It’s almost the first day of school and parents of students with eating disorders have additional concerns to address on top of the usual back to school frenzy. Transitions can be tough for all teens—they are especially difficult for those with eating disorders. However, there are some preparations you can make to help things go more smoothly.
If you have been supervising most meals your teen has been eating over the summer, the shift to a school day brings a significant change in schedule. A considerable portion of your teen’s day will be spent at school. You may need to increase the size of the breakfast your teen will consume before a long day away from home. Practice the breakfasts you will plan to prepare during the school year. Also be mindful that there may be less time for breakfast when you have to get your teen out the door—to ease the transition, have them practice eating within a reasonable time.
During the school day, your teen will typically need lunch and at least one snack. Now is the time to consider how you will handle these meals and snacks. If your teen is early in recovery it may be important to for them to remain under the full supervision of parents for all meals and snacks. If this is the case, you should speak to the school staff now and make arrangements. Most schools will allow a parent to come and have the teen come out and eat lunch in the car and then go back in. Other parents make arrangements for a staff person at the school (favorite teacher, school nurse) to supervise lunch. You may need to do the same thing with a morning snack. You may even consider only sending your teen for part of the school day until meals are going more smoothly.
If your teen is able to eat a meal and or snack on their own, don’t assume that doing so at school will be easy. Any change in location or schedule can increase the challenge for a teen with an eating disorder. I always suggest letting your teen know that if they can’t finish what you’ve packed, they should pack it up and bring the remainder home. It is important for you to know what they couldn’t finish so that you can add food later to make sure they don’t end up with a deficient intake which could lead to relapse. Let them know they won’t be in trouble!
Practice now with the foods you will send to school for lunch. If your teen is accustomed to hot lunches at home, have them practice eating the very foods you will pack in a school lunch to make sure they are comfortable eating those foods. I always suggest packing foods that are easiest for your teen to eat while being adequate nutritionally; save the fear foods for the meals they will be eating at home with you.
If your teen will be eating without supervision, discuss with whom they will eat. Do they have friends they feel most comfortable with? Even better if they have a friend who knows about their eating disorder and they can talk to ahead of time about making plans to eat lunch together. Encourage them to eat with friends who are good eaters.
If your teen will need to have restrictions from physical education, get a note from your treatment team and deliver it to their school.
Finally, I suggest watching closely during times of transition. This means weighing your teen regularly to guard against a significant weight change. Sometimes you can hit a bump and catching a problem early can go a long way in preventing a serious decline.
Have you been tracking your food via a calorie-counting app?
Maybe you’ve been tracking your exercise through a wearable or other system. Did you know such tracking:
May encourage a disordered relationship with food and your body?
May actually be jeopardizing your health rather than helping you to monitor it?
If you’ve noticed that you’re becoming obsessive about what you eat or how you move your body, it might be a good idea to examine your relationship with any tracking devices you are using.
People may track their weights, food consumed, and workouts in the name of health. But for many people, tracking such data can actually be detrimental. Preliminary research shows that the use of MyFitnessPal can contribute to eating disorder symptoms in undergraduates (Simpson & Mazzeo, 2017), adults with eating disorders (Levinson et al., 2017) and men (Linardon and Messer, 2019).
The research is not clear about exactly why these devices can be so detrimental. In my experience working with patients with eating disorders who track, tracking cuts people off from their bodies and their own regulatory systems. People who track become reliant on objective measures and data for making decisions about how much to eat and how hard to exercise. They lose awareness of their own bodies’ signals. Perfectionistic traits may drive them to eat fewer calories, take more steps, and increase their distance or pace during a workout. Even those who don’t struggle with a diagnosable eating disorder can be negatively impacted by these tracking devices and apps, with individuals who previously had a perfectly normal relationship with food suddenly feeling completely consumed with thoughts about what they’re putting into their mouths.
This was brought home to me when working with a patient who was obsessively tracking his workout metrics. As we discussed doing a bike ride without his fitness monitor–just as an experiment to see how it felt—he argued passionately with me, with one telling objection being, “How will I know when to take a drink?” He had been timing his consumption of water according to time and distance.
I asked him the same question back: “How will you know when to take a drink?” Hearing it from a third party, he realized how strange the question sounded and how disconnected he had become from his own body.
Similarly, patients who count calories and carefully dole out lunches of specific caloric allotments become frightened when faced with a lunch of unknown (and likely higher) caloric value. Knowing that restaurant portions are larger and more calorically dense then the meals they make at home, they ask me how they can possibly avoid overeating. And then they are amazed when they find that they are sometimes satisfied with less than the entire portion of the restaurant meal, precisely because it’s more calorically dense and satiating.
