Structured.

I blogged yesterday about Part One of Linda Hill's talk on The Noisy Brain, and, as I promised, here is Part Two of her talk from the 2010 International Conference on Eating Disorders. In the second half of her talk, Dr. Hill talked about the need for structure in AN recovery, specifically with respect to meal planning.

In the world of eating disorder recovery, Intuitive Eating is pretty much the holy grail of recovery. It's not a bad ideal, but eating when you're hungry and stopping when you're full can really only work effectively if your hunger and fullness cues are fully operational. In people with eating disorders, especially in early recovery, this really isn't true. At my last residential treatment center, we were taught Intuitive Eating (which wasn't a bad thing), but then we were also expected to be able to put this into action even as we were still in the beginning phases of normalizing eating patterns. Some people found this effective; I didn't. I failed at it miserably, and I had always blamed myself. Perhaps I didn't want recovery enough. Or maybe I wasn't good enough at fighting the ED voice.

You can imagine what a relief it was for me to learn that although the concept of Intuitive Eating is very useful, I can't rely totally on hunger and fullness cues to nourish myself. I definitely couldn't early in my recovery, and I still can't quite totally rely on them now. Instead, I need more structure to help me eat properly, and it's not a matter of personal failure but more of a matter of the very issue that made me so vulnerable to anorexia.

Dr. Hill talked about the need for structure in meal planning as it relates to difficulties in decision-making in people with eating disorders. Here's a segment of what she said (I inserted the links to help define some of the more technical terms):

Automatic emotional reactions don't seem to fire well because the insula is blunted. People with anorexia doesn't appear to have a free-flow ability [to move between emotional aspects of decision-making and evaluating long-term consequences]. Their planning ability seems to be firing overly well.

The AN/BN brain is impaired in identifying the emotional significance of stimuli, but it has an increased ability concerned with planning and executing tasks. There is an emotional blindness to decisions. If there is little or no internal regulation to help the person in decision making, it's easier not to decide. I need few to no options to help me in those decisions. [For people in recovery from anorexia], we need to increase structure and limit options for decisions. To compensate for inability to know what to do, the anorexic turns outward to social cues for rules and answers and to experience reward. In EDs, we begin with a meal plan, and then dose food level to match energy level. We take choice out of it.

So instead of saying "What kind of grain do you want with dinner?" it's more useful to ask "Did you want rice or pasta?" The first option is so open-ended and provokes so much anxiety that it's simply easier to skip that carbohydrate. The number of decisions I have to make when figuring out what to eat can be so overwhelming that I have to find ways to make it easier for myself. In my meal planning post, I wrote about how I have managed to work enough variability into my meal plan while simultaneously keeping the number of choices from getting overwhelming. My solution is the mix-n-match method (or what my dietitian jokingly refers to as the Deal-a-Meal) that keeps me from getting in an anorexic rut, fulfills my necessary exchanges, and allows for enough flexibility that I can go to a restaurant.

The balancing act can be rather precarious, and I think the eventual goal is to move off of a formal meal plan and into a more Intuitive Eating pattern. But the idea is that we use meal planning to shore up those areas in which we might have difficulties and let our strengths speak for themselves.

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17 comments:

Abby said...

This post came at exactly the right time, as I've recently re-implemented my own meal plan again and even though I was eating a lot before, adding in the variety and what I really need often leaves me paralyzed with indecision. When given a meal plan by a nutritionist or doctor, I had my struggles, but I trust that was what I needed and had no choice to make. It was eat what was prescribed or face the consequences.

I want options when I feel trapped, but I don't want option because then I feel overwhelmed and say, "screw it," and revert back to safety. I need the structure, but am finding it hard to force it upon myself. In other words, this post makes me feel a little less...weak?

Do you still have a prescribed meal plan or compose it yourself?

Kim said...

I really have started to see meal planning as a useful tool instead of an annoyance. There's nothing wrong with needing a bit of structure. I need way less than I did at one point, and I'm happy with that :)

e.motions and ana.lysis said...

Carrie-

I've been reading your blog for a long time and I wanted to say hello and let you know that you have a new "follower", not that you need any more. You're one of my blogging inspirations that helped me be brave enough to start something so public. I agree about the "gap" that you wrote about in the "Noisy Brain" post. It's nice (although not good that it occurs) to see that I'm not alone in the brain-abuse. Now if only it would leave us all alone.

-Em

marcella said...

I don't have an eating disorder. I've experienced a bit of disordered eating in times of stress or as a result of silly dieting in my time but I don't have a clinical eating disorder.

As a wife and mother in charge of a household (at the moment of just me, hubby and the cats), including meals, I DO appreciate meal planning. Old fashioned ideas such as "soup is warm and nourishing for a winter's day" or "when the weather is hot why not try some strawberries" along with local or religious traditions, fish on a Friday, the ice cream van on a Saturday and economic and social norms like eating locally produced seasonal food, make what could be a daunting decision easier and leave the family with the pleasure of just cooking the stuff and eating it.

