БРОНХИАЛЬНАЯ АСТМА – BRONCHIAL ASTHMA

In anorexia, the first goals are to stop the patient from starving and to reverse her weight loss. Only then can we work on the emotional problems that led to the disorder in the first place.

Another goal is to show her how to reduce anxiety, not just about weight gain, but about food and eating as well. For an anorexic, who also binges and purges, an additional goal is to stop her bulimic behavior. Although some of the methods described below are for inpatient treatment, they can also be adapted for use with outpatients.

As in bulimia, there are three phases of behavioral treatment. First is the evaluation. During this time we conduct medical tests and get to know the patient. We draw up the treatment contract, which spells out the goals for weight gain and which both the patient and her parents sign. In this early phase, we tell the patient she must maintain at least the same weight she had when she was admitted. Otherwise she will be confined to her bed to save precious calories.

Once things have settled down we move into the next phase, during which we work toward the goal of bringing her weight back up to a healthier level. The contract specifies this target range, which is not subject to further negotiation because it is based on what we believe will be physically healthy for the patient.

We monitor the patient’s progress by weighing her daily. To get the most accurate reading, we weigh her in the morning, before breakfast and after she has gone to the bathroom. She wears only a robe. If knowing her weight will make her anxious, she faces away from the scale. We reward her for actual weight gain, rather than for her eating behavior during meals. The reason for focusing on weight rather than eating behavior is that the patient may give the appearance of eating all she is being served but may be getting rid of the food when no one is looking.

Our usual inpatient contract asks that the patient gain one half-pound a day. Such a goal is both reasonable and safe. Gaining weight too fast can cause edema or cardiac failure. If the patient reaches this goal, and is in no medical danger, she earns full privileges, such as complete recreation and visiting privileges. A gain of between a quarter and half a pound means only partial privileges. No gain-back to bed. This isn’t a punishment-bed is simply the safest place for a starving person to be. We also negotiate other incentives for weight gain at various points along the way: new clothes or records, special trips outside the hospital, and so on.

Gaining weight requires more calories than simply maintaining weight. Patients gradually work up to eating perhaps four thousand calories a day. Since the goal is not to teach someone to eat huge quantities of food or become bulimic, I usually add high-calorie liquid supplements such as Sustecal or Ensure to her normal amount of solid food.

Instead of requiring a specific daily weight gain, some doctors use a graph. A curve on the graph represents what the patient should weigh as time progresses. As long as her weight stays above that line, she earns full privileges. This method has one advantage over a daily weight-gain requirement. Especially during the early phases, a patient’s weight may fluctuate quite a lot, even if she is eating well, due to changes in water balance. A graph can take such fluctuations into account, which may keep the patient from being unfairly penalized.

Critics of the behavioral contract point out that an anorexic needs to develop a sense of self. She must find an identity that doesn’t depend on starvation. The contract, they claim, robs her of the opportunity to grow by imposing on her a mechanistic, prefabricated set of rules.

I disagree. My experience convinces me that many people with eating disorders welcome intervention by others, so long as it is done in a way that genuinely respects their individuality. A contract sets up boundaries and limits. It gives shape and focus to a world that is spinning out of control. The patient knows what to expect and what the consequences of her actions will be. I’m not saying that she necessarily likes those limits. Sometimes one benefit of the contract is to give her something to react to-or against. She finally has a focus for her anger. This in turn might help her to express anger rather than turn it inward. For people with an eating disorder, recognizing and dealing with anger is a good step in the right direction.

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In 1987, Fay Hodge stepped onto a scale at a Weight Watchers meeting. It was the first step of a journey in which she would lose 111 pounds and find a tremendous power within herself: the power to choose.

Fay had struggled with her weight since childhood. Like most of us, she was taught to eat everything on her plate. «My grandmother used to say that what I didn’t finish at dinner, she’d scramble into my eggs the next morning,» recalls the Fairfax, Virginia, resident. «She was teasing, but I got the message. My family worked hard to put food on the table. My job was to eat it.»

Unfortunately, the combination of eating too much and exercising too litde quickly took its toll. At age 7, Fay was put on her first diet by her doctor. It didn’t work. Neither did the diets that followed. She just kept gaining. At age 33, she weighed 266 pounds— «I was uncomfortable in my own skin and getting ready to develop another set of stretch marks,» she says.

At the time, a friend of Fay’s was going to Weight Watchers, and she urged Fay to join, too. It was through the organization’s weekly meetings that Fay came to a profound realization: Her weight and her health are the culmination of countless choices that she makes every day.

«I can choose to eat the right foods in the right portions and be successful, or I can choose to eat foods and portions that will cause weight gain,» she explains. «The decision is mine. I’m in control.»

With a newfound sense of empowerment, Fay embraced the Weight Watchers principles, eating a wider variety of nutritious foods, monitoring her portion control, and drinking lots of water. She also increased her level of physical activity by walking briskly three or four times a week. And sure enough, the weight came off.

«There is nothing more exciting than discovering a hip bone. I felt like Columbus!» she says. «I was absolutely intrigued that there was a body underneath all of those layers.»

In just 1 year, Fay took off 111 pounds. And she has kept off the weight for 11 years. Today, at age 45, she’s a statuesque 5′ 11″ and a size 12. She was so inspired by her own success that she became a Weight Watchers leader, helping others take the first steps of their own weight-loss journeys.

WINNING ACTION

It’s never too late to lose. When weight gain starts so early in life, it’s all that much harder to realize that there is a thin person in there, just begging to come out. Overweight needn’t be anyone’s destiny. Determination and the realization that you will succeed is the first step. When you start to doubt, just think of Fay.

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