The following excerpt is taken from "Assessing Nutritional Status," an article that appeared in the September/October 1998 issue of Eating Disorders Review. The article is formatted as a question-and-answer dialogue between Diane Keddy, M.S., R.D., and Tami J. Lyon, M.S., R.D., C.D.E, both registered dietitians and eating disorder specialists.
This brief dialogue summarizes the dietician's role in the treatment of eating disorders and serves as an introduction to the material in this chapter.
TL: What role should the registered dietitian play in the treatment of eating disorders?
DK: I think the RD (registered dietitian) is responsible for teaching the client how to eat normally again. I define "normal eating" as eating that is based on physical signals and that is free from fear, guilt, anxiety, obsessional thinking or behaviors, or compensatory behavior (purging or exercise). The RD is also the team member responsible for making certain the client is able to select a healthy, nutritious diet that meets his or her nutritional needs. Feeling comfortable at a healthy weight and accepting one's genetically determined size are also areas for the RD to address. During the treatment process, the RD is responsible for monitoring the client's weight, nutritional status, and eating behaviors, and for disseminating this information to other team members.
TL: As part of nutrition counseling, what educational concepts do you believe are essential for treatment of anorexia and treatment of bulimia nervosa?
DK: For both anorexia and bulimia nervosa clients, I focus on a number of concepts. First, I encourage the client to accept a weight range versus one single number. Then we work on optimizing resting metabolic rate, regulating internal versus external hunger, determining the adequacy and distribution of macronutrients in the diet, and avoiding deprivation or restrained eating. We prescribe healthy exercise, social eating, eliminating food rituals, taking risks with food, and techniques for preventing disinhibition of eating. I also educate anorexic clients about the distribution of weight gain during refeeding, and with bulimic clients I explain the physiological mechanisms behind rebound edema and weight gain from abstinence.
TL: Is there a special technique that you believe has contributed to your success in working with individuals with eating disorders?
DK: Effective counseling skills are a must. I feel my ability to accurately assess my client's emotional state and capacity for change helps me to give appropriate and timely feedback. A therapist I worked with years ago told me something I have always remembered: "Lower your expectations of your clients." This adage has helped me remember how ingrained my clients' disordered eating thoughts and behaviors really are, thereby preventing frustration or disappointment when clients progress very slowly.
THE ROLE OF NUTRITION EDUCATION AND NUTRITION THERAPY
The American Psychiatric Association guidelines recommend nutritional rehabilitation as a first goal in the treatment of anorexia and treatment of bulimia. The guidelines do not address binge eating disorders. Since few therapists are formally educated in or choose to study nutrition, a nutrition specialist, commonly referred to as a "nutritionist" (usually a registered dietitian or other individual specializing in nutrition education and treatment) is a useful and often necessary addition to the treatment team of individuals with eating disorders. Eating disordered individuals often know a great deal about nutrition and may believe they do not need to work with a nutritionist. What they don't realize is that much of their information has been distorted by their eating-disordered thinking and is not based on reality.
For instance, knowing that bananas contain more calories than other fruits becomes, "Bananas are fattening," which becomes, "If I eat a banana, I will get fat," which means, " I cannot eat bananas." These distortions develop gradually and serve to protect those with eating disorders from feeling and dealing with other underlying issues in their lives as well as from having to make decisions regarding whether they will eat certain foods. Statements such as "If I'm bingeing all I have to think about is what I'm going to eat" or "If I have a rule about food, I don't have to even think about it" are commonly heard from individuals with eating disorders. The nutritionist can help individuals become aware of their faulty thinking or distortions, challenging them to face unrealistic beliefs that cannot be defended rationally.
Unrealistic beliefs and mental distortions about food and eating can be challenged by a therapist in the course of therapy. However, many therapists deal minimally with specific food, exercise, and weight-related behaviors, partly due to the fact that they have many other issues to discuss in their sessions and/or partly due to lack of confidence or knowledge in this area. A certain level of expertise is necessary when dealing with eating disordered individuals, especially those who are "nutritionally sophisticated." Once someone has an eating disorder, knowledge is distorted and entrenched, and the faulty beliefs, magical thinking, and distortions will remain until successfully challenged.
