At Ruby Oak Nutrition, we offer nutrition support for teens who struggle with eating disorders and disordered eating. Although treatment looks different for everyone, we most often use a Family-Based Treatment (FBT) model to help parents navigate the recovery process at home.

Parenting a child or teenager who struggles with an eating disorder can be scary, and then some. You might panic because it suddenly feels like your child is keeping secrets from you. Mealtimes might feel like a battleground. And well-intentioned questions and comments about food and body size can cause even more tension.

Because eating disorders are so complex and consuming, it might even feel like your child has turned into an entirely different person. You probably also feel like there’s a huge strain on your relationship with them that wasn’t there before. No doubt, adolescent eating disorders are really tough to navigate for both parent and child, and there’s no easy answer about how to best move forward.

All that said, Family-Based Treatment (FBT) can provide structure and support for the recovery process at home. While the approach isn’t a cure-all and it certainly has its challenges, it’s a roadmap for making progress towards recovery. And, it’s a good measuring stick for whether or not at-home eating disorder recovery is possible for your child and your family. (Let me be very clear: You are not a failure if you can’t manage eating disorder recovery at home. Sometimes it just doesn’t work, and there are options for various levels of residential and intensive outpatient care.)

What is Family-Based Treatment (FBT) for eating disorders?

Also called the Maudsley Method, Family-Based Treatment is an alternative to other forms of eating disorder treatment (like residential or inpatient care) for adolescents. (I’ll say it again here: Sometimes residential or inpatient treatment is necessary and family-based treatment isn’t an option. That isn’t a failure, it’s just the reality of some eating disorders.)

In FBT, parents take on a very active role in their child’s recovery from an eating disorder. Parents completely take over planning and preparing meals, and are responsible for making sure that their child completes all meals and snacks.

Because FBT is challenging, it’s crucial to work with a treatment team — a therapist, primary care doctor, and dietitian at the very least. As dietitians, we help parents plan meals that contain the right amount of energy and nutrients. We also provide support for parents during the FBT process, since getting an adolescent who’s stuck in an eating disorder to complete meals can be really challenging.

What are the three “phases” of Family-Based Treatment (FBT)?

1. Phase One: Weight Restoration.
   In the initial phase of FBT, the focus is on restoring the client’s (AKA the adolescent’s) weight to a place that’s appropriate for them. This target weight is typically set by a physician, but might be set by a dietitian in some cases. (More on that below.) In order to reach this weight, the dietitian will outline a flexible meal plan that provides adequate nutrition for weight gain.
   
   Parents or caregivers are in control of food during this phase, with the ongoing support of a registered dietitian for guidance on meal planning and creating the right environment at mealtimes. The client doesn’t get to make their own food choices and shouldn’t be part of the cooking process. Parents/caregivers are responsible for ensuring that the client eats according to their meal plan, and for monitoring their behavior to prevent compensatory behaviors like purging or over-exercising. During this phase, the dietitian usually works primarily with the client’s parents/caregivers, not the adolescent themselves.
   
2. Phase Two: Returning Control to the Client
   Once the client’s weight is at a level that’s appropriate for them and the frequency of their eating disorder behaviors (like restriction or bingeing) have drastically reduced the focus gradually (and big emphasis on gradually) shifts to returning control over eating to the client. Both the client’s dietitian and their therapist are crucial in this process. The dietitian and therapist will also help guide the family in empowering the client to make their own food choices and manage their eating behaviors.
   
   During this phase, the client will slowly start plating their own meals and making decisions about what to eat. They’ll have more autonomy over their food choices, and will be able to spend more meals away from their parents. Learning to cook, or learning to cook new things, can also be a part of this phase.
   
3. Phase Three: Establishing Healthy Adolescent Identity
   The final phase of FBT aims to help the client develop a healthy adolescent identity, which includes a healthy relationship with food and a positive self-image. The client will continue working with their therapist to identify and address the emotional and mental health aspects of the eating disorder.
   
