Essentials for Spotting and Managing Eating Disorders

Eating Disorders (ED) affect millions of people across all ages, races, sizes, gender identities, sexual orientations, and backgrounds, with an estimated 9% of the global population impacted. Sadly, EDs lead to 10,200 deaths each year, highlighting the urgent need for comprehensive care.

Treating an eating disorder requires a thoughtful and detailed approach to help patients achieve full, successful recovery. The sooner someone receives support, the better their chances of avoiding long-term or irreversible consequences.

Registered Dietitians play a vital role as part of a multi-disciplinary team, which also includes a medical doctor, psychiatrist, therapist, and family members. As a dietitian, you’ll create personalized nutrition plans tailored to each client’s needs, considering lab results, food recall, medical history, body weight, BMI, exercise regimen, and eating disorder history.

You’ll work closely with your clients to monitor their progress, help them understand proper nutrition, recognize their physical hunger cues, and differentiate between true needs and intrusive thoughts around food. Your guidance is essential in supporting them on their journey to recovery.

❗️It’s important for all RDs to be equipped to identify and care for clients with Eating Disorders. These disorders are often “intersectional,” meaning they can be present alongside other issues your clients may be discussing with you. In fact, both diagnosed and undiagnosed Eating Disorders are becoming increasingly common, making it even more essential to recognize and address them.

Eating disorders are serious psychological conditions that involve abnormal or disruptive eating habits, often accompanied by distressing thoughts and emotions. There are several types, with the most common being anorexia, bulimia, and binge-eating disorder.

  • Anorexia Nervosa: This involves consuming too few calories, leading to dangerously low body weight. People with anorexia often have an intense fear of gaining weight, regardless of their actual weight, and may struggle to see their body as it truly is.
  • Bulimia Nervosa: This condition includes episodes of binge eating followed by compensatory behaviors like fasting, self-induced vomiting, excessive exercise, or using laxatives/diuretics. Those with bulimia are usually very concerned about their weight.
  • Binge-Eating Disorder: Individuals with this disorder experience recurrent episodes of binge eating, often eating rapidly, until uncomfortably full, or consuming large amounts without being hungry. These episodes are often followed by feelings of guilt, disgust, or sadness.
  • Other Eating Disorders: These include conditions like Body Dysmorphic Disorder, Avoidant/Restrictive Food Intake Disorder, Pica, and Rumination Disorder.

Disordered eating, on the other hand, refers to a range of abnormal eating behaviors that don’t necessarily meet the criteria for a full-blown eating disorder but can lead in that direction. These behaviors might include chronic dieting, compulsive eating, or binge eating, often with a sense of loss of control.

Whether a client is dealing with disordered eating or a diagnosed eating disorder, a dietitian’s role is to support them on their journey to a healthy, sustainable recovery, working at a pace that’s right for them.

Statistics from: National Association of Anorexia Nervosa and Associated Disorders.

 

Do’s and Don’ts of Working with Eating Disorder (ED) Clients

Here’s a quick summary of some key practices for working with clients who have Eating Disorders. We also have a variety of Client Education Resources and additional materials in our Resource Center to help you learn more.

The Don’ts 🛑

  1. Avoid letting your clients see their weight if they step on a scale: For clients with ED, seeing their weight can be a significant trigger. Some might hear a voice telling them “that weight isn’t low enough,” while others may become overly focused on the number, increasing their anxiety. Instead, work closely with their Primary Care Physician to track progress. If your client is underage, collaborate with their parents to get weight updates periodically. Parents can share this information via email, text, phone, or Healthie. If the client is older and without parental support, consider asking if a trusted loved one or neighbor could assist. It’s crucial that whoever is helping is supportive and committed to the client’s recovery.
  2. Don’t ask your clients to count calories: Just like with stepping on a scale, focusing on numbers can be triggering or even traumatizing for clients with ED. Emphasizing calorie counting can worsen ED behaviors. We’ll later discuss how to use structured Meal Plans that don’t involve counting calories.
  3. Be cautious with food logs: As a general rule, food logs can sometimes make things worse by placing too much focus on calories. However, it’s perfectly fine to have clients journal about their meals and share their thoughts in those entries.
  4. Remember, they’re not a standard client—they have unique needs: It’s important to respect the boundaries and limitations of ED clients. Fay is designed to be a safe, trigger-free environment, so you can provide high-quality care tailored to their specific needs.

