Caroline Adams Miller, 53, hasn’t stepped on a scale in 30 years. Technically, she has – during her visits to the OB-GYN for her three pregnancies – but she never looked at the number.

“I would go in and I would say, ‘You’re not going to weigh me unless I stand on the scale backwards, plug my ears and you do not tell me what my weight is,’” says Miller, a positive psychology coach in Bethesda, Maryland, and author of “My Name is Caroline,” the first major autobiography by a bulimia survivor. Her latest book, “Positively Caroline: How I Beat Bulimia For Good and Found Real Happiness,” describes her long-term recovery.

Weight gain from pregnancy, medications or just life happens to most of us. But when it happens to people who have had eating disorders, weight loss often has to be approached with more care.

“You have to accommodate your vulnerabilities in life and when you have this one, restricting food and so on and so forth poses certain risks,” says Marsha Marcus, a professor of psychiatry and psychology at the University of Pittsburgh School of Medicine. “It doesn’t mean you can’t do it, and certainly for some people, maybe they should, but there’s no one answer.”

Redefining Success

According to the National Eating Disorders Association, eating disorders affect about 20 million women and 10 million men in the United States. Many more have likely experienced disordered eating patterns. That means plenty of people who have struggled with the conditions are among us at the gym, the grocery store – and the doctor’s office, where their histories may go undisclosed.

“They might go to see their primary care physician and [he or she] says, 'Hey, you really need to lose some weight,’ but the physician may not even have a clue that the patient has a history of an eating disorder,” says Cynthia Bulik, director of the University of North Carolina’s Center of Excellence for Eating Disorders.

That’s important because, while people with eating disorders can and do recover, certain things like the number on a scale can remain vulnerabilities, experts say. Cutting calories and amping up exercise – touted as the hallmark of healthy weight loss – in and of themselves can be risky for people who’ve had eating disorders, since being in a state of “negative energy balance,” or expending more energy than you're consuming, might trigger those unhealthy patterns again, Bulik says.

“For most of us, that's a really uncomfortable physical experience: When we’re hungry, we get irritable, we get headaches and it’s not a good feeling,” she says. “For people with anorexia nervosa, it’s probably their favorite physical state – it feels good to them. They feel worse when they’re full.” Bulik says this trait is likely due to a biological mechanism that made them more vulnerable to an eating disorder in the first place.

For Miller, such potential vulnerabilities are part of the reason why she doesn’t step on the scale, doesn’t drink alcohol and swims competitively for the love of the sport, not its body-shaping effects. “I had to go back and redefine what I want my body to do, not what I want it to look like,” she says.



Do Ask, Do Tell

One of the most important ways for people with histories of eating disorders to stay healthy while losing weight is to discuss their backgrounds with their doctors and even their personal trainers or fitness instructors, experts say.

Bulik, for one, would like to see “eating disorders” as a checkable box under medical history at doctor’s appointments, right alongside history of heart disease or glaucoma. That way, clinicians might rethink how they’re prescribing weight loss or choose to focus on aspects of a patient’s health other than weight.

“Whatever approach is taken with these folks has to be an anti-dieting approach,” Bulik says. For example, the goal might be to lower cholesterol or to increase physical activity. Striving to hit a certain number on the scale, on the other hand, is “the danger zone” for people who have or have had eating disorders, Bulik says.

The conversation about eating disorder history should also happen at the gym, says Jodi Rubin​, a social worker and eating disorder specialist in New York who founded “Destructively Fit,” a program that trains fitness professionals to recognize eating disorder symptoms in their clients and then address those issues appropriately and sensitively.

“What I’ve found is that nobody talks about eating disorders – they talk about food, they sort of dance around it, so what I encourage people to do is ask, ‘Have you ever had an eating disorder or do you now, and how is exercise connected to that?’” Rubin says.

If a client does reveal a history of disordered eating, his or her personal trainer might consider focusing on measurements such as how much weight the client can lift or how quickly he or she gets winded after climbing the stairs, since stepping on the scale at each session could be “devastating," Rubin says.

People with histories of eating disorders might also benefit from exercising away from the mirror and learning how the proper techniques feel, rather than how they look. Exercises like yoga that open up the body and facilitate connection with it, too, can be good choices for people with histories of eating disorders, Rubin says. Of course, all these approaches can be motivating for people who have never had an eating disorder, too.

At the end of the day, experts say, there is no one-size-fits-all approach to how people who have had eating disorders approach weight loss later in life. In fact, Miller says, if they received appropriate treatment from a mental health professional and recovered by learning to address the condition’s underlying factors, their approach to weight loss later on might not be all that different from the rest of ours.