Anyone can call themselves a "nutritionist," and there is no way to distinguish by this title alone who has training and competency and who does not. Although there are various kinds of nutritionists who are properly trained and work well with eating disordered clients, a licensed registered dietitian (RD) who has a degree from an approved program is the safest choice when looking for a nutritionist, because the RD license guarantees that the person has been trained in the biochemistry of the body as well as extensively in the area of food and nutrition.
It is important to understand that not all RDs are trained to work with eating disordered clients. (The term client is most often used by RDs and thus will be used in this chapter.) Most RDs are trained with a physical science frame of reference and are taught to explore the quality of a diet with concerns such as "Is there enough energy, calcium, protein, and variety in the diet for good health?" Even though many RDs call their interactions with their clients "nutrition counseling," the format is usually one of nutrition education.
Typically clients are educated about nutrition, metabolism, and even about the dangers their eating disorder behaviors could cause. They are also given suggestions and helped to see how changes can be made. Providing information may be sufficient to help some individuals change their eating patterns, but, for many, education and support are not enough.
For individuals with eating disorders there are two phases of the nutritional aspect of treatment: (1) the education phase, in which nutrition information is provided in a factual manner with little or no emphasis on the emotional issues, and (2) the experimental phase, where the RD has a special interest in long-term, relationship-based counseling and works in conjunction with other members of a treatment team.
In addition to the educational phase, eating disordered individuals will, for the most part, need a second experimental phase involving a more intensive intervention from the RD, which calls for some understanding of the underlying psychological problems involved in eating disorders and a certain amount of expertise in counseling skills.
All registered dietitians have the qualifications for the education phase, but to work effectively with an eating disordered client, RDs need to be trained in a "psychotherapeutic" counseling style. RDs trained in this type of counseling are often called nutrition therapists. There is some controversy over the use of the term "nutrition therapist," and the term may be confusing. The reader is advised to check the credentials of anyone doing nutrition education or counseling.
For the purpose of this chapter, the term nutrition therapist refers only to those registered dietitians who have had training in counseling skills, supervision in performing both phases of nutrition treatment for eating disorders, and who have a special interest in doing long-term, relationship-based nutrition counseling. A nutrition therapist works as part of a multidisciplinary treatment team and is usually the team member assigned the task of exploring, challenging, and helping the eating disordered client replace the mental distortions that cause and perpetuate the specific food and weight-related behaviors.
When working with eating disordered individuals, a treatment for eating disorders team is important because the psychological issues involved in the client's eating and exercise patterns are so intertwined. The nutrition therapist needs therapeutic backup and must be in regular contact with the therapist and other members of the team.
Sometimes eating disordered clients, in the effort to avoid psychotherapy altogether, will call a registered dietitian first, instead of a psychotherapist, and begin working with the RD when not concurrently in psychotherapy. All registered dietitians, including those who are also nutrition therapists, should be aware of the eating disordered individual's need for psychotherapy and be able to guide the client to that knowledge, understanding, and commitment. Therefore, anyone working in the area of nutrition should have resources for psychotherapists and physicians skilled in treating eating disorders to whom the client can be referred.
