Edit: A reminder I write for adults in active recovery. This is not a blog saying that children, or people who are generally resisting recovery, or people who are in need of IP care, or people who can not (yet) access desire should not be on a meal plan. As I have stated, meal plans have a place for some people in recovery. The point of this blog, is that they are not a sustainable, long-term solution for full recovery, and should not be treated like the holy grail of how to eat.
For full recovery to be achieved, a person at some stage has to learn how to be in relationship with their body. If a method of eating is given, it should be stressed, that this is a temporary, non-perfect, stop-gap. Not doing so can set people in recovery up for a life-time of disordered eating.
Here is a snippet from an email from a client:
I’ve got so much conflicting information from different treatment centres. Eat three meals and two snacks a day. Eat three meals and three snacks a day. Eat by exchanges. Eat by a meal plan. I’m bogged down on the detail and the numbers.
I feel like I have exchanged one set of rules for another. My eating disorder rules have turned into being my eating disorder recovery rules.
I’ll keep the person who gave me that quote anonymous. Whilst this was one person’s experience, it is also many people’s experience. I have heard this wail many times. I don’t think any individual treatment provider means to do harm. I think most of them are rather oblivious to the lives of their patients when that patient moves on, so they are not considering that a single person may have many experiences of treatment and each time be told of a new “way to eat.”
Or maybe, for many people working in treatment centres, they simply don’t know better. They are newly qualified, relatively cheap to employ, and don’t have the confidence or the knowledge to do anything other than follow the protocol.
Either way, treatment providers are generally good people who are trying to help. And treatment has to change. Treatment for eating disorders needs to unequivocally support the patient’s relationship with their own body. Right now, treatment often actively encourages distrust between the patient and their biology, specifically their desire to eat and their ability to eat in an unrestricted, natural, and confident manner.
Dear Dietitian
Stop methodizing eating.
Telling someone a “way to eat” is ridiculous. Let’s pause and think about that for a moment and wonder how the fuck the human race evolved without the exchanges system and/or meal plans.
Meal plans, exchanges, counting calories, whatever the method of the moment is — it is all disordered.
You can’t cure disordered eating with disordered eating.
I know your intent is to provide a stepping stone, a pathway towards normalcy. But in many cases, the second you tell someone with an eating disorder to eat two proteins, two carbs, and one fat at lunch, unless you also told them that they are allowed to ignore it all and eat to hunger and desire should hunger and desire bless them, you have fucked them over. With the best of intentions, I get it. But you just took them out of one cage and popped them in another. Sure, they may achieve a smigen of weight gain, or be able to eat a bit more for a while, or they may change an eating pattern you were working on changing. You will rejoice about that. I hate to break your bubble but if you did achieve anything, it’s probably temporary.
It is temporary, because like I said, you just put them in another cage. And this cage is different so something may look different for a little while, but all the cages morph back into the same problem in the end. Your client will become trapped in and obsessed with the new method of eating you gave them.
Why? Because all methods, ways, plans, of eating are disordered. Quite simply, this is not how humans eat. We don’t eat by numbers. We don’t eat by macronutrients. We eat by desire. Always have. Always should. As soon as you focus someone on anything other than eating by desire, you make them eat dishonestly. You disable the ability to even detect desire — let alone follow it — when you break food down into macronutrients. Even worse, you collaborate with their eating disorder, which is already telling them they can’t trust their desire to eat.
Oh I know, it’s messy and scary to eat by desire. And I know that many of your patients turn white at the thought of it. And some can’t detect their desire at all. Others refute it. Helping people with restrictive eating disorders uncover what it means to eat truthfully, and without restriction is difficult. It is so much easier to give them a sheet on it and tell them to eat by numbers and job done. Except it never is.
Well, it’s not job done for your client. It might be for you. Your client will try, and at some point stumble — because eating by numbers or exchanges or whatever isn’t natural so nobody can truly be happy and free doing so. And they will go see someone else. Then they will be given a new sheet. This one will say only one carb, two proteins, one fat for lunch. Or it will say three snacks rather than two. Because whomever wrote it read a different book on nutrition than you. And then that client will experience anxiety, doubt, hopelessness, because they will lose trust that anyone actually knows how to tell them to eat.
