When It's Not About The Food...

Ever since I made the decision to become a Dietitian, I always knew my goal would be to impact the lives of those with eating disorders.  I, myself, struggled with atypical anorexia in middle school, and am lucky to say I've been recovered for 15+ years.  However, since working at an eating disorder clinic since March of 2017 - and now in the residential setting - one thing has become quite clear:  there is MUCH to be done for the education (especially for RD's) working in the mental health field.  I was recently consulting with a colleague, and we both agreed that neither of us obtained what we'd consider sufficient mental health background prior to making our mark as ED dietitians. I mean, the terms "coping skills," "trauma" & "de-escalation techniques" are like second nature to me now, but these were for sure never covered in my Medical Nutrition Therapy courses!

Whether you are a Dietitian working with eating disorders or not, I think it's still important to be aware that EVERYONE experiences some sort of trauma in their life, and having the tools necessary to work with all types of individuals and diagnoses is a great skill to have in your professional tool-box.  

So what IS trauma?  A very general definition would be "a highly stressful event," which may result in some eyebrow raising from readers.  The answer is YES - EVERYONE experiences some sort of "trauma" in their life, ranging in severity and negative long-term effects.  These can range from accidents, natural disasters, negative family relationships, divorce, weight stigma...to all forms of abuse, neglect, violence...and much more.  I will be the first to say I am obviously NOT the most well-versed in this area; the link What is Trauma? provides much more extensive and in-depth descriptions than my RD self ever could.   

So why do I think dietitians should have at least SOME exposure to education on this topic?  Because as I've mentioned already, EVERYONE experiences some sort of stressful event in their life.  A previous supervisor of mine described them as "Big T's" or "Little T's" - our body may not always know the difference between big and little "traumas," but still present with a number of physical or mental health concerns as a result.  Sooooo...no matter if your client is diagnosed with Type 2 Diabetes, Cancer, Anorexia, Bulimia, Binge Eating Disorder, Depression, Heart failure, PTSD, food allergies, or a combination of the above (or even a completely different medical condition) you best believe they have lived experiences that have shaped them into who they are today.  And ALL health professionals - including RD's - should be aware and know how to respect & communicate appropriately in hopes to provide the best clinical outcomes.

Where do RD's play a role you ask?  In my job setting, it's right away at our initial assessment.  One of the first things I do when I meet with a new client is gather their entire health & social history, not just ED symptoms.  Not only does this allow me to gain rapport & build a therapeutic relationship, but it also gives me background on their life story.  I get to know them; understand where they're coming from; how their struggles may have developed.  After working with 100's of clients over the past 1  and 1/2 years, I noticed so many ED patients had significant traumatic events in their history - and for some reason I was shocked that this relationship didn't occur to me sooner!  I mean, I had an eating disorder as a teen, but I definitely feel I fed into the stereotypical version of desiring thinness for external validation.  I sometimes feel guilty, because I never experienced anything as traumatic as some of my clients - desiring to be thin to avoid sexual attention; being harassed about their weight by family members, etc.  Again, I think Medical Nutrition Therapy courses could easily include mental health and Health at Every Size topics for future RD's to know when discussing eating disorders (you know, the 1-day discussion we had). ;-)

But back to what I was saying: the phrase "Biology loads the gun, environment pulls the trigger" is so true -  While eating disorders do have a genetic component, the environment one is born into or surrounds themselves also impacts a person's development.  'Environment' could be defined as broad as society/media, or down to family/friends & home life...and just like tornadoes, when the conditions are perfect, a storm (or eating disorder, or other mental illness) can occur.  (See the Bio-Psycho-Social model below).

If you would still like more resources on this topic, I suggest checking out the TED talk How Childhood Trauma Affects Health Outcomes - it's a quick 15 min. informative speech on implementing preventative measures in patients who present with multiple adverse childhood events (ACES).   I mean, preventative medicine that isn't weight biased and actually dives into someone's lifestyle factors vs. using a number on the scale seems like a pretty easy switch to me! That is, if our society TRULY values health vs. "beauty standards"....but I digress...

Obviously, this blog post is only briefly touching on such a broad and overarching, but NEEDED, topic.  And if you are an RD and find yourself needing some more guidance with ED-specific clients who present with other circumstances, below are a few tips I've compiled:

• REMEMBER EATING DISORDERS/TRAUMA DO NOT DISCRIMINATE

It's a common misconception that eating disorders only affect middle & upperclass white women in their teens an 20's...but that couldn't be farther from the truth.  ED's can impact all genders, ages, races, socio-economic classes, and sexual orientations.  Also remember that you do not need to be "stick thin" to be diagnosed with anorexia, nor do you need to be classified 'Obese' to have binge-eating disorder.

With eating disorders affecting such a broad range of people, it is to be expected that their life experiences are variable as well.  Just remember to always be mindful and show compassion around these topics - as most likely they stir up a lot of deeply rooted emotions.

• WORK WITH A MULTI-DISCIPLINARY TEAM.  

