Meal Support, Part II

(Click Here to read Part I, which introduced the concept of meal support, and discussed its benefits and drawbacks, and issues of practice during treatment. The second article in this two-part series describes meal support guidelines at the St. Paul’s Hospital Eating Disorders Program, Vancouver, British Columbia.)

A Brief History of the SPH Meal Support Program

Meal support began at St. Paul’s Hospital (SPH) Eating Disorders Program in 1994. At that time the average length of stay in the inpatient program was reduced from 3 months to 3 weeks. Understandably, the treatment team was concerned that the program shift might interfere with the clients’ ability to become medically stable and to begin weight restoration. Meal support was introduced to solve this treatment dilemma. The rationale for meal support is the same today as it was 6 years ago: to respectfully monitor clients’ food intake and to provide them with emotional support during meals.

Making the Decision to Eat with Clients

Establishing meal support at SPH has been a process of trial and error. Unfortunately, nothing could be found in the scientific literature that could be used as a reference or a guide. Thus, client feedback and staff observations have shaped the manner in which meal support is provided to clients.

Shortly after meal support was implemented, the SPH team made the decision to eat with the clients because patients felt self-conscious and “watched” during the staff-supervised meals. Almost immediately after the staff began eating with patients, the patients reported feeling more supported with eating. As part of a survey study in spring 1999, 18 clients were asked how helpful it was to have support staff eat a “balanced” meal with them. Using a five-point Likert scale, ranging from “extremely helpful” to “not helpful at all,” 100% of the clients responded that it was “extremely helpful” to have staff members eat with them.

Almost All Team Members Participate

All team members in the inpatient program and almost all the outpatient treatment programs take turns providing meal support to clients. Depending on what the patient is eating, the support staff will have a hospital tray or a meal brought from home. Hospital trays for both patients and support staff are funded by the treatment programs and are provided by the patient food services department at SPH.

The SPH team believes that meal support is an exceptional situation that requires modeling healthy eating behavior for clients. The staff eats a “balanced” meal that includes at least 3 of 4 major food groups. While personal dietary practices and preferences are a part of real life, staff members are aware of their potential negative impact on clients. Thus, dietary practices such as vegetarianism and diets necessary for medical reasons are acceptable during meal support, but eating patterns that exclude one or more food groups or that emphasize low-fat and diet food items are not.

Meal Support Guidelines

Staff observations and client feedback have also been instrumental in the development of meal support guidelines. In the survey study mentioned earlier, 62.5% of clients reported that staff needed to be more aware of eating-disordered behaviors. One client responded: “The staff needs to be aware of the specific rules around meal-taking at all times and keep their eyes open to suspicious eating disorder behaviors. We are the experts, you know!” Patients also stated that support staff were not consistent about checking meal trays and permitting clients to get up from the table during the meal.

The results of the survey study were used to revise existing meal support guidelines in an attempt to improve consistency among support staff. The following guidelines are currently used in the inpatient and out patient programs:

Duration of the meal. To encourage healthy social and emotional aspects of eating, clients on the inpatient unit are asked to remain seated at the table for at least 20 minutes; patients in the outpatient day treatment program remain at the table for 30 minutes. Having clients stay in their seats creates a less disruptive environment during the meal. To avoid procrastinating with eating, inpatients have a maximum of 60 minutes to finish eating; outpatients have 45 minutes to do so.

Pre- and post-meal checks. To ensure that clients have the necessary food items and proper portions, the staff checks the clients’ meals against their prescribed meal plan before they begin to eat. At the end of the meal, the staff conducts another check to determine the amount of food the client has eaten. In the outpatient day program, patients may have meal checks stopped once they reach their maintenance weight range and/or are near discharge from the program. This option gives clients the opportunity to take responsibility for eating according to their meal plan.

Eating 100% of the meal. To improve their nutritional status and physical health, all clients on the inpatient unit and the outpatient programs are asked to eat 100% in accordance to their prescribed meal plan. Patients are asked to eat all the food items at the meal and not to save them for another meal or snack later in the day.

Replacement of uneaten food. To assist in the renourishment process, clients on the inpatient unit replace uneaten food with an equivalent serving of another food item or a predetermined quantity of liquid supplement. Patients have a maximum of 15 minutes to take the replacement in the presence of staff.