Once they are no longer eating according to self-imposed strictures, eating becomes a different experience. They gain the capacity to tune in to how they feel while eating the food, rather than just eating to completion of their allotment–and they find that their bodies tell them when to stop eating. Life without tracking can become a freeing and enjoyable experience in which you can be fully present during meals and exercise and engage with the people around you and your surroundings—having deep conversations without intrusive thoughts and becoming mesmerized by beautiful surroundings when you exercise outdoors, for example.
Our bodies are wonderful, self-regulating mechanisms. Our bodies tell us when we need to urinate or have a drink of water or when it’s time to eat and when it’s time to stop eating. When we succumb to diet or wellness culture and stop trusting our bodies and start relying on external systems to tell us when to drink or how much to eat, we become disconnected from our bodies and we lose the ability to recognize these signals.
How to Stop Tracking
If you find that you are obsessively tracking your food or workouts, I invite you to try the following experiment:
Fitness tracking: do one workout without your monitor. During and after your workout, rather than looking at your metrics to evaluate the workout, ask yourself instead how your body feels/felt during the movement and afterward.
Food tracking: eat a meal where you do not know the caloric content. Tune in to how you feel while eating it. How does it taste?
Levinson, C. A., Fewell, L., & Brosof, L. C. (2017). My Fitness Pal calorie tracker usage in the eating disorders. Eating Behaviors, 27, 14-16.
Linardon, J., & Messer, M. (2019). My fitness pal usage in men: Associations with eating disorder symptoms and psychosocial impairment. Eating Behaviors, 33, 13–17.
Simpson, C. C., & Mazzeo, S. E. (2017). Calorie counting and fitness tracking technology: Associations with eating disorder symptomatology. Eating Behaviors, 26, 89-92.
A difficult concept in recovery is knowing when to let go of an activity or even a job that could potentially re-ignite the eating disorder. As a therapist I find myself guiding my clients towards the realization that the sport or career path they had loved so much might be the very thing that holds them back and sets them back up for relapse. It isn’t always an easy decision.
Letting go of something that may have predated the eating disorder can lead to questions as to why it cannot remain in someone’s life in recovery. Many clients in the early stages of eating disorder treatment have to face the fact that they have to stop their sports if they are trying to regain weight or are working on eliminating behaviors that could leave the body physically weak. It is no surprise that once stabilization begins there is an urge to return to previously enjoyed activities. However, returning to these activities could potentially hinder full recovery.
Sports like gymnastics, running, figure skating, wrestling, and dancing are incredibly wonderful. As a figure skater myself, I can attest there is no greater feeling than gliding over the ice. But these same sports, especially at the elite level, can be incredibly demanding on the body. Behaviors required for full recovery can go against what a coach may be preaching to athletes to be in top physical form. What is expected of top athletes could look like disordered eating and poor body mentality from an outside perspective. The eating disorder itself may take what is used to condition a top athlete and manipulate it for its own gain.
It can be difficult to find the balance between a recovered mindset and meeting the demands of a sport or career. With some of my clients in the entertainment industry, there are pressures to look a certain way and fit a mold that their bodies may not be meant to fit. It can be difficult to navigate knowing they need to eat a certain amount of times a day and then have an agent say, “Lose five pounds for this role.”
The hardest decision is when there is a realization that staying in either the sport or career is just too detrimental to your health. It is certainly not easy to walk away from something you’ve put work into. And that can also be said about your recovery. Are you willing to give up a healthy body and mind for a potential chance at a gold medal or lucrative career even if it means killing yourself along the way? I’ve worked with a client who was a dancer who recognized as she was going through treatment that going back into a dance studio would be too triggering. She knew that staring at herself in a mirror and comparing herself to her classmates would lead to restricting her meals. It wasn’t an easy decision to walk away, but she knew there was no way she was in a place to be able to dance without being triggered.
In some circumstances, you may not have to completely quit your previous passion. You might be able to approach the activity differently. You may not be able to return to a sport as an elite athlete, but you could still engage in the activity at a more recreational level. I’ve seen some of my clients shift from being an athlete to being a coach. Actors going from television and movies to doing local theater. Sometimes you can still do what you love but it just needs to be re-configured to fit into your recovery lifestyle. For many, it can be comforting to know they can still act or model or run, but just do it less intensively.
You may also have the option of challenging what a sport or career emphasizes as far as body image and diet pressures. There are many models and actors who are embracing bigger bodies and not letting the pressures to lose weight define them. With this option, there is a risk of rejection along the way as we do still live in a culture that overvalues thinness. With that being said, this may be a safe option primarily for those who feel stable in recovery and are able to actively use coping skills to fight urges. If your recovery has reached a place of advocacy this definitely could be a path to take.
Leaving a passion behind or re-defining how it fits into your life can be a huge change. You may feel sad or mad. That’s okay. Ultimately, the decision you make will be the one that supports you in your recovery. If staying in the activity is going to trigger calorie counting, weekly weigh-ins or criticism for not looking a certain way, is it worth it? If you know where the eating disorder thrives then why play with fire? Ultimately, the decision will be based on what will make you healthy and happy and not allow you to compromise with the eating disorder.
