Learning to Eat Normally When
Recovering From an Eating Disorder
Recovering from an eating disorder means re-learning how to eat normally. Recovery time varies based on the individual. Individual variation, attributable to age, length of time one has been sick, co-occurring disorders, social support and the degree to which one has obsessed about food, needs to be taken into account in the treatment of a person recovering from an eating disorder as they start to normalize eating.
It may be helpful to look first at what is not normal in the eating behaviors of a person diagnosed with an eating disorder.
In anorexia nervosa eating is accompanied by fearful, obsessive ideas about foods and the quality of foods. Often there is excessive focus on numbers, such as calories and grams of a macronutrient (fats or carbohydrate are often focused on). There is fear of weight gain and over evaluation of body shape, weight and size. There is concern about eating not only certain types of foods, but in eating foods prepared by others and often there is concern about eating in front of others. Activities involving foods, such as shopping, can be anxiety producing. Feelings of fullness and satiety as well as hunger can all cause worry, as various levels of subjective meaning are assigned to each.
Bulimia Nervosa and Binge Eating Disorder
Individuals with bulimia nervosa experience many of the same food and body image concerns as those with anorexia nervosa. They often worry a lot about gaining weight. They binge on foods, sometimes eating a large amount and sometimes eating what they feel is a large amount even though it would not seem large to others. Then they feel the need to “undo” the binge. Various forms of purging behaviors follow the binge, including self-induced vomiting and compulsive exercise, along with use of laxatives, diuretics, and diet pills. Food eaten is not tolerated and retained. Some people with bulimia actually do consume enormous quantities of food, and will report they feel out of control with their eating.
Binge eating disorder involves eating a large quantity of food, feeling as if one is not in control when eating, sometimes eating odd concoctions of food, eating at odd times of the day or night, secretive eating, and then not “undoing” the binge (purging), but retaining what is eaten.
Eating disorders tend to incorporate rules about foods and eating, many of which are untrue and promoted by fear and lack of flexibility. Thus, eating without fear and with the ability to be adaptive and flexible are hallmarks of normalized eating. At the same time, it needs to be recognized that with over 50% of those diagnosed with anorexia nervosa there are co-occurring anxiety and obsessive compulsive disorders. Clinicians need to work with those disorders as well as they often underscore the eating disorder. Normalization of eating can only occur once physical health is restored and after a person has done initial work in halting eating disorder behaviors such as purging.
If the above represent “abnormal eating” then what are guidelines for normalized eating?
Normalized eating guidelines first of all are just that…guidelines. The dietary prescription has to take into account the unique traits, lifestyles, and food preferences of an individual. For a child, developmental stage is important. For children and adolescents the family is usually incorporated into the treatment, doing home based refeeding of the medically stable child or working with a treatment center for discharge planning and home feeding following treatment. Thus, family food preferences need to be examined and sometimes altered if they get in the way of adequate refeeding. For example, if a family was very restrictive in their eating and/or avoided eating very much fat in their diet, their child would need more fat in the diet in order to gain weight, if weight gain was necessary.
Whether starting the work of refeeding and normalized eating in the outpatient setting or within a treatment center, most people diagnosed with an eating disorder receive some type of meal plan. Meal plans provide organization to eating. Regular eating patterns provide “permission to eat” for many patients, and de-mystify the job of eating. Ultimately, the goal for normalization of eating is to not follow a meal plan but to intuit (to just know through intuition or insight) appropriate food intake. Having a meal plan initially helps accomplish this goal by demonstrating normal food quantities and types. As the individual becomes comfortable, the idea is to gradually ease off the meal plan. This ultimate goal of intuitive eating may not be attainable for those with very severe illnesses, and the rate at which patients reach this goal varies. For some, it can take years to fully normalize eating.
