How Much Food to Feed?

In Family-Based Treatment (FBT), we charge families with nourishing their teens back to health through meals at home. Because FBT is a parent empowerment model, parents are often given little specific guidance about how to do this. If you are like other families with whom I’ve worked, now that you understand this important point, you are likely wondering, “How much should I feed?”

The answers are usually:

• Way more than you think!… And
• As much as you can!

We are so warped by diet culture that many parents are unaware of the high caloric needs of healthy teens, and even less aware of the even higher needs of teens who need to restore significant weight and may be hypermetabolic.

Early and Adequate Weight Gain

So many parents starting FBT feel excited when they get their teen to eat more complete meals than they were eating previously—before the parents started intervening. They are surprised when their teen does not gain any weight or even loses weight after this seemingly significant increase in intake. And then precious time is wasted with no early weight gain.

Early weight gain of at least four pounds in the first four weeks is predictive of more success long-term with FBT, so we try to hit the ground running. Clinical trials affirm this fact: families who ultimately succeed with FBT demonstrated early weight gain during treatment.

Ideally, we would like to see two or even as much as four or five pounds of weight gain a week. Many teens have 30 or so pounds to gain. Do the math: if the teen gains half a pound a week (something parents are usually initially encouraged by), it will take 60 weeks—over a year—to gain the 30 pounds. By contrast, if the teen gains three pounds a week, it will take only 10 weeks!

Also, keep in mind that steady weight gain does not mean a steady caloric intake. In fact, the more someone weighs, the more calories they burn because they need more calories to just maintain a higher mass. This means that weight gain is usually EASIER for a more malnourished teen; As the teen gains weight, there is often a need to increase their diet to maintain the same rate of weight gain. Many families find that they need to increase calories every week for a while.

Faster Weight Gain With Higher Calorie Meal Plans

Faster weight gain is usually better:

• Better for their long-term health—every day a teen spends malnourished increases the risk of a longer-term toll on their body
• Better for their psychological help—they can get back to their full lives sooner
• Better for the parents—it keeps them from burning out

Many parents feel tempted to “go slower” to “make it easier and reduce stress.”

However, a recent study out of UCSF’s eating disorder program showed that a lower-calorie meal plan—compared to a higher-calorie plan—did not reduce distress among hospitalized teen and young adult patients with anorexia nervosa (AN) and atypical anorexia (AAN) (Accurso et al., 2023). Teen and young adult patients fed a higher calorie refeeding diet did not have greater complications with food refusal, mealtime distress, and affective states.

The researchers noted that most individuals preferred lower-calorie refeeding plans, but the results suggest that “the perception or anticipation of increased calories is more distressing than the actual presentation of increased calories on the meal tray.” They noted that most participants who received the lower-calorie refeeding diet believed they had received the higher-calorie diet. This is consistent with the pathology of anorexia and atypical anorexia: most patients perceive any adequate caloric plan as “high calorie.”

So if your teen will experience the same amount of distress regardless of the amount you feed, why not feed more?

Always Screen for Refeeding Syndrome

So, How Much to Feed?

If your teen has already been cleared for outpatient refeeding at home, then we usually recommend starting at around 2000 to 3000 kcal per day and over the course of a few days, increasing these amounts. Many teens will often need 4000 to 6000 kcal per day to achieve the weight gain goal of one to two pounds per week (and remember, more is even better). Yes, you heard it—6000 kcal a day! This is especially true for teens who are male, still growing or have a history of being highly active.

Such high-calorie needs often perplex teens and their parents. It takes a surprising amount of energy to restore a starving body to health and rebuild everything that was depleted during the period of restriction. During the process of renourishment, individuals with anorexia nervosa often become hypermetabolic—that is, their metabolism has kicked into high gear (Marzola et al. 2013). The body may convert additional calorie intake into heat rather than using it to build tissue. This paradoxical symptom makes recovery even harder. Hypermetabolism can persist for up to two years after weight restoration. Thus you should anticipate higher calories as the ‘new normal’ and only reduce if truly your child’s body makes it clear they no longer need as much to grow normally.

You may want to incorporate supplemental nutrition shakes to help achieve these high calorie goals.

Tracking Weight

As one gains weight, the body burns more energy, so calorie needs further increase. As a result, individuals recovering from anorexia nervosa usually require escalating calorie intake to maintain a steady weight gain. Weekly weigh-ins to record progress are a prudent way to track whether calorie

intake is pacing the body’s changing needs. A minimum of once a week helps track progress during the weight gain phase. If you are concerned, you can weigh more frequently. Increase calorie intake if and when the rate of weight gain slows or stops. Sometimes weight can increase in spurts—don’t immediately panic if the pace of weight gain slows one week. But if it slows for more than one week, definitely increase the meal plan.

On the other hand, don’t panic if you get four or more pounds of weight gain in a week. I have seen families and teens panic after one significant increase—which early on, especially, may be largely water weight—presume they are “feeding too much” and cut back, and then experience no gain or even a loss the following week. If you get a few weeks of four or more pounds of weight gain in the beginning, this is a great start. Keep going!

Don’t Wait for Hunger Signs To Feed More

If your teen eats everything easily, seems interested in more, or asks about upcoming meals with interest, those are signs you might be able to easily increase portions. Do not expect or wait for your teen with an eating disorder to openly express hunger. Teens with eating disorders rarely ask for food or express hunger until much further on in recovery. However, experiencing hunger during the early phases of recovery can be scary. Feeling hungry on a refeeding diet also can lead to shame for a person with an eating disorder. I advise parents to try to stay ahead of hunger; this is kinder.

Learn more about the importance of setting appropriate goal weights in eating disorder recovery.

Learn Strategies For Increasing Caloric Density

Learning strategies for increasing the caloric density of foods can greatly help with high-calorie needs. Learn more in my book–When Your Teen Has an Eating Disorder presents a family-based treatment (FBT) method. It teaches strategies you can apply to assist your teenager in their recovery journey. This resource will provide you with insights into effectively supporting your teen’s nutritional rehabilitation, normalizing their eating habits, and handling mealtimes. Additionally, you’ll gain the knowledge needed to guide your teen in expanding their food choices and equipping them with coping strategies and recovery skills to reduce the risk of relapse. With the guidance of this empathetic handbook, you’ll feel empowered to nurture your teen’s recovery and keep them on the path to healing.

Get Help For Your Teen’s Eating Disorder in California

Our eating disorder specialist therapists provide FBT for teens in California by telehealth and in the office in Los Angeles. Start by Contacting EDTLA. 

Sources

Accurso, E. C., Cheng, J., Machen, V. I., Buckelew, S., Kreiter, A., Adams, S., Le Grange, D., Golden, N. H., & Garber, A. K. (2023). Hospital-based higher calorie refeeding and mealtime distress in adolescents and young adults with anorexia nervosa or atypical anorexia nervosa. International Journal of Eating Disorders, 56(6), 1219–1227.

Marzola E, Nasser JA, Hashim SA, Shih PA, Kaye WH. Nutritional rehabilitation in anorexia nervosa: review of the literature and implications for treatment. BMC Psychiatry. 2013 Nov 7;13:290. doi: 10.1186/1471-244X-13-290.