Nutritional Rehabilitation for Eating Disorders: River Centre Clinic Program Description

    

    

    Figure 2:  One large apple = 2 fruit exchanges. All three of the apples above
are “large” apples. What determines the eating disorder patient’s choice
versus that of the diabetic patient?
    
    

With the Exchange System, eating disorder patients intentionally or sometimes unintentionally tend to “shave” Calories by picking a smaller quantity of food or lower Calorie food items (e.g. low fat, diet foods) having the same exchange value. The problem with the exchange system is that it is inherently imprecise and allows for systematic estimation errors, in the context of extreme fears of “eating too much.” The consequence is a tendency to drift toward restricting caloric intake over time. As stated earlier, the final goal of treatment is to help patients become more relaxed and natural in their approach to eating. However, it is not necessary to progress toward this goal in a linear manner. We use the analogy that structured eating is like a splint on a broken bone- it maintains rigidity and structure while healing takes place. In this case, structure allows a period of stability followed by gradual and incremental progress toward a more flexible or “normal” eating style. The intensity of fear around eating is overwhelming early in treatment and this fear can be lessened by reassurance that the system that we use is precise and that we are committed to not having patients eat one Calorie above their meal plan and by the same token, we want them to not eat one Calorie less. By having knowledge of exactly how many Calories patients are consuming, and carefully monitoring their weight, we can assure them that they will not be allowed to gain outside of their weight range. The reassurance, predictability, and safety are of paramount importance. This practice helps build trust between patients and staff as well as trust in the program’s efficacy. Later, once the patient can see that weight and weight changes are predictable, with staff being equally willing to cut Calories as to raise them in accordance with the nutritional plan, patients are reassured. They virtually never are enthusiastic about weight gain but in many cases, the lack of predictability is the major source of fear. Patients in our program have expressed that it is easy to “manipulate” the exchange system and avoid challenging feared foods.

The meticulous attention to detail related to nutritional rehabilitation (i.e. prescribing precise Calorie levels, showing painstaking vigilance during meals, and therapists having daily access of body weight) is meant to reassure patients that their worries about food and weight are taken very seriously. We jokingly assert that we are even more “obsessed” about Calorie level and weight than most patients since our reputation depends on them being able to trust that we will be conscientious and that we are ultra-responsible in temporarily “managing” body weight. Thus, the structured nature of the nutritional rehabilitation plan is designed to increase the person’s control over the eating process and to minimize the tendency to lose control over eating and body weight. The aim is for patients to begin to develop confidence that they can eat the specified amounts of food without inappropriate weight gain. We encourage “good data” by discouraging symptomatic behavior so that patients can develop confidence in their weight and intake over time.

Does Calorie-counting increase preoccupations with food and Calories?: One of the most commonly raised criticisms of counting Calories and fat grams in meal planning is that it serves to reinforce obsessive preoccupations with food. First, it is hard to imagine how one could increase the level of Calorie preoccupation in a group of eating disorder patients who are already obsessively fixated on Calories. If there is a ceiling effect to preoccupation, most seriously ill eating disorder patients are very near this ceiling. Second, particularly for highly anxious, obsession and perfectionist patients, a more precise system of quantifying food intake (devoid of estimation error) increases certainty and predictability and this allows most to rather quickly begin eating a wide range of foods in appropriate amounts. These perfectionist patients have a cognitive style characterized by a preference for order, precision, exactness, symmetry and sameness in the interest of avoiding perceived adverse outcomes. In this way, the cognitive style and information processing biases are harnessed in the interest of the therapeutic goals of nutritional rehabilitation. Third, this structured system related to food intake also works well for impulsive patients who benefit from external controls to counteract their tendency toward poor planning and impetuous decisions related to food choices. Finally, perhaps the most compelling argument for the system we propose is empirical in that we have achieved very positive body weight outcomes using this nutritional rehabilitation plan [3].

Calories as energy: It is often helpful to defuse the surplus meaning that is ascribed to the word “Calorie” with a psychoeducational approach. For patients, the word has often taken on a special and pejorative meaning associated with body fat. Patients benefit from being reminded that a Calorie is defined technically as a unit of energy equal to the amount of heat required to raise one kilogram of water by 1° Celsius under standard initial temperature. Calories, just like British Thermal Units (BTUs), are simply units of energy. At least for the purposes of energy and weight gain, patients need to be reminded that “a Calorie is a Calorie is a Calorie” [9]. The same is true for the pejorative connotations for word “fat” including the myth that dietary fat converts directly to body fat unlike other sources of food energy. Psychoeducation that reviews the importance of dietary fat can be very helpful. For example, some essential fatty acids require consuming dietary fat and lipids are necessary for the absorption of fat-soluble vitamins, cellular membrane function, gene regulation, wiring between brain regions (see [55] for an excellent summary).

