Eating Disorders:
Nutrition Education And Therapy

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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:

• Collect a detailed history with relevant information in order to:

  • Determine the variety of and quantity of weight loss and eating disorder behaviors

  • Determine nutrient amount and intake patterns

  • Identify effect of behaviors on client's lifestyle

  • Develop treatment plans and goals

• Establish a collaborative, empathic relationship.

• Define and discuss principles of food, nutrition, and weight regulation, for example:

  • Symptoms and bodily responses to starvation

  • Metabolic shifts and responses

  • Hydration (water balance in the body)

  • Normal and abnormal hunger

  • Minimum food intake to stabilize weight and metabolic rate

  • How food and weight-related behaviors change during recovery

  • Optimal food intake

  • Set point

• Present hunger and intake patterns (calories included) of recovered persons.

• 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:

• Separate food and weight-related behaviors from feelings and psychological issues.

• 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:

  • Being purge free or eating better for months does not mean recovery.

  • Setbacks are normal and are learning opportunities.

  • Self-monitoring techniques should be chosen and used carefully.

  • Target specific medical or cosmetic concerns first (results are easier to see).

  • Make changes little by little.

• Slowly increase or decrease weight. Proceeding too quickly may cause the client to become defensive and withdraw.

• Learn to maintain a healthy weight without abnormal or destructive behaviors.

• 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.

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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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