Further recommendations

The following text should be taken as recommendations based on experience from work with eating disorder patients. They are meant namely for parents and partners. Their application in a household may be accompanied by patients´ indignation, as they limit options to manipulate food in order to reduce its intake. This is why it is advisable to mutually explain individual steps and try finding an agreement.

1. Do not accept following requirements:

* The patient will eat alone and at other times than rest of family;
* The patient will eat only what she has prepared;
* The patient will cook alone – she may prepare a snack as needed, later another meal;
* The patient will not eat as others unless they eat dietary food;
* She will eat only when she is hungry and what she likes;
* She will not eat with some family member. It often happens that a daughter refuses to dine with her father.
* That others must eat the same portions or larger ones;
* That she will not eat after 18 o´clock.

2. Do not talk into meal eating

We will avoid conflicts and scenes namely in children, if we do not comment on the patient´s behaviour during meals. We better leave the comments or criticism after the meal is finished.

3. Food and weight

In no case we shall recommend connecting food with body weight control by weight watching. Regarding the latter, it shall be done max. twice a week before breakfast in underwear. Such results are at least approximately comparable. A more frequent weight watching usually leads to a higher control over food intake.

Overeating and diet

Binge eating (possibly followed by vomiting in bulimia) relates a lot with great fluctuations in eating, fasting and massive reduction of food consumption. Similar to anorexia, the fear of overweight is very important. To estimate whether your body weight is normal, i.e. optimal, you can use orientation BMI (see here for more information).

 Overeating connects also with various physical and mental problems, a number of which may directly threaten your life (see here for more information). It is known that a repeating „roundabout“ of fasting, overeating and vomiting leads to development of depressions, it decreases self-confidence and increases body weight. This naturally boosts the fear of further weight gain and bulimic problems grow significantly. The patient becomes addicted to overeating followed by vomiting as if she were a drug addict.

 Proper food handling may markedly help in breaking the vicious circle in order to facilitate further treatment.

 1. Regular eating

Division of daily food intake into five meals is very advantageous both for the body and for the change of wrong eating habit. It is crucial to comprehend that I will not gain weight if I eat regularly, but I will certainly put on weight in case I reduce food, then overeat and vomit. It is necessary to get rid of eating extremes and to reach balance. If I fast or extremely restrict food choice, I markedly raise the risk of overeating or getting a bulimic attack.

It is not suitable that our yesterday diet affected today´s life – we must start every day from the beginning otherwise we never break through the vicious circle!

 2. Gradual widening of food selection

The menu of mental bulimia patients is often very poor and stereotypical. The aim is to enrich their menu so that is becomes varied and balanced, and there are less restrictions. It is good to list meals or foods that the patient has forbidden herself and that she avoids, and order them by difficulty. Then we choose meals that are suitable for including on the menu again and we start with the easier ones.

It is not necessary to start eating food one has never eaten before. Everybody is entitled to personal taste preferences and to not eating some stuff, but such a thing should be exceptional. On the other hand it is advisable to exclude junk food (like chips or peanuts) and temporarily restrict food that often triggers bulimic attacks.

 3. I know what I eat

Apart from menu composition and regular eating, we can prevent overeating by being aware what and how much we have eaten. It helps a lot to put the food on a plate, sit by a table and do nothing else but eat – we let nothing else to disturb our attention from food.

It is unsuitable to eat directly from a cooking pot as we cannot estimate the portion size. Another bad habit is to eat by TV – we do not concentrate on food and we eat more than we really need.

 4. To reduce food in a fridge

It has proven useful to temporarily change a way of grocery shopping in one´s household, to restrict food stocks to a minimum. This also relates to food planning for a following day.

A full fridge markedly increases the risk of bulimic attack at the time of „weakness“.

Underweight and diet

Underweight along with general malnutrition are among basic symptoms of anorexia nervosa (there is a type of anorexia nervosa without underweight and on the other hand, underweight may be due to another severe disease). Body weight can be estimated by orientation BMI that tells us whether our weight is within norms, i.e. optimal (see more).

Long-term underweight associates with numerous physical and mental consequences, some of which may be directly life-threatening (more here). It has been proven that maintaining body weight under a normal level is markedly affected by distorted body image (disorder of body scheme), thus increasing anxiety of gaining weight and significantly deepening anorectic troubles.

Achieving weight gain is rather difficult for the patients as it brings a host of anxiety, reproaches and feelings of failure. Yet is is necessary! Food is a major medicine against anorexia nervosa.

1. Sufficient daily income It is necessary to repeat that if I want to recover, I must gain weight. In order to do this I must eat more than until now. The orientation value of daily energetic intake during treatment of anorexia nervosa is ca 3500 kCal. This means eating 6 times per day – main courses, snacks, second supper. It is also necessary to reduce active movement (sports, exercise) to a minimum. Then it is possible to achieve the weight gain of 0,5-1 kg per week. A concrete example of diet can be found here. The increase of food intake can be gradual but it should not last longer than a week. Feelings of fullness, loss of appetite, anxiety before eating and reproaches afterwards are rather normal at the start and they must be overcome. An expert and family or partner support may help significantly. Precise calory counting is harmful, it usually raises anxiety and need of control over food intake. Consuming low-fat and low-energy products is unsuitable as they only fill up the stomach but do not provide sufficient energetic and nutritional value. Exercise after meals to push off remorses is absolutely inapt. It brings about a bad habit and thus it slows down and prolongs the time necessary to achieve optimal weight.

