The appropriate level of eating disorder care depends on a patient’s ability to consume and retain proper nutrition. A qualifying criterion to enter a residential treatment center is that they are unable to maintain the necessary nutrition intake required for their physical and psychological health. A second criterion is that they have difficulty maintaining reasonable nutrition consumption for themselves while living at home, even while receiving care in a partial hospital program or intensive outpatient program.
Residential treatment provides necessary, 24-hour support for the patient with a multidisciplinary team who will help interrupt the personal battles patients experience to balance their nutrition intake. Over time, the patient can regain personal intake management, develop their independence and confidence in eating, and transition to a lower level of care.
Nutrition rehabilitation interventions hold a vitally important role in the residential level of care during eating disorder treatment. As each patient works towards recovery, they achieve the best results with hands-on food experiences that engage all their senses, including seeing, smelling, touching, and tasting. Living vibrantly with food encompasses being able to hold conversations about food and cooking as well.
With these thoughts in mind, Hidden River developed a unique and customizable nutrition and culinary skills training program for their patients.
Research supports this approach: A narrative review from 2018 found that culinary skills programs ultimately boost young people’s healthy eating behaviors (1). Let’s take a closer look at the main tenets program.
Nutrition Evaluation
To start, each patient participates in an in-depth nutrition evaluation by a Registered Dietitian. The assessment reveals the patient’s current and historical relationship with food. The assessment reviews the patients’ beliefs about the various categories of foods, food habits, food-related social activities, and their process of eating in a variety of social settings.
Many patients have misconceptions about foods and food products that contribute to their disordered eating. When the Registered Dietitian and patient review the assessment results, they identify key issues to address and reasonable goals to achieve over the course of treatment to receive the most benefit. The highest goals may include nutrition education, enhancing their food selection, broadening their palate, and establishing a realistic home-based meal plan menu.
Culinary Knowledge Evaluation
At admission, the patient participates in an interview about their culinary knowledge, food preparation experience, and cooking skills. The patient will be given several unique quizzes to obtain their baseline of culinary knowledge. The assessment and interview approach reveals their level of culinary comfort on the Likert Scale. The unique quizzes assess the patient’s current knowledge surrounding grocery shopping, meal planning, food preparation, safe food storage, and the use of basic kitchen appliances and utensils. The food preparation skills assessed include spicing, baking, boiling, basting, frying, roasting, and the use of sharps. Additionally, they consider a patient’s understanding of kitchen safety, techniques, cleaning tips, and more.
When the RD and patient review the assessment results, they identify where the patient will benefit most from the culinary skills training program. All patients will be guided through the standard features of the program that include establishing a realistic home-based meal plan menu, grocery shopping, developing kitchen safety knowledge and skills, and possibly even preparing a meal or snack on their home-based meal plan. Additional education and skills training will be added to the patient’s treatment experience based upon their unique needs in preparation of establishing their aftercare plan.
The culinary evaluation also determines the steps needed to accomplish the established goals. Some patients lack adequate culinary skills and benefit from receiving basic education and training. Other patients are well-versed with culinary skills and benefit from taking on the challenges related to fearful foods, uncomfortable textures, tastes, or smells. The Registered Dietitian supports the patient to begin the culinary skills training program from a safe emotional and psychological position.
Individualized Meal Plans
Based on the results of the nutrition assessment, the patient and Registered Dietitian collaborate to create a customized daily meal plan that focuses on resolving fear, increasing confidence, and supporting their medical nutrition needs. The daily meals and snacks are prepared by in-house chefs with fresh ingredients. The patient will fill out a weekly menu for each meal that offers a main course and an alternative. The foods consumed are monitored to ensure the patient ingests the adequate energy intake their body requires.
Nutrition Education
Each patient participates in daily supported meals and snacks and weekly nutrition education lectures. Throughout the treatment, patients tackle personalized food challenges to resolve distorted thought patterns, irrational fear, and self-destructive behavioral patterns. Nutrition education provides science-based information on nutrition, micro-nutrients, digestive processes, and how the body uses the nutrition it receives. Education is designed to address food and body misconceptions through accurate information of food and body science.
Nutrition Programming
Each week the patient’s schedule includes many food exposure episodes as the key feature of the program. In addition, they will participate in one individual nutrition counseling session per week, one nutrition education group, and a culinary skills training event.
Exposure Response Prevention Therapy
Exposure Response Prevention (ERP) therapy focuses on helping individuals improve their distress tolerance skills as they face their fears. Eating disorder recovery is particularly challenging because patients are frequently confronted by triggers — in the kitchen, at the dining table, in the grocery store, and so on. During their time in residential treatment, it’s imperative that the patient’s practice skills enable them to handle these diverse events by enhancing their situational awareness, arresting impulsive actions, implementing effective responses, and boosting their confidence.
The ERP program works by identifying their resilience strengths as well as personal vulnerabilities promoting a range of emotional distress that activates eating disorder behavior. The Registered Dietitian and patient identify the patient’s mild, moderate to severe emotional distress reactions from a multitude of nutrition and culinary experiences reviewed. The ERP program is categorically arranged to strengthen the patient’s ability to successfully manage events that create a moderate distressful emotional response with the goal of reducing the emotional response to the mild range.
Once this goal is achieved, a subject higher on the moderate to severe scale of distress may become the area of focus. The Registered Dietitian and patient keep in mind that practicing distress tolerance skills during the ERP sessions is the primary skill to realizing a successful outcome. Ultimately, the patient is guided to address forthrightly many distressful facets of their life that hinder their ability to consume their daily nutrition requirements. When the patient returns home to resume an improved quality of living, it is important that they have the knowledge with the forethought of applying effective distress tolerance skills to enact healthy eating behavior.
Hidden River’s program is in part developed from current research which suggests that culinary skills training programs are especially effective when combined with ERP therapy. Specifically, one study revealed that, based on the shared symptoms of anxiety and anorexia nervosa, ERP is an appropriate treatment approach to avoid relapse of eating disorders (2).
The most common hope is that the nutrition and culinary skills program assists patients in healing their relationships with food.
Each individual experiences an emotional connection to food, tying specific memories to the meals. Family relationships and vibrant social events often include meals. In that sense, food is so much more than nutrition. Food is part and partial to the celebration of relationships with family and friends. Cultural traditions as well are ripe with the inclusion of food to highlight one’s heritage, express appreciation, and show love. Ultimately, when a patient begins to rediscover food as part of a joyful life, they can rest assured that the path to healing is possible.
References
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