And the secret aways was that nobody else was ever supposed to tell them how to eat. Because that was always supposed to be the job of their body. And because you never taught them to eat to desire, they will forever be searching for something that doesn’t actually exist: an equation for eating.
Please, use meal plans with caution. And if you do, heavily preface them with words explaining that this is a temporary measure, and not the bible, and that trusting and listening to one’s body is the most glorious and achievable thing. The true path to health and happiness. Because for some people meal plans are needed tools. Stepping stones. But don’t give them out willy nilly. Some, most, of your clients are secretly desperate for you to tell them it is okay, optional actually, to listen to their screaming hunger.
Assisting someone on the path to collaborating with and trusting their own body is an incredible gift to give.
Nobody has to give you permission to eat. Eating is messy. That’s okay.
Eat what you want, when you want it, in the quantity that you want it in. Without judgement.
Your body is the expert here. Listen to it. If your body asks for chocolate donuts and sausages for breakfast that is what you eat. Your body knows what it needs.
Recovery can be enjoyable. Eating is enjoyable.
Timing is impeccable, as always. Really appreciate everything you do, thank you!
I’ve had a really hard time with this during my entire recovery. I am naturally inclined to think in black & white terms. I like right and wrong answers. I like rules and being told exactly what to do in order to succeed. It’s been really challenging to learn about intuitive eating, listening to hunger cues, checking for fullness, etc. It’s really hard work. Thanks for this post!
This made me very angry.
Many sufferers are close to death or, at the very least, suffering extremely serious health issues. They need to put on weight swiftly and effectively.
To just say – oh let desire take its course is laughable. Firstly – whilst they may want to recover, their actual desire for food may lag somewhere behind that intention. However if there health is at a critical juncture, then there’s no time to wait for desire to catch up. They need a plan, and they need a plan they should follow irrespective of whether the desire is there in order to her their physical health substantially improved.
So yes – desire is all well and good, but meal plans have a very important role to play as well.
While what you say wrt to critically ill patients is true, you miss the bigger picture. I think Tabitha is referring to the role of the meal plan as you move into recovery. My daughter has been fighting a restrictive ED for the past five years. She has spent 11 of the past 14 months in IP/RES/PHP. While the meal plan was fine initially – it provided structure and eased her mind about refeeding syndrome during the early parts- it became a tool of the ED as she progressed. This was especially true when she began IOP. For example, she was actually told that her protein needed to be 3 oz – meaning she needed a 3 oz serving of chicken or fish or whatever. Who the F eats a 3 oz portion?? NO ONE!! The only way to get that size is to restrict from the typical portion size. The treatment center saw nothing wrong with this. Her ED absolutely LOVED IT!! Furthermore, she was told by the treatment center staff more than once that she had put “too much” of whatever on her plate at dinner…but to “go ahead and eat it anyway”. This sent her anxiety through the roof! IMO, this is borderline negligence or incompetence. The ED loved this as well. Where did all this get her? Relapse. She worked so hard and made great progress through PHP (she had a GREAT therapist at that level) but then was completely abandoned in IOP. Tabitha is correct. Treatment needs to change. Once the meal plan is no longer medically necessary, work should be done to move them off the “plan” or maybe provide plans that are simply minimums – but structured in a way that the ED can’t use it against them. The meal plan was one of the primary tools to ED used to retake control. Like Tabitha stated – just a different cage. We’ve lived it. We’re still living it every day. It needs to change. There is no “perfect” amount or type of food. Our bodies do quite well as long as they get enough. We need to stop thinking we know better. For someone with a restrictive ED, there is really no such thing as too much and if someone is blessed enough to be hungry for God’s sake let them eat!
EdDad! You are a super dad!!!! Thank you for your words and your defense of all of us whose lives have radically changed through the words of freedom shared by Tabitha!
I completely agree and hate the exchange system which is easy to adjust so ED is happy. Two carbs can look vastly different in terms of calories. I do, though, wonder what might be helpful for those who’s hunger/fullness cues remain faulty. I was never diagnosed with AN but probably had it well into my 30s. I have always felt full before i probably should have because i often struggked to keep weight on. I now try to eat a bit beyond my fullness. If i listened to my body I would not be well. While most can learn to listen to their bodies some can not. What then?
Like!
I understand the message but understanding what your body wants isn’t that simple. What’s the advise for that? If you have been overweight and an over eater who made poor choices, it is doubtful that you would be willing to eat chocolate donuts for breakfast. I think this advise is just as difficult if not more difficult than being given guidance on what to eat.
