Normal eating and Normalising Eating
Treatment from an eating disorder can sometimes seem strange – we encourage people
to eat the foods that make them highly anxious. We have guidelines as rigid as the
eating disorder that people are expected to abide by! There is a reason why we do these
things and it often helps when entering treatment or supporting someone in treatment if
you know why!
The first thing I am interested in discussing is what is normal eating??
It sounds like such a simple concept! But Normal is very subjective; each person’s
individual social or cultural group has a different set of standard that are considered
normal!
Normal Eating
The best definition of normal eating I have come across is (CEED):
Eating in a relaxed and flexible manner in response to the bodies’ normal cues
of hunger and satiety.
I interpret this as meaning eating without guilt and connecting with the body. Not
following rules or other external stimuli! Sounds quite different to an eating disorder and
its rules doesn’t it!
Normal eating is being able to eat when you’re hungry and continue eating until you are
satisfied. It is being able to choose food you like, and eat it and truly get enough of it,
and not just stop eating because you think you should.
Normal eating is being able to use some moderate constraint in your food selection to
get the right variety or balance of foods, but not being so restrictive that you miss out
on pleasurable foods.
Normal eating is giving yourself permission to eat something because you’re happy, sad
or bored, or just because it feels good. Normal eating is three meals a day, or can be
choosing to munch along. It’s leaving some cookies on the plate because you know you
can have some again tomorrow, or it’s eating more now because they taste so wonderful
when they’re fresh.
Normal eating is overeating at times, feeling stuffed and uncomfortable. It is also under
eating at times, and wishing you had more. Normal eating is trusting your body to make
up for your lapses in eating. Normal eating takes up some of your time and attention,
but it keeps its place as only one important area of your life. (From CCI)
In short, normal eating is flexible. It varies in response to your emotions, your
schedule, your hunger, and your proximity to food.
Normalising Eating
Normalising eating is the process of systematically challenging eating disorder thoughts,
rules, and behaviors’ to improve the variety of acceptable foods and confidence in
including them in a regular diet. It is continually challenging the eating disorder rules to
see that including a food does not lead to excessive weight gain or other fears based in
the eating disorder.
Normalising eating may involve a meal plan (set by a dietitian), guidelines (such as full
cream, or butter on bread) and challenges (eating out, eating take away) to help get to
a place where you can be more flexible and spontaneous with food choices.
It is not that we consider having butter in bread normal for everyone or a necessity for
everyone; but practicing it again and again until you get to a place where it doesn’t
cause anxiety anymore will help once you are recovered. You may go to someone’s
house or a café that uses butter and you will still be able to enjoy the foods.
The Eating Disorder Spectrum
Normal
eating
Disordered
eating
Subclinical
eating
disorder
Diagnosed
eating
disorder
Eating in the Recovery Spectrum
Wellness
Close to Full recovery
Physically safe/normal weight
for the individual
Able to manage Eating disorder
thoughts and urges
Declined incidence of ED thoughts
And urges. Internal cues of when to eat.
Eating in response to the
body’s internal cues of hunger
and satiety
Unwell with an ED
Eating disorder strong and
overwhelming. Feeling unable to
overcome the thoughts or urges to
engage in eating disorder behaviours.
Low weight, malnutrition and possible
medical risk. External Cues to eat.
Following a meal plan with
specific guide on when to
eat, types of foods, portion,
and sometimes even how to
eat. External cues to eat.
Cant I just put on the weight?
It can be hard sometimes to learn that in recovering from an eating disorder there is an
expectation that you will put on weight AND eat scary foods. Often people believe that
they can recover and gain weight to a safe weight by including only the foods that are
safe to them only.
The risk of this is that you may be a safe or normal weight but still be plagued by eating
disorder rules, thoughts, urges and behaviors’. This will mean that people may be off
your back about regaining weight but that your anxiety remains high and your ability
to fully engage with life will be compromised. You would not be challenged the eating
disorder rules that stop you from eating out, choosing off a menu or eating foods that
others have prepared. This may leave you feel just as anxious, overwhelmed and
isolated that you did pre treatment.
Use of meal plans in treating eating disorders
Why do we support people to eat ‘take away’ or ‘junk food’ or why do the meal plans
have set quantities and ‘full fat’?
“That is not normal!” we hear many people say.
Are we trying to cause heart disease, diabetes and obesity?
The answer to the above is obviously ‘no’. The biggest compromise to the health of a
person in treatment for eating disorders is most clearly the eating disorder and the
physical and psychological complication of starvation in almost all situations.
The aim is to help clients improve their relationship with food and their body so
that they can learn to trust them again. Often, but certainly not always, the foods that
are excluded by eating disorder rules are the ‘sometimes’ foods that people refer to as
junk foods. Eating them or not eating them is entirely irrelevant when you can choose
whether to or not to eat them. Generally people with an eating disorder need to re
learn how to eat them and include them in their diet before choosing not to eat them
moderately or not at all.