There are real scientific and brain reasons why people with clinical eating disorders need structure to help them eat healthily, but the rest of society could benefit from a bit of structure too.

Cathy (UK) said...

If I ate intuitively I would never eat enough. Therefore, meal planning and timing of meals are essential for me.

Basically, I don't enjoy food. I don't like the feel of it in my mouth, the taste it leaves behind, or the sensation fullness it creates. If I wanted to lose weight (which I certainly don't...) I would find it really easy.

I never ate intuitively pre-AN (due to food phobias and emetophobia) and I cannot imagine ever eating intuitively.

James Clayton said...

I'm the same and every time I eat intuitively I don't eat enough (I don't eat the right mix). Until I'm better at it and until eating disordered tendencies aren't so instinctive and natural, some structure needs to be in place.

Thanks as ever for writing about the talks and keeping the helpful posts coming Carrie!

Coco said...

What a great post! Sometimes I feel silly and childish being a 22-year-old woman who can't even function without a meal plan, but you know what? That's what I need, and I'm glad to hear it is helpful for many people in recovery. After all, if I was trusted to "intuitively eat", I'm pretty sure my ED would intuitively eat....nothing.

EvilGenius said...

I would add that there is definitely a middle ground between structure and intuitive eating. I say flippantly that I eat 'intuitively' but it is true that I have crap hunger cues sometimes and my digestion is pretty rubbish, so following hunger all the time would lead to me losing weight. but I don't solve that by meal planning or structure, more by a general awareness that 'more is better'...that *I* need to be careful to get more calories in, so even if I'm eating what I want, when I want, it's always best to add in some extra cheese/a glass of juice/etc. so although my eating is 'normal', my awareness of my history means that I err on the side of caution in a way that normal people don't. I also know 'what is normal' in the sense that I don't need a meal plan to tell me that having one slice of toast for breakfast is a bad idea, and if I'm not hungry I should shower/read for a bit or something until I have the appetite to eat more.
ditto with measuring food...this may seem a bit cheeky but I've never understood why people in recovery measure things 'to make sure' because their appetite isn't good enough. neither is mine, but cause I know the risks of getting too little I just go a little heavy on the cereal/PB/whatever to make sure. after all, most recently weight restored people can't afford to lose weight but it wouldn't do us any harm if we gained a little by being extra careful ;)
not meant to be a dig :) but just an idea that eating 'freely' (I won't say intuitive, it's a dirty word :P ) is more achievable than it may seem :)

Katie said...

Not that it'd be any surprise to anyone who knows me, but I have to agree with EvilGenius on this one. I feel the same way as her - most of the time these days I eat without thinking about calories or measurements. If I'm stressed out I do lose my appetite, but after over a year of recovery I don't need a meal plan anymore to keep myself on track - I just eat more and I trust my own judgment.

When I started recovering I thought trying to eat intuitively was a bad idea for anyone with a history of eating disorders, but eventually I realised that I had little evidence for this, I was actually just too scared to try it. In the back of my head I thought that either my body would demand far too much food and I'd balloon if I didn't keep track of things, or that I wouldn't know how much to eat and I'd relapse. In the event, neither happened. It became obvious if I hadn't eaten enough on any given day - I would feel cold, tired and irritable, so I didn't need my absent stomach hunger cues - and I never seemed to feel like overeating. If I was more hungry on a particular day I wouldn't panic, I would chalk it up to hormones and eat more. If I wasn't so hungry I would chalk it up to stress and not take advantage. I've maintained my weight within 3lbs since January, so it's clearly working for me.

I wonder what makes one person able to implement this when another finds it harder? I was a restrictive anorexic, I've been ill for well over a decade and I had no previous experience with maintaining my weight, so theoretically intuitive eating should have been out of my reach. On the other hand I did recovery entirely by myself. I created my own meal plan, monitored my own weight gain and made my own meals. Maybe I learned to trust myself and my body throughout that process. I'm sure it's a very individual thing though, as is usually true of the experience of eating disorders and recovery.

Angela E. Gambrel Lackey said...

I am so glad to know I'm not the only one who struggles with "intuitive eating." The first time I left hospitalization I was so sure I would be able to eat intuitively and failed at it miserably - I almost never feel hunger and I keep wondering when the hunger cues will kick in. I also feel the same way as Cathy from the U.K. - I don't like food, the feel of it in my mouth nor the feeling of fullness afterward.

I just left PHP and am again in the middle of weight restoration (you can probably already guess what happened - as soon as I crossed over that magical 85 percent number the insurance started making noises about how I no longer needed treatment; although I was ready to leave anyway [another story])

So I've decided to add a dietician to my treatment team because I feel I need that structure in order to continue with recovery. I've basically given up on intuitive eating and have decided that if structure is what is going to get me well and keep me there, then structure it will be even though I am a bit embarrassed to need it at 44! Intuitive eating will have to wait until I feel safe with it. I wasn't really an intuitive eater even pre-AN, so I am coming to terms with the fact I might need some form of meal structure for life.