The Do’s 👍

  1. Use structured meal plans: After introducing your ED clients to the food groups, there are several strategies you can use to help them achieve their goals. For example, Modified Food Exchange Plans or Meal Plans without calories can be really helpful. Note: Don’t assume your clients already know about the food groups—teaching them about these is an important first step.
  2. Incorporate Intuitive Eating Principles: These principles can be introduced at different stages of the care journey, depending on the client. For Binge-Eating Disorder, they’re useful right from the start. For clients with Anorexia, we usually begin with structured meal plans until they’ve developed their hunger cues. Once those cues are more established, we can start to introduce Intuitive Eating Principles.
  3. Partner with parents/guardians when working with children: As mentioned earlier, parents can provide weight updates (remember, the child should never see the numbers on the scale). It’s also helpful to use Ellyn Satter’s framework on Division of Responsibility when educating parents. We want to work together to “monitor growth or decline slowly.” For Binge-Eating Disorder clients, this means ensuring children grow into their weight. For Anorexia clients, it’s about maintaining a healthy weight and preventing further decline.
  4. Schedule weekly sessions with your clients: This is a best practice for several reasons. Regular check-ins help us monitor progress and ensure safety. It’s also important to know when a higher level of care, such as inpatient or partial hospitalization, might be needed. If you think you might need to recommend a higher level of care, it’s helpful to set expectations with the client in advance. For example, you might say something like, “We need to see a pound or two of weight gain by [X] date, or I may need to recommend a higher level of care.”
  5. Use the Nutrition Care Process: We’re all familiar with this framework, and it can be a great tool when working with clients who have Eating Disorders. Below, we’ve provided more details on how to tailor this process for ED clients.

Deep Dives & Details

Nutrition Care Process

While RDs don’t diagnose eating disorders—that’s done using DSM-5 criteria (Diagnostic and Statistical Manual of Mental Disorders)—we play a crucial role in supporting the patient’s overall health and fostering self-acceptance. Our key responsibility is to assess, evaluate, and implement a nutrition care plan tailored to the patient’s diagnosis, ensuring it promotes health and monitors progress.

RDs should apply their deep understanding of the Nutrition Care Process when working with ED patients, upholding the highest standards of practice and attention to detail.

Assessment

Conducting a comprehensive nutrition assessment is central to our role. This includes evaluating the severity of the ED through diet history, physical data, beliefs around eating, and environmental factors like food security.

This assessment helps us gauge the risk of malnutrition and current nutritional status using evidence-based tools. Paying close attention to these details ensures that the care plan we develop is aligned with the patient’s health and recovery goals.

Diagnosis

While diagnosing an ED is beyond our scope, we use the assessment data to create a nutritional diagnosis for the patient. This could involve improving lab results, managing weight and nutritional intake, or educating the patient on the importance of balanced nutrition.

The nutrition diagnosis forms the foundation for setting outcome goals, choosing the right interventions, and tracking progress.

Intervention

According to the American Dietetic Association, nutrition intervention, including counseling by an RD, is vital in treating ED patients. Diagnostic criteria for EDs provide essential guidelines for identification and treatment, but understanding the complexities—like influencing factors, comorbid conditions, medical and psychological challenges, and boundary issues—is key to effective care.

Our interventions are based on assessment results, professional judgment, and the specific nutritional diagnosis for each patient. This process involves providing nutritional counseling, recognizing clinical signs related to EDs, and supporting medical monitoring, all while considering the patient’s psychological and medical needs.

Nutrition Intervention: Key Components

Nutrition intervention involves two closely connected steps:

  1. Planning: This is where we prioritize the nutrition diagnosis, discuss goals with the patient and their support system, review guidelines, and outline the specific strategy for the nutrition intervention.
  2. Implementation: The action phase involves putting the plan into motion, collecting data, and making adjustments to the intervention strategy as needed.

When creating an intervention plan for your ED patient, some key areas to focus on include:

  • Meeting the patient’s calorie needs
  • Improving lab results through targeted nutrition
  • Understanding the patient’s beliefs and behaviors around food
  • Addressing any associations between food and self-judgment (e.g., labeling food as “good” or “bad”)
  • Working through feelings of distrust or discomfort with food
  • Developing and implementing an eating plan that suits the patient’s needs

Monitoring & Evaluation

Monitoring and evaluating the nutrition intervention is crucial to ensure it’s effective and patient-centered. This helps us understand if the intervention is working and what adjustments might be needed.

RDs should keep an eye on indicators and outcomes directly linked to the intervention. This includes tracking progress towards goals, patient preferences, and any necessary revisions to the plan. Here are some areas to consider:

  • Nutrition Outcomes: Changes in knowledge, behavior, and food/nutrient intake
  • Clinical & Health Status Outcomes: Changes in lab values, body weight, blood pressure, and other health indicators
  • Patient Outcomes: Improvements in quality of life, satisfaction, self-management, and functional ability
  • Health Care Utilization/Cost-Effectiveness Outcomes: Changes in medication use, clinic visits, and hospitalizations

Documentation of nutrition monitoring and evaluations should be:

  • Specific
  • Measurable
  • Attainable
  • Relevant
  • Timely
  • Comprehensive
  • Accurate
  • Dated & Timed

For more detailed information, check out the Academy of Nutrition and Dietetics: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Eating Disorders.

