On diet

Did I startle you with that title? Ha! No, I'm not on a diet. The topic is diet! Dieticians, really.

Another person at AED this year was my friend, Therese Waterhous. Therese is a dietician from Oregon and over the years I've known her I think we both feel there have been positive changes in the field. She and I share a dual interest in helping individual families while trying to change the big picture, too, working within the professional field. We both also geek out on information: throughout the conference in Miami she and I would criss-cross and compare notes - we both love the science of it.

Therese is an example of an individual practitioner out there in the hinterlands working hard to create networks and teams to treat eating disorders and support families facing these disorders. She believes in a true team approach and has worked hard to instill that value in others.

But how common is this, and why does it matter? It's not common, is the problem. Much of what gets called "multidisciplinary team" is really just a couple of clinicians from different fields who refer patients to one another. As a parent and from watching parents negotiate these teams I can say that this rarely works well. The parents, who bank their time, money, and fragile authority with their child on consulting "the experts" only to find that the clinicians routinely countermand one another's recommendations, fail to differentiate their roles, and leave gaps of coverage of issues necessary to creating a full circle of support.

In an eating disorder specialist clinic the specialization and coordination are likely to be better than an outpatient team, but surprisingly often a family finds gaps or overlap or conflicting information there as well.

And what is the role of the dietician? (that's a technical term, and more accurate than the term I like better, nutritionist)  It's a question that I know Therese and others have had to struggle with. Most dieticians are not eating disorder specialists and in fact many have training and orientation that will make their advice actively harmful during eating disorder treatment - especially in an era of "healthy diets" and weight loss mania. Even in the specialty of eating disorders disagrees on the role of dieticians in treatment - Family-Based Maudsley treatment excludes that role entirely. But let's face it: food and eating and feeding are a basic part of ED treatment and few families have a hold on the how and the what and the who without some coaching and education - this is a natural role for dieticians who have specific, evidence-based training.

Many families I know find having a dietician on the team is really important, though they don't do it in the traditional way. Instead of having children and adolescents meeting directly with the dietician many families choose to meet as a family or to have only the parent consult the provider. Later in treatment, appointments often become more centered on the patient and become individual sessions as recovery progresses - still keeping parents in the loop.

I envision a new era of how dieticians work in eating disorder treatment teams: one like Therese advocates. One, working in a dedicated team that has coordinated responsibilities and shares a common orientation to the family. Two, where the family is appropriately central to the educational and accountability responsibilities. Three, using a family-centered approach even with older patients - according to need.


  1. though i never had family-based treatment, i definitely agree with this post. i had some of the best team treatment while outpatient, in my opinion. my therapist and dietician knew what their specialties were and weren't, and worked together to find what worked best for me. they also encouraged me to make my parents more involved, which i totally rejected for a while. i love that they didn't want me to make the parents the enemy, though i am/was old enough to technically leave them out of the picture.
    my team constantly touched base on my treatment and status. i wish more people could have what i have.

  2. My RD was the first member of my team. And if I had to choose only one person - RD, T, or MD to remain on my team, I would DEFINITELY choose my RD. She is up to date on the science of eating disorders, she's so easy to talk to and approachable, I have such an easy time being honest with her even when I don't with others, she has become not only my RD but also a therapist, a life coach, an inspiration. I trust her with all of my heart. She doesn't give out diety advice. She makes me feel like I am allowed to eat anything. She makes me feel safe to experiment with food. She helps me separate the ED brain from the other parts of my brain. She helps me recognize what getting hungry does to my brain and why it triggers restriction urges. She has empowered me with self knowledge and motivated me by showing me how to be the woman I want to be.

  3. This is particularly relevant for me, at the moment, as the next C&M film http://www.youtube.com/user/CandMedPRODUCTIONS is going to be about food, feeding, calories and menus and I was just about to post everywhere asking for people's help, opinions and views. It seems to be the second most asked question on the forum. Therese, if you are reading this, beware - I am going to pick your brains.

    Thank you, Laura, for once again reading my mind.

  4. I am proud (as in proud of my country and the committee who are organising it, it wasn't my own doing) to say that the plenary session at EDIC 2012 http://www.premierhosted.co.uk/Home.aspx will be about FOOD

  5. This post hit home for me - I have had frustrations with the disjointed team giving my daughter contradictory advice; the gaps in what gets addressed, and what gets communicated to parents (as in leaving it up to the patient to inform (or not) her mother that she had begun losing weight again....). I had to find the MD, the therapist and the nutritionist separately, and do not believe they had ever worked together before. Although they tell me they will speak to each other, too often the connections are not made. We are also finding out the hard way (see: losing weight again, above) that all the team members - and this includes the nutritionist - are focused on exploring D's emotions rather than on coaching her to eat.
    Laura, I like the vision that you and Therese Waterhous share. Here's hoping that it comes to be the norm.