It is likely that an eating disorder has being governing the clients food choices for some
time and accepting the management of the dietician and treatment team may be
challenging.
Individual meal plans are set for each person taking into consideration each
individuals’ current weight, healthy weight goals, metabolism, medical conditions, and
wherever possible moral or religious preferences and perhaps most significantly
nutritional needs.
The meal plans generally involve 3 meals and 3 snacks each day; Six meal times are set
throughout the day to:
1. Meet metabolic needs. While people are restoring weight they often need
more food to meet their energy requirements.
2. Allow the volume of food to be spread throughout the day. Snacks/ midmeals are an important way of getting all the nutrients the body needs
throughout the day.
3. Relearn hunger cues. Eating regularly throughout the day helps us to
relearn hunger and satiety cues, so we can learn to trust our own bodies
again.
4. Ensure that food is consumed regular during the day to prevent extended
periods without eating leading to being very hungry – or needing to eat a lot
leading to feeling very full – both of which are common triggers for
binging. Learning to include a wide range of foods; including trigger foods is
one of the other important tools in managing binge urges.
It is important clients follow their individual meal plan closely. This will help restore
physical health but also help in retraining thinking about what is normal;
o
o
o
Meals
Meal times
Portions
If you have questions about yours or your loved ones meal plan feel free to talk to our
dietician about them.
Having set meal times and quantities provides the client with guidance on how to eat
normally and when followed provides the opportunity to relearn hunger and satiety
cues, and ensures all nutrition needs are met.
Why full fat foods
Although starting with ‘F’ fat is not a four lettered word. Fat is an essential part of the
diet each day and is essential for the body to function.
Choosing low fat products might be important for someone who is at risk of heart
disease and has an excess in their diet. A person with an eating disorder is likely to
have fat deficiency!
Low fat products and omitting fats from cooking can feed in to the dieting
mentality of restricting and compel further restriction. Often people report that
when they restrict – choose a low fat product- it is very difficult to return to the
full fat products because it allows an ‘in’ for the eating disorder thinking. This
can often have a ‘snowball’ effect- “I restricted yesterday so I couldn’t possible
have more today”.
Having full fat products is a normal part of everyday life and helps you to feel
comfortable with all foods in all situations. There will be times where you are in a
situation where there are only full fat options. It is important to be able to
confidently and comfortably choose these options to alleviate future restriction
or bingeing and purging activity and to help alleviate anxiety.
Food as Medication
The difficult thing about making steps towards recovery is that the person in treatment
needs to face their eating disorder fear by doing the behavior that immediately confronts
their fears.
Eating disorders are often understood that the control over food intake and body shape
helps people to cope; similar to an alcoholic or drug addict. The tough thing is though if
drugs and alcohol is what is being used to cope we would take these away and work on
abstinence as part of treatment. You cannot abstain from food – it is essential to life!
So treatment means facing your greatest fear, (as one client once described to me –
being ask to jump off a cliff) 5-6 times per day. (It’s hard to believe it but your
treatment team is at the bottom of the cliff with a very soft mattress ready to catch
you).
So though it is a struggle each and every time you have to eat – food is the best
medication you can have for your eating disorder! It will help to physically restore your
health, reverse the physical and psychological symptoms of an eating disorder and
challenge, disprove and eventually overcome the rules and beliefs of the eating disorder.
A ‘Food is Medication Food’ approach supports the equal rights of all foods and
opposes the vilification of foods based on class. Food is food, the wider the range of
food that you eat from the better your diet is likely to be. Try and think in terms of
‘sometimes’ food and ‘often’ foods.
In a ‘Food is Medication’ approach there is no other explanation. This sounds
frustratingly simple and I’m afraid it is! If it is not an eating disorder behavior then you
could eat it. If you can eat it then the challenge is on – demonstrate your freedom to
eat by eating. If it is an eating disorder behavior it becomes a focus for treatment.
“Everyone needs to have nutrition each day”, even though they are probably a bit
scared of some foods at the moment, or even feel that they don’t deserve to eat, eating
is necessary to both physical restoration and it is also important in the psychological
aspects of recovery from an eating disorder; to enable optimum brain function and in
challenging the eating disorder.
When we say that food is your medication it is like applying the same conditions to food
that you would to a drug prescribed to treat a serious medical condition.
Food is your medication and as such eating does not depend on;
1. Liking the food (sad but true, medicine doesn’t always taste nice!)
2. Feeling like it (after all, when would you ever; and you don’t rely on ‘feeling like
it’ to take prescription medication – hopefully)
3. How full you feel (eating disorders confuse satiety signals and the feelings that
you rely on to indicate fullness become unreliable to you)
4. What other people are doing (being on a ‘normalizing’ regime and so it is not
reasonable to make those types of comparisons and you don’t take medication
that those around you take…or insist that they take yours!)
