Registered dietitians

Some basics

• Restriction of food, dieting, or weight loss is not recommended for treatment of any eating disorder.  
• Any body shape or size can struggle with a severe eating disorder.  The size of the person does not determine what eating disorder someone might be dealing with.  Please do not assume what eating disorder (or behaviors) someone might be wrestling with based upon their body shape and size.
• Patients with eating disorders have often spent hours of their lives counting and tracking calories. Additionally, they often label foods as “good” versus “bad” or “healthy” versus “unhealthy.” This way of thinking leads to the restriction of food groups and a reduction in the amount of food consumed in a day. The results are weight loss, nutrient deficiencies, and a negative relationship with food. If we use this language during our visits, we are feeding into the eating disorder and affirming its voice in their mind. Our goal is to take the morality out of food and assign a neutral value to all foods. We want to avoid using the words healthy, unhealthy, good, bad, and calories when describing foods. Other ways to describe foods would be to focus on the taste, texture, and smell of food, how the food makes them feel (for example, energized versus tired), its nutrient content, and the energy/fuel it provides our bodies. 

Helpful vs harmful talking tips (for both providers and families) 

Helpful information to learn 

• Referring provider or primary care provider—request signed release of information from patient/caregiver(s) for care coordination
• Therapist (or other mental health providers:  psychologist, psychiatrist)— request signed release of information from patient/caregiver(s) for care coordination
• Medical diagnosis and any pertinent medical history 
• Mental health, including but not limited to: self-harm, suicidal ideation, anxiety, depression, OCD, and any other general mental health or diagnoses
• Any diagnosis or suspect for neurodivergence, ADHD, autism, borderline, bipolar, OCD
• Trauma, abuse, bullying, adverse childhood experience(s)
• Sensory concerns
• Previous and/or current eating disorder diagnosis/treatment
• Orthopedic issues or injuries, over-use injuries, including fractures and stress fractures
• Surgeries
• Allergies (and testing done when and how), intolerances, avoidances, special dietary concerns
• Menstrual history, last menstrual period, regularity, amenorrhea, and hormone use
• GI:  

- Bowel movements (constipation, diarrhea, any medication use, frequency of bowel movements, presence of blood)

- GERD

- Early satiety (fullness after eating minimal amount)

- Throwing up (frequency, method used, presence of blood)

• Weight/growth history:  highest body weight, lowest body weight, current body weight, desired body weight, and ages at these weights
• Thoughts and feelings about their body image or appearance
• Growth charts
• Medications, supplements, drugs, tobacco, alcohol
• School placement/level of functioning
• Family members living at home, friends, level of support
• Access to food
• Motivation level of patient and caregiver(s)
• Give patient opportunity to share why they believe they are seeing RD and patient/family goals of treatment 

Food recall

In eating disorder care, you will still ask for a detailed food recall .

Ask about the following:

• timing of meals/snacks, servings, brands, and amount actually eaten
• snacks, fluid, and caffeinated beverages too
• vitamins, medications, supplements

if they know how many calories their intake usually is:
we don’t recommend calorie counting but it is important to know if it is happening

if food logs/diaries are being kept by patient/family:
we do not want to encourage tracking apps; however, it is important for us to know if it is happening 

• See also below behavior section for additional prompts to ask regarding food intake/restriction

Learning about your patient’s behaviors

Behaviors are happening and it is our responsibility to ask in a gentle way about eating disorder behaviors, with no shame, judgment, or lecture to follow.  It is also helpful to understand the frequency, duration, and last time engaged in.  