For many of my patients who have firmly joined the anti-diet camp and embraced a Health at Every Size approach® (HAES) to health, dealing with family members entrenched in diet culture can be a minefield that is tough to navigate. Let me say that I get it! I also have friends and family members who remain focused on thinness and weight loss. It’s hard!
I notice that for many of my patients, it feels like HAES opens a huge chasm between their beliefs and the beliefs of their family members. It’s an entirely different world view. In fact, the only parallel situation I have observed is the divide between patients who are liberal in their political beliefs and their conservative family members. There is almost no bridging the gap. They cannot see eye to eye and they feel no political discussion with these family members is safe.
If you feel the HAES paradigm has been personally helpful, you grow eager to share your knowledge with family members. You may want to help release them from their own diet prisons as well as transform them into HAES advocates and supporters for your health.
However, I recommend setting modest expectations. You have probably worked hard at recovery, meeting with a HAES treatment professional, reading, studying, and doing the work. You have spent countless hours on your personal journey breakup with diet culture. This has been a long and involved personal process.
Consider your family member: they have not invested the time or energy in this project that you have. They are probably still wedded to diet culture. They are not likely to be swayed merely by your testimonial that HAES has been helpful for you. After all, they still get diet messages everywhere they turn. They have been absorbing these messages for many years.
People rarely disavow diet culture immediately upon learning about HAES. I know this because I know the process you have been through. Even as a professional immersed in the eating disorder world, my own evolution to a firm HAES stance developed over a period of about 5 years. I see with my patients too that it is a process. Some aren’t ready to let go of diet culture and don’t return after a first session when I convey that I do not support the pursuit of weight loss. For those who stick with treatment, it can take many months to evolve into a HAES adherent.
Your exuberance about HAES may fall on flat ears. Remember this chasm between HAES and diet culture is just as vast as that been liberals and conservatives. So, I recommend taking a page from the people I’ve worked with who have a political divide in their family: set your expectations and Agree to Disagree. Use radical acceptance. Do not focus on proselytizing your family members. This can lead to conflict and disappointment.
You can let family members know that you have given up dieting. Do not expect them to do the same. You can offer them information about HAES by sharing some articles or favorite blogs or podcasts but do not expect they will read them. Be happy if they do, and offer to discuss these ideas if they want to. Be satisfied if they accept the recommendations. Practice empathy for their perspective; they are a victim of diet culture just as you once were.
Focus on setting a healthy boundary. You can ask them not to comment on your body or comment on your eating in your presence. This request is not hard for them to meet. You can also ask that they try to refrain from diet talk in front of you. Over time, you can remind them and train them.
I know from experience. I have been at this with my family and friends for years. I have a close family member who continues to be diet-focused but for the most part, knows they cannot discuss this in front of me. Recently, they told me (several times) about how a friend had lost so much weight and how great it was. I told them I was not interested in hearing about their friend’s weight loss. They told me, “Oh, I forgot who I was talking to.”
One of the cardinal rules of dieting is “Eat only when you’re hungry.” I often find that the fear of eating when not hungry is one of the most difficult bits of dogma to overcome. People with eating disorders and good dieters everywhere have been taught that this is all that stands in the way between us and complete loss of control and utter disaster in our lives. Many don’t even see it as an actual choice or symptom of the eating disorder.
Successful recovery from an eating disorder or disordered eating or chronic dieting requires overcoming and challenging this rule.
Just off the top of my head, I can think of a lot of reasons to eat when not hungry. Here are a few related to disordered eating:
You have overridden your hunger cues for years from cycles of dieting, bingeing and purging. You don’t recognize normal hunger cues or satiety. Your treatment team has told you to eat regularly—three meals and two to three snacks per day. You feel like it is too much food and you’re not hungry. Should you follow their meal plan? Yes! Eating regularly is a crucial step in recovering from any eating disorder and it helps to regulate your hormones and circadian rhythms so you can regain your hunger and satiety cues and become a more intuitive eater.
You are in recovery from a restrictive eating disorder and rarely feel hunger. You are told you need to eat more, but you don’t believe it. Isn’t it better to delay eating until later in the day? Should you really eat breakfast and lunch at the times scheduled by your dietitian? Yes, absolutely! Regular meals are critical to getting all of your body functions to work properly again. One of the reasons you may not be feeling adequate hunger could be delayed gastric emptying, which occurs when someone is undereating and food remains in the stomach far longer than it should. One of the consequences is low appetite. The solution: eat regularly as prescribed, even if you’re not hungry.
I can think of many more situations that apply to all of us, not just those with eating disorders:
You normally eat dinner at 7 pm and your circadian rhythm is conditioned to get hungry then. But your sister has scheduled a family dinner at 5:30 to accommodate her children so they won’t be cranky at the table. Should you eat at 5:30 before you are hungry? Absolutely! Adjusting our schedules allows us to have meaningful social interactions that typically revolve around eating.
