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When treating eating disorders, the role of nutrition is essential in rehabilitating the body and preventing further medical complications or mortality. Nourishment during recovery comes in the structure of a meal plan prescribed by the dietitian.
At an inpatient level of care nourishment will be more aggressive. As patients transition to less intensive levels of care meal plans will transition from being highly structured to more accountable and intuitive. Before recommending a meal plan a dietitian must first assess a patient’s needs.
Assess Appropriate Level of Care
Before deciding on a nutrition intervention, the appropriate level of care must be determined. Dependent on the severity of an eating disorder a team may recommend one of the following levels of care:
- Inpatient Treatment Center
- Residential Treatment Center
- Partial Hospitalization Program (PHP)
- Intensive Outpatient Program (IOP)
When recommending a level of care the severity of behaviors and the risk on refeeding must be taken into account. It’s important to identify if a patient is medically stable and as nutrition professional we have a duty to acknowledge when a level of care is not serving out patients appropriately.
Assessing Current Behaviors and Risks
The extent and combination of behaviors will play a role in determining the appropriate level of care. A patient can suffer from restriction, bulimia, binge eating, over exercise, laxative and diuretic abuse, etc.
Indications for inpatient hospitalization or a higher level of care include :
- Bradycardia or tachycardia
- Low blood pressure
- Symptomatic hypoglycemia
- Uncontrolled vomiting or purging behaviors
- Weight <75% of ideal body weight (IDW)
- Rapid loss of weight
- Lack of improvement or worsening despite outpatient treatment
Patients requiring a higher level of care may be at higher risk of refeeding syndrome and electrolyte imbalances.
Assessing Individual Energy Needs
When assessing for energy requirement some dietitians may use qquations such as Harris-Benedict and Mifflin St.Jeor can be used to measure resting energy expenditure (REE) or basal energy expenditure (BEE) . Others may use the recommended starting range of 30-40 kcal/kg .
Once energy requirements are estimated it is the dietitian’s responsibility to monitor labs, vitals and appropriateness of meal plan increases and changes. It is appropriate to increase energy needs every 2-3 days when aiming for a 2-4lb weight increase weekly . The type of meal plan will be chosen based on the dietitian’s assessment and the patients level of care.
Types of Meal Plans for Eating Disorder Recovery
When creating a meal plan it’s important to understand what a patient is suffering from and the overall role of nutrition in recovery. Remember the more severe the eating disorder the more structure required.
As a patient progresses through the process of renourishing their body, they are also able to progress to less structured meal plans. The most structured meal plan starts with the exchange system.
Exchange System for Eating Disorders
The exchange system takes the patients focus away from counting calories and highlights the bodies need for all macronutrients and micronutrients. There are 2 resources a patient will need for support.
First, a patient will need an exchange book laying out food groups and measurements for exchanges. Second, a patient will need an individualized meal plan from the dietitian.
On a patient’s meal plan the dietitian will need to indicate how many carbohydrate, protein, fat and fruit or vegetable exchanges are required at each meal and snack. Here is an example meal:
- 2-3 Carbohydrates
- 2-4 Proteins
- 1-3 Fats
- 1 Fruit
The exchange system probably takes the most time to learn and can seem complicated at first, but for a patient needing to gain weight of just improve their relationship with food this method is an invaluable starting point.
Entree-sides method works away from measuring and counting and towards a more visual method of plating meals. At all meals the goal would be to have an entrée and at least 2 side items.
Similar to the exchange system this method will provide structure with consistent meals and snacks. As a dietitian our job is to a guide a patient by providing lists of appropriate entrée and side examples. For snacks patients would be prompted to choose 2-3 items from again a snack list provided.
Here is an example template to use when building a meal plan:
- Breakfast: Entrée + 2 sides
- Snack: 1 item from list A, 1 item from list B
- Lunch: Entrée + 2 sides
- Snack: 1 item from list A, 1 item from list B
- Dinner: Entrée + 2 sides
- Snack: 1 item from list B, 1 item from list C
The entrée-sides as well as our next meal plan option, rule of threes, are both go to options when stepping down from the exchange system.