Nutrition focused physical exam (NFPE) micronutrient possible findings: 

• Hair: alopecia and/or brittle hair - falling out more frequently in shower or hair brush, flag sign (alternate banding of dark and light colors in hair), lanugo (fine, soft, un-pigmented hair development due to lack of fat present on body to keep the body insulated)
• Eye: broken blood vessels in eyes, light sensitivity
• Mouth: cuts, fissures, swelling inside mouth (purging)
• Lips: cry, cracked lips
• Taste: taste aversions
• Teeth: tooth discoloration, decay, or sensitivity (may be a sign of purging due to emesis of undigested food and stomach acid)
• Nails: brittle or easily broken nails
• Skin: dry skin, petechiae (usually under eyes or on cheeks, may indicate purging), pitting edema in extremities, poor skin turgor, purple hands and/or feet, cold extremities, slowed capillary refill time, hypothermia, cold intolerance
• Hands: Russell’s sign (dorsal lesions are caused by repeated contact of the incisors to the skin of the hand that occur during self-induced vomiting).
• GI signs: constipation, diarrhea – may indicate laxative or diet pill abuse
• Swollen parotid glands (purging)

Nutrition restoration (weight gain)

The expected achievable rate of weight gain varies by treatment clinic; however, about a pound per week with weekly outpatient treatment is appropriate.  In FBT, it is not uncommon to experience more rapid rates of nutritional restoration, sometimes >3 pounds per week.  

Growth charts and “targets”

• Determining a “target” weight for kids and adolescents is difficult because they are in a state of growth and development; there isn’t an “arrived” spot.  Growth plots for healthy and growing children are expected to move upward with natural growth and development. 
• It is imperative to examine patient’s growth patterns and history before estimating where a patient may need to return to for health and healing from eating disorder.  It is just as important to reassess this estimate throughout treatment.

Please note:  disordered eating and body image distress typically starts at least 6 months prior to changes that can be reflected on a growth chart.

• Additionally, give careful consideration if you need to provide a “target” number or range since we know this number or target will be moving.  Sometimes simply offering “returning patient back to their pre-eating disorder percentile range” is sufficient.  
• For the health and safety of patient and family, please do not provide a weight suppressed “target” (a weight that is less than the child’s pre-eating disorder growth curve).  This has been found to be associated with worse health outcomes.  Full and complete nutritional restoration (weight gain) is crucial for treatment of an eating disorder.  
• Patient and caregiver(s) may benefit from being reminded patient is in a state of growth and development.  Treatment “targets” and nutritional needs will change with time as patient continues to grow and develop.

Resource videos can be found by searching online for:

• “Growth charts Musby” 
• “Eating disorders growth charts and goal weight made simple” 
• “Poodle Science”

Nutrition prescriptions 

Patients who develop eating disorders often have higher calorie needs than other adolescents. This is because when a patient goes a long period of time without sufficient nutrition resulting in weight loss, the body begins to compensate. The body’s metabolism will begin to slow down to ration any available energy from food towards life sustaining functions like pumping the heart, breathing, consciousness, rational thinking, movement, etc. However, organs like the brain and the heart can be significantly impacted, thus, resulting in slowed functioning. As the nutrition rehabilitation process starts, the metabolism may start to speed up to capture this new source of energy. This process may temporarily put the body in a hyper-metabolic state, so higher nutrition prescriptions to promote continued weight restoration is important. Based on growth trends, nutrition prescriptions can be adjusted as needed.  Noteworthy:  If the patient is not at risk for refeeding syndrome, then it is imperative to not underfeed the patient.  For more information on risk factors for refeeding syndrome please search: Academy for Eating Disorders.  Eating Disorder:  A Guide to Medical Care.   

Children's Wisconsin: estimating nutrient needs

• Energy:  EER (using ideal body weight or actual body weight) x PAL (low active, active or very active) for nutritional restoration

Use actual body weight if patient’s weight is >/=100% IBW

• Protein: RDA or 15-20% of total caloric intake (0.95-2g/kg) 
• Fat: 25-30% of total caloric intake 
• Fluid: maintenance needs per Holliday-Segar Method 

Other Example: 

• Energy: REE x 1.8-2.0
• Increase calories if not gaining weight/weight stable at goal calorie level

Basics

• Eating disorders are a life-threatening illness and require intense treatment and intervention.
• It is important to help families understand that they did not cause the illness nor did the child pick this illness.  
• It is also important for families to fight FOR the child.  
• Caregiver(s) are encouraged to take over all grocery shopping, menu planning, meal preparation, and plating of meals.
• Food purchased should not be diet/light/fat-free food/low sugar/low carb.  
• When food is prepared the child should not be in the kitchen.
• Caregiver(s) (or trained support) are responsible for supervising all meals and snacks.
• All meals and snacks are eaten while seated at a kitchen/dining room table or counter top surface (reduces the options for disposing/hiding food).

