Healing your relationship with food from the inside out.
Dr. Anita Johnston explains the hidden meaning behind one’s relationship to food and eating and how this can aid in the process of healing from an eating disorder.
It’s essential to incorporate nutrition therapy for eating disorders into a holistic eating disorder treatment program. With nutrition therapy, patients gain the knowledge and tools they need to effectively meet their nutritional and nourishment needs in the process of recovering from their eating disorder.
Nutrition therapy is a vital component of a comprehensive treatment for eating disorders. A treatment program is best delivered by a multidisciplinary clinical team, which consists of our psychological, medical, and nutritional specialists with particular interest and background in eating disorders. A competent nutritionist or dietitian plays a key role in helping a patient deal with the nutritional as well as medical issues that can result from disordered eating behaviors.
During the initial stages of treatment, nutritional support is more structured. A Registered Dietitian or nutritionist closely works with the patient to set personal goals and design individual meal plans. As the treatment process progresses, such goals and meal plans are updated as the patient gains and applies useful skills and better health habits.
A patient’s mindset, behaviors, and nutritional needs evolve throughout the treatment period, making it crucial to have regular consultations with a Registered Dietitian in order to discuss necessary adjustments. In our residential eating disorder treatment program here on Maui, all of our patients receive nutrition therapy for eating disorders on an individual basis at least once per week, as well as interacting with our dietetic staff regularly through nutrition groups, during food outings, and also at supported meals and snacks.
Here at ‘Ai Pono Hawaii, our nutrition therapy for eating disorders takes into account the entire person, and helps each develop better relationships with nutrition, body image, mindset, movement, and other important aspects of their life.
We believe that all effective treatment programs for eating disorders—at whichever level of care—depend on a collaborative interdisciplinary process that puts the patient at its center.
Nutrition therapy for eating disorders helps patients in managing their medical conditions and/or other physical or nutrition-related symptoms that result from their eating disorder. Patients are often unaware of how their eating disorder has changed the functioning of their bodies.
Eating disorders can often cause nutritional deficiencies, dehydration, and/or digestive issues which may significantly affect their health. In our program, we discuss various health issues that can arise or be worsened when individuals fail to absorb the right nutrients, at the right amount.
Before commencing residential treatment in ‘Ai Pono Hawaii, our patients are required to go through an extensive medical clearance process in which they are thoroughly evaluated by our licensed physician. This helps us learn the impact a patient’s eating disorder has on their body, and enables us to provide the right support for each patient.
Our residential program in Maui provides intensive and comprehensive nutrition therapy for eating disorders, along with 24/7 nursing support. However, if a patient is severely malnourished or deficient in certain nutrients, we may recommend that they undergo a period of medical stabilization before beginning residential treatment in an inpatient or hospital setting.
The components of our nutrition therapy for eating disorders include performing dietary assessment and screening for eating disorders; instructing patients on what dietary changes may be advised to meet the required nutrition needs of their body; educating patients on how to develop healthy behaviors and attitudes toward food and/or eating; and guiding them on how they can connect with their community and build trustworthy support systems to help them in their healing journey, among others.
Education and behavioral counseling are fundamental elements of nutrition therapy.
Our nutrition specialists and therapists with work patients to “tease apart” physical hunger from emotional hunger and regain trust in their bodies and intuitions. Unlike typical nutritionists or dietitians for the general public (who mostly teach about nutrition and create meal plans for their clients), our nutrition therapy specialists immerse patients in self-discovery by challenging their food-related thoughts and behaviors. In addition to debunking myths surrounding nutrition, they ensure a non-judgmental space for patients to talk about, examine, and reframe their dysfunctional thoughts and behaviors.
Patients with eating disorders may have irrational thoughts about their body and food, but within the framework of the eating disorder these thoughts seem logical or natural. ‘Ai Pono Hawaii’s dietary team guides patients in challenging and reframing their misconceptions, false beliefs, and unsustainable attitudes related to food, while offering useful and accurate information on food, nutrition, and metabolism to support patients’ recovery at the same time.