SPECIFIC TOPICS THAT NUTRITION THERAPISTS DISCUSS
Competent nutrition therapists should involve the client in a discussion of the following topics:
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What kind and how much food the client's body needs
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Symptoms of starvation and of refeeding (the process of beginning to eat normally after a period of starvation)
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Effects of fat and protein deficiency
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Effects of laxative and diuretic abuse
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Metabolic rate and the effect of restricting, bingeing, purging, and yo-yo dieting
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Food facts and fallacies
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How restricting, bingeing, and taking laxatives or diuretics influence hydration (water) shifts in the body and thus body weight on the scale
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The relationship between diet and exercise
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The relationship of diet to osteoporosis and other medical conditions
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The extra nutritional needs during certain conditions such as pregnancy or illness
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The difference between "physical" and "emotional" hunger
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Hunger and fullness signals
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How to maintain weight
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Establishing a goal weight range
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How to feel comfortable eating in social settings
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How to shop and cook for self and/or significant others
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Nutritional supplement requirements
GUIDELINES FOR NUTRITION THERAPISTS REGARDING COMMON ISSUES IN THE NUTRITIONAL TREATMENT OF EATING DISORDERS
WEIGHT
Weight is going to be a touchy issue. For a thorough assessment and to set goals, it is important to obtain current weight and height for most clients. This is especially true for anorexic clients, whose first goal should be to learn how much they can eat without gaining weight. For clients with bulimia nervosa or binge eating disorder, measurement is useful but not necessary. In any case, it's best not to rely on the client's own reporting of either of these measures. Clients become addicted to and obsessed with weighing, and it is helpful to get them to relinquish this task to you. (Techniques for accomplishing this are discussed on pages 199 - 200.)
Once clients learn not to associate food with weight gain or normal fluid fluctuations, the next task is to establish weight goals. For the anorexic client, this will mean weight gain. For other clients, it is very important to emphasize that weight loss is an inappropriate goal until the eating disorder has been resolved. Even for bulimics and binge eaters, a weight loss goal interferes with treatment. For example, if a bulimic has weight loss as a goal and eats a cookie, she may feel guilty and be driven to purge it. A binge eater may have a great week with no bingeing behavior until she weighs herself, discovers that she hasn't lost weight, becomes upset, feels that her efforts are useless, and binges as a result. Resolving a client's relationship with food, not a certain weight, is the goal.
Most nutritionists refrain from trying to help clients lose weight because research shows that these attempts usually fail and can cause more harm than good. This may seem extreme, but it's important to avoid buying into the client's immediate "need" to lose weight. Such a "need" is, after all, at the core of the disorder.
SETTING A GOAL WEIGHT
To determine goal weight, a variety of factors must be considered. It is important to explore the point at which the focus on food or on weight began and to explore the intensity of the eating disorder symptoms in relation to body weight. Get information on food preoccupation, carbohydrate craving, binge urges, food rituals, hunger and fullness signals, activity level, and menstrual status. Also ask clients to try to recall their weight at the time they last had a normal relationship with food.
It's difficult to know what an appropriate weight goal is. Various sources, such as the Metropolitan Life Insurance Weight Tables, provide ideal weight ranges, but their validity is the subject of debate. Many therapists believe that in the case of anorexics, the weight at which menses resume is a good goal weight. There are rare cases, however, of anorexics who regain their menses when they are still emaciated.
Physical parameters, including body composition, percentage of ideal body weight, and laboratory data, should all be considered when establishing goal weight. It may also be helpful to obtain information about the client's ethnic background and about the body weights of other family members. The target goal weight range should be set to allow for 18 to 25 percent body fat at 90 to 100 percent of ideal body weight (IBW).
It is important to note that goal weight should not be set at ranges below 90 percent of IBW. Out-come data show a significantly high relapse rate for clients who do not reach at least 90 percent of IBW (American Journal of Psychiatry 1995). Take into account the fact that clients do have a genetically predetermined set-point weight range and be sure to obtain a detailed weight history.
WHAT IS IDEAL BODY WEIGHT?
Many formulas have been devised to determine IBW, and one easy and useful method is the Robinson formula. For women, 100 pounds is allowed for the first 5 feet of height, and 5 additional pounds of weight are added for each additional inch of height. This number is then adjusted for body frame. For example, the IBW for a women with an average frame who is 5 feet and 4 inches tall is 120 pounds. For a small-framed woman, subtract 10 percent of this total, which is 108 pounds. For a large-framed woman, add 10 percent for a weight of 132 pounds. Thus, the IBW for women who are 5 feet and 4 inches tall ranges from 108 to 132 pounds.