If a child has any form of purging behavior (self-induced vomiting, laxatives, exercise, etc.):  

• The bathroom should be used prior to eating and not again until 30 minutes following snack or 60 minutes following meal.  

If a child is taking an extended amount of time to finish a meal or snack, limit the time allowed to eat snacks to 15 minutes and meals to 30 minutes.  Often, as time to finish a meal or snack gets longer the child’s anxiety increases.  

• If food is not consumed within that time frame, then an oral nutrition supplement is provided.  If supplement is refused this may indicate need for tighter consequences or more support such as higher level of care.  

The 4C’s of meal support for caregiver(s) (Source:  Kelty eating disorders)

• Remain Calm. Children are typically stressed and sensitive to others’ negative emotions during meals. Staying calm helps foster a more peaceful and predictable environment.
• Be Confident. The more confident you appear the more reassured the child will feel.
• Be Consistent. Stick with what you’ve decided and don’t negotiate.
• Be Compassionate. Understand that they are doing something that is very difficult for them.Meal supervision and support search using:  “meal support Kelty eating disorders” 
• If meal support is needed at school-- check with what school resources are available, one staff person that is willing to sit with student and have general conversation (not about ED) or allow student to bring one friend and have an staff person oversee food consumption.

Family Based Treatment (FBT)—Nutrition

Historically, RDs were not part of FBT and still aren’t in traditional FBT.  However, many treatment teams and clinics are recognizing the value and expertise that a RD can offer being part of the FBT treatment team.  Some such areas include:  recommendations on nutrition prescription, contributing to restrictions/guidelines/recommendations with physical activity, growth chart interpretation, and establishing nutritional restoration targets/goals/benchmarks.  As well as providing eating disorder education and caregiver coaching and support.  FBT has three phases that the RD may be invited to help in:  

• Phase 1 – Focus on nutritional and health restoration along with behavior reduction.  All meals and snacks are plated/portioned/supervised by caregiver(s).
• Phase 2 – Continued focus on nutrition and health restoration (once some success has been achieved in this area), meals and snacks can slowly be returned to patient while teaching patient skills around food. 
• Phase 3 – Patient has regained food autonomy, working on issues outside of the eating disorder.

What are signs/behaviors an individual may display if purging?

Individuals who struggle with purging may display the following behaviors: 

• Frequent trips to the bathroom either during meals or right after eating. May also flush the toilet multiple times, running water from sink or the shower while in the bathroom to disguise vomiting, taking more than one shower a day to provide an opportunity to purge, using a lot of mouthwash or breath mints to hide the smell or a raspy or scratchy voice.
• May also develop spot damaged teeth and gums, swollen salivary glands in the cheeks and/or sores in mouth and throat.
• Laxative abuse
• Excessive exercise

Can you tell if someone has an eating disorder just by looking at them?

No, you can’t tell if someone has an eating disorder based off appearance alone. An individual’s appearance may not match the anxiety they feel inside when presented with food. Individuals who struggle with eating disorders also often have a distorted body image or are preoccupied with their physical appearance to the point that it is crowding out other thoughts. And from an outsider point of view, the individual may look “perfectly fine” or “healthy.”

When might an eating disorder patient be at risk for refeeding syndrome?

• If a patient is malnourished, starved, or underfed for 7-14 days
• If weight loss of ≥ 10% in the preceding 1-3 months (including patients that live in a larger body with significant weight loss). 
• If weight/length or BMI/age z-score < – 3 
• If NPO for longer than 5-7 days

What is the purpose of offering a variety of food to patients who struggle with eating disorders? 

Many patients with eating disorders will only eat a restricted range of foods. Sometimes this started as a way of eliminating just one type of food but then progressed to the point that it severely limits food intake. Consequences of a restricted range of food intake can include nutritional deficits, maintenance of weight too low for your body or getting stuck in a cycle of binging or purging. Each of these, in turn, could cause serious medical complications. Increasing the range of foods eaten is a primary goal for patients of any eating disorder diagnosis. A variety in diet can help improve food flexibility, improve nutrition intake and overall successful treatment in eating disorders.