   It’s recommended that the client continues working with their dietitian during this phase as well. It typically takes years to fully recover from an eating disorder, so a dietitian can help manage anxieties around food that continue coming up. Dietitians can support the work done in therapy sessions by providing accountability for food choices, supporting the client in pushing back against eating disorder thoughts, and helping with meal planning and preparation.

Is Family-Based Treatment effective for teen eating disorder treatment?

When done properly, FBT basically mimics a treatment center environment, but from within the client’s home.

The benefits of FBT over residential treatment include:

• No need to miss school
• Sleeping in your own bed every night
• Not being separated from family for an extended period
• Outpatient treatment is less expensive than residential treatment
• No risk of being triggered by other adolescents who are also struggling with eating disorders at the treatment center
• You can stay with your existing outpatient providers

But of course, there are some huge challenges to doing all this at home, including:

• Strain on the relationship between parents/caregivers and the child
• A parent needing to understand the meal plan, then prepare and be present for every meal
• The home environment feeling different and maybe a bit tense than it did prior to FBT
• The adolescent having more free time to fill, because they’re not able to engage in activities like sports (because exercise is usually not recommended during recovery) or going to friends’ houses for sleepovers (because their food intake and eating disorder behaviors can’t be monitored)
• Needing to fit in several weekly appointments with your doctor(s), dietitian, and therapist

Does Family-Based Treatment for eating disorders work for every family?

FBT is the right choice for some people, but it’s not for everyone! As group of dietitians who have tried this approach with hundreds of teens and their families, we’ve seen firsthand how the approach just isn’t a good fit for every family, and not because the parents “don’t care.” Some teenagers are just too resistant to following the meal plan. Other families have two working parents and busy schedules, which just doesn’t leave enough time for treatment planning and implementation. The reality is that FBT takes a ton of time, energy, and mental and emotional bandwidth. (Speaking as an eating disorder dietitian: If I was parenting a teen with an eating disorder, I’m not sure I could handle doing FBT on top of my full-time job and other responsibilities.)

It’s absolutely OK to realize that FBT isn’t working for your family, and that residential or intensive outpatient treatment would be a better fit. It doesn’t mean that you’ve failed as a parent if you’re not able to keep up with FBT. Many, many parents struggle with it because it really strains their relationship with their teenager. We’ve heard many eating disorder clinicians say that they’re not sure they’d be able to do it with their own children!

What is an “expected bodyweight” in weight restoration for eating disorder recovery?

As mentioned above, phase one of family-based treatment lasts until the client is at their appropriate body weight, also called an expected body weight (EBW). This weight is typically set by a doctor, but sometimes it’s set by the dietitian.

EBWs are often a point of contention for clients (and sometimes their parents, too!). They’re individual, and based on a client’s growth charts — which, ideally, go as far back as birth. An eating disorder specialist will look at the client’s growth charts and see what percentile their height, weight, and BMI have typically fallen on throughout their lives. Most people trend along a certain curve (for example, the 40th percentile, or the 90th percentile) pretty consistently throughout adolescence.

During an eating disorder, many adolescents ‘fall off’ their curve — AKA, their weight drops below the percentile they’ve been trending on. For example, they might go from the 55th percentile to the 25th, or from the 90th percentile to the 50th. The goal of weight restoration is to get the client back on their growth curve. If they’ve been trending along the 90th percentile throughout adolescence, their estimated bodyweight will be set around the 90th percentile. If they’ve been trending on the 40th percentile, their estimated bodyweight will be set around the 40th percentile.

This can create lots of fear and anxiety for both the clients and their parents. If someone has trended at a higher percentile throughout their life, they may feel that an estimated bodyweight in a lower percentile would be a more appropriate target. But, getting back on their established growth trajectory really increases the chances of a full, permanent recovery.

If you’re struggling with an eating disorder or disordered eating, we can help! We’re a group of dietitians who take a non-diet, body-positive, identity-affirming approach to recovery and healing your relationship with food. Go here to learn more about nutrition counseling for kids, teenagers, and adults, in-network with most major insurance companies and offered virtually to clients in North Carolina and over a dozen other states.

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