Book Review: Crosbie & Sterling's How to Nourish Your Child Through an Eating Disorder

Written by Meghan Kacmarcik, RDN

Book How to Nourish Your Child Through an Eating Disorder: A Simple, Plate-by-Plate Approach to Rebuilding a Healthy Relationship with Food

Authors  Casey Crosbie, RDN, CSSD & Wendy Sterling, MS, RDN, CSSD

Year Published 2018

Target Audience Parents/caretakers of children with eating disorders

Verdict: Very helpful for parents involved in their child’s eating disorder recovery 

Written by two dietitians specializing in eating disorder (ED) treatment for children and teens, How to Nourish Your Child Through an Eating Disorder provides some ED-basics groundwork and introduces an approach to eating called the “Plate by Plate” method that’s rooted in family-based therapy (FBT), one of the most well-researched and effective ED treatments for adolescents. The book walks you through the three stages of FBT and the role of the parent/child in each, as well as what parents can expect during each of these phases and tips to handle it. 

The authors’ breadth of knowledge is evident in their writing. Before they dive in to the nutritional aspects of recovery, they take a closer look at details of eating disorders that parents may be wondering about (especially if this is their first experience with eating disorder treatment). The authors cover the medical complications of eating disorders, the importance of having a team including an MD, therapist, and dietitian (and a psychiatrist as needed) in place, and how to handle exercise during eating disorder recovery. This provides much-needed background before discussing how to choose, prepare, and serve food which is the focus of the second part of the book.

The majority of the book is spent explaining the plate-by-plate approach, which was developed by Crosbie & Sterling as a simple and adaptable way of feeding your child. The goal is to take away the stress of numbers and exact measurements, which can be a source of stress to parents trying to care for their child in recovery. The idea is to use the plate to visualize portions and adequacy with 50% of the plate as starch, 25% protein, and 25% fruit/vegetable in addition to a source of dairy and fat. The book includes examples of meals and snacks, including photos, as well as questions for parents to ask themselves to ensure their child’s plate is adequate. The photos included in the book to demonstrate portion sizes are incredibly helpful in giving parents a better idea of what portion sizes should look like which can feel particularly challenging after a child’s eating disorder has been guiding those decisions. They also provide guidance in setting limits and expectations with a child who might be upset seeing their portion sizes change. This is a great starting point for parents who are hoping to manage their child’s eating disorder at home versus at an eating disorder treatment center although the strategies discussed in the book could certainly translate to a higher level of care as well.

The authors cover a wide breadth of topics related to recovery, but each chapter is broken down into manageable, bite-sized pieces (no pun intended). They detail the ins and outs of eating disorder recovery in a way that feels clear, straightforward, and compassionate. This book addresses questions that I get from parents frequently in my individual sessions, including how to talk about weight and body image with their kids, how to handle vacations or meals outside the home, vegetarian or vegan eating patterns, and when to start re-introducing challenge foods. It can be difficult to provide parents with guidelines to feeding their child in recovery and the plate-by-plate approach makes this simple and easy to implement for most families.

The authors provide strategies for setting limits and expectations when implementing family-based therapy at home including making the child aware of what the expectation is for meals and implementing a supplement protocol as needed. One thing that is not addressed is how to handle these conversations and situations with teens who have any co-occurring behavioral concerns which is something I see frequently in my own practice. However, the book lays out a foundation helpful in navigating this at home and even having this conversation with a child’s psychologist or psychiatrist who might be able to provide more strategies specific to any behavioral concerns.

The authors share about their own roles as dietitians working with parents and children and how they support both during treatment.

Having a child in eating disorder recovery can be incredibly challenging and exhausting. How to Nourish Your Child Through an Eating Disorder is a compassionate, comprehensive overview of eating disorder recovery for adolescents and teens that answers parent’s questions and equips them with the tools to support their child in recovery. I would recommend it for any parent in this situation or any dietitian working with families and teens.

12 Strategies to Support Eating Disorder Recovery on Campus

It’s the start of the new semester, and the return to campus can bring up challenges in recovery for lots of reasons. A lot of folks I speak with about this find dining halls, on-campus food options, and dorm or apartment kitchens and shared spaces to be overwhelming. Here are a few strategies to stay rooted in your recovery game plan and support consistently nourishing your body.

1) Eat consistent, adequate meals
This advice is for everyone across all symptoms and diagnoses. Nourishing your brain and body with enough fuel to support your activities and keep you energized is a top priority. Eating satisfying meals is an important tool in interrupting disordered eating patterns or eating disorder behaviors. Our bodies need meals and snacks at regular intervals (think every 3-4 hours), and eating consistently during the day can help manage sensations of hunger and fullness. Essential tips here: start your day with breakfast and avoid meal skipping.