How might an eating disorder affect the body physically? 

Over time, inadequate nutrition can affect the body in a multitude of ways

• Stunted puberty
• Affected menstrual periods. If an eating disorder develops before an individual with a uterus’ first period, periods may not start. For individuals developing eating disorders later, periods may stop.
• Anemia (low count of red blood cells) causing tiredness, weakness and dizziness.
• Stunted growth that could be permanent (i.e., height, bone development)
• Always feeling cold because the body has lost the fat it needs to keep warm.
• Stomach pain, constipation, and bloating.
• Dental complications – if purging
• Cardiac complications – bradycardia

What is the difference between overeating on occasion and binge eating disorder?

Overeating on occasion or on holidays, is normal.  By contrast, binge eating is the frequent consumption of a large amount of food associated with a sense of loss of control over eating. Binging is usually secretive and accompanied by feelings of embarrassment, shame, depression and guilt over the behavior. It often includes eating when not hungry, eating rapidly, and until uncomfortably full.

Nutrition intervention for patient in a restrict/binge cycle? 

Meal plan with structured eating opportunities throughout the day.  Include binge foods into scheduled meals and snacks.  

Should we acknowledge their weight trend since last visit or avoid discussing “the number”?

Will this information benefit the patient or the eating disorder?  Typically, this information is being sought out by the eating disorder and as someone progresses in recovery, we will hear less of this voice wanting to know numbers.

Do review of symptoms and/or lab indicators provide any motivation for patients? 

Depends on the patient.  For many patients, the drive for thinness can outweigh the concerns about their medical wellbeing.  For athletes, sometimes having to stop their sport or training can provide some motivation for nutritional restoration.

How to manage expectations for patients that are athletes, like a dancer or wrestler? 

Have to fuel to perform.  Gas for car to go.  It’s key to have caregiver(s) and coaches on board to follow through on boundaries.

How do you gently reflect that the presenting problem (example:  GI issue-loss of appetite, weight loss) may be related to eating disorder?

Affirm the symptoms and your patient’s experience.  Then ask permission to share what you are thinking.  Once permission is given then gently provide patient and family with symptoms that could be tied to the body getting insufficient fuel (such as:  decreased/loss of appetite, early satiety, SMA, GERD, diarrhea/constipation, heart racing, lightheaded/dizzy). 

What can the RD do in a short (10-15 minute) clinic visit, if there is suspect of an eating disorder?

Focus on the necessities of that clinic visit, find out what other providers they are seeing (specialty medical providers, therapists), reflect care and concern regarding what you are hearing and thank them for sharing.  Follow up with patient’s medical/therapy providers regarding your concerns so appropriate follow up can be established.  

Can laxatives be used for treatment of constipation? 

Osmotic (e.g., polyethylene glycol or Miralax) or bulk-forming laxatives are preferred over stimulant laxatives (e.g., Senna) due to risk of abuse and to the potential hazard of “cathartic colon syndrome.”

This meal plan is growing in popularity and is often the go to meal plan with Family Based Treatment.  Caregiver(s) are not expected to know/understand exchanges, weigh/measure, nor count calories.  Caregiver(s) (and trained support persons) would be responsible for all food purchases, cooking, portioning, plating, serving of the meal, and full supervision of meal.  (Through FBT, treatment team would provide direction and timing on when food independence would be shifted back to loved one with an eating disorder).  A great resource for providers and Caregiver(s) if using the Plate by Plate meal plan is “How to Nourish Your Child Through an Eating Disorder” by Crosbie C. and Sterling W.

General guidance the RD provides:

--Start with a 10” plate for all meals—try to have plate with no inner rim so that entire plate may be filled.
--Plate all food groups: 50% of plate with grains, 25% of plate with protein, 25% of plate with veggie or fruit, then add fats, and full serving of dairy.
--The entire plate should be filled, no empty space. 
--Plan for 3 meals daily and 2-3 snacks daily (2-3 food groups per snack)
--Include variety of foods that fit together, caregiver(s) have the ultimate final say in what the loved one eats.

