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March 2, 2023

When, Why, and How to Use Meal Plans in Eating Disorder Recovery

When, Why, and How to Use Meal Plans in Eating Disorder Recovery

Individuals with eating disorders frequently employ a meal plan developed with the help of their dietitian. This plan provides structure and supports a person in having the type and amount of food their body needs, divided over consistently timed meals and snacks.

What Is a Meal Plan for Eating Disorder Recovery?

While meal plans are often used in fad diets, a meal plan for eating disorder recovery is very different. First of all, meal plans for fad diets are often not created by a Registered Dietitian and are not individualized. Meal plans in recovery are created for an individual’s specific needs by a Registered Dietitian.

While fad diets establish diet culture rules, often exclude essential nutrients, and reinforce shame, meal plans for eating disorder recovery provide a framework to meet individual needs while allowing flexibility and a variety of food types. Instead of being restrictive in nature, they are additive and focus on ensuring that nutritional needs are met. Eating disorder recovery meal plans also set the stage for future eating practices in addition to providing resources to use as a backup as needed.

The level of structure can vary depending on what is best for each individual. Some clients require a highly detailed exchange-based meal plan, while others may need to simply follow an intuitive eating-based approach. None of the meal plan types are better or worse than the other. What is important is providing the appropriate level of support and structure. Often, meal plans are modified over time to adjust to wherever the person is at in their recovery from an eating disorder.

To reiterate the difference between fad diets and eating disorder meal plans, it is important to emphasize that the goals of recovery meal plans are NOT to:

  • Lose weight or control weight
  • Restrict food
  • Promote one food, nutrient, or type of food over another
  • Create a “perfect, healthy eater”
  • Follow a meal plan forever

Now that we truly understand why meal plans in recovery are different from non-medical diets, let’s move on to some different types of meal plans that can help people manage an eating disorder.

The level of structure provided by a meal plan can vary from a highly detailed exchange-based plan to a more general entrée-sides plan to more of an intuitive eating-based approach. No meal plan style is necessarily better than another; what is important is that it provides the right level of support for that person at that time. As a person’s ability to manage food intake changes, their meal plan is often adjusted as well. Let’s look at some of the different styles of meal plans in a bit more detail.

What Is The (Eating Disorder) Exchange System?

In this style of meal planning, a person works with their dietitian to create a “meal pattern,” which outlines the timing, type, and amount of each food category over the course of the day.

A sample meal pattern

The meal plan is organized using a system of exchange lists. These lists contain foods grouped together because they are nutritionally similar. The seven exchange lists include grains, protein, fruits, vegetables, calcium/milk, fats, and desserts. The eighth category is called other, and it is generally used for supplements to the meal plan. Here is an example of what a section of the grain exchange list looks like. The full list is much longer and contains many other food options.

A sample grain exchange list

In the above example, a person can fulfill a one-grain serving by having a slice of bread, ½ cup of pasta, or ¼ cup of lentils. The three are nutritionally equivalent and one can be “exchanged” for another.

If a person is new to this type of system, it can take time to learn and get comfortable with, but it has proven to be invaluable in helping to re-regulate the eating process and support weight restoration and/or stabilization.

Working closely with an experienced eating disorder dietitian is essential to develop and help put into action an individualized meal plan. While this style of meal plan can be highly effective, sometimes there are reasons a dietitian might choose not to use it. Often individuals with a history of weight-loss dieting, for example, find that such a plan looks too much like restrictive diets they followed in the past, making their use counterproductive.

What Is The Plate-by-Plate Approach to Eating Disorder Recovery?

The Plate-by-Plate Approach was developed by Registered Dietitians for children and young adolescents as a supplemental meal planning tool for parents, but it can be used for adults as well. This method incorporates five food groups, including grain/starch, vegetable/fruit, protein, fats, and dairy. There are two visual plate model variations, one for weight restoration and one for weight stabilization. There are three key aspects to this meal plan type:

  1. Put parents in charge of all aspects of food
  2. Utilize a 10-inch plate
  3. Emphasize variety and exposure to all foods from the start (dependent on parent knowledge/nutrition counseling)

What Is The Rule of 3’s Meal Plan?

Also developed by a Registered Dietitian, the Rule of 3’s method focuses on regularity of eating and eating a balanced diet, in order to help in recovering from an eating disorder.

The Rule of 3’s meal plan is categorized by six different food groups, including calcium, grains/starch/complex, carbohydrates, proteins, fruits or vegetables, and fats. This plan is more appropriate for someone who has a moderate or high risk of refeeding syndrome or someone who is experiencing moderate or severe malnutrition. The Rule of 3’s is made up specifically of these guidelines:

  1. Eat at least three meals and up to three snacks a day (you might think of this as a breakfast, lunch, and dinner meal plan)
  2. Eat at least three food groups per meal (and two per snack)
  3. Allow no more than three hours between eating

What Are Entrée-Sides Meal Plans?

Another approach, the entrée-sides meal plan, has features of the exchange-based meal plan but with more general categories for food and less exact portion sizes.

