I am writing to you from Berlin tonight and thinking about a recent article written by Dr. Bulik on the challenges of international travel for those with an eating disorder, in particular anorexia nervosa. In the article Dr. Bulik talked about time changes and irregular meals, of long distance transportation being a danger to those whose brain chemistry is less anxious when they don’t eat and more anxious when they do. It's how a person’s weight may slide down inadvertently, because of having to miss some food, taking them down a slippery slope of satisfaction through calorie restriction. At first only components of the meals may be missed, then with a nine hour time change -- in Europe for example-- whole meals. After that, "skimming" bits of most meals begins and suddenly the weight is off. This can be exacerbated by the increased walking of tourism and shopping, to say nothing of what we at Kartini refer to as “lose weight, get happy”.

I have watched this play out over many years of seeing our patients graduate from acute care settings (hospital, day treatment, intensive outpatient). They, and frequently their parents as well, are excited for them to spend a semester abroad or to go on a mission trip to dig wells or build houses for the poor, or perhaps make that long-awaited cultural trip to Italy or France to practice language skills they have so diligently acquired in school. If they are still in treatment with us, we ask them to plan their trip carefully with their parents and with their family therapist. Where will they shop for food? What kind of food and meals can they expect? How will they know when they have "over-done it" while walking around new and exciting places. How will they know when they need more fuel?

But in fact rarely does a patient (and family) excitedly plan such an adventure with us. Usually -- being teens or young adults -- they are resentful of our intrusion into what they view as their private life. They are reluctant to plan. They “just want to get away from it all” or “be normal”, “just like all their friends”. Perhaps surprisingly, given the immense sacrifice and dedication that treatment requires of them, parents are often reluctant to insist that a weight/medical safety net be put in place before allowing their child to go. They are reluctant, for example, to insist that unless their child packs some Benecalorie for emergencies, they are not going. In fact, when I get push-back from a patient about the simple expediency of packing half a dozen Benecalories (light weight, need no refrigeration and you cannot get them overseas or even sometimes in major cities here), I am glum. I know this means they are not serious about maintaining their weight at all cost. I know that the unconscious works in devious ways in all of us and when we have the chance to be free of our constraints, even if it leads down a path of ill health (which most people do not associate with weight loss, btw) -- well, they couldn’t help it, could they?

I've seen this play out so many times that I'm sad when parents excitedly ask me what I think about their child’s upcoming trip. What can I say? I wish them well, but if they are unwillingly to plan carefully, the subtle workings of the eating disorder will find a way to achieve unconscious weight loss goals.

Like most people who do not have an eating disorder, I'm distressed by missing a meal. It’s bad enough to miss sleep! And when I go through the airport, having just been exposed to truly unacceptable airplane food, and still can find nothing I would describe as edible, I think about our kids and how hard it would be for them; and finding that crack in the system, how the eating disorder would leap through it and rear its ugly head. I can only hope that they would not be defenseless, that they and their parents would have done the planning needed ahead of time.  

And I wish them well.