“Intuitive Eating”: The structured eating plan we advocate sharply contrasts with the intuitive or mindful approaches to eating that emphasizes learning to eat in response to physiological cues rather than situational or emotional cues [56,57]. Intuitive eating is considered to have three central features: 1) unconditional permission to eat when hungry and what food is desired; 2) eating for physical rather than emotional reasons; and, 3) reliance on internal hunger and satiety cues to determine when and how much to eat [57]. It rests on the assumption that greater attention to hunger and satiety cues are sufficient to override the profound physiological disturbance created by severe or prolonged weight suppression and chaotic eating. We believe that intuitive eating is a very constructive approach for chronic dieters who may have mildly disordered eating and weight preoccupation. It is the cornerstone of the progressive approach to size acceptance as an alternative to traditional weight loss programs [58,59]. Moreover, it has been shown that in obese chronic dieters, this approach does not lead to weight gain in the long run and it is very helpful in improving the psychological functioning of those plagued by the pattern of oscillation between dieting and overeating [56]. However, given what we know about the profound disruption of internal cues that results with significant and sustained weight suppression (e.g. think again about the starvation volunteers), it is naïve to assume that simply exerting greater willpower and redirecting attention more sharply on internal cues are sufficient to correct the problem with those with serious AN. As indicated earlier, in BN, the magnitude of weight suppression can be as great as for AN but the premorbid weight is simply higher [60]. Therefore, it is our view that intuitive eating is a misguided approach to those with serious eating disorders. At least in the short run, structured eating provides a more effective framework for holding turbulent and unreliable physiological and psychological cues in check while the salubrious effects of nutritional rehabilitation take place. Patients report having attempted “intuitive eating” prior to seeking treatment but have been unsuccessful in their failed attempts to attend to unreliable cues for hunger/fullness and/or their emotional states which results in inconsistencies in gauging quantity and quality of food intake.

Types of Foodstuffs

At the beginning of treatment, most patients have little sense of what constitutes “normal” eating. They try to restrict food intake, delay eating and divide food into “good” and “bad” categories, and engage in a host of idiosyncratic food avoidance and weight-losing behaviors. It is common for patients to defend their food choices by suggesting that they are mere “preferences.” It is more likely that they feel compelled to make certain choices or engage in food-related “safety-seeking behaviors” due to extreme fear of weight gain or loss of control. Food choices are sometimes based on nutritional myths (e.g., “Calories from dietary fat are stored as body fat, in contrast to Calories from protein and carbohydrate, which are burned off”). Some behaviors represent extreme interpretations of otherwise sensible dietary guidelines. For example, limiting red meat, saturated fats, or sugar may be sensible for the general population; however, avoiding them because of an intense and irrational fear may be linked to eating disorder psychopathology rather than based on sound health recommendations. Even after considerable work has gone into refuting nutritional myths, patients are typically overwhelmed by intense anxiety elicited by certain foods and bodily sensations (e.g. fullness) that have become associated with feared consequences. Patients are anxious about the types of food they eat, the amounts they consume, the timing of meals and the sensations of fullness that they experience after consuming even meals of moderate size. Their worry and anxiety about eating is the stimulus driving compensatory behaviors. The most effective strategy to diminish intense foodrelated anxiety is repeated exposure to the food stimuli (quality and quantity) that elicit the anxiety. Exposure therapy is a cornerstone of our nutritional rehabilitation treatment plan. For exposure to be successful, patients need to be exposed to fear eliciting food stimuli, to be convinced that the dangers that they perceive to be associated with these foods are unwarranted.

To ensure that exposure is maximized during the phase of treatment where all meals are supervised, patients must select feared foods as part of their meal plan. They are typically allowed to select no more than three specific foods that they simply do not like (as opposed to foods that elicit fear because of their perceived or real caloric density). Since most patients fear dietary fat, in our program, meals consist of at least 25% dietary fat. Larger percentages of dietary fat are sometimes prescribed to: 1) reduce the volume of food for those who are prescribed a large number of Calories (3,000 or more); or 2) to reduce the percentage of carbohydrates because of heightened risk of refeeding syndrome or because they are diabetic; 3) to reduce hunger, and 4) to provide exposure to certain feared foods.

