WHAT WE TALK ABOUT WHEN WE TALK ABOUT FOOD

Sometimes I imagine that people see the word “Dietitian” and instantly conjure images of a woman in a white lab coat, making notes on a clipboard, while doling out rigid advice about what not to eat to improve health outcomes. But I can’t think of a role farther from what I hope to achieve as a Registered Dietitian Nutritionist practicing through a psychodynamic ( or “relational”) lens. Some people might be surprised to learn that sessions about food often turn into conversations around a wide variety of unexpected topics that, while seemingly unrelated, almost always tie-in to food and body image.

And perhaps that is the keyword: Conversation. I invite my clients to come with their own agendas, asking them “Where should we begin today? What should we be discussing?” and letting the dialogue flow from there. I pay close attention to what the client is saying and describing, and equal attention to what I am feeling - what is being “stirred up” in the session. If someone says they don’t have much to talk about, but they happen to mention a recent meal with a parent or sibling, and I feel tension in the room, I might inquire how that meal went. What was it like to eat with that person? What was the conversation like? How did they feel afterwards? How did it impact their appetite and how much food they were actually able to take in? It usually leads to a larger conversation about the context of the meal and how it might be informing their reticence in our session that day, far beyond the nutritional content of the meal itself.

Other times, a conversation about anxiety over weight loss or weight gain might prompt me to ask what the client’s anxiety level is like when we talk in session. This allows them to put words to what is happening in the moment and understand how weight fears can be tied to relational fears. In short, it’s using the clinical relationship as a “proxy” for what is happening with the client’s relationship with food and body. In another example, a client might come to session feeling desperate to lose weight, trying many different diets and extreme measures, in an attempt to reduce the desperation. I might ask about what it’s like to not receive a diet plan or diet advice from me, and allow them to put words to their desperation, wanting something so badly and arriving at disappointment and helplessness that I cannot give them what they request. But perhaps I can offer them something else, and sit with them in their despair so they can tolerate it in relationship.

I think it bears considering that most, if not all, of people’s relationships with food and body are born in relationship to other people, usually the parents or caregivers, so it stands to reason that relationships with food and body will also be healed in relationship, with clinicians and sometimes with other clients in group settings. And while I am a Dietitian who can and does provide concrete recommendations around meal and snack ideas, nutrient and energy needs, and strategies for grocery shopping and feeding oneself, I find it far more effective to simultaneously refer back to the clinical relationship in order for any real, meaningful change to occur. Otherwise I could simply give clients worksheets and books and other learning materials and send them on their way - God knows there are enough materials out there! But it is the unique bond, the “therapeutic third” in the room that allows for something more, something intangible that invites the client to cultivate deeper meaning beyond behavioral change alone. This blog on grief by Jasmine Cobb, LCSW gives a beautiful example of the therapeutic third in grief work, which often comprises a signifiant portion of eating disorder work.

So if talking about food is really talking about desperation, hopelessness, fear, disappointment, grief, and so much more, it would only make sense that I invite these feelings into the room too, naming what is happening between myself and the client, and allowing equal space to digest food and feelings.

"PHANTOM LIMB" FEEDING

In June’s blog post, “When Food Hurts,” I wrote about how we might consider feeding ourselves when food causes digestive distress - because of an untreated chronic gastrointestinal condition, for instance. But I thought it would be interesting to explore the flip side of that: What happens when the digestive condition is effectively treated or managed and food that was once “off limits” can now be eaten freely? Is it the relief we might expect? Or are there other feelings that might surface in response to such “food freedom”? 

When I work with clients who have been suffering for an extended period of time with undiagnosed, untreated digestive distress, the focus is so often on what cannot be eaten - what must be avoided to prevent exacerbating the symptoms and how the client can structure their life around these limitations. But when foods that historically caused pain no longer have the same effect, I have seen a sort of “phantom limb” effect: There is an expectation of distress and pain, but none exists. And as relieving as this may be on the one hand, it can feel disorienting and frankly, a little disturbing, to live in the absence of the expected reactions. It’s like a familiar structure is no longer present; something that governed nearly every aspect of meals is no longer there to provide a sense of stability and direction when it comes to feeding.

So now there is the opportunity for clients to create a new frame and set of guidelines around how they choose food, but it can feel overwhelming at first and stimulate new, unfamiliar feelings of being nourished, of feeling a different kind of fullness and satisfaction, and of being deserving of this kind of food. And these feelings, while perhaps “good” may also feel overwhelming, scary, and unwelcome. There might be complicated feelings about a food that once felt so bad suddenly feeling and tasting really good. And perhaps even fear about new potential repercussions, like weight gain.

And while it might make practical sense to start incorporating all the once-unsafe foods back into the diet once it is physically possible, it may not be emotionally possible or tolerable right away. The same can be said for “fear foods” with clients have who have suffered from eating disorders. Just because they come to nutrition therapy for help with the eating disorder doesn’t not necessarily mean they are emotionally prepared to introduce these fear foods; they may introduce them more slowly, on their own terms, even when they are physically capable of handling more. And this process might take longer than a regularly scheduled introduction of fear foods, but in my experience, it is also a more effective, long-lasting result.

