Eating disorder meal plans are kind of like casts when you break a bone: they’re necessary for healing, and are eventually and carefully discarded when it’s time. As an eating disorder dietitian, I view meal plans as temporary tools to help patients build healthy habits in place of disordered ones and stay regularly nourished. However, the same tool doesn’t work for every person, so eating disorder meal plans need to be created on an individual basis to best support a patient’s unique physical and mental needs. Read on to learn why meal plans are important in recovery, different types of meal plans, and how we create them, as well as how to follow one and when it’s time to let go of your meal plan.

The purpose of eating disorder meal plans

When you’re consumed by an eating disorder, it’s nearly impossible to properly judge the energy (calorie) and nutrient requirements for you to be physically, mentally, and emotionally healthy. A meal plan takes that responsibility away from the eating disorder brain, providing a meal-and-snack template designed to help bring your mind and body back into balance.

“Meal plans provide the structure of what to eat, how much to eat, and when to eat that people need in order to fuel adequately despite the eating disorder voice telling them they’re full, not hungry, or don’t need to eat,” says Equip lead dietitian Tanya Hargrave-Klein MS, RDN. Since eating disorders sever the connection between the brain and body, meal plans provide an external guide while that connection is being restored. “Meal plans are important early in eating disorder recovery when individuals can’t rely on hunger and fullness cues because these cues have been blunted or muted by the eating disorder,” Hargrave-Klein explains. “People often need to rely on mechanical eating—or eating by the clock—to ensure they’re meeting their nutritional restoration needs, because they can’t rely on their body to prompt them to eat.”

Aside from aiming to restore energy balance, meal plans are also meant to help you find relative balance by incorporating all food groups (grains, proteins, fats, fruits and veggies, and dairy) and a mix of nutritious and “fun” foods, along with fluids. “Meal plans ensure the body is refueled with enough food, replenish any nutrient deficiencies, and address any nutrition-related conditions such as Celiac disease,” says dietitian Kristin Draayer, MS, RDN. “Meal plans help people relearn skills for creating adequate, balanced meals for long-term recovery and gain independence in making food choices.”

According to Hargrave-Klein, meal plans can also be helpful for challenging the harmful messages society sends us about food and eating. “Between the eating disorder voice and the diet culture we all try to exist in, many people have been fed big lies about what their bodies need to survive and thrive,” she says. “A meal plan can aid them in learning or re-learning how to nourish their body in a way that promotes physical and psychological health.”

Different types of eating disorder meal plans

Eating disorder meal plans are never one-size-fits-all, and there are various styles for different circumstances, preferences, and personalities. “There’s no right or wrong meal plan, as it’s dependent on the individual and a variety of factors including co-occurring conditions like OCD or ADHD, prior experiences using meal plans, diagnosis, treatment approach, and many other nuanced variables,” Hargrave-Klein says.

Here are some of the most common eating disorder meal plan styles:

Calorie-based meal plans

According to Equip’s 2023 study on digitally delivered dietary interventions, calorie-based meal plans typically include a daily calorie target goal, which is provided to parents or caregivers of the eating disorder patient by their dietitian. They’re also given the number of meals and snacks the patient should have, with individual calorie targets for each. Calorie-based meal plans are often used in Family-Based Treatment (FBT), since someone other than the person with the eating disorder is typically in charge of the food and menu in FBT. “Caregivers may find calorie-based plans helpful, as they provide measurable reassurance,” Draayer explains. Since discussing calories can be triggering for the person with the eating disorder, it’s not recommended that they are involved in the calorie goal conversations. Outside of FBT, there are only a few instances when calorie-based meal plans could make sense, according to Dylan Murphy, RD, LDN. “There are some scenarios where a client has a neutral relationship with calories and seeing those numbers,” she says, “and in those cases, using calorie-based meal plans may be beneficial.”

Plate-by-Plate

The plate-by-plate approach is a numberless, flexible meal structure that emphasizes including all food groups at meals and snacks. It’s visually based, using a plate to help patients and caregivers create adequate and balanced meals. It was originally created for FBT, but is now used widely in all types of eating disorder treatment. The approach includes different guidelines for building meals and snacks, depending on treatment goals. For weight restoration, for example, it’s recommended for starches to take up half the plate, protein to take a fourth, and fruits and veggies to take the remaining fourth; dairy and fat sources are included on the side or within the meal, as determined by the dietitian. The plate-by-plate approach also includes similar guidelines for snacks. “Plate-by-plate is the meal plan we use most often because it takes numbers and counting out of the picture and focuses more on how the food items should look on the plate,” Murphy says. “This approach is especially beneficial in outpatient settings when we’re working on increasing flexibility with food, like eating out and traveling.”

