The innovative “Plate-by-Plate Approach” offers guidance for parents nourishing their child through an eating disorder
By Wendy Sterling, MS, RD, CSSD and Casey Crosbie, RD, CSSD
I wish this meal-time guidance provided by Wendy and Casey had been available when I was age 11 and an eating disorder was raging and embedding in my brain. Together with the support of Family-based Treatment, my parents would have felt confident and empowered to help me quickly get my life, and that of our entire family, back on track. – June Alexander
Parents are often frightened and overwhelmed when a health professional announces their child has a diagnosis of an “eating disorder.” Parents wonder how involved they should be in helping their child – should they stand back and allow their child to navigate this difficult time by themselves? Or should they roll up their sleeves, and start preparing and supervising their child’s every bite? Their independent child might proclaim that they “have it under control” and parents might want to desperately allow that, but as they watch their child chop the apple even smaller and push their food around even more, they realize quite quickly, that their child does not have this under control at all.
Parents are best equipped to help their child fight against this terrible disease, and can help their child successfully, right at home, in a way that is safe and effective. This approach is known as Family-based Treatment (FBT), and is the most researched and effective method for eating disorders treatment to date1-3. It is the leading outpatient treatment for adolescents with eating disorders, and is generally considered to be the first recommended line of treatment. With this approach, parents are initially asked to take charge of their child’s nutrition entirely: meal preparation, grocery shopping, and all choices regarding food planning, in the face of their child’s clear inability to do so, “for now.” Parental involvement can prevent the child from requiring a higher level of care such as a partial hospitalization – or inpatient program (these programs can sometimes become necessary if the child’s eating disorder behaviors cannot be interrupted).
Re-thinking meal support
Historically, FBT did not include a dietitian. With the help of an FBT-certified therapist, parents are empowered to tap into their parental instinct, and to feed their child what they know their child needs in order to restore health. The presence of an “expert” or a “meal plan” was thought to dis-empower the parent.
Although parents know best what their child needs, feeding a child with an eating disorder is not intuitive for most. The caloric requirements necessary to accomplish this task can be 2-3x that of the child’s baseline, making this task challenging, even for the most nutritionally savvy parent. Second, malnutrition makes refeeding and weight restoration challenging – a child will feel bloated, constipated, overly full, and the eating disorder will negotiate every bite – “chicken over steak” or “brown rice instead of pasta” making mealtimes exhausting.
Parents often express feeling confused, overwhelmed, and quite frankly, stressed. Their questions include: How do we start? How do we navigate these challenges? Are there tricks to ease the physical discomfort associated with malnutrition? How long does it take to get better? How far apart should we space the meals? How big should the meals be? Is it okay if our child eats brown rice every day, as long as she is eating…?
When parents learn that eating disorders are life threatening, they understandably may become fearful of “feeding their child incorrectly” or “not doing it fast enough” or simply just want to reach out because they “need some support.”
Solution: The Plate-by-Plate Approach
As registered dietitians with over 30 years of combined experience treating eating disorders in adolescents, we have written a book entitled, “How to Nourish Your Child Through an Eating Disorder: A Simple Plate-by-Plate Approach to Rebuilding A Healthy Relationship with Food,” to address the concerns and questions raised by families undergoing FBT who are seeking additional guidance. We have developed the “Plate-by-Plate Approach” to help parents navigate the high-calorie demands of malnutrition and weight gain, while helping them reacquaint their child with foods they used to love.
No measuring or counting
No measuring or counting is involved. We find this approach is helpful at a time when kids are facing the challenge of reducing their obsessiveness with numbers and their rigidity, while working on becoming more flexible with food. In time, this approach eventually provides for a seamless transition back to normal eating.
There are 3 key aspects to this approach:
1) Parents are put in charge of all aspects of food (however, the approach can be used directly with teens not involved in FBT as well).
2) Parents need only a 10-inch (25.4cm) plate to help their child accomplish the medical goals of weight restoration, metabolic recovery, resumption of menses, and reversal of medical complications.
3) There is an emphasis on variety and exposure to all foods from the start.
