Establish Your Role
Establish your role and responsibility for physical health, as well as your relationship to other care providers who may be involved.
Cultivating trust is particularly relevant in the context of treating people with eating disorders. You are asking someone to give up behaviours that, despite being maladaptive overall, serve some purpose; you are asking patients, who may feel that much of their life is out of control, to relinquish control over their weight and their eating behaviour. You will need to earn their trust.
Manage Your Reactions to the Patient
For many health care providers, the seemingly conscious element of control in people with eating disorders can be frustrating. It is important to understand that although issues around seeking control may catapult someone into an eating disorder, the problem ends up controlling the person.
Moreover, eating disorders cause numerous medical and psychiatric complications, but they may also serve some adaptive function for patients (e.g., helping them to feel more in control, being praised for weight loss). If you find out what that function is, patients are more likely to feel that you “get” them as a person beyond their weight and their symptoms.
Even though formal eating disorders services are scarce and have long waitlists, you may need to enlist a nutritionist or dietitian to assist with meal planning, a counsellor or therapist to offer support and psychotherapy, and a psychiatrist to provide consultation.
You are strongly encouraged to take a team-based approach using the resources in your community. Such an approach helps your patient to meet broad needs and helps you to shoulder the responsibility. If the family is involved, recognize them as collaborators with tremendous expertise in the life journey of the patient. Family members can provide valuable collateral history, but they also likely feel overwhelmed and worried, and need your support.
Although people with eating disorders may seem to have an encyclopedic knowledge of nutrition, it often is infused with mythology and morality. Patients may also feel alone and unique in their problems. But there are many accounts of eating disorders and strategies for coping with them that patients and families can access and identify with. Hearing about others’ experiences can help people see the connections between the symptoms that actually bother them (trouble sleeping or concentrating, mood instability) and their eating disorder, which may increase motivation to get better.
Self-help books and guided self-help (regular meetings with the primary care practitioner) can also make a difference, primarily for binge eating disorder and, to a lesser extent, bulimia nervosa. See the Resources section for a list of the best self-help books.
Monitoring and Nutrition
You can play a key role not only in monitoring progress and complications but also in liberating patients from the tyranny of bathroom scales. Assume responsibility for regularly monitoring weight and have the patient (and often reluctant family) throw out the scale at home. This makes weighing less frequent and patients less able to regulate their self-esteem and self-appraisal by minor fluctuations in weight. For underweight patients, establish a healthy weight range (not a single number because weight naturally fluctuates) that can be maintained without undue dieting and that will allow a return of regular menses.
Asking patients to keep a regular diary of their eating and associated behaviour can also be informative and transformative. It tells you what actually goes on, and patients begin to see the connections between food, weight, emotions, thoughts and behaviours. Many self-help books provide templates for this kind of self-monitoring.
Restoring regular eating is an important therapeutic goal. Patients who feel that a “good day” is one where they have not “given in” to hunger during the day are far more likely to binge eat at night, perpetuating the cycle of restriction and loss of control. Realizing that their fear of gaining significant weight from a single meal is not realistic will help to reduce anxiety about eating and the fear that it will become a runaway train.
A rate of weight gain of 0.5–1.0 kg per week is appropriate in anorexia nervosa when moving toward a target weight range.
In Eating Disorders: