1) Good outcome : weight >10th BMI percentile and regular menstruation

2) Intermediate outcome: >10th BMI percentile but amenorrhea (i.e. the absence of menstruation for at least the past three months)

3) Poor outcome: weight <10th BMI percentile and/or presence of bulimic symptoms.

As they melded the “good” and “intermediate” outcome groups into one acceptable group for analysis and contrasted that melded group to the “poor outcome” group, to belong to the successful group a patient could be amenorrheic (no menses) and weigh any number above—even slightly above—the 10th percentile for age. AND, if I am reading their tables correctly, by eighteen months (!!) only slightly more than 17% had achieved this modest outcome in the TAU group and about 40% in the TAU + family therapy (TAU+FT) group.  

Now, that’s some damned poor outcome after a very long time.  A closer look  (see table 3) shows that only about 27% of the TAU group achieved a BMI greater than the 10%tile for age and 53% in the TAU+FT. Worse, about 65% in the TAU group were still amenorrheic and a third were still amenorrheic in the TAU+FT group.  I would not publish this data if I were them, unless I wanted to blow the whistle on a national disgrace.

From my Kartinian point of view I struggled with two main issues of the authors’ approach to pediatric eating disorders:

1. Their definition of a healthy weight is so flawed as to be malpractice.  How can one define a healthy weight for a given child/teen as “that weight which is above the 10th percentile for their age?”  Have they had no clinical experience with eating disordered children?  How about normal children? Surely it matters what the starting point was?  A child who grew happily along the 50th percentile prior to their illness could not be said to have achieved a “healthy weight” if they have been returned to a weight which represents the 15th pecentile for age.  Who cares about the average BMI centile for age? Individual healthy weights will fluctuate wildly with Tanner stage (SMR), genetics and menstrual history.  This lack of understanding of the crucial role of weight restoration and individual healthy weights is no doubt why they got such abysmal results.

2. Although I am aware that even people who agree with me up to this point may now depart from my analysis, this article is a perfect example of why I cannot agree that all that is “evidence-based” is gold.  There is a lot of so-called “evidence” out there that is misleading and even demonstrably false.  And an even larger pile of “evidence” that has been erroneously interpreted.  This article is a perfect example of the latter: drawing the wrong conclusions from the data, probably a result of bias in concept to begin with.  This research represents a randomized controlled study (RTC), considered to be the gold standard for evidence.  I say:  caveat emptor!  Let the buyer beware!

The Spring following, by the Prescription of some Emperick, she took a Vomit (I think by this he means an emetic, i.e. something to make her vomit therapeutically), and after that I know not what Steel Medicines (some form of iron supplementation), but without any Advantage.  So from that time loathing all sorts of Medicaments, she wholly neglected the care of herself for two full Years, (wow! a great description of "denial of the seriousness of the illness" which is reported in modern systems of classification for anorexia nervosa) till at last being brought to the last degree of a Marasmus (wasting), or Consumption, and therefore subject to frequent Fainting-Fitts, she apply’d herself to me for Advice (remember what he said about late advice in these cases, from his introduction and discussion).

I do not remember that I did ever in all my Practice see one, that was conversant with the Living so much wasted with the greatest degree of a Consumption, (like a Skeleton only clad with Skin) how often I have made this observation to medical students when caring for our most severely wasted patients yet there was no Fever again he is differentiating this illness from the Other consumptive illness of the day: TB, but on the contrary a Coldness of the whole Body; no Cough or Difficulty of Breathing, nor an Appearance of any other Distemper of the Lungs, or any other Entrail: no Looseness, or any other sign of a Colliquation, or Preternatural Expence of the Nutritious Juices  -- over-exercise?  Only her Appetite was diminished, and her Digestion uneasy, with Fainting-Fitts (fainting is still a very common way for eating disordered children to present to the general pediatrician or family doctor), which did frequently return upon her.  Which Symptoms I did endeavor to relieve by the outward Application of Aromatick Bags made to the region of the Stomach, and by Stomach-Plaisters (this was done as recently as my grandfather’s day) as also by the internal use of bitter Medicines, Chalybeates, and Juleps made of Cephalick and Antihysterick Waters, sufficiently impregnated with spirit of salt Armoniack, and Tincture of Castor, and other things of that Nature (ick!).  Upon the use of which she seemed to be much better; but being quickly tired with Medicines, she beg’d that the whole Affaire might again be committed to Nature, whereupon, she was after three months taken with a fainting-Fitt and died.

