By: Erica Parker
At my recent rotation with Children’s National Hospital, I had the opportunity to shadow two different dietitians who primarily work with kids struggling with eating disorders. I was interested to see what therapies were used for these patients, since I struggled with disordered eating when I was a teenager. My first week was spent working with the in-patient eating disorder dietitian. This is where I first learned about the eating disorder protocol used for inpatients at Children’s National.
This protocol consists of nightly tube feeding that supplements the patient’s eating. The goal is for day-time calorie intakes of 2400-2700 kcal and 1200 kcal through the tube feeding. I was surprised by such a high calorie intake goal for the children, but it’s necessary to help them regain weight they’ve lost. Patients start out with a lower energy intake of oral and tube feeds equal to around 70% of their goal rate, which is advanced over four to five days to reach the goal rate. This gradual increase in energy intake helps prevent refeeding side effects. The patient is also given a multivitamin, thiamine, and Phos-NaK to help replenish nutrient stores and prevent refeeding syndrome. The dietitian orders three meals per day specific to the patient’s caloric needs and up to two snacks may be included to help meet the patient’s calorie goal for that day. The patient is given 30 minutes to complete each meal, which is supervised by a staff member. The caloric value of any uneaten food is estimated and these calories are provided with the corresponding amount of Boost supplement to be consumed within 15 minutes. Any unconsumed Boost is then provided by nasogastric tube (NGT). While the patient is not able to choose their own meals, they are allowed to pick three specific foods they dislike, which will not be given at any meal or snack. The ultimate goal is for the patient to gain about a half pound per day from the increased energy intake and have stable electrolytes indicating they are no longer at refeeding risk and are safe to discharge home or to an appropriate facility for further treatment. If patients are discharged home from the hospital, they likely will receive a recommendation to follow-up with the outpatient dietitian and/or a therapist to help continue and maintain recovery at home.
In my second week at Children’s National, I worked with the outpatient dietitian specializing in eating disorder treatment. I was able to shadow her at two clinics outside the hospital and one clinic within the hospital. I learned about the Plate-by-Plate method, which is often used in combination with Family Based Therapy (FBT), for feeding adolescents struggling with eating disorders. This is a similar idea to the My Plate, but the proportions of food groups are changed to provide more energy in each meal.
The Plate-by-Plate Method consists of a 10” plate made up of 50% grains or starches, 25% vegetables or fruit, and 25% protein and includes a side of dairy and fat. The fat can be the oil or solid fat used to cook the meal or something like peanut butter, nuts, cheese, or hummus. The most important part of this meal approach is that it is entirely controlled by the parent, which is a cornerstone of FBT. FBT believes the parents and family are the best people to help their children recover and does not blame them for their child’s eating disorder. Until the child makes progress, they are not supposed to be given any influence over the meal choices.
During my outpatient shadowing experience, I saw how important a dietitian is to help uncover a patient’s thoughts and feelings about food. Often, the patient’s family is at a loss for how to feed their child and a supportive dietitian can help ask the right questions and take time to listen to what is and isn’t being said by the patient and the family. A dietitian who clearly understands the patient and family’s situation and eating habits is more likely to offer realistic solutions to treat the eating disorder.
Being able to see two different sides of eating disorder treatment in adolescents was a very interesting experience. It allowed me to learn about the Plate-by-Plate method and FBT, which I had never heard of before. The experience also gave me a chance to reflect on how essential a healthy relationship with food is to living a well-balanced life. Eating disorders can be all-consuming and very upsetting and frustrating to the family who just wants to help their child. It truly takes an interdisciplinary approach and a dedicated family to help a child recover from the grips of an eating disorder.