Reprinted from Eating Disorders Review
May/June 1999 Volume 10, Number 3
©1999 Gürze Books
Developing a realistic perspective on one’s health status is an important aspect of nutritional recovery in anorexia nervosa. Addressing patient denial, including unhealthy belief systems about food and weight, is a standard component of treatment.
As part of nutritional counseling, assessment of patient denial and belief systems begins during the initial evaluation and continues throughout counseling. The dietitian’s task is to find ways to challenge unhealthy beliefs without “losing the client” in the process. Forming and maintaining a strong therapeutic relationship with the client is essential for this task. In addition, I have found some comparative and visual techniques are quite useful for integrating reality testing into nutritional counseling sessions, thus enabling the client to begin entertaining the possibility of new health-related truths.
Addressing patient denial
Addressing patient denial of low weight status is a universal task of health-care professionals working with eating disorder patients. I approach this by using comparative statements to engage the client in discussions about the disparity between her beliefs and her actual health situation. In addition, I’ve found that anthropometric and laboratory data provide objective information to incorporate in these discussions. I frequently use weight, pulse, blood pressure, mid-arm muscle circumferences and electrolyte values.
I begin by asking the client what she values about her eating and exercise style, and her present physique. A common reply is that she follows her present diet and exercise routine in order to be healthy and fit. This disclosure provides an opportunity to begin a discussion about the inconsistencies of the client’s beliefs and present health status. For example, I might say, ” If you are eating to be healthy, I don’t think you are getting the desired result. Your heart rate is 45, which is not a healthy heart rate. This heart rate indicates that your body is struggling to perform basic functions because there is a lack of energy from inadequate food intake. In fact, your weight loss has compromised your health so much that you can no longer participate in the cycling (or swimming or jogging) you enjoy so much. You also have to visit your physician once or twice a week for medical follow-up. Does this sound like a healthy place to you?”
Different physical parameters can be incorporated to keep these health-related inconsistencies present during nutritional counseling. This approach is not new, nor is it a quick fix. Instead, it is a consistent message that challenges the client’s denial. The message is, this present pursuit of fitness has lead to an unhealthy place. Extremes don’t lead to maximum benefit.
Taking recommendations to extremes
Another common belief of clients is that general nutrition recommendations must be taken to an extreme to obtain the maximum health benefit. A good example is the client’s interpretation of the current public health recommendation that fat contribute 30% of total dietary calories.
During the initial nutritional assessment, I begin the process of challenging nutrition assumptions by asking the client what dietary guidelines she follows. I ask this question prior to any type of intervention so that I can obtain as honest an answer as possible. (Asking this question after providing nutritional information may taint the client’s reply, due to shame, fear, or a desire to please you.) A typical response to this question may be, “I try to eat as healthy as possible. I follow a low-fat, no-saturated-fat, high-fiber, and low-sodium diet.”
As part of intervention, I challenge clients’ perception that their eating habits are healthy in several ways. First I ask the client who she believes the target audience is for the low-fat diet message. Infants? Children? Teenagers? Average healthy adults? Individuals with medical illnesses? The goal here is to have the client identify to whom the general message is targeted, and for whom it may and may not be appropriate. For example, infants and people who have special needs or who are ill are probably not the target audience of this message.
I then ask the client two questions: With her current nutritional and medical status, is she part of the general population? And, second, how does her present fat intake compare to the 30% of calories from fat recommendations? Is her intake higher or lower than what is recommended for a healthy diet?
Illustrating the patient’s weight and health
Using a piece of paper and pen to illustrate these concepts, I draw a line and place a mark in the middle to indicate individuals of average weight and health. At each end of the continuum, I place a mark to indicate individuals of low and high weight, respectively (Figure 1). I then ask the client where she would be on this continuum, based on her present weight and health status. We can usually come to an agreement that she would be grouped with underweight individuals and not with the general population.
We then move on to the question of percent of calories from fat. We determine what percentage of daily calories the client is obtaining from fat—this frequently results in less than 10%—and compare that to the guidelines for the general population. For emphasis, I return to the continuum and place a 30% near the average person mark and a 0% and 80% at the left and right ends of the continuum, respectively. I then ask the client to place a mark that would reflect her current fat intake. The visual clarity of her fat intake being significantly below what is considered a low-fat intake provides an opportunity to discuss several concepts. For example, does her present weight status reflect a healthy diet and lifestyle, and does she receive any health benefits from her current fat intake?
This process can continue with a calculation of the actual grams of fat in the client’s daily food intake, then a comparison of this amount to the number of grams of fat that would reflect 30% of total dietary calories provided by fat. This comparison can be made using the client’s present caloric intake and target caloric intake.
Using the visual tool of the line continuum helps to emphasize the disparity in the client’s verbal goals and actual behaviors. Use of these visual tools also provides the client with a take-home reminder of the discussion that can be helpful in keeping the message alive between sessions.
— Tami J. Lyon, MPH, RD, CDE