You have a meeting that is scheduled from 12 to 3 pm. You’re not hungry at 11 am; breakfast was only at 8:30. You have the option to have a proper lunch at 11:30. Should you? Of course! Be practical—it’s better to eat before your meeting. Then you’ll be properly fueled and will be better able to concentrate during the meeting. Our brains don’t function as well when they’re low on glucose. Planning ahead and adjusting mealtimes accordingly is an important act of self-care.
You are traveling to another country. You arrive at your destination and it’s dinnertime. Your circadian rhythms are all thrown off. You feel like you’ve been eating constantly. Should you eat? Yes! Acclimation to a new time zone is ushered along by institution of regular eating at the times appropriate to the destination. You will adjust faster if you get your body in synch.
You just had a rough breakup. You’re eating meals, but sad. Your friends show up and want to take you out for ice cream to cheer you up. You’re not hungry. Should you go and eat ice cream with your friends? Absolutely! Food is not solely about nutrition – it’s also about bonding and comfort, and you should let the ice cream and your friends soothe your broken heart.
You’re stressed and preparing for a presentation tomorrow. You’ve eaten adequately throughout the day and are not truly hungry. But you know that crunching on some popcorn will soothe your nerves. This is an old behavior that you’ve overused in the past. Contrary to popular belief, emotional eating is not itself a problem. Food is our earliest comfort and humans are designed to find food to be rewarding. If it were not, we would have died out as a species. There is no shame in using food as comfort—what can be problematic is if there are no other tools in your emotional toolkit. If eating is your only coping skill then I encourage you to learn some other strategies for managing negative emotions to give you a broader range of alternatives.
So, not eating when you’re not hungry is a rule that should be confronted. How can you start to challenge this rule and, if you have one, the eating disorder that uses it as an excuse?
You must face it head-on with new behaviors, deliberately defying it. If you have been instructed to follow a meal plan: follow it. If you have been told you are undereating: practice eating one thing per day when you are not hungry. The next time you have something in your schedule that interferes with a normal meal time: eat beforehand. Accept invitations to eat at times to which you are unaccustomed. Eat something spontaneously when it shows up, even if you are not hungry.
By practicing these behaviors, you will become less fearful of eating when not hungry. You will learn that this, too, is a normal part of being a human. You will be more relaxed around food and you will see that nothing horrible happens if you eat when you’re not hungry. You do not have to continue to be a victim of diet culture.
Family-based treatment (FBT) is the leading evidence-based treatment for teens with anorexia nervosa and bulimia nervosa. While in an ideal world, every person with an eating disorder would have access to a full treatment team including a therapist, a dietitian, a medical doctor, and a psychiatrist, FBT calls only for a therapist to guide the parents and a medical doctor to manage medical needs. A dietitian is not required, but I have found that a dietitian who works primarily with the parents can provide valuable guidance. Sometimes there are other treatment providers. If there are multiple providers, it is important that team members are in agreement about treatment philosophy and goals. Otherwise, a nonaligned team can potentially be detrimental.
Overview of FBT (3 phases)
Family-based treatment is a manualized therapy, presented in a “manual” with a series of prescribed goals and techniques to be used during each phase of treatment. It focuses on empowering the parents to play a central role in their child’s recovery, using contingencies to reverse malnutrition, increase weight, and eliminate symptoms including restrictive eating, bingeing, purging, and overexercise. FBT is based on five principles:
Agnostic view of illness—there is no need to find a cause or underlying issue that caused the illness.
Initial symptom focus—the focus is on reversing malnutrition and eliminating other eating disorder behaviors.
Family responsible for refeeding/addressing behaviors—parents are empowered to take charge of all meals—including planning, cooking, serving, and supervision—to ensure they are consumed as well as preventing other behaviors such as bingeing and purging.
Non-authoritarian stance—the therapist is a guide and partner that empowers parents to help their child.
Externalization of illness—the illness is seen as an external force that is threatening the child’s life.
FBT consists of three phases:
Phase 1: Parents are fully in charge of and supervise all meals until behaviors have largely ceased and weight is nearly restored.
Phase 2: Once behaviors are largely eliminated, weight is nearly fully restored, and meals are going smoothly, parents gradually hand back some control of eating to the adolescent in an age-appropriate manner.
Phase 3: Once the adolescent has resumed age-appropriate independence over their own eating, the focus of therapy turns to other adolescent development issues, any remaining comorbid problems, and relapse prevention.
