Nutrition Therapy at the Beginning of Residential Treatment

By Jodi Krumholz, RD, LDN

When a patient first comes into residential eating disorder treatment, the  dietitian performs a very thorough assessment.  We ask a patient about their ED behaviors as well as their weight history. We also want to know if they engage in food rituals such as cutting their foods up into small pieces or eating foods in certain order.  The assessment is an opportunity to really understand a patient’s history as well as figure out who their main support will be when they return home. As residential dietitians, we work diligently to include family and friends in nutrition sessions.  We educate them on how to support their loved ones nutritionally upon return home.

From the first day of treatment, every patient is started on a well balanced meal plan that includes a variety of food groups at each meal.  For example, a meal might include a turkey sandwich with cheese and mayo as well as a cup of fruit and a side salad with dressing. Residential patients may also be started on snacks or supplements like Boost Plus depending on their caloric needs.  One of the biggest goals is to introduce patients to “normal eating.”  Therefore, we serve a variety of cuisines such as pizza, Mexican, Greek, Asian, etc.  We have all patients eating at least 3 desserts weekly because we want to show patients how desserts can fit into a healthy lifestyle.  We teach what normal portions look like based on the USDA guidelines.  Regardless of whether someone is obese or underweight, the goal is to teach all patients what normal eating looks like and that all foods can fit into a healthy lifestyle.  We will accommodate allergies or special diets as needed.

Patients start out in treatment selecting food from a specific menu and then all meals are portioned out and placed on the table when patients enter the dining room. We have staff present to monitor that patients are completing meals and not acting out on any eating disorder behaviors such as hiding food, restricting, etc.  If patients are engaging in behaviors, they would be moved to a separate dining room where there is closer monitoring.  As patients in treatment are meeting nutrition expectations, they are able to progress to walking  through the serving line and choosing their own meals with the assistance of a dietitian.  They can practice asking for the portions they need as well as serve themselves from our salad bar.

Through the use of food journals we assist residential patients to see that their symptoms (i.e., restricting, binging, purging) are really just a way to avoid uncomfortable  emotions. We work closely with our patients in individual sessions to see how emotional experiences influence behaviors and actions. For example, we might look at how a patient restricting a meal in treatment reduces the anxiety or guilt they experience in the short term.  However, we help them to see that overtime in their attempt to relieve these emotions they end up feeling worse about themselves and staying stuck in a vicious cycle.  Patients journal about their meal and emotions throughout the entire day.  Patients learn a lot about themselves this way and the residential dietitians use these journals in sessions as an important tool in teaching patients how their emotions impact the ED. This is a skill that is very unique to a well trained residential ED dietitian.

As dietitians, we have weight goal expectations for patients who need to gain weight (less than 95% IBW) but we never focus on weight loss.  Patients who have previously binged will naturally lose weight from eating normally, but we keep the focus on normal eating and not weight loss.  We look to teach everyone that all foods can fit into a healthy lifestyle and to take the emphasis off weight. Most of the patients are extremely disconnected from their hunger and fullness and will need to eat “mechanically” and follow a meal plan for a long time to come. As part of their experience, we will begin to take them to restaurants and teach them how to prepare well balanced meals for themselves.  We will also practice grocery shopping and have more advanced residential patients take passes to practice eating out with family and friends.

The residential experience is truly a unique one in that we are working on a variety of skills a patient will need to be successful.  We are also implementing  a  lot of structure around mealtime that we want to have incorporated at home. The dietitians work very closely with other team members to help patients eliminate behaviors and understand the function of these behaviors. We believe this paves the way to a successful recovery!