How can dieticians be helpful? (Warning: disordered eating)

March 30, 2022 3:38 AM

Asking for a friend. She was diagnosed as pre-diabetic and was sent to a dietician to get help with her blood sugar. My buddy has seen this professional twice. Buddy has no idea what, exactly, she should be asking dietician about or how dietician can help her. Do you have any ideas?

At second appointment buddy told dietician that buddy believed she might qualify for binge eating disorder (which she will discuss with her shrink and GP soon) and also, apples did not agree with her (because dietician has told her several times, during both appointments, that buddy should eat better snacks such as peanut butter on apple slices, which will never ever happen).

Eating and nutrition are huge huge topics. In theory buddy is seeing dietician about the blood-sugar issue but buddy feels that topic is being lost. Buddy has reduced her diet soda consumption to 3 daily cans from 4; recently she was able to eat 5 cookies only instead of 25. Which is just to say that she is truly making an effort. (Important note: A second test showed that buddy was not pre-diabetic. Also: She has ADHD, treatment-resistant depression, and maybe anxiety.)

The dietician appointments are maybe 30 minutes, by phone, and infrequent. The next one is in two months. PLEASE, NO COMMENTS ABOUT BUDDY'S EATING. Buddy just wants to know if there is a good way to make use of this professional's time and expertise, because so far buddy is deeply disappointed and may just stop the appointments. The topic is so huge, buddy doesn't even know what to ask and is tired of being told to eat protein when she is eating protein. Buddy feels like she is not being listened to and is hoping knowing what to ask or what help is realistic may make a difference. Thank you, hive mind!

posted by Bella Donna to Health & Fitness (15 answers total)

I meet with a dietitian every so often as part of weight loss treatment. Normally, I am asked what I’ve been eating and then they make suggestions for substitutes that would be better from a weight loss perspective. Some of these are useful, some not so much.

One way to approach this would be to take observations like the apple/peanut butter example and not take them literally but conceptually. The dietitian is saying that a healthy snack should include fruit/veg AND protein. She’s using her example because it is easy and accessible for lots of people. If apples don’t work for your friend she could ask about alternative fruit/veg options or about savoury alternatives.

Another way to use the dietitian would be to think about what parts of buddy’s schedule, commute, budget cause them to make less than ideal dietary choices, describe the situation and what they normally reach for and ask about different ways to approach this part of their routine. Buddy is unlikely to be the only person struggling with whatever it is and there are many ways to approach things. The dietitian should have plenty of ideas how to overcome these problems.
posted by koahiatamadl at 4:07 AM on March 30, 2022 [4 favorites]

My MIL is diabetic and I’ve visited some dieticians with her. I can only comment on those appointments, but they were all both correct and kind of frustrating. They mostly involved showing portion sizes and making 1/2 your plate vegetal and providing one week meal plans and lists of snacks other things that are true but that is kind of tired food advice.

My MIL brought in food journals and I was there to listen and help meal plan to support whatever she did (part of our deal is that she never has to cook again as she hates it) and there were a few areas where I got some practical advice for how to substitute/calibrate things but they were relatively small bits of advice, like cooking en papillote.

Ironically, after losing a lot of weight in one particular way and then slowly going back to more standard ways of eating, my MIL has landed about where the recommendations were. But the dietician wasn’t the person that found the path to the ideal the dietician was laying out, if that makes sense? The great news is my MIL’s health situation is much better.

I heard a comment, I think on Maintenance Phase, that food experts often claim all of the authority but none of the responsibility and although I have a lot of respect for dieticians vs. Diet “experts,” I think that the whole field of giving support (as opposed to dieticians working in food planning for like, hospitals) lives in that space.

Sorry to be a downer, I hope others have had better experiences.

So basically - my experience with two dieticians was that it wasn’t super helpful unless there were really specific questions.
posted by warriorqueen at 4:09 AM on March 30, 2022 [8 favorites]

If the dietitian isn't listening to buddy and is telling buddy to eat protein when she is eating protein, this just might be a bad fit. Sometimes health professionals don't listen, and I don't know a way to fix that aside from finding a different health professional.