By doing this, patients can eventually form a healthier and more beneficial relationship with food, nutrition, and their own body. Our dietary team is also equipped to offer interventions in clinical nutrition and treat or manage health issues that are linked to eating disorders. Our 24/7 nursing support and regular monitoring of labs further supports the nutritional restoration for our patients.
Patients in our residential treatment center may gradually internalize our nutrition specialists’ words, replaying them in their mind whenever they face a challenging situation that provokes them to resort to disordered eating behaviors. By repetition and constant internalization, our patients grow to turn those repeated, healthy messages into their own mantras that support a better way of living.
Relevant medical history (including family)
Medications and over-the-counter supplements being taken
Weight history (this can also be requested from the assigned medical doctor)
Diet history (including allergies, past diets, nutritional issues, and so on)
Diet recall (list of foods and drinks that the patient has consumed)
Behaviors related to eating disorder/s
Physical symptoms
Current lifestyle
Concerns and questions about food, eating, or health
Likes and dislikes (or fear foods v. safe foods)
Hopes or expectations from nutrition therapy
Experience (if any) collaborating with a nutritionist/dietitian
What motivates them in their recovery journey
The importance of vitamins, minerals, and other nutrients
The natural power and capacity of our bodies to arrive at balance, if we allow ourselves to listen
Ways to recognize their fears or other unpleasant emotions regarding specific foods
The importance of their “feared” foods to their body
How their eating habits are influenced by their emotions, and vice-versa
The metaphorical meaning of the foods we crave and avoid as well as the behaviors we engage in
Many patients who suffer from eating disorders begin receiving treatment with a lot of hesitation, especially when they’ve been suffering for years and have tried multiple times to heal, but to no avail.
With this in mind, our eating disorder recovery center’s team of nutrition specialists usually also provide motivational counseling to support patients who want to implement necessary change. We do this by working out the motivators of each patient and reminding patients of those throughout their recovery journey, particularly at the toughest times.
A skilled dietitian or nutritionist will determine what motivates their patients and help support them through difficult changes. We believe that while each patient should consciously choose to heal from their disorder, recovery itself takes a lot of effort and time, and inevitably comes with fear and uncertainty. Both of these are normal and need not be avoided for true healing to occur.
In our more than three decades of experience as an eating disorder treatment center, we observed that many patients suffer from deficiency or imbalance. These deficiencies and imbalances may be present in various eating disorders—not simply in patients who are primarily restrictive or in those who engage in purging.
The minerals that are most commonly deficient among patients struggling with an eating disorder are zinc, copper, iron, and selenium (3). Iron deficiency may lead to anemia, while selenium deficiency may lower one’s immunity and hamper one’s ability to regulate moods.
For vitamins, the most commonly deficient among patients struggling with an eating disorder are vitamin D, vitamin B1, vitamin B9, and vitamin B12. Low levels of vitamin D are strongly associated with lower hip bone mineral density, the most common chronic complication in anorexia nervosa [3]. This can cause various long term effects like osteoporosis, osteopenia, and higher risks of sustaining fractures and breaks.
Evidently, insufficient levels of vitamins and minerals have negative effects on a patient’s physical, mental, as well as emotional wellbeing. Therefore, it is important to receive treatment in a center that has trained and experienced professionals who can evaluate the patient’s eating disorder using multiple lenses. Moreover, the said professionals should work closely and directly together as a team in order to provide a more complete and cohesive treatment plan for each patient’s recovery.
Patients with eating disorders may also suffer from low electrolyte levels as a result of purging episodes and/or the abuse of medications such as diet pills, laxatives, and diuretics. Electrolyte disorders can cause hypomagnesemia, hypokalemia, and even sudden cardiac arrest [4]. Laxatives can lead to fluid retention and cause edema [6].
Our eating disorder treatment center regularly monitors for edema or fluid retention, because these may be signs that a patient requires immediate medical attention. Hydration may also be compromised because of fluid restriction or avoidance due to a patient’s irrational fear of weight gain.
