There are many factors in this - her age, current weight, height, amount of weight to be re-gained...

It takes a certain amount to cal per day just to stay alive, i.e. to support breathing, blood circulation etc. Then add the amount needed to maintain weight only - for my adult daughter this is about 2500 cal/day. She adds extra cal if she exercises.

Then add the amount needed to gain weight. This varies between individuals, but can be a significant amount, especially when refeeding someone very underweight. Metabolism will speed up as calories are increased, and it can be difficult to keep on top of this.

I would recommend that you consult with an experienced physician, specializing in ED treatment, and a nutritionist to figure this out.

Also, I would recommend that you don't involve your daughter in the calorie counting, keeping track of her weight, etc. This is a burden that feeds the ED, and your daughter should be relieved of it. Stress health above all, not numbers.

Keep up the good work!

3,500 calories! Right now, that seems nearly impossible. I suppose the foods we're refeeding with are not nearly calorie-dense enough--as a family we were already very healthy eaters, and it's difficult to refeed with these same eating habits.

Should we not worry about high fat/ high cholestrol levels right now? in other words, if I can get her to eat bowl fulls of ice cream and chocolate, we shouldn't worry about trans/sat fats right now?

Dear INOH:

I've been thinking about what you wrote in your P.S on your first post.  You said that you think most of the AN thoughts are gone but she still restricts some foods.  I think my d was very similar to yours, she was also very compliant when it came to eating, the most she would do is sob silently while eating, but she always did it.  This lead me to believe that she was recovering at an amazingly fast pace mentally.  Then, the ED hit me right in the face.  About 2 months into refeeding, gaining wonderfully, much happier than she had been, we discovered at our Drs. appt that she had lost 3 pounds in a week and a half.  I could not figure out how because she was eating.  Then, she broke down and admitted that she had been dumping her Ensure shakes bit by bit when I would turn my head, and admitted that the AN thoughts in her head were worse than ever although she was cooperating with everyone.  Please keep a close eye---this ugly monster rears it's head just when we think it's weakening.  Although, I know you will, you sound like a great mom and your d is lucky to have you!!  Best wishes,

Becky

Are there other suggestions for snack time 'super' calories in addition to milkshakes?

I made those huge banana nut muffins last night and my daughter ate one this morning.  With a glass of instant breakfast.  YeaH!  By the way, they are REALLY good.  She picked a few nuts, but that's okay.

I also discovered that kielbasa is loaded with calories.  Something like 200 calories in a 2 oz. serving.  I had my d eat about 800 calories worth last night. 

Wow!  400 cals just from capsules.  Paydirt.  GNC here I come.

I have her taking some biotin for her hair loss.  I also put some ground flax seed in the muffin mix since it is supposed to be loaded with omega 3.  Thanks for the tip.

Well, we're nearing 2000 calories a day now, and I can see the AN thoughts are not completely gone because d's stress and anxiety levels are rising with the calories. She ate her Peanut Butter Nature Grain Bar today all by herself, but agonized over it for hours afterward.

She's about 5'1 and 13 years old...She has also always had a small frame--will she be needing many more calories? I can't think how I'll manage to get them into her anymore... She's complaining of eating all the time, although she admits that the stomach bloating/pain in almost all gone, and that she even feels like eating sometimes. This seems to frighten her--she's afraid that after she gains back all the weight, she'll continue snacking all the time out of habit and become obese. I keep telling that that if she's hungry, that means she should be eating, but she'll only say that she's not really "hungry" per say, but just feels like putting something in her mouth--like an unhealthy craving for ice-cream or something.

Isn't it natural that these girls have huge appetites right now? After their bodies heal, their appetities will reduce, won't they? I believe they will, but I can't be absolutely sure. Does anyone know? D admits to still feeling like eating after consuming the big meals and snack I give her...which is great, except she still refuses to eat because she's afraid of developing bad habits!

Anorexia (lat. "lack of appetite") is very misleading. Actually, most anorexics are hungry all the time. That's one of the reasons they are so obsessed with food. Being hungry all the time = you think about food all the time. Many comes up with elaborate techniques to calm the hunger-pangs - drinking lots of water, coffee, smoking, chewing gum. This is one of the saddest aspects of anorexia - knowing they are so hungry, but unable to eat because of fear.

Your daughter is hungry because her body is telling her she needs to eat. Lots. Although starvation sometimes induces binging when nutrition is restored (as happened in the Minnesota starvation studies from the late 1940's), this usually will pass and normal hunger signals will resume. It is rare that recovered anorexics become overweight. 

My daughter found some safety in her meal-plan. If she stuck to the plan she knew she wouldn't go too far either up or down from her healthy weight. Others have found that a meal-plan is too structured for their daughters, and encourage them to let go of all the calculating and measuring. Both approaches have merit, in my opinion.

