption and non-learning – and the occasional upended desk and/or textbook-missile. This frustrated and upset me: I desperately wanted to learn. Ironically, my school was not the place for this. The gids hadn’t had to navigate this at their own comfortable schools, where learning and good grades were paramount, and it showed: they struck me as overwhelmingly confident in their own abilities. I know now that life was probably not so perfect for them but, as is so often the case, this did not occur to me when I was in the moment.

Much like diet, academia is rife with nodding dogs, science isn’t about perfection but about questioning, assessing and adapting the question. We have a replication crisis because science isn’t that clear. To achieve consensus we need peer review in which the correct behaviours are rewarded…find a dissenting answer and you’re pushed out. Art is similar, and writing the same. What is deemed grade A is defined by those in authority and utilising different styles etc is punished. I used to listen to a grammar radio show early on a Monday morning and be amazed and the two professors arguing. One wished to protect his beliefs around correct language usage…the more modern one kept asking why he defaulted to a set timestamp and anything after was wrong but anything prior he did not care to consider. Perfection depends on our perspective and in reality is not an actuality.

What did ‘eating perfectly’ mean to me? Surprisingly, it did not mean eating ‘clean’. On THAT bandwagon I never jumped. Small mercies. Before my eating disorder, I loved chocolate – and I have never stopped eating it. It is an every-day-staple, and always has been.  It comforts me, and so I wanted to ensure that I could keep eating it. To my thinking, this meant that other things had to be reduced. I never cut anything out, never restricted entire food groups, I just reduced portion sizes (after all, isn’t the medical-nutrition literature/mafia always urging us to do this…Michael Mosley, anyone…?) – less cereal at breakfast, less bread at lunch, fewer potatoes at evening meal. Less meat, less milk, less pasta. In other words, all the food that a young body – ANY body – needs for optimal functioning. I quickly lost weight and, because I was already lean, I very quickly became underweight. During this period, I probably never dropped below 1500 calories a day, but it was markedly less than I was used to, hence the weight loss.

I went from my normal BMI of 18 (low, yes, but healthy for me – slim but covered, no visible bones, physically strong, regular menstrual cycle, c.2,500 calories a day) to a BMI of about 15. My periods stopped. Stupidly, this didn’t worry me at the time – I actually thought that it made my life easier. If I could throttle my younger self, then I gladly would. Idiotic doesn’t even come close. I hovered around this BMI for years, ultimately reaching my lowest BMI of 12.9 at twenty-nine. My calories had dropped to 1,200-1,400 a day by this point. My parents were naturally beside themselves this whole time but their pleading failed to penetrate. I love my parents, I would have been devastated had they been the ones that were critically underweight and steadily becoming more so, but I was unable (unwilling?) to see it from anybody else’s perspective. I knew that my situation wasn’t right but I was locked inside it. It became who and what I was. How my life was lived on a day-to-day basis. Those days accumulated and, quicker than you could whisper wasted decade, they had transformed into years and I found myself nigh on ten years older.

At twenty-nine and my lowest BMI, I finally decided to reach out for help. I was still very much locked inside but I wanted to at least look for a key. I was exhausted – physically, mentally, emotionally. I couldn’t keep going – I perpetually felt on the brink of collapse. I went to my GP and was referred to my borough’s eating disorder service. After a wait of a few months, I had an initial assessment. Though eating disorders have the highest mortality rate of all mental illnesses, they receive the least funding. Teams are small and they are inundated with referrals, now more than ever – as with all mental illnesses, there has been a massive spike in referrals since COVID and the isolation of ’lockdown’.

At such a low BMI, I technically should have been admitted to an eating disorder ward as an inpatient. The idea of this terrified me, I had no framework for it bar horror stories that I had seen on the News, so I asked if I could try treatment as an outpatient first. Despite my critically low weight, my bloodwork was acceptable, as was my ECG, so it was tentatively agreed that I could try their outpatient pathway. My cognitive abilities were still sharp and it couldn’t be argued that I was not of sound mind, another criterion for inpatient care. I saw a clinical psychologist and a dietitian weekly and had regular blood tests and ECGs. I attended the service as an outpatient for ten months. I gained no weight during this time. This is not a reflection of the care that I received. The help was certainly offered. I was sincere in my efforts, I wanted to recover, I felt bad about wasting everybody’s time, not to mention vital NHS resources, but I could not allow myself to eat more. I just couldn’t do it. It was beyond me.