By definition – those with eating disorders have shown that their desire “switch” is utterly out of tune with what the body needs.
Your approach, whist it does have some merits, is so very naive. This notion that someone with a serious eating disorder can simply turn on and respond to their desires is shockingly… daft!
That’s not to say they won’t with time, but a plan is often needed to kick start and then guide. A comfort, something to hold on.
I think this is so wonderful post. It helps me a lot. I have been in impationed treatment for so many years in different treatment centers. I was always treated with meal plans. It help me to survive, that’s true. But it that definitely not help me to recover. It made me so confused. I feel I have to recover two times now, I have to recover from Anorexia nervosa and I have to recover from all the meal plans Exchange plans et cetera. What really helps to recover the approach of this blog, the approach of trusting the body and eating without restriction and without judgement. Think that many people who posted comments should maybe read some more of this blog to really understand the concept of unrestricted eating… Yes, when you’re very underweighed maybe it is helpful with a meal plan. But actually I don’t think so. I was very very underwheigt, but what I would have needed at this time was somebody tells me to eat as much as I can. I needed a permission to eat and I needed empowerment. I definitely did not need a meal plan. This made my mind even more confused. I wolud love if every dietitian would read this post and the treatment of Anorexia nervosa would change fundamentaly… You’re doing a wonderful job Tabitha
Brilliantly written, Tabitha. I think it’s a reflection of the mentality though, whether or not a person is truly prepared for recovery. When you get to a stage where you feel frustrated by the confines of a prescribed meal plan to adhere to during recovery, and start secretly wanting or wishing to rebel against it, that I think is a sign the person is ready for real recovery.
Because like you said, the business of eating is messy and undictated, and eating disorders are fundamentally not about the food but about the behaviour and thoughts, primarily that of control, order and structure. Thus the focus of recovery from an eating disorder shouldn’t be about the “what” and the “how much” of food, but rather the “how” to eat again, which a very wise person once said: Eat when you’re hungry, stop when you’re full, then go do something else with your life.
Never experienced ‘extreme hunger’ or even much in the way of desires for particular foods in any weight restoration/recovery phase in any of my admissions for anorexia. I also forgot the way ‘normal’ people actually eat. A guide of sorts was definitely necessary.
To the last two comments. I think the intent of the message is just to say that nothing is perfect and we need to be more forgiving with ourselves. Some of us need strict guidelines for now to help manage our eating as we overcome the disordered mind and we can’t trust our hunger/satiety cues. Others will be liberated by the idea of being able to let go of all the rules and learn to eat intuitively. We all will make “mistakes” and recovery is really, really hard. This brings me to the idea that every person is an individual, which is not and idea that’s embrace by the “professional” community. That’s what irks me about the intensive inpatient approach. I want my “team” to listen to me, not assume I’m like everyone else when it comes to symptoms or psychology, and help me move forward in a way that will be relevant long-term, rather than creating static guidelines that are supposed to create normalized eating, when all they really do is leave everyone more fucked up than when they were admitted.
I reflect Maggie’s response and would add. Try not to overthink. It can be very stressful for a starving brain to cope with getting it right in recovery and there’s alot to be said for letting it just happen! Tune into your body and if it’s thinking about food it means you need to eat. For sanity’s sake, nourish yourself and start to live again.