Traditional Eating Plans

Traditional eating plans focus on the nutritional value of food, such as energy, macronutrients, food groups, and recommended amounts (like calories or portion sizes). While these plans can be helpful for learning about food and how it affects us, they can also lead to disordered thoughts or behaviors around eating over time.

While traditional eating plans can be a useful tool, they’re not ideal for patients with eating disorders (ED).

Why Move Away from Traditional Plans for ED Patients?

Weighing, measuring, counting calories, and strict label reading can promote disordered eating habits. These types of eating plans can interfere with living a balanced life.

Instead of traditional diet-focused plans, which often involve precise measurements and counting, we recommend structured meal plans for ED patients. These plans help patients learn about nutrition, recognize their hunger cues, and meet their nutritional needs without falling into the dieting mindset.

Structured Meal Plans

Structured meal plans are ideal for ED patients. These plans provide a framework to help patients gradually move towards independent eating, where they can recognize their physical hunger cues and maintain a healthy eating pattern.

Benefits of Non-Diet Eating Plans:

  • Modified Food Exchange Plan
    • Focuses on food groups and serving sizes without strict counting
    • Encourages flexibility within guidelines, helping patients eat more intuitively
    • Provides structure without promoting restrictive behaviors
  • Plate Method
    • Educates on food groups, mixed meals, and how to create a balanced, nutrient-rich plate
    • Uses hand-based estimates for portion sizes, making it simple and less restrictive
    • Be sure to clarify guidelines to avoid confusion
    • Unlike MyPlate, this method is structured enough to support those struggling with eating enough and includes guidance on mixed foods and added fats
  • Pattern Guides
    • Focuses on food groups and adequate portions
    • Provides structure by assigning certain types of foods to meals or snacks

For ED clients, using a meal plan without discussing calories can be particularly beneficial. It’s important to first educate patients on food groups to ensure they understand how to properly fuel themselves.

Regular weekly check-ins are essential to ensure patients are following the plan, learning, and making progress. These check-ins also allow for timely adjustments to the plan, as well as close monitoring of the patient’s weight, health, and overall progress.

Plate-by-Plate Approach

Registered Dietitians (RDs) play a key role in eating disorder treatment by helping patients achieve better energy intake and variety in their diets for balanced nutrition.

Family-Based Treatment (FBT) is one of the most well-researched approaches for treating eating disorders. It’s divided into three phases:

  • Phase 1: Focuses on weight restoration and nutritional rehabilitation.
  • Phase 2: Gradually allows the patient to take more responsibility for their food choices.
  • Phase 3: Involves the patient and their primary caregiver working together to overcome obstacles, increase independence in food choices, and prevent relapse.

The Plate-by-Plate approach complements FBT and has three key elements:

  1. Primary caregivers take charge of all aspects of food selection and preparation.
  2. Portions are determined using only a plate—keeping it simple and straightforward.
  3. Variety and exposure to all food groups are emphasized.

This method helps patients experience what normal eating habits and patterns feel like.

Using Professional Judgment

When working with your patient (and their parents, if involved), start by discussing their history and screening for any eating disorder or disordered eating patterns.

Focus on understanding the main concerns of the client and how much structure they might need. Use your best judgment, based on the information you gather, to select the most suitable plan or combination of methods for them.

Progression

Principles of Good Nutrition for Eating Disorder Recovery

Adequacy ➡️ Balance ➡️ Variety ➡️ Moderation ➡️ Nutrient Density ➡️ Autonomy ➡️ Confidence

Pitfalls to Avoid

  • Assuming clients already know about food groups: Always start with a clear explanation to make sure everyone is on the same page.
  • Assigning eating patterns without considering habits or preferences: Tailor recommendations to fit each client’s unique habits and tastes.
  • Providing eating recommendations without detailed explanations: Help clients understand the “why” behind your suggestions for better adherence.
  • Giving calculations without real-life context: Make sure clients can apply the information practically in their daily lives.
  • Always requiring food logs: Use food logs thoughtfully and be mindful of their impact on the client’s experience.

Food Logs

Food logs can be a useful tool at times, but they’re not always necessary for every client.

When might food logs be helpful?

  • To increase awareness for clients who feel disconnected from their eating patterns
  • When there’s a mismatch between reported and observed behaviors
  • To track patterns in symptoms
  • To provide a sense of accountability and security

However, it’s crucial to use them in a way that doesn’t lead to obsession or stress. Balance and flexibility are key!

Use Structure as a Starting Point

  • Aim for Independent Eating: The goal is to help clients move towards eating independently.
  • Structure as Education: Using a structured plan helps educate clients and guide them toward this goal.
  • Understanding Physical Cues: Structure can aid clients in recognizing and responding to their body’s hunger and fullness signals.
  • Monitor Nutrition: It’s important to keep an eye on nutrition intake and patterns.
  • Medical Guidelines: Clients may need to follow specific guidelines for medical reasons.

Guiding clients from a structured approach to more intuitive eating is key to their success.