Key Takeaways
- People recovering from anorexia nervosa often need 3,000–5,000 calories per day to restore weight and health, which can feel overwhelming but is necessary for recovery.
- Refeeding syndrome is a serious risk during recovery, so medical monitoring of electrolytes and nutrients is critical in the early stages.
Meal plans are an essential part of anorexia nervosa recovery. They help provide structure and ensure proper nutrition that helps people recovering from anorexia gradually rebuild a healthy relationship with food. These plans are guided by healthcare professionals and designed to make the path to recovery more manageable and sustainable.
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Why Meal Plans are Important for Anorexia Nervosa Recovery
Meal planning is a vital part of anorexia recovery. The malnutrition that accompanies anorexia nervosa can negatively impact all systems of the body. Restoring weight and nutritional health is an essential component of treatment.
That said, it’s not a quick or easy process. Restoring a body malnourished by anorexia nervosa may take many months or even years. People with anorexia nervosa should generally be under the care of a treatment team, which commonly includes a medical doctor, a registered dietitian nutritionist, a psychotherapist, and a psychiatrist.
Anyone beginning nutritional rehabilitation must be aware of the potentially fatal refeeding syndrome. Refeeding syndrome involves a sudden shift in fluid and electrolytes that can lead to serious and dangerous complications.
Outpatient Nutritional Rehabilitation
While some people may be hospitalized during eating disorder recovery, others receive treatment as outpatients. Research has shown that more aggressive, faster refeeding protocols lead to faster recovery and better overall outcomes for those not at risk of refeeding syndrome.
It is not uncommon for the daily caloric needs of people recovering from anorexia to reach 3,000 to 5,000 daily calories. The goal is to gain 1/2 pound to 2 pounds per week until achieving the goal weight. This is especially true for adolescents who are still growing and young adults.
Adolescents participating in Family-Based Treatment with parents in charge of nutritional rehabilitation support can usually be safely started at an intake of 2,000 to 2,500 calories per day. With an outpatient team supporting and monitoring recovery, parents are often encouraged to increase the intake to 3,000 to 5,000 calories per day for weight restoration.
Achieving High Calorie Intake Requirements
Parents and people who are being treated for eating disorders are often perplexed by such high caloric needs. Why are they so high?
- Elevated metabolism: Individuals with anorexia nervosa often become hypermetabolic, which means their metabolism has kicked into high gear as the body tries to rebuild all the tissue lost during starvation.
- High body temperature: Individuals commonly experience elevated body temperature as energy intake may be converted into heat rather than solely used to build tissue. This paradoxical symptom makes recovery even harder.
- Excessive exercise: People with anorexia nervosa may engage in excessive exercise despite severe emaciation. Such exercise may be hidden and further undermine attempts to gain weight by increasing calorie expenditure. Exercise is usually not medically advised in the initial stages of nutritional rehabilitation, but people recovering from anorexia may need monitoring to prevent it.
It is important to note that because increased caloric intake generates significant anxiety in those with anorexia nervosa, achieving these caloric goals may be very challenging even with additional support. However, it is imperative to ensure adequate caloric intake to allow the body to fully recover.
Weight goals should always be calculated by your medical team. The return of menses in females is critical. Your team can calculate your specific individual calorie needs as they shift during the recovery process.
Suggested Meal Plan Guidelines
You may consider beginning nutritional rehabilitation if:
- You are consuming more than 1,000 calories per day as your starting point
- Are not at risk for refeeding syndrome as discussed above
- Have been medically cleared to do so
Please consult with a medical doctor and registered dietitian to tailor recommendations specifically for your body.
For example, the following could be an illustrative nutritional rehabilitation recommendation for a 90-pound patient not at risk for refeeding syndrome.
- Day 1–4: 1,200–1,600 calories/day
- Day 5–7: If no weight gain is observed, increase by 400 calories per day to 1,600–2,000 calories/day (if weight gain is occurring, you may increase more gradually)
- Day 10–14: If weight gain is not reaching 1 to 2 pounds per week, increase daily intake again by 400–500 calories/day to 2,000–2,500
- Day 15–21: 2,500–3,000 calories/day
- Day 20–28: 3,000–3,500 calories/day
Remember, caloric needs often increase as weight increases. This means:
- Gradual calorie increases: People recovering from anorexia nervosa often require escalating caloric intake to maintain a steady weight gain.
- Monitoring progress: For this reason, weekly weigh-ins that record progress are desirable.