Beyond me mentally. Certainly not beyond me physically. I never lost my appetite, perhaps because I at no point restricted to the extent that most people with a restrictive eating disorder do. Most go below 1,200 calories a day. Significantly below 1,200 calories a day. I never did. I was always hungry, always thinking about food, both before outpatient treatment and during, but allowing myself to eat more felt wrong. Morally wrong, almost. Though I didn’t like the overall look, though my skeletal frame made me feel self-conscious when in company, deliberately adding flesh to a body that I had stripped of all flesh ‘felt’ wrong. Counter-intuitive. Adding flesh would be akin to dropping food all over a freshly laid carpet, splattering a whitewashed wall with mud. Spoiling. Ruining. Destroying.

That appetite remains is an amazing sign of innate biology at work, the brain doing what it needs to do in the here and now. Yet we are socially engineered to consider hunger a bad behaviour. Over eating, eating between culturally acceptable meal times are all thought of as bad behaviours…”you can’t be hungry, you just ate.” Biology does not work to these rules which we try to achieve.

In addition to the feeling of wrongness, adding flesh would rob me of my safety net in the event of a splurge. At a BMI of 12.9, I knew that I could potentially over-indulge, even binge, with little consequence to my weight – the odd day of over-indulgence would not make me fat. But, if at a normal BMI, this buffer zone would be lost and a splurge could edge me towards the other side of the scale.

In reality this occurs the other way, under eating causes the brain to lower metabolic needs to create energy buffers.

Gosh Almighty…it could tip me into the murky realm of Chubbiness. (By the way, YES, I am being 100% ironic.) It felt safer to defer the weight gain and therefore bank potential splurge-sessions. I often fantasised about having the freedom to feast on whatever I so desired during the weight-gain phase. Once weight restored, this weight-gain-feasting would be consigned to the past and I would have to moderate my eating patterns – so, much better to keep postponing the weight-gain phase and thus have all those wondrous treats to look forward to. They would be there, wating for me, for when I really needed them. Really needed the comfort and pleasure of them.

After ten months of zero weight gain, my treatment team issued an ultimatum: enter inpatient care or take a break from treatment altogether. Outpatient care, according to them, wasn’t working. I saw their reasoning but did not agree with it entirely. I hadn’t gained any weight, that could not be disputed, but, from a psychological perspective, I felt myself in a better position. In this sense, then, outpatient care had been working. I had started to see that I was not the eating disorder. If I chose to, I could separate myself from the eating disorder ‘voice’. I could be a witness to it. Watch it, acknowledge it, feel it – but not act. I understood this on a cognitive level, but I wasn’t ready to put it into practice. Recognising the duality of me and the eating disorder was progress. Massive progress.

Though the thought of inpatient care still terrified me, the thought of going it alone terrified me even more. If I couldn’t allow myself to eat more with the support of a clinical psychologist and a dietitian, then what were the chances of my managing it solo? I didn’t like my odds. So, inpatient care it was to be. Looking back, I don’t think that my outpatient team would have been allowed to discharge me at such a low weight had I refused the option of inpatient – they likely would have forced me to go in via a medical intervention. This didn’t cross my mind at the time, though, and so didn’t factor into my decision to admit myself. I knew that something drastic was needed to pull me out of the quicksand.

Life on an ED ward is not easy. It is a toxic environment, infused with a macabre competitiveness. Who can get to the lowest BMI? Who can ‘be’ the sickest? Who can refuse the most food? Who can monopolise the most staff? It was littered with tortured souls. Whilst on the ward, I learned that two recent patients had committed suicide shortly after being discharged. And yet. It was the right decision. It helped me a lot. Or, I was able to help myself whilst in there. I engaged with the program. I worked with the staff. I committed to the weight gain plan. My weight increased every week. This felt like my last chance – I took the leap that had seemed impossible as an outpatient.

How did I feel about the constant weight gain? I loved it. JOKE!! I absolutely HATED it – even though this was my sole purpose for being there. I felt like the ‘fat one’ on the ward. Many patients don’t embrace the meal plans, and so very little in the way of weight gain actually occurs. For most, inpatient care is about stabilising vital signs. Any weight gain is a bonus. My vital signs were relatively stable before being admitted, so for me it was about weight gain. This might sound bizarre, but I was really angry at my body. I felt betrayed. Let down. Compared to what I ate prior to my eating disorder, I was not actually eating a significant amount. Three meals, a dessert, three snacks with milk. I was on the highest meal plan - I cleared it with ease and could have eaten more. This filled me with guilt and made me feel greedy, especially when I could see how much others were struggling with just one bite.

