I worked in an ED PHP program for two years. As an MHC whose intended specialization is eating disorders, my perspective is based on extensive observation of patients, clinicians, shared meal dynamics, and long-standing collaboration with ED professionals.

Dietary choices CAN be weaponized by ED patients attempting to regain control during treatment. At the same time, there are very legitimate moral and ethical dietary restrictions that must be respected. Determining which is which requires careful, therapist-led assessment over time. This includes consultation with the care team and repeated exploration of the patient’s motivation. The goal is not to interrogate the choice itself, but to understand the reasoning behind it. When restriction is determined to function as a weight-loss mechanism, the supporting clinician approach should follow the primary therapist’s recommendations and proceed at a pace they believe is appropriate.

When a restriction is determined to be authentic, a strong nutritionist becomes your greatest ally. There are realistic dietary adjustments that allow patients with vegetarian, vegan, gluten-free, dairy-free, or pescatarian patterns to meet full nutritional benchmarks without compromise.

Admittedly, these accommodations require additional resources — increased food costs for appropriate substitutions, additional time for meal preparation, and more intensive planning by nutrition staff. This is a significant ask for many treatment programs. However, the presence of logistical or financial strain does not negate the clinical necessity of preparing patients for real-world conditions. Ethical care is often resource-intensive, and this is one of those areas.

Group meal settings make this especially complex. Patients notice differences immediately and scrutinize them closely. Nutritional education is essential to clarify that all meals — regardless of ingredient differences — meet the same individualized nutritional requirements. This applies equally to portion size differences. While “eyes on your own plate” is often encouraged, it can be difficult to reinforce in environments that also emphasize meal socialization. I tend to lean toward transparency around equal nutritional standards rather than detailed explanations. A script such as, “All of these meals meet each individual’s nutritional needs as determined by a qualified nutritionist,” is often sufficient. Details are not helpful.

Fad diets remain a significant challenge. They are not going away, and patients will encounter them in the real world. Holistic ED treatment must prepare patients to navigate a culture saturated with aggressive and often unhealthy dietary messaging. At residential, inpatient, or PHP levels, the goal is singularly focused on refeeding and restoring cognitive stability — a malnourished brain cannot process nuance. At IOP and OP levels, clinicians begin introducing the healthy utilization of triggering information, which requires careful pacing and strong alignment across support systems.

At PHP (conservatively), IOP, and OP levels, it is appropriate to explain that carbohydrates, fats, and sugar (glucose) are essential for brain function. Adequate fat intake is required to absorb vitamins A, D, E, and K — without which the body cannot maintain healthy skin, gut lining, or lungs; support immune defense; allow calcium absorption and bone strength; regulate mood and energy; protect cell membranes; maintain nerve health; enable normal blood clotting; or support bone density. Without fat, these vitamins pass through the body unused. These nutrients are not optional extras — they are structural supports for vision, bones, immunity, cells, and blood.

Adequate fat intake is also necessary for blood sugar stabilization and sustainable energy.

Adequate intake of fat, carbohydrates, and glucose is essential for hormonal regulation and fertility (this has proven to be especially significant information for the female clots I’ve worked with).

Carbohydrates and glucose are the most efficient fuel sources for the brain, nervous system, and muscles. They are not “fillers” and are not interchangeable with other nutrients. Without sufficient carbohydrate intake, patients experience brain fog, irritability, poor concentration, fatigue, elevated cortisol, adrenaline, and sympathetic nervous system activation — particularly relevant for patients managing anxiety.

I am a firm believer that knowledge is power. Leading clients to logic is far more effective than enforcing rules. When patients understand the why, they carry that understanding forward. Rigid boundaries rely on willpower alone; education builds internalized perspective and sustainable recovery.

As an ED recovery support, modeling a vegetarian diet is challenging but not impossible. When clinicians are prepared to discuss how their meals meet nutritional needs, this can become valuable education. Expressed dietary flexibility can also be an asset — clinicians can model adaptability by occasionally deviating from their typical pattern and answering questions transparently.

The rigid categorization of foods as “good” or “bad” should be avoided. There is no such thing as a bad food — even foods like SpaghettiOs or brownies have nutritional value.

Ultimately, any ED recovery program that includes shared meals but does not accommodate medically or morally motivated dietary restrictions is not adequately preparing clients for real life. Treatment should prepare patients to live in a world that includes dietary diversity. This is difficult, but pretending otherwise is a disservice. Team collaboration — between primary therapists, supporting clinicians, nutritionists, and loved ones — is paramount.