Role of a Registered Dietitian/Nutritionist in Eating Disorder Care
By Hilary Raciti, RDN CDN
A Registered Dietitian/Nutritionist (RDN) can work in a variety of settings with a great diversity of clientele. Often when thinking of a nutritionist one thinks of a professional who helps people eat “healthier” for weight management or weight loss. Often I hear people calling me the ‘food police’ and get ashamed to admit that they nibbled on a cookie over the weekend.
The truth is, dietitians utilize the science and art of medical nutrition therapy to improve clients’ medical status. This does not necessarily indicate weight loss or removal of certain foods; dietitians promote optimal nourishment and often this means promoting balance and eradicating nutritional myths. When working with eating disorders, a dietitian is drastically removed from this stereotypical role.
Let’s first define what an eating disorder is. An eating disorder is any of a range of psychological disorders characterized by abnormal or disturbed eating habits. This includes but is not limited to Anorexia Nervosa, Bulimia Nervosa, Avoidant Restrictive Food Intake Disorder (ARFID), and Binge Eating Disorder. For more information about eating disorders outlined in the DSM-5 please refer to the link below.
Eating disorders come in all shapes and forms and often do not fit perfectly into the categories above. Usually in that case one will be diagnosed with EDNOS or Eating Disorder Not Otherwise Specified. A Dietitian who works with clientele displaying symptoms of an eating disorder must be aware of the various diagnoses, assess individual behaviors, thoughts, external factors, and medical and family history to best develop a nutrition treatment plan. One must be ready for hurdles and necessary changes to this treatment plan, as an eating disorder is a dynamic struggle that requires consistent care and modifications. Working with a treatment team including a therapist, primary physician and often parents and other support figures is absolutely necessary. Successful treatment of an eating disorder requires consistent collaboration with the whole treatment team, as it is a genetically, socially and environmentally based condition with threatening physical outcomes if not treated.The role of a RDN in the care of eating disorders is similar to that of all other conditions: he or she develops and implements the nutrition treatment plan while providing support in accomplishing the goals set out in the treatment plan. Just like with any other client, the dietitian works with the individual based on his or her unique eating disorder behaviors, needs and motivation level. Dietitians who are involved in the treatment of eating disorders must take time to understand the client’s motivation for recovery and readiness level while respecting the individual as a person, not an eating disorder.
A Registered Dietitian will calculate the individual’s energy, protein, vitamin/mineral, and fluid needs and assist the client in creating a meal plan that is realistic and adaptable to his or her daily life. During times of severe caloric restriction, a dietitian will strategically increase energy intake in small increments to prevent re-feeding syndrome, a potentially fatal condition in which shifts of fluids and electrolytes occur in a malnourished person. Once a client or patient is medically stable, the introduction of new or “challenging” foods continues at a slow pace, however, energy or calorie needs are often heightened due to prolonged abuse and damage to internal organs from long-term malnutrition.
Many patients with a diagnosis of anorexia nervosa or those with restrictive intake patterns may experience hypermetabolism with symptoms of extreme hunger and night sweats in the beginning of recovery. This is due to the body’s sense of security that nutrition will again be provided and thus turning its engine on to replace fat and muscle stores, organs, bone mass, hair, nails- all that were depleted during prolonged starvation or restriction. A dietitian will guide the client during this phase to ensure sufficient energy, protein and fluid intake.
What about those with binge eating disorder or those with restrictive-binging tendencies that are at a healthy weight or even potentially overweight? A dietitian will never promote weight loss or diets for clients who display BED (binge eating disorder). In this case a dietitian will work with clients to promote regular or normalized eating habits, sufficient nourishment throughout the day, and detection of external or internal triggers that may result in the binges. Working on techniques to battle these triggers, gain control of eating behaviors and prevent the sense to restrict or compensate after a perceived binge is essential in the treatment of these conditions.
Educating clients about nutrition while challenging clients’ food roles and fears is another important role of a dietitian in the care of eating disorders. Many clients have false beliefs about what composes a healthy diet and gravitate to extremes to gain a sense of control. Clients with eating disorders necessitate proper education that all foods do fit in a balanced diet. Carbohydrates and fats are extremely important components of our diet, but societal cues today cause much confusion. Trained Eating Disorder dietitians will often execute exposure relapse prevention with the client. This consists of creating a hierarchy of fear foods starting from those that are least anxiety provoking to those that cause intense stress or discomfort. A dietitian will carefully expose a client to these foods, one at a time, continuously until his or her SUD (subjective unit of distress) decreases. This is a great method to overcome food fears for those with eating disorders.
Although the main goal for a dietitian working in Eating Disorder care is to promote adequate, balanced nutrition with decreased irrational thoughts, behaviors and fears about food and the body- clients often display comorbid medical issues such as gastroparesis (slow digestion/poor muscle motility in your stomach), bone loss and amenorrhea (loss of menstrual cycle) due to long-term restriction or compensatory behaviors. A dietitian will have to be wary of such conditions and assist with symptom alleviation while ensuring sufficient caloric and protein intake via liquid supplements, low residue foods, and high-density meals and snacks. Proper supplementation is also crucial for many in recovery due to bone loss, deficiencies and hormonal imbalances.
A Registered Dietitian/Nutritionist is a vital component of eating disorder care. He or she takes the time to work through a client’s struggles, food beliefs, personal preferences, social support team and medical history to create a nutrition treatment plan personalized for his or her specific needs. The dietitian will need to work with other clinicians including a therapist and primary physician to guarantee dynamic care. Remember an eating disorder is rarely about food and an eating disorder dietitian understands this.
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