2. Regular eating Based on our experience, we know that before eating becomes a part and parcel of everyday life, it is helpful to draw a time plan when I will eat breakfast, snack, lunch etc. It may help relieving anxiety before eating as the unpleasant decision-making whether to eat know or later (and skip the meal completely) is gone. It may also markedly help in communication with others (family, partner) on food and their support. A daily plan needs to respect such a plan, on the other hand we have to be realistic when making it and consider work or school rhythms, home habits etc. The patients who have already planned their timing and diet, should not be forced to eat anything more. They have enough trouble to cope with this and we would ask them more than they can manage at this time.

3. Gradual widening of food selection The diet of anorectic patients is often very poor and stereotypical. The aim is to enrich their diet so that is becomes varied and balanced. It is helpful to list meals or foods that the patient has forbidden herself and that she avoids, and order them by difficulty. Then we choose meals that are suitable for including on the diet again and we start with the easier ones. It is not necessary to start eating food one has never eaten before. Everybody is entitled to personal taste preferences and to not eating some stuff, but such a thing should be exceptional.

4. Meat on the diet? Meat provides the body with many important nutrients, some of which cannot be gained otherwise in adequate quality. Moreover, it is energetically rich. So we recommend its inclusion on the diet, but it needs not be everyday (at least five times a week). It is suitable to alternate kinds of meat (fish, poultry, beef, pork, venison) and their preparation. If the person with anorexia nervosa doesn´t eat meat (refuses on various grounds), we shall find out when she stopped eating it. If it was at the outbreak of disease, we can perceive this decision rather as a manner of reducing food intake and an effort to control body weight. If there is a vegetarian tradition in the patient´s family or the decision was made long before the outbreak of anorexia, we shall respect it. Leaving meat off the diet means increasing portions of main meals (lunch, dinner) so that the meal is sufficiently substantial.

Size of portions

To know how big a portion should be in order to satisfy hunger and yet not to overeat is often a major issue for eating disorder patients.

The old proverb that „fear has big eyes“ often applies in anorexia nervosa – the patient sees portions on a plate larger than they really are and she thus tends to serve herself less or not to finish. In bulimia, the problem with estimating portions is similar but tendencies are rather contrary – if I eat more, it is wrong, unpleasant feeling will appear and a bulimic binge may develop.

Correct food handling may markedly help in reducing anxiety from mistakes, it may stop the falling body weight or reduce risk of overeating.

1. Portions are estimated, not calculated Eating disorder patients (and not just them :-)) frequently aim to control energy intake by caloric values, some even know caloric tables by heart. However, a normal and practical way in long term is to know how a portion can be estimated, not calculated or weighed. Calory counting increases a pseudocontrol over food intake, anxiety feelings during eating, and it definitely affects the choice of food in an unhealthy manner.

2. How to estimate portions The size of portions depends on the fact whether we are underweight and we need to gain weight or we don´t. Portions listed are for an adult with a common daily activity. The daily food intake is divided into 5 – 6 meals.

Patients with anorexia or bulimia have difficulty estimating their portions as well as withstanding unpleasant feeling related to serving themselves such portions and really eating them. If there is a mutual agreement, a family member or partner may help serving in the beginning.

Basic recommendations

In general, there are many popular prejudices and misconceptions concerning a „correct“ nutrition. Healthy nutrition has nothing in common with monotonous diet, forbidden food or counting calories.

People with eating disorders have linked food with fear, control over their look and body weight. Constant concerns about food increase anxiety and tendency toward extreme eating behaviour. This brings about various reduction diets, fasting, binge eating.

1. Our diet should be varied and balanced
Only this way we can provide all necessary nutrients to our body. Some foods like vegetables, fruit, cereals and dairy products are needed every day, others like meat (of all kinds) are also important for healthy nutrition, although not every day. Our selection should not be among allowed and forbidden foods. The matter is that we eat something less and something more.
Unbalanced and stereotypical diet may not provide all inevitable nutrients to our body. Thus it increases our bad feelings about food. The increased control often results in anorectic reduction of body weight or development and sustenance of binge eating and possible vomiting in bulimia.

2. We should eat regularly
It is a big mistake to think that if I eat regularly (optimum is five times per day), I will always gain weight. The truth is that this way I let my body manage the consumed food well and if I eat adequately to my age and daily activity, I will feel well and my weight will not be affected. (Now I am not referring to diet for underweight people with anorexia nervosa, there the selection of portions and their sizing matters enormously.)
Skipping meals of the day (breakfast, lunch and dinner) affects my metabolism adversely. Even though I may not always be aware of hunger feeling, my body suffers and both physical and mental ailments emerge – increased fatigue, irritability. Also the risk of overeating gets higher.