- Further increases may be needed: If and when the rate of weight gain slows or stops, caloric intake must be increased.
The Meal Plan Recipe For Success
Since a calorie-focused meal plan could be triggering for those recovering from anorexia, it is not necessarily the first choice for registered dietitians to recommend. However, it could be helpful to have an idea of what calorie count to target, especially when reading food labels and menus.
A good initial rule of thumb for a basic meal plan is three 500- to 800-calorie meals plus at least three 300-calorie snacks, but only after initial caloric estimates are calculated and monitored and refeeding syndrome has been ruled out.
Again, calorie levels are always a moving target, depending on the rate of weight gain. The preferred meal plan model for anorexia nervosa recovery is the exchange system. It is often used in hospital, residential, and outpatient eating disorder recovery treatment.
Originally designed for people with diabetes, the system is versatile in recovery because it considers macronutrient proportions (protein, carbohydrates, fat) without directly focusing on calories.
For metabolic efficiency, calculations often aim to reach:
- 50–60% of total calories from carbohydrates
- 15–20% from protein
- 30–40% from dietary fat
Each “exchange” (starch, fruit, vegetable, milk, fat, protein/meat) equates to a certain food and its portion size. This allows for focusing on balanced food group selection during meal planning.
However, a balanced diet may not be as important as increasing caloric intake during weight restoration. A Registered Dietitian Nutritionist can help calculate and design exchange meal plans considering all of this.
An illustrative 3,000-calorie exchange system meal plan for a day might comprise 12 starches, 4 fruits, 4 milks, 5 vegetables, 9 meats, and 7 fats. A daily regimen might divide the exchanges into meals and snacks as follows:
Breakfast: 2 Starch, 1 Fat, 2 Meat, 1 Milk, 2 Fruit
- 2 slices of toast (2 starch exchanges) with 1 tsp. butter (1 fat exchange)
- 2 scrambled eggs (2 meat exchanges) made with 2oz whole milk plus 6oz of whole milk on the side to drink (total-1 milk exchange),
- 4 oz of orange juice & 1/2 cup fruit salad (total-2 fruit exchanges)
Lunch: 2 Starch, 2 Vegetable, 3 Meat, 2 Fat, 1 Milk
- Grilled cheese sandwich: 2 slices of bread (2 starch exchanges), 2 tsp butter (2 fat exchanges), 3 slices of cheese (3 meat exchanges)
- Tomato soup (1 cup tomato soup condensed-2 vegetable exchanges) made with 1 cup whole milk (1 milk exchange)
Dinner: 4 Starch, 3 Meat, 3 Fat, 2 Vegetable, 1 Fruit
- 1 cup cooked pasta (2 starch exchanges)
- 2 pieces garlic toast (2 starch exchanges) + 2 tsp butter (2 fat exchanges)
- 3 oz of ground beef or turkey (3 meat exchanges) browned in 1 tsp olive oil (1 fat exchange)
- ½ cup tomato sauce with ½ cup cooked broccoli (2 vegetable exchange)
- 1 orange (1 fruit exchange)
Snack #1: 2 Starch, 1 Milk
- 1 large muffin (2 starch exchanges)
- 1 cup whole milk (1 milk exchange – half & half could be added for more calories)
Snack #2: 1 Fruit, 1 Milk
- ½ banana (1 fruit exchange)
- 1 cup whole milk yogurt (1 milk exchange)
Snack #3: 1 Meat, 2 Starch, 1 Vegetable, 1 Fat
- 1 tsp peanut or almond butter (1 meat exchange)
- 2 bread slices (2 starch exchanges)
- 1 cup raw carrots (1 vegetable exchange), 1 oz hummus (1 fat exchange)
Other Meal Plan Strategies for Weight Gain
To increase caloric intake to achieve a steady weight gain course, you can always remember some simple tactics:
- Caloric density: Adding fat while cooking, such as oil, butter, cream, or cheese, can increase calories without increasing portion size.
- Fewer raw fruits and vegetables: Although nutritious, these foods can contribute to early fullness and prevent weight gain.
- Eating frequency: Instead of eating three times per day, increase to six.
- Portion size: Serve larger portions for each meal.
- Supplement with liquid nutrition: Products like Ensure Plus and Boost Plus provide 350–360 calories per 8 ounces. This could prove very helpful for caloric density. Liquid nutrition in this form is recommended immediately as a replacement for skipped or unfinished meals or snacks.
