Using image-based food journaling with eating disorder patients in an out-patient setting.


Dietary counseling is central to rehabilitating patients with eating disorders. Encouraging patients to develop healthy and regular eating patterns forms the crux of effective therapy. Because many patients with eating disorders experience anxiety about food quantities, calculating precise nutrient intakes is not typically recommended. Obtaining an accurate log is nonetheless essential to troubleshooting, making meal photographs an invaluable tool in effective nutrition counseling.

The Center for Eating Disorders (CED) in Helsinki, Finland, has used MealLogger with 40 outpatients for an average duration of 3 months with each patient. 23 of the patients had been diagnosed with anorexia, 10 with binge eating disorder, and 7 with bulimia. Each received extensive app-based outpatient support.

Clinicians found that connecting patients to professionals via MealLogger enhanced support in a way that enhanced face-to-face counseling. Helena Nenonen, a psychiatric nurse at the CED, remarked, “The continuous connection between the counselor and the patient creates security and support. And this extends into the patient’s everyday life.” While positive feedback is essential to ingraining new habits, weekly or biweekly in-person sessions provide insufficient opportunities to reinforce healthy eating behaviors. “MealLogger offered a channel through which we could provide patients with continuous validation and encouragement, which in turn has resulted in feelings of empowerment and amplified self-efficacy” Helena continued.

Get to know your patient

Counseling at the CED begins with several meetings. During these sessions, conversations and questionnaires offer professionals a glimpse at the personalities and thought processes of their patients. During the first meetings of the pilot, counselors invited their patients to photograph their meals using the MealLogger app. No pressure was applied and all were told that they could decline if they wish. Interest proved high, as over 80% of patients decided to use the app. Retention was equally impressive. More than 90 percent of those who did, continued to use it for the entirety of their treatment.

With a plan in place, the counselor and patient then devoted an average of three months to building their relationship and affecting meaningful behavioral and dietary changes.

Establish a rhythm

A common initial goal for patients with eating disorders centers upon establishing regular dietary patterns. Eating meals and snacks with consistent frequency not only conveys metabolic benefits, it allows patients to know what will happen next. It helps them take comfort in routine. Photographing meals requires that we pause before eating and facilitates self-reflection. Furthermore, a timestamp automatically appears beside each uploaded meal, allowing patients and counselors to review meal timing objectively.

To illustrate, anorexic patients typically follow a restrictive diet, often eating just one or two small, unbalanced meals per day. Many counselors opt to initiate treatment by ensuring that patients sit down to, and photograph three meals per day. Once this habit becomes routine, they may decide to shift focus towards the nutritional contents of these meals.

Treating bulimic patients also tends to start with the establishment of regular eating patterns. Eating at regular intervals helps maintain healthy blood sugar levels and shields them from excessive hunger. Since high levels of hunger commonly trigger binge episodes (which are then accompanied with vomiting), attention to meal timing reduces the likelihood of perpetuating the cycle.

Once this has been addressed, portion sizes and satiety, meal composition and diversity, can all receive attention. Examining thought processes surrounding treats also seems particularly valuable since nearly all eating disorder patients view certain foods as “prohibited.” Removing triggers associated with such foods takes time but yields important psychological benefits.

See beyond what words reveal

Eating disorder patients often experience a strong desire to please others and appear successful, leading them to unintentionally misrepresent their thoughts and progress during verbal communications. But photographs speak volumes. CED counselors using MealLogger reported gaining more accurate information about their patients’ status than they would have otherwise gleaned. Nenonen explained, “Increased anxiety among patients with anorexia shows in the overemphasis of separating foods on the plate, increasing meal intervals and decreasing portion sizes. Pictures also indicate whether the client’s eating has suddenly become too relaxed. This makes us question whether the anorexia has changed into bulimia nervosa.” Such invaluable and otherwise inaccessible information suggests to the counselor that immediate intervention is needed. Without such indicators, quality of care would diminish as this knowledge might only surface once weight or health indicators took a turn for the worse.

Even background imagery can provide useful insights. High-end cutlery and cloth napkins may suggest that the meal was eaten at a restaurant while a takeout bag and another hand in the photo may reveal that the meal was eaten at a friend’s home. Learning whether the event took place in a high- or low-pressured environment promotes greater understanding as to why particular food choices were made.

Offer continuity of care

Frequent and easy mobile interactions enable counselors and patient to continue care when they would have otherwise stopped. Virtual support for CED patients has, in many cases, replaced one weekly appointment outpatient appointment. “This is significant because many patients can’t afford appointments as often as we would recommend,” says Nenonen. In fact, counselors at CED found that by integrating mobile tools into their treatment, they were able to reduce the cost of treatment while improving outcomes. This increased their bandwidth and enabled them to work with a larger patient load to the satisfaction of the management, counselors, and patients alike.

As the technology develops, Nenonen notes that the benefits of MealLogger can be expanded even further. Developing uniform practices and building out appropriate tools and features, such as ways to measure mood and appetite in various situations, would provide counselors with even more leverage to help their patients. Even in its current state, Nenonen confidently affirms that both counselors and patients benefit from using MealLogger. “The tool is easy to use and it’s exciting to see that our reach can extend beyond the walls of a weekly counseling session.”


Above – example weekly journal of an anorectic client at the beginning of treatment.

Below – example weekly journal of same patient after approximately three months of treatment.


The Center for Eating Disorders is Finland’s first private care facility specializing in eating disorders. It is owned by the non-profit association Hunger for Life, and its operation is led by Executive Director Pia Charpentier. The Center for Eating Disorders was born out of the desire to provide a holistic and high-quality care for all who have struggled with eating problems.



One thought on “Using image-based food journaling with eating disorder patients in an out-patient setting.

  1. Pingback: MealLogger at the Nordic Eating Disorder Conference | MealLogger

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