12 Reasons to Use a Meal Plan in Recovery from Anorexia
Recovery from anorexia is simple (if not easy): Part I (Why a plan?)
Posted Sep 30, 2017
Once the decision to start recovery from anorexia has been made, it’s easy to reject the idea of eating according to plan in favour of an immediate leap to eating in some idyll of unfettered spontaneity. I think this is a mistake. Here’s why.
1. One of the reasons for aspiring to the model of unplanned or intuitive eating is, I think, a mistaken idea of what life without anorexia is like. Living happily and healthily with food is not, on the whole, a blissful hippy dream of plucking the ripe fig from the overhanging branch at the precise moment when the swell of appetite sings sweetly enough. It’s having a routine, going shopping in advance so there’ll be stuff to cook when you get home tired. It’s eating at mealtimes because that’s what other people do. It’s adjusting to circumstance rather than treating oneself as the ultimate arbiter of everything. Yes, it’s also deviating from the routine when it’s sensible or pleasurable to do so – changing your plans at the last minute because something comes up, or eating something totally weird at a totally weird time just because you feel like it. Possibility – for fun, for silliness, for romance – is a wonderful thing. But acting on it is the beautiful exception, and the norm is roughly predictable. More prosaic, perhaps, but much more attainable. So, don’t fall for the hippy idyll.
2. OK, you say, but I never thought the rest of my life was going to be like that. Don’t you still have to cast off the anorexic habits decisively in order to be able to get back to that middle ground? Why expect recovery to look the same as post-recovery?
Indeed, recovery is not like life after recovery. But I think recovery is more likely to be successful if it’s more solidly supported by routine than ordinary life is, not less so. Think about what your starting point is: probably rigid routines tightly encompassed by fear. What happens if you try to fling every routine to the four winds immediately? Most likely, panic. On the other hand, what happens if you decide to add a specific amount to what you’re already eating? Fear, perhaps; distaste; reluctance. But a sense that this is achievable. That you know what needs doing and you think you just might be able to do it. This was the only thing, I think, which made me embark on my final recovery effort when I did: the fact that someone told me ‘add 500 kcal a day to what you’re eating now, and you’ll gain half a kilo a week’. I could understand that, hold on to it, decide for or against it. Eating limitlessly, or in limitless trust of an appetite so long mistrusted, is not an easy thing to sign up for. So, don’t underestimate the value of a concrete thing to say yes to.
3. On the theme of recovery not being the same as life after it: I think one of the easiest errors to make is to expect (knowing the illogic, but giving in to it anyway) that you should be at the end as soon as you begin. Of course you can’t be. You need to start from where you are and keep going until you get to somewhere different. This means that if your eating is fairly rule-bound and rigid, you start with that, and turn it to your advantage. I think for most people with anorexia, the idea of turning one’s iron will on its head to insist on immovably eating more, not less, is likely to be distinctly less terrifying than the idea of eating with no guidance beyond ‘as much as possible’. So, embrace the control that lets you eat how much you decide to; now it can be your ally not your enemy.
4. But how, you ask, is anything going to change if I’m still just relying on the same old messed-up attitudes, just turning them in the other direction? Again, this is to discount the thing you know perfectly well, at least in theory: the whole point of eating more is not that it just makes your body bigger, it’s that it changes everything. It nourishes your brain, along with all other tissues; it is the medicine to take you from illness to health. That is, once you’ve been eating for a certain length of time, your mind will be working differently. What twisting the anorexic style of control to the positive allows you to do is the most important thing you need to do: eat. Eating will itself undermine that control from the inside. So your victory over it is most complete not by falling for the mistaken violence of premature rejection, but by acknowledging that the way to destroy it is by making it defect to its greatest enemy: self-nourishment. So, remember the point of all this: that eating will change your mind and your life, so you need to do it however you can.
5. It’s the same point, put differently, but it bears repeating: eating is your first priority. And this is not a sprint; it’s a long, long walk through vastly changing terrain. Whatever allows you to eat consistently and adequately, month after month, is what you need to be doing. Terrifying yourself by eating vast amounts for a week and retreating with relief back into restriction is not a good outcome. Trying this is likely to give you the impression of a false equation between not-eating and control versus eating and loss of control. In fact, eating more is exerting the greatest possible control, and eating to plan is what allows you to appreciate the reality of this. So, don’t forget that controlled eating is what you’re good at, and eating is what you need to keep doing above all else.