Here are some examples of meal plans and eating guidelines:
Marcia Herrin has a “Rules of Three” meal plan that serves as a very useful guide and assumes 3 meals, 3 snacks and no more than 3 hours in between eating episodes. She provides a meal plan template that includes food components for each meal and snack. Meals generally include a calcium containing food, protein food, fruit or vegetable, complex carbohydrate food and a fat source. In her template fat and protein can be options at breakfast and a “fun food” is included at lunch and dinner which can be a dessert or food such as chips. (1)
Lori Lieberman provides excellent advice about the need for variety in one’s diet and inclusion of all types of foods in her eating for recovery cookbook, Food To Eat: Guided, Hopeful & Trusted Recipes for Eating Disorder Recovery (2). She talks about “eating enough” and why consumption of large amounts of low energy dense foods can undermine recovery. She and co-author Cate Sangster address the eating disorder voice when it comes to certain foods and how you can overcome that voice with food facts.
There is research showing that as a person recovers from an eating disorder, higher dietary variety and greater dietary density are predictive of better prognosis.
- Food choice and diet variety in weight-restored patients with anorexia nervosa
- Dietary energy density and diet variety as predictors of outcome in anorexia nervosa
The US Dietary Guidelines, also lay out a template for “adequate eating”. A few sections of the Dietary Guidelines are included below. Again they demonstrate that dietary variety, with inclusion of all macronutrients (protein, carbohydrate, fat) is important.
- Increase vegetable and fruit intake. Eat a variety of veggies of different colors, especially orange, red and dark-green. Add some peas and beans to your diet, as well.
- At least half of the grains you eat should be whole grains. Use whole grains in place of refined grains.
- Eat a variety of foods high in protein, including, lean meat, poultry, seafood eggs, legumes, soy products, and unsalted nuts and seeds.
- Increase the amount and variety of seafood consumed by replacing some meat and poultry with seafood.
- Increase dietary fiber, potassium, calcium, and vitamin D in your diet, as these are all nutrients of concern in a typical American diet. You can do this by eating more fruits, vegetables, whole grains, milk and other dairy products.
In addition, the US Dietary Guidelines encourage adequate consumption of calcium containing foods and moderation in use of salt and alcohol.
The eating disorder diagnosis, stage of illness and degree of severity are the first considerations for helping the patient eat normally. If they have anorexia nervosa and need to gain weight the meal plan will be different (higher in calories) than if the person has anorexia nervosa and is at the stage of recovery where weight needs to be maintained. Research supports faster rate of weight gain, and higher energy density and variety in the diet are all predictive of good outcome. The weight maintenance part of treatment in anorexia nervosa is much more difficult than many clinicians realize and is mostly accomplished in the outpatient settings. Once a patient re-gains the weight necessary to maintain physical health, they are not “done with the illness”. In reality they are at the beginning stage of learning to eat normally, be in charge of their food (if an adult) and tolerate the many triggers in their environment. Helping a person maintain weight can be a difficult task and it involves the constant feedback to help decrease fear about certain foods. This feedback may include that the patient’s weight is normal, that the food they are eating is not causing wild fluctuations in weight, and information about specific foods and the effects of those foods on their body.
Those diagnosed with bulimia nervosa or binge eating disorder may have very different food plans than those with anorexia nervosa. Patients with binge eating features may not need to gain weight, and might have physical and psychological issues with certain types of foods. Many patients with binge eating disorder have co-occurring insulin resistance and as such, ought to be steered away from high glycemic index foods and encouraged to eat in a manner that minimizes the effects of insulin resistance. All people diagnosed with an eating disorder, whether they have restricted food intake or have binge eating disorder, need to be evaluated for abnormalities in glucose metabolism and insulin function, as the abnormal eating can alter these metabolic processes. When these processes are altered, the appetite and hunger signals can become abnormal. Regular eating can help reverse this.
