Casey Crosbie, RD, CSSD and Wendy Sterling, MS, RD, CSSD joined us for an interview on their book How to Nourish Your Child Through an Eating Disorder: A Simple, Plate-by-Plate Approach to Rebuilding a Healthy Relationship with Food. What follows are our questions in italics, and their thoughtful responses.
As a complement to FBT, your book, How to Nourish Your Child Through an Eating Disorder: A Simple, Plate-by-Plate Approach to Rebuilding a Healthy Relationship with Food, offers the “Plate-by-Plate” approach. Please explain what guided you to develop this augmentation?
The Plate-by-Plate approach came about after years of work with families undergoing FBT. Historically, FBT does not utilize a Registered Dietitian based on a core principle that parents intuitively know how to feed their child. However, parents, faced with the challenging task of refeeding a child with an eating disorder, were seeking out additional nutritional guidance. We wanted to help these families without imposing complicated numbers-based methods of refeeding traditionally used in eating disorder treatment. More complicated methods, such as the exchange system, break down daily needs into specific portion sizes of each food that an individual can then “spend” throughout the day. For example, one might be allotted “10 starch exchanges or 6 dairy exchanges” where 1 starch exchange equals 1 slice of bread and 1 dairy exchange equals 8 ounces of milk. It focuses on precise portion sizes to sort foods into their respective categories which can lead to more rigidity and obsessiveness. Another means to meal planning is calorie counting. Not surprisingly, however, a 2017 study conducted by Simpson et al. found that counting calories using tracking apps, triggered, maintained or exacerbated eating disorder symptomatology.
Our Plate-by-Plate approach aims to accomplish the goals of nutritional rehabilitation while working on improving variety and flexibility, without numbers or counting. By using a visual tool – a 10-inch dinner plate – as the foundation of our approach, we are able to guide parents to plate enough volume and variety of food to refeed their child quickly while keeping with the tenets of FBT.
Plate model approaches have been around for a long time. MyPlate, the USDA’s version was created to educate the general public about balanced eating, however it falls short in the treatment of eating disorders. MyPlate focuses on fruits and vegetables, low-fat dairy, whole grains, and lean protein, with no mention of including or cooking with oils/fats. It is insufficient for teens recovering from an eating disorder and can be insufficient for teens in general. The Plate-by-Plate approach addresses this shortfall by reducing the fruit/vegetable portion of the plate to allow for more grains/starches. It also identifies that dairy products should be 2% or whole and that fats should be included in every meal. It focuses on variety, exposure, and volume of food all in a parent-led, no-numbers approach.
A key goal with “Plate-by-Plate” is a major shift in parental confidence. Can you address this?
FBT is considered the first-line treatment for adolescent eating disorders. At its core is empowering parents to make intuitive choices about how to refeed their child at home. However, refeeding a child with an eating disorder isn’t intuitive, even for the most nutritionally savvy parents. Traditional methods of nutrition education for eating disorders are numbers-based and complicated – just what an eating disorder pulls for! The Plate-by-Plate approach, instead focuses on simplifying nutrition and allowing parents to feed their child what “looks normal.” In this way, when the eating disorder pulls to make meals more complicated, the Plate-by Plate approach keeps it simple, allowing parents to focus on fighting the disease rather than nutritional minutiae. Nan Shaw, LCSW and author of Chapter 2 in How to Nourish Your Child Through an Eating Disorder describes the combination of FBT and the Plate-by-Plate Approach beautifully, she says “Where the FBT approach offers parents a general map, the Plate-by-Plate approach adds a compass, both integral tools to help navigate the tricky terrain that is eating-disorder recovery. The exact route taken, however, is still very much in the hands of parents.”
Oftentimes, parents are not aware of the complications of low bone-mineral density in both males and females, and those diagnosed with Anorexia Nervosa or Bulimia nervosa. What changes when parents are equipped with this knowledge?
According to Dr. Susanne Martin (author of Chapter 4 in How to Nourish Your Child Through an Eating Disorder) “Peak bone density refers to the bone’s maximum strength and density, and is typically achieved during late adolescence. Ninety percent of an adolescent’s peak bone density is reached by age eighteen for girls and by age twenty for boys, making adolescence an important time to “invest” in bone health”. Malnutrition interferes with this process and in some instances, the resulting bone damage can be irreparable. Knowing this information is powerful for parents of teens struggling with eating disorders as it speaks to the time-sensitivity of nourishing their child back to health. Once equipped with this knowledge, parents often begin to understand the importance of their female daughter having a return of regular menses, or their son’s testosterone levels returning to normal as both of these hormones play an integral role in achieving peak bone density. Our colleague, Signe Darpinian, LMFT, CEDS-S, likes to say, “Awareness + Action = Change!”