And preventing these deaths are what it’s all about.

Of A nervous Consumption

A nervous atrophy or consumption, is a wasting of the body without any remarkable Fever, Cough, or shortness of breath; but it is attended with a Want of Appetite, and a bad Digestion, upon which there follows a Languishing Weakness of Nature, and a falling away of the Flesh every day more and more. [He notes that weight loss is the presenting complaint. But note that he nowhere talks about a desire to be thin.  In Morton’s day weight loss was not seen as a good thing since it was a common symptom of consumptive illnesses like TB, which were fatal.  It was therefore important for other physicians to be able distinguish between these conditions and so he emphasizes that there is no fever and no cough or other lung symptoms present.]

Which kind of Consumption I have sometimes observed in England, but most frequently among those that have lived in Virginia, after they have come over hither. [now that’s interesting…. I wonder what that could mean?]

In the Beginning of this Disease the state of the Body appears oedematous and blouted, and as it were stufft with dispirited Chyle;  [his observation of water retention] the face is pale and squalid, the Stomach loaths everything but liquids, the Strength of the Patient declines at that rate, that before the fleshy Parts of the Body are evidently consum’d, he is render’d plainly feeble, and almost always confin’d to his Bed.  The Urine also keeps not constant to any Color, though for the most Part it be high-color’d, and but little in quantity.  [We see urine of this dark color in those patients who restrict their fluid intake as well as their food; in my experience this is common in the very young patient.]

Yet it is sometimes, (as it happens commonly to be in Nervous Distempers) though seldom, pale and plentiful.  [This is common where the patient drinks a lot of water-- often the patient who is older, say 15 years or older.]

But there is no considerable Fever to be discovered, either by the Pulse, or a Thirst, or Heat, how high-colour’d soever the Urine appears.  So that the Pathognomonick Signs, or those which do evidently manifest the beginning of this Consumption, are a Decrease of the Patient’s Strength, and a Loss of Appetite, without any remarkable Fever, Cough, or Shortness of Breath, though in the Progress of the Distemper, when a Consumption of the Flesh has gradually affected the whole Habit of the Body, there is some Difficulty and Trouble in breathing to be observed, as it uses to happen to all those who are under a great Weakness. [A “pathognomonic” sign is one which is so characteristic of a given disease that its presence means the disease is almost certainly present; Morton is re-iterating his teaching point that despite the wasting there are no fevers or pulmonary symptoms.]

The Causes: The immediate Cause of this Distemper I apprehend to be in the System of the Nerves proceeding from a Preternatural State of the Animal Spirits, and the Destruction of the Tone of the Nerves; whereupon I have used to call this a Consumption in the Habit of the Body.  [It seems to me that Morton is saying that this illness which leads to the observed wasting, is a brain disorder, emanating from the nervous system, of which the brain is but a part.]

For as the Appetite and Concoction are overthrown by the weak and infirm Tone of the stomach, so also the Assimulation, the Fermentation, and Volatilization of the Nutritious Juice are hindred in the whole Habit of the Body, from the distemper’d State of the Brain and Nerves. [Again, the ‘distemper’ of the brain and nerves are causative.]