6. One thing that makes the planned approach so much less daunting than the unplanned is the sheer weight of decision-making it sidesteps. Spiralling quantities of choice are a large part of the misery (if sometimes also the joy) of the modern condition, and reducing the number of decisions that need to be made in life is more important the more over-stretched your mental capacities already are. Making one global decision that will carry you through weeks at a time is simply the cognitively efficient option. So, choose not to make every minute into the site of yet another potential decision about whether, what, how much. Choose the easy option.
7. Easy probably means possible; difficult quite likely means impossible. The senses in which you’re not ready for uncontrolled eating are all-encompassing, psychologically and physically. Everything in your body as well as your mind has adapted – or attempted to adapt – to the prolonged strain of eating too little over months or years. For all this time you’ve refused to act on your body’s signals that you need more food, so expecting them to bounce back instantly, reliably, from the moment you start to eat more again is like expecting a long-abused animal to be instantly trusting and trustworthy. It won’t be. Everything about your eating habits needs retraining, from appetite (via the secretion of hormones in preparation for predictable eating, for example) to digestion (in everything from stomach expansion to increases in metabolic rate). This retraining requires eating to happen reliably enough for long enough for your body to stop preparing for the famine that as far as it’s concerned might at any moment be imminent, and start relaxing into knowing food will be forthcoming. Hunger simply cannot be relied upon in the first months of weight restoration. Extreme hunger (hyperphagia) is for most people the baseline, the foundation of the physiological drive to get you the energy you need to heal (Dulloo et al., 1997). On top of that you have many layers of physical and psychological complication: from the inefficiencies in your digestive system which make you feel full too quickly, to the coagulated motivations that have slowly stifled the pragmatics of every eating habit you’ve ever had, and can so easily turn ravenous hunger to feverish nausea with no more justification than the five minutes you didn’t think you’d need to wait. So, remember with humility that eating with flexibility is a skill that needs to be relearned, and a privilege to be re-earned.
8. Relatedly, it’s mistaken to think that in the weight-restoration phase of recovery, you can and should eat until you’re full. If your objection to eating with a plan is that you owe it to your body to eat until the hunger goes away – bear in mind that your hunger is unlikely to go away, really go away, for many months. The fullness that is only a shallow overlay to endless hunger is for many people, I think, as for me, a reality that ends only when weight restoration (the full extent of that restoration, not some arbitrary numerically demarcated subset of it) comes to an end. That is, the endless hunger ends when this phase your recovery does. Until then, eating until your hunger is sated is not possible: you can feel full, yes, but while still oddly wanting more, feeling emptiness too. Of course, this doesn’t mean don’t listen to your hunger at all. You should, more and more as the process proceeds. But not to the extent that you kid yourself that hunger alone can be your guide.
Trying to dictate your daily routines on the whims of what anorexia has reduced your appetite to is to condemn yourself to an exhausting ritual of endlessly repeating self-questioning: What does my appetite tell me to do? Does it really? What if it’s all in my mind? What if I’m just comfort eating? But that doesn’t matter, aren’t I meant to be eating as much as I can anyway? But how much is as much as I can? Do I just need to keep eating constantly forever…? The last thing someone so depleted by illness should be having to do is constantly second-guess their own hunger. Related to what I said in point 6, inflicting this amount more decision-making on yourself at such a fragile time as this is a recipe for meltdown. Decide roughly when and what and how much to eat in advance; then do it. One decision, efficiently acted on for however many times that part of your routine holds. Not a constant flood of them through an embodied brain without the wherewithal to process them. Hunger is not yet a reliable signal. One day it will be. Not treating it as one now is how you bring that day closer. So, set your long-term course by the light of the pale waxing and waning moon that is hunger, but don’t scorn those pretty, strategically placed solar-powered fairy lights to illuminate your path at ground level.