Another formula commonly used by health professionals is the Body Mass Index, or BMI, which is the individual's weight in kilograms divided by the square of her height in meters. For example, if an individual weighs 120 pounds and is 5 feet and 5 inches tall, her BMI equals 20: 54.43 kilograms (120 pounds) divided by 1.65 meters (5 feet 5 inches) squared (2.725801) equals 20.
Healthy ranges of BMI have been established, with guidelines suggesting, for example, that if an individual is nineteen or older and has a BMI equal to or greater than 27, treatment intervention is needed to deal with excess weight. A BMI between 25 and 27 may be a problem for some individuals, but a physician should be consulted. A low score may also indicate a problem; anything below 18 may even indicate a need for hospitalization due to malnutrition. Healthy BMIs have been established for children and adolescents as well as for adults, but it is important to remember that standardized formulas should never be relied on exclusively (Hammer et al. 1992).
Both of these methods are flawed in some respect, as neither takes into account lean body mass versus fat body mass. Body composition testing, another method of establishing goal weight, measures lean and fat. A healthy total body weight is established based on lean weight.
Whatever method is used, the bottom line for determining a goal weight is health and lifestyle. A healthy weight is one that facilitates a healthy, functioning system of hormones, organs, blood, muscles, and so forth. A healthy weight allows one to eat without severely restricting, starving, or avoiding social situations where food is involved.
WEIGHING CLIENTS
It is important to wean clients off of the need to weigh themselves. Clients will make food and behavior choices based on even the most minimal change in their weight. I believe it is in every client's best interest to not know his actual weight. Most clients will in some way use this number against themselves. For example, they may compare their weight to that of others, may want their weight to never fall below a certain number, or may purge until the number on the scale returns to something they find acceptable.
Relying on the scale causes clients to be fooled, tricked, and misled. In my experience, clients who don't weigh are the most successful. Clients need to learn to use other measures to evaluate how they feel about themselves and how well they are doing with their eating disorder goals. One doesn't need a scale to tell them if they are bingeing, starving, or otherwise straying from a healthy eating plan. Scale weight is misleading and cannot be trusted. Although people know that scale weight changes daily due to fluid shifts in the body, a one-pound gain can make them feel that their program isn't working. They become depressed and want to give up. Time and again I've seen individuals on a very good eating regimen get on the scale and become distraught if it doesn't register a loss in weight that they expect or if it registers a gain they fear.
Many clients weigh themselves several times a day. Negotiate an end to this practice. If it is important to get weights, ask a client to weigh only in your office with her back to the scale. Depending on the client and the goal, you can make agreements as to what information you will reveal, for example, whether she is maintaining (i.e., staying within 2 to 3 pounds of a certain number), gaining, or losing weight. Every client needs reassurance about what is happening with her weight. Some will want to know if they are losing or maintaining. Those whose goal is weight gain will want reassurance that they are not gaining too fast or uncontrolledly.
When clients are on a program of weight gain or are trying to lose weight, I think it is best to set an amount goal; for example, I will say, "I will tell you when you have gained 10 pounds." Many clients will refuse to agree to this, and you may have to set the first goal as low as 5 pounds. As a last resort, set an amount goal such as "I will tell you when you get to 100 pounds." However, try to avoid this method, because it lets clients know how much they weigh. Remember, weight gain is extremely scary and disturbing to clients. Even if they have verbally agreed to gain weight, most do not want to, and their tendency will be to try to stop the gain.
FINDING AND CHOOSING A NUTRITIONIST
There are many things to consider when choosing a nutritionist to work with an eating disordered individual. It has already been mentioned that a registered dietitian is the safest bet to ensure adequate education and training in the biomechanics of nutrition. It has also been stated that those registered dietitians who are further trained in counseling skills and are called nutrition therapists are even a better choice. The Yellow Pages of the phone book or The American Dietetic Association, which has a consumer hotline at 1-800-366-1655, may be able to provide readers with the names and numbers of qualified individuals in the caller's area.
