The Plate-by-Plate Approach to Disordered Eating by Wendy Sterling, MS, RD & Casey Crosbie, RD
Updated: Nov 14, 2019
Last week, we looked at the prevalence of eating disorders worldwide and examined the many different ways they can manifest. Over the past few decades, a therapy known as family-based therapy, or FBT, has become the gold standard for the successful treatment of eating disorders. In this post, we’ll look at FBT and at an additional approach that provides much-needed support to families in FBT. Re-thinking meal support Traditionally, FBT does 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 believe their child needs in order to restore health. The presence of an expert or a meal plan can often disempower the parent. However, 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? Feeding a child with an eating disorder is not intuitive for most people. The caloric requirements necessary to accomplish this task can be two to three times that of the child’s baseline, making this task challenging, even for the most nutritionally savvy parent. And malnutrition makes refeeding and weight restoration challenging: a child will feel bloated, constipated and overly full. The eating disorder will negotiate every bite: chicken over steak, or brown rice instead of pasta—making mealtimes exhausting. Knowing that eating disorders can be life-threatening, parents may feel stressed about feeding their child incorrectly or not restoring weight quickly enough and may be looking for support and guidance they can trust.
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 these concerns and questions raised by families undergoing FBT. We developed the Plate-by-Plate approach to help parents navigate the high-calorie demands of malnutrition and weight gain and guide them in reacquainting their child with foods they used to love.
No measuring or counting There is no measuring or counting 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 offers a seamless transition back to normal eating.
The three essential elements of the Plate-by-Plate approach are
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)Parents need only a 10-inch plate to help their child accomplish the medical goals of weight restoration, metabolic recovery, resumption of menses and reversal of medical complications An emphasis on variety and exposure to all foods
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. By referencing the Plate-by-Plate visual (shown later in this article) as well as photos of example plates, parents are guided to feed their child three meals and two-three 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 approach provides customized recommendations based on each person’s individualized nutritional goals.
Variety helps build confidence Parents are advised to include a variety of foods 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, they are not enough. The work must continue in order for the child to successfully rebuild their relationship with food. Encouraging variety helps to excavate the remnants of disordered eating 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 friends’ birthdays, too!), eat in restaurants, have pizza with their friends and travel—without having an intense escalation in anxiety. Parents are encouraged to expose their child to all the foods that create an acceleration of anxiety in their child. Exposure works by confronting the item that induces anxiety and allowing the person, through repeated exposures of that trigger, to acclimate or “habituate” to it. The once-scary or avoided food becomes more commonplace as the child is desensitized to it. Successful de-escalation of food fears through exposure also helps build positive experiences that reduce fear overall. The Plate-by-Plate approach encourages parents to come up with lists of foods to target during this process. These foods can be arranged into a hierarchy from least to most scary. From there, successful exposure treatment requires repetition. Though challenging, this is generally a very rewarding part of recovery. How to start using the Plate-by-Plate approach To follow the Plate-by-Plate approach, parents are prompted to begin plating balanced meals, according to the diagram below, and to fill 100% of the plate with food. 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 schedule each day. The child may negotiate for a plate that is mostly fruits and vegetables, but parents should be aware that a plate primarily containing fruits and vegetables will likely contribute to increased gastrointestinal distress and bloating. A plate that is too high in protein, as some kids might request, will likely result in increased fullness, making it difficult to complete the remainder of the meals that day. Parents should also bear in mind that there is often a high caloric requirement associated with refeeding as the metabolism shifts towards becoming hypermetabolic along the way (think of a fire that has just been stoked and needs more logs to keep its flame going), and more calorically dense plates are necessary to meet nutritional requirements. Snacks should include foods from at least two different food groups. They can be increased to as many items or food groups as are necessary to meet the nutritional needs of the child. If a child is currently eating a two-item snack and struggling to gain weight, the parent may wish to consider increasing the number of snacks per day and/or the number of items at each snack (from two items to three items).
Above are two versions of the plates being used in the Plate-by-Plate approach. The plate on the left, where 50% of the food comes from starch, is designed for someone undergoing weight restoration, such as someone with anorexia nervosa or amenorrhea (lack of menses). It is also used for individuals with higher caloric demands due to age, growth or a high activity level. The one on the right represents a plate where 33% of the food comes from starch. This plate is appropriate for someone who does not need to gain weight but is looking for help with balanced eating, such as someone with bulimia nervosa or binge eating disorder. The plate on the right can also be used to help transition someone back to weight maintenance after weight restoration, and eventually to an intuitive eating plan.
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 about 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, to help navigate the tricky terrain of eating disorder recovery. The exact route to take, however, is still very much in the hands of parents. Parents are empowered to lead their child through nutritional rehabilitation and so that their child can eventually make a smooth transition to normal eating.
Crosbie, Casey and Sterling, Wendy. How to Nourish Your Child Through an Eating Disorder. The Experiment, July 2018. www.amazon.com/Nourish-Through-Eating-Disorder-Plate/dp/1615194509Sterling, Wendy et al. "The Use of the Plate-by-Plate Approach for Adolescents Undergoing Family-Based Treatment." Journal of the Academy of Nutrition and Dietetics. In press. jandonline.org/article/S2212-2672(18)30433-7/pdf
Wendy Sterling, MS, RD, CSSD & Casey Crosbie, RD, CSSD
Wendy Sterling is a registered dietitian and 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. Her research on osteoporosis, menstruation and metabolism has been published in the International Journal of Eating Disorders and the Journal of Adolescent Health. She was most recently published in the Journal of the Academy of Nutrition and Dietetics for her work with the Plate-by-Plate approach in Fall 2018. She is the team nutritionist for the Oakland A’s.
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, California, 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. Her research focusing on refeeding syndrome in adolescents with eating disorders was published in Nutrition in Clinical Practice and in the Journal of Adolescent Health. She was most recently published in the Journal of the Academy of Nutrition and Dieteticsfor her work with the Plate-by-Plate approach in Fall 2018.
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