Eating disorders are complex mental health conditions with significant physical and psychological consequences. They necessitate a multidisciplinary approach, involving various specialists, including dietitians. This article explores the critical role of dietitians in the treatment of eating disorders, particularly anorexia nervosa (AN), and their involvement in family therapy approaches.
Understanding Eating Disorders
Anorexia nervosa (AN) is a psychiatric disorder affecting both physical and mental health. It is characterized by restrictive eating, low weight, and malnutrition. AN has one of the highest mortality rates amongst all psychiatric conditions, ranking second after substance abuse. It is also associated with severe medical, nutritional, and psychological consequences.
Eating disorders are more severe than dieting or having food binges. When someone has an eating disorder, it isn’t about food. Those with eating disorders are often preoccupied with food, weight, or body shape and size. They may also experience anxiety about eating or the consequences of eating certain foods.
The exact cause of eating disorders is unknown. But research suggests there are several possible factors that lead to eating disorders, including genetics, brain biology, cultural and social ideals, and underlying mental health conditions.
Anyone at any age can develop an eating disorder. They’re most common among adolescents and teenagers. You may be more at risk if you:
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- Have a history of eating disorders or other mental health conditions in your biological family.
- Experienced trauma (physical, emotional, or sexual).
- Have an underlying mental health condition like anxiety, depression or obsessive-compulsive disorder.
- Participate in activities where your weight or body size is a factor (like gymnastics, wrestling or swimming).
- Go through a major change like starting a new school or job, a divorce or a move.
- Have Type 1 diabetes.
- Have a driven personality and strive for perfection (perfectionism).
The Multidisciplinary Team and the Role of Dietitians
Treatment models for adolescent AN view the family as a valuable resource in supporting recovery. Interventions employing a family-based approach are widely recommended. Family therapy for anorexia nervosa (FT-AN) is often recommended as a first-line treatment.
A multidisciplinary team (MDT) approach is paramount to ensure holistic care, including nutritional, physical monitoring, medication, and psychiatric assessment. Dietitians are core members of this MDT. They are skilled in the assessment and management of disordered eating patterns, malnutrition, underweight, and nutritional-related deficiencies.
Dietitians are well-placed to support nutritional-related issues arising from AN. However, eating disorder-associated behaviors and their impact on nutrition are symptoms of the illness, rather than the cause. Dietetic interventions, aimed at managing malnutrition and supporting refeeding, are often recommended as part of the specialist MDT, whereby psychological therapy (such as FT-AN) and medical management are central parts of treatment.
Conflicting Views and the Need for Further Research
Within family approaches to the treatment of AN, there has been some difference in opinion over whether or how a dietitian should be involved. For example, the family-based treatment (FBT) manual does not recommend dietitians as part of the direct treating team; however, dietitians are mentioned as potential members of the consulting team, and in clinical practice, dietitians routinely work in parallel with FBT therapists.
In FBT, the nutritional guidance on weight restoration delivered by a dietitian is perceived to have the potential to undermine parental confidence in their ability to feed their child and make healthy food choices for them, just as they had done prior to them becoming unwell with AN. In the Maudsley FT-AN manual, however, dietitians extend the nutritional knowledge base of the MDT, providing nutritional psychoeducation in collaboration with therapists and devising standard meal plans that are used to provide guidance in the initial stages of the treatment.
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Given these conflicting views about how and when to involve dietetics within two very similar treatment models, further research exploring dietetic roles in the outpatient treatment of eating disorders in children and adolescents is needed, in addition to clear guidelines describing the role of the dietitian in FT-AN.
Key Responsibilities of Dietitians in Eating Disorder Treatment
A nutritionist, specifically a registered dietitian nutritionist (RDN), helps clients understand how food and eating impact their health. A nutritionist with specialized training in eating disorder treatment plays a vital role on the treatment team. Often, people with eating disorders do not understand how food supports their body’s functioning and health.
The role of the dietitian is to identify the severity of malnutrition, the presence of disordered eating habits, and deficits in nutritional skills and knowledge that inhibit the attainment of adequate nutrition. Dietitians manage the nutritional care process by facilitating a comprehensive nutritional assessment, formulating a nutritional diagnosis, implementing a nutritional intervention, and monitoring progress toward treatment goals through an ongoing evaluation process. Dietitians also assess other common comorbid conditions, such as refeeding syndrome, diabetes mellitus, food allergies, food intolerances, gastrointestinal conditions, and osteoporosis. This information is collated to inform the nutritional diagnosis, identifying if the nutritional presentation is associated with eating disorder behaviors and differentiating between disordered eating and that of limited food acceptance.
Dietitians play a major role in providing care as part of a multidisciplinary team. They often work alongside mental health professionals, therapists, doctors, and nurses to provide services for people who are suffering from eating disorders. When they collaborate with other healthcare professionals, dietitians share in decision-making about a person’s care to help them achieve the best health outcomes.