The problem is that many individuals do not live in an area where registered dietitians, much less nutrition therapists, are available. Therefore, it is important to consider other ways of finding competent individuals who can provide nutrition treatment. One way is to ask a trusted therapist, doctor, or friend for referrals. These individuals may know of someone who can provide nutrition counseling even though he does not fit the registered dietitian or nutrition therapist category. Occasionally other health professionals such as a nurse, medical doctor, or chiropractor are well trained in nutrition and even in eating disorders.
In instances where a registered dietitian is not available, these individuals may be useful and should not necessarily be excluded from consideration. However, it is not always true that some help is better than no help. Misinformation is worse than no information. Whether or not the person being consulted to provide the nutritional aspect of treatment is a dietitian or a nurse, it is important to ask questions and gather information to determine if they are qualified for the position of working as a nutritionist with an eating disordered individual.
INTERVIEWING A NUTRITIONIST
Interviewing a nutritionist over the phone or in person is a good way to obtain information regarding his or her credentials, special expertise, experience, and philosophy. It is important to keep the following considerations in mind:
An effective nutrition therapist should:
- be comfortable working with a treatment team;
- be in regular contact with the therapist;
- know skilled therapists and be able to refer the client to one if necessary;
- understand that the treatment of eating disorders takes time and patience;
- know how to provide effective interventions without a meal plan;
- know how to address hunger and satiety issues; and
- be able to address body image concerns.
An effective nutrition therapist should not:
- simply provide a meal plan;
- give and expect a client to follow a rigid meal plan;
- indicate the client will not need therapy;
- tell a client she will lose weight as she normalizes eating behaviors;
- shame the client on any level;
- encourage a client to lose weight;
- suggest that certain foods are fattening, forbidden, and/or addictive and should be avoided; and
- support a diet of less than 1,200 calories.
Karin Kratina, M.A., R.D., is a nutrition therapist specializing in eating disorders. She believes that dietitians who work with eating disorders should be nutrition therapists but also recognizes that this is not always possible. She has provided questions to ask a professional for nutritional counseling. Karin has also provided the response she would give to each question to help the reader better understand what kind of knowledge, philosophy, and response to look for.
QUESTIONS TO ASK AND ANSWERS TO LOOK FOR WHEN INTERVIEWING A NUTRITIONIST
Question: Could you describe your basic philosophy in treating eating disorders?
Response: I believe that food is not the problem but a symptom of the problem. I work with long-term goals in mind and don't expect immediate changes in my clients. Over the course of time I will discover and challenge any distorted beliefs and unhealthy eating and exercise practices you have and it will be up to you to change them. I prefer to work in conjunction with a treatment team and stay in close communication with its members. The team usually includes a therapist and may include a psychiatrist, a medical doctor, and a dentist. If you (or proposed client) are not currently in therapy, I will provide feedback on the need for therapy, and if needed, refer you to someone who specializes in the treatment of eating disorders.
Question: How long could I expect to work with you?
Response: The length of time I work with any individual client varies significantly. What I usually do is discuss this with other members of the treatment team, as well as with the client, to determine what the needs are. However, recovery from an eating disorder can take a significant amount of time. I have worked with clients briefly, especially if they have a therapist who is able to address food issues. I have also worked with clients for over two years. I could give you a better indication of the amount of time I would need to work with you after an initial assessment and a few sessions.
Question: Will you tell me exactly what to eat?
Response: Sometimes l develop meal plans for clients. In other cases, after the initial assessment, I find certain clients would be much better off without a specific meal plan. In those cases, I usually suggest other forms of structure to help clients move through their eating disorder.
Question. I want to lose weight. Will you put me on a diet?
Response: This is a somewhat tricky question, because the appropriate response of, "No, I will not put you on a diet, I do not recommend that you try to lose weight now because it is counterproductive to recovery from an eating disorder," will often result in a client choosing not to come back. (A favorable response should include information to the client that most often weight loss and recovery do not go hand in hand.) What I have found in my work with people with eating disorders is that diets often create problems and interfere with recovery. Dieting actually contributes to the development of eating disorders. I have found that "non-hunger eating" is what usually causes people to gain weight, or makes it more difficult for them to reach their set-point weight range.
