Outer Limits

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A little over six years ago, I wrote a blog entry in which I attempted to rebut the notion that discussing topics other than food in our sessions somehow qualifies as psychology. In reference to intuitive eating, I wrote, “What does it say about how disconnected our culture teaches us to be from our internal signals regarding eating that an approach that encourages us to pay attention to said signals triggers connotations of therapy?”

After reading the blog, a friend of mine – a clinical psychologist himself – offered something along the lines of, “Maybe the reason your work is effective is because you include some psychology.” No, I bristled. Staying within my scope of practice is important to me, and certainly anything that qualifies as psychology is beyond what a dietitian can offer, I reasoned.

Given that, I have occasionally second-guessed myself when conversations with patients have strayed into more distant orbits around food. On one hand, I have tended to listen to my instinct to prioritize what my patients want to discuss and to follow the natural flow of conversation so long as what we are talking about ultimately relates to their eating. On the other hand, when conversations become less about nutrition and more about things like body image, weight stigma, or even happenings in someone’s life that are tangential to their eating, I have worried that perhaps I have inadvertently crossed the line from where a dietitian’s work ends and that of a therapist begins.

Then along came a session at the 2021 Multi-Service Eating Disorders Association (MEDA) conference that alleviated my worry and helped me to see the matter in a different light. In their talk, entitled “Staying in Your Lane – Until You Can’t: Balancing Scope of Practice and Competent Client Care,” Anna Lutz and Sandra Wartski, a dietitian and psychologist, respectively, delved into the issue of professional bounds.

One of the most validating concepts that I took away from their talk is that there is no crisp line separating the work of the two professions, but rather there is an overlap, a gradient that bleeds from one realm of expertise into the other. In other words, some topics, such as weight stigma, are appropriate for discussion with both a dietitian and therapist, and each practitioner can bring different perspectives that hopefully complement one another.

Furthermore, scope of practice is amorphous, fluid, and depends on context, such as an individual patient’s needs at a specific moment in time and the practitioner’s own comfort level. Sometimes a patient is unable to address the work at hand, and simply having a human connection is more constructive. Anna gave an example of a time when a patient was too preoccupied with other matters to discuss food, something I have experienced with patients of mine on occasion, so they spent the entirety of their appointment talking without ever discussing the patient’s eating.

Having said all that, scopes of practice can only stretch so far. If a patient raises an issue that is beyond my ability to expertly handle, such as a disclosure of trauma that they are hoping we can process together, I am responsible for making my limitations known. Similarly, a good therapist knows better than to delve into the specifics of nutrition. Part of the reason why collaboration between treatment team members is so important is because we can let each other know when something comes up that is better handled by the other practitioner.

For me, their talk validated my intuition and reassured me that the way I approach my work is well within my professional bounds. For our patients who are reading this, I hope hearing about their session resolves any lingering questions you may carry about possibly having overshared and similarly serves as encouragement to remain open going forward.


Thoughts on the 2016 Multi-Service Eating Disorders Association (MEDA) Conference

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On May 14th, I attended the 21st annual two-day conference held by the Multi-Service Eating Disorders Association (MEDA). This year’s conference theme was “Thinking Outside the Body: Empowering Yourself, Your Clients and the Community.” I was only able to go to day two of the conference, but I feel like I learned a lot during that one day of presentations and thought it would be helpful to summarize some of what I learned.

The first talk I attended was the day’s keynote address, “Gender Identity, Gender Expression, and Eating Disorders,” presented by Carly Guss, MD, Allegra Gordon, MPH, ScD, and Jerel Calzo, PhD. Obviously, the topic of gender identity has been on the forefront of many people’s minds given the latest legislation around transgender individuals being able to use public restrooms. While I am familiar with transgender issues, I have only worked with one transgender individual in my practice, so I was very interested in hearing what the presenters had to say on the matter.

While the presenters gave a helpful primer on gender identity, their main focus was on the prevalence of eating disorders (EDs) in the transgender community. According to the presenters, two recent studies found that compared to cisgender heterosexual women, transgender men and women have 4.6x odds of past-year self-reported ED, were more than twice as likely to have used diet pills and purging in the past month, had 4.8x risk of being “underweight,” and had 2.5x risk of being “obese”.  Two other studies on ED risk in the transgender community found that the majority of participants (transgender men and women) reported a history of disordered eating and that there was a “strive for thinness” to suppress unwanted secondary sex characteristics, particularly in people who were gender assigned “female” at birth but identified as males. It makes a lot of sense if you think about it – if one were to identify as a male but were born female, that person might want to prevent the development of curves and beginning of menstruation that naturally occur as a girl becomes a woman. Restriction and maintaining a very low body weight can prevent these developments from occurring.

My takeaway from this talk was that it is important for practitioners to be aware of the challenges that transgender individuals face in our society (particularly in healthcare) and their increased risks for EDs and body-image issues. It also made me examine my own practices when working with transgender clients, including how to make them feel most comfortable (e.g., using the client’s preferred pronoun[s] and having gender-inclusive language on our patient forms) and incorporating the best strategies to help them recover from their EDs.

The second talk I attended was “What You Need to Know about Trauma and PTSD: A Personal and Professional Perspective for Working with Eating Disorders.” The first presenter was Jenni Schaefer, a very well-known figure in the ED community. Ms. Schaefer is a self-described individual who has fully recovered from an ED and has written a number of books on her recovery journey. What I (and perhaps many others in the audience) was not aware of was that Ms. Schaefer is also a survivor of trauma. Her presentation was quite an eye-opener as it described how her trauma and ensuing Post Traumatic Stress Disorder (PTSD) were impacted by and complicated by her ED. This part of the presentation was especially illuminating for me, as I have a number of patients who have been victims of trauma and struggle with both PTSD and EDs. The second presenter was Luana Marques, PhD, and she discussed the different therapeutic options for patients struggling with both disorders. While the content was not exactly geared towards registered dietitians, it gave me some insight into how PTSD can affect recovery from ED and vice versa.