I have seen a few dietitians - I would only characterize one as actually helpful. The helpful one had me write out a three-day food diary and then did an assessment of what I was actually eating. She was able to suggest specific ways to improve based on the diary. She also showed me what I was doing "right" in addition to things that could be improved. Also, I told her that I will never again count calories or points or anything like that, and she was able to roll with that.

The comment about protein makes me wonder if this dietitian is not looking very specifically at what your friend is eating. "Eat more protein" is not helpful advice. "You are a little low on protein - if you like almonds, maybe you could eat ten almonds before you eat cookies" is more helpful. A good dietitian will help with problem solving and not expect you to be a robot who will be able to instantly do what she says.

Some dietitians just aren't good with emotional issues related to food, and it sounds like your friend really needs one who is. I will never forget being in a class taught by a dietitian when one woman raised her hand and said she just couldn't stay away from chocolate. The dietitian said, "We all like chocolate," and that's when I knew she didn't get what we were dealing with at all.
posted by FencingGal at 4:15 AM on March 30, 2022 [7 favorites]

My experience with nutritional counseling with a dietician for diabetes was a structured, one-on-one program. We met for 6 hour-long sessions, once per month. Normally we would have met in person but this was at the beginning of 2020 so we did video sessions, which worked out fine.

We talked for a little bit each session about how I was doing, if I had any questions or concerns come up since the last visit. Then we went over the topic for the session. She had prepared materials to go over each session and reference materials for me to keep. We talked about the effects of food on diabetes, and while she did make some suggestions of good food choices for me, she listened to my feedback on what I liked to eat, how much cooking I was willing to do, challenges I faced with my food choices, and she would offer alternative suggestions based on that.

I knew a fair amount about nutrition and what I should be eating as a diabetic when I went in there. I did find it very helpful that she helped me learn to how to use insulin along with diet to keep my blood sugar under control, and how to manage carbs. The sessions were overall helpful and informative, and I appreciated the ongoing support while I was getting used to my new treatment plan.

All that said, your buddy's experience sounds very frustrating. Is there a possibility she could switch to someone else? I'm not sure how to make the experience better if the dietician does not respond appropriately to your friend's feedback. The suggestion for eating better snacks like peanut butter on apple slices is a perfectly fine one, but when your friend said apples don't agree with her the dietician should have suggested some similar alternatives such as peanut butter on celery or veggies with hummus or whatever until they hit upon some suggestions that your friend agreed would be doable. If the dietician is not listening and being genuinely responsive, I'm not sure what help she can actually be.
posted by Serene Empress Dork at 4:43 AM on March 30, 2022 [2 favorites]

Is buddy fat? Because this sounds like fat hatred from the dietitian. Maybe buddy could try a dietitian who works from a Health At Every Size perspective.
posted by shadygrove at 5:54 AM on March 30, 2022 [8 favorites]

I was referred to a dietitian because of a chronic condition (not diabetes). I told the doctor making the referral that I am vegan, do not drink carbonated beverages, and do not drink alcohol. I requested that the doctor make the dietitian aware of this ahead of time. When I met with the dietitian I also told her these things at the out-set. 5 minutes into the session she informed me that carbonated beverages should be avoided. 10 minutes into the session she said that meat should be eaten in limited capacity. She was in rote mode and could not make the adjustments that reflect my actual diet. I called her out, and she was simply not able to advise me beyond her rote mode. Like the apples and peanut butter. All to say, that I think there's a problem in the profession.
posted by Pineapplicious at 7:00 AM on March 30, 2022 [21 favorites]

I went to a dietician for 3 sessions. I would not say it was a waste, but I also would not say it was a help. It is my experience that most people know what they have to do to eat right. It has been ingrained in us since elementary school. It is easy to say cut out the diet coke, it is another thing to actually cut out the diet coke.

When I met with the dietician, it was sort of a joke (to me at least) in that the person said to cut out all sweeteners, sugar or artificial. No duh. Cut out the refined white flour items. No duh.

I see many dietician's role as accountability for the patient. Having to report in sometimes forces people to be "good", at least in the few days before the appointment. Once a month is not a lot of accountability.

