What is an expert?

With heart disease there are cardiologists. Diabetes: endocrinologists. Who is in charge of eating disorders?

We all hear that eating disorder treatment involves a multi-disciplinary team approach. The most common members: psychotherapist, physician, nutritionist, and psychiatrist. But who leads the team? And how many patients actually work with a coordinated team? How effective ARE these teams? In my observation the dream of a coordinated team is a fantasy: very few families encounter one and rarely for long.

I also worry because parents don't know that anyone can call themselves an eating disorder specialist or expert. It is, largely, a self-designation. There is no license, degree, or common training. Professionals are licensed in their field, none of which have a specialty in eating disorders.

Eating disorders occupy a rather unique position: they are considered psychiatric but the medical consequences of the behaviors bring on additional mental and physical symptoms. Physicians struggle to deal with the psychological barriers to compliance. Psychotherapists struggle to cope with the medical aspects. Nutritionists are often treated as secondary or tertiary to the team’s work yet are in charge of perhaps the most eating disorder specific symptom: the food.

One idea would be for a new specialty: a multidisciplinary eating disorder specialist. This would be a specialized field within one of the allied professions treating eating disorders. This would allow for professional licensing standards, specialized training, and accountability.

Another idea would be for specific training and certification to exist in every field involved with ED care. Both these options would take time to create and disseminate.

There’s another option, however, that would be possible much sooner: shared protocols. If protocols for medical, psychiatric, nutritional, and psycho-therapeutic elements of care were created and adopted across fields and countries we could improve treatment and strengthen the impact of all clinicians. This would benefit patients and their caregivers who would also have access to these protocols.

I'm interested in thoughts on this out there.


  1. you bring up many excellent points. As a physician who cared for the medical side of things, and often was the only provider the patient was seeing :( there is definitely room for improvement. Would the team leader be a therapist? an MD? a PA? Team meetings are hard getting everyone together, and likely not "cost-effective" (ahem)
    I like the idea of protocols, but who would write them? There would need to be a different one for different diagnoses. AN vs BN for example, and how to deal with individual complexities? At least a framework or decision tree? Perhaps something built into the medical record. Like at the VA, if the BP is elevated, it forces the clinician to click off that she has noted it and click on a course of action. Maybe something like that to cover more bases...
    Just a few thoughts... I like this train of thought. A one year fellowship? (I know palliative care has recently developed fellowships...)
    Keep this train of thought going. You are on to something. A tool for the rural nurse practitioner who could get the ball rolling in the early critical days with a decision tree?

  2. I guess this would be different for different people, but for me, an eating disorder specialist probably wouldn't be much help. My eating disorder is a coping mechanism for dealing with depression and anxiety. For me it isn't its own discrete illness, but a symptom of depression and anxiety. To focus on the eating disorder so intensely is to miss the point. Yes, it absolutely needs to be addressed, but it is the depression that needs the focus. It would be like treating an infection with painkillers and fever reducers instead of antibiotics. It is more likely to cause me to be misunderstood than I already am if the focus was more on the eating disorder like that.

  3. I like the idea of shared protocols Laura :) However, it would be necessary in the first instance to develop a protocol that benefits the majority of patients. Therein lies the problem.

    There is a range of personality types across EDs, including within the individual subtypes. There are different triggers (social, interpersonal, intrinsic, hormonal, metabolic etc.) which influence the presentation of the ED. For these and other reasons it's difficult to devise a one-size-fits-all protocol.

    It is interesting that the role of the nutritionist/dietician is often considered relatively minor. I have a friend (dietician) who specialises in ED treatment. She always emphasises the primary role of re-feeding (anorexic patients), attainment of a healthy weight, regular balanced meals (etc.) as being paramount to recovery. I agree with her. She works closely with ED patients offering also encouragement, support and CBT.

    Glad you had a fruitful time in Salzburg. It sounds as if it was a very interesting conference.

  4. Laura--Did you read this link from Autism Speaks? http://www.autismspeaks.org/science/programs/atn/index.php
    It was what I was referring to as needed in the world of ED's (in my note on ATDT's summary of LV Seminar)

    This is EXACTLY what they are doing in the field of autism--sharing protocols.


  5. In Canada at least, a psychiatrist who specializes in EDs HAS usually done a residency in an ED unit. This is similar, though not always completely true, with social workers and psychologists.

    The program I went to (and I still see the dietican, therapist and psychiatrist from this team)"the team" were always on the same page and although the psychiatrist was the medical director, I think he often deferred to the judgement of other professionals in matters outside his speciality.

    It is essential to have a multi-disciplinary team for EDs. When I first relapsed I was angry that my therapist couldn't make me recover -- but really, her expertise lies in psychotherapy as opposed to medical intervention or nutritional rehabiliation. When I began to see a dietican/psychiatrist things became much easier as the three professionals work together but manage different aspects of the disorder. They acknowledge the limitations of their speciality.

    I would say my dietican has played a VERY major role in my recovery. That said she is NOT ED trained and worked as a medical dietican before switching to eating disorders. I find her approach compassionate but firm and definately logical. She does not make the mistake of giving a sufferer too much information regarding calories, etc and is tactful in eating disorder matters. I've seen ED dieticans who SUCK, so training does not ALWAYS equal a better professional.

    My therapist could not guide me in upping my food intake and overcoming food challenges. She wasn't equipped to do that. My psychiatrist could not do this because I only saw him every 6 weeks and for 30min at most. My dietican has been an essential part of my behavioural change, at least with eating, while my therapist has allowed me to work on my depression, anxiety and distorted thinking.

    If a team is to work effectively, all professionals must acknowledge that no one is superior. Or rather, EVERYONE is superior within their own speciality.


  6. I want to point out that the 'range' in autism is similarly vast--yet, if they can create shared protocols that are effective, then the ED treatment world should be able to do likewise.

    And, as Cynthia Bulik once said to me, if an ED was a coping mechanism for anxiety/depression, then why wouldn't you JUST have depression or anxiety alone?? Why add an ED into the mix too? Something else has got to be going on here (she said it better than I'm saying it).

    You need to focus on both if they co-exist, but I'd argue the ED first as weight restoration and brain healing will often (not always) help depression resolve. If it does not resolve with weight restoration, then treating the depression is also needed. If you don't treat the ED, then neither the ED symptoms/behaviors nor the depression are likely to abate.

  7. The great Lefty Kreh, in one of his fly fishing videos broke down the definition of an Expert thus:

    An X is an unknown factor and a Spurt is a drip under pressure.

    I doubt this furthers the conversation much, but you would be amazed how handy it has been to have this explanation at hand when one meets an intolerable fool.



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