For free visual graphic visit:  https://www.platebyplateapproach.com/product-page/how-to-follow-the-plate-by-plate-approach-50-starch

Example lunch: 

Cheeseburger on bun with chips or fries (50% of plate grains + 25% of plate protein + added fat from cheese), whole apple (25% plate fruit), glass of milk (dairy)

The entrée/side meal plan is an attempt to move towards more normalized language and thought about a meal and uses serving sizes (instead of exchanges).  

Start with an entrée and then build sides that fit with that entrée to form a meal.  An entrée is made up of three components:  2 grains, 1 protein, and 1 fat.  To visualize an entree example, picture a sandwich or burger:  2 grains (bun), 1 protein (burger patty or deli meat), 1 fat (slice of cheese or spread such as butter or mayo).  

Patients/Caregivers are provided education on serving sizes and food groups.  RD uses the nutrition prescription to build a meal plan per the general caloric value of these food groups.
Some food items could be considered a protein, dairy, or a fat; the important piece to remember is that foods cannot be “double counted”.  For example:  peanut butter could be considered a fat (1 Tbsp) or a protein (2 Tbsp), but if you wanted to count it as both a protein and a fat in a meal/snack you would need 3 Tbsp in that meal/snack.

Example lunch:  

Entrée (2 grains + 1 protein + 1 fat):  PBJ sandwich*.  (*Peanut butter and jelly sandwich would be made with 2 Tbsp PB [protein] + 1 Tbsp of either more PB or butter [fat])

Side:  chips (1 serving).  

1 dairy:  serving of yogurt.  

1 fruit:  whole apple.  

Another example:  

Entrée (2 grains + 1 protein + 1 fat):  1 cup casserole  

Side:  additional ½ cup casserole.  

1 dairy:  8 oz dairy milk.  

1 fruit:  whole apple.  

This meal plan is based on the diabetic exchange lists.  Food groups (grain, protein, dairy, etc.) are known as exchanges.  Numbers next to the food group indicate how many exchanges of that food group patients are required to have at that meal/snack.  Caregivers need extensive education on exchanges and serving sizes.  Caregivers are responsible for portioning/plating all eating episodes.  A RD uses a general caloric value of each food group to determine how many exchanges the patient would need to consume either per meal, or snack, or per day. (Exchange values along with portion sizes can be found by searching diabetic exchange lists.)  

Note:  Children’s Wisconsin inpatient eating disorder unit uses exchanges in order to provide careful refeeding structure for their acute patient population.

Example lunch:

3 grains:  bun (top and bottom bun) + chips (1 serving)

3 proteins:  ~3 oz burger (1 oz = 7 g protein/exchange = total of 21 grams protein)

1 fat:  (chips above count as 1 grain + 1 fat)

1 dairy:  8 oz dairy milk

1 fruit:  whole apple

Calorie prescribed meal plans are not typically advised; however, if caregiver(s) are already counting calories, we can use that “skill” to ensure their loved one gets adequate nourishment.  An important piece of this meal plan is to ensure that caregiver(s) are able and willing to do all cooking, plating, and serving of food; and that caregiver(s) understand that calories should not be discussed or disclosed with their child in any way.  Caregiver(s) increase portion sizes or added energy in order to meet the caloric prescription.  For families that are not engaged in calorie counting, it would NOT be recommended to initiate a calorie prescribed meal plan.

Example lunch:

Cook, serve, and plate child what family is eating.

Ensure that child is served portion of meal (including beverages) to total:  2500 calories

Food from the meal plan needs to be consumed.  When food is not eaten, a recommended practice is to supplement using a formula (or high calorie nutritious beverage) for the energy that was not eaten.  Commonly used supplements include: 

• Ensure Plus
• BOOST Plus
• Pediasure 1.5

Supplement protocols varies depending upon institution/clinic/caregiver preference; however, two common protocols may include (but is not limited) to the following options.