I am a senior dietitian working in an inpatient unit for young people aged 11 to 18 who have severe eating disorders, mainly anorexia nervosa. When patients are admitted, the first thing I need to do is to find out what they have been eating during a typical day. Typically, patients will have been eating very little immediately before admission. The information I get varies – if the young person is motivated to receive help and get better, I can feel fairly confident in what they are telling me, but if they are very poorly and resistant to treatment, they may be less forthcoming. Speaking to parents can also help to build an accurate understanding of eating patterns. The risk I am concerned about is re-feeding syndrome – dangerous metabolic problems which can occur if people move a severely restricted diet to a greater food intake too fast. It is my job to assess that risk and develop an individual meal plan for each patient. The plan will be very technical and precise, with exact measures of calories, protein, vitamins and minerals. This planning takes place “behind the scenes” – my dietetic prescription is carefully followed by the chefs, then the nursing staff eat with the young people, gently but firmly supporting them.
I also work with every patient on a one-to-one basis, in psycho-education sessions on food and nutrition. Of course, people with eating disorders tend to be very focused on diet and food. They may have misinterpreted what is “healthy eating” and will have strong beliefs that even small amounts of particular foods will make them fat. I need to challenge them with the nutritional facts, but we also have to affect psychological change. There will usually be strong phobias about certain foods and when this is the case, I need to work closely with the occupational therapists to challenge patients. For example, we might order in takeaway food, which is a common fear food, and the occupational therapists will support patients to eat it in our OT kitchen and dining area. Throughout treatment, we are always supporting the young people to eat a wider range of foods, to understand normal portions and to be flexible about where they eat. I’ll co-ordinate with the occupational therapists on “snack out” when they go out with the young people and support them to have a snack or a meal in a local café. That can be an enormous challenge, eating out is part of the normal life we want our young people to return to.
Often, I am the unpopular person on the unit. The dietitian is the one who keeps increasing intake on the meal plan, to ensure there is consistent weight gain. This is something which is non-negotiable. Many times, patients have been very angry or upset and stormed out after I’ve explained changes to their meal plans. I have to stand firm, but the nursing team will then support them and help them to cope with the difficult feelings and emotions they are experiencing. This is how the multi-disciplinary team works; we all have defined roles and play different parts in patient’s route to recovery.
Re-feeding is essential to the whole work of the unit. Until patients are taking in enough food to nourish the brain, they can’t fully engage in therapy, because cognition is compromised. Once nutrition starts to take effect, there can be a “lightbulb” moment when the young person can suddenly seem like a different person. That’s what I love about my job – when recovery begins and and their personality returns.”
Samantha Grigg is a Specialist Dietitian at Newbridge House in Birmingham