When my d. started eating spontaneously she was both very hungry and very frightened of how much she was eating.  We told her that just as we wouldn't let her lose wieght so she was unhealthy, we wouldn't let her gain until she was unhealthy, either.  She went through a few weeks of eating incredible quantities (one day, instead of an energy bar for a snack, she had a box of energy bars--over 2,000 calories) and was then angry at us for not stopping her. We explained that her eating so much for a short while (it lasted about 2 weeks) was healthy because she was listening to her body tell her she needed to catch up, and it shortened the time she needed to spend gaining.  This explanation seemed to work for her. 

Best,

Whistler

In trying to help with the questions in this thread, it brings back lots of memories of the past few months with our d. 

I also manage a nutritional pharmacy for a group of complementary physicians (doing both traditional and nutritional treatments to prevent and treat disease).

In helping your child to eat more, maybe it would be helpful to please read or reread pg 157-162 of Help Your Teenager Beat an Eating Disorder by Lock and leGrange "Help Your Child to Eat More".  It talks about helping parents realize that setting clear expectations and clear consequences actually helps reduce the adolescent's anxiety about eating.  And it gives guidance how!

We found that during the meal, having several different items to eat were helpful instead of one "mountain" of chicken and noodles, for example.

Regarding stomach aches, I cant find the reference in the Help Your Teenager book, but many parents say their teens (including my own on occasion) complain about it.  The book states somewhere that a lowering of a couple of digestive enzymes due to, I think, the malnutrition and slow motility of AN, were the cause of the stomach aches. The solution to getting thru the stomach trouble for the most part, was to restore proper nutrition and changes would happen at the cellular level in the body or (pg 162) "...it is really not the physical problem that is causing discomfort - though it seems to your child that it is-, but more the emotional discomfort she feels about eating and the anxiety she has about gaining weight that's at the root of her complaints."

Regarding Omega 3s - absolutely helpful in brain health.  Without the calorie discussion, flax is good, fish oil is better - most important is the purity (especially in fish oil!).  Flax meal is only good in cold form - cooking it ends its helpful properties (eg. flax meal is great when added to salad dressing or part of yogurt and granola).  A company that has a great reputation for health food store pure deep sea fish oil is Nordic Naturals.  Getting EFAs (essential fatty acids) that are Omega 3s are EPA and DHA.  You won't need the extra vitamin A with a cod formula.  Look for the EPA and DHA only if looking at the Nordic Natural line or organic Flax otherwise. 

I too have read about the helpfulness of Zinc in regards to appetite - and immunity.  My d takes a multi, zinc, and Omega 3 for sure.

Bring back the butter, whole milk, whole yogurt, skin-on chicken, & sauces.  Enjoy premium icecream with strawberries and whipcream (great deserts Cheforexic recommends wholeheartedly as I remember) or a triple chocolate cake!  The only health consciousness I work on (besides enough protein/fruits/vegetables, etc) is that I get low homone/antibiotic/organic products especially with dairy, eggs, and meat where I can if convenient bcz we do eat more of it now.  

It has been so helpful to entice appetite! ! The oreos reappeared at our house.  Gramma helps by making regular chocolate chip cookies.  Chips with sourcream and lipton onion soup mixed for snacks came back too. We have come to believe that giving our d full nutrition including great snacks and deserts is the greatest present toward helping get her life back from her ED that we can give. 

The sooner she is not malnourished and her brain begins to work better, the harder she can fight the disease with us.  It helps me to remember she is suffering longer the slower we take to restore full nutrition and weight.

An early refeeding journal was:

2 crepes (easy to make) with crm chz, cottage chz, sugar and applesauce

bacon

juice

snack: yogurt with fruit and granola

fettucini alfredo w/peas and chicken

fresh fruit

chocolate milk with whey protein added

snack: chips or bagel/butter and peanutbutter

goulash

fresh fruit with a honey sauce

brownie with whipped cream

chocolate milk with whey protein

snack: smores at a bonfire  or the premium icecream smoothie

Hope it helps!

Thank you all for your help--do protein bars make good meal replacements?