Question: On what kind of meal plan will you put me (my child, friend, and so on)?
Response: I try to work with a flexible meal plan that does not get caught up in calories or weighing and measuring food. Sometimes clients do better without meal plans. However, we can get specific if we need to do so. What is important is that there are no forbidden foods. This does not mean you have to eat all foods, but we will explore and work on your relationship with different foods and the meaning they have for you.
Question: Do you work with hunger and fullness?
Response: Dealing with hunger and fullness is part of my job. Usually clients who have eating disorders or have a long history of dieting tend to ignore their signals of hunger, and feelings or fullness are highly subjective. What I do is explore with you various signals that come from different areas of your body to determine exactly what hunger, fullness, satiety, and satisfaction mean to you. We can do things like use a graph on which you rate your hunger and your fullness so that we can "fine-tune" your knowledge of and ability to respond to your body's signals.
Question: Do you work in conjunction with a therapist or doctor? How often do you speak with them?
Response: Nutrition is only part of your treatment plan, psychotherapy and medical monitoring is another. If you do not have a professional in those other areas I can refer you to those with whom I work. If you already have your own I will work with them. I believe that communication is important with all of the members of your treatment team. I usually speak with the other treating professionals once a week for a period of time and then, if appropriate, reduce it to once a month. However, if your exercise or eating pattern changes significantly at any given time, I would contact the rest of the treatment team to inform the members and discuss with them what difficulties might be happening in other areas of your life.
Question: Do you now or have you ever received professional super-vision from an eating disorder professional?
Response: Yes, I have received both training and supervision. I also continue to get supervision or consultation periodically.
OTHER INFORMATION TO OBTAIN
- Fees: If you are unable to afford the nutritionist's standard fee, can adjustments be made or a payment schedule be arranged?
- Hours: Is the nutritionist able to schedule you at a convenient time? What is the policy regarding missed appointments?
- Insurance: Does the nutritionist accept insurance and, if so, help submit claims to an insurance company?
WHAT TO AVOID
Individuals with eating disorders often go into the field of nutrition as a result of their own obsession with food, calories, and weight. Any nutritionist should be assessed for signs of eating disorder thinking or behavior, including "fat phobia." Many individuals with eating disorders are fat phobic. If the nutritionist is also fat phobic, nutrition therapy will be negatively affected.
Fat phobia can refer to dietary fat or body fat. Many people are afraid of eating fat and of being fat, and this fear creates a negative attitude toward food with a fat content of any kind and fat people. The existence of fat makes these fat-phobic individuals fear the prospect of losing control and becoming fat. The prevailing cultural attitude is that fat is bad and fat people should change. Unfortunately, many nutritionists have perpetuated fat-phobia.
When discussing body size and weight, individuals should look for a nutritionist who does not use a chart to determine a client's proper weight. The nutritionist should discuss the fact that people come in all shapes and sizes and there is no one weight that is a perfect body weight. Clients should be discouraged by the nutritionist from trying to make their bodies conform to a certain selected weight but rather encouraged to accept that, if they give up bingeing, purging, and starving and learn how to properly nourish themselves, their body will reach its natural weight.
However, avoid a nutritionist who thinks natural eating alone will always restore a person to a normal, healthy weight. For example, in the case of anorexia nervosa, an excessive amount of calories, beyond what is considered normal eating, is necessary for the anorexic to gain weight. It may take as many as 4,500 calories or more per day to begin weight gain in severely emaciated individuals. Anorexics must be helped to see that in order to get well they need to gain weight, which will require an excessive amount of calories, and they will need specific help in how to get those calories into their diet.
