Meal Support Guidelines for the Meal Supporter

Meal support and supervision is the process of providing emotional support, encouragement, and reassurance before, during, and after mealtimes to an individual with an eating disorder, in an effort to improve their nutrition intake.

The goal of meal support is to facilitate the completion of all food, fluid, and supplements prescribed as part of the nutrition management plan, to support the individual to challenge engagement in disordered eating behaviours, and work to normalise eating.

The following guidelines should be consistently adhered to by all meal supporters:

1. Preparation for Meal Support:

• Meal trays should be delivered directly to the nursing staff, rather than to the patient. Meal trays should never be left with patients unattended by a staff member.

• The food on the meal tray should be checked against the meal plan and amendments made accordingly.

• Be aware of the amount required for the supplement exchange if the complete meal is not eaten, so that it can be easily measured out without delay.

• Once the meal or snack time commences the patient should not be left unattended for any reason.

2. Expectations of the Patient:

• Ensure that the patient understands the expectations of them before, during, and after the meal, including - when, where, and what the meal is, duration of the meal or snack period, what are appropriate and inappropriate eating behaviours, limitations around bathroom access, expectations around the 2-step or 3-step meal plan.

• It may be helpful to provide the patient with the Meal Support Guidelines for Patients leaflet at the beginning of the admission and remind them to read it well ahead of the meal/snack.

3. Distractions:

• All other tasks such as documenting, reading, recording in medical records, or cleaning up, should be put aside during mealtimes so that all focus is on meal support.

• Notify your colleagues that you will be in meal support and supervision over the next 60- 90 minutes so that you are not disturbed.

4. Eating Environment:

• Try to ensure a calm and uninterrupted environment for mealtimes. Close the door if the patient prefers or draw the privacy curtains.

• Clear a space in the patient’s room for the meal.

• Remove objects that may be used to engage in eating disorder behaviours such as buckets or bins, which may be used to hide food.

• Encourage the patient to sit out of bed to have their meal if it is safe to do so.

5. Time:

• Meals should be completed within 30 minutes, and snacks within 20 minutes.

• Notify the patient when the meal or snack time has started, when they have 10 minutes to go, and when the snack or mealtime is over. It may also be helpful to ask the patient when they would like to be reminded of the time or to have a clock visible for them to see.

6. Bathroom:

• Encourage the patient to use the bathroom before the mealtime commences.

• No bathroom access is permitted during meals.

• Any bathroom visits within 1 hour of the main meal or 30 minutes of the snack finishing, should be supervised. This may involve keeping the bathroom door ajar a few inches and asking the patient to count, talk, or sing whilst using the bathroom to deter them from using behaviours such as vomiting or exercise

7. Eating Behaviours:

• Encourage ‘normal’ eating behaviours during mealtimes. Gently remind the patient if they engage in a disordered behaviour that it is important for them to refrain from using that behaviour.

• Disordered eating behaviours may include cutting food into tiny pieces, picking or pulling food apart, eating very slowly, playing with food, smearing food, etc.

8. Negotiations:

• Meals and snacks are to be eaten as they are provided. There should be no negotiations with the meal supporter to make alterations to the meal or snack.

• If the patient tries to negotiate to make alterations to the meal or snack, kindly remind them that there are no changes that can be made and that this should be directed to the Dietitian or team to be discussed at a later date.

9. Post meal supervision:

• Patients should rest after meals, for 1 hour after main meals and 30 minutes after snacks. This means staying in bed or in a chair with minimal walking

• All food and the meal tray should be removed from the patient’s room after meals.

• They should be supervised (including visits to the bathroom) during this period as there may be a temptation to compensate for the food eaten by using eating disorder behaviours.

• It can be helpful to encourage the patient to engage in quiet activities to distract themselves after a meal, this may include watching TV, playing a board game (i.e. Monopoly, Scrabble, a puzzle), playing a card game (i.e. Uno, solitaire), colouring in using a colouring in book, doing a crossword, Sudoku, journalling, or taking up knitting or crocheting.

• It may be helpful for them to reach out to family and friends to talk, however the role of the meal supporter is also to support the patient in the distress after meals. This might be allowing them to talk about how difficult the meal was, or to talk about other things to distract them.

10. Documentation:

• Clearly record food intake and food not eaten, engagement in any disordered behaviours, observations of the patient’s mood and affect, strategies used that helped to alleviate anxiety and distress.

Therapeutic Approach

Offering effective meal support for a person with an eating disorder is reliant upon the development of a strong therapeutic alliance between the meal supporter and the patient. Uphold the 4C’s of meal support – remain calm, be confident, be consistent, and be compassionate. Display empathy and an unconditional positive regard for the patient.

Externalise the eating disorder. Separate the eating disorder from the person, by talking about ’the illness’ or 'the eating disorder' rather than referring to the patient as if they are the problem. “It looks like the eating disorder is finding it difficult to stop picking food apart. What can I do to support you to stop doing that?” Maintain clear boundaries around scope of practice, sharing of personal information, and confidentiality.

You can find more detailed information on how to support the patient on the Meal Support in an Inpatient Setting resource.