Our nutrition professionals here in ‘Ai Pono Hawaii recommend patients to undergo complete blood work to obtain a complete picture of what impacts an eating disorder may have had on the body. Their results help us in assessing if there’s a need for supplementation and guide us in designing meal plans that are best suited for their individual needs.
We believe that in order for nutrition therapy for eating disorders to be truly effective, it needs to be individualized, with the patient at the center. For us, no two patients are alike, despite having the “same” eating disorder. Each patient has unique fears and beliefs and, thus, presents a unique medical and psychological case.
We work with each patient in recognizing their clinical symptoms, attitudes, and food beliefs. Then, we support each patient by providing corrective nutrition education based on facts, while challenging their erroneous beliefs regarding food, and nutrition misinformation. Many of those beliefs overlap with negative childhood experiences, so our treatment program usually involves working with therapists to tackle their somatically engrained traumatic experiences [2].
A meal plan is an indispensable component of eating disorder recovery. It serves as a framework for a normal or healthy eating pattern. Members of our dietary team here in ‘Ai Pono Hawaii will create a meal plan that’s customized for each patient’s unique needs.
This meal plan acts as a structure and external guide for our patients. Many patients who suffer from eating disorders are unable to recognize natural hunger cues in their body, which leads them to eat absentmindedly. The meal plan is similar to “training wheels,” helping each patient to gradually relearn their natural hunger and fullness cues, until such a time that the meal plan is no longer needed.
Meal plans (sometimes called food plans) categorize foods that have similar contents in terms of energy, macronutrients, and micronutrients. An effective meal plan is one that’s designed to meet a patient’s unique energy and nutrient needs, organizes and guides food consumption, and dissociates foods from a patient’s fears, binges, or purging.
Initially designed to meet the patient’s energy requirements
Targeted for meals and snacks
Customized with stepped changes done to match each patient’s current food intake
Easy to understand and follow
More flexible as patients see progress in their recovery journey (i.e. providing opportunities for patients individually plate and portion their food, prepare food in the kitchen, or eat independently for some meals)
In addition to formulating meal plans for our patients, our Registered Dietitian uses a variety of tools together with patients in order to make the most out of those food plans. These include (but are not limited to) maintaining food records, monitoring labs, setting short and long-term goals, and observing signs of hunger and satiety.
At ‘Ai Pono Hawaii, all meals and snacks are considered therapeutic groups. We designed our treatment center to provide a setting of safety, ease, and comfort. We honor this time and space by promoting mindfulness and appetite awareness.
Our team determines when patients are ready to internally regulate their food intake. Our nutrition specialists teach patients how to perform mindful eating and appetite awareness on their own.
Practicing guided meditation
Writing in a food journal (includes specifying hunger or fullness level)
Checking in and out using hunger and fullness cues
Providing support before, during, and after all meals
Post meal process groups for some meals so that patients can have a space to process and discuss what may have come up for them emotionally during meal times
Our dietary and medical team members are especially qualified to provide nutrition therapy to help patients normalize their eating patterns and improve their nutritional status. They are adept in recognizing clinical symptoms of various eating disorders, offer nutritional counseling that’s customized for each patient, and perform medical monitoring to complement the psychotherapy and pharmacotherapy programs designed for each patient.
A big component of our nutrition therapy for eating disorders involves teaching patients to tune back into their personal intuition and trust their body's natural cues for hunger and fullness. Many patients who trust us for their residential treatment have been trying to cope with their eating disorder for years (or even decades), so this process of tuning back often takes some time and practice.
We provide our patients with support before, during, and after every meal. They attend both individual and group sessions with our dietary staff in order to work on important skills and tools related to intuitive eating, food selection, hunger and fullness cues, plating and portioning, ordering out, and other important topics.
Food exposures and outings are also essential components of our nutrition therapy for eating disorders. Our nutrition specialists typically work alongside the psychotherapist and/or other members of the multidisciplinary team in the exposure and skills work element of nutrition therapy.
Together, we plan out the strategies that could be useful for each patient to relax in these exercises such as DBT skills or mindfulness practices. This includes planning when challenging foods will be introduced into a patient’s meals and techniques they can use to cope with those challenging situations.