When to Add Other Providers
Many parents are incredulous that family-based treatment is a standalone treatment. It is primarily a behavioral treatment focused initially on a brain rescue and then on eliminating symptoms. Medical providers unfamiliar with FBT and treatment centers that insist on having complete teams may pressure families to add an individual therapist for the patient with the eating disorder to the team. This is not always advisable. Sometimes, in FBT, less is more; the work of the parents can be undermined by an individual therapist who either does not believe in or support FBT. Additionally, research shows that at least in the case of bulimia nervosa, no additional therapy may be needed: issues with depression and self-esteem resolved during FBT treatment.
For families that want to work with a dietician who is familiar with FBT, my colleague, Katie Grubiak, RDN, and I have worked out the following successful protocol. In Phase 1 of FBT, the dietitian is only included when needed and only meets with the parents. This helps to empower the parents and prevents the dietitian from inadvertently colluding with the eating disorder. When a dietitian meets the teen too soon, we have found that the eating disorder tries to ally with the dietitian and the teen spends the time trying to negotiate for preferred “eating disorder foods.” We find it more effective to avoid giving the eating disorder that voice. Parents—who have after all been feeding their child since birth—know what their teen truly likes and can avoid being manipulated by the eating disorder.
The situations in which I have found the dietitian to be necessary include the following:
The adolescent has another issue that necessitates dietary restriction such as celiac disease, diabetes, or a food allergy.
The teen’s eating has been extremely restrictive and the range of foods at the outset is extremely small
There is concern about medical issues such as refeeding syndrome and intake must be more closely measured
There is a history of an eating disorder in a parent and they feel insecure about challenging their child’s eating
The parents are highly anxious and unusually overwhelmed and benefit from greater support and direction from a dietitian.
Towards the end of Phase 2, I find it very valuable to have the dietitian begin meeting individually with the teen. This can be helpful in trying to increase the teen’s responsibility for their own recovery. The dietitian can also bridge the gap between the parents being in charge and the child being in charge by temporarily overseeing the child as the parents relax control. We have found it very beneficial for the dietitian to help the adolescent work on determining portion sizes and exposure to fear foods and eating in different contexts and to have some initial meals without the parent and see how they do.
Resources are limited: families have limited finances and there are not enough eating disorder providers to meet the demand of people with eating disorders. I believe that in most cases we should wait until Phase 2 of FBT before adding additional therapies. In this way, we can see what issues resolve on their own when weight is restored. After a teen has resumed regular eating and has nutrition sufficient to support higher level brain functioning, individual therapy can be added if it is needed. This is the point in therapy at which the adolescent is likely to be more receptive and able to benefit from individual therapy.
Having worked alongside several individual therapists providing individual therapy while I provided FBT, I have some suggestions that can help keep all providers on the same page and maximize benefits to the family. The most common scenarios I have encountered include the following:
Adolescent therapist addressing comorbid anxiety, depression, self-esteem, or interpersonal issues
The biggest problems I have encountered occur when individual therapists focus on coaching the adolescent to individuate and stand up to parents. This is inconsistent with the early stage of FBT, which requires the parents to be empowered to make all food decisions for an adolescent who is incapable of making reasonable decisions about food given their brain starvation. In FBT we don’t encourage independence in eating until the teen shows they can handle it. Similarly problematic are providers who educate the adolescent about his parents being too “enmeshed.”
On the other hand, I have had great experiences with individual therapists who understood that keeping the parents in charge of eating was crucial for the teen’s recovery. Instead, these therapists worked to empower the parents to help the teen eliminate other obsessive behaviors such as compulsive exercise. I have also worked with successful DBT teams that focused on teaching the adolescent skills to manage their distress while not attempting to question or undermine the parents’ authority over food decisions.
Advice for The Individual Therapist
My advice for the individual therapist:
Don’t blame parents for causing ED
Don’t disempower the parents
Don’t question parents being in charge of food
Don’t suggest compromising on food choices
Don’t describe parents as enmeshed—instead, reinforce their instincts in attending to a very ill child
Don’t focus on empowering the adolescent to share frustrations about parents being in charge
Do focus on empowering the adolescent to demonstrate recovery behaviors even if it is for show (“acting as if”)
Help the adolescent to develop coping skills to use when the FBT process is upsetting to them
Respect parents’ choice to stop activities until they eat (delineate consequences before meals)
Help the adolescent fill their life with other things
Remind the adolescent that the parents will be able to give back control as the adolescent demonstrates readiness
Let the adolescent vent about their frustration over parents being in charge
Acknowledge that although there are many things the teen can do on their own that are developmentally appropriate, at the present time eating independently is not one of them
Food for us comes from our relatives, whether they have wings or fins or roots. That is how we consider food. Food has a culture. It has a history. It has a story. It has relationships. –– Winona Laduke
Food is about more than sustenance. It is about pleasure and joy and connection. Food is one of the ways we connect with our cultural traditions and our ancestors. This is one of the reasons I am so passionate about my work to help people with eating disorders. When someone has an eating disorder and they are fearful of eating or of eating certain foods, they miss out on the pleasures of food and they miss out on the opportunities to connect with others through food. They also miss out on their own connection with their relatives and their cultural heritage.