5. Intolerances and allergies (a favorite and safe haven for eating disorder thoughts,
as with medication; gentle and graded exposure generally builds tolerance. An
exception are those conditions, such as ceoliac disease that is confirmed by
genetic testing and so is not challenged )
Those comparisons may seem a little stretched but the ‘Food as Medication’ approach
places as much emphasis on food for the treatment of eating disorders as any person
with a severe illness would on regular medication.
It is a straightforward approach that goes wherever an eating disorder goes. Sometimes
it requires that you eat everything except the pattern on your plate. On other occasions
it requires you to leave food on your plate. This sounds contradictory but it isn’t. The
approach is not just about nutrition it is also about challenging food rules wherever they
exist.
Food Challenges
Eating disorders often develop from a simple, innocent rule created about food – that
someone follows (ie not having chocolate) and this in turn helps them to feel in control.
The more they avoid the fear food the more it generates more anxiety about the idea of
having it – so they avoid it more – making the food seems even scarier.
And then another food gets added to the ‘bad’ list and so the lists of avoided food grow
and the list of acceptable foods shrinks! The rules may develop around other aspects
of eating as well; including where you eat, how, with who, who prepared the food etc!
No one cares if someone eats takeaway – what people care about is than an eating
disorder has taken away your freedom to make that choice. The controlling and
restricting influence of the eating disorder then moves on to other foods until what you
can eat is extremely limited.
Part of recovery and normalizing an eating disorder is challenging these rules to see
that there is not a catastrophic outcome (as the eating disorder is probably telling you
there is) and in fact the more you practice breaking the rule – the weaker the rule
becomes until you forget about it.
Treatment often involves identifying fear foods and challenging situation and then
setting challenges about how, when and how we will break these rules – and how you
can support yourself with the anxiety created or the eating disorders backlash that
comes afterwards. Sometimes your treatment team may ask you to challenge foods or
behaviors’ that you don’t believe are helpful in recovery or for the rest of your life – like
eating McDonalds or having full cream milk. It doesn’t matter if you do choose to
continue to include certain foods in your diet post treatment– it only matters that you
can eat them. That you rather than your eating disorder can make that choice; And that
when you are in social situations you can be flexible and spontaneous allowing you to
fully engage in and enjoy life.
Moving off a meal plan
There will come a time in treatment when it is appropriate to move off the meal plan
and start to practice listening to and trusting the body more. This is an important step
– as staying on a meal plan for the rest of your life would be disordered and limiting
also!
Don’t worry – this won’t be a sudden shift – but something that the journey of treatment
is preparing you for in all the activities that you do. Being able to let go of a meal plan
comes at a time when you are able to acknowledge the eating disorder thoughts or
urges that you are having – but not act on them. Your eating disorder may be
suggesting ordering a skinny coffee- but you are able to order a full cream one with little
to no anxiety or compensation behavior latter. It will come at a time when you are able
to be mindful and connect with your body. This will enable you to be able to determine
what physical hunger feels like and to be able to act on it – also to be able to determine
what you feel like to eat. This will take practice of course! When some one is moving off
a meal plan they need to be able to be honest with themselves and their treatment
team about what is coming from their true self and what is eating disordered.
This is often a slow process where someone may start eating their snacks to appetite but
follow their meal plan at meals – or it may happen naturally where they start to eat
more flexibly when they are hungry, stop when they are full and be able to eat flexibly
during the day.
Working with a meal plan
The natural urge of an eating disorder can be to work against a meal plan! Also family
and friends around you are not experts in treating eating disorder so may not
understand the importance of following a meal plan or may make triggering or unhelpful
comments.
It is important to remember that some level of food rules or disordered eating in our
society is accepted as normal. In recovery we are trying to move you as close to normal
eating as possible (see diagram above) and this may mean being more flexible then
others around you. This can be important to remaining in recovery as for at least a
period of time you will be vulnerable to lapses and relapse and the more normal you can
be the less vulnerable you will be.
It is important to try and support yourself in recovery as much as possible. This
may include things such as …..
Have the foods on your meal plan available.
Plan ahead. When are you going to eat, what and with whom? What constructive
things can you do to ensure this happens?
Actively seek support; let people know you will be calling them after a meal or
making sure someone is home to eat with you.
Plan coping strategies in advance for times when anxiety will be triggered.
Remember to focus on you longer term goals and motivations for recovery. Have
them written down some where accessible to read over when you need to.
Remember that others who understand are there to support you – this may be a
co – client, therapist or even attending session run by recovered people. (Or
reading some of the positive recovery literature that is available).
Remember to acknowledge the small achievements along the way – it can be
easy to dismiss something as unimportant that is actually a very positive step in
recovery.
Remember to have small realistic goals along the way – you need to learn to walk
before you can run!
When others are supporting you in recover it is important to remember …..
Don’t assume others will know what to do –give them some guidance about what is and
is not helpful in terms of comments and actions. And if you are not sure what is helpful
then be honest with them and let them know that it is a learning process for both of you!