How the Food Exchange System Is Used in Eating Disorder Treatment

June 21, 2023

If you or a loved one has been diagnosed with an eating disorder, navigating meal and snack choices can feel overwhelming. The food exchange system offers a proven way to reduce stress around meal planning while rebuilding your relationship with all foods during eating disorder treatment and recovery.

“A food exchange is not meant to be rigid or to create new food rules,” says Adee Levinstein, MS, RD, LD, CEDS-S (she/her/hers), nutrition manager at Eating Recovery Center (ERC). “Instead, it’s meant as a guide to ensure patients receive enough food, challenge their existing food rules within a supportive environment and understand nutritional needs beyond the bounds of treatment.”

The food exchange system explained

The origin of food exchanges can be traced back to 1950 [1]. That’s when the American Diabetes Association (ADA), American Dietetic Association and the U.S. Public Health Service developed a food exchange list to help people with diabetes regulate their blood sugar. Over the years, food exchanges have also proved helpful in supporting nutritional rehabilitation for people with eating disorders, and the ADA has updated the list of approved exchanges [2].

The U.S. food exchange list divides foods into six different groups:

Starches (carbohydrates)
Proteins
Fats
Dairy
Fruits
Vegetables

Foods within each category can be substituted -- or “exchanged” -- for another food within the same category.

“The exchange system provides a structure for people with eating disorders to incorporate a variety of foods and learn practical, real-life ways to meet their energy needs in various settings,” Levinstein says.

Benefits of food exchanges

The main goal of food exchanges is to make sure individuals with eating disorders receive the appropriate amount of nutrients at each meal and snack. Food exchanges also give people with eating disorders and their caregivers the structure and tools they need to:

Plan adequate, well-balanced and consistent meals and snacks
Increase personal knowledge about food and nutrition
Boost self-confidence around food selection
Reduce anxiety around challenge or fear foods
Decrease the focus on calories
Learn what proper portion sizes look like for meals and snacks
Distinguish between eating disorder thoughts and their true feelings

Above all, food exchanges play a vital role in helping patients reimagine their relationship with food.

“Because an exchange-based meal plan helps mimic an appetite-based schedule, it helps individuals restore their natural hunger and fullness cues,” says Kathryn Johnson, MA, RD/LD, CEDRD-S (she/her/hers), nutrition director at ERC Dallas.

This resource offers real-life examples of food exchanges that can create well-balanced, supportive meal options for people in eating disorder recovery.

Which patients with eating disorders do food exchanges support?

At ERC, food exchanges are used to treat individuals diagnosed with:

We do not typically practice food exchanges with individuals diagnosed with avoidant restrictive food intake disorder (ARFID) or binge eating disorder (BED) in our care. These conditions often require a more flexible meal plan.

For example, those diagnosed with BED often use a separate type of nutrition therapy (called the CARE plan) that emphasizes starches, fats and proteins instead of specific exchanges. People receiving care for ARFID, Johnson explains, will receive a more individualized nutrition plan based on their subtype.

Learn more about nutrition and meals in eating disorder treatment.

How we incorporate food exchanges into eating disorder treatment

At ERC Pathlight, meals play a crucial role in eating disorder treatment and nutritional rehabilitation. We believe that all foods fit -- there are no “good” or “bad” foods. Our goal is to teach our patients how to have a peaceful relationship with food.

“We will support patients in being able to incorporate any item,” Johnson says. “Their meal plan is never meant to be restrictive.”

During treatment, we use exchange-based meal plans to give patients flexibility and help them meet their nutritional needs. Patients receive support in planning their meals for the week, including breakfast, lunch, dinner and snacks. Adults choose their own menus. Caregivers plan menus for children and adolescents. The treatment team evaluates each patient’s nutritional status and adjusts meal plans as needed.

“We monitor each patient closely to make sure we are safely refeeding a patient. We can’t go too fast, too quickly,” Johnson says. “And it’s incredibly important to make sure patients are using their gastrointestinal tract for nutrition so they can normalize their hunger and fullness cues.”

Our dietitians support patients by answering questions about meal planning and the types of foods to select. On the way, they teach patients how to align their actions with their values and recognize food as one of many important parts of their lives. As patients’ brains and bodies heal, we find that they become less preoccupied with their food and their weight.

Learn more about refeeding syndrome prevention.

What else does the nutrition program at ERC include?

Food exchanges are just one part of ERC’s comprehensive and multidisciplinary nutritional program. Learn more about our approach to nutrition as an integral part of eating disorder treatment and recovery.

We’re here to support you

Call us at 866-622-5914 or fill out this brief form to set up a free eating disorder screening or get matched with the exact support you need.

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Sources

Diabetes.co.uk. (Jan. 15, 2019, reviewed Jan. 25, 2023). Food exchange (US). Retrieved May 8, 2023 from https://www.diabetes.co.uk/bmi/food-exchange.html
National Heart, Lung and Blood Institute. (n.d.) Food exchange lists. Retrieved May 8, 2023 from https://www.nhlbi.nih.gov/health/educational/lose_wt/eat/fd_exch.htm

Written by

Kyle Hardner

Kyle Hardner is a writer and content strategist based in Pennsylvania. He's led content development and creation for leading health systems and has extensive expertise writing about healthcare,…