In this style of meal plan, there is still an emphasis on eating regularly spaced meals and snacks. However, instead of breaking meals down by various exchanges, there are just two categories, entrées and sides. Here is an example.

A sample entree-sides plan

Examples of entrees and sides

The advantage of this approach is that simplifies food choices and uses everyday language we typically hear when thinking about meals. Snacks are similar; the lists of snack options include commonly consumed snacks but in differing quantities and combinations in order to provide the needed nutritional level. This plan is our front-line approach for adolescent clients as it is family-friendly and easy to adapt to family meals. However, it lacks the level of precision many individuals need when the eating disorder is more in control, which is why it is frequently a step-down method for adult clients once an exchange-based meal plan is no longer required.

What Is an Intuitive Eating Meal Plan for Eating Disorders?

Intuitive eating focuses less on creating an external framework by which to make eating decisions and more on reconnecting with the body’s physical hunger and fullness signals to guide the timing and amount of food chosen. Below is an example of a hunger/fullness scale that can be used to help identify varying levels of sensation associated with the body’s physical state. 

A hunger/fullness scale

Getting in touch with internal cues for hunger and fullness is then paired with developing, or reclaiming, a sense of what the person is truly hungry for and/or what they know their body needs to balance out their intake for the day. Intuitive eating is often used interchangeably with “mindful eating,” though subtle differences exist. The term “attuned eating” is sometimes preferred, as it incorporates the idea that we are likely to be influenced by a host of factors that prevent us from being truly intuitive eaters. Instead, we might be “attuned” to our body’s needs but also aware that food and eating choices are going to be influenced by what else is going on in our world.

As appealing as intuitive eating may seem, a fair amount to work needs to go into being able to follow body cues to lead food and eating decisions. Those active in their eating disorders often find physical signals of hunger and fullness either unavailable to them or that these signals have been hijacked by disordered thoughts, judgments, or associations. Eating disorders are masters at using approaches such as intuitive eating to justify over/undereating or to avoid certain foods out of “preference,” when in reality it just serves as a way to legitimize disordered eating behaviors. Those dealing with, or who have a history of, an eating disorder need to work closely with an eating disorder specialist to explore how to transition to this style while not inadvertently slipping back into disordered patterns.

Other Meal Plan Approaches

In addition to the meal plan styles listed above, there are numerous variations of other meal plans designed to meet either specific food/eating objectives or to act as building blocks toward more structured plans. It is also possible that the meal plan will include recommendations for fluid intake. Each person’s needs are taken into account when determining what meal plan is right for them right now.   

No matter what meal plan you follow to bring structure and logic to your food and eating choices, consider taking a minute to see if it is truly meeting your body’s nutritional and food satisfaction needs. Talking with your treatment team about the above approaches could also be helpful. Regardless of which approach you take, the goal is to support you in regaining your ability to nourish yourself in a way that brings joy, satisfaction, and optimal well-being to your life.

Key Takeaways

  • Meal plans in eating disorder recovery are not diets: They are individualized tools created by registered dietitians to provide structure, support nutritional needs, and establish healthy eating patterns.
  • Various meal plan types exist: The exchange system, plate-by-plate, rule of 3’s, entrée-sides, and intuitive eating are all approaches used in recovery, each with varying levels of structure and flexibility.
  • Exchange system: Focuses on food groups with exchangeable items, aiding in re-regulating eating and supporting weight restoration.
  • Plate-by-plate: Utilizes visual plate models for weight restoration or stabilization, empowering parents in meal planning for children and young adolescents.
  • Rule of 3’s: Emphasizes regular, balanced meals with specific food group combinations, suitable for those at risk of refeeding syndrome or malnutrition.
  • Entrée-sides: Simplifies meal planning with broader food categories, often used as a step-down approach or for adolescents.
  • Intuitive eating: Encourages reconnecting with internal hunger and fullness cues, but may require professional guidance to avoid reinforcing disordered patterns.
  • Individualized approach: Meal plans are tailored to each person’s needs and may evolve throughout recovery. The goal is to foster a healthy relationship with food and achieve optimal well-being.

ABOUT THE AUTHOR


Hilmar Wagner

Hilmar Wagner, MPH, RDN, CD

Hilmar Wagner (he/him), MPH, RDN, LN, CD, is a Clinical Outreach Specialist for Accanto Health, the parent company of The Emily Program and Gather Behavioral Health. In this role, Hilmar has presented on a wide range of eating disorder topics and related nutrition topics at local, regional, and national conferences. In addition to his deep understanding of evidence-based eating disorder care, he has a particular interest in the application of mindfulness and body-centered, somatic approaches to the nutritional treatment of eating disorders.

Hilmar received his bachelor’s degree in Nutrition/Dietetics and master’s in Public Health Nutrition from the University of Minnesota. Prior to joining The Emily Program in 2006, Hilmar worked as a Registered Dietitian in a variety of clinical, outpatient, community, and supervisory settings. In his over 15 years of experience, Hilmar has worked directly with clients of all eating disorder diagnoses in a variety of clinical settings. He has also served in management roles at the site, regional, and organization-wide levels.



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