You provide a concrete section entitled “Assess Your Child’s Diet.” This assessment must increase parental awareness on many levels. What feedback have you received?
In this section, we ask parents to keep a 7-day food record which helps to provide a “snapshot” of how their child is eating. We coach parents to reflect on questions such as, “How many meals a day is your child eating? How many snacks?” When your child eats, how full are the plates?” Parents are asked to list which kinds of foods their child eats in each category of grains, proteins, fruits, vegetables, fats, dairy, fluids, and snacks. These questions help parents prioritize strategies for increasing volume and variety. They begin to realize which areas need improvement and these insights become their customized “road map” for their child’s recovery.
Parents are often surprised by what they learn. They may not realize just how repetitive meal patterns have become! They know that their child’s diet is limited, but it isn’t until they map it on a 7-day food record and “see” it visually, that they realize their child was having quinoa 10 out of 14 lunches/dinners, and oatmeal for 6 out of 7 breakfasts. This is impactful, empowering, and motivating, it gets parents to take action.
Your guidelines regarding plate size and design, food groups, space on the plate, cohesiveness, and challenging the child are graphic and specific. Please summarize the essential nature of these guidelines.
There are 3 key aspects to our Plate-by-Plate 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 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.
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 are encouraged to use a 10” plate, not a salad plate, or a toddler plate. They can choose a meal schedule of 3 meals + 2 snacks or 3 meals + 3 snacks (depending on their child’s individual needs) 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. Also, there is often a high caloric requirement associated with refeeding as the metabolism shifts towards becoming hypermetabolic along the way, and more calorically dense plates are necessary to meet nutrition requirements.
Snacks are defined as at least 2 different food groups but can increase to as many items/food groups as are necessary to meet the nutritional needs of the child. If a child is currently eating a “2 item” snack, and struggling to gain weight, the parent may wish to consider increasing either the number of snacks per day, and/or the number of items at each snack (from 2 items to 3 items). Parents are encouraged to step back and check in as to whether the meal makes sense, and whether they are happy with the plate overall.
LEGEND: Above you will see two versions of the plates being used in the Plate-by-Plate Approach. The plate on the left, where 50% of the plate is coming from grains, is designed for someone undergoing weight restoration, such as someone with anorexia nervosa, or amenorrhea. It is also used for individuals with higher caloric demands due to age, growth, and activity level. The chart on the right, represents a plate where 33% of the plate is coming from grains. This plate is appropriate for someone who does not need to gain weight but is looking for help on balanced eating, such as someone with bulimia nervosa, or binge eating disorder. The plate on the right, the 33% plate, can also be used to help transition someone to weight maintenance, and eventually to an intuitive eating plan.
After the child has moved through Phases 1 and 2 of FBT, there’s still work to be done. What advice do you have for parenting at this point in the process of recovery?
As your child moves from Phase 1, to 2, and on to Phase 3, there is a shift from actively fightingagainst the eating disorder, to supportingyour child’s return to normalcy. Parents and children are now on the same team, and there is a more collaborative discussion around food – for the first time in this whole process. Parents will begin to say, “I’ve got my kid back!” – a phrase that for any clinician in the field of eating disorders, is the purpose behind continuing to fight this terrible illness.
In this phase, there may still be strong body image concerns, as the child gets reacquainted with their nourished body. There might be tears the first time the child heads to the beach with friends and has to put on a bathing a suit, or when they reach for their favorite pair of jeans that no longer fit. Nan Shaw, LCSW, our FBT certified expert, and therapist to many of our families, reminds parents to trust their instincts. She writes in our book, “You now have the advantage of knowing what the eating disorder looks like, which you didn’t know at the beginning. You’ll see it, if it returns, and you’ll know what to do.”
As kids transition to a more flexible meal plan, with more independence, the Plate-by-Plate approach, makes this easy for them. They don’t need to first learn a new meal plan; instead, the plate-by-plate approach can be taken to the college dining halls, or on a backpacking trip that they are now cleared to go on.