Our program rarely uses liquid supplements. High Calorie liquid supplements have been recommended in to promote weight gain with a smaller volume of food and to help patients who are struggling with satiety; however, they can also reinforce food avoidance and foster dependence on artificial food sources [11]. It has been our experience that some patients prefer liquid supplements because they permit avoidance of feared foods and negative feelings associated with eating. In these cases, it is important to emphasize that exposure and desensitization to a wide range of food items is central to overcoming eating fears and ultimately being able to regain personal control of eating and eat in a “normal” manner. For a very small minority of patients who are unable to complete meals early in treatment, we may temporarily use liquid supplements along with regular meals.

Microwavable frozen entrées

The technology that we have employed for more than 20 years relies heavily on commercially available frozen entrées. We realize that there are valid criticisms of the widespread use of commercially available frozen foods such as excessive sodium content and potentially unwanted ingredients. However, the use of microwavable foods is not being advocated as a lifestyle choice for the general public but rather as part of a simple, and effective remedial strategy that has proven helpful in assisting eating disorder patients in nutritional rehabilitation. Commercially available packaged foods have several distinct advantages over the traditional “cafeteria” dining used in most eating disorder programs.

1. Portion-size controlled: A significant advantage of microwavable frozen entrées is that the portions are predetermined eliminating the guesswork in determining portion size. The controlled portions and the precise measurements reduce fears of loss of control. It also helps patients estimate portion sizes and appropriate servings when they transition to a more flexible eating plan.

2. Calories and macronutrients are exact: The nutritional information on the package specifying Calories per serving and the grams of macronutrients (including dietary fat) are unambiguous. This minimizes debate about the number of Calories in meals since the content of each meal is printed on the package. Foods other than packaged (e.g. frozen vegetables, liquids, and other readily available foods) are also used but the portions are measured precisely and checked by staff trained in meal planning. If certain meals are not available, patients can easily switch one meal for another that is calorically equivalent underscoring the primacy of Calorie content over caloric connotation.

3. Technology can be transported home: One of the most important benefits of microwavable meals is that the methodology employed throughout treatment can be readily implemented with the same precision outside of treatment (weekend home visits) and after discharge. This means that the blueprint for eating is consistent throughout the course of treatment and after discharge. In contrast, some other approaches (such as using hospital-based meals) require the patient to adjust to an entirely new eating plan at discharge. We tell patients that relapse prevention in the eating domain starts on the first day of treatment and they can have confidence that what they learn in treatment can be deployed once they are discharged. Also, nutritional information is widely available for most foods in restaurants which allow patients to engage in more “normal” eating in social events.

4. Commercial health standards are high: Flash freezing and commercial packaging reduces risk of spoilage and rapid heating of frozen foods reduces leaching of water-soluble nutrients from microwavable foods. Studies have shown that the nutritional value of frozen fruits and vegetables are generally equal to or higher that their fresh counterparts [61,62]. The CDC estimates that each year 48 million Americans get sick, 128,000 are hospitalized and 3,000 die of food borne illness [63]. This risk is minimized in flash frozen meals.

5. Wide range of meal selection: The range of microwavable frozen entrées available maximizes the ability to individualize exposure to feared foods during the course of treatment. Schebendach and colleagues [64] found that energy density and diet diversity are predictive of weight maintenance in AN patients.

6. Cost-effective: In the treatment setting, microwavable foods reduce costs since kitchen staff and an expensive commercial kitchen are not required. The cost-savings can be reallocated to therapy staff or translated into more economical treatment.

7. Simple and efficient: Relying on commercially available microwavable frozen entrées makes meal preparation simple and efficient. All meals can be reduced to interchangeable Calories and this minimizes the amount of time immersed in meal preparation. The simplicity of planning meals reduces obsession ruminations surrounding meal planning and preparation.

8. Patients take responsibility for meal planning and preparation: Early in treatment, patients select meals with staff assistance and later take responsibility for planning and preparation of all meals.

Common objections to microwavable foods

Patients and families often raise objections regarding the use of microwavable foods. It is important to address these objections and to reiterate that this aspect of meal planning is not intended to be part of a permanent lifestyle change but rather is a plan that is effective in healing the greatest health risk currently facing the patient.

Objections that need to be countered:

1. Using microwavable foods teaches poor nutrition: This argument does not consider the context of the person trying to overcome a life-threatening eating disorder. A major impediment to eating is worry and uncertainty related to the effects of food on body weight. The goal of frozen entrées is not to achieve a theoretical ideal of “optimal nutrition” or to make a permanent lifestyle choice but rather it is part of a remedial strategy that is very effective in dealing with treatment and relapse. Also, this “mechanical eating plan” is efficient because it reduces the agonizing and time-consuming decision-making that can take away from discussing meaningful psychological topics. It is important to emphasize relative health risks by weighing the enormous dangers associated with an eating disorder versus the minor putative risks of microwavable or processed foods.