As stated above, there will be those patients whose illnesses are very severe, maybe accompanied by OCD tendencies or very high anxiety, and it could take a long time to wean from a meal pan. Some individuals may do best if they retain a meal plan essentially forever. People wean from meal structure or meal plans at varying rates and clinicians should not be in a rush to achieve this goal. Usually it is done gradually, and may entail a “two steps forward, one step back” approach. For adolescents, weaning needs to be developmentally appropriate. A gradual approach might look like: first advising the patient to fix their own snack in a manner different than on their meal plan and, if the meal plan used measured amounts of food, asking the patient to “eyeball” the amounts of food instead of using measuring cups. Keep working to have the patient gradually buy foods, prepare foods, and plate their own foods in a qualitative manner. At each stage, evaluate the patient by watching for weight maintenance, anxiety while around food, during eating, or immediately after eating, and any other relevant clinical indicators. Normal eating will mean something different for each individual, and clinicians should work one on one to tailor meal plans and weaning processes. Incorporating challenges and desensitizing a person to these situations takes time, but having the patient gradually face fears about food should slowly decrease anxiety and thus allow for normal eating. Normalized eating involves flexibility, few if any rules about foods (the exception being those with diagnosed food allergies or intolerances), and incorporates joy and /or social aspects of eating.
Clinicians working with people diagnosed with eating disorders must be aware of their own food rules and biases. They might elect to take the “Food Rules Measure” (3) and talk to other clinicians about whether they bring into their work their own food rules. The field of nutrition is often misinterpreted by the media in terms of what to eat, when to eat, what to avoid, and how bodies need to look. Many patients need help replacing these ideas with more realistic ones.
Work toward eating in a qualitative vs. quantitative manner. For example do not count calories. Start living one day at a time and one meal at a time.
Sometimes it helps to think of food as medicine. You may not want to take it, but it is necessary for you to eat it, in order to recover. You can also think of food as fuel. Your body needs that fuel in order to be able to function properly.
Remember that the voice in your head is lying to you. If it tells you not to eat, go against it and eat. By doing this, you will be able to start taking back the control the eating disorder has. Many people believe that if they don’t eat, they are the ones in control. The reality is, if you do not allow yourself to eat, the eating disorder is the one controlling you.
In the beginning practice “mechanical eating.” This means to eat your meals at predetermined times, whether you are hungry or not. The physiological mechanisms that signal hunger and fullness may not be functioning properly. In time, these signals will return, allowing you to know when you are hungry and when you are full.
Remind yourself constantly that NO food will make you fat, as long as it is eaten in moderation. Your treatment team will work to help you maintain a healthy state of health and a healthy weight.
Stop buying “diet” foods. Buy foods that you would like to eat, do not buy them because they are low in calories.
Normal eating does take time and it should be done slowly so that you do not become too overwhelmed. It does take a lot of hard work in the beginning, but in time it will become a normal part of your day.
About the Author:
This article was written by Therese Waterhous, president of Williamette Nutrition Source. She specializes in providing medical nutrition therapy for people with eating disorders. You can reach her through her Company Website or Twitter.
(1) Herrin M and Larkin M. Nutrition Counseling in the Treatment of Eating Disorders. 2013. 2nd edition. Routledge, New York and London
(2) Lieberman L and Sangster C. Food to Eat: Guided, Hopeful and Trusted Recipes for Eating Disorder Recovery. 2012.
(3) Brown, JA, Parman KM, Rudat DA, Craighead LW. (2012) Disordered Eating, Perfectionism and Food Rules. Eating Behaviors. 13,347-353
Schebendach JE, Mayer LE, Devlin MJ, Attia E, Contento IR, Wolf RL, Walsh BT. Dietary energy density and diet variety as predictors of outcome in anorexia nervosa. Am J Clin Nutr. 2008;87:810-816.
Mayer L, Roberto C, Glasofer D, Etu S, Gallagher D, Wang J, Heymsfield S, Pierson R, Attia E, Devlin M, Walsh BT. Does percent body fat predict outcome in anorexia nervosa. Am J Psychiatry. 2007;164: 970-972.
O’Toole J. Determining ideal body weight. Kartini Clinic for Disordered Eating Web site. http://www.kartiniclinic.com/ blog/determining-ideal-body-weight/. Posted July 22, 2008. Accessed October 10, 2010.
Written – 2015