Risk of Refeeding Syndrome During Recovery
Refeeding syndrome is caused by the rapid refeeding of someone in a state of starvation, usually chronic, and it may be fatal. It is characterized by electrolyte and fluid shifts associated with metabolic abnormalities in malnourished people who are undergoing nutritional rehabilitation.
How could finally eating after a period of starvation possibly be harmful to the body? Biochemistry tells us that ketone bodies and free fatty acids from the breakdown (catabolism) of muscle and adipose tissue replace glucose as a major energy source in starvation.
During refeeding, there is a shift from fat to carbohydrate metabolism. The resulting insulin released from the pancreas increases cellular uptake of glucose, phosphate, potassium, magnesium, sodium, and water. The body also shifts into a building (anabolic) state of protein synthesis, which requires more nutrient uptake into the cells.
The body is then at risk of not having enough of these vital nutrients in the bloodstream. Clinical consequences may include:
- Irregular heart rate
- Congestive heart failure
- Respiratory failure
- Coma
- Seizures
- Skeletal-muscle weakness
- Loss of control of body movements
- Neurological symptoms
Preventing Refeeding Syndrome
To avoid refeeding syndrome, the following must be monitored for the first 5 days and every other day for several weeks:
- Phosphorus
- Magnesium
- Potassium
- Calcium
- Thiamin
An electrocardiogram (EKG) should also be performed. Strict medical oversight is required.
The National Institute for Health and Care Excellence Criteria for Patients advises that there is a significant risk for refeeding syndrome if your starting point is 1,000 or fewer calories per day.
Refeeding syndrome risk increases greatly in people who have one of the following indicators:
- BMI: Body mass index of less than 16
- Electrolyte imbalances: Low levels of potassium, phosphate, and/or magnesium before refeeding
- Recent intake: Little or no nutritional intake for more than 10 days
- Weight loss: Losing more than 15% of body weight in the past 3–8 months
People with two or more of the following indicators are also at higher risk of refeeding syndrome:
- BMI: Body mass index of less than 18.5
- History: Alcohol misuse or drugs, including insulin, chemotherapy, antacids, or diuretics
- Recent intake: Little or no nutritional intake for more than 5 days
- Weight loss: Losing more than 10% of body weight in the past 3–6 months
Persistence of BMI
Body Mass Index (BMI) is a dated, biased measure that doesn’t account for several factors, such as body composition, ethnicity, race, gender, and age. Despite being a flawed measure, BMI is widely used today in the medical community because it is an inexpensive and quick method for analyzing potential health status and outcomes.
Overcoming Weight Restoration Challenges
Since a primary symptom of the disorder is a dietary restriction, what patient with anorexia will willingly eat more?
Resistance is common and calls for direct support from loved ones and a team of professionals who can help hold people accountable to meal plans and weight gain, as well as challenge the eating disorder mindset and encourage consumption of fear foods on a daily basis.
Vegetarian, low-fat, low-carb, and non-dairy diets should be discouraged (unless a diagnosed allergy) as they often are a symptom of the disorder and not based on legitimate health concerns.
Delayed gastric emptying or gastroparesis is common with anorexia nervosa and can contribute to early fullness and bloating. This further complicates the renourishing process as eating the required increased intake may be physically uncomfortable.
Strategies that can help people manage these challenges include:
- Eating small, frequent meals: Frequent nutrient-dense meals and snacks that allow for smaller portions without sacrificing calorie content are the key to overcoming this hurdle. Eating disorder recovery teams can help support renourishing’s physical side effects and psychological resistance to such aspects of recovery.
- Working with a treatment team: Teams usually include a medical doctor, registered dietitian nutritionist, psychotherapist, and psychiatrist. When searching and building outpatient teams, it is advisable to make sure practitioners have expertise in the treatment of eating disorders.
- Getting help from a support system: Allowing a loved one to help with accountability and provide recovery support can be extremely powerful in recovery. Family-Based Treatment (FBT or Maudsley) is an evidence-based model designating parents as the primary support for refeeding of children and adolescents with anorexia nervosa. Other models of treatment that provide family support for adults with anorexia nervosa have been developed as well.
Recovery is not a linear process and may be slow. Remember that life stresses and major life changes can possibly activate relapse. Support and re-evaluation of progress and goals are constantly needed. Making peace with food and having restored psychological, emotional, and physical health and well-being are indeed possible.