The Causes which dispose the patient to this Disease, I have for the most part observed to be violent Passions of the Mind, the intemperate Drinking of Spirituous Liquors, and an  unwholesome Air, by which it is no wonder if the Tone of the Nerves, and the Temper of the Spirits are destroy’d. [This leaves a lot to be argued about, doesn’t it?]

This Distemper, as most other Nervous Diseases, is chronical, but very hard to be cured, unless a Physician be called at the beginning of it.  [The chronic nature of this illness and the need for early recognition is something I and others have written about repeatedly.]

At first it flatters and deceives the Patient, for which reason it happens for the most part that the Physician is called too late.  [Oh god! This is the most true and the most painful statement in the whole discussion and it resonates as loudly today, across the span of nearly a third of a millennium, as it did then]

And at last it terminates in an Hydropical and Oedematous Swelling of the body, especially of the lower and depending Parts, in which case there remains no hopes of the Patient’s Life, neither is there anything more to be done for his Cure, than giving him some Ease, whereby his miserable Life may be lengthened for some days. [Not so fast! We have ways of dealing with these medical complications today]

There follows a long recitation of medications and herbals to be given, such as balm of Gilead, filings of steel, old conserve of red roses, spirit of hartshorn and many other things too numerous to go into here, but available to read about on Google Books.  

Morton ends his discussion on ‘cure’ by saying:

Let the Patient endeavor to divert and make his Mind cheerful by Exercise, and the Conversation of his Friends. [Please note his consistent use of the pronouns “he” and “his”.]  

For this Disease does almost always proceed from Sadness, and anxious Cares.  Let him also enjoy the benefit of an open, clear, and very good Air, which does very much relieve the Nerves and the Spirits.  And because the Stomach in this Distemper is principally affected, a delicious Diet will be convenient, and the Stomach ought not to be too long accustomed to one sort of Food.

I guess we must ask ourselves: have we learned anything new in 300 years?

I was given this lovely plate after the FEAST conference, by a mom, with the following kind words:

Dr. O'Toole,

Thank You for believing in parents and for all your hard work and dedication in the treatment of EDs, and understanding that EDs are a biologically based brain illness, and that our children DO NOT choose this, and we as parents DO NOT cause EDs but rather can be part of the solution that helps to heal and re-feed our children. I hope the "Magic Plate" has found its way and a new home in your office.

It is my greatest hope for all those who view this “Magic Plate” that it will empower them with the strength and courage they will need to stand up, show no fear and fight against ED. Food is medicine, there is hope and recovery is possible!

It starts with full nutrition every day and requires a lot of time, a halo of patience, more time with plenty of persistence and perseverance, but it is so worth all the effort to get our children back!

Behold the power of the Golden Fork! Again it was such an Honor to meet you.

Respectfully,

Denise

So what is a “magic plate”?  Well you might ask!  It is essentially the embodiment of how we have been teaching our parents to feed their children since the first days of Kartini Clinic: parents in charge, parents shopping for food, preparing food and sitting down to eat with their child in a firm spirit of love and support. It has always been –and remains—the foundation for weight restoration in our patients.

And in the spirit of synchronicity, here is what the FEAST website says about their magic plate:

“In the first stage of recovery, medical restoration to healthy weight is the primary goal of care. The Magic Plate is a simple way of describing how caregivers provide meals and snacks to patients.  The planning, cooking, and serving is done without help or input from the patient, whose only job is to arrive at the table and eat. This loving technique can be effective because it intentionally relieves them of the anxiety they experience when they have to make decisions around food.”

So here is my magic plate, proudly displayed in my office at Kartini Clinic.  It’s lovely, isn’t it?

Common sense would dictate that we not become aggressive, belittling or demanding of professionals on whom our child is temporarily dependent for medical intervention, however you should not hesitate to inform yourself, rely on your intuition and experience and ask questions.  The days of “because I said so and I am the doctor” are gone in medicine, or should be.