Dietitians work to dismiss common misconceptions surrounding food that an individual may have learned online or from other sources about diet and nutrition. They also advise patients about the negative impact restrictive dieting, bingeing, and purging behaviors can have on their oral health.
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Specific responsibilities of dietitians in eating disorder treatment include:
- Nutritional Assessment: Evaluating a patient's nutritional status, identifying deficiencies, and assessing their relationship with food.
- Meal Planning: Developing individualized meal plans that provide necessary structure while offering appropriate amounts of choice, variety, and flexibility.
- Nutrition Education: Teaching patients the fundamentals of nutrition, how it impacts their health, and the importance of balanced eating.
- Behavioral Interventions: Helping patients develop healthier coping skills and addressing problematic eating behaviors such as restricting, bingeing, and compensatory methods.
- Collaboration: Working closely with other members of the treatment team to ensure a cohesive and integrated approach to care.
The Importance of Collaboration and a Case-by-Case Approach
A core theme in eating disorder treatment relates to collaborative working between dietitians and therapists and professionals and families. Responses reinforce fidelity to the FT-AN approach, whereby all MDT members provided specialist input as a cohesive joined-up team. Incorporating dietetics within the treatment.
Dietitians can take a core role as collaborators within therapy-led teams that facilitate joint working and sharing of expertise. However, dietetic input should be considered on a case-by-case basis, given its potential for creating an over-focus on nutrition and potentially diminishing parental confidence in feeding. When indicated for selected cases, nutritional counseling should be offered in joint sessions with the therapist rather than separately.
Addressing Common Misconceptions
For example, one unfortunately common misunderstanding about nutrition is that following a “healthy diet” somehow means abandoning enjoyable foods, sacrificing choice, and limiting variety. Not true! As dietitians help patients develop their meal planning skills, they will introduce them to the wide range of delicious options.
Dietitians work to dismiss common misconceptions surrounding food that an individual may have learned online or from other sources about diet and nutrition. They also advise patients about the negative impact restrictive dieting, bingeing, and purging behaviors can have on their oral health.
The Role of Meal Plans
People who receive treatment for eating disorders may have a wide range of problematic behaviors from restricting to bingeing to compensatory methods. In all cases, a dietitian can help the patient develop a meal plan that provides necessary structure while also offering appropriate amounts of choice, variety, and flexibility. The dietitian can also help the patient understand the nutrition and behavioral concepts that are fundamental to a healthy relationship with food. As a result, patients won’t merely follow a schedule that tells them when, what, and how much they should eat. Instead, they will have a firm grasp on the reasons for their new behaviors.
To support patients in following their new meal plans, dietitians may also work with them to develop healthier coping skills. Regaining control of one’s thoughts, decisions, and actions is a vital part of eating disorder recovery.
The Dietitian's Approach
An eating disorder dietitian does not focus on what their client is or is not eating. RDNs have advanced training in nutrition and how it impacts the body. Those who specialize in eating disorders have additional training in treating those with eating disorders and eating disorder recovery. Eating disorder treatment involves a team that usually includes a physician, mental health professionals, and a registered dietitian who works with eating disorder patients.
The RDN’s treatment approach should align with the patient’s approach to and goals for recovery. Choosing an RDN to work with on eating disorder recovery can feel overwhelming.
The Importance of Addressing Malnutrition
Dietary restriction often demands urgent weight restoration, education about the effects of starvation, and minimization of medical risk. For this reason, it is proposed that when we are treating people with an eating disorder, it is very likely we are also treating clinically significant malnutrition. However, since many eating disorder specialists do not believe dietetic care is necessary for all patients with an eating disorder, clinical malnutrition may be inadequately treated without referral to a clinician skilled in nutritional management.
In treating malnutrition, dietitians go beyond creating an energy surplus to support weight restoration, by also addressing energy availability, the timing and distribution of macronutrients across the day, and optimizing opportunities to meet micronutrient needs through dietary change. It is this focus on dietary quality and the role it plays in optimizing the nutritional rehabilitation process where dietitians can value add in the course of treatment - elevating malnutrition to the significance it deserves and treating it in a clinically relevant manner.
Finding the Right Dietitian
When looking for a dietitian to assist with eating disorder treatment, there are many factors to consider. Your health insurance may cover treatment for eating disorders. The dietitian you are considering should have advanced training in working with eating disorder patients. The only internationally recognized certification for those who work with eating disorder patients is the Certified Eating Disorder Specialist (CEDS) through the International Association of Eating Disorder Professionals. Having a dietitian close to you to work with is important if you want in-person sessions.
Treatments for Eating Disorders
Treatments for eating disorders include therapy, education, and medication. Finding the right type of eating disorder treatment depends on the disorder and its symptoms. Eating disorder treatment also involves taking care of other medical problems that an eating disorder causes or makes worse. These problems can be serious or even life-threatening if they go without being treated for too long.
Whether you start by seeing your primary healthcare professional or a mental health professional, you'll likely benefit from a referral to a team of professionals who specialize in eating disorder treatment. A mental health professional, such as a psychologist or therapist for talk therapy. Your parents or other family members.