What Does a Nutrition Therapist Really Do?
By Sondra Kronberg, MS, RD, CDN, CEDRD-S
It’s Monday morning, and I now invite you into my office. I want to share a sampling of patients with you and hopefully broaden your understanding of the actual role of a nutritionist when working with a patient struggling with an eating disorder.
My first patient, Sally, is a new patient: Sally is a 40-year-old woman in a larger body. She enters, looks me over, sits down, and says, “What does a skinny broad [really, she says bitch] like you know about losing weight?” Hmmmmm.
Midway through the day, 25-year-old Kaitlyn, who struggles with symptoms of anorexia and exercise bulimia, enters and declares that she won’t sit on the chair! She must stand and walk around the room or she won’t be able to stay. During the session, she discloses that she ate a muffin with her girlfriends and then went home to cut the word FAT onto her arm. Hmmmmm.
My last client, Matthew, an overly anxious 12-year-old, is practically dragged in by his mom, who is equally anxious and weeping hysterically because they had another eating battle this morning. She fluctuates between frustration with and empathy for Matthew. He will only eat five specific foods, of specific brands, at specific times and exact temperatures. He is also now refusing to go to school. Hmmmmm.
I am a seasoned nutritionist with years of experience, better described as a nutrition therapistwho specializes in the treatment of eating disorders. What is my role? What really goes on in my office? Is it about the food, or is it not about the food? How does a nutrition therapist contribute to the treatment team to help patients recover?
In the early days of my practice, encountering these behaviors would often leave me feeling like a deer in the headlights, immobilized and stuck—perhaps similar to how the patients were feeling. The traditional role of the nutritionist in the medical model is to provide information to the client: to devise and implement a meal plan that fixes the problem and to provide some oversight to ensure accountability or compliance for a relatively short time. Armed with scientific training and medical model concepts, I was geared up for providing patients with information and meal plans. Having acquired the scientific answers about food, nutrition, health, weight, and bodily function, I was now qualified to help others improve their nutritional status. I was naive enough to believe that merely knowing information and providing direction would catalyze action and create change. My job would be to: 1) Assess patients’ physiological status; 2) Determine their nutritional needs; 3) Calculate the correct percentage of macronutrients and micronutrients to be included in the daily allotted calorie intake; 4) Produce a food plan that meets their nutrient and energy needs; 5) Provide a brief assist in getting started. While all these tasks are an important part of the nutritionist’s role, they are only a piece of the whole when it comes to treating individuals with eating disorders.
The majority of patients who struggle with eating disorders find themselves in my office because they don’t feel good about themselves and they have adapted food and body beliefs as a mechanism of self-evaluation. Most have long ago lost connection to their own inner knowledge, wisdom, and life force. This exhausting struggle with food, weight, and body image often stems from a sense of worthlessness. It is an all-consuming attempt to feel better about themselves, numb their pain, cope with feelings, or gain a sense of control. This eating-disordered symptomology is not only a clever adaptation for survival, but also a crucial means, often the only means, of communication. As destructive as it may seem to the outside world, the eating disorder can be a mechanism of self-care and a measure of security for the person who is struggling. It takes a lot more than information and direction to reach, understand, and shift the eating-disordered thoughts, beliefs, and behaviors that have been purposefully integrated.
No amount of nutritional information and schooling regarding the roles and functions of protein, carbohydrates, and other nutrients, and no amount of meal planning expertise would even touch the depth of what is attached emotionally, physiologically, and behaviorally to these patterns that get communicated through food and body dialogues. How in the world would a 30-minute session about what foods to eat and how to nourish oneself compete with the thoughts and mechanisms that have evolved in the formation of these patients disordered relationships with their food, their aversions or compulsions, and the embedded perceptions of their weight or bodies?
Understanding the depth of the behaviors, the purposes they serve, and the mechanisms involved has taught me that the role of the nutritionist in the treatment of eating disordersgoes well beyond the setting up of a meal plan and the supervision of its adherence. Providing a meal plan is a small part of the whole process. Progress and recovery can only really occur through the relationship the patient and nutritionist can develop. Patient willingness to progress is connected to the ability of the nutritionist to both have empathy for the patient’s current adaptations and hold hope for a different future.
I have learned and grown from each patient. I know now and teach that the role of the nutritionist in the treatment of eating disorders is to create a healing, collaborative, and communicative environment where thoughts and beliefs about food and life can be spoken and, when needed, challenged. I must work to create a safe place of trust and support within which risks can be taken. It is in the context of these relationships, and in the net that the nutritionist and the team have woven to hold each patient, that patients’ behaviors and fears can be understood and explored; their lives and hopes can be restored. For this reason, the nutritionists who treat eating disorders have collectively evolved through training, experience, and supervision to be identified as nutrition therapists. Nutrition therapists uncover cognitions, behaviors, and values that cement the eating disorder behaviors, through food dialogues. This is adjunctive to the psychotherapist’s role of unearthing and understanding the underlying issues. With the help of both, a strong and cohesive net is formed to move the patient out of the stuck-ness toward their potential.
