Nutrition
What is the Meal Plan?
The meal plan is designed to provide the necessary caloric requirements to promote weight gain and stabilization. There is a general meal plan that the dietitian follows; however, it is shaped to your child’s specific needs depending on weight goals and other nutritional concerns.
The general meal plan consists of breakfast, mid-morning snack, lunch, afternoon snack, dinner, and an evening snack. A caloric beverage is generally required at all meals. Dessert is required at lunch and dinner and should contain at least 300 calories. Snacks should be at least 250 calories in addition to a caloric beverage. The dietitian will explain your child’s specific meal plan and you should feel free to ask questions when they come up.
A saving grace to some patients are nutritional supplement drinks such as Ensure or Boost. It can be overwhelming for patients to take in the necessary calories required by the meal plan. After restricting food intake for some time, they are not accustomed to eating this volume of food. The meal plan can also be both visual and physically overwhelming and cause significant anxiety. To replace a meal, your child should drink two (2) Ensure Plus. If she/he had consumed 50% or more of the meal, your child should drink one (1) Ensure Plus. To replace a snack, one (1) Ensure Plus should be consumed. Keep in mind that the meals and snacks include a caloric drink and/or dessert. If these are not consumed, one (1) Ensure Plus should be given.
The general meal plan consists of breakfast, mid-morning snack, lunch, afternoon snack, dinner, and an evening snack. A caloric beverage is generally required at all meals. Dessert is required at lunch and dinner and should contain at least 300 calories. Snacks should be at least 250 calories in addition to a caloric beverage. The dietitian will explain your child’s specific meal plan and you should feel free to ask questions when they come up.
A saving grace to some patients are nutritional supplement drinks such as Ensure or Boost. It can be overwhelming for patients to take in the necessary calories required by the meal plan. After restricting food intake for some time, they are not accustomed to eating this volume of food. The meal plan can also be both visual and physically overwhelming and cause significant anxiety. To replace a meal, your child should drink two (2) Ensure Plus. If she/he had consumed 50% or more of the meal, your child should drink one (1) Ensure Plus. To replace a snack, one (1) Ensure Plus should be consumed. Keep in mind that the meals and snacks include a caloric drink and/or dessert. If these are not consumed, one (1) Ensure Plus should be given.
Why should my child follow the meal plan?
It is essential that your child’s weight and nutritional status return to normal as soon as possible. The longer your child remains underweight or continues to restrict, binge, and/or purge, the harder it becomes to recover. There is also a greater chance your child will suffer from health problems the longer she/he remains ill.
Why is my child eating "unhealthy" foods?
To some, the meal plan may seem to contradict much of the information that is circulating about nutrition. Your child will most likely fight part of, if not the entire, meal plan because it appears to be ‘unhealthy’. There are two things to keep in mind: a great deal of information that is out there is in response to the “obesity crisis”, and it is unhealthy for anyone to label foods as ‘bad’ or ‘unhealthy’. Your child is most likely not obese and will require a significantly greater amount of calories than the typical 1,200 fad diets. Foods should be enjoyed, and your child will have difficulty establishing a healthy relationship with food if they are labeled ‘off-limits’. The meal plan should be a chance for your child to not only become comfortable with foods she/he once enjoyed but to also try new foods as well.
There are concerns among both patients and their parents regarding the possibility of binge eating and establishing an unhealthy diet leading to excessive weight gain. Adherence to the meal plan prevents binge eating. In fact, binge eating is often a sign that the patient is not complying with the meal plan. When your child reaches her/his weight goal and has consistently held her/his weight there, the dietitian will revise the meal plan to ensure stability.
There are concerns among both patients and their parents regarding the possibility of binge eating and establishing an unhealthy diet leading to excessive weight gain. Adherence to the meal plan prevents binge eating. In fact, binge eating is often a sign that the patient is not complying with the meal plan. When your child reaches her/his weight goal and has consistently held her/his weight there, the dietitian will revise the meal plan to ensure stability.
What is ‘set-point weight’? How is it determined?
The ‘set-point weight’ is a certain weight goal that should be met and maintained. The dietitian will determine this weight by examining your child’s growth charts and taking into account your child’s age. Each person has a weight at which she/he is healthiest, and there are a range of weights that could be healthy for a certain height. Your child could be healthiest at the lower end of the range or at the higher end of the range. For example, if your daughter had been in the 65th percentile in terms of weight her entire life, her healthiest weight at this point of development may also be in the 65th percentile. One thing to keep in mind concerning adolescents are that they should be growing and gaining weight. Therefore, if your child was a certain weight a year ago before she/he became ill, it is more than likely that your child should weigh more now. It is important to tell your child’s dietitian about your child’s history so she/he can make the most informed decision.