In my own family, my 103-year-old Nana has always been known for her piano playing and her delicious poundcake. While her prized Steinway piano now stands in my home, I did not inherit her piano-playing her abilities. I did, however, learn her poundcake recipe.
From the time I was a young girl, I have memories of “Nana’s poundcake.” Simple to make with only 5 ingredients, buttery and yummy. During visits to Kansas City, I looked forward to making it with her. And when she visited us in New York we would make it together. And, occasionally my mom and I would make it without Nana. My kids have had the experience of making poundcake with my Nana, their great grandmother. And they have made it with me. After she eventually passes, we will retain this connection to my Nana and my kids will hopefully continue to make and share her recipe with future generations.
Photos of my daughters making poundcake with Nana back in 2012 at her apartment (she was 96)
I am glad to have this connection to Nana and to be able to fully enjoy making and eating poundcake with all its rich butter and sugar. What joy and connection I would be missing out on if I were afraid of eating it. To be able to make it and eat it with enjoyment enriches my life and allows me to have a shared experience through four generations of my family. I will always have joyful memories of baking and eating poundcake with the different generations in my family.
Bonus Feature — Nana’s Poundcake Recipe
1/2 pound salted butter (2 sticks) – softened
1 3/4 cup sugar
2 cups sifted flour
2 T vanilla
Cream butter and sugar
Add eggs one at a time while beating constantly
Add flour and flavoring
Pour into well-greased loaf pan (or bundt pan)
Bake at 350° for 90 minutes
Photos from a poundcake I made with my daughter in 2019.
When parents are renourishing a child with an eating disorder and that child gets sick, parents often don’t know what to do. Some families may back off on feeding every time a child gets any illness, which can be a risky practice. Especially during Phase 1 of FBT, ensuring eating is a priority. To help parents, I’ve asked Jennifer Johnson, MD, a medical doctor who specializes in treating patients with eating disorders, to share some advice.
First, let me say that in general, minor illness should not cause a kid with an eating disorder to lose weight. Parents who are refeeding their child know that even missing a meal or a snack makes a difference in their progress. Don’t let illness throw you off course. As you know, failure to gain as expected may occur if nutrition is even a bit compromised. It is absolutely not a given that illness or surgical procedure must cause weight loss. When I hear that someone has lost 3 pounds “because they had a cold” the previous week, I ask a lot of questions – that should not have happened.
Second, plan ahead. After you’ve read through my answers and looked at other parents’ recommendations, be proactive. Make a plan with your child and treatment team about what you will do if they get sick (which they inevitably WILL at some point during recovery). They should know that they WILL still be eating. But talk about what foods they tend to like when they are ill, and think about how to plug maximum nutrition into them. Buy any non-perishable supplies and stock up on over the counter medications for colds, coughs, and fever. (And please have a thermometer on hand! A $10 digital one is plenty good to give us doctors valuable information.)
What should parents do in terms of feeding when a child with an eating disorder has a head cold or sore throat and loses their appetite? Is it necessary to avoid dairy?
If your child is listless and feeling unwell, they will often not be very hungry for a couple of days. A sick child needs care and comfort. Caring for a sick child who has an eating disorder includes keeping up the nutritional intake. You don’t want the eating disorder to think that illness is a good way to sneak through the back door. And, there are other times when your child is not hungry, just from refeeding itself, and they have to eat anyway. So, push ahead, but gently. Present nutrition dense food and beverages that will be particularly appealing to your child. Does a milkshake sound appetizing? You can add a packet of Benecalorie. (There’s nothing wrong with dairy, by the way.) Chicken noodle soup? Maybe add some extra pasta. There are lots of helpful posts from parents on the Around the Dinner Table Parent Forum.
What about if they have a fever?
Having a significant fever (101 or above) increases fluid needs as well as metabolic rate (more calories are burned). Your child will feel better if you control the fever with regular doses of acetaminophen or ibuprofen. Giving the medication at regular intervals, say every 6 hours for acetaminophen, may prevent the fever from getting as high as it otherwise might. This also helps with the headaches that usually accompany fever. Keeping your child hydrated, particularly with something like Gatorade, will also help them feel better – and thus more likely to have some appetite. Some kids maintain their appetite when they have a fever and of course, it’s fine to continue refeeding. Otherwise, know that keeping up nutrition during an illness helps your child feel better sooner, and push on. Again, it’s helpful to adjust what you give them based on their preferences.
What about when kids in recovery have the stomach flu?
What do you do if they’re vomiting?