Exchange system

The exchange system is what’s often used in higher levels of care at eating disorder treatment centers. It was developed by the American Diabetes Association and groups foods into six categories, with each exchange indicating a specific amount of food (for example, an 8-ounce glass of milk counts as one dairy exchange). The exchange system encourages balance and adequacy while including numbers other than calories (i.e., the number of exchanges needed), and typically requires some measuring of foods. “These meal plans offer precision in terms of serving size and number of servings, so there’s little room for the eating disorder to negotiate,” Hargrave-Klein says. “And the meal plan feels very black-and-white, which can be comforting for those experiencing an eating disorder.”

Rule of Threes

Another more fluid meal structure, the Rule of Threes includes a simple rule of thumb to follow daily: include three meals and up to three snacks, each containing all three macronutrients (carbs, fats, and proteins), and eat about every three hours. “This less structured approach is ideal for clients who need some guidance with flexibility,” Draayer says. Like the Real Food Guide, a flexible yet comprehensive eating disorder meal planning tool studied in 2018 in Australia and New Zealand, the Rule of Threes provides you with a template to develop a menu with your dietitian that fits your energy and nutrient needs. Eventually, it can be used to guide you in making present-moment food decisions.

“The suitability of meal plans varies, because everyone is different, and so is every eating disorder,” Draayer explains. “Sometimes a more structured meal plan is preferable, such as when a person is earlier in recovery or for children and teens, while more flexible plans might be appropriate as recovery progresses or for someone with heightened anxiety around rigidity.”

In my practice, I’ve discovered that merging two meal plan approaches can be supportive sometimes, such as an exchange-based plan fused with the plate-by-plate approach, so the client thoroughly understands how much food they need from each food group and how it translates to a plate. Sometimes, understanding your needs in multiple ways can support a more natural transition into a more flexible and intuitive way of eating. When clients need to understand what a serving of a food looks like, I also find it most helpful to use objects instead of measuring cups or utensils. For instance, one cup of rice is about the size of a baseball, three ounces of meat is like a deck of cards, and two tablespoons of peanut butter is about the size of a Ping-Pong ball.

How RDs create eating disorder meal plans

When creating an eating disorder meal plan, dietitians consider several factors. According to Hargrave-Klein, some factors that need to be taken into account include:

  • Whether or not a patient needs to weight restore
  • Cultural and religious-related food preferences
  • Access to food and food preparation facilities
  • Whether the patient or their supports will be in charge of food preparation

The starting point for the meal plan is determining the amount of energy (calories) a patient needs to support physical and psychological health, and from there, dietitians create a structure, usually using one of the meal plan styles explained above. “The dietitian supports the individual or caregiver in determining how best to divide up their food intake between meals and snacks,” Hargrave-Klein explains.

Throughout treatment, meal plans are usually adjusted depending on how a patient’s body responds and your needs change. One 2023 study concluded that extra care needs to be taken when preparing meal plans for eating disorder patients, because even small changes can cause significant issues for patients mentally and emotionally—it’s one of the reasons why collaboration and ongoing communication are key. “We want to make sure creating a meal plan is a team effort, so we have several sessions where we go over what the meal plan looks like and then work with the client to come up with meal and snack ideas that fit the parameters of the meal plan,” Murphy says. “We want to ensure the meals and snacks are ones the client would enjoy or typically consume.”

Dietitians also assess factors like your cooking skills, access to food, and budget, all of which can be accommodated. “A dietitian can collaborate with patients and families to craft an individualized meal plan,” Hargrave-Klein says. “The plan can include the foods that a person has access to through a food pantry or that can be purchased using SNAP benefits.” Specific dietary needs are also considered, such as dairy or egg allergies. “Meal plans also should be flexible to accommodate traveling, eating out, and special celebrations,” Hargrave-Klein adds.

Often, meal plans are necessarily more structured and fixed in earlier and more acute stages of recovery (when the eating disorder brain is its loudest) and can become more flexible once a patient has gained adequate weight (if necessary) and addressed any nutrient deficiencies. In my outpatient practice, meal plans are the backbone of my eating disorder patients’ energy and nutrient needs at first. Once they’ve progressed and are eating regularly, we can explore increased flexibility, variety, and autonomy in eating, and start to dabble in intuitive eating practices, like acknowledging hunger and fullness cues—all within the structure of a meal plan. Research shows it’s possible for eating disorder patients to eat intuitively eventually, however it’s important to approach it with awareness and intention, and not to rush it.

