FOUR: Paradigm Shift is long over due in Eating Disorder Treatment
I love to read scientific articles and attend conferences like ICED to learn about the latest research in the eating disorders field. This article by Stuart Murray spoke to the need to look beyond weight as an indicator for recovery. We should never assume that weight-based recovery is a proxy for broader cognitive recovery. This is not supported by evidence. This has been a motivation for me in my clinical work in the development of the Eating Disorder Global Evaluation (EDGE). I strongly recommend the use of symptom assessment in both the physiological and behavioral realms. The EDGE is not yet validated and should be used along with the EDEQ.
The EDGE instrument allows clinicians within 5 minutes to identify symptoms. I recommend that it is used this at baseline and every three months during treatment. The beauty of the form is that noting frequency can score symptoms: daily, weekly or in the last month. These scores typically reduces with nutritional restoration and time in treatment. Often residual behavioral symptoms are targeted during phase 2 and 3. Since anorexia nervosa is ego syntonic and our clients could be very young; providers can utilize dual or parent-report observations of symptoms.
Why use the EDGE instrument in your practice?
THREE: Know and Practice your FBT Assumptions
RDNs who interact with parents, professionals and clients need to operate and communicate with five key FBT assumptions. It is vital that professionals remain consistent with what we say in our counseling sessions and in our written communication to the treatment team.
1. Do not focus on the why (Agnostic view of causation).
“Instead of focusing on why this happened; can we use our time to focus on solutions?“
“You did not cause this illness.”
“It was a perfect storm.”
Maintain a “no-blame” stance. Guilt leads to immobilization. Empower parents and help families see their strengths or enhance their skills. Join with family and collaborate to combat the eating disorder.
Eating disorders are genetically influenced by personality traits and cognitive patterns that reveal core biological risks factors. Direct to resources on neurobiology, genetics, and the Ancel Keys research.
2. Externalize the eating disorders.
“Your child/adolescent/teen has been hijacked by ED and she is under the influence.”
“If your child had cancer you would insist they takes their medicine.”
“Food in the medicine for malnutrition.”
The eating disorder is viewed as separate from the child or as an outside entity (like the diseases model in which the disease is not seen as the person). The eating disorder is the problem not your child.
3, Parents are experts on their child. RDNs serve as consultants.
“You know how to feed your child.”
“Your commitment to their recovery is key to their success.”
“You have successfully fed your older/other children with success.”
“Would you be interested in nutrition resources?”
“How can I be of help?”
RDNs who offer parent coaching; referred to as parent intensive counseling (PIC) or Parent Assisted Meals and Snacks (PAMS). Encourage re-integration of previously consumed foods and caloric density. Offer support with food planning as needed. This is done in a non-authoritative way.
4. Empower Parents and caregivers.
“You are doing a great job with….”
“Your child’s health and nutrition must come first.”
“If I were to write a check at the end of the month for the work you are doing for your child it would be over $?0,000 dollars.”
RDNs may feel more comfortable with a direct approach in nutritional counseling. We need to pivot to offer coaching and empowerment. We can address nutritional beliefs that are barriers to recovery. We can support parental empowerment and build confidence through competence. Assist parents in understanding how current food practices affect weight progress.
5. Initial focus is on weight restoration & symptom management.
“From the EDGE results I am concerned for your child’s health.”
“I am seeing some red flags (physical symptoms) and without an increase in food and nutrition we may need a higher level of care.”
“Everything stops until they eat.”
Use the shock of the parents to create a therapeutic bind to create energy, urgency and momentum for nutritional rehabilitation. Provide a simple explanation on metabolism to help parents and possibly the mature teen to understand the consequences of poor energy balance and what symptoms reveal. Validate progress as you see symptoms improve with weight restoration and adequate nutrition.
For more information on how the RDN can implement FBT informed treatment.
Save your spot for the fall webinar series by Melanie
RDN need to be prepared to strengthen the team that is not FBT informed or trained. In rural communities RDNs may find themselves as the most seasoned expert in adolescent nutrition and eating disorders. This work is not for the faint of heart. Build relationships and use documentation as way to educate and train others on the approach. Build a team that works in concert to bring about the best results and resist splitting due to misunderstandings or miscommunication.
TWO: Instill a unified approach and communication style with medical providers, therapists and parents.
2. Provide websites and reference to help the team understand the phases of treatment.
3. Share this article with MD's and pediatricians.
4. Strengthen yourself by getting supervision, training and mentoring.
Family-based treatment (FBT) originated without Registered Dietitian Nutritionist (RDNs). Many RDNs are now finding themselves either being asked to contribute to a treatment team who uses FBT or are interested in launching the FBT principles in their work with adolescents who have eating disorders. It makes sense to me to follow the only evidence-based treatment for adolescence with eating disorders. My hope is to share my wisdom gleaned over the nearly 10 years working with a collaborative team in an outpatient setting. RDNs are well positioned to coach parents in the vital task of in-home re-feeding.
Here is my top 10 things to know, use and expect... One at a time.
ONE: Identify potential team members
- Discuss who will discuss and make exercise recommendations.
- Review protocols for checking clients who are at medical risk.
- Agree on treatment weight goals.
- Do you have their cells phones, emails and fax numbers?
- Know your residential or IOP options
- Suggest discharge meal planning happen directly with the parents not child or adolescent.
if I think back to why I originally became a registered dietitian it was because I knew that this career would allow me to spend time with my family and work. In 2015 everything came to a halt with my busy private practice Nutrition Therapy in Troy Michigan. My husband who works for Ford Motor Company was asked to take an assignment and Chongqing, China.
It has truly been a life changing adventure! I have a new perspective. I understand food In the context of the culture you live in I see the world a bit differently. As my sabbatical has officially ended. I am at a crossroads. I am asking myself how can I best use all my talents, abilities and expertise in eating disorders and yet keep this beautiful balance the “sweet spot” of caring for your children. The children who grow up so fast.
Melanie Jacob RDN is a seasoned eating disorder professional that found her niche in treating adolescents with eating disorders. When the FBT research surfaced in 2006 she transitioned her approach to follow the evidence.