There are basically two types of medical hospitalizations for eating disorder crises: 1. the emergent kind at the nearest hospital, regardless of that hospital’s specific eating disorder expertise and 2. the urgent kind in a hospital which you have sought out specifically because of their expertise in treating the complications of eating disorders.

In the first kind of hospitalization, you may need to be patient until imminent danger of death has passed and then arrange transfer elsewhere.  An example of this might be an admission to an internist, pediatrician or hospitalist at a community hospital for dehydration, electrolyte imbalance, severe inanition (wasting) or syncope (fainting).  We had an adolescent patient referred to us once whom the police had found semi-conscious at the side of the road, grossly starved and cold.  This extreme is what I mean by an emergent admission for inanition. If such an admission is needed and the hospital team does not have an AED handbook for medical care, provide them with one.

The second kind of admission (urgent, experienced or specialist hospital) is more usually done for a patient who may or may not be expected to die without such care, but who is in any case compromised medically and/or may reasonably be feared to be in danger of re-feeding syndrome if re-fed in another setting.  Such patients might be expected to meet AAP admission guidelines for orthostasis, bradycardia, etc.

The following is a check list I am proposing for parents to use in evaluating the adequacy of their child’s hospital care:

1. Does the hospital team resent your involvement as a parent?  Are you blamed for your child’s illness?  Is your hospital contact with your child severely limited?  If the answer to any of these questions is “yes”, move this hospital to the “unacceptable” pile and seek care elsewhere as soon as you can.
2. Who is principally in charge of your child’s medical care?  This needs to be an attending physician or nurse practitioner.  If it is a team of doctors who rotate, ask who will be responsible for communicating daily with you about such things as weight progress and labs.
3. How often is phosphorus checked?   This will need to be daily (or more often in the Intensive Care Unit, aka ICU) as long as calories are still being adjusted upward.
4. What does the doctor/team consider a preliminary goal weight?  Most hospitalizations are not long enough to achieve full weight restoration and ultimate goal weights usually only matter this early in the hospitalization in those cases where a need for weight restoration is ignored, for example where the doctor/team argues that the “patient’s BMI was too high to begin with” (!!).  For most patients the issue addressed under Point 5 below is much more critical.  I strongly recommend that weight goals not be shared with the pediatric patient either by the staff or by the parent.
5. Although it is common for a patient to actually lose weight for the first 2-4 days of re-feeding due to fluid shifts, after that the weight curve should be steadily upward.  Ask:  who will calculate weight gain and is it done daily?  Excellent weight gain should average 0.2 kg/day.  If it is lower than that see Point 6 below.
6. Calculating calories/food intake:  the majority of patients hospitalized for an eating disorder will have lost weight relative to their own norm.  This means they will enter the re-feeding process hypometabolic as the brain tries to conserve energy in a time of famine.  Once you begin re-feeding, however, the metabolic fires will jump up and the patient will need many more calories than ever before.  It is critical that calories/food are titrated to weight gain, so that if the rate of gain is much less than 0.2 kg/day more food will be added.  Fat must never be allowed to be restricted.  On this specific point your questions for your treatment team are:  What is the start point for caloric intake (low is fine)? How will the calories be increased? By whom? How often? And—importantly—is phosphorus checked during this time?  I strongly recommend that discussions of calories/exchanges/fat grams not be shared with the pediatric patient by the staff or by a parent.
7. How are meals supervised?  I can’t tell you how often kids report back to me that they were able to hide food or spit out medications because of a lack of adequate staff supervision.
8. Aftercare should be discussed from the outset, after about 24 hrs of hospital care.  Everyone is usually too upset for the first 24 hours to take in much information about aftercare planning, but in order to maintain the gains made in the hospital and prevent re-hospitalization, it will be important to hand-off the pediatric patient to an outpatient team whether that team is a “Maudsley” style team, a day treatment team or other.  How will the hospital team plan for follow-up care and communicate with those providers (including the family of course!)?
9. What criteria do you use for discharge?  
10. How do you monitor access to the bathrooms in the hospital so that my child is safe from exercise or purging? Experienced teams will always have a plan for this.  It matters.
11. Are patients with very low heart rates or personal histories of fainting monitored on telemetry?  We have had a handful of patients who experienced “asystole” or stopping of the heart, which caused them to “faint”.  Had they not been on telemetry we might have just ascribed this to “dehydration”. On the cardiac monitor we were clearly able to see how, in some vulnerable patients, the heart can be acted on by a simple stimulus such as a blood draw, standing up from lying down, etc. with an episode of cardiac arrest.

