Guest blog by Brittaney Berendsen, RD
Eating disorders are oh-so complicated. They are both profoundly common and profoundly complex mental health conditions. They affect individuals of all ages, sexes and genders, physically, emotionally, and mentally and are among the deadliest of all mental health diagnoses, second only to opioid overdose [1].
Registered dietitians – with sufficient training and the right meal plan – are uniquely qualified to guide patients towards recovery.
A meal plan is a personalized roadmap designed by dietitians to provide their clients with balanced and adequate nutrition. There are a variety of meal planning approaches for eating disorder recovery, each with its own strengths and weaknesses.
The benefits of a meal plan cannot be overstated; they play a pivotal role in restoring your patients’ physical health, stabilizing their emotions, and empowering them to develop a healthier relationship with food.
In this blog post, you’ll learn exactly how meal plans support your client’s recovery. You’ll also be equipped with new knowledge about the different meal-planning approaches for eating disorders so that you can better support your own clients in their treatment.
Let’s get started with just how many ways a meal plan can support your client.
Disclaimer: As with all articles, this is general information for educational purposes only and not individual advice or recommendations.
How an Eating Disorder Meal Plan Supports Recovery
How can the right meal plan help your patient on the path to recovery? Let me count the ways!
Provides Structure and Routine
This is probably no surprise to you, but eating disorder clients often follow irregular eating patterns and chaotic meal schedules.
This is where a meal plan comes in; it provides a clear framework for regular, consistent meals and snacks.
This structure helps stabilize their eating habits and reduces their anxiety; double win!
Contributes to Nutritional and Physical Stabilization
The profound nutritional deficiencies common with people with eating disorders can have serious health consequences.
A well-designed meal plan consistently includes essential nutrients and addresses the deficiencies that have arisen. By providing the patient’s body with the nutrition that they need, a meal plan helps to restore bodily functions, including digestion and hunger/fullness cues.
For those in need, eating disorder meal plans also assist with weight restoration.
Helps to Reduce Anxiety and Fear around Food
For patients with eating disorders, anxieties are often lurking around at mealtimes. Meal plans offer clear guidelines around food choices, including what, when, and how much to eat, which can ease anxiety.
When the person in treatment has less anxiety around meals and snacks, they are better able to make their own nourishment choices.
Meal plans also act as a framework to gradually reintroduce and tolerate a greater variety of foods. With time, practice and skill building, meal plans also equip patients to challenge food fears.
Enhances Accountability and Monitors Progress
Meal plans provide a framework for monitoring eating habits which serve as a daily motivation and accountability tool. A meal plan allows for adjustments as recovery progresses, allowing your patient to see where they are making progress and bringing focus to areas that need more support.
In order to understand the pivotal role of an eating disorder meal plan in supporting recovery, you need to understand five main principles that are the foundation of every meal planning approach.
Nutrition Foundations
There are five progressive nutrition stages to ensure that a person achieves re-nourishment safely. Your patient needs to master one at a time, not moving to the next before fully mastering their current level. The expectation is that the specific goals of each level will continue as they move to the next.
- Level 1 – Enough and Regularly: Consistent intake of preferred or safe foods every 3-4 hours.
- Level 2 – Macronutrients: Meals and snacks are optimized to a balance of all three macronutrients.
- Level 3 – Variety: Food variety is gradually expanded by alternating safe and preferred foods.
- Level 4 – Challenge: Feared foods begin to be introduced in a systematic and structured way.
- Level 5 – Spontaneity: Work on demonstrating flexibility in food choices and navigating various eating situations without experiencing significant distress.
The five progressive nutrition stages serve as the foundation of nutrition rehabilitation. They should be integrated into and regularly adapted for whatever meal planning approach is selected. Having an understanding of the different meal planning approaches ensures an optimal fit for your client.
Different Approaches to Eating Disorder Meal Planning
There are several meal planning approaches used within the eating disorder field, each with its own advantages and disadvantages. In the following section, we’ll evaluate the pros and cons of different meal-planning strategies for eating disorders.
Calorie-based Meal Plans
A calorie-based meal plan is an approach that outlines the specific amount of calories an individual should consume daily. Most of the time this meal-planning approach includes specific guidance on how the calories shall be allocated across the daily meals and snacks.
Pros of Calorie-based Meal Plans
- Calorie-based meal plans may help to normalize eating patterns and offer a concrete way to measure dietary intake.