Change and growth are hatched and nurtured until patients grow strong enough to hold themselves and connected enough to reach for support when they need it.
I have discovered that working with people, their food choices, eating behaviors, preferences, weight, or aspirations is complex and multidimensional. It involves so much more than choosing an apple over a pear or setting up a theoretical eating plan. I have learned that food has meaning. There are foods that have sentimental value, those that are rewards, and others that are used or taken away as self-punishment. There are foods that are exciting and others that are comforting. I found that there are food-related behaviors and rituals that bring pleasure and some that bring pain. I have become aware of foods as part of customs and family traditions. Many food choices emanate from our ethnic, religious, philosophical, and personal beliefs, as well as cultural messages. Current cultural messages emphasize clean eating: including foods that are superfoods and eliminating foods that are “toxic” or create toxins. There are food choices that have both sensual and sexual links. There are also food aversions and phobias, many of which are related to fear of weight, illness, or sensory intolerances. Often, a person’s identity, worth, or purpose is attached to his or her food choices. My early training did not prepare me for the psychodynamics I would encounter. Crucial to my ability to help patients progress was to first meet them where they were at and get a better grasp on how their eating disorder thoughts, feelings, and behaviors trapped, served, or secured them, before we could move forward together.
Nutritional therapy is a medium for challenging distorted beliefs about food and later recognizing where similar beliefs have been operating in other areas of the patient’s life. It is a forum to challenge old thoughts, behaviors, and patterns in a safe and supportive place. Calculated challenges are agreed upon to broaden the comfort zone. Gradual risks to change meal variety, content, calories, social settings, and timing are negotiated and the consequences explored. Taking risks with food paves the way for taking parallel risks in life.
Now, in my role as a nutrition therapist, I do so much more than provide a meal plan and monitor its adherence. I will shop, cook, and eat out with patients. I use these experiences and events to model choice, acceptance, assertiveness, mindfulness, balance, flexibility, and joy. There is a vulnerability to being with the patient while coming in direct contact with their greatest fears and challenges regarding food, weight, and their bodies. It is not something just talked about or a meal plan on a piece of paper; we are often in the lion’s den together and confronting the patient’s inner eating disorder voice. While food, weight, and body may be the language that is spoken, it is the willingness to confront the eating disorder together that fosters trust and progress.
Beyond the exchange of nutritional information between me and my patients, I have experienced patterns of compliance, adherence, and defiance firsthand. These mechanisms, which are often deep-rooted in personality, past experiences, and upbringing, usually play out with the nutritionist over a food plan, office visits, meal support, or other experiential activities.
Patients are affected by messages from me all the time: Some I give out, and some they perceive or create and attach to me. Everything that happens in my sessions can be a tool for growth and change or a vehicle for disruption. I have learned that being told what to do or eat can trigger old feelings and activate defense mechanisms. I know that the way I look, the things I say, and the ways my patients feel understood, visible, or cared about affect their ability to listen to or take in my words, believe me, or trust me. I have become aware of how relationships and dynamics affect our counseling, meal support, and experiential sessions.
I am also aware that at any moment, I can be viewed as the good mom or as the bullying friend. Entrenched emotional and behavioral patterns can play out over the food plan or over any new food or body challenge. Cognitions and belief regarding whether to comply, the ability to have choice, the need to have control, or the fear of losing control are almost always present in some form. I often bear witness to a full-blown panic attack when food is prepared “wrong” or a calorie or weight number is unexpectedly revealed. Unsolicited comments or disruptions of routines can be triggering and result in exacerbation of disordered behaviors. Nutritional therapy requires an understanding of these dynamics. It requires the ability to negotiate pitfalls and impasses that may get in the way of progress.