So to recap the questions:

1. Does the hospital team resent your involvement as a parent?
2. Are you blamed for your child’s illness?
3. Is your hospital contact with your child severely limited?
4. Who is principally in charge of your child’s medical care?
5. Who will be responsible for communicating daily with you about such things as weight progress and labs?
6. How often is phosphorus checked?
7. What does the doctor/team consider a preliminary goal weight?
8. Who will calculate weight gain and is it done daily?
9. What is the start point for caloric intake?
10. How will the calories be increased? By whom? How often?
11. Are calories increased to meet any loss of weight or stagnation in weight gain?
12. Is phosphorus checked during this time (of caloric increase)?
13. How are meals supervised?
14. How will the hospital team plan for follow-up care and communicate with those providers?
15. What criteria do you use for discharge?
16. How do you monitor access to the bathrooms in the hospital so that my child is safe from exercise or purging?
17. Do they keep their patients with bradycardia (low heart rate) on telemetry?

I myself answer these questions on a daily basis, as does my partner.  I am relieved and happy to see a parent with a written list of questions for me, as that means I can easily be held accountable for getting to all of their concerns.  Expect no less.

Our daughter was diagnosed with Restrictive Anorexia Nervosa (RAN) when she was 11 years old. She was born a little premature and was a small baby.  By 18 months, she developed what would be her body for the next 8 years. She was a solid toddler, strong and active. At the yearly pediatric checkups, she would be in the 75 – 80th % for weight and height. When she started school, she had a good relationship with food and seemed comfortable with her body.

At 11, she started wanting to eat healthy food. This surprised me, but I didn’t really concern me as I just knew that she liked junk food and would probably go back to her old eating habits. She did not, and this was the beginning of a downward spiral into restriction of an increasing number of foods.

We did notice that she was thinning out, but, in our ignorance, we believed this meant she was stretching out and that it was a natural process girls went through. I didn’t realize at the time that the opposite happens to girls as they are getting ready to hit puberty; they fill out as the first symptoms of puberty appear.  A relative was visiting us at that time and she pointed out our daughter was not eating at the table. I started to insist  she eat her supper. She started fighting back.

I took her to our pediatrician, who took all of her vital signs, did some blood work and asked her a few questions. She privately asked me a lot of questions and said that our daughter was either at risk for RAN or that she already had it. She diagnosed daughter based on the fact that she had grown 3 inches in the previous year but had not put on weight. She also based diagnosis on her behavior during the visit. The pediatrician said she had to refer us to the right person because if we went to the wrong therapist, our daughter could be messed up for life. She had seen this happen to too many girls, and she was not going to let this happen to our daughter.

We saw the therapist, who confirmed that our daughter had RAN. She was the youngest child that this therapist had ever treated; previously, her youngest patient had been a 12 year old. She told me that RAN was a biological brain disorder, that we had not caused it, our daughter hadn’t chosen it and that we had to be in charge of her food. We had to prepare her food and she had to eat it.

The therapist asked our pediatrician to set a weight goal. Instead, we saw a different pediatrician in the practice, who sat with the chart in front of us, drew a circle between the 45% and 55% and said “we don’t like kids to be much above or below this area”.  She zoned in on the 50th percentile and gave us that number, give or take  2-3 lbs, as her target weight. There was no consideration given to her growth trajectory up until that point or to the fact that she was a growing pre-pubescent child whose weight target should be moving upward for the next few years.

