Restrictive Eating Disorders:
Why Reassuring Your Patient Can Backfire  

  by Francie White, MS Nutrition, Registered Dietitian 

Did you know that telling a patient with anorexia nervosa or bulimia that they are medically stable or “improving” in any way is highly likely to provoke a major downturn? Few physicians or nurses understand the paradoxical nature of restrictive-based eating disorders in which patients compete to be as physically sick as possible. Hearing that their vitals or lab values are within normal range can be the kiss of death (figuratively speaking), since the term “normal” is the epicenter of what they are driving away from. Never mind that any medical reassurance feeds the denial that breeds restrictive eating. Although this is true for adults, it is especially true for adolescents. What follows is a brief explanation of this paradoxical disease. 

Anorexia and bulimia (normally begins as anorexia and evolves into bulimia) are more than obsessive fears of being fat. Most of the time, at the core of the disorder is a formula that looks something like the equation below. Each person varies as to how they restrict food and whether liquids or exercise is a part of the problem.  

The least food consumed + the least water + the most exercise + the least relaxation/pleasure + the most academic or career work = Self Worth + Strength + Superiority to others who have less willpower + Its my secret; I don’t share this inner game. 

This is such a seemingly bizarre dynamic: feeling good only if you’re feeling bad. This is a poorly known dynamic in the medical field. Well meaning physicians reassure patients that they are stable or healthy. In doing this, they unknowingly sabotage inroads the eating disorder specialists have made. This means that even if you as a medical professional have to reframe the truth, when patients are holding up against starvation, avoid reassurances about their health. Otherwise, your kind words become filtered through their distorted paradigm and inspire a deeper commitment to their eating disorder behaviors. See recommendations for ways to express concern, even if weight is gained, vitals improve, or labs are within normal range.  

So, each time patients get concerning news about their health, they get a ‘hit’ of accomplishment, which then becomes addictive. Here is why: 

1. Staving off hunger or exhaustion is associated with a core sense of character strength, forming a new identity, a “cohesive function,” that acts like organizing glue to the pain and chaos of life. 

2. Family and friends initially reinforce and praise the patient’s weight loss and what looks like healthy diet changes. That praise does much to support this new identity and sense of power.  

3. What few understand is that when a restrictive eater deprives him/herself pronounced anxiety relief occurs.

4. The anxiety relief and building sense of a ‘strong identity’ set up an addiction to the feeling of being empty. Empty means pure, clean, superior, high, thin. 

5. This is perhaps the only disease on the planet where a patient experiences humiliation when taking the steps to improve. Yes, there can be some pride, but the entire time they are working to get better they feel weak, shameful, and as though they are losing something precious and core to their sense of worth. 

Below are recommendations: 

WEIGH-  INS: Explain to patient that you blind weigh them by having them turn around so they don’t have to deal with numbers. If the patient says they see their weight at the gym or a home scale, I suggest you maintain that since scales vary and yours may weigh high, they needn’t bother with seeing it. If they insist, it’s your call. Consult the dietitian or treatment team about how to proceed with weigh-ins. 99% of the time, the treatment team will have negotiated blind weights. 

For nurses, it is best to say absolutely nothing after weighing. Please be careful. Patients may hear the weight being communicated to the MD and may see you write it down in the chart. If an anorexic patient’s weight has improved, say nothing, show concern, or just use comments such as, “Are you eating enough?” or “As you know, you need more calories” or “I continue to be concerned about you.” 

VITALS: We recommend orthostatic vitals as these are the most sensitive indicator of inadequate food. Many of our patients are athletes or former athletes, so physicians often make this devastating comment: “Oh your vitals are fantastic. Your heart rate is lower than average because you have an athletic heart.” This comment translates to, “Go ahead and exercise, eat like your are eating. You are a picture of health.”  

 We treat any low heart rate as an opportunity to give them grave news and use it to restrict activity and increase their food plan (via “Dr’s orders and RD”). If vitals are within normal range, you may still want to say something about being concerned, and that we don’t want to see further drops in their heart rate or blood pressure. For those with a high heart rate, why not use that as well? If this patient is adolescent, pull the parents out to explain your tendency to emphasize the negative and give them the honest feedback, of course. 

LAB VALUES: Our next newsletter will address new medical indicators of eating disorders. In the meantime, if lab values are off… relate them to starvation or purging (including over exercise as a purge). If they are not off, explain that “Blood values do not change much while the body is eating its own muscles and organs. These labs do not mean you are healthy. They can eventually change, which is very serious and something that we don’t want to see.”

Generally avoid the following statements:                         Instead: 

“You are medically stable.”....................................................... “I know this is a hard time, be sure and follow your food                                                                                                             plan. Food is the best antidepressant out there for you.” 

“You are doing fine, or doing better.”.......................................... “How is your energy? I wouldn’t be surprised                                                                                                                   if you were tired.” 

“Your weight is the same.”........................................................ “I am not to report your weight but I am concerned.” 

“Your weight is up.”.................................................................. “What we are working toward now is getting your  

                                                                                                          metabolism strong. Hang in there, and I still need                                                                                                             to see you soon.” 

“I’m proud of you, or good job.” (Praise can be humiliating).......... “I’m concerned about you.” 

“Your labs are fine.” ................................................................ “Lab values don’t reflect the metabolism changes, bone loss,                                                                                                         fatigue and brain drain caused by your eating disorder.” 

“Your vitals look great.”............................................................ “It is important to restrain from exercise until your treatment                                                                                                               team says it is OK. Your body needs time to heal.”