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Over 45 Years of Eating Disorder Specialty Practice

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14 Basic Tenets of Good Nutritional Practice in the Treatment
of Eating Disorders

Created by
Abigail H. Natenshon, MA, LCSW, GCFP
North American Serial Rights 2011

1. Understand the full implications of eating disorders… know what they are, and what they are not. Extreme, unbalanced, immoderate eating, excluding food groups, skipping meals, ritualizing eating behaviors or eating the same food items every day with no variation are all indicators of pathology. Eating disorders represent the misuse of food to resolve emotional problems. Emotions underlying dysfunctional ED behaviors are critical factors driving these disorders and must be addressed. Nutritionists must be capable of speaking the language of psychotherapy, just as psychotherapists must be capable of speaking the language of food and nutrition.

2. Start where the client is. Understand and respect the legitimate intention and purpose that the eating disorder fulfills for the client. Beware of clients seeking assistance to eat “healthier,” a euphemism for wanting to learn how to become thinner.

3. The client’s initial goals are generally protective of the disorder and at odds with professional and family goals; it is for the clinician to bring the client to a place where he or she seeks a recovery which is marked by the reintegration and return of the core self.  It is the client’s developing trust in the practitioner that ultimately leads to a developing trust in one’s own capacity to trust oneself to manage food and life autonomously.

4. Start out slowly in asking for weight gain, when risk levels permit. If the anorexic client requires 2400-3500 calories daily but is currently consuming only 500 calories, starting with a goal of 800 to 1000 calories daily may be an appropriate beginning challenge.  Re-feed slowly, increasing demands gradually; keep expectations realistic, always considering the unique needs and capacities of the client. In re-feeding a malnourished eating disordered individual, weight goals are approximately ½ to 1½ pounds per week. With the severely malnourished body, anticipate that caloric intake may not produce an expected weight gain immediately, as the body "cashes in" on the caloric debt, restoring function before weight. A condition called "hyper-burn" represents a quickening of the metabolism at the start of the re-feeding process that may result in weight gain delay. For hospitalized clients at physiological risk, overly rapid re-feeding can be life threatening.

5. Understand the unique qualities of the eating disorder recovery process which is generally long-term and challenging, riddled with backslides and regressions. There is more to eating disorder recovery than weight gain; recovery indicators include the client's increasing self-awareness, sound judgment, self-reliance and courage to seek change, all benchmarks of the repair of a dysfunctional relationship… not only with food, but with the self. Self awareness, self acceptance and self actualization are what make sustainable weight restoration possible.

6. Learn to recognize a typically elusive recovery progress which is often hidden within the smallest details of change, and in what may appear to be regression. Sometimes the best learning occurs in the face of trail and error.  How much evidence might you need to recognize positive aspects of change, and to help your client learn to differentiate and judge them accurately? When you see something positive, point it out. When you see something that is not, let the client try to bring it up and explicate it. The recovery process is not about seeking perfection; it is about seeking change.

7. The quality of the client/clinician relationship will significantly impact the nature and timeliness of recovery. A good relationship will inspire trust in the practitioner, ultimately resulting in the client’s own self trust, motivation, determination and capacity to make changes that approximate, and ultimately facilitate recovery.

8. Eating disordered clients are typically obsessed with their weight and the process of measuring weight as determined by the scale and by distorted self perception. Do not perpetrate the myth that weight is the central issue propelling these disorders; banning home scales can diminish compulsive preoccupations. Eating disorders are disorders of control, the loss of self and self regulation, and of relationships, not only with food, but with oneself and others. A client's weight is significant in alerting health professionals to the possible need for immediate medical intervention.  Weight shifts are significant for the motivations behind them, the manner in which the weight was lost or gained, and the feelings evoked through that process. Achieving and maintaining an appropriate weight needs to be recognized and appreciated as an outward manifestation of inner change.

9. Do not misconstrue fluid shifts and imbalances to indicate true weights. Remember too, that setting arbitrary “target” weights for the client (based on weight charts) is counter-productive.  The healthfully fed body needs to be held responsible for determining its own proper set point weight range.  The body's set point weight is determined by the body's metabolism, not by the preference of the client or practitioners. Full recovery does not happen short of regaining the body's full set-point weight; at the same time, full recovery is not assured simply through achieving that weight. Night sweats are typically a common indicator of the resumption of healthy metabolic function following a protracted stall.  You can assure the client that bloating, reflux and numerous other gastroenterological problems generally heal completely within three months post-recovery.

10. Welcome your client's resistance to therapeutic change that comes in many forms, including denial, avoidance, non-disclosure, hostility, oppositional behavior and manipulation. Managing resistance takes courage and foresight. Attempt to separate the eating disorder from the person whose brain and body it inhabits. Through tough love, demands, limit-setting and empathic and caring warmth, nutritionists communicate an understanding and non-judgmental acceptance of the enormity and implications of these problems. Meeting resistance head-on offers an invaluable opportunity to begin a dialogue with the eating disorder within. Consider the declarative "No" or the passive refusal to cooperate to be the start of a conversation…not the end.

11. In working with highly resistant eating disordered clients who refuse to participate or engage in treatment, you might consider offering the client self-determined healing for a specific and limited amount of time without therapeutic assistance. Make a contract with the client and parents to start nutritional care and psychotherapy upon discovering that these attempts did not meet with success.  It is for you as the professional to help the client determine what constitutes a successful outcome. If outpatient work does not prove to be successful, make it clear that the treatment may need to be upgraded to a more restrictive environment. The need for more restrictive recovery opportunities may include a short-term day program milieu, hospitalization, residential care, or a halfway residence, to be determined by the client's needs and the input of the outpatient professional team.

12. Collaboration with the wider treatment team takes time and effort….particularly at the start of treatment, and/or when a client is in physiological danger and may need to be referred to an inpatient milieu. Nutritionist, therapist and medical doctor need to stay in touch, communicating in person, by phone, fax or via email. With their clients, nutritionists must become comfortable wearing the various "hats" of collaborating team members, “understudying” each others parts, identifying and addressing medical and psychological issues across the board, referring clients back to specialists for additional care.

13. The message your client hears is not always the one you or your team mates intended to send. Listen "between the lines" to the client's thinking and responses. If you were to say "You're doing great! (based on weight gain), I won't need to see you now for a month," your client may be hearing, "You are comfortably fat now and sufficiently over your disease to stop your efforts to recover. You've gained enough weight so you are free to start restricting again." Help the client to field and resolve any team-based miscommunication.

14. Don't lose sight of the importance of assessing and managing the frequency and duration of physical exercise for eating disordered clients. The amount and nature of physical exertion will determine how many calories a person requires in order to restore weight, nourish and sustain a healthfully functioning body, and sustain that bodily status. It is for the nutritionist, in conjunction with the therapist and medical doctor, to decide how much exercise is appropriate, and at what point in the recovery, to allow eating disorder recovery to occur. Be aware that exercise in eating disordered individuals, anorexic and bulimic alike, is typically used as a purge technique.  Nutritionists require continual access to pertinent information about exercise activities.



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