Wednesday, March 11, 2009

Dietitians and fat bias

This study, which shows that dietitians (like doctors) suffer from a significant amount of fat phobia, does not surprise me. Why should dietitians be different from any other group of medial professionals?

One or two sessions with a dietitian is really all it takes to learn the necessaries on nutrition for someone recovering from an ED. Yet our family--like so many others--was told to make weekly appointments with a nutritionist.

As it happens, the nutritionist we saw was not fatphobic; she was just ignorant about how to talk to my daughter. In fact she was a very tall and large woman who told Kitty, at our one and only appointment, "Don't worry, honey. I used to have an eating disorder too, and look at me now."

It was almost funny, really, except that it took hours of reassurance to get my daughter back on track.

Which is why I like to talk to medical professionals--not just about eating disorders but about attitudes toward fat, obesity, and "wellness" curricula in schools.

So if you know of a group of doctors, nurses, nutritionist, or other medical professionals in training or in practice who could benefit from a talk, let me know.


Emi at Project Swatch said...

I'm not surprised that many dietitians/ nutritionists are unhelpful, but mine is great. I'm currently recovering from bulimia, and she's been amazingly helpful - I am simply not capable of figuring out what I need to eat on my own, so we work together to come up with a plan made of foods I like that feels okay to me and that is nutritionally adequate. I have significantly increased what I'm eating and decreased my binging since starting to see her (yes, weekly).

I don't think she's fatphobic at all, either in terms of eating fats or gaining weight. I saw her today and she assured me that eating a whole avocado at lunch is a good thing, and not something that will have any negative repercussions on my health. She also encourages me to eat animal/saturated fats more, but they're harder for me. And, although my BMI is in the normal range - not close to underweight - she thinks I need to gain 3-5 pounds to be at a healthy weight. Of course, BMI is totally crap, but what I'm saying is that she isn't trying to say, get me to maintain a BMI of 18.5, she's trying to get me to eat more, enjoy my food, and maintain a weight that seems more natural to me, no matter what it is.

I'm not disagreeing with your post or the study - just wanted to note that in the midst of a lot of misguided medical professionals, there are some really amazing ones out there.

Harriet said...

I'm glad you've got a good one, Ellie! I know there are excellent nutritionists and dietitians out there--but the field does seem to lend itself to fat phobia, sadly.

Good for you!

Anonymous said...

As a former dietitian at an eating disorders clinic, I agree with you that the majority of dietitians are "fat phobic" outside of this field. In fact, I once worked with a patient who told me all dietitians outside of the ED world are "evil.":) (I don't agree but I thought it was funny.) However, I also don't agree that people being treated for eating disorders should limit their sessions to one or two. It often takes many more sessions to debunk all of the negative messages and misinformation that feeds an ED (i.e. carbohydrates and fats are bad, don't eat after a certain time, etc.) More importantly, patients need constant reassurance that their prescribed eating patterns are normal and need someone to push them to challenge themselves with new foods, social situations, etc. Dietitians also establish and monitor the goal weight, interpret weight graphs, strategize ways to decrease symptoms, discuss childhood eating patterns and influences, etc. While dietitians at an ED clinic are not psychologists, they are trained to look at things from a behavioral standpoint to promote change. Research has shown that a team (consisting primarily of MDs, psychologists, psychiatrists and dietitians) approach to treating eating disorders is the most effective. If someone is being treated using the Maudsley approach, their sessions may be cut back sooner rather than later but often parents can benefit from several sessions of education as well. (I know Maudsley doesn't recommend utilizing dietitians but most psychologists will admit they don't know enough or feel comfortable enough to solely educate the families about nutrition and effective feeding practices.) In short, everyone's treatment plan should be a little different but the majority of patients require several sessions with a dietitian. I'm sorry you had such a difficult session with your dietitian and that her comments about her own body and eating disorder undermined your daughter's treatment. I agree her comments would NOT be helpful to anyone struggling with an ED.

Harriet said...

You make good points, Anonymous. I think what you're describing is the ideal dietitian-ED patient interaction. I do think that most families know how to feed their children and don't need much in the way of nutritional info. In our case, the info I really could have used--the fact that my daughter would require 3 to 4 thousand calories a day during refeeding--did not come from the dietitian but from my own observations and from other families.

I don't know how most ED dietitians approach things, but I also worry that any talk of calories, portion sizes, etc., can be very triggering to someone recovering from anorexia. (Bulimia may be a different story; I don't know much about that.) In our one session, for instance, the dietitian made a fist and said something along the lines of, "That's the idea serving size for a piece of meat or fish." Unh-unh, at least not during refeeding. But I saw my daughter make a fist over her plate many times in the months that followed.

So . . . I don't know.

Anonymous said...

I think you're much more educated than the average person! Some our patients' parents also had eating issues and therefore required a bit more education. It sounds like you met with someone who wasn't trained to work with people with eating disorders. At my previous place of employment, we rarely talked about calories and tried to avoid numbers (i.e. weight) but did talk about portion sizes. I agree it may be helpful for some individuals but not others. We also slowly increased the meal plan (for people who needed to restore weight) to prevent refeeding syndrome, extreme GI distress or electrolyte imbalances. We explained that an initial meal plan was a guide until they could regulate their own intake on their own. Also, treating adults is quite a bit different than treating adolescents (something I didn't clarify in my last post).... adults didn't always have the support at home that your daughter does.

As a side note: I've often wondered how we as a society can teach nutrition without focusing so much on nutrients, calories, portion sizes etc. (I love Ellyn Satter's philosophy.) You wouldn't believe how many people on my case load stated their eating disorder was triggered by health class in school where they were asked to count how many calories they ate in a week, how many fat grams they consumed, and educated on how many calories were in a slice of pizza.

