Families often ask whether they should proceed with a previously scheduled trip or take a well-deserved “break” during the refeeding process. We advise that travel during Phase 1 of FBT be avoided if at all possible. We know several families who have vacationed with a child well along in treatment for anorexia and found their child lost 5 to 10 pounds over the course of a week, erasing months of progress. Children and young adults with anorexia have difficulty with change; if a child is having difficulty completing meals in the home, it is unlikely that they will be able to do so on vacation, where most meals will be eaten in an unfamiliar setting in the presence of non-family members.
During vacation, parents may be tempted to give in more easily to the anorexic thinking and behaviors because they do not want to upset other diners in a restaurant or because they “don’t want to ruin” the vacation after they’ve invested a lot of money in getting there. The food may be different than that available at home, or it may be difficult to get the types of foods on which the family has been relying. Children and young adults with anorexia are inflexible; if the food is different than that to which they are accustomed, they may refuse to eat at all. Sightseeing often involves a lot of walking, which can burn a lot more calories and require even greater caloric intake to offset. Many vacations occur in warm climates, where health problems related to malnourishment or dehydration may be magnified. If families do travel during Phase 1 or Phase 2, they should be cautioned that it may cause a setback and prolong the recovery process.
If due to family emergency or some other reason travel cannot be avoided, then parents and caregivers need to have confidence they can feed the way they have been feeding: similar foods, meals timed in the same manner, supervision of the child for the duration of each meal, not allowing for any slip-ups such as skipping a snack. There must be a plan in place for contacting the treatment team, if needed. Follow our instructions below for preparing for travel and feeding during travel, but proceed with great caution.
Many parents ask about dangling out the promise of a trip as a reward for weight gain. This is not recommended, because weight gain is hard to predict and does not necessarily occur in a linear fashion. For this reason, it is better to tie consequences to behaviors (100% meal completion) versus outcome (pounds gained). It is also unfair to set up a child in recovery to be responsible for the loss of a vacation perhaps at the expense of other children. It is better to postpone the trip entirely until the child is healthier.
Travel may be attempted late in Phase 2 or preferably not until Phase 3.
Signs that your child with anorexia is ready for travel:
- Eats most meals and snacks willingly
- Eats a wide variety of foods and does not get upset when there are changes or new foods are presented.
- Can handle eating at restaurants and in public and ”fast food”
- Has handled a shorter overnight trip away successfully
- Comfortable eating in front of others
- Comfortable having others comment to them about how “well they are doing” and has discussed their reaction to this situation with their therapist.
- Not bothered by seeing others eat, or seeing what foods others choose in social situations (being around a lot of people choosing foods with which they are uncomfortable can be a trigger)
- Parents feel empowered to step back in if there is a regression during travel
How to prepare for travel:
- Set expectations appropriately – expect that even a dormant eating disorder may reemerge in an unfamiliar setting
- The family and treatment team should discuss ahead of time what could happen, when it could happen, and the appropriate response. Consider writing a contract about expected behaviors and consequences if behaviors cannot be maintained
- Discuss in advance about how to ask others treat an anorexic child, and be aware that you will have to coach well-meaning friends and relatives in how to talk with the child. This can feel very awkward and even cause friction with relatives, so if the family is not confident they can handle this they should reconsider whether the risk of the trip is justified
- Talk with the child: how do they feel about travel, being in front of other friends or family, going to restaurants? Discuss the child’s concerns with the treatment team. This is a great opportunity to expose other fears, faulty thinking, and worries – and to create plans to combat them.
- Talk to others who will be part of the trip to make sure they understand the plan and can help in handling a difficult situation.
- Before embarking on a long trip, observe how the child copes with a practice mini-vacation (an overnight to a nearby destination, allowing an easy retreat to home if things are not going well)
- Research the cuisine and get menus ahead of time –the treatment team can help adapt the current meal plan to the cuisine at the destination, if this seems necessary
- Before the trip begins, have the child practice eating the type of the cuisine that will be available at the destination
- If travel will involve long car trips, plan out the rest stops and meal locations beforehand. Pack a cooler with the family’s regular foods for the trip
- Plan airplane and airport meals ahead of time and pack extra snacks in case of delays (remember that liquids are not normally allowed through security)
- If dealing with time changes, discuss with the treatment team how to arrange for this. It is recommended to maintain consistency in the intervals between meals and snacks despite any changes in time zone
- Set consequences for uneaten meals: finishing food back in the room with a parent, restriction of activities until all food is eaten, and so on. The family should discuss a plan with the treatment team and feel confident that they will be able to follow through on the plan. They must not be intimidated by the eating disorder, even if it means making a scene in front of others.
- Buffets may be especially overwhelming to a child with anorexia – parents should consider either eating at restaurants with a menu option or making their child’s plate if a buffet is unavoidable.
How to feed on vacation
- Maintain as consistently as possible the feeding routine established at home. Keep a regular structure of meals and snacks. This is the number one priority
- Provide the same supervision for meals as at home
- Follow through on any consequences that have been established, even if it means “ruining the vacation”
Try to remember that putting your child’s recovery first and putting off all nonessential travel until your child is weigh restored will go a long way to improving their chances for a full and faster recovery. Once they are well, you will be able to better enjoy your vacations. Much further on in recovery, travel can be a great opportunity to expose him/her to new foods and increased flexibility.
Therese S. Waterhous PhD/LD is owner of Willamette Nutrition Source, LLC in Corvallis OR where she does medical nutrition therapy primarily with people diagnosed with eating disorders. Her doctoral work was in nutrition biochemistry and during her graduate work she completed a fellowship in pediatric nutrition, working with children with special health care needs. During that fellowship she had formal training in interdisciplinary team treatment of chronic illness. She has training in family based treatment of eating disorders and is often asked to coach families in refeeding, to coordinate outpatient teams or to educate other health professionals about eating disorders. She recently co-authored the first practice paper for the academy of nutrition and dietetics on nutrition intervention in eating disorders.