After weight restoration, a return to more normal eating will sustain weight, but a higher calorie level than individuals without a history of anorexia is usually required. Binge eaters who become obese from bingeing and who desire to return to their more normal weight may have to eat a diet that is lower in calories than the amount originally needed to sustain their pre-bingeing weight. It is important to reiterate that these circumstances as well as all areas involved in the nutritional treatment of eating disorders require special expertise that takes into account a variety of circumstances.
HOW OFTEN DO CLIENTS NEED TO SEE A NUTRITIONIST?
How often a client will need to see the nutrition therapist is based on a number of factors and is best determined with input from the therapist, the client, and other significant members of the treatment team. In some cases only intermittent contact is maintained throughout recovery as the psychotherapist and client deem necessary. In other cases continuous contact is maintained, and the nutritionist and psychotherapist work together throughout the recovery process.
Usually clients will meet with a nutrition therapist once a week for a thirty- to sixty-minute session, but this is highly variable. In certain instances a client may want to meet with a nutritionist two or three times a week for fifteen minutes each time, or, especially as recovery progresses, sessions can be spread out to every other week, once a month, or even once every six months as a checkup, and then on an as-needed basis.
MODELS OF NUTRITION TREATMENT
Listed below are various treatment models that can be used with eating disordered clients depending on the severity of the clients illness and on the training and expertise of both the nutritionist and the psychotherapist.
FOOD PLAN ONLY MODEL
This involves a one- or two-session consultation where an assessment is made, specific questions are answered, and an individual food plan is designed.
EDUCATION ONLY MODEL
The nutritionist meets with the client six to ten times discussing various issues in order to meet the following five objectives:
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Collect a detailed history with relevant information in order to:
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Determine the variety of and quantity of weight loss and eating disorder behaviors
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Determine nutrient amount and intake patterns
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Identify effect of behaviors on client's lifestyle
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Develop treatment plans and goals
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Establish a collaborative, empathic relationship.
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Define and discuss principles of food, nutrition, and weight regulation, for example:
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Symptoms and bodily responses to starvation
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Metabolic shifts and responses
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Hydration (water balance in the body)
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Normal and abnormal hunger
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Minimum food intake to stabilize weight and metabolic rate
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How food and weight-related behaviors change during recovery
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Optimal food intake
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Set point
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Present hunger and intake patterns (calories included) of recovered persons.
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Educate the family on meal planning, nutrient needs, and effects of starvation and other eating disorder behaviors. Strategies for dealing with food and weight-related behaviors should be done in conjunction with the psychotherapist.
THE EDUCATION/BEHAVIOR CHANGE MODEL
This model necessitates that the nutritionist has special training and experience in treating eating disorders.
Education Phase. This comes first and early in treatment (see education model above).
Behavior Change or Experimental Phase. The second, or experimental, phase of this model begins only when the client is ready to work on changing food and weight-related behaviors. Sessions with the nutritionist are intended to be the forum for planning strategies for behavior change, thus freeing psychotherapy sessions for exploration of psychological issues. The primary objectives are:
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Separate food and weight-related behaviors from feelings and psychological issues.
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Change food-related behaviors slowly until intake patterns are normalized. Behavior change is most effective when coupled with education. Treatment must be individualized and not oversimplified. Clients will need constant explanation, clarification, reiteration, repetition, reassurance, and encouragement. Topics that will need to be covered include the following:
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Being purge free or eating better for months does not mean recovery.
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Setbacks are normal and are learning opportunities.
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Self-monitoring techniques should be chosen and used carefully.
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Target specific medical or cosmetic concerns first (results are easier to see).
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Make changes little by little.
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Slowly increase or decrease weight. Proceeding too quickly may cause the client to become defensive and withdraw.
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Learn to maintain a healthy weight without abnormal or destructive behaviors.
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Learn to be comfortable in social eating situations (usually in later stages of recovery). Changes in social eating habits can be directly related to eating and weight issues but can also be due to relationship difficulties in general. (Refusing to eat may be a way of controlling the family or avoiding abuse or embarrassment.)