Was this guilt at not feeling like you were one of them? Or that you feel they haven’t reached a point where they are ready to take steps to escape the grips of behaviourism. Lots about your biology fills me with hope, your body sends the right signals and I know from previous years that I would have an initial contact from you and then it would be months while you battled with the issues and responded. Over time you have made strides towards facing this.

When I got to a BMI of 15.6 (from 12.9), I asked to be discharged back into outpatient care. My team were in agreement. Inpatient care is designed to be the start of the ‘journey’, not the whole journey. Bad habits can be picked up so protracted stays are not advisable. I could feel myself getting drawn in to the competitiveness at times and I did not like it. Moreover, I wanted to break the connection that had formed in my mind between finishing a full meal and feeling greedy. By leaving the ward and mixing with ‘normal’ eaters (though this is becoming increasingly difficult – so many ‘normal’ eaters exhibit disordered eating patterns, fuelled, no doubt, by the rise of social media and ‘wellness’ platforms), finishing a meal in its entirety would be normalised again. Fortunately, my parents and brother are very normal (no inverted commas!) eaters. Inpatient wards are necessary and they save lives – but, because they throw together a group of people who are battling the same thing, they can make eating disorders worse. Inpatient care is a gamble but one that has to be taken when the eating disorder path has been traversed so aggressively.

I think this is a valid point, nobody is normal eater, we must remember that I feel the last time we actually eat intuitively is probably around 2 years old when we cannot speak. Through cries and other noises our parents put us to sleep, change or nappy or feed us. Once we can communicate we begin being told “you can’t be hungry” as we progress through life the idea of “X needs more food because they are having a growth spurt” disappears. Our growth slows but movement, mental tasks, social patterns that push on our energy reserves continue.

My plan on discharge was to keep gaining weight, seeing the process through and reaching a healthy weight. This was what I told myself, how my head answered when the question filtered through as I prepared to leave the ward. In my heart, I think that I had no intention of going further. Though still only BMI 15.6 (no longer critically underweight, but still firmly in the underweight category), I was struggling with the weight gain – with seeing an increased number on the scale. Objectively, I knew that I looked MUCH better. Fuller in the face. My shapely, strong legs were returning. My hips looked more womanly. I could sit and lie in comfort, my bones no longer sticking out. I felt more energised when walking. I wasn’t weight restored, but I’d made a good start. I was a fair way along the journey. Subjectively, however, the weight gain was difficult to process. Difficult to accept. For years, my identity had been that of a skeletal ‘girl’. Of a girl that was perpetually worn-out and sickly. Akin to allowing myself to eat more, pushing away from this identity felt wrong. Self-indulgent. Too much like self-care. Self-love. I didn’t know how to let myself thrive. How to let myself be well.

Planning on gaining weight is akin to dieters seeking to lose weight, it is an arbitrary number and in reality means little. Bone mass, organ mass and even adiposity all play vital roles but the number means little, may be unachievable and feeds the fear.

I returned to the outpatient service and the care of my clinical psychologist and dietitian. My psychologist told me that my progress had shocked her given my previous weight gain attempt with them. I was half in appreciation of the comment and half offended. A back-handed compliment if ever there was one – but, I guess, a deserving one. I was honest from the start and explained that, while I wanted to gain more weight, I didn’t feel as though I could accept more weight at this time. It was decided that my aim would be to engage with the psychological aspect of recovery whilst maintaining my discharge weight.

I did maintain my discharge weight – by returning to about 1,400 calories a day. I didn’t want to lower my calories. This was the last thing that I wanted to do. In hospital, I had got used to eating a higher amount (c.2,500 calories daily). Ironically, in terms of calories, the ward’s highest meal plan was what I ate to maintain a very lean weight prior to my eating disorder. Given that I had gained each week on this amount when in hospital, I knew that I couldn’t eat the same and expect to maintain my discharge weight. Again, this angered me and I resented my body. In reality, there was no justification for the resentment: my body was rightly responding to the environment that I had created. A decade of undereating and keeping myself underweight had lowered my metabolism, and so a sudden upsurge in calories resulted in weight gain. Simple Mathematics. I remained with the outpatient service for about nine months. At this point, I had had my allotted number of sessions with them and was discharged from the service. Time served, out the door, next one in…

