What does an eating disorder dietitian do?
Two Reasons People Struggling with Eating Disorders or Disordered Eating need Nutrition Therapy from an Experienced Nutrition Professional. (This article is part 1 of 2.)
Since moving to Germany, multiple therapists and dietitians in Europe, who work in private practice and school settings, have told me finding high-quality nutrition care for individuals with eating disorders (EDs) is extremely hard.
Differences in care practices and clinical guidelines for individuals struggling with eating disorders exist across the world. In Germany, it is not always the norm to have a nutrition professional skilled in eating disorder treatment as part of the care team, especially in the outpatient setting.
As a new expat in Germany, offering my services to clients in the US and Germany, it is important to explain why nutrition therapy is integral to a client’s recovery. And, to define nutrition therapy for those who do not know or may have had a poor experience with a nutrition professional.
Below are 2 reasons a dietitian/nutrition professional with ED experience should be on a client’s team. In Part 2 of this article, I will list a few more reasons.
Reason 1: We work with clients to help them normalize eating - in a healing, sustainable way.
Reason 2: We help clients understand the 'why' so they feel less out of control.
Reason 1: We work with clients to help them normalize eating- in a healing, sustainable way.
Clients can normalize eating patterns in various ways; it depends on the client and the therapeutic tool(s) the dietitian uses. Here are some examples.
‘Fact checking’ the eating disorder part with the client.
Are carbs actually bad? Is that based on science?
Is it really possible to gain 10 lbs/4.5 kg in a week?
Is eating snacks really a sign of weakness?
If hunger passes, does that actually mean you don’t need to eat?
The eating disorder is ridiculous in how much it can make up to lead us further and further away from ourselves, while also - in many clinical presentations- making us only think more about our bodies (Cook-Cottone, 2015). Once we understand how the ED works and can ‘fact-check’ it, it is easier to change behaviors and try something different with food. We can also offer the ED part some compassion, as it has served a purpose.
Just take a client whose eating disorder tells her she has gained 'a lot of' weight in three days because she integrated carbs at lunch. We 'fact check' together- can you actually gain weight in 3 days? What are carbs used for? Why are they important to you for recovery? What has gone well the last 3 days? Come to find out, the client is no longer ravenously hungry for dinner, but the ED part wants her to cut back because eating carbs means the ED does not have as much control. The ED part is scared to not have so much say! We thank it, acknowledge the feelings of unease that come with trying something new, and focus on the benefits of the change.
Reengaging with and overcoming fear around certain foods or behaviors around food, along with understanding the deeper meaning.
This could mean:
Doing an exposure around food that is scary, to form a new relationship with it.
Eating with other people to work on tolerating social discomfort.
Cooking a new meal with a favorite food that a client used to binge on.
These "experiments" help clients realize their worst fear may or may not come true, but either way- they can weather the discomfort and be okay.
Take a client who binges on protein bars. We may experiment with eating this ‘fear’ food as a snack with a piece of fruit, in a setting that is comfortable and supportive (maybe with others, maybe not), taking their time, etc. We would also unpack how protein bars got a 'bad rap' at home as a 'non-necessary food'. The issue is not the food, per se, it is how the feelings, emotions and thoughts about the food manifest. Once we move past that, the client can decide how they want to integrate protein bars!
Eating enough food. Most clients, no matter their diagnosis, are not eating enough food. This includes not only the client with restrictive eating but also clients struggling with ARFID, binge eating (which is restrictive, too!), chronic disordered eating/dieting, and other clinical and subclinical diagnoses/presentations.
Without nourishment the brain cannot function properly. Period.
In fact, there is data that shows white and gray matter in the brain of people with active anorexia nervosa is reduced (Seitz, et al 2014); whether this affects cognition is unknown. However, we do know that when nutritional needs are not met chronically, our bodies will slow down. Why doesn’t someone get a period when they are not eating enough? Because having a baby is not a priority!
A client with very low food intake says to me: “I was running faster but now I'm not, and on top of that, my grades are declining. I am forgetting things!” The brain has to be functioning to study, make decisions, engage in therapy, and more. And for the brain to function, you need food. Without food, the brain will not function at 100% capacity. And, the ED will be louder. Nutrition interventions that increase intake are necessary to help this client move forward.
Reason 2: We help clients understand the 'why' so they feel less out of control.
Why am I restricting my food? Binging and purging? Feeling out of control while eating the bag of chips? Experiencing feelings of body shame?
When clients understand the ‘why’, they can connect the dots. They understand the societal, familial, relational, biological, cultural, and psychological inputs. They feel less out of control. Keep in mind, there is never just one or two things that are the ‘why’. We are people, and hence, complex beings with many ‘why’s’.
A client reports they are eating in secret and feeling ashamed. They also used to do this as a teen because they were never allowed to have certain foods in the house. And, their therapist has told me they never had their emotional needs met by their parents. Taking these pieces, and layering on top of that the fact that this client did not eat enough during the day, it makes sense why they may eat in secret and feel ashamed. Biologically, we are driven to eat when we haven’t nourished ourselves - it is how we survive- and psychologically, eating in secret is a coping strategy to manage emotional needs while also being in a space where they are not be shamed by others for food choices. So, hunger, the client's learned behavior and their need for emotional support are all parts of their why. With this insight, the client can work from an awareness lens, eating more adequately during the day, making peace with all foods and allowing them in their house, and in therapy, healing the younger self whose needs were not met.
Nutrition Therapy is a NOT just meal planning
Nutrition therapy for eating disorders/disordered eating is complex. Meeting clients where they are at, and working with them to understand themselves and their relationship with food and body in the context of their life is key.
Nutrition therapy is:
- Talking about food and understand what and how clients are eating,
- Providing tips and recommendations to help clients meet their nutritional needs,
- Engaging clients in skill-based learning like cooking and meal prep, and...
- Monitoring clients' nutritional status.
And, it is ALSO connecting food and eating behaviors to the client's beliefs, feelings and thoughts- to allow for self-awareness, create dissonance between ED behaviors and beliefs, and try new things that allow for recovery to happen. Providing nutrition therapy that honors clients, helps them understand themselves, and ultimately, allows them to find food and eating enjoyable and part of self-care is the ultimate goal of nutrition therapy.
If you or your loved one is struggling with disordered eating, contact me. Getting help early rather than waiting improves prognosis.
P.S. Stay tuned for Part 2 of this blog article, coming soon!
Seitz J., Bühren K., von Polier G.G., Heussen N., Herpertz-Dahlmann B., Konrad K. Morphological changes in the brain of acutely ill and weight-recovered patients with anorexia nervosa. A meta-analysis and qualitative review. Z. Kinder. Jugendpsychiatr. Psychother. 2014;42:7–17. doi: 10.1024/1422-4917/a000265.
Catherine Cook-Cottone (2015): Embodied self-regulation and mindful self-care in the prevention of eating disorders, Eating Disorders, DOI: 10.1080/10640266.2015.1118954.