At some point in my clinical training, I learned the basic guideline, “When the gut works, use it.” In other words, do not utilize TPN (intravenous feeding) if the gastrointestinal tract is healthy enough for at least enteral (tube) feeding. If the latter is called for, depositing into the stomach rather than the small intestine is better, if medically possible, in order to utilize as much of the gastrointestinal tract as possible. If the patient can eat by mouth, even better.
Working in an outpatient setting, I use meal plans similarly to how clinical dietitians utilize TPN. Both are treatment options that have their place, but better to avoid them if possible. Whereas clinical dietitians resort to TPN only when the patient’s gastrointestinal tract is not functioning well enough to rely on other options, I use meal plans only when a patient’s ability to make sound eating decisions on their own is significantly compromised, as can be the case when one is in the early stages of recovering from a restrictive eating disorder.
In these situations, meal plans can help in a multitude of ways. By making some of the decisions regarding what, when, and how much to eat, meal plans streamline the choices that patients have to make themselves. Rather than patients and their parents arguing over meal compositions and quantities, they can refer to the meal plan, thereby reducing the strain that eating disorders can place on families. When followed, meal plans provide enough nutrition for the body to rebuild itself and hopefully keep the patient out of a higher level of care.
Despite these upsides, meal plans also have their downsides, one of which is that they simplify nutrition to a fault. Rather than specifying what a patient is supposed to eat at a given time, meal plans typically utilize an exchange system that allows the patient to select the foods that fit the indicated criteria. For example, one patient’s meal plan might say to have one protein and one grain at snack time, so then the patient would survey the provided list of foods that qualify as proteins and their respective quantities and decide which one to have, and then they would make a similar decision about which grain to have.
The problem is the oversimplified rounding off necessary in order to force foods with complex nutrient profiles into these basic categories. For example, we classify chickpeas as a “protein” when in reality only approximately 23% of their calories come from protein and 10% and 67% come from fat and carbohydrate, respectively. How does that make sense? Cashews are 19% protein, 42% fat, and 39% carbohydrate, but our exchange list says a patient can count them as a protein or a fat. Huh? We treat all cooked vegetables the same even though spinach is significantly higher in protein than carrots are (48% versus 8%, respectively) and much lower in carbohydrate (41% versus 89%, respectively). What?
But is this oversimplification really a flaw? Consider that many (but certainly not all) patients with restrictive eating disorders are high achievers with perfectionist tendencies, and their disorder drives them to seek out and consume exactly what and how much they believe they are supposed to eat. Part of their recovery entails helping them to understand that a drive for perfection, which might be an asset in some realms of life, is unnecessary and counterproductive when applied to eating.
The human body is adaptable and can thrive under a variety of eating conditions. Some populations rely heavily upon starches, fruits, and vegetables, while others get by subsisting on fatty meats. Looking at our country’s own nutrition guidelines, the recommended ranges for protein, fat, and carbohydrate are quite wide. For example, the acceptable macronutrient distribution range for carbohydrate is 45% to 65% of one’s total energy intake, which is quite broad.
Barring certain medical conditions, we do not need to be exact in our eating in order to provide our bodies with the nutrients they need. In that sense, whether we classify chickpeas as a protein or a carbohydrate, or cashews as a protein or a fat, etc., really does not matter; the body will still receive the nutrition it needs regardless. So, while we could view such oversimplifications as cons, I see them as pros, as they teach and reinforce flexibility and freedom in eating, which are important aspects of recovery, rather than rigidity and precision.