There is a common misconception out there that Kartini patients are fed on a strict meal plan for the rest of their lives. But what exactly is our meal plan? And while we talking about it, what’s our approach to meals and food in general?
there’s the “parents in charge” (of all meals) thing
there’s the recording on the food journal thing
there’s the whole-milk-no-low-fat thing
there’s the hyper-palatable food thing
there’s the push to 100% weight restoration thing
If you are interested in more details, the links above are to specific blogs focused on individual aspects of our treatment. But for now, let’s take a brief look at these features of the meal plan one-by-one, as patients transition off the meal plan and back to whatever else works for them and their families.
Parents in charge: anorexia nervosa is a brain disorder; one with high morbidity and mortality that quite simply must be brought under control in order for a child or young person to grow and develop normally. At Kartini Clinic we put the parents in charge of food until a child is old enough to begin planning for college — and I do not mean at age 13. Parents are in charge of cooking family meals for our patients until about age 17 when the patient, if doing well, can shift focus to learning independent living skills. As I and others have written about extensively, this is a cultural shift for many modern parents who are often interested in divesting themselves of cooking for the family or sitting down to family meals as soon as they can.
It is a mistake, in our experience, to shift responsibility for their own food to a child or young person if they are not in good remission: both physical and psychological. Parents need to stay in charge until this important transition can be safely effected. And we strongly advise not below age 17, barring very unusual circumstances. After all, it is a privilege to cook for and eat with our families! We should all enjoy it while we can. Too soon our children will be grown and gone and you will be staring at an empty place.
A food journal: our parents record on their child’s food journal (since, after all, they are in charge of meals) for about a year, assuming treatment is successful. Somewhere after the first year of treatment is successfully completed we discuss ceasing to record intake. Why would we continue? For that matter, why do it in the first place? Well, the food journal is a bit like a check register. If you do not record the checks you write or are written (electronically or physically) you will not be able to figure out why your check bounced. In other words, the food journal will give us the data we need to analyze what might have gone wrong (or right) and what, if anything, we should do about it. It should help take the argument out of “I did too eat all of it!”, “No you didn’t…”, etc.
Family dinners: you’d think there would be no controversy about this. Even if it is honored more in the breach, pretty much everyone knows that family dinners are good for children, both nutritionally, psychologically and socially. They are good for families. They are good for combating obesity and poor intake. They let us (force us) to talk to each other and our children. Kartini Clinic patients are never released from the expectation of family meals. That doesn’t go away.
Whole milk dairy products: once children have been returned to good health, and are a year out from diagnosis, parents are free to return to eating their customary dairy products, if they insist. However, we do not advise things like a return to “low fat” products. We are aware of recommendations by the American Academy of Pediatrics (and others), but we have too often seen this behavior be the beginning of a return to eating disordered preoccupations, contributing ultimately to full-blown relapse. So why risk it? If you are eating on our meal plan, you have less than 30% of your calories from fat anyway. There is no medical need to go lower. If you are worried about your heart, try using nuts, fish and olive oil as your sources. If you eat the same number of calories but restrict the amount coming from fat, something will make up the difference, and chances are that something will be sugars.
I don’t rule the world, but if I did, low fat dairy items would be in the garbage bin along with the artificial sweeteners and diet drinks, labeled “hazardous waste”.
Hyper-palatable food thing: this is a biggie. The restriction on hyper-palatable food during the first year of treatment for kids with anorexia nervosa, bulimia nervosa and binge eating disorder is a sticking point for many people. They just don’t understand it. But as far as we are concerned, it’s based on scientifically valid concerns for developing or rekindling bingeing as well as concerns for compensatory behaviors. Please do click on this link as the subject is complex and beyond the scope of this summary. The link speaks for itself in regard to bingeing, although compensatory behaviors are even more common. These are where a hyper-palatable food is eaten and the patient feels so guilty (and no, not because of our meal plan — that is a drop in the ocean of their eating disorder guilt about ‘fattening foods’) that they engage in compensatory behaviors to make up for it. Such behaviors would be an increase in exercise to “work it off”, attempts to decrease intake in subsequent meals or simple “melt-downs” and food refusal.
When a patient is doing well, about a year after diagnosis (time chosen based on Key’s evidence), the restrictions on hyper-palatable foods are removed.
I’ve often asked myself why some consider a refusal to eat Oreo cookies somehow “giving into eating disordered behaviors” or “not eating normally”, but a refusal to eat, say, GMO products is somehow admirable? Nothing is really lost by avoiding these foods, provided the rest of the meal plan is delivering adequate nutrition including enough calories from dietary fat.
Artificial sweeteners: our recommendations for avoiding artificial sweeteners and eating lots of vegetables, especially fresh vegetables are recommendations for life. As for fresh vegetables, see this.
100% weight restoration: why settle for less? Children need to grow, and even those teens and young adults whose linear growth may be over still have bone and brain growth. Don’t shortchange them.
So in summary, some things on the Kartini Meal Plan are in fact phased out, for example the interdiction on hyper-palatable foods, keeping a food journal, and — eventually — parents in charge of all meals. On the other hand, some things I believe are solid recommendations for life: good weight restoration, real foods, lots of vegetables, adequate fat, eaten together in a spirit of joy.