Mealtimes are known to be a period of heightened distress for individuals with eating disorders. They often experience an increase in negative emotions, which can include fear, anxiety, frustration, anger and sadness. These emotions can lead to certain avoidance behaviours such as hiding food, avoiding eating certain foods and not wanting to eat with others (Harvey et al., 2002; Levinson et al. 2018; Long et al. 2012; Monaghan & Doyle 2023). This combination of emotional and behavioural responses to mealtimes makes getting the appropriate amount of nutrition each day very challenging.
Therefore, it is essential for personalised meal support to be offered as part of eating disorder treatment, especially within an inpatient setting for individuals with acute needs. Meal support can create a structured and supportive environment to help an individual navigate their meals and re-establish normal eating behaviours (Hage et al,. 2017).
However, a recent systemic review of meal support interventions by Ellis et al (2024) highlighted that there was no consistent approach on how to best support an individual during mealtimes. The review, which was published in Eating Disorders Journal, concluded that due to the absence of a standardised framework, a co-designed approach, complete with training and evaluation, could yield the best results for patients.
Clinicians at Rhodes Wood Hospital in Hatfield also came to this conclusion after they received feedback from the young people who use the service on how they would like the consistency of mealtime support to be improved. In this CYPMHS EveryExpert article, we speak with Vincent Cheung, Hospital Director, on how the multidisciplinary team (MDT) and service users co-produced meal support training and guidance at Rhodes Wood.
Co-produced meal support at Rhodes Wood
Rhodes Wood Hospital, part of Elysium Healthcare’s CYPMHS division, is a specialist inpatient eating disorder service for children and young people aged 8-18 years. The MDT provides an evidence-based inpatient treatment programme within a warm and nurturing environment, focusing on moderate to severe eating disorders. An Ofsted-registered school is also available onsite to enable the young people to continue their schooling while in treatment.
Vincent describes how, during a ward community meeting, the young people explained ways in which they would like the meal support experience to be improved.
Vincent says: “The young people shared with us that, although some of the team were really good with meal support, there were inconsistencies that they wanted to change. For example, during some mealtimes, there was very little talking, and some were even in silence. We have conversation cards that could be used, but there were times when they were not.
“In general, the feedback highlighted that if there was a standardised approach to delivering the support, in a way that was personalised and meaningful, the mealtime experience would be better. So we decided to do something about it, working together with the young people, to understand exactly what they considered to be ‘good’ mealtime support, and then co-produce training with them for the wider team.”
What does good meal support look like?
During the following ward community meeting, the co-production training development idea was presented and received well by attendees. Several young people agreed to participate, and decided that training should take a role-play format. Attendees also discussed what is important in meal support and created a list of ‘dos’ and ‘don’ts’ that were used to inform the training. The young people also wrote down on paper what good meal support looks like from their perspective.
Here is a selection of their comments:
- “Not starting support late in the meal.”
- “Don’t be scared to begin meal support.”
- “Offer hand support but don’t force it”
- “Read our ‘dos’ and ‘don’ts’.
- “Don’t make negative comments on food.”
- “Use conversation cards.”
Co-produced meal support training
The training consisted of three role-play scenarios, all co-produced with the young people and delivered by volunteer patients and a staff member.
The role-playing covered three key areas:
- What good meal support looks like
- What bad meal support looks like
- Meal support that needs improvement
Vincent explains how it was important for all staff to attend the training and understand meal support from the young person’s perspective.
Vincent says, “We knew that the consistency of patient experience could only be achieved if all team members attended the training. So the different wards supported each other to do that, and we amended the rotas to ensure all staff on shift could attend.
“It was also essential that the perspective of the young people was prioritised in the training and that the team were confident in their understanding of how the young people felt. At the end of each session, there was a Q&A with the young person, where they answered questions on what did and didn’t work for them during mealtimes – it was very useful for the staff to hear it in the young person’s own words.
“We received positive feedback from both the young person involved in the training and the staff, and we received suggestions for additional role-play scenarios for future training.”
Key learnings and recommendations
The training session highlighted a number of key learning points for the team. Vincent shares how they will use what they learnt to improve the ongoing delivery of meal support at Rhodes Wood Hospital.
Vincent says, “The training was a valuable learning experience for everyone who participated, and there were many key takeaways. I think a major learning is the need to always think about the young person’s experience and tailor the mealtime support to their individual requirements. This can be done in a number of ways, for example, by reading the ‘Dos and Don’ts’ so that you are aware of what the young person wants. Or instead of assuming a person needs hand support, offer it and see what their response is before implementing.
“Conversations and how we go about initiating them was also a key learning. Beginning a conversation before a meal makes it easier for the young person to respond – they are not consumed by the distress of the meal. Remembering to use the conversation cards is also important – they can be used to stimulate positive conversations that the young person is comfortable with, and it makes the whole experience easier for them.
“Lastly, we realised that it is important for new team members to observe first, so they can see how meal support is delivered before participating. Unless you see successful mealtime support in action, so to speak, you won’t be able to replicate it, and then inconsistencies will occur. If a new team member watches and learns before participating, then mealtimes will remain a stable experience for the young person.”
Next steps
After gathering feedback from participants and assessing the effectiveness of the training, the team have been considering what’s next for co-produced meal support training at Rhodes Wood. Vincent shares what they have been planning.
Vincent says: “Now that we have completed the initial training, we want to repeat the session with a new group of staff and incorporate both individual and group scenarios. These new scenarios will make the training more realistic and include all the different circumstances that you might encounter at mealtime. We will share any feedback from our next sessions with other wards for potential implementation and ensure consistency across the service.
“We also want to recognise the endeavours of our team and the hard work they put into meal support. By using feedback from the young people, we want to acknowledge outstanding staff, and we’re looking at different ways to collect that feedback. We’re currently thinking about doing weekly vote counts and announcing a staff winner in community meetings.
“It is important to continue to support our team to work together with the young people in the true spirit of co-production. So this process will evolve as needs change, it will be an adaptive process that we work through together.”
References
Ellis, A., Gillespie, K., McCosker, L. et al. (2024). Meal support intervention for eating disorders: a mixed-methods systematic review. J Eat Disord 12, 47.
Hage, T. W., Rø, Ø. & Moen, A. (2017). “Do you see what I mean?” staff collaboration in eating disorder units during mealtimes. BMC Nursing, 16 (1), 40.
Levinson, C. A., Sala, M., Fewell, L., Brosof, L. C., Fournier, L. & Lenze, E. J. (2018). Meal and snack-time eating disorder cognitions predict eating disorder behaviors and vice versa in a treatment seeking sample: A mobile technology based ecological momentary assessment study. Behaviour Research and Therapy, 105, 36–42.
Long, S., Wallis, D., Newman, L. & Meyer, C. (2012). “All eyes are on you”: Anorexia nervosa patient perspectives of in-patient mealtimes. Journal of Health Psychology, 17 (3), 419–428.
Monaghan, M., & Doyle, L. (2023). ‘It stopped you thinking about food’–The experiences of mealtimes and attending a post‐meal support group for young people with anorexia nervosa. International journal of mental health nursing, 32(1), 128-138.
Harvey T, Troop NA, Treasure JL, Murphy T. (2002) Fear, disgust, and abnormal eating attitudes: a preliminary study. Int J Eat Disord, 32(2):213–8.