Ambivalence about engaging in treatment is common among eating disorder sufferers and ranges in intensity. The individual with anorexia nervosa, bulimia nervosa or eating disorders not otherwise specified (EDNOS) typically dislikes having abnormal eating behaviors but is afraid to give them up. She is apt to approach nutrition counseling cautiously, perhaps insisting that she is already knowledgeable about healthy eating and doesn’t need to see a dietician. Yet there is more to learn from nutrition counseling than patients initially realize. Although information about the basic food groups is included, so are meal planning and the kinds of support and perspective that foster healthier, more realistic attitudes about food and weight. A positive rapport with a dietician can be instrumental in an individual’s journey to health.

First, the dietician obtains information from the patient and often, from her family. How long has she been attempting to lose weight? What specific foods is she eating? Does she engage in purging behaviors? Which kind(s) and how often? Is she involved in sports and other physical activities? How frequent and intense are her workouts? For the patient who is severely underweight, nutritional restoration is urgent in order to prevent or correct medical complications. Using growth charts where applicable and communicating with the other professionals on the team, the dietician establishes a healthy weight range for the individual and sets out to help her reach it.

Central to nutrition counseling is the theme of eating balanced meals, which means drawing from all of the food groups. In learning about the roles of proteins, carbohydrates and fats the individual begins to appreciate why an adequate intake of all these components is essential for fuel and health. Chances are the underweight individual has had trouble seeing her needs for food realistically. Thus, the dietician talks about energy expenditure as it relates to nutrition and weight, explaining that the patient’s intake of nutrients is below the recommended levels. And just as the heart, lungs, kidneys and liver require a baseline level of nutrition in order to function efficiently, so too does the brain. Such topics can lead to valuable dietician-patient discussion about physical and psychological changes associated with starvation.

Genes, the dietician emphasizes, play an important role in determining size and shape. The body is healthiest in its genetically programmed weight range (also called set-point weight) and strives to stay there. Eating habits and exercise do impact weight but to a much lower degree than many people realize. An underfed body tries to protect itself against starvation by slowing its metabolism (rate of energy production) and this adaptive mechanism can gradually lead to vital sign abnormalities and other physical symptoms. Psychological signs of starvation include increased depression and relentless thoughts about food, calories and weight that can interfere with concentration. The message that improved nutrition will help diminish these painful food obsessions helps motivate some individuals to modify their eating habits.

Misconceptions about food and weight are common. For example, it is not unusual for a patient to equate dietary fat with body fat. To address this, the dietician explains that calories that develop into fat derive from a combination of foods, not just from fatty ones. It is not unusual for an individual to deem some foods “good” and others “bad” based on fat and/or carbohydrate content. The truth is that there are no such categories. Yet many individuals, whether or not they have eating disorders, see dieting as normal and expected. Thus, dieticians often devote considerable attention to the reasons why dieting is counterproductive, and why it is important to eat three balanced meals plus snacks each day.

Other topics that may be covered in nutrition therapy include the recognition of hunger and fullness cues, difficulties eating in social situations, and the vicious cycle involved in bingeing and purging. Cognitive behavioral interventions that are introduced in individual and/or group therapy can be used in nutrition counseling. Thus, the patient practices reframing her negative food and body thoughts into positive, life-affirming ones that can help inform behavior change. Through empathy and through facilitating reflection about the advantages and disadvantages of disordered eating, the dietician aims to improve the patient’s readiness to change so that she can regain her health and go on to lead a full and productive life.