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Tuesday 10 January 2012

A very good place to start

When you read, you begin with ABC.

Where do you begin when your child has just been diagnosed with an eating disorder?  Well, if you are anything like me, you begin from a place of total ignorance, prejudice and despair.  Unhelpfully, the majority of Tier 1 clinicians in this country (GPs, Practice Nurses and the like) are also starting from this place.  I learnt that eating disorders are covered at medical school in an afternoon.  An afternoon, you say, to learn about the most lethal psychiatric disorder?  Surely not?

Personally, I blame Freud.

"Ever since a long time ago (1892), Freud was much more interested in describing closely the symptoms of Anorexia in every detail, attempting to describe it more precisely with each case but not with the purpose of realizing a medical profile identification. He preferred to establish the psychical mechanism that the symptoms were exhibiting.

Freud established the "cannibal" or "oral" as the first sexual organization. The nutritional pulsion remained there supported.
As a general knowledge, he enunciated that neurosis sometimes appears in pubescent girls. This fact reveals that these girls are not sexually "authorized" and thus present anorexia as a consequence.
Freud associated nutritional neurosis (nervous anorexia) with Melancholy in presence of an under-developed sexuality:
Freud settled anorexia as a hysterical mechanism."
This kind of nonsense has permeated our understanding and treatment of eating disorders for over 100 years. This means that the majority of our GP's (and other non-ed specialist doctors) believe at an almost subconcious level, that eating disorders are self-induced, attention seeking behaviour from young girls who weren't breastfed, are in love with their fathers and have deep distress because they were born without a penis.  I think Sam Thomas might have something to say about this.
Hence, when one presents with an eating disorder, it is hardly surprising that the GP's tend to view the sufferer with great sympathy and tell the concerned parent to "try and get her to eat a sandwich".
A sandwich is not going to cut it.  Sorry.  This paper gives you some idea of what nutritional requirements are needed to help someone recover from anorexia and a sandwich is nowhere near going to make a difference.
"Oral feeding requirements
The estimated average energy requirement in the UK for healthy girls aged 11–
18 years ranges from 1845 kcal to 2110 kcal (7750–8860 kJ) per day; for boys of the
same age the range is 2220 kcal to 2755 kcal (9325–11 570 kJ) per day (Department
of Health, 1991). As with adults, children and adolescents with anorexia require
hypercaloric diets in order to gain weight, especially when approaching a
minimum healthy level. Most authorities suggest that teenage girls who are
anorexic require an energy intake in excess of 3000 kcal (12 600 kJ) daily to
achieve full weight restoration, whereas the American Psychiatric Association
(Anonymous, 2000) recommends 70–100 kcal/kg (295–420 kJ/kg) per day. Energy
needs are obviously greater in young, growing adolescents and it often becomes
difficult for those with anorexia to ingest enough energy to gain weight.
Increased energy needs continue into the maintenance period. Kaye et al (1986)
have shown that people with anorexia require an extra 200–400 kcal (840–1680 kJ)
a day for up to 6 months after reaching maintenance weight. Weltzin et al (1991)
reported that recovering patients required 45–50 kcal/kg (190–210 kJ/kg) per
day to maintain 95% average weight for height, compared with 30 kcal/kg (125
kJ/kg) per day in a healthy control group. The American Psychiatric Association
(Anonymous, 2000) suggests using 40–60 kcal/kg (170–250 kJ/kg) per day during
the weight maintenance period. It has also been demonstrated that people with
restricting anorexia require significantly more energy than those with the binge/
purging subtype (Kaye et al, 1986; Weltzin et al, 1991)"
It would have to be an almighty sandwich.
If it were me and I had my time again, I would use this menu, adding 200 calories per day until my d was gaining 1lb per week, minimum.  For us that required 3,500 calories a day, on average, for a whole year.  We didn't stick exactly to the menu after 10 days (and the risk of Refeeding syndrome had passed).  We branched out into a variety of other calorie dense food.
For further help and information, I would suggest here and here


  1. That really is a massive sandwich. Also makes me want to go out and buy some bacon.

    Caloric guidelines are a nightmare. Pretty much any anorexic and many professionals prefer to stick to the lowest supposedly healthy number, when that is often nowhere near sufficient. If I listened to my remnant ED thoughts I would be quite drastically undereating on the 2000/day recommended by the government (let alone the 1600 or so that 30kcal/kg would put me at). Two YEARS post weight restoration I still need around 2500 to maintain, although I don't count as a rule (I occasionally tally during the events to see if I'm on the right track if I'm feeling particularly hungry or weird, and it can be anywhere between 2200-3000). I don't actually lose weight very quickly, if at all, on 2000ish, my metabolism seems to slow down to compensate - but those dreaded ED thoughts get a lot louder, I find it much harder to concentrate, my hormones get all wonky, I become irritable and anxious and so on. The amount I eat still gets remarked on sometimes at college, and I take great wicked pleasure in saying "what a thing to say to a recovering anorexic" before falling off my chair at their expression of horror. I am evil sometimes...

  2. Falling off my chair laughing, that should've been. Was too busy giggling to type properly.

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