RD's can obviously calculate someone's nutrition needs and assist with meal plans, weight restoration and nutrition counseling, but our scope of practice does not include prescribing anti-depressants or conducting medical assessments/EKG's or having family therapy sessions.  Hence why at MINIMUM an MD, therapist and RD should be seeing an ED client together (my recommendation when working outpatient).  In residential I'm lucky to work in the same building with not only those mentioned above, but also nurses, ED techs, kitchen staff, yoga instructors, and so forth.   Reason being: in sessions a client may be discussing how their past experiences have shaped their eating patterns - this is obviously in my scope of practice.  But if a client is trying to dive deep into seemingly therapy topics, I kindly encourage them to speak to their other providers :)

• IT'S NOT ABOUT THE FOOD.  

I always tell my clients "Eating disorders may present as being all about food or compensating for eating (restriction, bingeing, purging, over-exercise, etc), but at the same time, eating disorders aren't JUST about the food."  Very rarely do I get a client that's sole purpose of their ED is "too get skinny."  Nine times out of 10, there's an underlying reason why food and body image are a concern.  Hence, why learning about trauma and childhood experiences have become of interest to me.

• DO AS MUCH CONTINUING EDUCATION AS YOU CAN

Before I specialized in eating disorders, this was still the main topic of many of my CEU's for licensure.  Even webinars and conferences that didn't offer continuing education, I still chose to watch/listen so I could learn as much as I could about mental health - as that is where my passion lies.  

• ASK CLIENTS OPEN ENDED QUESTIONS 

I have the luxury of getting to eat with my clients most days of the week, in which I can observe their table behaviors or resistance in real-time.  My biggest take away for interns is to utilize motivational interviewing, reflective listening, and ask questions starting with "What...?." or "How..?" vs. yes or no questions.  You are going to get a MUCH more in depth response from a client if you ask "What makes bread or pasta a fear food for you?" vs. "Are grains a fear food?"  Most likely the client will give you more back-story, in which you can continue the conversation.

• SMALL CHANGES ARE STILL CONSIDERED PROGRESS

Recovery is not linear.  Small decrease in [insert symptom use here] is still progress; Body image perception does not change overnight.  Jessica Setnick, a well-renowned ED RD said in her workshop "Getting a client to eat green beans 3x/day vs. just 1x/day is STILL CONSIDERED A SUCCESS.  

• YOU ARE NOT RESPONSIBLE FOR SOMEONE ELSE'S REACTIONS

 I can count a handful of times I've said what I perceived to be "the wrong thing," which was the biggest fear of mine before becoming an RD.  I've had clients leave my office in tears after discussing body image, I had a client tell me she was triggered by our conversation, etc.  You best believe I felt HORRIBLE after these instances, but after consulting with a supervisor, it was reflected to me that the reason my clients reacted this way is because I stirred something up in them & their eating disorder reacted first.  Basically, I was doing my job and unfortunately, eating disorders can be shameful to discuss.  Being someone who does not do well in conflict, this job has definitely pushed me out of my comfort zone & has helped me strengthen my clinical skills.

On the other hand, you are also not responsible for someone's entire recovery.  I can conduct a million nutrition assessments & provide as much education & "food therapy" techniques, but at the end of the day - it is a client's decision if they are motivated for recovery.  Plain and simple...and honestly, that sucks.  I would LOVE to see all of my clients recover and go on to do great things, but sometimes, there are chronic cases who will always be sick.  When I started taking the pressure off of myself feeling I had to "fix" everyone, and just looked at my appointments as conversations with pretty cool people, there was shift in both my personal & professional outlook.  I'm human, I may make mistakes, but if I can teach even one person something about themselves they didn't already know, I'm doing my job and making a difference.    

• GET SUPERVISION

I used to think asking questions meant admitting I wasn't competent in my job...that couldn't be farther from the truth.  On the daily I'm asking fellow RD's, therapists, MD's, nurses and other staff their take on a recommendation I may have for someone.  Also, it's okay to be stuck with a client and not sure what to do - because I'm HUMAN and NOT PERFECT.

• NUTRITION IS IMPORTANT, BUT IT'S NOT ALWAYS THE MAIN FOCUS

While I love to toot my Dietitian horn every now an then and discuss why we are important in ED recovery, sometimes I do have to reign it in with some humble pie and remember the whole picture.  There have been many times where clients may NEED to see a Dietitian, but because a multitude of external factors, they may not be motivated at that time, or they are referred to work on trauma and take a break from seeing their RD.  But as a side note, it is very rare would someone be referred to see a trauma therapist or program until they are eating regularly, d/t needing adequate nutrition to retain the information.

• CLIENTS ARE SERIOUSLY THE BEST

In my opinion, eating disorder clients are the most intelligent, creative, unique, inspiring, spunky, frustrating, funny, uplifting and AMAZING people on the planet.  I have numerous thank you cards, art work, notes & memories from so many who are fighting on the daily.  I get the best laughs from my clients, and they warm my heart at the same time.  I'm so happy to be in this field making a difference - I seriously love my job!  It may be hard work, but I wouldn't change a thing.