Cons of Calorie-based Meal Plans
- They can contribute to rigidity and food preoccupation.
- The focus on the numerical value of calories disregards the nutritional quality of foods.
- The flexibility provided by the number’s focus can easily be hijacked by the eating disorder. This can lead to increased restriction, avoidance of certain foods/food groups and an imbalance in nutrient intake.
- The rigidity of counting also makes this meal plan less adaptable to different cultural foods and social situations.
Another significant limitation is that there is no validated energy expenditure calculation for use with eating disorders. This means that predicated calorie needs are likely inaccurate as they fail to account for metabolic changes that occur within eating disorders. This results in reduced effectiveness in meeting nutrition and energy needs.
Exchange-based Meal Plans
Exchange-based meal planning has been used for eating disorder recovery since the mid to late 20th century. It categorizes foods into groups based on macronutrient content and portion sizes, assigning a specific number of servings, or “exchanges,” for each. The number of exchanges assigned is determined by estimated calorie needs.
Pros of Exchange-based Meal Plans
- Exchange-based meal plans normalize eating patterns and promote balanced nutrition through allocating exchanges for different food groups.
- They provide some flexibility with food choices, allowing patients to choose different foods from each of the food groups.
Cons of Exchange-based Meal Plans
- Exchange-based meal plans may provide structure but at the detriment of rigidity. Some clients may become preoccupied with counting exchanges and meticulously planning meals. This can lead to heightened anxiety and fixation on food.
- Another limitation of exchange-based meal plans is that the serving sizes of foods in each exchange group are different. This can contribute to overwhelm and poor adaptability to social situations as it requires memorization or frequent referencing of lengthy exchange guides. It is important to note that cognitive functioning is impaired in a state of malnourishment, and the complexity of exchanges may take the place of time and energy that could be better spent on other recovery activities.
- Similar to calorie-based meal plans, exchange-based meal plans may not meet nutritional needs. The amount of exchanges a person is allotted is calculated using calorie estimation equations. As previously reviewed, this approach may not fully meet the changing needs caused by metabolic adaptations in eating disorders.
- Exchange-based meal planning is more aligned with Eurocentric eating patterns. This poses challenges for people from diverse cultural backgrounds and can negatively impact recovery outcomes.
Rule of Threes (RO3)
The Rule of Threes (RO3) meal plan was created by dietitians Marcia Herrin and Maria Larkin [2]. RO3 centers around three key guidelines:
- Consuming three meals daily
- Eating at least every three hours
- Including at least three different food groups in each meal
The Rule of Threes meal plan also provides a concise list of portion sizes for each food group.
Pros of Rule of Threes Meal Plans Meal Plans
- The RO3 meal plan approach offers a simplified alternative to traditional exchange-based meal planning.
- It provides some guidance on portion sizes for each food group, without requiring any counting.
- Although it is less rigid, the defined portion sizes included in this meal planning approach may still contribute to heightened anxiety and fixation on measuring foods, depending on the individual.
- The three key guidelines promote balanced nutrition, allow for flexibility in food choices, and enable clinicians to make changes based on individual client progression, as opposed to calorie equations.
Cons of Exchange-based Meal Plans
- This meal-planning approach may have limited cultural adaptability as it also aligns more closely with Eurocentric eating patterns.
- Similarly, adaptability to social situations may be somewhat challenging due to the defined portion sizes.
- Lastly, a criticism of RO3 is the classification of some foods as “fun foods”. This can be harmful because it perpetuates a dichotomy between “good” and “bad” foods. This labeling system can reinforce unhealthy and rigid beliefs about food, potentially leading to feelings of guilt or shame. Moreover, it can hinder progress towards a healthier relationship with food by attaching emotional significance to certain foods, rather than valuing all foods for their diverse contributions of nutrition and satisfaction.
Plate-by-Plate
The Plate-by-Plate approach is a visual method meal planning method developed by dietitians Wendy Sterling and Casey Crosbie [3]. It focuses on balanced eating by breaking down meals into different components on a 10-inch plate. There is also the option to include 2-3 snacks per day consisting of 2-4 items, depending on individual needs.
Pros of Plate-by-Plate
- This meal planning approach most closely resembles normal eating and promotes balanced nutrition.
