Most of you will have heard me say that weight restoration is the cornerstone of treatment in childhood anorexia nervosa, without which you get nothing. It makes sense, you say? And yet we still get children referred to us who have been in hospital or residential centers and were discharged well below a restored weight—or even discharged weighing less than when they entered! How can that be? We gnash our teeth.

In my opinion it is a reflection of the general reluctance to accept that medical, not psychological interventions, must come first. A child must be weight-restored before medication, social support, psychotherapy, cognitive restructuring, etc. can have a fighting chance of working. This reluctance to acknowledge the physiological takes many forms, depending on the stage of treatment for the child.

Currently, in the Pacific Northwest, we find ourselves finally able to convince insurers, other physicians, and families that weight restoration is so important that they can accept whatever means we use to get there: nasogastric feeds, supplements, no-choice oral feeds, etc., as long as the patient is in the hospital. It’s when the patient enters day treatment and subsequent outpatient care that wishful thinking enters the picture in a big way. She looks so much better, why can’t we let her eat normally now?

“Eat normally” usually means “eat whatever she wants”, and parents are thrilled to see an appetite that includes ice cream, cookies, frappuccinos and the like. Yet Ancel Keyes, in his seminal study of starvation in humans, warned us what would happen when ad lib (“as you like”) re-feeding is offered a person recovering from starvation of any cause: they gain too much weight.

At Kartini Clinic we have a Food Plan. It’s base calories are 2150/day; three meals and one afternoon snack– not many small meals, as I do not want the patients to be spending the entire day either thinking about what to eat or engaged in eating—how eating disordered is that? All dinners are family dinners, parents do the grocery shopping and the meal preparation. Why? Because they are the grown-ups. Kids need to busy themselves with doing well in school, building lasting friendships, exploring their environment, helping with family chores and finding out what their interests are. They do not need to pay the mortgage or feed the family. The food on our Food Plan is pretty much what Michael Pollan so succinctly called “real food, not too much, mostly vegetables.” It uses only full fat options, no diet/lo-cal etc. Total percentage of fat is a bit under 30%, depending on choices. It can be made to look like a regular American diet with peanut butter and jelly sandwiches, cereal for breakfast and steak for dinner, if that’s what you like. Or it can be Chinese stir-fry (though it’s a bit low on fat for many Chinese recipes) or Italian pasta, or Russian or German or absolutely gourmet, but it cannot be fast food. When I said real food, I meant real food, made from real ingredients, made at home and eaten in the company of people we love.

There are no desserts or sweets on our Food Plan for the first year, not because there is anything wrong with desserts or sweets, but because these hyper-palatable foods encourage—even prompt—overeating during the early phases of re-feeding.

When a child is in the hospital being weight-restored, their food plan is the floor beneath which they cannot fall; in the outpatient setting it is the ceiling above which they cannot rise. Our patients would not trust us if we restored their weight and let them keep going up and up. It wouldn’t be fair or healthy, yet with ad lib feeds, it is common.

For patients who struggle with bingeing or purging, ordered eating (eating enough fat and calories to achieve satiety at predictable times, starting early in the day) will help prevent binge eating, craving and consequent purging.

Many college students who have left our program for independent living tell me that “the Food Plan” has been their salvation. They fought against having to follow it when they were younger, but they lean on it now.

When problems arise with our food plan they rarely come from the patients themselves, but rather from their parents. American parents resist having to sit down and have family meals, shoving work schedules and sports schedules (the sacred cows of American life) before them as an excuse. Many cannot stand to have the full adult responsibility for feeding their families, whether or not they work, and constantly ask when their teen children can cook for themselves (or for everyone else). We have to break the hard news to them: they are the grown-ups and feeding a family is a grown-ups’ job.

Following a food plan brings order and predictability to the life of a child with anorexia nervosa. These children are almost always compliant and grateful. Many manage their anxiety by eating the same thing every day. This is fine. Compared to starving, it is a home run and should be seen as such. Parents, once their child is out of immediate danger, may begin to engage in wishful thinking, believing their child should now be “normal about food”. Their child may one day be “normal” or they may never be “normal”, but we do not focus on “normal eating” as a goal for at least the first year after re-feeding has begun. Rather, we relax into ordered eating and allow the child to achieve normal physical growth and social development as our first year’s goal. Dessert comes later.

Stick to the Food Plan. parents. The kids will too, and it’s worth it.