  6. So pleased to see RDs getting some much deserved praise. Recently I've seen /heard a lot of comments saying they are not important members of a treatment team - it's just food, after all. I think the care and advice a good dietitian that specializes in eating disorders can have to offer is invaluable.

    The key of course is just that - "good" because just as in any profession, there are nitwits out there that give a poor name to the field and "specializes" because eating disorder treatment requires specific expertise no different than renal dietetics, diabetic dietetics, etc.

  7. We had a horrible RD who called herself as an ED specialist, but who used outdated methods and actively colluded with our d's illness. Our d was 10 at the time and the RD let her choose low cal foods and kept her on a very low calorie meal plan which we were not allowed to modify. We lost a good 6 months working with this person. She also told me my cooking was the problem (ha!) and that my husband and I needed to stop "pushing" our d. Unfortunately I have now spoken with several local parents who have gone through the same problems with this RD. Once we learned about FBT and started magic plate, things got better. Would I have appreciated support from a nutritionist who could help me come up with meal ideas? You betcha. Sadly, those RDs are far and few between.

  8. As an RD specializing in EDs, I'd like to add a few points. Our role is as variable as the clients, and the families, that present to us. Perhaps one of the most critical roles is identifying when our outpatient approach is failing--before their vitals do. An underfed patient can do little with even the greatest therapist, so in my mind, working on refeeding is number one.

    In spite of attempting to function as an outpatient team (which is very successful with the right combination of practitioners, using email, faxing, phone, etc, even in different locations), I often find my self at odds with the family in denial or with the uneducated physician, so I may end up being the first one off the team!

    I'd like to add, that all of my ED training was on the job, and under the wing of ED therapist when I first entered private practice 22 years ago. Perhaps programs now include better training in this area.

  9. I think RD's will vary as much as doctors do, some being--like Dr Waterhous (RD)-- completely up to speed and innovative in family based treatment approaches, others engaging in enabling and bargaining over fat free food items.

    Although we do not use RD's at Kartini Clinic and never have, I can easily imagine a multidisciplinary team where a particular RD serves as the team leader. It is very operator dependent. I believe that LeGrange does not use RD's either, not sure about Locke, although Stanford used to have a dynamite RD as team leader.

    We coordinate care for many patients, both giving to and receiving advice from Therese Waterhous about patients in our area. I admire her approach where she discusses food and meals with the parents rather than the child, in support of the concept of parents being responsible for providing meals.

    Perhaps, though, we need to manage family expectations about the role of RD's on any given team as I recently had a parent complain that Dr Waterhous "only" saw her and "never even talked to" her child---not understanding that her child was receiving state-of-the-art care from Waterhous while the parent was still operating under the old-fashioned expectation of the opposite.....grrrrr..

  10. It's an EATING disorder... how can there not be someone in charge of the food? I'm curious, how to teams without an RD keep track of the food and work with the food? I'm really surprised to know that the Katrini Clinic, a place I've heard astounding things about, doesn't use an RD. So why not?

  11. I'll let Dr. O'Toole respond on that, but highly recommend the Kartini website and O'Toole's book "Give Food a Chance" for a full understanding - I don't think a one-paragraph explanation does it justice.

    What it comes down to for me is that with Kartini the physician takes the role of dietician, and with FBT the parent does. The success of either depends on the skills of the doctor or the parents concerned. Not all doctors, and not that many parents, are ready to take that on without a structure and ongoing coaching.

    I see a future for dieticians to specialize in EDs and provide an important role - even a primary role - in eating disorder treatment. Right now, however, many dieticians do play a central role but without a team approach and without necessary training in evidence-based practices.

  12. Anonymous, in FBT the team is comprised of a therapist and MD at a minimum. If medication is used as an adjunct, a psychiatrist is involved as well. Food and eating is the main focus of treatment and those professionals are knowledgeable about the importance of nutrition and requirements for weight restoration and guide the parents in helping their kids eat enough (quantity and variety) to recover. Just because an RD isn't involved doesn't mean that food and eating are not central concerns.

  13. I fed my d before she developed anorexia and she ate really well -- a variety of foods, including fruits, pastas, veggies and fun foods like cake and ice cream. the RD that set us back introduced foods into our diet that we never ate before ED, like lo-calorie frozen yogurt, frozen turkey meatballs, Wasa crackers (European cardboard ;)

    Once I learned that I had been responsible for her food before ed and I could be again during her recovery, we reintroduced the foods she had eaten prior to ed.


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