Nutrition and Eating Disorders: A Shared Journey
My perception of nutritional wellness, nutritionists and the role of nutrition in recovering from an eating disorder has been a progression, a shared journey. Early in my practice, armed with scientific training and medical model concepts, I was geared up for providing patients with what I have come to call the “quick fix.”
Having acquired the scientific answers about food, nutrition, health, weight and how the body works, I was now qualified to help others improve their nutritional status. Patients came to me seeking advice. I was naive enough and they were desperate enough to believe that merely knowing what their body needed would catalyze their transformation toward health. My job would be to 1. assess their physiological status, 2. determine their nutritional needs, 3. calculate the correct percentage of macro-and micro nutrients to be included in the daily allotted calorie intake, 4. produce a food plan that meets these needs and 5. provide a brief assist in getting started. I bore the burden of responsibility and, in line with my training, thought that was what I had to do.
I had to take care of them.
The majority of people who show up at my office do so because they don’t feel good about themselves and have made the erroneous assumption that losing weight, wearing a smaller size or restricting their food intake will either make them feel better about themselves, give them a sense of control or make them eligible for a better life. They are people of all shapes, sizes, ages and gender seeking help for their eating disorder under the guise of nutritional counseling either because it feels safer and more acceptable or because they see me as another means to the ultimate end: thin, thinner or thinnest.
The eating-disordered patients I see – a mix of housewives, ballerinas, athletes, grandfathers, wrestlers, teenagers and models – cross all socioeconomic boundaries. In their search for information and magical answers on how to fill their internal void, these patients are continually seeking external expertise: the latest exercise guru, the best nutritionist, the newest diet plan. Most have long ago rejected their own inner knowledge, wisdom and life force. A common thread of low self-esteem, often no self-esteem, bonds them together. Those that seek the advice of a nutritionist are attempting to silence the inner orchestra of perpetual self-loathing by fixing the external package.
This exhausting struggle with food, weight and body image stems from their sense of worthlessness. Sufferers embrace popularized concepts of health and fitness and distort the data into rigid beliefs and behaviors that serve to preoccupy and distract them from their life circumstances. It is an all-consuming attempt to feel better about themselves, numb their pain, cope with feelings or punish themselves. They frequently become entrapped in extreme rituals which create severe physical and nutritional symptoms.
This eating disordered symptomatology which I was initially so eager to fix and change is not only a clever adaptation for survival but is a crucial means, often the only means, of communication. As destructive as it may seem to the outside world, the eating disorder is a mechanism of self-care and a measure of security. Working to change this is no “quick fix.”
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 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. There are food choices that have both sensual and sexual links. There are also food aversions and phobias. Often a person’s identify, worth or purpose is attached to his or her food choices. My early training did not prepare me for the psychodynamics I would encounter. My “quick fix” mentality was ineffective and, in many cases, detrimental.
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. The physiological component is determined by biochemical factors, such as nutrient deficiencies, blood sugar fluctuations, metabolism and genetics. 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.
The behavioral components such as bingeing, purging, starving and over exercising are patterns which evolve over time and have become routine ways of managing situations. All three of these areas need to be addressed to facilitate changes in eating behaviors and nutritional status.
I no longer bear the burden of responsibility. I view the treatment as a shared journey, a collaborative effort. The treatment requires a team of specialists, who have an awareness of the depth and magnitude of eating disorders. It is a partnership. Patients are the experts on themselves, their behaviors and thoughts. The nutritionist is the expert on physiology, nutrition information, eating thoughts and behaviors.
The therapist is the expert on the emotions and underlying dynamics that support the eating disorder. Other professionals, including physicians and pharmacologists are involved, usually with less frequency. Responsibility and answers lie within the patient, and the team is a guide.
Nutrition, the physical nurturance of the body, mind and spirit, is a reflection of personal growth. How one nourishes one’s self with food mirrors how one feels and cares about one’s self. Nutrition therapy helps our patients observe and understand how variations in their carbohydrates, protein, fat and caloric intake impacts their physical and emotional well-being.
Patients learn to recognize and meet their physical needs. Nutritional therapy includes the development of skills for identifying, satisfying and distinguishing emotional and physical hunger. It also provides tools for prioritizing time, money and energy so patients are able to meet their own needs as opposed to the needs of others.
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 the 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.
Crucial to one’s ability to change and successfully meet these challenges is the development of positive self-talk and affirming dialogues. Replacing the dysfunctional inner food dialogues and the unspoken message of the eating disorder with a strong and healthy new voice is an important goal of the treatment.
I have seen that successful changes takes place only over an extended period of time. It is a progression through phases of awareness, contemplation, preparation, actions, maintenance and ultimately terminating of the behavior. (Prochaska, Norcross & DiClemente, 1994). The nutritionist must provide a purposeful, safe, long-term and supportive environment for this process to occur. It is in this environment that patients will learn to become aware of, acknowledge, express, meet and tolerate their needs and feelings with food.
Years of working with eating disorders have changed the face of my work, the relationships I share and the roles that I embrace. At this point in my journey, my awareness of the connection between the mind and body is ever present when I listen to the language of food. I listen more carefully to what patients are truly saying through their food choices.
My work is much more intrapsychic for I see eating as a refection of who people are, as opposed to what they know. The idea that people could change their eating behaviors with only nutritional knowledge and a brief assist seems unrealistic now. The evolution of my nutritional beliefs, and practice has deepened over time. I have transformed as a nutritionist the way I am hopeful my patients will transform through observation, awareness, support, risk and discovery.
The goal of treatment is to move the patient from a place of worthlessness, where food choices are aimed at fixing oneself, to a place of self-loving and self-acceptance, where food choices are based on caring about oneself. Nutritional wellness is a lifelong process of listening to one’s needs. In my practice this is a shared journey of self-care, self-discovery and self-fulfillment – both mine and my patients’. I have furthered my training, sought support, took some risks and made many discoveries.
My patients have learned to challenge their fears and take back their lives. Our work still requires a large amount of education, information and knowledge, but I know now that it is the delivery of this knowledge, and the relationship which develops around this delivery, that fosters the healing, not the “quick fix.”
Prochaska, J, Norcross, C & Declemente, C. (1994). “Changing for the Good”-New York. William Morrow
Sondra Kronberg, MS, RD, CDN, CEDRD is the Founder and Nutritional Director of the Eating Disorder Treatment Collaborative. Author of the Learning Teaching Handout Series Manual recently produced on CD. Sondra speaks nationally on the prevention and treatment of eating disorders. Please visit www.sondrakronberg.com for more information.
Article originally published in the AABA Newsletter-Fall 1997.