In addition to those, our dietary team encourages exposure and skills work by scheduling trips to the grocery store or restaurants in order to practice skills and endure these challenges with substantial support.
Besides providing education and retraining, our registered dietitians help patients in treating nutrient deficiencies to enhance their overall health. Because of this, our patients benefit in a variety of ways.
One benefit that patients observe right away is improved digestion and nutrient absorption. We ensure that our patients eat a balanced diet in every meal. This allows their body to stabilize blood sugars, giving them more energy at a sustainable rate. They also report feeling a more positive mood and having a better outlook in life as a result.
‘Ai Pono Hawaii’s nutrition therapy for eating disorders includes the provision of expert advice on each patient’s unique dietary and medical needs in order to design the right meal plan for each patient. We work from an “all foods fit” model and believe that balance is a necessary part of eating disorder recovery. Our dietary experts help patients set goals and guide them through the challenge of learning to manage their food related behaviors.
Our nutrition specialists collaborate with our center’s therapists and medical doctors in designing and implementing nutrition therapy that empowers each patient to enjoy nutritious meals on a daily basis. This includes retraining patients to realize and appreciate when they feel hungry, full, satisfied, and so on.
Our team members possess extensive knowledge and experience in applying nutrition therapy for eating disorders. Their expertise goes beyond just nutrition; it also includes physiology and skills training, which fosters behavior modification to promote the various psycho-socio-cultural elements of eating.
While there is no doubt that nutrition is connected to people’s physical health, few are aware of its effects on mental health. This is particularly important for eating disorder patients because irregular and/or inadequate eating behaviors can result in problems in memory, concentration, cognitive flexibility, and even fear response.
There are many promising areas of research that can help guide future interventions for treating physical and mental health conditions like eating disorders. Our center’s nutrition specialists constantly update their knowledge in this important field and refine our therapy programs with relevant evidence-based findings.
Nutrition therapy for eating disorders is a specialized type of nutritional counseling. In it, we combine nutrition education, meal planning, goal setting, cognitive behavioral therapy, skills development, and hands-on exposure.
As a vital component of ‘Ai Pono Hawaii’s multi-disciplinary approach to treating eating disorders, our nutrition therapy zeroes in on patients’ food-associated behaviors, while psychotherapy focuses on tackling patients’ underlying issues and triggers. Our ultimate objective is to enable each patient who’s healing from an eating disorder to build a healthier relationship with food and enhance the outcomes of their nutrition.
Not all dietitians or nutritionists are specialists in treating eating disorders, so it’s crucial for patients to find a center with highly experienced and well trained dietitians and nutritionists. It’s also ideal that they are part of a comprehensive treatment team that regularly communicates with one another.
Our dietary team members here in ‘Ai Pono Hawaii understand the complexities of eating disorders. Their training is specific to handling the medical, mental, and emotional challenges that eating disorders can result in.
Armed with their deep knowledge of food, nutrition, and metabolism, they are able to help our patients determine their energy requirements, set a healthy weight goal, lower the risk of (or treat) malnutrition, and learn as well as apply a variety of effective strategies to implement behavioral change.
In the end, we know that ‘Ai Pono Hawaii’s nutrition therapy for eating disorders has worked for our patients once they regularly practice healthy eating behaviors, meet their daily nutritional needs, and let go of negative and distorted beliefs related to food, their body, and their own identity.
[1] Achamrah, N., Coëffier, M., Rimbert, A., Charles, J., Folope, V., Petit, A., Déchelotte, P., & Grigioni, S. (2017). Micronutrient Status in 153 Patients with Anorexia Nervosa. Nutrients, 9(3), 225. https://doi.org/10.3390/nu9030225
[3] Hanachi, M., Dicembre, M., Rives-Lange, C., Ropers, J., Bemer, P., Zazzo, J. F., Poupon, J., Dauvergne, A., & Melchior, J. C. (2019). Micronutrients Deficiencies in 374 Severely Malnourished Anorexia Nervosa Inpatients. Nutrients, 11(4), 792. https://doi.org/10.3390/nu11040792
