A Dietitian’s Role in Family Based Therapy
By Reva Schlanger MS, RD
Family-based treatment, otherwise known as “FBT”, is the leading evidence-based treatment for children and adolescents struggling with eating disorders, particularly anorexia nervosa and bulimia nervosa. Typically, FBT calls for a therapist to guide the parents and a medical doctor to manage medical needs. A dietitian, although not required, is extremely useful in helping to educate both parents and kids to make the refeeding experience as pleasant as possible. More recently, treatment facilities have been practicing FBT, while ensuring the team consists of a therapist, a medical doctor and a registered dietitian. This team provides the greatest level of support during this stressful time, and increases positive treatment outcomes.
FBT consists of 3 phases. Phase 1 is when parents are fully in charge of and supervise all meals and snacks until eating disorder behaviors are mostly absent and weight is close to being restored. Phase 2 involves gradually handing back some of the control around eating to the adolescent in an age-appropriate manner. Once the adolescent shows responsibility in resuming appropriate feeding and eating behaviors, FBT moves on to Phase 3 where the client resumes full independence, and the focus of therapy turns to other issues outside of the food realm.
Seems pretty easy right? Well, putting these 3 phases into effect while at home can be quite challenging. Not all parents have a unbiased nutrition knowledge, nor are they able to find an appropriate meal plan for their child’s weight restoration or health management. This is when the importance of having a dietitian on the team comes into play. A dietitian can understand the different metabolic needs in various stages of life, and can help curate an individualized meal plan to help ensure a smoother FBT journey. A dietitian is also able to monitor a child’s weight to determine when calories need to be increased or decreased to accommodate a maintenance plan. The RD serves to teach the family and the child or adolescent how to eat, what to eat and eventually the why of eating. While therapists and medical doctors are helpful resources, dietitians are trained specifically to understand a child’s individual needs and strategize ways to help fulfill those unique needs. This is not to say that having a therapist and doctor on the team is unnecessary, as they have other very crucial roles in the FBT model.
Frequently, the treatment team focuses strictly on weight restoration for the ability to move to phase 2. It is important to remember that weight gain is a byproduct of nutritional rehabilitation, where the body is provided with the essential nutrients to repair, rebuild and improve physiological functioning. Weight gain by itself is a very narrow marker of improved health. In treating malnutrition, dietitians go beyond just creating a weight gain meal plan, by also addressing energy availability, the timing and distribution of macronutrients across the day, and optimizing opportunities to meet micronutrient needs through small dietary changes. How the day is organized affects hormones, mood and satiety. Learning the how to eat and why to eat is crucial for full recovery, versus weight restoration. It is here that one can understand the dietitians’ critical role in optimizing nutritional rehabilitation in a clinical manner.
With the goals of supporting nutritional rehabilitation and establishing a positive relationship with food, the nutritional care process has much to offer beyond the focus of weight and eating behavior. Basing malnutrition solely on current body weight threatens to miss severe, life-threatening complications of those with a restrictive eating disorder who are not underweight. Malnutrition can be in all different types of bodies, requiring comprehensive assessments for all eating disorder presentations, regardless of diagnosis and body size.
As a member of the multidisciplinary team, the role of the dietitian is to identify the degree of malnutrition, the presence of disordered eating habits, and deficits in nutrition skills and knowledge that inhibit adequate and joyful nutrition. Dietitians help manage the nutritional care process by facilitating a comprehensive nutritional assessment, formulating a nutrition diagnosis, implementing a nutritional intervention, and monitoring progress towards treatment goals through an ongoing process. Dietitians also have the ability to assess other common co-morbid conditions like refeeding syndrome, diabetes, food allergies, food intolerances, gastrointestinal conditions and osteoporosis. When this happens, they work closely with a medical doctor and tailor the meal plan to ensure the safety of the child and or adolescent. Dietitians help support the team and parents to get the individual to a place where she/he is able to independently feed themselves and establish a healthy relationship with food, movement and body image.