I enjoyed your comments. Thanks for your response!

Harriet said...

I enjoyed your comments too.

And yes, I would believe it. In my own anecdotal and informal survey of what triggered EDs in people, middle school health class was the number one culprit, followed by a stray comment from a peer.

Emi at Project Swatch said...

In response to the second anon comment, I actually like the idea of talking about portion size but not mentioning calories. At this point in my recovery, I need concrete guidelines on how much to eat - if my nutritionist says, "4 oz turkey" or "a cup of rice." That helps me both eat enough and be at ease emotionally that I'm not eating too much. Knowing the calories is just too hard - I could very easily add up how many calories/day I'm eating, but I'm resisting that because at this point that would just least to trying to eat fewer each day. My nutritionist counts my calories, i know, which is just fine by me. Figuring out the number of calories and translating it into a meal plan with portion sizes is her job; eating the meal plan is my job.

Anonymous said...

I loved anonymous' comments on the value of a nutritionist as part of the team. Working on the medical side of things, I see so much value added when the nutritionist is regularly meeting with the patient to discuss options. A lot of patients find it incredibly helpful to find different options that still taste good to them (as one of the most common things I see in recovering patients is a total lack of variety in the meal plan) I know I didn't get nearly enough education on nutrition in medical school, so I sincerely doubt even the caring psychologists involved in Maudsley really feel completely comfortable with those issues.
I do know, though, that nutritionists not used to work in this area can sometimes make big mistakes. As an undergraduate, I went to a nutritionist to get advice on how to eat "healthier" as I was running competitively. She gave me a little sheet with an 1800 calorie meal plan. I knew nothing about calories, so I set upon following the plan without any qualms. Within a couple weeks I felt exhausted, and my clothes were fitting quite a bit looser. So, I dropped the meal plan and headed back to my normal eating pattern. Knowing what I do now, I can see that an 1800 calorie meal plan for someone running 50 miles a week is ridiculous!! But at the time, I was so clueless.
So, all of that long story to say: I think nutritionists are an important part of the team if you can find one experienced in working with ED patients and their families.

Anonymous said...

In response to the anonymous former ED Dietitian.

I have been in inpatient treatment multiple times. I have hit very scary weights. I've managed to stay out of inpatient treatment for about 7 months now. My treatment center definitely took the approach of involving all the specialists they could. We all had individual Therapists, Psychiatrists and Dietitians. When I left treatment I ended up being able to work my Therapist and Dietitian on a private basis. Unfortunately I could not afford that for very long and then on top of that I lost my insurance. I didn't see a Therapist or RD for over 5 months. I was really trying and wanted recovery sooo badly, but little by little I started slipping again. I didn't realize how far down I had fallen until my finances finally worked out again and I went back to my Therapist and RD. I had been in complete denial. All in all I've been working with my RD for around 2.5 years now and sometimes I feel like I could be a Dietitian myself (LOL), but none of my knowledge means anything when I am consumed with that "ED" voice telling me that pretty much EVERY kind of food is bad for very specific reasons. It can sometimes feel impossible to get out of my head. My RD is constantly reassuring me that the thoughts are my ED and explains to me in detail why my beliefs are incorrect. I constantly need to be reassured that she will not make me fat. I need her. I can't fight those negative thoughts on my own. I've tried many times. I need her tell off my ED voice every now and then. I know from our years of working together that she doesn't just see me as some random client. She has seen my talents and gotten to know me through and through. I would honestly say just as well as my Therapist, if not better. She could be a Therapist herself. She cares about me as a person. She calls randomly just to check in between sessions. I know that the last thing she would want to do is harm me is any way. Although I constantly question her I have an immense amount of trust and faith in her. No matter how much I slip up and how many times I have given up on myself she has and never will give up on me.
I wholeheartedly agree that ED patients need to see an RD frequently. We may know all the nutrition stuff through and through (my RD jokes that I know more about how many calories are in foods than she does), but that intellectual knowledge just isn't enough to combat ED when his words start to tear me down.

Anonymous said... addition to my last post addressing the anonymous Dietitian...

I also wanted to comment on something else that was written. It is common knowledge in the ED world that RD's don't discuss numbers with their clients. I can't tell you how many times I tried to get info on my weight and all while in inpatient treatment and she never would tell me stating that it was her job to monitor that and not mine. The tough part about trying to recovery nutritionally from an ED is I know the numbers for everything. I can always manually calculate the caloric information in my own meal plans. I'm like a walking calorie counter and I hate it. Having been diagnosed with both Anorexia and Bulimia at separate times I can obviously say my eating disordered life has taken many turns. I will tell you though that it never mattered if I was in an Anorexic or Bulimic phase I have always obsessed over the numbers. ALWAYS...I would give anything to be able to unlearn all of those damn numbers.

Anonymous said...

I have to agree with earlier poster. I am a masters' level RD and have worked with ED recovery programs. We did not discuss weights or numbers with clients, IN GENERAL. There are a few select situations where it was necessary, but for the most part, patients were not given that information because they are numbers-obsessed to begin with. Our job was to educate patients on the role of macro and micronutrients in the diet, the purpose of these nutrients and how they helped repair and replete the body. We discussed intuitive eating, satiety vs. hunger, etc. Some RD's really shouldn't treat those with ED's....I mean, it's a highly specialized area. Would you go to a nephrologist for your broken arm? Or would you see an oncologist for your heart condition? Same with RD's...most specialize in something, so I'm sorry if you had a bad experience, anyone, with an untrained RD or someone who really doesn't understand ED's. There are many GREAT dietitians out there who really 'get' it.