Eating Disorders:
Nutrition Education And Therapy

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 treating anorexia and 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 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 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

advertisement

Competent nutrition therapists should involve the client in a discussion of the following topics:

• What kind and how much food the client's body needs

• Symptoms of starvation and of refeeding (the process of beginning to eat normally after a period of starvation)

• Effects of fat and protein deficiency

• Effects of laxative and diuretic abuse

• Metabolic rate and the effect of restricting, bingeing, purging, and yo-yo dieting

• Food facts and fallacies

• How restricting, bingeing, and taking laxatives or diuretics influence hydration (water) shifts in the body and thus body weight on the scale

• The relationship between diet and exercise

• The relationship of diet to osteoporosis and other medical conditions

• The extra nutritional needs during certain conditions such as pregnancy or illness

• The difference between "physical" and "emotional" hunger

• Hunger and fullness signals

• How to maintain weight

• Establishing a goal weight range

• How to feel comfortable eating in social settings

• How to shop and cook for self and/or significant others

• Nutritional supplement requirements

pages: 1 2 3

top ~ next ~ send page to a friend