THE INTERMITTENT CONTACT MODEL
Intermittent contact with the dietitian (who is trained in eating disorders) is maintained throughout recovery, as the client and the psychotherapist deem necessary.
CONTINUOUS CONTACT MODEL
Both the therapist and the dietitian work together with the client throughout the recovery process.
NUTRITIONAL SUPPLEMENTATION AND EATING DISORDERS
It is common sense to assume that individuals who restrict or purge their food may have specific nutrient deficiencies. There has even been some question and research as to whether certain deficiencies existed before the development of the eating disorder. If it were determined that certain deficiencies predisposed, or in some way contributed to, the development of eating disorders, this would be valuable information for treatment and prevention. Regardless of which came first, nutritional deficiencies should not be overlooked or undertreated, and correcting them must be considered a part of an overall treatment plan.
The area of nutrient supplementation is a controversial one even in the general population and even more so for eating disordered individuals. First, it is difficult to determine specific nutrient deficiencies in individuals. Second, it is important not to impart to clients that they can get better by the supplementation of vitamins and minerals instead of the necessary food and calories. It is common for clients to take vitamins, trying to make up for their inadequate intake of food. Vitamin and mineral supplements should be recommended only in addition to the recommendation of an adequate amount of food.
However, if supplements will be consumed by clients, especially when adequate food is not, the least that can be said is that clinicians may be able to prevent certain medical complications by prudently suggesting their use. A multivitamin supplement, calcium, essential fatty acids, and trace minerals may be useful for eating disordered individuals. Protein drinks that also contain vitamins and minerals (not to mention calories) can be used as supplements when inadequate amounts of food and nutrients are not being consumed. A professional should be consulted regarding these matters. For an example of how future research in the area of specific nutrients may be important in the understanding and treatment of eating disorders, the following section on the relationship of zinc deficiency to appetite disturbance and eating disorders has been included.
ZINC AND EATING DISORDERS
A deficiency of the mineral zinc in eating disordered patients has been reported by several researchers. It is a little-known fact that a deficiency in the mineral zinc actually causes loss of taste acuity (sensitivity) and appetite. In other words, zinc deficiency may contribute directly to reducing the desire to eat, enhancing or perpetuating a state of anorexia. What may start out as a diet motivated from a desire, whether reasonable or not, to lose weight, accompanied with a natural desire to eat, may turn into a physiological desire not to eat, or some variation on this theme.
Several investigators, including Alex Schauss, Ph.D., and myself, who coauthored the book Zinc and Eating Disorders, have discovered that through a simple taste test reported years ago in the English medical journal The Lancet, most anorexics and many bulimics seem to be zinc deficient. Furthermore, when these same individuals were supplemented with a certain specific solution containing liquid zinc, many experienced positive results and, in some cases, even remission of eating disorder symptoms.
More research needs to be done in this area, but until then it seems fair to say that zinc supplementation looks promising and, if done wisely and under the supervision of a physician, may provide a substantial benefit with no harm. For more information on this topic, consult Anorexia and Bulimia, a book I wrote with Dr. Alexander Schauss. This material explores nutritional supplementation for eating disorders and specifically how zinc is known to affect eating behavior, how to determine if one is zinc deficient, and various reported results of zinc supplementation in cases of anorexia nervosa and bulimia nervosa.
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laxatives
Many people with major depression will deny that they are sad. In this case, you can usually "read" depression in a person's face. People with depression look as if they are about to cry; the features of their face are distinctly "pulled-down." Some people will report depression as "the blahs," or "feeling nothing," or they complain of aches and pains rather than sadness. DSM-IV indicates that signs to look for are "tearfulness, brooding, irritability, obsessive rumination, anxiety, phobias, excessive worry over physical health, complaints of pain." People with depression are experiencing tremendous distress. This mental and physical anguish is very real for them.
"It worried me that my parents were spending a lot of money when I was in the eating disorders treatment center,'' she said. "And I shouldn't have been worrying when I needed to concentrate on getting better.''