2) Go for a balance of food groups
Our bodies need all the macronutrients (carbohydrates, proteins, and fats) to function well. When you’re in line at the register, run through a mental check list to be sure you’re including these five key components in your meal: 1) carbs or grains; 2) protein-rich foods; 3) a source of dietary fat; 4) fruits and vegetables; and 5) fluids. Don’t skip any food groups.

3) Develop a game plan
A lot of dining halls offer information on menus on their websites. It can be helpful to look at the options ahead of time to reduce overwhelm when you’re actually in the dining hall. Familiarize yourself with the different meal stations when the dining hall isn’t packed. If planning ahead isn’t helpful (for example, if too much nutrition info is also posted online or you find yourself bogged down in the decision-making process), talk through the stressors with your treatment team.

4) Variety is important
Try to switch up what you’re eating on a day-to-day basis. Take advantage of the dining halls’ changing selections to vary your intake. Not only does including a variety of foods keep things interesting in terms of flavor and give us access to a wider array of nutrients, it is a helpful tool in itself for limiting eating disorder behaviors. Choosing different foods and not opting for a few safe options at every meal can help keep our options from getting progressively narrower. Try to include combination foods and prepared entrees rather than cobbling together separate components into a single meal.

5) Use the salad bar appropriately
What role are salads playing in your meal choices? How often are you having them? Salads often have the allure of being a “healthy choice,” but they don’t always serve our recovery goals. The foods we’d pick at the salad bar can be healthful and delicious, but salads can be problematic if they displace other important food groups, contribute to limited variety, or are chosen because it is a “virtuous” choice. If you do have a salad for a meal, be sure to get sufficient portions of carbohydrates, protein-rich foods, and fats (dressing).

6) Listen to your body
Some dining halls and meal plans have the option for unlimited servings and courses. Others portion meals on the plate for you. Check in with your hunger and fullness cues to help determine what portions will truly satisfy you at that meal. Give yourself permission to throw away unfinished portions if you’re challenged by the need to always clean your plate. Listening to these cues and developing trust in your body can feel challenging and take time. Work with your dietitian for guidance around portions and body cues.

7) Don’t restrict yourself
Include desserts and fun foods in your eating patterns. Give yourself permission to eat what is enjoyable, nourishing, and satisfying. Explore and honor taste preferences. Recognize when rigid or black-and-white thinking limits what your choices are or dictates what you “should” eat. Physiological and psychological restriction can leave us vulnerable to disordered eating patterns or behaviors.

8) Surround yourself with appropriate social supports
Eating in a dining hall can be anxiety provoking. Sometimes it feels like others are watching our choices. It’s helpful to reality check these thoughts; most of the time, others aren’t evaluating what we’re eating. If others are truly checking in (like a concerned friend, for example), try to figure out what kind of support is most helpful during the meal. If there are others with whom there is a triggering element of comparison, try to eat with supportive and nonjudgmental friends.

9) Recognize and process potential triggers
The dining hall might have posters or messages about healthy eating or more general nutrition advice presented through menus and visual displays. Ingredient lists, allergen warnings, and nutrition information can sometimes surprise us and cause us to doubt our choices. Understand that these messages may not apply to your individual situation or recovery.

10) Snacks are important
Snacks are a helpful tool in managing hunger, achieving adequate intake, and having access to fun foods between meals. Snacks are generally a combination of two or more food groups. Not all dining halls allow you to take food with you to snack on between meals. If that’s the case, plan where and how can you obtain snacks. Keep portable snacks in your bag so you’re not stuck at the library or class with nothing to eat.

11) Know your schedule
Get a sense of what your schedule looks like and think about when and where you’ll eat most meals. When are your busiest days? Which options are close enough to visit between classes? When do you need to plan for and pack a snack? Try to identify tight timelines, conflicts, or areas where unsupportive habits might enter the picture ahead of time.

12) Work with your team
Not all of these strategies will fit your situation exactly. Some tips may feel more or less relevant, depending on your individual recovery. It’s extremely helpful to have a treatment team during the school year and process challenges as they come up. Try to get an understanding of the resources available to you ahead of time (even if you feel you won’t need to utilize them). It’s good to know who and where to turn to for increased support if the need arises.