Generally, vomiting is worst at the onset of an episode of stomach flu and becomes less frequent over the next 24 hours. A parent’s main goal when a kid is vomiting is to keep them hydrated. I recommend not giving anything by mouth for 2 hours after they’ve thrown up. Then you can give them ice chips or a couple of teaspoons of water. This liquid will get absorbed from the mouth. Do this every 5 minutes or so for half an hour. If they haven’t vomited again, you can have them try slightly larger amounts of liquids at less frequent intervals. They should be able to keep down about 2/3 of a cup of liquid, and be hungry, before you try a very small amount of food. Slowly increase the amount you give them. Kids may become ravenous and eat a huge meal, but then throw up everything they’ve just eaten. A kid who throws up a day or two into recuperation may have just overdone it. In that case, you’ll need to let up a bit before pushing back into refeeding.
What about diarrhea?
For kids with diarrhea, we don’t generally recommend giving any medications that are designed to decrease the number of stools (bowel movements). No major food restrictions are needed. There is nothing magical or beneficial about the so-called BRAT diet (bananas, rice, applesauce, toast), which is of low nutritional density. Studies have shown that having diarrhea for a few days does not make someone lactose intolerant. We know that eating when you have a “stomach bug” with diarrhea will generally increase the number of diarrheal stools. But we also know that at the end of the illness, people who have continued to eat will end up better nourished (= digested more calories). And that, of course, is the ultimate goal.
One thought: you may want to speak with your child’s doctor about a proactive prescription for a small number of anti-emetic tablets (that dissolve in the mouth) to have on hand in case your child gets stomach flu. I don’t normally recommend this but refeeding is an exception. We want to minimize the duration of nausea and vomiting to make it easier for your child to eat. Also, many of my patients who have eating disorders are afraid of truly fearful of vomiting (a condition called emetophobia), which only makes stomach flu worse for everyone. If your doctor is willing to do this, they undoubtedly want you to call before you give the medication.
What if your child has no appetite (due to illness)
Biology is on our side. When a kid (or another human being) eats less due to a minor illness, appetite typically returns with a vengeance and we make up for what we’ve missed. For a kid in the early refeeding phase, of course, it is normal to not feel hungry. So you may not know whether your child is not hungry because they’re not feeling well or because they’re refeeding. In either case, your eating disordered child needs you to continue to push forward. Refeeding is the mainstay of treatment and you’re the team leader. Go for it!
Please note that none of the above should be construed as medical advice. If you have concerns about your child’s health, contact their doctor. Some examples of when you should call the doctor are: Bloody diarrhea, high fever (102 or above), vomiting that continues more than 24 hours, weakness, severe dizziness or fainting, or very little urine.
About Jennifer Johnson, M.D., MS, FAAP
Dr. Johnson is a medical doctor. She has more than 20 years’ experience as a pediatrician and adolescent medicine specialist. She practices in Newport Beach (Orange County), California.
Dr. Johnson is certified by the American Board of Pediatrics in Adolescent Medicine as well as in Pediatrics. Dr. Johnson also has an advanced degree in public health. She has been a professor in the Department of Pediatrics at the University of California, Irvine School of Medicine, where she served as director of the adolescent medicine program. Dr. Johnson has taught medical students, residents, faculty, and community physicians, for whom she continues to present educational programs. She has presented at national meetings of many organizations, including the American Academy of Pediatrics and the American Academy of Family Practice. Dr. Johnson has written many research articles and book chapters related to adolescent and young adult medicine.
Dr. Johnson is an advocate for adolescents and young adults. She is a Fellow of the American Academy of Pediatrics (AAP). She has led many activities in the Academy’s Section on Adolescent Health and served as its chairperson. Dr. Johnson is active in the Orange County chapter of the AAP, as well. Current projects include the Teen Safe Driving Initiative and healthcare for GLBTQ teens.
Dr. Johnson has also been active in the Society for Adolescent Medicine. As a member of the medical advisory board for Teengrowth, Dr. Johnson wrote many articles and answers to reader questions. Articles and webcasts by Dr. Johnson are posted at Healthology.com, medbroadcast.com, and the New York Daily News.
Dr. Johnson is on the medical staff of Hoag Hospital in Newport Beach.
Mayo Clinic researchers are conducting a study examining parents’ perspectives on eating disorder recovery. We believe that parents have valuable information about their children that can help us better understand eating disorder recovery and improve treatment outcomes. If you are a parent of a child or a teen with an active or past eating disorder, we would appreciate your input by taking an online survey. If you are interested in participating, please click on this link:
You may share this message and link with anyone else or any group that you think might be interested in participating.
This survey is for parents who:
Have a child or a teen who was diagnosed with an eating disorder before the age of 18
Have access to some data about their child’s heights and weights prior to diagnosis, at diagnosis, and after diagnosis (any measurement system is fine!)
We will be asking you questions about your child’s illness and aspects of recovery, including weights and heights if you have them. If you have growth records, it would be helpful to gather them before taking the online survey. The survey should take about 30 minutes to complete and will be anonymous.