I believe my child should be a certain weight. Why should I allow my child to weigh what the treatment team has determined to be her/his ‘correct weight’?
There are certain ideas circulating about what a person should weigh and look like. As a parent, you want your child to be as healthy as possible. However, the media sends messages that may be skewed in some way and/or may not pertain to your child. The treatment team members are knowledgeable on health and nutrition, and are also up-to-date on current research. It is important to trust that they are trying to restore your child’s health—this includes believing that they will make an informed decision about your child’s ‘set-point weight’. To ensure that they can determine a healthy weight, all necessary and relevant information should be given to the treatment team.
Group Therapy
What are the Groups?
During treatment two groups offered are the nutritional group (or affectionately called ‘food group’) and the process therapy group. Many patients come to the nutritional group in the earlier phases of treatment; depending on a person’s individual needs, however, some continue to attend later into treatment. The purpose of this group is to build comfort around food and practice the meal plan. A meal is served at every food group meeting, and after the meal patients can talk about eating-related issues and struggles with fellow members.
Patients are invited into the process therapy group based on age and their need to develop basic skills needed to form and maintain relationships. This group focuses on learning to build trust and camaraderie, and serves as an opportunity for patients to practice assertiveness skills. Most importantly, they learn to share things that are going on in their lives and recognize the value of maintaining these interpersonal skills to prevent relapse.
Patients are invited into the process therapy group based on age and their need to develop basic skills needed to form and maintain relationships. This group focuses on learning to build trust and camaraderie, and serves as an opportunity for patients to practice assertiveness skills. Most importantly, they learn to share things that are going on in their lives and recognize the value of maintaining these interpersonal skills to prevent relapse.
Why should my child attend these groups?
Since patients often feel that no one understands what they are going through—attending the groups consist of other patients in different stages of treatment, these meetings provide a safe environment for individuals to talk about the struggles they are facing. Patients in earlier stages of treatment are free to ask questions and seek advice from those further along in the process. Adolescents may feel more comfortable sharing things with group members that they may not be able to share with their parents or treatment team. If subjects come up during the group that are important for you to be aware of, however, the dietitian will bring these up in the next individual appointment.
Since many eating disorder patients have anxieties about eating in front of other people, “food group” is a place for patients to practice the meal plan in a safe environment. The size of the group not only allows patients to realize that their anxieties are unsubstantiated, but also allows them to see what a ‘meal plan plate’ should look like. Contrary to what your child may tell you, the servings given during group are normal, though exceptions are made to those who have higher caloric needs. These patients include athletes who are extremely active and those who are not able to achieve a healthy weight on the general meal plan.
Since many eating disorder patients have anxieties about eating in front of other people, “food group” is a place for patients to practice the meal plan in a safe environment. The size of the group not only allows patients to realize that their anxieties are unsubstantiated, but also allows them to see what a ‘meal plan plate’ should look like. Contrary to what your child may tell you, the servings given during group are normal, though exceptions are made to those who have higher caloric needs. These patients include athletes who are extremely active and those who are not able to achieve a healthy weight on the general meal plan.
What happens in these groups?
“Food group” begins with the serving of the food—the dietitian makes each patient’s plate, and the patients eat the dinner which is served with a caloric beverage and dessert. All group members are expected to eat all that is served to them, including the drink and dessert. Ensure Plus is given to those unable to eat the meal. During the meal, members talk about things not related to the eating disorder—this includes what activities they may have engaged in during the weekend or movies they have recently seen. This type of conversation promotes normal social eating that patients should experience outside the group setting. Once the meal is completed, the subject matter turns to issues related to eating disorders. Members can bring up experiences they are having with treatments and/or the illness or the dietitian will introduce topics for discussion. Topics such as methods of restricting, other forms of destructive behavior, and/or an individual’s weight are not permitted in the group discussion.
In the process therapy group, members often discuss events occurring in their lives that they feel they need to talk about and/or for which they need feedback. The primary goal of the process therapy group, however, is for the members to talk about the experiences that occur right there in the group. Members are encouraged to confront and discuss reactions and thoughts about the group the moment the occurrences happen. This is to promote assertiveness and the ability to effectively communicate with people outside the group environment.