Binge Eating Disorder and Body Image

The experience of living in and relating to your body when you have binge eating disorder or are bingeing has been coming up a lot for me this month, both in my research work and in session with clients. I wanted to repost a recap I wrote a few years ago when I served as a panelist in a discussion of BED treatment. Stemming from this conversation, here are a few suggestions to help you in doing this hard work:

1. Increase the visibility of body-positive images in your online world: The kind of images we see or intentionally expose ourselves to can make a difference in our own perception of our bodies. Tumblr and Instagram are places where images of people in larger bodies loving their bodies are abundantly available.

2. Improve physical spaces to the best of your ability, or admit and address shortcomings: If you’re in recovery, update mood boards or the art the decorates your home, office, or online space to be positive about food and bodies or to shift towards subjects or topics that aren’t about your eating but come from another interest or passion. If you’re a clinician, make sure your offices and waiting rooms have comfortable, accessible, and accommodating furniture. Have interesting artwork and reading material outside of the standard magazines that display only certain types of bodies. If this isn’t doable, talk openly about what’s lacking. Try to help clients be as comfortable as possible at all times so discomfort doesn’t go unacknowledged or dismissed.  

3. Boost your connection with community: joining Facebook groups or support groups for BED can help you feel plugged in to a wider group of people who understand or are similarly struggling with eating or body image issues. Sometimes starting a conversation with friends can be eye-opening and healing for everyone (just know you’re not responsible for other people’s recovery — sometimes talking to a friend who is struggling can make it feel like you need to do something about it, and it’s OK to not take that on).

4. Focus on the body in positive ways: do you hide or avoid certain body parts? What would it be like to explore those physical spaces without judgement or criticism? This can be a foreign and difficult task. As an example of what this might look like, eating disorder recovery podcast Recovery Warriors describes dedicating a few minutes, or even as little as 30 seconds, a day to massaging lotion onto body parts that you dislike (which can be novel and intense, especially if we’re used to regarding these parts with judgement… or something stronger). When we compare our bodies to others' or body check for reassurance, we rarely come away comforted or reassured. Instead, we often wind up feeling worse about our bodies and how we look. However, I've had clients tell me that when they take the time to be aware of their bodies and treat them with kindness, their perception of their body shifts and improves.

Being at home in our bodies can be tough, especially if you’re recovering from an eating disorder or living in a body that is stigmatized or faces judgement from the world around us. It can be slow work, and it’s OK to reach out for help from others.

Key Principles of Meal Planning

I have five words that I use over and over when describing what goes in to a healthy meal plan, and how to bridge the transition from using a structured meal plan to more intuitive or mindful eating methods. They are:

1. Adequacy

2. Balance

3. Variety

4. Moderation

5. Nourishment

Adequacy: By adequacy, I mean the meal plan or meals we eat provide enough energy, major macronutrients (protein, fat, carbohydrate), micronutrients (calcium), and fluid that our bodies need to function optimally and to support life-long health. This means we're eating enough to support our bodies through day-to-day activities like school and work, and we're giving ourselves fuel to support physical activity (rather than exercising to compensate for what we've already eaten or are planning to eat). We're generally getting this nutrition through 3 meals and 2-3 snacks each day.

Balance: All of the major food groups are present in meals, and generally two are present at snacks. The body needs adequate amounts of carbohydrate, fat, and protein to function well. We can have favorites, but this isn't a low-carbohydrate or low-fat diet. We're including fruit and vegetables at every meal, but we're having more than a simple salad for lunch. 

Variety: Get the nutrition we need from a variety of foods. Switch things up to help ensure your body gets exposed to a variety of phytochemicals and miconutrients. There's no magic superfood, but incorporating different kinds of foods into our meals and snacks helps us maximize the nutrition we are getting. It also means we don't get stuck in a rut, eating the same foods day after day, either because it feels like the safe thing to do or the only thing we know how to do.

Moderation: This is the complement to the adequacy piece above; we absolutely want to meet our nutrition needs, but we also want to stop at a comfortable place where we've had enough. A lot of my patients are surprised to hear that desserts are included in the meal plan, and snacks and meals are made up of what we want to eat, what we're in the mood for, or what sounds good. Learning when and how to say "that's enough" can sometimes take practice, so if you need help, ask for it (a good dietitian can be a great asset here). 

Nourishment: This is the place where food feeds the soul. We eat for enjoyment, to socialize, because we're intrigued by something new or returning to an old favorite. We eat for other reasons besides hunger and biological need; that's part of being human, and it's OK to do this. This is the place where we get to experiment. We can and should eat fun, thrilling foods. 

If you feel like you want or need help with meal planning or any of the components outlined above, you can find a dietitian here, or reach my Cambridge-based office here.