Thanks for the post!

C said...

Interesting post. I don't have an actual eating disorder, but sometimes wished I didn't have to eat. I would always rather be doing something else, more fun, more interesting than cooking and eating, which to 'normal' people sounds strange. I was very slim when I was younger, I didn't keep regular meals when I started living away from home and sometimes I'd forget to eat when I was especially busy. I could take or leave food, it was no issue to me. My sister was the same and we joked that we were 'anorexic' in the sense that we felt that we could do without eating, if we didn't have to eat to keep alive. Not anorexia nervosa but simply anorexia.

As I got older though, I had to make myself eat regularly or my health and strength suffered more (especially as I have Crohn's disease, which often has lack of appetite as a symptom of active illness), and getting migraines for lack of food also pushed that forward. Now I have a normal weight and even have to watch it sometimes. I don't feel as 'anorexic' as I felt back then (sorry if I offend anyone by using the term, I do not mean to minimise the actual illness, AN). I know I *have* to eat, so I always make sure I eat something reasonably substantial. Structured eating has helped me because I would be able to ignore hunger if I didn't have immediate bad effects like migraines etc. I think learning to eat intuitively is not that helpful if you have problems with disordered eating, ironically. I think it is best for 'normal' dieters who are a bit overweight. For disordered eaters, I think a good aim would be to have structured eating with flexible meal options.

Stephanie said...

After awhile of the structured meal plans, though, you CAN naturally progress into intuitive eating. This is what has happened for me, and I just love it. I do, however, eat much of the same foods day after day. These are the foods I am comfortable with, but they also meet my nutritional needs when I eat intuitively and make sure to consume enough but not too much.

I still, however, need to learn intuitive exercising. :)

Anyways... hope you are well Carrie!

Mimi said...

So funny I should read this now- I just had a similar revelation myself! I have known for a long time that decisions around food are soooo hard for me, but never knew what to do about it. And for my evening snack, it's particularly difficult. I just don't know what to eat. So I randomly combine, and it either ends up way too little or much too much. But yesterday I wrote a meal plan with menu-like combinations of alternatives. And it was just such a relief! That snack suddenly was easy and free of any anxiety. Love it!

Anonymous said...

I've dealt with AN and severe overexercising, so maybe my experience is different, but meal plans have always been a bad idea for me when it comes to recovery. I'm dealing with my second relapse now and am counting the calories in everything I eat. I don't know how/want to eat the right foods, so eating 3 tiny "meals" a day isn't effective and leaves me hungry. Unlike others who've posted, I can't go for hours on end without feeling hunger cues--nor do I get a high off of it. For me AN is extremely masochistic and about being in pain (and depriving myself). I get hungry at the normal times but get so anxious about eating that it's always a struggle. I'm terrified that if I ate intuitively that I'll no longer be underweight and that I'll balloon into a "fat" person-so meal planning for me is more destructive than helpful.

kitty_fontana said...

Isn't intuitive eating, at least in the early days of recovery, nearly impossible to sustain considering the actual brain structure of eating disordered people? I've been working on a paper about neurotransmitters in those with AN & BN, so I've been reading a lot about the brain & EDs (thanks for all the links & info here, Carrie) & intuitive eating seems a bit too much to ask, at least early in treatment.

Also, most "normal" people have something like a mealplan too. If you have a structured life, you can't go around listening to your stomach all day, you have to eat breakfast & lunch at certain times if you go to school or work. In the morning, whether I'm hungry or not, I need to eat breakfast or else I'll get the shakes in the middle of work, before my lunch break - you get the picture. I guess a meal plan tells you what your going to eat instead of letting you feel your way around it, but that's what most people do.

You should never feel like a failure for needing a meal plan. Your brain & body chemistry, plus the nature of modern life, make some structure necessary.

sayhealth said...

One of the things I really like about the head dietitian at The Center for Balanced Living is that her method reflects an understanding this neurochemistry. She knows that stressing variety too early can be very, very overwhelming. Rather, she stresses meeting your nutritional needs, and if you need to do some repetitive eating to get there and make it feel doable for a while and reinforce that it's okay, so be it. She also provides flexible meal plans, but will endlessly help you figure out what specific foods you can have to meet it, and if someone is struggling at a group meal, she'll come over with a couple of options, and just say, "Pick one of these," or "Pick two of these."

In more advanced recovery, she"ll help with adding variety, moving away from the meal plan, etc., but she knows that it can be overwhelming and set someone up for failure if it's done too early.

sayhealth said...

Oh, also, just fyi, her name is Laura Hill; it was correct in the previous entry. :-)

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I'm a science writer, a jewelry design artist, a bookworm, a complete geek, and mom to a wonderful kitty. I am also recovering from a decade-plus battle with anorexia nervosa. I believe that complete recovery is possible, and that the first step along that path is full nutrition.

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nour·ish: (v); to sustain with food or nutriment; supply with what is necessary for life, health, and growth; to cherish, foster, keep alive; to strengthen, build up, or promote



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