Understanding Carers’ Experience in Treatment for Their Child’s Eating Disorder
You are being asked to participate in a research study to understand carers’ experience in treatment for your child’s eating disorder. This invitation is being posted on blogs, social media groups and sent to listservs for parents of children or adolescents who have had/ currently suffer from an eating disorder. If you agree to participate, you will be asked to spend approximately 30 minutes completing an online survey. We will ask you questions about your experiences during your child’s treatment and your personal definition of “recovery” for your child. The survey is anonymous, so your answers cannot be identified or traced back to you. The risks and burden associated with this research study are minimal. While there is no direct benefit to you if you choose to take this survey, we believe that this research study will provide a better understanding of carers’ perspectives of their children’s treatment and recovery, with the goal of improving treatment and outcome assessment. Please understand that this is a voluntary study and your current and future medical care at Mayo Clinic will not be affected by whether or not you participate. Contact the Mayo Clinic Institutional Review Board (IRB) to speak to someone independent of the research team at 507-266-4000 or toll-free at 866-273-4681 if you have questions about rights of a research participant. Thank you for sharing your time and expertise.
In November of 2018, my boyfriend proposed to me. It was one of the most exciting days of my life thus far. With a proposal comes the next exciting chapter: wedding planning. For many brides-to-be, this entails finding that perfect gown.
Sadly, although not surprising, once I got on bridal mailing lists, I learned I was also being targeted by gyms for “Bridal Boot Camps” and “Sweatin’ for the Wedding.” The weight loss industry found yet another way to weasel their way into a life event that should have nothing to do with changing one’s body.
Why is it that you could be with someone who you love for a certain amount of years, and suddenly the moment they place a ring on your finger you need to change your body? Why does looking beautiful equate to weighing less?
Unfortunately, it has become the norm in our culture to experience pressure to lose weight for special events. A friend once shared that when she was dress shopping her consultant actually wrote down smaller measurements because “all brides lose weight.” When my dress consultant mentioned letting her know if I lose weight, my initial thoughts were, “Are you telling me I need to lose weight? Am I supposed to lose weight? What if I like my body where it is? What if I want to gain weight?”
Granted, our bodies can change. But, hearing about weight loss, exercise programs, and diets specific for the big day can be detrimental to our physical and mental health. The diet industry has found another market and doesn’t care how it impacts the people getting married.. Wedding planning can be stressful enough with trying to create a special day without the added pressure to create a “perfect” body.
But, here is the thing. Your fiance asked to marry you not because of what you’ll look like on that one specific day, but because they are in love with you and everything about you. Getting married is about making a commitment of love to one another. Your wedding day should be a celebration of that.
As brides or grooms, we should dress up and present ourselves the way we want to on this day but, it should not be at the expense of our health and well being. Remember what this day is about. Your wedding is not about the celebration of the size of your body but about the love between you and your significant other and making a commitment to one another.
What to do Instead of “Sweatin it”
Here are some tips I have developed to use myself and also with my clients who were wedding dress shopping:
Buy a dress that fits you now. Don’t buy something a size smaller. Don’t use words like “my goal size” or “I’ll be pretty when I fit into this.” Fighting your body to go to a size it isn’t meant to be is only going to add more frustration, stress, and sadness. If the person selling you a dress keeps harping on “when you’ll lose weight” or “all brides lose weight” speak up and tell her that isn’t your plan. You do not have to be a victim of diet culture. Buy the dress that makes you feel pretty right now. Also, do not forget that many dresses you try on are just sample dresses. It’s okay if it doesn’t fit perfectly when you try the dress on. The one you get will be tailored to your already beautiful body,
With that, remind yourself of the things that not only make you look beautiful but what makes you feel beautiful. One of my bridal consultants asked me when picking out a dress, “Do you want to feel whimsical? Do you want to feel like a princess? Do you want to be sexy vixen?” Wedding dress shopping became ten times more fun when I could close my eyes and imagine what style of dress would make me feel the most beautiful.
Write down what you want to feel on your wedding day. Write down your hopes and excitements for this day. Think about what memories you want to hold onto. While the idea of “looking perfect” in your wedding photos may be a strong drive to engage in diet culture, think about what those photos are truly capturing. Most likely, you’ll want to remember this as a day of celebrating love and new beginnings with your partner.
It’s okay to exercise and it is okay to eat. It’s okay to follow your normal routine, As you plan for your wedding continue to follow your intuitive voice. For many people, weddings take months if not years to plan. Do not remove fun foods out of your diet for the sake of just one day. Listen to your body when it comes to exercise. Exercise because you want to give your body the gift of movement, but know it is okay to take days off too. Exercise should not be a punishment to your body.
You do not need to lose weight for your wedding day. Ultimately, remember what this day means to you and your partner. Your wedding dress should be the accessory to the already amazing you. You know, the person that your partner wants to spend the rest of his or her life with. So, when it comes to “sweatin’ for the wedding,” say, “I don’t.”