Healthy eating

One of the most difficult things for recovering anorexics is to establish a healthy eating regime. Teenage boys need more calories per day to maintain a healthy growth pattern than an adult male who works in an office. For most people the term 'healthy eating' conjures up images of grilled meat and fish with piles of salad, vegetables and fruit. Teenage boys and indeed girls need more than that to meet their dietary needs. Lots of carbohydrate, even in the form of junk food, is a necessary part of a teenager's diet, as well as a reasonable amount of sweets and puddings. This chapter provides some practical tips on how to:

• help an anorexic teenage boy put weight on

• ensure that a 'recovered' anorexic doesn't slide back down the slippery slope, simply because he or his carer has failed to recognise how much an active teenage boy needs to eat to maintain a healthy growth pattern

• ensure through this process that a healthy balanced diet is consumed.

At school children are taught at an early age about the different food groups and that a balanced diet must contain:

• proteins for growth and tissue repair

carbohydrates for energy

• fats to store energy and provide warmth

• vitamins for good health

• minerals for good health

• fibre to prevent constipation

• water to keep the body hydrated.

They learn why they need these different food groups, which foods provide good sources of these groups and the importance of eating a balanced diet which provides everything that is required for healthy growth, repair of damaged cells and enough energy for the body's activities.

Anorexics very quickly forget everything they have learnt about healthy eating. Many become preoccupied with the calorific values of everything they eat and they quickly learn which foods to avoid in order to achieve the maximum weight loss. Others are less scientific. They simply eliminate certain foods from their diet, which they fear will make them fat. The end result is the same. A very restrictive diet which lacks many of the vitamins and minerals needed to maintain good health and one which includes plenty of fruit and vegetables, a reasonable amount of protein, but very little in the way of carbohydrates and fat.

The problems for anorexics returning to healthy eating are huge and shouldn't be underestimated. Consider the following issues facing an active anorexic teenage boy:

• He must completely rethink his approach to food and overcome his enormous fear that certain food types will make him fat.

• In order to return to a more normal weight he must eat even more than his peers do and almost certainly more than anyone else in the rest of the family must.

• Undoubtedly his stomach will have shrunk and to start with, eating more food will make him feel extremely uncomfortable. He may even experience quite severe stomach pains at the beginning.

• Once he has achieved a reasonable weight he must learn how much to eat to maintain a healthy growth pattern.

• In doing this he must learn to balance his food intake with his physical activity and many anorexic teenagers are very active.

When Joe first came home to visit from the in-patient unit, he was still on his re-feeding programme. I was given very clear guidance for his meals and I soon learned how to boost the calorie count of a meal by adding butter or cream. He had to eat a lot of very rich food to ensure he consumed enough calories to gain weight. When he reached his target weight I was amazed how much food he had to continue to eat to maintain a reasonable growth pattern. Both Joe and I were nervous to start with but we muddled through and managed to find the right diet for Joe. When he was discharged from the in-patient unit he had reached his target weight, but was then told his target had been moved up by 2 kg because he was three months older than when the first target was set and he had grown taller. We faced the challenge of making sure he continued to gain weight or he would have to go back to the unit. Eating at home is never as easy as eating in a specialist unit where the staff are trained to deal with all types of eating disorder. In the unit Joe had no choice. At home he felt he could argue and negotiate when it came to food. I had to be very firm, but also let him start to take some responsibility for his eating. If he resisted one type of food I backed off for a while and made up for it by introducing a different food. Over time Joe stopped being fearful of dairy products like cheese and cream and he now eats a very well-balanced diet and lots of it.

As I have already explained, Joe was an in-patient in a specialist unit while going through his re-feeding programme and his diet was carefully worked out by a dietician. Of course it is possible to introduce a re-feeding programme or diet plan in the home, but it is an enormous challenge and it is worth considering the following issues:

• You cannot force a child to eat. You must work with him, give him lots of support and encouragement and he must want to get better.

• Sometimes it helps to have the endorsement of someone outside the immediate family that the child respects. This might your GP a favourite teacher or even someone in the wider family such as a sporty uncle.

• The earlier you start the better. A child who has only been restricting his food for a short period of time will find it much easier to reverse these habits than one who cannot remember a time when he didn't have a fear of many food types. Similarly a child who has only lost 10% of his body weight will find it much easier to regain that weight than a child who has lost 25% of his body weight and has become irrational through a long period of malnourishment.

• The basic aim is to increase the sufferer's daily calorie intake so that he starts to gain weight. At the same time it is important to make sure that his diet is well-balanced. As long as the carer has a good knowledge of the calorific value of food and a good idea of what constitutes a balanced diet, then it should be possible to put together a perfectly good diet plan both for weight gain and for maintenance of healthy growth once a reasonable weight has been achieved.

• If you are fortunate enough to have access to a dietician, perhaps through your local health centre, then it makes sense to seek his/her advice in putting together a diet plan.

• Sometimes it is impossible to persuade an anorexic to adopt a diet plan at home. If you try and fail you will be joining many other families who have gone through the same experience. Joe was very ill by the time his anorexia was diagnosed and we needed professional help to get him back on his feet. Never be afraid or embarrassed to go to your GP and ask for specialist help.

Once Joe was back on his feet and back home I needed to make sure that he maintained a healthy and balanced diet that would ensure he continued to grow. I found the food pyramid a useful way of ensuring that Joe's diet included a good balance of all the food groups. It was also a useful way of explaining to Joe why he had to eat certain types of food he wasn't too keen on. The food pyramid is an outline of what to eat each day based on US government dietary guidelines. It was developed by the US Department of Agriculture (USDA) and has been widely adopted by organisations interested in food and nutrition. The concept is simple. You eat more of the foods at the bottom of the pyramid and less of each category as you move up. The USDA also provides guidance on the appropriate size of each serving. The advice from the USDA is to eat at least the lowest number of recommended servings from the five major food groups listed below. You need them for the vitamins, minerals, carbohydrates and protein they provide. The USDA website can be found at www.nal.usda.gov

The Food Guide Pyramid

Fats & Sweets Use small amounts

Milk, Yogurt & Cheese Group 3 Servings (4 for teens)

Meat, Poultry, Fish, Dry Beans, Eggs & Nuts Group 2-3 Servings

Vegetable Group 3-5 Servings

The Food Guide Pyramid

Fats & Sweets Use small amounts

Milk, Yogurt & Cheese Group 3 Servings (4 for teens)

Meat, Poultry, Fish, Dry Beans, Eggs & Nuts Group 2-3 Servings

Fruit Group 2-4 Servings

Vegetable Group 3-5 Servings

Bread, Cereal, Rice & Pasta Group 6-11 Servings

Source: U.S. Department of Agriculture and the U.S. Department of Health and Human Services

Fruit Group 2-4 Servings

Bread, Cereal, Rice & Pasta Group 6-11 Servings

Source: U.S. Department of Agriculture and the U.S. Department of Health and Human Services

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