Food

These are some of the rituals Joe developed. Some appeared at home when he was cutting down on food. Others appeared when he was on his re-feeding programme at the in-patient unit and he couldn't face eating the entire enormous meal placed in front of him.

• Avoiding certain food types - chocolate, chips, cheese, cream, full fat dairy products.

• Cutting out meals - Joe started by cutting out on his school lunch and snacks.

• Reducing the amount eaten each meal - for two months Joe ate slightly less at each meal at home.

• Cutting out fluids - Joe was slightly unusual in this respect. He found it difficult to swallow anything. It is more common for anorexics to drink lots of diet drinks and/or water to fill themselves up.

• Complaining of stomach pains - as Joe lost more and more weight his stomach pains became more and more severe.

• Encouraging other family members to eat more - Joe was forever giving extra snacks to his younger brother.

• Eating slowly - as Joe found it more and more difficult to eat, it took him longer to eat each tiny meal.

• Playing with food - this is a favourite anorexic trait. Food is chased around the plate, but never quite makes it into the mouth. Joe used to hope we wouldn't notice he hadn't eaten anything.

• Dropping food off the plate onto the table, onto someone else's plate, into the dog or onto the floor. We didn't have any pets, but very often one of us would find we suddenly had extra potatoes or meat on our plates.

• Eating incredibly quickly in order to get the ordeal over as quickly as possible. Once Joe had accepted his re-feeding plan, he started eating so rapidly that he couldn't possibly taste the food.

Other common food habits and rituals include:

• Eating piles of low calorie and/or high fibre food such as fruit, vegetables, salad and low fat yoghurts, but eating little else.

• Reducing the calories of food that is eaten. Anorexics have been known to water down milk, take nuts out of cereal, put a low calorie fruit bar in a Mars bar wrapper.

• Cutting food into tiny pieces and then only eating a few of them.

• Obsessions about the how food is positioned on the plate or how the table is set.

• Wanting to become vegetarian or vegan.

• Drinking lots of water and/or diet drinks to create a feeling of fullness.

• Threatening to be, or actually being, sick after a meal.

• Hiding food in clothes.

• Hiding food in the bedroom.

• Storing food in cheeks and then leaving the table to spit it out.

• Blowing nose at the meal table and spitting food into the tissue.

The bottom line is that anorexics will do anything to minimise their daily calorie intake. A young boy afflicted by anorexia might appear to be consuming 3,000 calories a day when in fact he is only consuming 1,000. The anorexia is constantly telling him not to eat. He will have no problem lying to you about what he has eaten or adopting some of the strategies mentioned above. If you believe your son is eating 3,000 calories a day, yet he is still losing weight, it is likely that he is either vomiting or he is just creating an illusion of eating a healthy diet.

You cannot make your son eat, but as a carer and provider of his daily needs you can adopt some strategies that will encourage him to eat sensibly and discourage him from the rituals and habits mentioned above:

• Try to have meals as a family so that eating becomes a social situation rather than just about food. Of course this is not always possible in today's hectic family lives, but even if families just eat together at the weekends this is preferable than not at all. Try to avoid situations where your anorexic son is able to eat alone.

• Try to make meals a fun time in which members of the family recount stories from their day, talk about the latest film, soap, football match or anything else that is light-hearted and not about food. We also found that playing a game of cards after a meal was a good way of keeping Joe at the table long enough for his meal to settle. Ensure that the rest of the family understand why they shouldn't talk about food at the table and that it is especially important that they don't comment on how much your son has eaten or not eaten. For example, a well-meaning granny can cause a huge amount of upset by commenting on how well or badly your son has done at a meal.

• Avoid confrontation at mealtimes. If you notice that your son is pushing food off his plate, spitting it into tissues or any of the other habits mentioned above, it is best to wait until after the meal. Later, perhaps at bedtime, you can let him know that you have seen what he is doing. Explain (again and again if necessary) why you want him to eat and gain weight. Be very loving and supportive. Tell him that you understand how difficult it is for him to eat a proper meal. Give him lots of praise for the progress he has made so far, but gently let him know that he can do better. It is unlikely that he will be able to give up his rituals straight away, but with lots of support he may gradually be able to let them go one at a time.

• Don't let your anorexic son prepare meals for himself or for the rest of the family. He is likely to overfeed everyone else and underfeed himself. Explain to him that once he has reached a reasonable weight he will be able to take more responsibility for his food intake. If you are preparing his food and he is eating it in front of you then you will have a much clearer idea of how much is actually being consumed.

• If your son gets into the habit of saying he is going to be sick because you have made him eat too much you might consider giving him a bowl at the table. It is unlikely that he will want to use it in front of everyone else. Many anorexics will threaten to be sick, but will never carry out that threat.

• When your son is at school it is impossible for you to see what he is eating. Depending on his age and/or social circle it might be appropriate to ask the teaching staff or one of his friends to keep an eye on his eating habits at school. You might also consider asking the school to provide special meals. For example, some anorexics are happy to eat a jacket potato and beans, but will not eat a roast lunch. In addition if he is on a re-feeding programme he will need to be served up larger portions. In some cases it is useful to tell your son this is happening, in others it might put him off eating at school altogether. We discussed with Joe various options including having special meals, sitting in a separate room with a couple of friends and taking a packed lunch to school. In the end he decided he would rather come home for lunch as he felt this was the most discreet option. Despite the fact that he was already very ill, he couldn't face his peers seeing him have special treatment at lunchtime.

There is a huge element of trial and error when it comes to eating with your anorexic son. What works for one family may not work for another. The most important thing is to try and make your son feel relaxed about mealtimes, avoid confrontation, and give him as much support and encouragement as you can. Don't be disheartened when there are setbacks, take a deep breath and carry on.

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