9. A not insignificant emotional drawback of attempting to eat according to appetite from the outset is that you can never be wholly successful. With a plan, once you’ve eaten what you planned to, you can stop, give yourself a pat on the head, and know you’ve done what you needed to for today. Eat according to appetite, by contrast, and there’s a danger that however much you eat, however far you push yourself beyond the boundaries of what was once possible, you’ll never be satisfied with what you’ve achieved, even perhaps feel a failure for not having crammed in that hypothetically possible last chocolate button, because there are no concrete criteria for what counts as success. Worse than that, success is by definition impossible. Until you come to the kind of sticky end the heroes of La grande bouffe do, you have not eaten as much as you could. To mix my cinematic references, there could always have been just one wafer-thin mint more. The opportunities for feeling good about yourself are few and far enough between as it is, in anorexia and in recovery from it. Seize them where you can, and be suspicious of strategies that rob you of yet more. So, choose what offers you the likelihood not the impossibility of success.
10. On success and failure: remember that what a plan means is a minimum. If you ate what you planned to today, you have done enough. But if you ate more than what you planned to today, you have excelled yourself. Greater successes are always possible, but success inheres already in just doing what you set yourself. So for you, on any given day in recovery, there is no such thing as too much food. But there is such a thing as enough.
11. One thing I’ve heard from various quarters about the supposed benefits of maximised eating is that if you don’t eat this way, the temporary overshoot in your bodyweight beyond its ultimately stable weight is more likely to happen / last longer / be larger. I know of no evidence to support this claim. The current clinical science of eating disorders includes, regrettably, no research on overshoot. The best evidence we have about it is from the wonderful Minnesota starvation study and from physiological research focused on obesity (some of it based on reanalysis of the Minnesota data) (Dulloo et al., 1997, 2017). We urgently need high-quality research that takes weight restoration after anorexia seriously. Until that starts being done, we mustn’t get confused about the various claims that might be made about eating and overshoot. What’s clear is that:
a) If you eat too little to regain all the weight your body needs to, you will not overshoot and you will not get fully better.
b) If you eat a large amount in an unstructured fashion and continue to do until you have regained all the weight your body needs to, you will probably overshoot and probably get fully better.
c) If you eat a large amount according to a plan and continue to do until you have regained all the weight your body needs to, you will probably overshoot and probably get fully better (because by the end you’ll have stopped needing your plan).
I say ‘probably’ because the research is still scant. But the principles behind why overshoot happens (basically, that fat tissue restores faster than fat-free tissue, so fat needs to get beyond 100% for the rest to get to 100%) seem solid, as does the anecdotal evidence (of both success and, far more commonly, failure). Again, eating to plan must not be confused with eating too little. A plan just means you decide some time in advance what you’re going to eat. The human body and mind probably tend to prefer this way of doing it to a nutritional free-for-all. Make the plan generous enough, and there’s no reason to think yourself debarred from any of the factors that might make your recovery ‘optimal’. Added to which, the idea that you might get to dodge overshoot, or sidle around needing much of it, just by eschewing a plan and cramming in today’s last doughnut, is a dangerous falsehood. If overshoot is going to happen, it will. There may be dietary factors that affect its extent or longevity, but planned versus unplanned eating is not one of them. So, don’t think you can defeat physiology with randomness.
12. Maybe what all this comes down to is something about an attitude, a feeling. The difference between giving in to hunger and responding to it. Between abandoning oneself to the vagaries of an unfamiliar impulse and setting oneself a defined task to complete. Recklessness, attention to instinct, refusal of the old rigidities – these all have irreplaceable roles to play in recovery. But I think they probably, for most people most of the time, fulfil those roles best when supported by the steady hands of the well-made plan, non-negotiably executed. So, don’t be scared to be strict with yourself; when you look carefully, you’ll know the difference between the strictness that will bring anorexia to an end and the strictness which is a continuation of it. Deep down, they really bear very little resemblance to each other.
And what exactly it means to exercise such strictness for the sake of future fluidity – to create a plan and wean yourself off it – will be the subject of Part III of the little sequence that begins here. Right after Part II, where I explore how to make the decision that takes you from agreeing to a plan in principle to following one in practice.
Dulloo, A.G., Jacquet, J., and Girardier, L. (1997). Poststarvation hyperphagia and body fat overshooting in humans: A role for feedback signals from lean and fat tissues. The American Journal of Clinical Nutrition, 65(3), 717-723. Abstract here.
Dulloo, A.G., Jacquet, J., Miles-Chan, J.L., and Schutz, Y. (2017). Passive and active roles of fat-free mass in the control of energy intake and body composition regulation. European Journal of Clinical Nutrition, 71, 353-357. Full text here.