‘Rotation Diet’. This diet varies energy intake from 600 to 1500kcal/day over a period of 4 weeks. It then provides for a maintenance dietary intake of 1800kcal/day, which increases the likelihood of micro-nutrient inadequacy. The basic premise of this diet is that by rotating energy intakes for weight loss, a rise in resting metabolic rate is achieved. This is NOT supported by research.

‘Fit for life’. Probably one of the most widely talked about diets available, this diet is low in milk, meat, breads and cereals, and very high in fruit and vegetables. Encouraging people to eat more fruit and vegetables is desirable, however the diet is based on unsupported claims that rat is accumulated by improper food combinations. It also misinterprets digestive physiology, particularly gastric emptying, and claims that certain macronutrient combinations ‘rot’ in the stomach and release ‘toxins’. These claims are NOT supported by research. Refer to Rosemary Stanton’s The Diet Dilemma for a more extensive review of this diet.

The Dr Atkins Diet’ and The Drinking Man’s Diet’. These diets are based on carbohydrate restriction. Adequate carbohydrate is required to maintain blood glucose levels, fluid balance and to spare amino acids from being used as a fuel source. Approximately 100 grams of carbohydrate per day is required to achieve the above and to avoid ketosis. Many examples of low-carbohydrate diets have existed over the years and these diets cause diuresis and loss of fluid weight in the first few days due to glycogen and fluid loss. Protein is catabolised contributing to a further fluid and weight loss. Other side effects apart from dehydration include fatigue, postural hypotension, taste changes, halitosis and altered biochemical parameters. Adequate fluid and carbohydrate intake are two nutritional recommendations that are NOT met by this form of diet.

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During the second phase, we continue to work on developing regular eating habits. We also begin to change the makeup of her diet.

As we have seen, people with eating disorders often adopt rigid rules about what can and can’t be eaten. They create a list of “forbidden foods”-fattening or sweet foods they want but won’t allow themselves to have. Avoiding these foods makes them feel in control. However, these are often the very foods they run to when they lose control and binge.

It’s a quirk of human nature: Whatever is forbidden becomes the thing we most desire. When a bulimic decides certain foods are “off limits,” she creates an overwhelming temptation. In Stage Two, we work to reduce her feeling that she is completely helpless in the presence of forbidden foods. The goal is to take the power away from food and return it to the patient.

One method is to rank these foods in order of “danger level” and then gradually reintroduce them into the diet, starting with the least “dangerous” food. When she learns she can eat a few French fries, for example, and not feel driven to binge, she starts to feel in control. Success breeds success. Regaining a little bit of control reduces fear and gives her encouragement to keep trying. She may need a lot of coaching from her therapist and from others in her family to reach this point.

The best way to handle a phobia is to gradually increase exposure to the thing you fear. When the patient learns how to manage forbidden foods, she conquers some of her fears. Sometimes, for example, a patient tells me she will only eat something if she knows its calorie content. As an exercise, then, we work on eating foods whose calories are unknown. Or she may dread eating in restaurants or at parties. We find ways to expose her to those situations and build up her tolerance. Doing so takes her out of the “danger zone.”

One method to help with purging is technically known as exposure plus response prevention. We expose the patient to the problem-feeling full after eating-and prevent her usual response to it-vomiting. If the patient is in the hospital, we ask her to sit with a staff member for an hour or so after a meal. Eventually she gets used to the feeling of having food in her stomach. She learns that she needn’t respond to the feeling by giving in to her urge to purge. This strategy works especially well when the patient vomits often, or when eating anything at all triggers purging. If needed, we can use the method with outpatients as well.

During the second stage, the patient does better if she reduces her “magical thinking” about food. She also needs to learn new ways of thinking about, and solving, her problems. As I’ll explain shortly, cognitive therapy helps her achieve these goals.

In many cases, at the end of the second stage the patient has stopped bingeing completely, or binges only once in a while. Her attitudes about weight, body shape, and herself are much healthier.

Stage Three

During the third phase, we continue to build on successes during the previous stages – continuing regular eating and relaxing the patient’s need to control her diet. But now we shift our focus and prepare the patient to leave therapy and strike out on her own.

Many patients notice that their normal feelings of hunger and fullness have returned. This in itself makes it easier to control eating. We still work with the food diary, which will indicate whether there’s a problem that we still need to work on.

In fact, slipping back gives us a chance to address a key issue: the risk of relapse. Patients are always in danger of slipping back into old habits. Perfectionism is hard to shake; many patients believe that once they regain control, all will be well forever. Not so. Better to face the reality that relapse is possible, especially during times of stress.

The message is that a little slip does not mean total, crushing defeat. Instead, I urge the patient to remember how far she has come, and that she has learned a lot about how to deal with her illness. Through her diary, she knows how to look at her situation and discover what may have triggered her binge. Eventually she will learn how to avoid these triggers.

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It was the worst—and, as it turned out, the best—moment of her life.

Devastated by the remark, Beth—then age 30 and 240 pounds—took out a tape recorder and started talking about how she felt. She stated the date and her height and weight. Then she let loose. Her voice quivering, she described the incident with her daughter’s friend. How she hated putting her daughter in such an awkward situation. How lonely and empty she felt. What it meant and felt like to be so heavy. How the laces hung on the sides of her shoes because she was too fat to bend down to tie them. How embarrassed she was to buy clothes. She said she hated the way she looked. She hated herself.

Calmed by the emotional release, Beth dried her eyes and, with more determination than ever, decided to do something about her weight. She studied the American Heart Association’s nutritional guidelines and memorized the USDA Food Guide Pyramid to learn how to eat more healthfully. She cut back on fatty foods and ate lots of fresh fruits and vegetables when she felt hungry. And she walked for 30 minutes every day—outside when she could, inside on her treadmill when then weather was bad. It took 2 years, but she lost 100 pounds.

Four years later, she needed the tape again. “I had gained 15 pounds, and my eating habits were terrible,” she says. “When I played the tape, I could hear the rain outside and the desperation in my voice. I was only 34 years old, and I didn’t want to go back.” It immediately turned her around.

Now Beth plays the same tape every year around October 1 to gear herself up for the holidays. This autumn ritual and the stinging remembrance of a little girl’s remark have helped to kept her weight under 150 pounds for more than 5 years.

WINNING ACTION

Use your low point for inspiration. In a journal, on a tape recorder, or just on a piece of paper, make a record of exactly why you want to lose weight at that low moment. Describe in detail how you feel and what you want to change. Read it over or listen to it when you’re tempted to fall off the weight-loss wagon. And, like Beth, hang on to it for the future, as a reminder of how far you’ve come. (I still have a few fat drawings that I made of myself more than 10 years ago!)

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