In the process therapy group, members often discuss events occurring in their lives that they feel they need to talk about and/or for which they need feedback. The primary goal of the process therapy group, however, is for the members to talk about the experiences that occur right there in the group. Members are encouraged to confront and discuss reactions and thoughts about the group the moment the occurrences happen. This is to promote assertiveness and the ability to effectively communicate with people outside the group environment.
Psychotherapy
Why should my child see a therapist?
Eating disorders can occur for many different reasons and is an indication that something is amiss in your child’s life. Each patient is a unique individual and a therapist will work with your child to figure out what is not working in her/his life. More importantly, the therapist will help guide your child to actively work toward changing these things.
Will my child need medication?
Some eating disorder patients require medication; others can recover without it. Depending on your child’s particular illness (the severity and other co-occurring mental illnesses), medication can make some of the mental, physical and psychological struggles easier to deal with. There is no medication that specifically treats eating disorders, yet medications are designed to help with symptoms such as anxiety, obsessive thoughts and depressed mood. The issue of medication should be discussed with your child’s psychiatrist. You should also feel free to do your own research to supplement the information given to you by the psychiatrist.
Health Concerns
What is the diagnosis for anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified?
* These current descriptions are derived from the Diagnostic and Statistical Manual of Mental Disorders Volume 4 – Text Revision, published in 2000 by the American Psychiatric Association.
Anorexia Nervosa
Characterized by the patient’s refusal to maintain a weight above 85% of the normal weight for that patient’s height and age. This can be achieved through losing weight or not gaining the weight required through physical development. Patients with anorexia nervosa have a great amount of fear about gaining weight, though they are significantly underweight. Patients also often deny the severity of their low body weight. They are unable to accurately perceive the appearance of their body. In women who have had their menstrual cycle, they suffer from amenorrhea, or do not have their period for three consecutive cycles. Many perceive anorexic patients as only using restrictive behaviors; some anorexics, however, also engage in binge/purge behaviors as well.
Bulimia Nervosa
Characterized by two specific behaviors: binge eating and purging. Binge eating is characterized by eating an excessive amount of food during a certain period of time. Patients often describe not being able to stop themselves once they have started. The most recognized form of purging is self-induced vomiting, yet there are other forms of purging that include the use of laxatives, excessive exercising, or fasting. Any extreme method of ridding the body of food and/or calories is considered purging. To meet the criteria for this diagnosis, an individual is binging and purging at least two (2) times a week for three (3) months. Patients evaluate their self-worth based on their perception of their bodies; bulimic patients are usually of normal weight and may sometimes be overweight.
Eating Disorder Not Otherwise Specified
This disorder, also know as EDNOS, is used when a patient does not fall under the specific criteria of anorexia or bulimia. The severity of the illness is still great—this disorder can be just as difficult to treat and can cause similar problems that occur in bulimics and anorexics.
What are health risks associated with the different disorders?
Anorexia Nervosa
Various health complications associated with anorexia nervosa are osteoporosis, kidney dysfunction, dehydration, fractures, anemia, arrhythmia (irregular heartbeat), heart failure, amenorrhea, gastrointestinal problems such as bloating and constipation, electrolyte imbalance, cavities, and tooth decay. Up to 15% of people with anorexia will die from complications associated with malnutrition or suicide. Many people with anorexia also suffer from depression, anxiety, personality disorders, obsessive-compulsive disorder, and drug and alcohol abuse. Many people who start engaging in anorexic behaviors eventually turn to bulimic behaviors as they are no longer able to maintain the restrictive diet.
Bulimia Nervosa
Many of the health complications associated with anorexia are also common in bulimic patients. Some of these complications are more pronounced due to the repetitive purging behavior. Dental problems and gastrointestinal problems are common in bulimics, and individuals who have suffered from bulimia have burst their esophagus, gone into cardiac arrest, and have suffered from ulcers. Many bulimics suffer from depression, anxiety, suicidal ideation, drug and alcohol abuse, and self-mutilation.
Eating Disorder Not Otherwise Specified
Those who meet criteria for EDNOS are susceptible to the same health complications as those of anorexics and bulimics. Exhaustion, lack of concentration, and a decline in mental ability (often marked by a drop in school performance) are common side effects in individuals with eating disorders. Eating disorders have the highest rate of death among all mental illness, a low rate of recovery and a high rate of relapse. It is therefore essential to treat the disorder as soon as possible to increase the chance of recovery and lower the possibility of relapse and death.
Health Concerns
What should I expect though the treatment process?
