THE ROLE OF THE REGISTERED DIETITIAN /NUTRITIONIST ON THE EATING DISORDER TEAM
By Karin Kaplan Grumet, R.D.
The management of an eating disorder requires a multi-disciplinary team consisting of a medical doctor, a psychiatrist, therapist, family members, and a nutritionist (or R.D.) who specializes in eating disorders. If a nutritionist decides to take on the task of working with eating disorder clients, it is essential that they work as a “team player”. In fact, one might consider it unethical for a nutritionist to be working alone and treating a client with an eating disorder. Being part of this team allows each team member to be the most effective in their role, minimizing “triangulation and splitting”, and allows continued communication between all parties involved. While each team member’s role within the team can often overlap, and the goal of recovery for the client remains cohesive, it is important to remember that each team member has specific boundaries.
In a client-nutritionist relationship, the therapeutic alliance supports the client’s need for behavior change. These changes are to challenge distorted and irrational thinking about food and weight, to explore feelings related to hunger and fullness, metabolism and body image. It is imperative that the client engages in nutritional counseling without any fear of being judged.
The nutritionist is responsible for designing a meal plan based on their client’s specific needs. They conduct a thorough assessment based on lab results, menses history, food recall, BMI, % body weight, exercise regimen and an extensive eating disorder history. A full nutrition assessment reveals current dietary intake, eating patterns, beliefs about food and weight, supplement use, who cooks/buys/prepares meals and an overall weight history. It is encouraged for a client to express their emotions, feelings and fears around food and weight and the goals they wish to accomplish. The nutritionist is then assigned the task of exploring, challenging and helping the eating distorted client replace the mental distortions that cause and perpetuate specific food and weight related behaviors. This is to allow the client to know that the overall goal is to return food and meals to their normal place as a source of “fuel.”
At this time, it is important for the nutritionist to set the appropriate boundaries needed. For instance, it is the role of the MD to make all medically related decisions regarding exercise as related to the client’s vitals and results of medical testing, to discuss medications, lab results, and make appropriate referrals. It is the role of the therapist to discuss all underlying psychological problems involved in the eating disorder. The psychiatrist provides continued psychotherapy as well as ongoing medication management. By defining appropriate boundaries within these team members and their client, it makes the communication as a team run smoothly with little chance of “splitting”.
Years ago, we were taught as nutritionists specializing in eating disorders that we are to give the client full autonomy with meals and leave the family members to be just that… family members. We were taught that the only one who can help the client get better, is the client himself or herself. While it remains difficult for a client to recover if they show no desire, current research has shown that family-based therapy (FBT) or the Maudsley method is very effective for anorexic and bulimic patients under the age of 18 with short duration of illness (3 yrs.) and that the family unit can provide effective treatment in the home setting. (1) Research is ongoing with older individuals and using FBT and another model is being researched using married couples and FBT concepts. (2) This treatment proves that caregivers, mostly parents, take control of the clients eating until weight is restored and control can be handed back to the adolescent. So one might now wonder, what happens to the nutritionist? Nutritionists can be an important source of support to the family during this time. They can educate the family about the ED, instructing families on how to refeed at home using recipes and various educational techniques related to food and preparation. This support has been shown to be helpful in alleviating caregiver stress. (3)
Nutrition counseling is recognized by both the American Psychiatric Association (APA; 2000) and the American Dietetic Association (ADA; 1994) as an essential component in the treatment of eating–disordered patients. As the ADA says, “R.D’s are food and nutrition experts, able to understand the complex relationship of food intake and overall physiological health, which can be used to form nutrition education and offer knowledge of foods, food products and formulas as needed by families and other health professionals”. It is important to remember that when working with clients diagnosed with eating disorders, that the collaboration of a multidisciplinary treatment team coordinated for consistent communication is necessary for recovery.
1. (Le Grange D., Eisler I. Family Interventions in adolescent anorexia nervosa. Child adolesc Psychiatric Clin A Am 2009;18”159-173)
2. (Bulik CM, Baucom DH, Kirby JS, Pisetsky E. Uniting couples in the treatment of anorexia nervosa (UCAN). Int J Eat Disord. 2001; 44”19-28).
3. (Kyriacou O, Treasure J, Schmidt U. Understanding how parents cope with living with someone with anorexia nervosa: modeling the factors that are associated with carer distress. Int J Eat Disord. 2008;41”233-242)
Karin Kaplan Grumet, R.D., is a registered dietitian/nutrition therapist with over 15 years experience specializing in Eating Disorders. She has a private practice in Summit, NJ. For information, please contact her at 908-373-0073 ext. 7 or kkgnutrition.com.