Dietitians are trained to individualize all of our advice to the nth degree. Every eating disorder dietitian I have had this conversation with HATES exchange lists, ESPECIALLY the way they are implemented differently and are able to be manipulated in order to restrict calories. Any treatment program protocol that tells everyone to eat the same way or suggests that 3 ounces of a food is an appropriate serving for an adult in recovery or even suggests weighing food in ounces I can almost guarantee you was created by a psychologist who had zero knowledge of eating disorder nutrition or even nutrition in general aside from their own biased personal beliefs. This letter should not be written to dietitians but to therapists who butt in to the nutrition side of eating disorder treatment instead of letting dietitians individualize as we were trained and sincerely desire to do. That’s why the treatment facility dietitians are always so young – because they are hired right out of school and told to silence their own training and use the treatment center protocol that was developed by a non-dietitian. Once they have any sense they leave that environment for private practice where they no longer have a therapist as their manager telling them what they have to do. The treatment centers that have dietitians at the top of the food chain have much better reputations, less turnover and better support of family members. It is the CBT-E therapists and their ilk who are obsessed with “manualized” treatment. Any treatment center should be embarrassed to brag about that. And individualized care is just words as well, until you get to actual individual care, i.e. the outpatient dietitian. Other than that it’s protocols falsely called “individualized” care. I also blame the psychologists who say that they can handle nutrition and that it’s “just three meals a day” and no one needs a dietitian unless they have an eating disorder and ALSO diabetes or also are pregnant, so they waste all kinds of time on their ridiculous eating advice, fail to address any other issues and then label the patient “non-compliant” because they didn’t just think their way out of malnutrition. So I agree there are all kinds of problems with eating disorder treatment – starting with the basic fact that no one has actually identified the root disease – but I do not believe that eating disorder dietitians are even in the top ten.
I sure wish I would’ve been encouraged to explore eating “what I want and until I was full” when in treatment instead of being put on a forever meal plan…as well as to explore why I felt so panicked about being full as it wasn’t really related to weight gain for me, more of a weird PTSD feeling when I felt full. My hope is that the treatment world is changing and learning new things about what does and doesn’t work, and that these conversations will be helpful to bringing new consciousness into the field.
i’ve always thought of it like this. meal plans do serve a purpose for a lot of people (like you said, who either refuse recovery or can’t respond to hunger and stuff like that) and i guess it did for me. however, they’re not a tool that you can use throughout the whole recovery process. a lot of people get stuck in the rules of their meal plan and if the amounts or timings etc are compromised they freak out, which actually also happened to me. and my doctors would absolutely hate me for saying this but meal plans are probably a huge reason behind why so many people either achieve the “i can cope with my eating disorder and eat enough but i still am not completely free”. because the meal plan makes sure you don’t die, but they also keep you inside your little bubble or rules…
my mom is the only person who supports me in putting the meal plan behind me. we still have rough times for breakfast, lunch and dinner (i think most people do because you need to time it with school/ work) but i basically snack whenever i want inbetween that – which is hard but that’s how it’s gotta be. my doctors don’t agree with it and i’m scared they will tell me i’m developing another diagnosis or something and that i have to go back to my restrictive meal plan. if the case is so, i hope my mom will argue for my sake at least. we both watch your videos Tabhitha and when i’m done reading Rehabilitate Rewire Recovery she will read it too. honestly, she says understands me and my struggles a lot better thanks to you (and especially when it comes to my hunger and my rage towards my meal plan)!
I am only six weeks into recovery and obviously not recovered by any means. But I will say that it gets a little easier everyday. Not my emotions, but the eating. Once I surrendered to my hunger and ceased fighting it I realized how truly and deeply hungry I was. And I mean hungry. Its scary because you don’t know when it will end, and you don’t know how much weight you will gain. It feels very much like walking in the dark. The only thing you have to guide you is your hunger cues and your bodies signals. And since I have been ignoring these for so long it is like learning a new language. But in a way it is a relief because I am desperately in need of a new guide. I tried using my mind as a guide to health but it is too easily tricked and deluded. I tried using cultural norms and pop nutrition science and it too lead me astray. So though I have not made it to the other side, I walk in the dark with my new guide hoping that soon I will see light. But no matter what I keep walking because I don’t want to go back to the place I left, a place I inhabited for over twenty years. And so I hand over my weight and my health over to my body because I must admit that “I” am wholly inadequate and a failure in dealing with such matters.
Where I have problems is food purchase and preparation. Okay, if the food is prepared and in the house I might still have problems. I just seldom get that far! Strategies (besides adopting an adolescent with food tastes like my own who adores leftovers and last-minute grocery runs) for having more than I think I need on hand without throwing out half a fridge-full every few days?
How can you get past eating on a meal plan? I have been on one for years and feel like it is ruining my life. I can’t eat out or be with my family without conflict. Do you just stop all at once? Can you do it gradually? How can anxiety about weight gain be avoided or decreased?
How do you get past eating on a meal plan? I have been on one for years, and I feel like it is ruining my life. I cannot eat out with friends, and it is creating problems in my family. Do you just stop all at once? Is there a way to gradually stop eating exchanges? What is the best way to avoid anxiety when doing this?