Buddy knows themselves better than anyone. I think they should decide what they want out of it, even if that is simply, "I am being told I am pre-diabetic. How do I not become diabetic?"
posted by JohnnyGunn at 7:03 AM on March 30, 2022 [2 favorites]

Now that your buddy knows she is not pre-diabetic, maybe she doesn't need to deal with the dietician on top of all the other stuff?

Dieticians are human too, and have their biases. When someone is not listening or responding to a person, it can be because they have (subconsciously) decided that person isn't worth their attention. That is not a good situation for you buddy.
posted by mumimor at 7:12 AM on March 30, 2022 [4 favorites]

Buddy just wants to know if there is a good way to make use of this professional's time and expertise, because so far buddy is deeply disappointed and may just stop the appointments...

A second test showed that buddy was not pre-diabetic. Also: She has ADHD, treatment-resistant depression, and maybe anxiety


I'm confident there are good ideas in people's suggestions, but I'm actually not sure that stopping the sessions is a bad idea. If she doesn't have pre-diabetes then why does she need treatment for it? Time spent on this is time not spent on other things that might have more value. And if the dietitian is not tailoring her input for someone who is concerned about having a potentially serious eating disorder, then how can her advice be trusted.
posted by plonkee at 7:13 AM on March 30, 2022 [10 favorites]

I agree with plonkee—with ADHD and multiple other issues of high priority, it probably makes sense for buddy to stop using up energy and executive function on seeing a dietician for a problem she doesn’t even have.

It is my understanding (like others here) that dieticians have a somewhat limited set of expertise to draw on, and that definitely does not include any of the mental health or emotional aspects of food and eating. I don’t know buddy’s situation, but if she is fat or has any history of food research at all, she probably already knows most of the information this dietician is likely to be able to tell her, and the dietician is extremely unlikely to be able to offer anything else. I don’t think buddy is going to get much more out of this relationship than “eat more protein and fewer carbs,” unfortunately.

I think buddy would be vastly better served by reallocating the time she spends with a dietician to meeting with her actual mental health providers. In this context I think a dietician is likely to do more harm than good by continuing to make buddy feel bad: not listened to, not respected, and not helped.
posted by CtrlAltDelete at 7:52 AM on March 30, 2022 [6 favorites]

I also have ADHD/depression/anxiety/disordered eating, and doctors look at my history of being overweight with concern about my blood sugar (which is always normal). With ADHD, the entire process of meal planning and maintaining a kitchen can be so overwhelming that it's difficult even to start, much less form good habits, even when highly motivated. And anxiety and depression sap motivation and concentration even further. It took me eight or nine months on medications and working with a supportive therapist before I was really able to start consistently improving the way I ate, and it's still been a very nonlinear process. For me, it's been even more important to find workarounds for the practical challenges of access, energy, and capacity than it has been to get specific meal plans. If your buddy has concerns about binge eating, and doesn't have a counselor/therapist they can talk to, that may be a helpful place to start.

If I were your buddy, it would be really important for me to write down a couple of goals for the short, medium, and long term outcome of these sessions, and work on getting these as specific as possible before the next visit. That way, if this nutritionist either dismisses the goals or says they can't help work towards them, it will be clear that they aren't the right fit. But if they respond positively and start to break down approaches for achieving the goals, then it might be worth continuing.

For example, I'd start with something like:
"Improve my ability to eat enough satisfying and balanced food at dinner so that I'm less likely to feel the urge to satisfy myself with a binge."
And then think about the things that currently get in the way of my doing so: too tired to cook, not enough time to cook, difficulty keeping kitchen clean, unsure how to prepare nutritious side dishes that will give me enough variety & flavor, shame at wasting good ingredients in the past, convenience of access and the appeal of binge foods vs the type of meals I'd like to eat, etc. And then I'd brainstorm solutions to these, leaving space for a good nutritionist to add suggestions and advice.
posted by notquitemaryann at 9:05 AM on March 30, 2022 [4 favorites]

I went to a dietician 25-or-so years ago when I received a diabetes diagnosis. The level of discourse was set when she pulled out and started manipulating plastic food on a little plate—I guess in case I wasn’t clear on what a pork chop, peas or mashed potatoes looked like. It was demeaning and worthless and I’ve never gone back. It was helpful in that it clarified my requirements for a physician—they have to treat me like an adult and pay attention to what I say, not just spiel off a polished presentation.