 8 oz. steamed whole milk with 1 packet Carnation French vanilla sprinkled with cinnamon and nutmeg

1 cup cheerios with 1 cup whole milk

Banana

8 oz. chilled whole milk with 1 packet strawberry Carnation

Peanut butter and Jelly Sandwich (2 T. PB, 1 T. jelly, 2 slices bread 100cal.each)

8 0z. chilled whole milk with 1 packet choclate Carnation

8oz. whole milk with (YOU GUESSED!) 1 packet carnation vanilla

whole grain rice (300) with steamed and buttered vegetables(160)

8oz. whole milk with 1 packet Carnation (she chooses flavor)

1 1/2 c. premium ice cream (benandjerrys)

I know many of you moms and dads create wonderful variety in your ds diets, but my d is currently paranoid of any variety and refuses to eat anything new without taking HOURS!  for the present only, we are using this meal plan, but i know it is rather weak.  However it packs a powerful 3450 cals.  Keep it up moms!

Dooger,

  I've looked at Flax Seed Oil pills, what brand has such high calories?  I can only find 10 cal. per pill.

It has a mild, little bit nutty taste, but I have never thought of trying it in milkshakes. It is expensive and has to be used up before it goes rancid.

We have tried a nutella milkshake recently though, it was delicious (at least I thought so). 

Hi INOH and everyone,

We only 2 weeks into the refeeding process and things going along OK, haven't seen much gain yet and that's alright, happy to see her returning to some relatively normal eating habits, and happy to see her compliant with all meals at this stage. Will increase as we can, tip-toeing at the moment and observing. I take great comfort from the advice I get here INOH, from those who have forged ahead before us, and I don't claim to be an expert at anything yet.

I will though offer all of you some info regarding a supplement that can be ordered online - it's called CALOGEN and it is a long chain tryglceride fat emulsion, made by a company called NUTRICIA - http://www. nutricia.com and go to Clinical Products Info. (Can be ordered without prescriptions etc).

It is a clinical product with proven success in weight gain in cystic fibrosis sufferers, who often lose massive amounts of weight like our kids.

It is a white liquid, with absolutely no taste, and 100ml of it equals 450 calories. I put it in my d's afternoon shake, with the milk, which it blends into nicely without taste, and it certainly helps add calories to anything milky or creamy.

They also have the products FORTISIP (which are tetra packs of high energy nutrient drinks - 300 calories each 250ml) and SCANDISHAKE, which is a powder that you mix into 250ml milk and gives you 600 calories (not as high in nutrients as Fortisip or Ensure, but certainly has the calories if you are giving the nutrients another way). Scandishake was not developed for AN but for weight gain in CF patients, but it can help and it comes in flavours, or vanilla (which you can add anything to). You can also use the Scandishake powder in custard, hot chocolate, fairy cakes, jelly, yoghurt, smoothies etc. Studies show significant increased weight gain, energy intake and fat intake (but the studies were with CF patients).

Hope this info may help someone. My printer works overtime taking suggestions from this forum, everything helps.

Sue

TABLE 3. Estimated Calorie Requirements (in Kilocalories) for Each Gender and Age Group at Three Levels of Physical Activity^a

Estimated amounts of calories needed to maintain energy balance for various gender and age groups at three different levels of physical activity. The estimates are rounded to the nearest 200 calories and were determined using the Institute of Medicine equation.

^a These levels are based on Estimated Energy Requirements (EER) from the Institute of Medicine Dietary Reference Intakes macronutrients report, 2002, calculated by gender, age, and activity level for reference-sized individuals. "Reference size," as determined by IOM, is based on median height and weight for ages up to age 18 years of age and median height and weight for that height to give a BMI of 21.5 for adult females and 22.5 for adult males.

^b Sedentary means a lifestyle that includes only the light physical activity associated with typical day-to-day life.

^c Moderately active means a lifestyle that includes physical activity equivalent to walking about 1.5 to 3 miles per day at 3 to 4 miles per hour, in addition to the light physical activity associated with typical day-to-day life

^d Active means a lifestyle that includes physical activity equivalent to walking more than 3 miles per day at 3 to 4 miles per hour, in addition to the light physical activity associated with typical day-to-day life.

^e The calorie ranges shown are to accommodate needs of different ages within the group. For children and adolescents, more calories are needed at older ages. For adults, fewer calories are needed at older ages.

http://www.health.gov/dietaryguidelines/dga2005/document/html/chapter2.htm

USDA Dietary Guidelines

find the most calorie-dense foods in the smallest pieces.

for the first week or so you shouldn't care about the cholesterol, just get food into her as long as it's nutritional.

i know people might kill me for telling anyone this, but do stuff like put full-fat milk into skimmed milk bottles, and make her see the lable as you pour out a glass for her; she'll be more likely to drink it. get powder protein, put it in water, and pour over vegetables.

in my house there are some mini banoffee pies; toffee, cream, pastry, white chocolate-- 118 calories a bite. offer her one after a week or so, but don't force it on her. after a day offer her one again, and try to persuade her. don't force her. try a bit more every day, and she'll eat it after a few days. then she'll get used to sweet food again, gradually give her more.