- It is the most flexible with food choices and variety at meals, as it does not involve any counting, measuring or tracking.
- While it still is easier to use with a Eurocentric eating style, there are many examples and tools for adapting mixed dishes and various cultural cuisines to the approach.
- Similarly, the absence of measuring and counting meals makes this approach more easily adaptable to social situations.
Cons of Plate-by-Plate
- There may be some limitations with adaptability for foods that are not served on plates (i.e. soups).
- This approach may be too flexible for anyone with a tendency to restrict portion sizes.
Optimal Attributes for Meal Plans
So which is optimal?
The optimal meal plan depends on the specific needs of your client; how much structure is enough, without feeling restrictive? What is the specific diagnosis? What are their preferred foods?
The following graphic summarizes the attributes of the different meal planning methods discussed earlier. As you can see, there is overlap in the attributes that they share, but they differ in their level of structure and adaptability.
Given that every person with an eating disorder is different, with different symptoms, concerns and goals, choosing the right meal planning approach can be a daunting task! In the next section, we will explore recommendations for the most effective meal planning approaches based on specific eating disorder symptoms.
Fueling Progress: Selecting the Ideal Meal Plan
The right meal plan approach for your specific patient depends on a variety of factors, including their individual eating disorder diagnosis/ symptoms, physical needs and the level of support that is available for putting this meal plan into action.
The following provides a brief overview of which meal planning approaches may be most suitable based on eating disorder symptoms.
- Anorexia: Involves restriction, so a more structured meal-planning approach, such as Exchanges or RO3 is likely initially needed in order to meet nutritional needs. More flexible meal planning approaches, such as Plate-by-Plate may be appropriate if they are being portioned by a supportive loved one or later in recovery.
- Bulimia: Involves recurrent episodes of binge eating and subsequent compensatory behaviors such as purging via vomiting, over-exercise and laxative abuse. Meal planning approaches that add structure, without too much rigidity, such as RO3 and Plate-By-Plate are recommended.
- Binge Eating Disorder: Involves recurrent binge eating episodes without compensatory behaviors. For this diagnosis, using a flexible meal planning approach that meets nutritional needs without too much rigidity, such as RO3 and Plate-By-Plate is necessary to reduce potential triggers for binge eating behaviors.
- Avoidant/Restrictive Food Intake Disorder (ARFID): Given the diverse presentations of ARFID, a more personalized meal planning approach is essential to address its unique challenges. While the foundational nutrition principles remain paramount, customizing portions and strategies proves more effective in navigating this particular eating disorder. Check out this FREE resource to learn more about the different ARFID presentations.
After carefully choosing the optimal eating disorder meal plan for your patient, it’s important to keep in mind that meal planning strategies are not set in stone; they will change over the course of your patient’s treatment.
Popular Eating Disorder Meal Planning Resources
Ready to update your tools? These hand-picked resources are a shortcut.
Snack Pack for Eating Disorder & Intuitive Eating RDs (Includes Non-Dairy, Nut Free & Gastroparesis)
How Approaches Evolve Throughout Recovery
As recovery progresses, meal planning approaches should shift too in order to better meet nutritional needs and eating disorder symptoms.
Initially, prioritizing structure supports nutrition and physical rehabilitation and as recovery advances, gradually introducing more flexible meal planning aligns with regular eating patterns. This transition helps people develop a healthier relationship with food and supports their ongoing recovery journey.
Intuitive Eating: The Last “Stop” In Eating Disorder Recovery
Intuitive Eating, created by dietitians Evelyn Tribole and Elyse Resch, is an evidence-based, weight-neutral, mind-body health approach to eating [4]. It includes 10 guiding principles designed to help individuals tune into hunger and fullness cues, reject diet culture and food rules, and eat for both nourishment and satisfaction. It encourages self-compassion, body acceptance and a balanced relationship with food.
Although the Intuitive Eating framework is beneficial for cultivating a healthy relationship with food, is not advisable in the early stages of recovery. Nutrition rehabilitation and structured eating are necessary before hunger and fullness cues can be used to regulate eating. Moreover, it is crucial to work through underlying emotional and psychological factors before embracing intuitive eating.
The shift away from a meal plan and towards intuitive eating should be gradual, and supported by professional guidance and medical monitoring [5].
