Last week I was pleased to discuss a paper by Walt Kaye and colleagues that I felt strongly supported ordered eating for people with anorexia nervosa.  Ordered eating on our Kartini meal plan has always been the cornerstone of our weight restoration strategy for children and young adults who suffer from this condition. It works and Dr Kaye’s research tells us why.

This week I would like to refer you to a blog written by Cindy Bulik of the University of North Carolina. Cindy is a very well known and respected researcher, particularly in the field of the genetics of anorexia nervosa, as well as a far thinking and clear writer.  Her blog, on negative energy balance, refers not only to frank restricting, but also to those life situations where either meals/snacks become irregular or food eaten is not sufficient to match energy expended.  A fancy way of saying you’re not eating enough for all the work/exercise/worrying you do.

A person who does not have the brain chemistry associated with this eating disorder (AN) may have periods—even a habit of—erratic energy intake without experiencing major harm. They may inadvertently or intentionally skip meals or be too busy to seek adequate nutrition. Then, as soon as they can, they end this unpleasant condition (hunger) and seek food. Food is hedonic (pleasurable), it is also anxiolytic (calming), it improves mood unless you have the neurobiology associated with AN, in which case hunger/poor intake is actually anxiolytic and mood elevating and eating can cause dysphoria (low mood). For people who are prone to AN, negative energy balance is, in Dr Bulik’s words, “a dangerous biological trap”.

Avoiding a dangerous trap would be the best strategy, clearly!

Dr. Bulik goes further: “Convenient but misguided explanations that focus on control, willpower, and even stubbornness fail to capture the biological reality that the physical experience of negative energy balance is fundamentally different in people prone to anorexia. The starvation state is alluring to them, not because it signals weight loss, but because it is anxiolytic. That means that negative energy balance actually confers a sense of calm on their otherwise unsettled biology.”

Boy, is this important to understand!  Even our parents (and to a certain extent many providers) who can accept the need for ordered eating on the Kartini Meal Plan during the initial stages of re-feeding, begin to ask the equivalent of “are we there yet?”, once life begins to assume some degree of normalcy. They go all wobbly and veer off from ordered, planful eating even when it is critical to their child’s continued health to hold the course. “None of their friends have to eat like this”, they tell us. The risk of erratic eating (either negative energy balance or a taste of the “feel good” that periods of low intake causes in them) is clear: relapse.

What Dr Bulik is trying to tell boils down to this: other people or other people’s kids can skip an occasional meal, eat erratically, grab a granola bar instead of showing up for dinner, etc with no adverse effects—but not someone who is anorexia prone.  This would explain why the virtually invariable prodrome that we see in our patients who experience relapse and who return to us for help, is that they go off the Meal Plan and begin to eat erratically with a resultant mismatch between energy expended and energy taken in.  This feels good to them, and then we are down the rabbit hole.

It can be tough to understand that steady predictable energy intake is critical to our patients, probably forever. This resembles the life that children and young adults lead who have type 1 diabetes. They cannot afford to skip meals and eat  “intuitively”. They will need to be planful—a hard thing for children and adolescents, as we all know. It is not a coincidence that the death rate from type 1 diabetes is highest in adolescence.

Dr Bulik leaves us with this thought: “During and after recovery, negative energy balance can sneak up and grab hold of you without even being aware that you are in its grip. Starting a new exercise program, travel and the attendant time zone changes and disruptions in routine, or a busy schedule that doesn’t allow times for planned meals and snacks can all blindside you into experiencing just a whiff of the seductive calm that mistakenly leads you to believe that starvation holds an answer to your discomfort.”

Be vigilant, she warns us.  Be vigilant.  And hold the course on ordered eating; it’s worth it.