2. Patients will become accustomed to eating “unhealthy” foods: Concerns are sometimes expressed that people will become “addicted” to microwavable meals or develop enduring unhealthy eating habits because of exposure to these foods. Again, context is everything. What is “healthy” in one context may not necessarily apply in another. We sometimes use the analogy that chemotherapy would hardly be recommended to facilitate health for the general public but in the right context, it can be lifesaving. Once the person’s eating disorder has been resolved, we fully appreciate that there are a range of non-eating disordered eating styles that could be considered appropriate as the long-term goal.

3. Patients will become accustomed to eating large amounts of food: Similarly, it has been argued that the amount of food in nutritional rehabilitation should not exceed the amount that patients would ordinarily eat at their target body weight based on the theory that the exposure to greater amounts will lead to tolerance to overconsumption [65]. This ignores the fact that the nutritional setting conditions for those who are underweight or weight suppressed are entirely different than those who have acclimated to complete nutritional rehabilitation. In our experience, eating disorders endure the same gradual normalization of appetite and eating patterns months after weight restoration as described by the Keys Starvation Study volunteers. Exposure to feared foods does not mean that people will grow to like them anymore that exposure therapy for a germ phobic (e.g. putting their hands in the toilet bowl to eradicate their fear) would lead them to develop an affinity for germs once the exposure therapy is complete.

Spacing Eating

The structured approach to meal planning includes eating prescribed meals and snacks at set times spaced throughout the day [9]. Ideally, the plan should include three meals and one or two snacks spread evenly throughout the day. In general, eating disorder patients have difficulties starting and stopping eating. Many are fixated on myth-laden dieting rules or are highly ambivalent about when and how much to eat. Typical problematic patterns are skipping breakfast, delaying eating, or deciding that eating is not permissible past a certain time in the evening. These tendencies can be lessened by eating at specific pre-set times. In this way, the clock becomes a potent discriminative stimulus for initiating meals which makes delayed eating less likely. Eating at prearranged times, along with other elements of meal planning mentioned earlier are designed to operationally define “not dieting” since many patients are very confused about what this means in practical terms. As mentioned earlier, to encourage compliance, it is helpful to educate patients about the metabolic benefits of spacing eating throughout the day.

There are circumstances where we deviate from the three meals and two snacks plan. For example, we typically ask most patients who begin in our 7-hours-a-day Partial Hospitalization Program to consume all Calories within the program day which means that they temporarily refrain from eating breakfast and evening snack. The rationale is to increase the likelihood that all prescribed Calories are consumed early in treatment for underweight patients who are nutritionally compromised or those prone to chaotic eating. We explain that this should not be interpreted as punitive in any way but rather reflects our concern that it would be unfair to burden them with choices about how much to eat outside of therapeutic supervision so early in treatment. It is important to be able to assure patients that the number of Calories consumed need to be exact so adjustments can be made to ensure that neither too many nor too few Calories are being prescribed. Once patients feel confident in eating per the structured meal plan, a breakfast and evening snack are incorporated. Psychoeducational topics are emphasized that support eating at regular pre-determined times. These include the metabolic advantages of spreading meals out over the day including increasing thermogenesis, lipid profiles and peak insulin response [66]. Finally, eating according to the clock reduces the likelihood of binge eating or under eating in reaction to internal or external non-nutritional cues.

In sum, nutritional rehabilitation plans vary significantly between different eating disorder programs; however, it is noteworthy that the details of this aspect of treatment are rarely specified and there is even less written on the theoretical principles behind these approaches. Despite the lack of detail, different approaches to nutritional rehabilitation have been used successfully in different eating disorder treatment programs. Our approach to meal planning and nutritional rehabilitation was developed to add structure to the eating plan in a partial hospitalization treatment and has been extended to adolescent residential treatment. It can be easily explained and has high patient acceptance by patients at the end of treatment. Moreover, it has been shown to be effective in our settings [3]. We have found that these same principles apply equally well with outpatients even though the same level of rigidity and structure may not be required. Nevertheless, given the notable contrasts between these approaches, it would not be surprising to find that some patients would find one system more palatable or more effective than another. Comparing the relative effectiveness of different methods and matching effectiveness to patient variables would be a fruitful area for future research.

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