The Parent's Guide to Eating Disorders
Supporting Self-Esteem, Healthy Eating, & Positive Body Image at Home
by Marcia Herrin & Nancy Matsumoto
Normalizing Eating with a Food Plan
The Basic Building Blocks of the Food Plan
Excerpt from The Parent's Guide to Eating Disorders
The individual components of the Food Plan are simple. Your child should have three meals a day, up to two to three snacks a day, and normal portion sizes. I encourage my patients to make their own food choices within food groups and to choose two servings of "fun food," foods eaten for pure sensory pleasure, every day. Including fun food is a particularly effective strategy for overcoming an eating disorder because it protects against bingeing. There should be no more than a three- to four-hour interval between meals and snacks, and your child should know when the next meal or snack will be eaten. Your child's eating schedule must, for the time being, come first; other commitments must be scheduled around the Food Plan.
The importance of this last point, that fixing your child's eating disorder has to be your first priority, was one that Cara's mother did not grasp at first. In the year after winning her state's Junior Miss contest, Cara lost 30 pounds. Although she still had a very pretty face when I began seeing her, it was hard to imagine her winning a beauty contest; her arms were spindly, her backbone protruded, and her breasts and buttocks were wizened. Where she once was able to convince a panel of judges that she possessed a sparkling intelligence to match her outward beauty, now she could barely carry on a coherent conversation.
Despite Cara's best efforts at sticking to the Food Plan I had drawn up for her, she lost more weight. As we explored possible solutions, it became clear that part of the problem was that she felt her mother, Helen, was more interested in feeding and caring for her new husband, Ted, than in her seriously anorexic daughter. Helen felt obligated to serve a nice, large meal at 8:00 pm, when Ted arrived home from work. By then, Cara was no longer hungry and just picked at her dinner. In fact, appetite does diminish for many people if meals or snacks are more than three or four hours apart. We came up with the solution of Cara having a large after-school snack, which would leave her appropriately hungry for a late dinner.
But Cara also made it clear to Helen what the real problem was, saying, "Mom, I feel you care more about Ted's eating than mine." Before Cara could make progress she needed to truly believe that fixing her eating problems was the family's primary goal.
Helen, though, was still not convinced this was the proper approach. She spoke to me privately, wondering if by coddling her daughter she would promote selfishness, or an unhealthy sense of entitlement on Cara's part. After all, she pointed out, Cara certainly, at age 16, was old enough and competent enough to fix her own dinner. I explained to Helen that Cara's eating disorder, in essence, had made her regress to the point where her needs and feelings were those of a much younger child.
This is what the Food Plan looks like:
To overcome an eating disorder, often families temporarily have to cater to their affected child's food needs in ways that the child, when she has recovered, will balk at. First, Helen made a standing date with Cara to take her out for a restaurant meal once a week, just the two of them. After discussing it with Ted, Helen offered to have dinner ready for Cara at 5:00 pm. I encouraged Helen to eat with Cara if she could, but also to join Ted later for a snack while he ate dinner. It occurred to both Helen and Cara that Ted's dinnertime could coincide with Cara's evening snack, providing important family time. Since we began working together, Helen and Ted have come a long way in giving Cara the support she needs to make her recovery. Cara's story, though, is still a work in progress.
As you will see, your child's pattern of eating is more important at this stage than what is actually eaten. At Toronto General Hospital, this phase of recovery is called "eating with training wheels," and that is what your child is doing—learning to eat all over again as if for the first time. An exception to this rule is the child who is seriously underweight or losing weight and needs to be eating an increasing number of calories per day. (See Chapter 15, pp. 282–86.) Mastering these "training wheels" will pave the way for your child to gradually be able to eat freely, without the aid of the Food Plan. While your child is on the road to recovery, however, the Food Plan will help ensure that you are introducing adequate protein, calcium, calories, fat, vitamins, and minerals into your child's diet. We also remind you that the Food Plan is based on minimum servings. Underweight anorexics, as well as highly active people, will need to eat more to meet their caloric needs.
As you can see, the formula is simple and much like the way a healthy eater eats without thinking about it. (Most people, in fact, would do well to follow this or a similarly well-balanced food plan.) The variety comes in the foods that you choose to fulfill each of these requirements. Although I discourage my patients from counting calories, for those who insist on doing so, the plan, depending on food choices and portion sizes, ranges from 1,500 to 2,500 calories per day. Most girls and young women will need at least 2,000 calories per day and more if they are very active. Boys and men, on the other hand, usually need at least 2,500 calories.
Getting the Most out of the Food Plan
Adapting the Food Plan for the Anorexic Child
Adding Calories to the Anorexic's Food Plan
For anorexics, the idea is to augment the Food Plan continually until your child is gaining weight. When weight gain stops, you need to add more food to the plan until your child has achieved a healthy weight. When adding food to your anorexic child's diet, you can either add additional food groups to meals and snacks, or increase the size of servings in both meals and snacks.
The abject fear most anorexic children have about gaining weight too quickly or gaining too much weight makes it prudent for parents to incorporate additional calories gradually. Your child's body weight will be your guide as to how slowly or how quickly you can, or need, to do this. If your underweight child is losing weight, you must insist that she increase the pace of her caloric additions. If her weight is stable, then one or two weeks in which little to no weight is gained can usually be tolerated without jeopardizing your child's health. If she does not begin to gain weight after that, however, or continues to lose weight, you should consult a professional.
Because rapid, unchecked weight gain will be your child's biggest worry, it can be helpful to tell her that such an occurrence is highly unlikely, mainly because it is very hard for an underweight person to gain weight. Because the starving body resists gaining weight, it takes well above and beyond a normal intake of food for most anorexics to begin to restore weight. Another reason out-of-control weight gain almost never happens with anorexics is that if a child has been undereating for any length of time, she is likely to feel quite full even after modest food intake, and will, at first, find it hard to eat the large quantities necessary for even moderate weight gain.
From a medical point of view, gaining weight quickly rarely causes problems. The exceptions are the rare cases in which a severely anorexic child who is being tube-fed is at risk for complications from refeeding. (See Chapter 6, pp. 126–27, for more information.)
Although, as we have said, we do not encourage calorie counting, when your goal is weight gain, it is helpful to keep in mind that each addition to the Food Plan should total at least 300 calories. Most anorexics can tolerate additions of about 300 to 500 calories per day. Since most protein and fun food servings are about 300 calories, adding a serving of either is an easy way to add on to the plan. A single serving of the other food groups (calcium, carbohydrates, fruit, and fat) are about 100 calories, so more of these would have to be added. Vegetables are so low in calories that most nutritionists do not allow vegetables to be counted toward any additions aimed at weight gain. (For more on adding calories to the anorexic's diet, see Chapter 11, pp. 218–20.)
When Kirsten needed to add to her Food Plan, I asked her what she wanted to add. Her first suggestion was a protein bar. Since I knew that was about 200 calories, I applauded her choice and then asked what she could add from the calcium, carbohydrate, fruit, or fat groups. "How about a yogurt?" she suggested. "An excellent choice," I responded. Kirsten and her mother figured out that she could add the protein bar to her afternoon snack and the yogurt to her breakfast meal. The next week, despite her good additions to the plan, Kirsten's weight was down again. Knowing that her lunch did not include a fun food, I suggested she add a dessert to lunch. Kirsten liked the idea of finishing lunch with a bowl of ice cream and a cup of tea.
As Kirsten's story illustrates, with a little basic math, most parents can figure out, without meticulous calorie counting, how to add the calories their child needs using the foods their child is most interested in.