Problems with Exchanges as an Eating Disorder Meal Plan

The exchange system is a common eating disorder meal plan, but it has many things that could be improved and more appropriately used. This blog post discusses the exchange system’s problems and shares other meal-planning tools in recovery.

If you’ve been to treatment for an eating disorder, you know what I’m talking about when I say exchanges.

If you still need to, allow me to introduce you to the concept. Exchanges are a type of eating disorder meal plan. With exchanges, each food group is broken down into units or portion sizes that are similar in nutrition value. Exchanges were initially developed by the American Dietetic Association along with the American Diabetes Association in the 1950s as a tool for helping people with diabetes practice “portion control” and eat consistent amounts of carbohydrate from meal to meal (note: most people with diabetes do not need to use exchanges, although it can be helpful in limited circumstances). These exchanges were adapted for use in eating disorder treatment, where they are used as a tool to provide structure and adequacy to eating.

As an example, a plan might prescribe a meal that looks like this: 3 starch exchanges, 2 protein exchanges, 1 fat exchanges, 1 fruit exchange, 1 dairy exchange. While the client could choose whatever foods they like within those specific groups, they would know the serving size of foods that count as an exchange and either measure or estimate their servings to meet their prescribed exchanges.

Now, before I dive into the problems with exchanges as an eating disorder meal plan, let me be clear that the point of this post is not to say that exchanges should never be used. If you’re on an exchange-based plan and it’s helpful for you – great! While I personally rarely prescribe exchanges for a client, I work with a lot of clients who were placed on them in treatment, and it works really well for them or is helpful for the time being. While the goal is always to gradually move away from exchanges on whatever timeline is appropriate for the individual client (because no one wants to be 80 and still using exchanges), it can serve a purpose. Exchanges can be a great tool as an eating disorder meal plan, but in my opinion, it’s an over and often inappropriately used tool.

What is the Purpose of an Eating Disorder Meal Plan?

Before talking about the problems with exchanges as an eating disorder meal plan, I think it’s important to ground the conversation in the purpose of a meal plan:

  1. Refuel the body with an appropriate amount of food and treat underlying malnutrition.
  2. Help spread intake relatively evenly throughout the day.
  3. Ensure a balance of nutrients by providing all the different macronutrients and food groups.

Ideally, an eating disorder meal plan will help a client relearn skills for creating adequate, balanced meals that they can use beyond treatment. When someone has an eating disorder, they often restrict calories, food groups, or put together odd combinations of food in an attempt to eat less. They’ve learned how to craft meals based on the eating disorders rules rather than their food preferences and body needs. The meal plan replaces the eating disorders rules and helps a client relearn how to feed themself.

When I work with a client in recovery, one of my goals in creating an eating disorder meal plan is to find a helpful balance of flexibility and structure. The structure is important because we need to ensure a client knows how much food to eat and prevent that sneaky ED from finding loopholes for restriction. But flexibility is equally important, and that’s often overlooked in treatment. Rigid thinking, especially around food, is a side effect of an eating disorder. Flexibility helps challenge that rigorous thinking and gives clients tools to adapt to different eating situations flexibly.

The flexible structure looks different for each client, and figuring out the most helpful balance is an individual and ongoing process.

Problems with Exchanges as an Eating Disorder Meal Plan

I see some problems with using exchanges for an eating disorder meal plan.

Exchanges are relatively inflexible and replicate some of the rigidity of counting calories.

When someone is in a higher level of care, like residential or acute hospitalization, it’s often important to have tighter control over caloric intake. The dietitian is trying to refeed their client quickly, without triggering some of the symptoms that can arise from feeding a client too much, too fast. In those cases, exchanges or calorie counting can be helpful.

However, once someone is better nourished and medically stable, especially in an outpatient environment where they might be going out to eat, the rigidity of exchanges can become a bit suffocating. From a medical standpoint, while a client will still need more food and consistency throughout the day, there’s rarely a clinical reason for nutrition intake to be so tightly controlled. Most people don’t need a particular amount of fat, protein, carbs, or produce at each meal. While their body still needs all the macronutrients when they eat, it’s also OK if they have higher or lower meals in different macros.

I often hear from clients who have used exchanges that it felt a lot like counting calories to them. By breaking foods down into small units, it activates the same brain pathways that were used in calorie counting. It also feeds into the fear of “going over,” which brings me to my next point…

Exchanges can make it seem like there is a “right” amount of food to eat.

An eating disorder meal plan should be used to prescribe a baseline amount of food, not a limit. Exchanges can unintentionally (or, unfortunately, intentionally, depending on the provider) send a message that there is the right amount of food and that going over the amount prescribed is wrong or bad. In reality, human beings are equipped to eat variable amounts from meal to meal and benefit from that flexibility. When someone is given the message that there is a correct amount of food to eat and that eating should be meticulously managed to prevent going over that amount, the eating disorder will flourish.



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