Rule of Threes
This approach allows for an easy way to remember we need 3 meals per day, up to 3 snacks per day and we should eat about every 3 hours. The rule of threes provides structure to build consistency with eating patterns as well as consistency including all food groups.
The rule of threes will also support patients in building each meal with the 3 macronutrients including carbohydrates, proteins, and fats and a fruit or vegetable. With this plan the dietitian can start by guiding patients to build a weekly menu for all meals and snacks. As the patient builds confidence in putting meals together, they will work towards planning meals in the moment.
The Plate-by-Plate approach is a dietitian designed method that helps families to support their children nutritionally. This method is generally used to support family-based therapy (FBT) and doesn’t always involve a dietitian .
The Plate-by-Plate approach promotes normalization of eating at home and supports reintroduction of food children may fear, but love. This method has to different visual plate options parents can follow to support weight gain or maintenance. As with the other meal plan options consistency of 3 meals and up to 3 snacks is recommended.
- Food to Eat That Makes You Feel Good
- What Are the Dangers of Fad Diets?
- How Your Metabolism Works
- Physical Cues of Hunger and Satiety
- Nutrition Counseling for Treating Eating Disorders
Intuitive eating is a non-dieting approach to eating. The intention is to support clients in shifting from a weight loss mentality to an ability to listen and hear the bodies needs and desires. This is a practice dietitians can support and guide patients in learning the 10 principles :
- Reject the Diet Mentality
- Honor Your Hunger
- Make Peace with Food
- Challenge the Food Police
- Feel Your Fullness
- Discover the Satisfaction Factor
- Cope with Your Emotions without Using Food
- Respect the Body
- Exercise – Feel the Difference
- Honor Your Health with Gentle Nutrition
The principles of intuitive eating can be learned while a patient is on another meal plan. Principles can then be applied and practiced when a patient is through the refeeding process and able to hear and listen to their body.
Gradually Building Goals and Interventions
You can see a common theme in all meal plans is healing the body and learning that all foods fit. Along with appropriate nutrition must come a couple key components in supporting knowledge, growth, and healing.
Throughout this process patients can often be confused and scared. As nutrition professionals it is our job to not just guide a patient to setting goals, but to support them in understanding why they are setting these goals.
In program settings nutrition education can be a part of sessions or weekly groups. Education related to the effects of malnutrition, metabolism, macronutrients, hydration, and more are essential in supporting the why and providing long-term motivation for recovery.
A meal plan includes all of the basics including macronutrients, micronutrients, and hydration. What a meal plan may not include is variety. Dietitians can support patients in not only healing their body, but healing their minds through supporting the incorporation of variety in exposure based treatment.
Exposure based treatment involves setting goals with patients to challenge foods and situations involving food that cause anxiety or distress. Exposure based therapy supports the idea that the more an individual is presented with a fear the more likely anxiety is to decrease over time. These exposures are also meant to build skills and support self-regulation of emotions.
The human body was made to move. When appropriate enjoyable and mindful movement should be incorporated into recovery. The incorporation of movement is a learning opportunity as well.
As movement increases whether normal daily movement or the addition of exercise the metabolism is impacted. These are key learning points where patients can work with their dietitian to increase nourishment and listen to the cues provided by the body.
Resources: Arthur, B., Strauss, L., & Mehler, P. S. (2015). Refeeding the Patient with Anorexia Nervosa: Perspectives of the Dietitian, Psychotherapist and Medical Physician. World Journal of Nutrition and Health, 3(2), 29–34. https://doi.org/10.12691/jnh-3-2-1  Cuerda, Vasiloglou, & Arhip. (2019). Nutritional Management and Outcomes in Malnourished Medical Inpatients: Anorexia Nervosa. Journal of Clinical Medicine, 8(7), 1042. https://doi.org/10.3390/jcm8071042  Eating Disorder Treatment | The Plate-by-Plate Approach. (n.d.). The Plate-by-Plate A. Retrieved August 23, 2021, from https://www.platebyplateapproach.com/  Tribole, E., & Resch, E. (2012). Intuitive Eating: A Revolutionary Program That Works (Third ed.). St. Martin’s Griffin.
Author: Raylene Hungate, RDN,LD/N
Page Last Reviewed and Updated By: Jacquelyn Ekern, MS, LPC on September, 27 2021