Creating meal plans based on calorie needs has been a staple of nutrition counseling for years. Is it time to say good-bye?
“The first session is about food. Every session after that is about why they [the patient] are not doing what I told them to do.”
That is how a seasoned colleague explained her work as a nutrition counselor to me when I was just starting out as a dietitian. With all due respect, the quote illustrates nutrition counseling gone awry, the result of an outdated, archaic, and ineffective approach that puts too much emphasis on information and too little on individuality and motivation.
A popular tool in dysfunctional nutrition counseling is the meal plan. While meal plans can take on different forms, the kind that I am referring to is based on an estimation of the patient’s calorie needs; those calories are then broken down into numbers of servings that said patient should consume from various food groups over the course of the day.
In theory, meal plans sound like a useful tool. From a dietitian’s standpoint, meal plans are easy to create, they give patients flexibility, and they put the responsibility for execution entirely on the patient’s shoulders. From a patient’s perspective, meal plans give a welcome sense of certainty and control, thereby temporarily relieving feelings of confusion and powerlessness. Just follow the meal plan and everything will be okay, right?
Unfortunately, the problems with these meal plans are extensive:
- Estimates of the patient’s nutritional needs are not tremendously accurate. The most accurate means of measuring one’s resting metabolic rate is through direct calorimetry, which involves spending time in a chamber that measures the heat he or she generates. To my knowledge, direct calorimetry never happens outside of a research setting. Even direct calorimetry has its problems, and every other method available has larger sources of error. Practitioners like us use algorithms that estimate calorie needs based on height, weight, age, gender, and similar data. Attempts to quantify calories expended through physical activity introduce additional error. Calculations of one’s calorie needs are at best just rough ballpark estimates. Therefore, the whole foundation of the meal plan is shaky.
- The reported calorie content of different foods can also be inaccurate. Whether due to faulty assumptions used in the calculations or labeling laws that allow for rounding off, what we believe to be the nutritional content of a given food is sometimes not quite true. Yet the numbers are taken too literally, and patients exhaust themselves with kitchen scales and measuring cups trying in vain to consume the exact number of prescribed calories, a goal that is virtually impossible to achieve.
- The expectations put on meal plans are unrealistic. With genetics, environment, stress, and other variables heavily influencing health and weight outcomes, the notion that a meal plan can guarantee virtually any measure of success is nonsense and misleads patients.
- Meal plans fuel the inaccurate “good food, bad food” dichotomy. Foods present on the plan are seen as “good,” while those that are absent are considered “bad.” One meal plan form that I used to use omitted some fruits for no other reason than space did not allow for a complete list, yet countless patients expressed criticism and fear of the fruits that did not appear on the plan.
- Meal plans focus heavily on individual foods, but much of the foods we consume in real life are combined with other foods in unknown quantities. Even when we prepare foods at home, estimating, for example, the volume of beans in minestrone soup, or cheese on pizza, or oil used in a stir-fry with any degree of accuracy is a time-consuming and tedious challenge. When eating in a restaurant or buying prepared foods, forget it; there is virtually, or in many cases literally, no way to know. The meal plan paradigm of tracking portion sizes fails when portion sizes are uncertain.
- Meal plans teach patients to follow external cues for their eating. This may work in the short term, but not in the long run. At best, relying on a meal plan delays the development of mindful-eating skills. If long-term change is to occur, it is virtually inevitable that one must learn to eat in response to internal cues.
Following in the footsteps of my more experienced colleagues, I put hundreds of patients on meal plans at the beginning of my career. Some of these patients saw short-term improvements in their health or weight, but I cannot recall even a single instance of a meal plan approach spawning long-term behavior change. When things inevitably fell apart, patients blamed themselves, but really the problem was the approach. For that reason, I recognized meal planning as the dated and ineffective technique that it is and almost entirely removed it from my counseling tool box.
The only exception is that I still use meal plans for some patients with eating disorders. Sometimes the stakes are so high that inadequate nutrition risks hospitalization or admission to an inpatient program, so in these cases I temporarily use meal plans in an effort to keep the patient safe. In the long run though, as the eating disorder is overcome, we leave the meal plan behind and work on mindful eating.
There are times I do devise lists of meal and snack ideas with my patients, but do not confuse these with the meal plans that I have discussed up to this point. Working together with my patients to devise individualized ideas for what they can eat in certain situations can be very helpful due to the customization and collaboration. The utility is quite different than just writing in some numbers on a meal plan sheet, handing it over to them, and then getting together next session to discuss why they are not following it.
To meal plan or not to meal plan, that is the question. A lot of people assume that since the majority of my patients are those with eating disorders, that I must use meal plans with all of my patients. This most definitely is not the case. When a patient first comes to see me, I spend the initial session (or two) learning about that patient: Why are they coming to see me? How have they been eating? At what point in their recovery are they? These are all questions that can help me decide whether a meal plan is indicated or not.
Meal plans, in my opinion, are training wheels for those struggling with feeding themselves adequately. Usually, if a patient has just left an inpatient or residential eating disorder treatment facility and is having a hard time eating all of her meals and snacks at home, I find that a meal plan can be very helpful to get her back on track. But, just like training wheels, the meal plan should not be permanent, and eventually the patient should be weaned off of it.
The ultimate goal that I want to help my patients achieve is the ability to engage in intuitive eating. In a nutshell, intuitive eating is eating when you are hungry, stopping eating when you are satiated, and eating what feels best to your body. This also means not eating according to external rules, but rather listening to your body and honoring its cues.
As I’ve mentioned before in other blogs, we are born with the innate ability to regulate our food intake. When a baby is hungry, she will cry until she is fed. When she is full, she will turn away from the offer of more food. Even toddlers still use internal cues to determine when and how much they want to eat. But, eventually, we begin to lose the ability to listen to our body’s cues when we start placing external regulations on our eating (e.g., eating according to a strict schedule, dieting, being a member of the clean plate club, etc.). This behavior causes us to lose touch with our body’s innate wisdom and can lead to disordered eating.
I rarely, if ever, use meal plans with my non-ED patients, although I’ve had many of them ask for one. I find that those patients who ask for meal plans are the ones that want to be told what, when and how much to eat and don’t trust themselves to feed themselves appropriately. They want to rely on external regulations around their eating, as they feel that if left to their own devices, they would devour an entire sheet cake in one sitting. In these instances, using a meal plan is not a good idea, as it just reaffirms in that patient’s mind that she is incapable of feeding herself solely by using her internal wisdom.
In sum, while I think meal plans can be a useful tool in ED recovery, they are not indicated in every instance. The ultimate goal is to relearn how to eat intuitively, and that means not relying on a meal plan, but instead listening to one’s gut.