Making Mealtimes Count: Part One - A Primer for Caregivers of Youth with Restrictive EDs
Where to start?
You may feel that mealtimes have gotten completely out of control. It is not uncommon when a young person has a restrictive eating disorder (ED) to feel like the ED is running the house. Sometimes your loved one is eating only alone, locked in their room. Or perhaps they are preparing every meal they eat, never touching foods you make for the family. Maybe they are sitting with your family but only eating a few bites. You have taken an important step, just by reading this. You’re beginning to unravel the eating disorder’s grasp on your family.
Make sure you’ve already read through the initial post on “what is an eating disorder” - it’s a critical place to start, because it offers you a firm foundation in the “why” of eating disorder treatment. What this post, and your ED team, will ask your family to do is going to be hard. AND it is critical to your loved one’s health - and perhaps even survival.
First, let’s examine what eating disorder specialists recommend for mealtimes. In a structured eating disorder treatment program, therapists will provided pre-selected meals for a young person with an ED, deliver the whole, medically prescribed tray to the young person, and provide non-judgmental encouragement and oversight at a meal. They ensure the youth eats the full quantity by both offering positive distraction via conversation about non-food topics & games. They also provide regular prompts to continue and “take one more bite” when the young person is struggling. They offer a time limit to the meal, to ensure this is not taking up the whole day (perhaps 30 or 45 minutes). When the mealtime is done, they often move on to nutritionally dense liquid meal replacements like Ensure Plus or Boost Plus, at a quantity that replaces the whole portion that was missed, rounding up. This also has a time limit. With this same caring, supportive, and nutritionally focused approach, many, many young people are restored to health.
Remember - for children and adolescents with eating disorders, you are one of the most important factors in your loved one’s recovery. Your role in helping the fight the eating disorder cannot be understated. Each meal together is a crucial opportunity to help your family member move towards their goal weight. For each meal you eat together - when your loved one has a restrictive eating disorder - select foods that will help them gain weight (if their care team has let you know they are underweight) or foods that will help them stabilize their nutrition and weight (if their care team has let you know they are at their goal weight).
Key Point: Food is your loved one’s medicine.
With this said, you are not expected to make your house exactly like an eating disorder treatment program, nor should you. Your home will provide unique benefits and challenges in the renourishment process.
How to begin at home? You will need to recall five key elements of mealtimes when you are adding structure into your routine: 1) Planning; 2) Preparation; 3) Presentation; 4) Backup; 5) Monitoring.
1) Planning. You will need to plan ahead either on your own, or with a dietician, to set goals for various nutritional components (including but not limited to calories, carbohydrates, fats, and so on) throughout the day. Then you will look ahead to your week of meals with your loved one and break these components down into, ideally 3 meals and 1-2 snacks throughout the day. This process should be done away from your loved one, as those suffering from eating disorders often will be unable to meaningfully participate in planning meals without the eating disorder taking over the conversation.
2) Preparation. This should be done again, away from your loved one, as often the quantities, ingredients, and choices inherent to preparing or plating meals is rife with distress for someone struggling with a restrictive eating disorder. To avoid the inevitable and unnecessary arguments over what goes into the food, do this on your own. We recommend reminding both yourself and your loved one that this is not a permanent process, but is to help them save their life and health. These are the stakes that necessitate this sort of limit setting, nothing less. Prioritize nutrient density - that means - make each bite count. Use full fat, not skim dairy products; use fats with your vegetable components. If your loved one may not initially eat the whole meal, ensure each bite is bringing them closer to wellness in this manner.
3) Presentation. The components of each meal or snack should be composed on a plate or plates, and presented in front of your family member. This is called the “magic plate” method - meaning - there is no negotiation or discussion. The medicine, or treatment, for their eating disorder is this food. Not other food. You have the knowledge to select what will help them get well. Just as you may have nourished them and selected what helped them thrive when they were very young, so now are you caring for them with this plate. That means - what arrives in front of them is their meal. During the meal - the talk should not be mostly about food! Yes, you are monitoring their progress, ensuring they are not hiding food, or feeding the dog. However, you are talking about people’s days, cracking jokes, playing word games, enjoying family time. This is a critical element of your loved one’s healing - restoring meals to a joy-filled communal experience. This will not happen overnight - and still, it is important work.
4) Back up. There are many forms this can take. Essentially - this encompasses anything you might do if your loved one does not complete the meal you have set in front of them with the expectation they eat. It could prompt a visit to the pediatrician, or it could mean there are limitations to activity as natural consequences for failure to take in sufficient nutrition (e.g. sport, movement, even walking). This could also look like adding in liquid nutritional supplements to replace what is not consumed - ask your care team about amounts and how to do so.
5) Monitoring. We recommend all families of youth with restrictive ED’s monitor for a period of time after meals, typically 60-90 minutes. This is to ensure there are no compensatory behaviors (purging, over-exercise, throwing away hidden food, etc.). Although this is an important element of the renourishment process, it need not be a terrible experience. This can take the form of family board games, watching TV together, taking a drive, or other non-energy-expending activities.