For all eating disorder diagnoses
The Plate-by-Plate approach is designed for use with all eating disorder diagnoses, and can be adapted to accommodate each individual’s nutritional goals. Through use of the following visual as well as photos of example plates, parents are guided to feed their child 3 meals and 2-3 snacks per day without ever taking out the measuring cups. The plates can be adjusted as the needs of the child change throughout treatment – increasing during times of weight restoration, and decreasing once the child hits their target weight range. The book provides ideas for how to adjust the plate based on individual nutrition goals and needs as well as ideas for how to make mealtime more successful for everyone involved.
Variety helps build confidence
Parents are encouraged to include a variety at all meals and snacks to increase their child’s comfort level with food. Weight restoration and resumption of menses are important, but by themselves, are not enough – the work must continue in order for the child to successfully rebuild their relationship with food. Encouraging variety helps to excavate remnants of eating disorder thinking, all while shaping the child into a confident and fearless eater. We ultimately want kids to be able to eat cake on their birthday (and their friend’s birthdays too!) without having an intense escalation in anxiety, eat in restaurants, travel and have pizza with their friends.
How to start using the Plate-by-Plate Approach
To follow the Plate-by-Plate approach, parents are encouraged to begin plating balanced meals, according to the diagram below, and to fill 100% of the plate. Parents should choose a meal schedule of “3 meals + 2 snacks” (or “3 meals + 3 snacks” if the child is already successful with “3 meals + 2 snacks”), and stick to that meal timing each day.
The child may negotiate for a plate that is mostly fruits and vegetables, but parents should be aware that a high fruit/vegetable plate will likely contribute to increased gastrointestinal distress and bloating. A plate that is too high in protein, as some kids might request, will likely cause increased fullness, making it difficult to complete the rest of the meals that day.
The Plate-by-Plate approach is a simple and effective strategy to help with the nutritional rehabilitation of adolescents struggling with eating disorders. Parents can use this approach, alongside FBT, for additional nutrition guidance. Ultimately, parents have the final sign-off for how they choose to plate the meal. If the plate looks good, even if it’s not quite matching our suggestions, that’s okay.
While FBT offers parents a general map to follow during their child’s nutritional rehabilitation, the Plate-by-Plate approach adds a compass, both pieces integral in navigating the tricky terrain of eating-disorder recovery. The exact route taken, however, is still very much in the hands of parents. Parents are empowered to lead their child through nutritional rehabilitation and eventually transition to normal eating.
- Lock J, Le Grange D. Treatment Manual for Anorexia Nervosa: A Family-Based Approach. 2nd ed. New York, NY: Guilford Press; 2015.
- Lock, James. “Evaluation of Family Treatment Models for Eating Disorders.” Current Opinion in Psychiatry, vol. 24, no. 4, 2011, pp. 274–279. doi:10.1097/yco.0b013e328346f71e.
- Lock J, Le Grange D. Family based treatment of eating disorders. Int Journal of Eat Disord. 2005;37:S64–7)
About Wendy: Wendy Sterling is a Registered Dietitian and a Board-Certified Specialist in Sports Dietetics. She is the co-author of “How to Nourish Your Child Through an Eating Disorder: A Simple, Plate-by-Plate Approach to Rebuilding a Healthy Relationship with Food.” and “No Weigh! A Teen’s Guide to Positive Body Image, Food, and Emotional Wisdom.” She worked at The Healthy Teen Project as well as the Eating Disorder Center at Cohen Children’s Medical Center of New York. She has been published in the International Journal of Eating Disorders and the Journal of Adolescent Health for research on osteoporosis, menstruation, and metabolism. She will also be published in the Journal of the Academy of Nutrition and Dietetics for her work with the Plate-by-Plate Approach Fall 2018. She is team nutritionist for the Oakland A’s.
About Casey: Casey Crosbie is a Registered Dietitian and a Board-Certified Specialist in Sports Dietetics. She currently serves as program director for the Healthy Teen Project in Los Altos, CA and is co-author of How to Nourish Your Child Through an Eating Disorder: A Simple, Plate-by-Plate Approach to Rebuilding a Healthy Relationship with Food.” Casey previously served as lead dietitian for the Lucile Packard Children’s Hospital Comprehensive Care Program for Eating Disorders at Stanford. She was published in Nutrition in Clinical Practice and in the Journal of Adolescent Health for research focusing on refeeding syndrome in adolescents with eating disorders. She will also be published in the Journal of the Academy of Nutrition and Dietetics for her work with the Plate-by-Plate Approach Fall 2018.