At the start of treatment, the dietitian and doctors will assess your child’s nutritional needs, physical and psychological health concerns. All aspects of treatment can be overwhelming; this stage of treatment can be especially tough as patients are thrown into a meal plan they are not accustomed to and are working closely with people they do not know or trust. There also tends to be a great amount of resistance from patients to attend nutrition group because they will be expected to eat, and they will have to interact with group members they do not know. This can be frightening to patients with interpersonal anxieties.
Your child will be expected to follow the meal plan as prescribed and make weekly weight gain/ maintenance goals. Depending on the progress made, adjustments will then be made to optimize potential strides toward recovery.
Once your child’s weight has stabilized and eating disorder behaviors have subsided, your child’s involvement in treatment will be reduced. However, it is important that your child is monitored closely as the relapse rate for eating disorders is extremely high.
Sometime during treatment, it may be determined that your child should attend the process group. This would be a good opportunity for your child because she/he will be able to work on building interpersonal skills will improve your child’s chances of recovery. Some patients are resistant to this group as well because they may be confronted with issues they do not want to address. In most cases, however, it is important that the patients acknowledge, if not actively deal with, the issues that could be hindering their recovery.
During the course of recovery there will be set backs. It is easy to get discouraged and place blame wherever possible. It is important, on the other hand, to keep in mind that difficulties will arise. Your life and your child’s life will present greater difficulties and heartbreaks if the eating disorder is not treated as early as possible.
Your child will be expected to follow the meal plan as prescribed and make weekly weight gain/ maintenance goals. Depending on the progress made, adjustments will then be made to optimize potential strides toward recovery.
Once your child’s weight has stabilized and eating disorder behaviors have subsided, your child’s involvement in treatment will be reduced. However, it is important that your child is monitored closely as the relapse rate for eating disorders is extremely high.
Sometime during treatment, it may be determined that your child should attend the process group. This would be a good opportunity for your child because she/he will be able to work on building interpersonal skills will improve your child’s chances of recovery. Some patients are resistant to this group as well because they may be confronted with issues they do not want to address. In most cases, however, it is important that the patients acknowledge, if not actively deal with, the issues that could be hindering their recovery.
During the course of recovery there will be set backs. It is easy to get discouraged and place blame wherever possible. It is important, on the other hand, to keep in mind that difficulties will arise. Your life and your child’s life will present greater difficulties and heartbreaks if the eating disorder is not treated as early as possible.
What types of behaviors should I look for?
One of the hardest parts of recovery is that the patient, who was once well-behaved and gave no reason to be mistrusted, will test their parent’s patience and trust. Patients are not always convinced of the benefits of recovering or that they even have an illness. They may become desperate to hold on to the illness and to prevent weight gain. Remember, eating disorders are psychological disorders, and this illness greatly affects your child’s way of thinking and perceiving situations. Your child’s behavior is not a reflection on her/him, but rather is a reflection of the eating disorder.
Parents also need to keep an open eye to ‘cheating’—this includes patients trying to get away with eating the smallest amount of food possible, hiding food, faking weigh-ins, secretly finding ways to exercise, and looking for other places besides the bathroom to purge. Eating disorder patients tend to be intelligent and motivated, so if they want to avoid gaining weight, they will find a way to achieve this.
Another behavior parents should look out for, particularly in patients who have only displayed restrictive behaviors, is purging. Many patients with anorexia nervosa are extremely fearful of weight gain. Either their own biology or the interventions of others force them to start eating more than which they are comfortable. They turn toward purging as a method of getting rid of calories—this presents a whole new set of consequences and monitoring strategies should increase.
Parents also need to keep an open eye to ‘cheating’—this includes patients trying to get away with eating the smallest amount of food possible, hiding food, faking weigh-ins, secretly finding ways to exercise, and looking for other places besides the bathroom to purge. Eating disorder patients tend to be intelligent and motivated, so if they want to avoid gaining weight, they will find a way to achieve this.
Another behavior parents should look out for, particularly in patients who have only displayed restrictive behaviors, is purging. Many patients with anorexia nervosa are extremely fearful of weight gain. Either their own biology or the interventions of others force them to start eating more than which they are comfortable. They turn toward purging as a method of getting rid of calories—this presents a whole new set of consequences and monitoring strategies should increase.
What should I do?
Supporting the treatment team is an essential act for parents to participate in. The team are professionals and have a great deal of experience; resist the urge to question or argue with the treatment team in front of your child. Doing so shows your child that you do not trust the very people who are treating your child and will increase her/his resistance. If you do have concerns or disagreements about your child’s treatment, bring these up with the team in the absence of your child.