Nutrition therapists treating eating disorders need to develop their own strong psychotherapeutic skills, network, and therapeutic alliances. The nutrition therapist, through practice, professional supervision, and self-examination, learns how to engage patients, sharpen communication skills, and facilitate change. The nutrition therapist uses the therapeutic strategies of cognitive behavioral therapy, acceptance and commitment therapy,and emotion regulation therapy to help patients become aware of their thoughts and values. Nutrition therapists integrate a number of these therapeutic modalities to help patients change behaviors related to food, weight, activity, and body dissatisfaction. The nutrition therapist guides the patient through the processes of change from awareness to alternative actions and, finally, to the elimination of the eating-disordered behaviors. Changes include taking risks to replace distorted beliefs and behaviors with healthier ones. The nutrition therapist guides the patient through the work. Changes in behavior result when the patientrecognizes the purpose of the eating disorder and is able to find new ways to satisfy those needs. Change takes place in stages over a period of time. Nutrition therapists work with patients at meals, in restaurants, in grocery stores, and in eating groups through planned exposure to expand their comfort around foods and social eating circumstances. Patients can share their thoughts as they arise, and the nutrition therapist can then help them to work through those fears and thoughts. It is important for the patient to gain exposure to uncomfortable eating events while in the company of a nutrition therapist, hopefully making it easier for the patient to face eating challenges that arise in day-to-day life with friends and family. Because nutrition therapists have the responsibility of discussing food with patients, they are in an optimal position to uncover and address the food and weight thoughts that affect each patient’s ability to function and participate in life. This information, when shared with the entire treatment team, can enhance the work of the other team members, strengthening the treatment path for that patient. The nutrition therapist adapts advanced therapeutic counseling skills and merges them with nutrition language. This unique combination of physiological knowledge and understanding of underlying psychological issues is what makes the nutrition therapist’s role so crucial in treatment. Information spoken to the nutrition therapist, embedded in the language of food and weight, offers valuable insights when communicated with the entire team. The nutrition therapist is a conduit from the patient to the multidisciplinary team throughout the continuum of care, modeling both communication and trust building so crucial to the patient’s healing.
In summary, back to my office and my role, I see my role and the role of nutritional therapy differently now. I have learned, and now teach, that there is so much more to the process of food choice and food behaviors than information, science, and plans. I now approach nutrition and disordered eating as an aggregate of physiological, emotional, and behavioral factors, and my role and skills need to encompass all of these areas. The physiological component is determined by biochemical factors such as nutrient deficiencies, blood sugar fluctuations, metabolism, and genetics. It is a key part of my role. The emotional component includes the ways in which one turns to or away from food to cope with intolerable thoughts or feelings, such as depression and anxiety. It includes thoughts the patient may have about trust, hope, and failure. The behavioral components, such as bingeing, purging, starving, and overexercising, are patterns that evolve over time and have become routine ways of managing feelings and situations. All three of these areas need to be addressed to facilitate changes in eating behaviors and nutritional status. All three areas require healthy collaboration among team members, caregivers and patients. Given the long-term nature and specialization of eating disorder treatment, the collaborative process takes a great amount of skill, commitment, and continued practice among nutrition therapists, psychotherapists, physicians, and psychiatrists. All team members need to be aware that therapeutic counseling skills are used by the nutrition therapist to facilitate change and that a skilled nutrition therapist is an effective tool in the treatment of eating disorders. Caveat: Not all nutritionists know how to treat eating disorders, as there is limited education in schools; hence, expertise must be sought out and developed.
Finally, the successful approach of the nutrition therapist depends less on imparting nutritional information and more on forming a trusting relationship in which the patient’s positive sense of self develops and the patient embraces a willingness to meet nutritional and biological needs.
Now I am grateful and share in the progress when: Sally calls to proudly say she is no longer bingeing and has gotten into a relationship; when Kaitlyn excitedly comes to the office, sits down, and tells me that she had a birthday party and ate her cake with no remorse, no cutting, or compensation; when Matthew’s mom sends me a thank-you note because he is now eating five more foods, including pizza with his friends, and he is participating in several groups at school, so she can’t thank me enough. I am aware that it was not about the information, knowledge, data, or meal plan I developed. The growth was more about the trust in our relationship, my collaboration with their therapists, the cohesive messages of the team, and our ability to form a net through which they all felt safe and supported enough to change.
I am hopeful that this article will provide insight into the extensive role of the nutrition therapist and incentive for more and more professionals and sufferers to better utilize nutrition therapists as tools in the collaborative treatment of eating disorders to enhance treatment and improve outcomes.
About the author:
Sondra Kronberg, MS, RD, CDN, CEDRD-S, is a seasoned nutrition therapist and recognized leader in the field of eating disorders. Founder and Executive Director, Eating Disorder Treatment Collaborative, FEED: IOP, CONNECT and CONCIERGE programs in New York. Sondra specializes in treatment and training of the collaborative approach to eating disorders. She is a founding member and past Board Trustee of the National Eating Disorders Association, (NEDA). The author of Comprehensive Learning/Teaching Handout Series Manual for Eating Disorders and contributing author to Eating Disorders: Clinical Guide to Counseling and Treatment and Eating Disorders in Special Populations: Medical, Nutritional and Psychological Treatments. Sondra received the International Association of Eating Disorder Professionals, (IAEDP), 2010 Certified Eating Disorder Specialists Award, the NEDA 2004 Excellence in Treatment Award and the 2002 SCAN Excellence in Practice Award. In 2018 Sondra received NEDA’s first Legacy Award. Sondra is currently an iaedp influencer and certification core course facilitator. She is a national speaker, treatment consultant and media spokesperson. She is also a consultant to the Carolyn Costin Institute. Sondra’s greatest passion is helping people learn to nourish their minds and bodies in order to reclaim their lives and thrive.
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