The same can be true for re-introducing foods that once caused physical pain. This is not to say that we don’t also find ways to make sure the client is properly nourished with energy and nutrients in the interim; it might just be with a more limited spectrum of foods right off the bat. It might also take many introductions of the same food before there is trust that this food is safe. Just like a young child learning to eat solid foods: There are multiple studies suggesting that it can take up to 20 times of introducing a food before a child accepts it as part of their regular food repertoire. Some of the clients with whom I’ve worked have carried digestive distress with them since early childhood, so in some ways, eating without pain and introducing foods really might feel like the first time. And so we proceed accordingly.

A final note about foods that have caused pain in the past: Let’s take something like ice cream. There may be a lingering sense of waiting for the other shoe to drop. So ice cream hasn’t caused pain for the first 10 introductions, but what about the 11th? And the 12th? There can be a sense of foreboding around a food that one has had to avoid for so long. And keep in mind, there is no requirement that any particular food be re-introduced, despite its safety, as long as energy and nutrient needs are being met with other comparable foods. Yes, it can be something to work through and explore, but I have found that making any food a requirement tends to have the opposite effect and lacks true, meaningful integration.

LOOKING BEYOND FOOD: A PARADOX

It feels a little blasphemous writing this as a Registered Dietitian Nutritionist, whose days are centered around helping clients explore their relationships with food and ease their ability to eat, and eat well, with attention to both satisfaction and nutrient/energy needs. But as I continue to work with clients who suffer from co-occurring eating disorders/disordered eating and gastrointestinal symptoms and disease (both diagnosed and undiagnosed), it falls upon me to hold space to consider that, rather than specific foods causing the issues, it is often underlying structural, chemical, and neurological conditions (or all 3!) that give rise to symptoms, symptoms for which food plays a mere supporting cast member role.

Let’s take an example like SIBO, or Small Intestinal Bacterial Overgrowth, a condition where bacteria that typically live in the large intestine migrate to the small intestine and cause bloating, distention, gas, abdominal pain, and a host of other symptoms unique from client to client. When someone suffering from SIBO eats, their symptoms generally get significantly worse, leading some to believe that the food itself is causing the distress and then eliminating food categories and volume as a result. However, once SIBO is accurately diagnosed and treated (including the underlying cause), most people can return to eating food without pain or complication.

So while it’s vital to acknowledge the reality that eating and eating certain foods can increase physical pain in the body (see the post When Food Hurts), it’s equally important to distinguish between the food being the cause of that pain and the underlying conditions that are the real culprits. Otherwise, we risk demonizing a large swath of foods unnecessarily, creating a risky scenario for disordered eating, nutritional and energy deficiencies, psychological distress, and increased difficulty re-introducing foods once the underlying condition is treated and better controlled or healed. And equally important, if we do need to limit certain foods to minimize pain and distress while the underlying condition is being evaluated and treated, the gold standard is always going to be finding alternative sources of energy, rather than simply eliminating foods, to keep the body and brain as functional as possible and minimize complications down the road.

Similarly, one of the golden rules of feeding during clinical nutrition training in a hospital setting, as I had so many years ago, is this: If the gut works, use it! This held true for some of the sickest patients we saw. Parental nutrition, or feeding intravenously, was only used as a very last resort because once we stop passing food through the gut, it becomes increasingly challenging to re-introduce food without significant complications and distress almost as severe as the distress that led to stopping PO feeding (food by mouth) in the first place.

Consider how this applies in a restrictive eating disorder: The less food passes through the gut, the more the body adapts to an under-active digestive system, including slower motility, fewer digestive enzymes produced, interrupted insulin secretion, and a whole host of other adaptations - a sort of “use it or lose it” scenario. Re-introducing food to a sluggish or inert digestive system that is under-resourced and functionally challenged can be a tedious, distressing, and long road. So for all these reasons, whether we are addressing an eating disorder, a digestive condition, or a combination of the two, it becomes crucial to find alternatives and substitutions for foods contributing to discomfort, rather than simply eliminating them all together.

And more importantly, the faster we can evaluate and treat the root cause of the distress (SIBO, IBS, IBD, MCAS, or a whole host of other potential conditions), the more quickly we can work to manage those conditions while maximizing the food diversity and volume to continue meeting nutrient and energy needs.

This is not to say that there are not certain underlying conditions that absolutely warrant avoidance of particular foods or food groups indefinitely (Celiac Disease and IgE food allergies come to mind), but even these conditions have a root cause beyond the food itself: Abnormal immune responses, that will likely some day in the not-to-distant-future have treatments that allow foods to be consumed without injury or threat. Even in our current GI climate, there are new enzymes that can assist with consuming foods formerly off-limits to people, those who follow a low-FODMAP diet for instance (a topic for another post!)

So let’s consider not demonizing the foods themselves, but conceptualizing the GI distress our clients face as underlying conditions that deserve thorough evaluation and treatment, of which food avoidance or adjustment may play a minimal supporting role.