I will not go into the details of the re-feeding process because it is not the theme of this story. We struggled trying to get her to put on weight for the next 15 months. She was underfed and underweight for about 18 months. Finally, I bumped into the ATDT forum and learned the “how to” of feeding my child at home through the use of Family-Based Treatment (FBT) and the Magic Plate approach. The therapists and pediatrician were on board with us helping our child through FBT and we worked as a team. The weight target remained at the 50th percentile.

Our daughter reached this target in about three months.  The problem was that our daughter was still desperately ill. We saw no abatement of her symptoms and the thoughts were more torturous at this point than before we had started re-feeding her. However, on the outside, she looked breathlessly beautiful. The bony and pinched look was gone. She looked healthy, willowy as if she could have been in the Justice for Girls Catalogue as a model. People would stop us to tell us how beautiful she looked and tell her that they wanted her legs. I both swelled with pride at the compliments and at the same time raged against people making  those triggering comments to her. I wanted her to stay that way: to have the ideal beautiful lean body AND be healthy at the same time, but it wasn’t happening. The fact is that she had come to like her new body and didn’t want to put on any more weight. By this time, she was 12 years old.

I went back to the ATDT forum and presented this problem. Why is she still so ill when she looks so healthy? Both the therapist and the pediatrician tell me that she is at her “goal weight”. How long will it be until the ED thoughts go away? The answer was that the weight needed to be higher. Since she was a growing child, we couldn’t go back to pre-AN weight. Therefore, we had to look at where she had tracked historically. I asked for some guidelines through ATDT forum and Dr. Julie O’Toole graciously wrote an article on Weight Restoration in Children and Teenagers. I took that article to my pediatrician and therapist and asked them to go back to the growth chart and take another look. We all saw that daughter had tracked in the 75 – 80th percentile most of her life. This meant that she had another 10 lbs to go.

I wrestled with the implications of putting 10 lbs on a 5’1” child. I knew that she wasn’t going to be willowy any longer. I was tortured by her accusations that I was trying to make her fat because I wasn’t sure that I wasn’t. I started pushing more calories and more food and as her willowy figure started filling out and those perfect looking legs started filling out into fuller and chunkier legs, I grieved the loss of that beautiful body. This became such a struggle for me because I was dealing with my own baggage. I had been an overweight child and teenager and I was afraid that I would make my child overweight too. I also knew that I had to be committed to this process in order for it to succeed. I had been successful with re-feeding because I had blind faith in the process. My daughter knew without any doubt that I believed in what I was doing and that I WOULD defeat ED. This time, my ambivalence was affecting the process because even though I was feeding her while faking confidence, in my heart I was trying to hang on to my daughter’s ideal body.  

One day, I had to face my fears and my ambivalence. I was alone and I said out loud “what is the worst thing that can happen to my daughter?” The answer was that she would die.  So, the obvious follow up question was “would you rather she is dead or fat?” This took my breath away as I weighed the implications of the two options. I let the thought hang in my mind and then said to myself.” I want my daughter alive and well and if that means that she is going to be fat, then so be it. I’ll accept that.” I grieved the loss of the child who would never be willowy and healthy at the same time and accepted that she wasn’t meant to be that way. After that I committed to the process with a vengeance and we succeeded in putting on those last 10 pounds.

