Eating Disorders:
Nutrition Education And Therapy

continued

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

advertisement

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.

pages: 1 2 3

top ~ next ~ send page to a friend