I would suggest your buddy find some books on nutrition—note, not “diet” books or fad books about “keto” or “atkins” or “paleo”, but actual nutrition, a librarian could probably find some for them—and read them. Make notes of questions in case they find a competent dietitian, otherwise ask their doctor.

It sounds as though they have an idea of how to proceed already. You can never go wrong recording everything you eat and drink in a diary because it’s hard to recall even the next day, much less the next month! Even if you never show it to anyone it helps from the mindfulness perspective.

I don’t know if this is helpful or not, but it’s all I’ve got. Good luck to them.
posted by Gilgamesh's Chauffeur at 10:48 AM on March 30, 2022 [2 favorites]

So there's are really two types of dietitians, those who primarily provide education (and sometimes very simplistic education with the little plastic plates) with some fairly general advice and then those who'll really provide more nutritional counseling services.

People with eating disorders/ disordered eating generally benefit more from the second, because they are much more open to exploring what is going on emotionally (and how hard it is!) and being able to work to create realistic, obtainable and goals based on where a person is at.

I've had dietitians through eating disorder clinics that have been better therapists than some of the therapists I know. I highly recommend if they have the money and time to speak to someone at a clinic targeted at those with disordered eating, instead of a generic prediabetic education dietitian.
posted by AlexiaSky at 11:34 AM on March 30, 2022 [5 favorites]

As a data point for the range on approaches, my dietician was all about learning how to count carbohydrates and testing and learning how to eat to my glucometer, and that was a pretty effective approach for diabetic ADHD-me.

All of the issues that you identified for buddy, it's not at all unusual for those conditions to coexist. If buddy is currently working with a professional that they like and trust for one of the other issues, it may be worth asking that trusted professional for dietician referrals or suggestions.
posted by gnomeloaf at 1:12 PM on March 30, 2022 [1 favorite]

(My biases: I am a therapist, but not your therapist and not an eating disorder specialist. I find the principles of the Health at Every Size Approach (HAES) to be the most humane way to talk about bodies, weight, and health-promoting behaviors. I find the principles of intuitive eating to be the most humane way to talk about bodies and eating. I believe it is vanishingly rare for a person to engage in binge-eating without there being a restriction component--whether it's a history of food insecurity that previously imposed restriction on the person, a past or present cycle of dieting and bingeing, or some type of emotional/mental restriction that doesn't literally involve restricting food intake. And, I believe that restrictions and moralizing around food are both harmful and counterproductive, often leading to increased bingeing and negative mental health outcomes.)

With those biases acknowledged, I want to share that your buddy deserves a dietitian who will listen to her and not prescribe specific foods arbitrarily as "good" or "healthy"--because apples are fine, but if they don't agree with your stomach, they're probably not "healthy" for you. HAES freaks some people out because there's a lot of knee-jerk "So you think it's fine to eat nothing but fast food and candy???" when you suggest a weight-neutral approach to nutrition. This is because we've conflated weight (a complex thing individuals have far less control of than we think) with either "good" or "bad" eating, and created a perverse system that promotes a cycle of virtuous compliance ("eating healthy," often by following an externally-prescribed diet, often not getting enough calories or pleasure from the permitted foods) and shameful failure (giving in and eating delicious, indulgent foods after restricting). I don't know if your buddy is fat, thin, or somewhere in between, but if she's being told to eat "healthy" snacks and "protein," without being adequately listened to and provided guidance on learning what her body actually needs, I'd assume she's being given the diet culture version of nutrition. Diet culture doesn't care if apples give you an upset stomach, or you really can't stand the taste of beans, or sometimes your ADHD prevents you from sticking to homemade meals--those are "healthy" and therefore good for you. HAES and intuitive eating offer a more wholistic and humane approach to eating and caring for your body within the context of your life, mental health, and other complicating factors. I'd encourage your buddy to see if her therapist can recommend any HAES-aligned dietitians, or she can google "HAES dietitian [my state]" and see who comes up.
posted by theotherdurassister at 1:59 PM on March 30, 2022 [6 favorites]