One day, my daughter woke up and she was a different child. It was as if the chains that had her tied to the disorder had fallen off. She ate her breakfast without protesting. She came home for lunch and enjoyed her lunch, etc.  When this happened again the next day, I took her in to our pediatrician’s office to be weighed. She was exactly at the 76th percentile of weight. Another side effect of being at this weight was that her natural hunger kicked in and she started eating the amounts that her body needed without us having to cajole her into eating. Since she was still growing, her weight became a moving target. She would go through periods were she would overshoot her target by a few pounds and would look a little chubby. Anytime this happened, I started worrying that she would become too heavy but a few days/weeks later, she would grow taller. This process lasted for about 18 months. Every time I tried to manipulate her caloric intake by cutting back, so that she wouldn’t overshoot her weight too much, her disordered behaviors and thoughts would come back and she would have trouble sleeping. By this time she was able to tell us that she was hungry or starving all the time. So, after a while we just fed her what her body needed and quit worrying about weight or targets. Once she was well into recovery and her cognitive abilities were back, we did have some heart to heart talks where I said to her, when she demanded some answers, that she was biologically and genetically programmed to be this way and that she would never be “thin” and healthy. It wasn’t who she was meant to be. I think that she also had to go through a grieving process where she had to accept that she was not going to be tall or thin.

We are now five years into recovery since we hit that first weight target. My daughter is now 17 and is an average size teenager. She is so beautiful and healthy, both inside and outside. She has a very free relationship with food and loves and takes pride in her body. Today, I can’t fathom that I ever wanted her to be willowy and thin because it simply wouldn’t be her. I would fight to keep her at this weight range if anything or anyone were to try to change her into someone that she is not meant to be.

I wish that I had never struggled with those thoughts. However, my feelings were very real and I am sharing them today because had I let them take over the target setting process, my child would still be struggling with this disorder.

“Kathy”

“I didn’t eat all day so I could pig out tonight”

“I’m going to break my diet today.  Usually I only eat 1600 calories since I’ve been enrolled in the X diet ”  

“Did you know there are xxx calories in a piece of pumpkin pie?

“Don’t worry, my cousin brought a pie made with no cream and no eggs and no sugar.”

“Did you see how much she ate?”

“Wow, this is a lot of food!”

“Let’s eat early so all that food doesn’t just sit in our stomachs and make us fat.”

“I’m so full I’m not going to eat for two days”

And then imagine the young eating disordered patient whose grandmother/father/aunt/uncle/cousin/neighbor says  “Honey, you look so great.  Finally you have a little meat on your bones.”  

Or  (to the actively eating disordered child)  “I wish I had your will power and just a small dose of anorexia myself….hehheh.”

How do we deal with this potential stress at Kartini Clinic?  Well, it depends on where the person is in their treatment.  If they are at a very early stage, say the first six months, we recommend that the family take a break from the Thanksgiving tradition of the past and plan a quiet family time with food, of course, but also with games and distractions and no food related comments.  Remember, tensions are likely to run high and it’s just not possible to “control the infield chatter” with a large group of well-intended people who may not understand what you and your child have been going through.

Our kids stay on the meal plan on Thanksgiving, and it’s not difficult to do so.  The meal plan perfectly accommodates turkey; mashed potatoes or sweet potatoes or stuffing or rolls; gravy; vegetables and salads. There is, however, one notable exception to this: the tradition of pumpkin pie.

Let’s talk about pumpkin pie.  Every year, without exception, I have been asked about having a piece of pumpkin pie (not on the meal plan).  But here’s the rub.  It’s almost never the kids who ask me, it’s almost always the parents.  I always say “sure, if he/she wants to.  But remember, it is extra, not a replacement for something else.  And no meals can be skipped because he/she ate a piece of pie” (also known as compensatory restricting).  Then I turn to the child and ask  “Would you like to eat a piece of pie?”  Contrary to what you might think, they nearly always say “not interested.”  I then let the parents know that the child can change her/his mind at the last minute, but that they should not be pressured to eat pie if they do not want to.  No one should make them feel bad because “not to eat dessert is not normal” or because “Grandma made it especially for you.”

Remember, everything we know about managing eating disorders the kids taught us.To reduce tension, make a plan.  Make a plan and then stick to it in a spirit of quiet family unity and gratitude.

It’s supposed to be thanks giving, right?