Returning to “normal” eating after bulimia treatment

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When entering treatment for bulimia nervosa (BN), individuals typically present with an irregular eating pattern, which is usually characterized by dietary restriction, rigid food rules, binging episodes, and purging via self-induced vomiting, excessive exercise, or use of diuretics and/or laxatives.

These unstructured eating patterns can make it extremely hard to break free of the binge-purge cycle. (1) Some may wonder how to eat normally after bulimia. During treatment for bulimia nervosa, instituting a pattern of consistent and adequate eating is one of the key building blocks of recovery.

Keep reading to learn more about what constitutes consistent and adequate eating and how to maintain regular eating patterns following treatment for bulimia nervosa.

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What does “normal” eating look like?

During treatment for bulimia nervosa, cognitive behavior therapy (CBT) is typically used to help patients restore regular eating patterns, which often includes three meals and two or three snacks a day. (1) It is also advised that individuals should avoid going more than four hours between episodes of eating.

It’s recommended that patients stick to eating these distinct meals and snacks in order to be intentional about getting enough food and being able to feel physically and mentally satisfied. Furthermore, in cases of bulimia nervosa, binging and purging should be avoided, which may require learning additional skills, such as emotional regulation, impulse control, and developing alternative strategies to deal with distress.

Tips for returning to “normal” eating

Getting back into a consistent and adequate way of eating is not easy when recovering from an eating disorder. Many people in recovery from bulimia nervosa can feel incredibly anxious about preparing food and eating, despite the desire to get better. Here are some suggestions for how to help you to ensure that you’re providing your body the nourishment and nutrients it needs, while not letting your fears overwhelm you.

Follow meal plans

During treatment, most people living with bulimia nervosa are provided with some kind of meal plan that is straightforward to follow and will help to ensure they’re getting enough food and nutrients to meet their body’s needs. However, when treatment is over, it can be difficult to stick to meal plans without the structure and support from treatment. These tips can help you to maintain consistent eating patterns and continue with nourishing your body:

  • Avoid clean eating sites: While some of these sites and social media pages are well meaning, they frequently promote restriction and label foods as “good” or “bad”, which can influence you in ways that contradict your recovery plan.
  • Draw on positive memories: Incorporate meals that bring back comforting memories, to help recreate positive associations with food. Drawing on your positive memories is a great way to help rebuild a healthy relationship with food.
  • Plan your meals ahead: Planning your meals for the week helps you to make sure you're eating an adequate and varied diet, while also taking away the stress of what you’re going to eat every day. This also makes it easier to plan and purchase groceries for the week without the anxiety of constant decision making. 
  • Meal subscriptions: Some individuals in recovery from bulimia nervosa really benefit from meal delivery services. Not only do they take some of the pressure and anxiety away from meal planning, but also encourage experimentation with previously feared or restricted foods, while maintaining adequate nutrition.

Learn how to build adequate and varied meals

While following a meal plan during treatment and early stages of recovery can provide crucial structure and guidance, many people in recovery from eating disorders eventually want to transition towards incorporating more autonomy and intuition into their meals and snacks. This can involve learning new cooking skills, considering your nutritional needs and preferences, and making sure that your schedule leaves you time to eat regularly throughout the day. 

If you are still working with an eating disorder dietitian or therapist at this stage in your recovery, they can help you gradually transition from a set meal plan to a more flexible and intuitive style of eating. There are also some helpful free resources online from eating disorder specialists that provide advice about how to maintain recovery while no longer relying on a meal plan. General tips include: (2)

  • Eat a variety of foods to make sure that you are getting all of the major macronutrients and necessary vitamins and minerals. This can look different for different people depending on nutritional needs, preferences, and allergies. If you have a limited palate, health conditions which are impacted by specific foods, or a history of nutritional deficiencies, it may be helpful to consult with your dietitian or another trained medical professional to make sure you are able to meet your nutritional needs while managing co-occurring health conditions.
  • Unless you have a known allergy or medical intolerance, no foods need to be off limits. Working with a therapist and eating disorder dietitian can help to challenge food rules and fears that certain foods must be avoided. Incorporating previously feared foods as regular parts of your meals and snacks can decrease the feeling that these foods are dangerous, forbidden, or addictive. 
  • Incorporate regular meals and snacks into your schedule. Some people prefer to eat more smaller meals or fewer larger meals, but as a general guideline, you should aim to wait no longer than 4 hours between meals and snacks. 