We also remind parents to model their own healthy approach to eating during this phase – eating 3 meals a day with snacks with a wide variety of food groups. We encourage families to eat together if possible – eating together is not just for eating disorder recovery! Research supports the benefits of family meals including: higher self-esteem, better academic performance, greater sense of resilience, lower substance abuse, lower rates of teen pregnancies, and lower rates of depression/anxiety (https://thefamilydinnerproject.org/about-us/benefits-of-family-dinners/).
When is a child ready for “normal eating”?
Kids who go through eating disorder recovery often yearn to be able to understand their own body signals – when they are hungry and when they are full. But it’s not until they are weight restored, out of medical danger, and/or their food intake has stabilized for a period of time, that they can begin to hear what their body is saying. Internationally recognized expert on feeding and eating, Ellyn Satter, MS, RD, characterizes “normal eating” in depth. We encourage you to visit Ellyn’s site for more information, but some of the characteristics include, “Going to the table hungry and eating until you are satisfied, Being able to choose food you like, eat it, and truly get enough of it; not stopping because you think you should, Being able to give some thought to your food selection so you get nutritious food, but not being so wary and restrictive that you miss out on enjoyable food, Leaving some cookies on the plate because you know you can have some again tomorrow, or eating more now because they taste so wonderful.”
Careful exploration is required before determining when to allow your child to transition to this last phase of eating disorder recovery, and requires input from the whole team. To start, the child must be medically stable, within a healthy weight range, and the parents/team must feel that the eating disorder has receded sufficiently for the child to successfully complete meals independently, unsupervised, and with success. We also like to see that the child is expressing some interest and enjoyment in food, asking for foods they used to like, eating some foods spontaneously (a forkful here and there, a taste of someone else’s meal, a sample at the farmer’s market). We want to see the stress level around food significantly reduced, and the flexibility significantly increased! We have outlined the criteria below. We also outline in our book some “red flags” that parents should watch out for (like weight loss) to ensure for continued success in recovery.
Your child is ready to take this next step when they:
❏ Consistently maintain medical stability, staying within a healthy weight range (REQUIRED)
❏ Can eat and complete at least one unsupervised meal per day (REQUIRED)
❏ Are getting regular periods (if applicable)
❏ Enjoy food again
❏ Make requests for foods they used to love
❏ Can eat spontaneously (i.e., asking for a few pieces of chocolate after dinner)
❏ Are more flexible with food, eating what is served without complaint
❏ Can eat out at a restaurant without heightened anxiety or stress
About the authors:
Casey Crosbie, RD, CSSD, is a specialist in adolescent eating disorders and currently serves as Director of Nutrition Services at the Healthy Teen Project, a partial hospitalization and intensive outpatient program for adolescents with eating disorders in Los Altos, California. She previously served as lead dietitian for the Lucile Packard Children’s Hospital (LPCH) Comprehensive Care Program for Eating Disorders at Stanford. Casey was published in Nutrition in Clinical Practice (2012) and in the Journal of Adolescent Health (2013) for research focusing on refeeding syndrome as well as increased caloric intake and reduced length of hospitalization in adolescents with eating disorders. Casey received her BS in food science and nutrition from California Polytechnic State University, San Luis Obispo, and completed her dietetic internship at UC Davis Medical Center to earn her RD.
Wendy Sterling, MS, RD, CSSD, CEDRD-S
Wendy Sterling is a Certified Eating Disorder Registered Dietitian and a Board Certified Specialist in Sports Dietetics in the Bay Area in California. Wendy is a co-author of “How to Nourish Your Child Through an Eating Disorder: A Simple, Plate-by-Plate Approach to Reestablishing a Healthy Relationship with Food (Instagram: @platebyplateapproach) and “No Weigh! A Teen’s Guide to Body Image, Food, and Emotional Wisdom.” Wendy is the Team Nutritionist of the Oakland Athletics since 2016 and has consulted for the Golden State Warriors, New York Jets (2006-2013), NY Islanders, and Hofstra University’s Women’s Lacrosse and Volleyball teams.
Wendy worked at The Healthy Teen Project, PHP/IOP from 2014-2017 and in the Eating Disorder Center/Adolescent Medicine Division of Cohen Children’s Medical Center of New York from 2001-2011. She has conducted research on adolescents with eating disorders in the areas of metabolism, osteoporosis, and menstruation. Wendy maintains a private practice in Menlo Park and Los Altos, California. For more information about her work, please visit: www.sterlingnutrition.com.