After an hour lunch break, I was thoroughly excited for the third talk of the day. As many of you know, Jonah and I identify as Health at Every Size® (HAES) practitioners and are supportive of the size acceptance movement. Well, we were absolutely thrilled to learn that Ragen Chastain (blogger at Dances with Fat), a world-renowned , self-described fat activist and proponent of “behavior-centered health,” was going to be presenting on both HAES and Size Acceptance in her talk entitled “The World is Messed Up, You are Fine – Helping Clients Deal with the Culture of Body Shame.”

Ragen gave an absolutely electrifying talk about how our society gives extremely damaging messages about our bodies via the medical community, the media, and even our politicians (e.g., Michelle Obama’s fight on childhood “obesity”), and how these messages can make recovery from an ED very difficult. She started the presentation by giving a quick primer on the principles of HAES and Size Acceptance, stressing the point that people of all body sizes have the right to exist and that healthy habits are more likely than body size to determine healthy outcomes.

After this introduction, Ragen displayed a number of images taken from popular magazines and websites, each showing how the media tries to manipulate celebrities’ appearances by using Photoshop. All of these manipulations aimed to make the subjects appear thinner and younger, perpetuating the idea that everyone (especially women and girls) are only beautiful if they are young and slender. A number of years ago, I never would have thought about how these images are manipulated, but now in my work with ED clients, I am super sensitive to how these images can be extremely damaging to girls and women, and I often suggest to my clients that they avoid certain magazines and publications for fear of triggering negative body image thoughts.

Ragen continued on to talk about the role of HAES in ED recovery and how important it is for ED healthcare providers to give consistent body positive messages that counteract the negative, fat-phobic messages that our patients receive every day. She gave examples of how practitioners could create a safe environment for their ED patients, such as providing a space that includes positive representations of diverse body sizes, creating “body affirming” spaces by having chairs that can accommodate people of all sizes, and being aware of our own beliefs and assumptions around weight and size.

While I was familiar with nearly everything Ragen discussed, for I am an avid reader of her blog, it was interesting to observe those in the audience who were hearing this information for the first time. There were a number of thought-provoking questions that were posed during the Q and A section at the end, and Ragen adeptly answered all of these queries with the grace and presence of someone who is confident as well as extremely knowledgeable about the topic on which she was presenting. Her talk finished with a standing ovation from the audience, something that I have rarely witnessed at any of the MEDA conference presentations I have attended. It was truly a special moment.

The presentation that followed Ragen’s was called “Taking the ‘Th’ Out of #Thinspiration – Utilizing Social Media to Encourage, Empower and Bring Hope to Those Battling or In Recovery from Eating Disorders”. The first half of the talk was presented by Donald Blackwell, a man whose own daughter had suffered from an ED and who himself became very active in ED recovery. Mr. Blackwell’s part of the presentation centered on the many different social media platforms that people use today. While I am already quite familiar with Facebook, it was helpful to learn more about the other commonly used social media vehicles, including Twitter, Tumblr, and Instagram, and how they are used in pro-ED (people who believe that EDs are “lifestyle choices”, not illnesses) as well as ED-recovery circles. I have always been aware of the numerous pro-ana (promoting anorexia nervosa [AN]) and pro-mia (promoting bulimia nervosa [BN]) websites out there, but this talk gave me an even clearer picture of the amount of harmful information that circulates on the internet.

The second part of the presentation was given by Joanna Kay Mercuri, an ED sufferer who is now in recovery. She went into even more detail about the pro-ED websites and their content as well as the pro-recovery websites and what they focus on. Ms. Mercuri also discussed her own blogging and how it helped her in her recovery, as it gave her a platform to discuss her feelings and struggles while connecting with others. The end of the talk centered on how we as a society can actually respond to the pro-ED social media and bring the pro-recovery content front and center. All in all, this talk was helpful in showing the influence and use of social media platforms regarding EDs, and it gave me a lot of insight into what my patients might be seeing online possibly every day.

The conference’s endnote address, “Overview of ARFID: Avoidant/Restrictive Food Intake Disorder,” was given by Ovidio Bermudez, MD. It was very interesting to learn about this relatively newly recognized group of disorders as it has recently been added to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). ARFID is defined by the Center for Eating Disorders as an “eating or feeding disturbance as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:

  • Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
  • Significant nutritional deficiency.
  • Dependence on enteral feeding or oral nutritional supplements.
  • Marked interference with psychosocial functioning.”

Those struggling with ARFID are not the same as those with AN or BN, as ARFID sufferers typically have no fear of weight gain and no body image distortion. Instead, individuals with ARFID are those who, due to a problem with eating, aren’t able to take in enough nutrition through their diet. Some examples of eating problems are difficulty with digestion of certain foods; strong aversions to colors, textures or smells; no appetite; or being afraid to eat as a result of a frightening episode of choking or vomiting. Sometimes individuals with ARFID can develop BN, AN, or other EDs, but not in every circumstance. I myself have worked over the past few years with several clients who have struggled with ARFID, so I found this talk most helpful in recognizing the signs and symptoms, treatment plans, and prognosis.

All in all, I found my day at the MEDA conference one filled with interesting ideas, helpful tips, and above all, support from my fellow colleagues. These types of conferences are not only a wonderful opportunity to reconnect with familiar ED treatment practitioners, but they are also a terrific time to meet the “new kids on the block.” I look forward to returning to the MEDA conference next year, for I am sure I will learn even more!