While intuitive eating may be the end goal for many some, it may not be an approach that is accessible to all. For example, some people may struggle with interoceptive awareness related to neurodiversity or medications, which may make this way of eating more challenging. In addition, some people with an eating disorder will require the structure and support of a meal plan for the rest of their lives.
No matter what, it is important that the meal planning and eating approach is individualized to personal recovery goals and provides support without causing harm.
The My Fuel Mix™Workbook Meal Planning and Macronutrient Guide can be a helpful tool for transitioning to Intuitive Eating.
Thinking Beyond the Meal Plan: Tips for Comprehensive Care
Meal plans play a significant role in eating disorder recovery, providing structure and guidance for nourishing the body. However, it’s crucial to recognize that they are just one piece of the larger puzzle. Eating Disorder Dietitians can assist with recovery by providing specialized support and guidance, well beyond a meal plan.
What is an Eating Disorder Dietitian?
An eating disorder dietitian is a highly specialized healthcare professional with extensive training and supervision in the treatment of eating disorders.
Eating disorders are extremely complex, and their nutrition management is very different from other conditions. This means that specialized training is necessary to provide safe and effective care.
Eating disorder dietitians undergo specialized training to ensure that they understand the unique medical complications of eating disorders and specific nutrition considerations. Just like you wouldn’t see a family doctor for surgery, you shouldn’t see a general dietitian for eating disorder help.
Qualities of an Expert Eating Disorder Dietitian:
What qualities make a dietitian well suited to this work? Here are our top considerations for a dietitian being a good match.
- Client-Centered: Beyond their specialized training, a defining characteristic of a skilled eating disorder dietitian is that they offer a variety of meal planning approaches and prioritize a collaborative client-centered approach.
- Intersectional Lens: Another distinguishing feature is that they practice with an intersectional approach. This means that they do not treat the eating disorder in isolation. Instead, they have a comprehensive understanding of how co-current mental health diagnoses, neurodiversity, trauma, gender and sexual diversity, racism, weight stigma and body image are involved in eating disorders and recovery.
- Weight Inclusive: It is also vital to work with an eating disorder dietitian who provides weight-inclusive care. This means that they value and respect diverse body sizes, recognize that health isn’t solely determined by weight, and do not encourage weight loss.
This is of the utmost importance as underfeeding individuals in higher-weight bodies causes harm and creates significant barriers to recovery. It is unethical to prescribe calorie restriction as a treatment for a higher-weight individual with an eating disorder but view it as something that needs to be treated in a person living in a smaller body.
Any meal plan has the potential to cause harm and perpetuate anti-fat bias/fatphobia (although it is seen more commonly in meal plans that use calorie estimation calculations). Meal plans should be communicated as tools that outline the minimum amount of nutrition needed. This helps prevent restrictive behaviors and protects your clients from feeling wrong or bad for needing to eat beyond the meal plan.
How does an Eating Disorder Dietitian Help in Recovery?
Beyond specialized nutrition assessment and meal planning skills, eating disorder dietitians support recovery by offering essential support and education. They assist individuals in understanding their eating disorders and navigating their relationship with food, body image, and emotions.
Looking for resources beyond meal plans to support eating disorder recovery? Check out The Ultimate Eating Disorder Gentle Nutrition Bundle with over 75 pages of client education handouts, and the Body Image Bundle!
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Summary
Meal plans are indispensable tools in the journey of eating disorder recovery, providing structure, stability, and balanced nutrition. They serve as vital guides, addressing physical health, stabilizing emotions, and fostering a healthier relationship with food.
The selection of a meal plan should be based on individual needs, diagnosis, and level of support available. As recovery progresses, flexibility in meal planning approaches can be introduced to align with regular eating patterns and promote a more intuitive approach.
As registered dietitians, it is important to remember that meal plans are just one part of a comprehensive recovery plan. The expertise of an Eating Disorder Dietitian is invaluable in providing specialized support beyond meal planning. They offer a holistic understanding of the complexities surrounding eating disorders, tailoring care to individual needs and ensuring a safe and effective path to recovery.
Brittaney Berendsen
Brittaney is a trauma-informed, anti-diet and weight-inclusive Eating Disorder Dietitian. She is a proud dog mom to a retired racing Greyhound and finds that she is fuelled by food, forests and fresh air.
Brittaney provides virtual eating disorder treatment and nutrition counselling for residents of Ontario, Canada. To learn more about working with Brittaney, follow the link below.