How do you stick to a meal plan?

When it comes to eating disorder meal plans, creating the plan is just the dietitian’s first step—we’re also equipped to help you develop strategies to follow your meal plan consistently. “Having a meal plan and actually consuming the meal plan are definitely two different things when it comes to eating disorder treatment,” Hargrave-Klein says. “The dietitian collaborates with the patient, client, or support person to identify foods that the patient or client might be willing to eat in order to meet the meal plan. They also provide psychoeducation about the value of consistent and adequate nutrition on physical and psychological health, offer simple tips and tricks to increase the density of meals and snacks when weight restoration is a goal, and troubleshoot perceived barriers to meeting the meal plan.”

In my practice, I work with clients to develop mealtime tools to overcome such barriers, which can be integrated into the meal plan itself. Common effective strategies include using nervous system regulation tools (i.e. breathing practices or music); increasing external safety cues with support people, comforting objects, or pets; and incorporating distress tolerance skills developed in therapy. Murphy says she starts with small goals to make meeting the meal plan achievable for her clients. “Depending on where the client is when we begin working together, we know 100% completion may not happen at first,” she says, “So we work to meet the client where they are and find ways to gently challenge them towards their goals.”

Sometimes, it’s helpful to log feelings and thoughts at meals and snacks to identify patterns that may be making it hard to meet parts of the meal plan. From there, together with your dietitian and therapist, you can start to understand how your eating disorder is functioning emotionally at specific points in your day and address hard emotions and disordered thought patterns to make it more realistic for you to get nourished.

Do you have to follow an eating disorder meal plan forever?

At this point, you may be wondering, “How long do I have to stay on my eating disorder meal plan?” The answer isn’t black-and-white, because everyone’s recovery moves at a different pace; however, they aren’t meant to be used forever. “Readiness to transition from a meal plan to a more intuitive eating style typically takes place later in treatment and recovery,” explains Hargrave-Klein. “The individual needs to be in a place of good psychological and physical health and demonstrate consistent flexibility around food and eating. Hunger and fullness cues should be reconnected and fairly reliable before someone is ready for intuitive eating.” Transitioning off of a meal plan needs to be done with awareness and care (and often in stages) together with your dietitian, and at a pace that feels safe to you and supportive of your recovery.

In the future, it may be helpful to return to your meal plan when you’re needing more structure and a tangible reminder of your nourishment needs. That might mean temporarily following your meal plan during big life transitions (like starting college), grieving periods after losing a loved one or an ending to a relationship, and an eating disorder relapse. So, when you and your team decide it’s time to let go of your meal plan, it’s wise to keep it tucked away somewhere you’ll easily be able to remember.

References
  1. Hellner, M., Steinberg, D. M., Baker, J. H., & Blanton, C. (2022). Digitally Delivered Dietary Interventions for Patients with Eating Disorders Undergoing Family-Based Treatment: Protocol for a Randomized Feasibility Trial12, e41837–e41837. https://doi.org/10.2196/41837
  2. How a Dietitian Can Help Create an Eating Disorder Treatment Meal Plan. (n.d.). Eating Disorder Hope. https://www.eatingdisorderhope.com/nutrition-counseling-eating-disorders/meal-plan
  3. ‌ Hart, S., Marnane, C., McMaster, C., & Thomas, A. (2018). Development of the “Recovery from Eating Disorders for Life” Food Guide (REAL Food Guide) - a food pyramid for adults with an eating disorder. Journal of Eating Disorders6(1). https://doi.org/10.1186/s40337-018-0192-4
  4. Langlet, B., Nyberg, M., Wendin, K., & Zandian, M. (2023). The clinicians’ view of food-related obstacles for treating eating disorders: A qualitative study. Food & Nutrition Research67. https://doi.org/10.29219/fnr.v67.8771
  5. Richards, P. S., Crowton, S., Berrett, M. E., Smith, M. H., & Passmore, K. (2017). Can patients with eating disorders learn to eat intuitively? A 2-year pilot study. Eating Disorders25(2), 99–113. https://doi.org/10.1080/10640266.2017.1279907
  6. Ekern, B. (2016, August 13). Meal Plans & Long Term Eating Disorder Recovery. Eating Disorder Hope. https://www.eatingdisorderhope.com/blog/understanding-meal-plan-eating-disorder-recovery-long-term#:~:text=A%20more%20structured%20meal%20plan
Caroline Young
Contributing Writer, RD
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