Attending family therapy sessions is another essential part of treatment. This does not necessarily imply you have a dysfunctional family. These sessions provide a safe environment for you, your child, and other family members to talk about family issues. A therapist, trained in family therapy, is present to facilitate the process.
Parents should also do what they can to promote enjoyment in your child’s life. Most likely your child has been miserable for awhile—take him/her to a movie or treat your child to a manicure or pedicure to make him/her feel more positive. Show your child that life can be enjoyed and will only get better the healthier she/he becomes.
Most importantly, tell and show your child you love her/him. Say “I love you”, give your child a hug, whatever you feel would show your child that you care. Apologize for your mistakes. This will teach your child to do the same and will also prevent your child from feeling like she/he is being treated like a three-year-old.
Avoid talking about bodies, weight, food, or diets. People with eating disorders are consumed by these thoughts throughout the day. They are constantly looking for ways to confirm the need to lose weight, restrict, purge, and/or feel inadequate. When referring to others, mention positive innate aspects rather than dwelling on the person’s physical appearance. This will show your child that you value people for their insides rather than for superficial aspects. Your child will start to think of others, and eventually themselves, in the same way.
Being firm on treatment expectations and protocol are also important in helping your child recover. He/she should go to all groups and appointments, eat the full meal plan and take medication as prescribed. Letting them slide on treatment shows your child that you do not take treatment seriously. Have a strong stand that you are behind the treatment given to your child. It will be difficult! Expect that it will be!
Attending family therapy sessions is another essential part of treatment. This does not necessarily imply you have a dysfunctional family. These sessions provide a safe environment for you, your child, and other family members to talk about family issues. A therapist, trained in family therapy, is present to facilitate the process.
Parents should also do what they can to promote enjoyment in your child’s life. Most likely your child has been miserable for awhile—take him/her to a movie or treat your child to a manicure or pedicure to make him/her feel more positive. Show your child that life can be enjoyed and will only get better the healthier she/he becomes.
Most importantly, tell and show your child you love her/him. Say “I love you”, give your child a hug, whatever you feel would show your child that you care. Apologize for your mistakes. This will teach your child to do the same and will also prevent your child from feeling like she/he is being treated like a three-year-old.
Avoid talking about bodies, weight, food, or diets. People with eating disorders are consumed by these thoughts throughout the day. They are constantly looking for ways to confirm the need to lose weight, restrict, purge, and/or feel inadequate. When referring to others, mention positive innate aspects rather than dwelling on the person’s physical appearance. This will show your child that you value people for their insides rather than for superficial aspects. Your child will start to think of others, and eventually themselves, in the same way.
Being firm on treatment expectations and protocol are also important in helping your child recover. He/she should go to all groups and appointments, eat the full meal plan and take medication as prescribed. Letting them slide on treatment shows your child that you do not take treatment seriously. Have a strong stand that you are behind the treatment given to your child. It will be difficult! Expect that it will be!
Eating Disorder Not Otherwise Specified
The termination of treatment should be a collaborative agreement between the treatment team, you, and your child. The professional team knows the consequences of premature termination: RELAPSE!! They will evaluate your child’s current physical and psychological health and eating behaviors. The length of time at which your child has shown stability will also be taken into account. When all participants feel comfortable with your child’s progress and recovery, it may be appropriate to end treatment.
However, if the treatment team is saying one thing and your child is saying another, a red flag should go up. Keep in mind that your child could be attempting to find a way out of treatment. Treatment is a hard process that your child needs to participate in until physically, emotionally and psychologically ready to discontinue. Parents may display certain behaviors in group or mention things in individual appointments that cause concern. Please keep an open dialogue with the treatment team so you are aware of their concerns.
However, if the treatment team is saying one thing and your child is saying another, a red flag should go up. Keep in mind that your child could be attempting to find a way out of treatment. Treatment is a hard process that your child needs to participate in until physically, emotionally and psychologically ready to discontinue. Parents may display certain behaviors in group or mention things in individual appointments that cause concern. Please keep an open dialogue with the treatment team so you are aware of their concerns.
Is it my fault that my child has an eating disorder?
It may not be possible to pinpoint the actual cause(s) of your child’s illness—most likely, her/his disorder stems from many different sources. It is harmful to your child’s treatment to blame anyone for the disorder, including your child and yourself. Rather, it is important to focus on the present and how to work out current issues and problems—the most important goal at this point is your child’s recovery.