Jessica Setnick, MS, RD, CEDRD, joined us for an interview on her book, Academy of Nutrition and Dietetics Pocket Guide to Eating Disorders, second edition. What follows are our questions in italics, and Jessica’s thoughtful answers.
In your introduction to Academy of Nutrition and Dietetics Pocket Guide to Eating Disorders, second edition, you note that the small number of those with eating disorders who start treatment, few complete treatment. What are some of the reasons that drive this unfortunate dilemma?
Successful treatment takes a long time and a huge commitment – some data suggest seven years of slowly decreasing levels of care to reach a point of remission. For many, treatment must be lifelong to prevent relapse. Treatment modalities are effective sometimes, but not others. This is discouraging and many sufferers do not have the financial resources to continue in treatment until it is complete, and insurance payments can be criminally difficult to obtain. Beyond that, some eating disorders are ego syntonic, meaning appealing to the individual, so they are unable to participate in their needed treatment. When an individual is experiencing anosognosia, an inability to recognize the severity of their illness, leaving treatment early or against medical advice is common. Possibly the most frustrating aspect of all is the mistaken belief that weight is a proxy for recovery, which leads individuals, support partners, and insurers to prematurely terminate treatment long before the eating disorder has been contained.
Can you please comment on the value of asking about food availability during a nutrition assessment?
Food insecurity in childhood can be a major driver of lifelong dysfunctional eating behaviors, as well as a source of shame. It can be caused by poverty of course, but also refugee situations, war, hurricanes or droughts, living in a large family or foster care, being raised by an impaired or absent caregiver, and even being put on a diet at a young age or being punished by withholding food. Dietitians are trained to assess an individual’s abilities to obtain, prepare, chew, swallow, and digest food. During this process we often uncover a current or past history of food insecurity that is influencing an individual’s ability to stay nourished in the present. Addressing these issues is essential, otherwise the best nutrition advice in the world cannot be implemented.
What, in your opinion, is the difference between a diet and a meal plan developed between a patient and a seasoned eating disorders nutritionist?
That’s simple. A diet is static and one-size-fits-all – you can type it on your blog for everyone in the world to see. Everyone who wants to lose weight eats cabbage soup all day. Everyone who overeats has two cups of vegetables before each meal. Everyone with anorexia eats 5000 calories a day. There’s no individualization, no taking into account your personal preferences or nutritional needs. It’s not specific to your body, your schedule, your life. Every time you look at the page, it still says the same thing. There is no flexibility. You don’t like cabbage? That’s your problem. 5000 calories feels like bingeing? You’re not committed. If you can’t follow it, the problem is you. You’re lazy, a failure, lacking will. And you can never be free. You need the diet because you are inherently flawed. You can’t trust yourself, your hungers, your desires. When you follow your own lead you screw up, again and again and again and again until you believe that only the next best diet will solve this mess…
A meal plan made by you and a dietitian is the exact opposite of this. It’s developed by considering dozens of different areas – What time do you wake up? Leave for work? Take a break? How long do you have for lunch? Do you pack or buy? Do you like to cook? Do you have a fridge? Who lives with you? I could go on and on. There are no two meal plans exactly alike. And that includes your own meal plan from day to day. On Tuesdays you have class at night? The meal plan accommodates that. Next month you start traveling for work? We adjust. When your life changes, your plan changes. And even better, when you try something and it doesn’t work out, you’re not the problem, there’s no one to blame… we just modify the plan and see how that goes. A dietitian can craft a meal plan that takes you from living with a feeding tube to eating all your food, from infertility to pregnancy, from guilt and shame to peace. And the ultimate goal is that you learn to find your internal compass again, so that YOU tell US what your next step will be. You’re ready to try broccoli? Stromboli? Cottage cheese? You want to try eating in a restaurant without looking up the menu in advance? You want to try keeping ice cream in the house? We’ll honestly advise you on what we think will help, and even slow you down if we see you skip ahead. And when you don’t need us anymore? We’re happy about that, too.
Please define “legalizing food” and how does this process begin?
Legalizing food means removing a moral value from food, and by association, any moral value that passes to the eater of that food. Different foods provide different nutrients, and foods can be supportive or unsupportive depending nutritional needs; even the same food at different times. But a human being does not become “good” or “bad” depending on what they eat. The process starts by accepting that we all have a universe of qualities and characteristics, and we all need nourishment. They are mutually exclusive. You may not like yourself, but you don’t have to earn the right to be nourished by how you behave; even people on death row still eat several times a day. If you eat something you regret, you are not bad and you don’t deserve to be punished. The concept of legalizing food can sound very simplistic, but let me assure you, it can take years to untangle the unfortunate messages many of us received about food morality from family, peers, society, school, religious culture, and so on.
You recommend nutritionists discourage eating disorder patients from brushing their teeth after vomiting. Please explain.
This is a recommendation that dental professionals make to avoid damaging tooth enamel further by brushing in the stomach acid.
What are some of the challenges of staying in your lane or “keeping the focus on nutrition” with a patient?
Because the hallmark symptom of an eating disorder is that food and eating become intertwined with non-nutrition areas of life, eating disorder dietitians are in a constant assessment process to determine which aspects of a patient’s eating can be addressed nutritionally versus which must be referred to a medical or mental health professional. When a patient brings in non-nutrition topics to a session, we can often bring the conversation around to nutrition by linking the difficulty to how it influenced or was influenced by the patient’s eating. But, in cases where the difficulty has no relationship to nutrition, the dietitian will need to set clear boundaries. I go into this in detail in Eating Disorders Boot Camp, as it is an issue that probably every dietitian experiences at some point. In cases where a dietitian is the first point of contact, we have the responsibility not only of identifying which issues belong to which discipline but also of introducing the concept of a team approach to treatment. At times, when a patient or support partner resists the recommendation to bring a mental health professional onto the team, it is the dietitian’s responsibility to explain the rationale for this recommendation and to determine the limits of his or her ability to help.
What documentation do you recommend an eating disorder nutritionist record for their files?
It would be great if we had a common language (as opposed to narrative which is not concise or false proxy measurements such as weight or BMI which are not accurate) to document the improvements that individuals are able to make as a result of their nutritional counseling and rehabilitation. The nutrition diagnoses were intended to facilitate this process but they are not widely used. The result is that, at times, the unique contributions of eating disorder dietitians are not recognized as essential to the recovery process. Instead, they are blended in among the general outcomes of treatment and we are not able to make a successful case for reimbursement for our services. Without being able to quantitatively demonstrate the benefits of our work, professionals who rigidly define “evidence” as journal publication mistakenly believe that nutrition counseling is peripheral to eating disorder recovery, or that it can be provided equally effectively by anyone who has read a book about nutrition. In the one published study that I am aware of where recovered patients were asked about their work with an eating disorder dietitian, 63% stated that their work with that dietitian was essential to their recovery and 25% identified nutrition counseling with their eating disorder dietitian as the single most important factor in their recovery. We need to determine a method where we can document these results in a way that will help more individuals with eating disorders access our care.
For more information on the role of the Eating Disorder Dietitian in treatment or to find an Eating Disorder Dietitian in your area, visit www.EDDietitians.com.
About the author:
Jessica Setnick has one of the most recognizable names in the eating disorders treatment world, thanks to her engaging and charismatic presentation style, her unique point of view, and her genuine ability to connect on a deep level, even from the podium. Jessica’s mission is to work toward a world where everyone who needs care for eating issues has access to qualified professionals, and no one is turned away due to insurance issues or mistaken stereotypes.
Jessica is a registered dietitian with a master’s degree in exercise physiology and sports nutrition, and you can learn more about her work here.