Boost your food flexibility

Research shows that patients recovering from bulimia nervosa who adopt flexible eating habits demonstrate a significant reduction in binging and purging behavior. (3) Furthermore, a more varied diet reduces the likelihood of labeling some foods off-limits which makes them more likely to trigger binging and purging. (3)

Help boost your food variety and flexibility by making a list of your “banned” foods or food groups and situations around food which you would avoid, such as eating out with others, and work on incorporating them gradually throughout your recovery. You may have already done this during treatment in exposure therapy, which involves repeated exposure to the “feared” thing, you learn that nothing bad happens and the fear and anxiety reduces.

Ask for meal support

People recovering from bulimia nervosa may benefit from meal support, which is essentially emotional support during meal times. This may have formed a part of a person’s treatment plan but can be continued outside of treatment by asking a family member or friend to join you during meal times to help shift the focus away from food and to create an enjoyable experience.

Self-monitoring

Self-monitoring can help you keep on track with your regular eating. If you’re struggling to stick to a regular eating pattern, consider setting alarms as reminders of when you should eat, particularly if you’ve returned to your normal school, work, or home activities.

Note down if you engage in binging or purging, or experience any disordered eating thoughts and what you were doing or thinking at the time, without shame or judgment. This will help you analyze what circumstances or emotions may have contributed to these thoughts and behaviors, so you can be more aware of triggers and implement alternative coping strategies in the future.

Avoid the scales

Many people struggling with bulimia nervosa place extreme value on their weight or body shape and size, and noticing or anticipating how these things may change in recovery can be very stressful. Discussing these concerns and distress with your treatment team or other supportive individuals can be a helpful way to process them and avoid triggering a return to eating disorder behaviors. 

For many people in recovery from bulimia nervosa, it may be most beneficial not to weigh themselves or see their weight at all. If the treatment team believes it is necessary to monitor changes in weight which could indicate serious medical complications in early recovery, doing blind weights which are tracked by the team and not revealed to the patient can be helpful. Beyond that, different people’s bodies respond differently to cessation of binging and purging behaviors and focusing on adequate food intake, managing any medical complications, and providing emotional and behavioral support are more important aspects of recovery than weight. 

Listen to your body

When you’ve been stuck in a cycle of binging and purging you can lose track of your body’s natural cues for hunger and satiety. Once you have been following a meal plan and eating regularly for a while, it may become more possible to listen to your body to gauge feelings of hunger and fullness. 

It can be helpful to check in with your body during and after each meal or snack to see how you are feeling and assess whether you feel physically and emotionally satisfied.

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Final thoughts

For people who struggle with eating disorders such as bulimia nervosa, especially those who have had disordered eating behaviors for long periods of time or since childhood, it can feel scary and difficult to imagine ever achieving a regular and non-disordered relationship with food. Approaching this process gradually with the support of medical professionals, family and friends, and peers in recovery can help to address fears and adjust to eating consistently and adequately. Over time, some people may feel interested in and ready to transition from a structured meal plan to a more flexible and intuitive style of eating. 

It is also important to remember that there is no single definition of “normal” eating. Nutritional needs vary from person to person and even across a single person’s lifetime. There are many different ways to enjoy food and meet your nutritional needs depending on your schedule and preferences. Recovering from an eating disorder such as bulimia nervosa does not mean you need to have a perfect relationship with food or match an arbitrary standard of “normal” eating, as every person is different and you get to discover what works for you.

Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.

Resources

  1. Elisha Carcieri, P. D. (2020, November 24). How cognitive behavioral therapy helps eating disorder recovery. Verywell Mind. Retrieved August 31, 2022, from https://www.verywellmind.com/regular-eating-for-eating-disorder-recovery-4109419 
  2. Guidelines for Americans healthy eating pattern 2015-2020. (n.d.). Retrieved September 1, 2022, from https://health.gov/sites/default/files/2019-10/DGA_Healthy-Eating-Pattern.pdf 
  3. Lauren Muhlheim, P. D. (2021, October 11). Reasons to increase food variety in eating disorder recovery. Verywell Mind. Retrieved August 31, 2022, from https://www.verywellmind.com/food-variety-in-eating-disorder-recovery-4159544 
  4. Smith, R. C. (2017, November 16). Meal plan tips for eating disorder and anorexia recovery. Patient.info. Retrieved August 31, 2022, from https://patient.info/news-and-features/meal-plan-tips-for-eating-disorder-recovery

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