Fast-forward to the present day and four years have passed. What has been happening in the interim? A few months after overall discharge, I began to think about and research metabolism. I was still maintaining my weight – by eating less than my body needed and wanted. I knew that this wasn’t right: I was essentially still locked in the restrictive eating patterns but at a slightly heavier weight. My research led me to the world of reverse dieting, the idea that metabolism can be ‘improved’ by very slowly and consistently increasing calories; as calories are raised in a controlled way, metabolism should adapt accordingly – and therefore energy supplied (via food) should be utilised and weight gain should be minimal. Billy’s name came up amidst the metabolism research and I read about his 6,000 calorie ‘experiment’. His experiment seemed to imply that, with consistency, metabolism can be primed to adapt to any environment – including a high number of calories. Billy significantly increased calories in a consistent and systematic way and his body did not respond by gaining excessive weight. I reached out to him, via e-mail, and told him about my situation.

I am not primed to any environment, if a famine occurred (unlikely) I would have perished first. I struggled to work and social situations were odd (not for me) because I wanted to eat constantly and consistently. Meal timings were my priority. Life was like clockwork and to some degree that is disorder…

My situation at the time of first contacting Billy can be summarised thus:

•  BMI: still c.15.6.

• Average daily calorie intake: still 1,400.

• Sedentary job. Little exercise. This ignores cerebral and emotional activity

• Osteoporosis. Alas, inevitable given my history. But no less devastating. A constant worry. The fear that my neck and spine would ‘snap’. The fear that I would develop curvature of the spine.

- Two aims:

• To increase daily calories to at least 2,500

• To weight-restore (returned menses, fully-functioning, physically strong) but remain very lean – as lean as I was prior to the eating disorder.

Was this possible? Could I repair the damage from years of undereating and remain lean? Though weight, namely the desire to be a low weight, didn’t lead me to the eating disorder, weight did become a fixation once I slipped into an underweight range. I feared that I would lose control and binge if I allowed myself more food – I feared that, as a result, I would not remain lean.

Billy and I arranged a Zoom session, wherein we spoke about my history and my current situation. The best approach, we agreed, was to build up calories by adding in an extra one hundred each month. Consistency was key in order to train my metabolism to adapt to the new amount. I put the plan into action and increased by one hundred calories. Month two came and I found that I would not allow myself to go any further. The months accrued. Another year passed. I had dropped back down to my starting point of 1,400 calories a day.

I reached out to Billy again, and a second Zoom session was organised. I decided that I would try again. The same situation occurred: I would not allow myself to increase by more than one hundred calories. Anything more seemed unacceptable and indulgent. Again, it felt ‘wrong’. Wrong to add weight when I had endured so much for so many years to strip my body of weight. I still feared that I would lose control and binge if more food was permitted – I would get a ‘taste’ for the food and not have the required self-control to stop. I think that a part of me did not trust in the process and thought that my metabolism was beyond ’repair’. The fact that I had gained weight so easily when in hospital played on my mind.

A month ago, I reached out again. A third Zoom session was arranged. We discussed the idea of us both writing about my situation. I would be brutally honest when giving my perspective, and then Billy would give his from the vantage point of science. Writing would allow me to see my situation from a wider perspective and, crucially, might help others who are going through something similar.

My BMI, as I write this, is about 15, a slight drop. I am eating between 1,200 and 1,400 calories daily. These past few weeks, my energy levels have felt particularly low. I am always tired. My mood is low, as is my sense of self-worth. I am perpetually worried about my osteoporosis. Will I snap a bone? Is my posture erect? Do I walk ‘funny’? I HATE the fact that my own actions have caused it. I go on holiday at the beginning of July, and I feel as though I will not be able to wear the clothes that I would like to wear. If my arms are on show, then will people be looking at them and passing hurtful comments amongst themselves? I do not like how thin my arms look, yet allowing them to look ‘bigger’ STILL feels wrong. Beyond frustrated!

Ultimately, I feel as though I have wasted my youth – my best years have been blighted by all this; I am no longer young and my time to address this is running out. I will blink and, BAM, I will find myself another fourteen years older and nothing will have changed. I want to eat a lot more, but I also want to be lean. Am I kidding myself that the two can go together? Is wanting to be lean a disordered thought in itself? Do I only want to eat more because I am food-obsessed? Am I a compulsive eater? Will the doubts and fears and questions ever stop?