Podcast Episode 206: Dysfunctional Eating Behaviors – Jessica Setnick

[00:00:00] Melissa: Hello and welcome to the sound bites podcast. Today’s

episode is about eating disorders and disordered eating or dysfunctional eating

behaviors. What they are, how to understand them and their origins better and

how to better manage and treat them. This episode is for anyone who is

interested in the topic for themselves, for a friend or a family member, or as a

healthcare professional, who wants to be a better practitioner.

Now I do want to let you know that if you have had or have any kind of

struggles with body image dieting or the like, I would like you to consider that

the topic we’re covering might not be in your best interest, if it leads to anxiety

or other triggering emotions, we are trying not to share anything too specific or

triggering today, but we aren’t able to predict how different people will react to

some of the information we discuss.

So just know that it’s important for you to do what you need to do in order to

take care of yourself. I also want to let you know that we are submitting this

episode for free continuing education credits for registered dieticians, diet

technicians, and diabetes educators. So be sure to check back at

soundbitesrd.com/freeceus for updates on all of my free continuing education

activities.

My guest today is Jessica Setnick. You may know her as the eating disorder

nutrition expert behind eating disorders bootcamp, or as the author of the eating

disorders clinical pocket guide. For nearly 25 years as a dietician, Jessica has

worked in all levels of eating disorders.

From private practice to large facilities. Welcome to the show, Jessica.

[00:01:43] Jessica: Thank you. Excited to be here,

[00:01:45] Melissa: You know, I actually interviewed you for my blog. You’ll

remember back in 2014 after we met I believe it was a dieticians in business and

communications panel that we were on together. I remember! It was a long time

ago though.

You’re very memorable! So are you! I really enjoyed connecting. And we

haven’t really, our paths haven’t crossed much since then. But that blog that I

did, where I interviewed a lot of dieticians, it turns out it was the precursor to

my podcast. That was unbeknownst to me at the time.But, you know, we just kind of got reconnected recently through a mutual friend

Neva Cochran. And I would love for you to tell us more about yourself and your

background and the work that you do. Sure.

[00:02:34] Jessica: I’d be happy to. And thanks for having me. And, you know,

I always tell Neva that technically she’s a dietician, but her real job is

connecting people.

So she did a great job this time. Always. So my path as a dietician is. Very

accidental one. I took nutrition as an elective in college because a friend told me

that it was an easy “A” which, by the way, it wasn’t. But nevertheless, taking

that nutrition class made me fall in love with nutrition, the idea of what happens

to food pnce it goes inside your body, why you make the food choices you

make, how the food gets to you in the first place.

All of it was so fascinating to me. And I was actually an anthropology major at

the time. And couldn’t quite figure out how it was going to make anthropology

into a career. But if you’re not familiar with anthropology, it’s the study of

human development on a macro scale, human cultures, human physiology.

And to me, nutrition was more of Human development on a micro scale, how

we develop throughout life, how we develop the culture of eating in our own

homes and in how we reflect the bigger culture with our eating, it was all just

amazing to me. So I changed course there and went to get a master’s degree in

nutrition.

Even though I think that the whole psychology of eating or the anthropology of

eating, or whatever you want to call it about the pieces of the puzzle, that aren’t

just the nutrition process inside your body. I felt like that should be important in

every area of nutrition and dietetics. But at the time when I was at school in the

1990s, really the only area where it was kind of kosher to talk about that stuff

was in the eating disorder field.

And so that became really my fascination, because it was where we were really

looking into those things. And it took a while for me to realize that I was

actually in recovery from my own eating disorder. I was one of those people that

sort of looks at the diagnostic criteria and says, well, it wasn’t that bad.

So I guess I didn’t really have a problem. And it took me a long time to really

accept that Yes, I had had an eating disorder. And even though I was able to get

into somewhat of a recovery without professional help, I really needed a lot ofcounseling and eventually medication to really actually get into what I consider

remission, which is not having Not as many thoughts, and definitely no

behaviors. And it just gave me such an important insight. Having gone through

that process, myself, into what I brought into the field. So my work is now

mostly educating other health professionals because I was in private practice.

As you mentioned for a lot of years, I started in the hospital in an eating

disorder program, went into private practice and then realized that there was so

little education and this is going to make me sound really, really old, but you’re

going to remember this too. But when I started working in an eating disorder,

Program at a hospital. This was sort of the Dawn of the internet. There was no

Google. There was nowhere to look things up.

And so if you needed information, you had to get in touch with another

dietician. And so for dieticians, who weren’t specializing in eating disorder, It

was really challenging because they would literally have to call information,

asked for the phone number of a different hospital call a different hospital, ask

for the nutrition department, ask if they had a dietician who specialized in eating

disorders or who could advise them if the answer was no, they’d have to hang up

the phone, call information, get the phone number for another hospital.

I mean, it was really a labor intensive process to try to find someone that could

help you. And when the Dawn of the internet, happened there was one listserv

for all of the academy. I don’t know if you remember that – it was called the

ADA at the time, but there was one lisstserv for every dietician. And so what

would happen is the dietician could look on their census in the morning, see that

there was someone with an eating disorder type into the list serve “Can anyone

help me with this patient?” And by the time they came back down for lunch

someone like me would have answered and said, Hey, give me a call. I can talk

you through it type of thing. And so through that process, I became known as an

expert in eating disorders. And so that’s really where everything in my mind

kind of began.

I don’t know if it was right place right time, but also that willingness to help a

colleague. And so over time, I was then asked to give talks on eating disorders. I

came up with my own workshop, eating disorders bootcamp. And so that aspect

of my career started to overwhelm the patient care aspect where I couldn’t be

traveling and presenting and also be there for my patients when they needed me.

So over time, I ended up closing my private practice and just doing the

education piece, which is what I do now.[00:06:57] Melissa: Okay. Excellent. Yes, I do remember all of that you know,

before the internet, before we used email at work and, and things like that I

think we’re, we’re pretty much contemporaries

[00:07:07] Jessica: there. We had email but pe printed out all the emails I don’t

know what we thought we were going to do with.

Well,

[00:07:17] Melissa: that is funny. I do remember doing that. Yeah. Or if you’re

going to a website, you would just print out the information because of course

you didn’t have a mobile device to look it up on the go. And, oh my gosh, you

know, you, you called a restaurant and got directions on how to get there. You

didn’t, you know, use Google maps or anything.

But I digress and I’ve told this story on the podcast before I think, My very first

TV segment was the first day of my second job, which was my outpatient

dietician job, which was my favorite job. I loved it. And that first day on the

job, my boss came to us at lunch and there was about 10, 12. I was the only

outpatient dietician, everybody else was inpatient.

And she said, the TV stations coming, who’s going to do the TV interview.

Everybody said, I’m not doing that. I’m not doing that. And I was mortified that

everybody was being so insubordinate. And I thought, well, I guess I’ll do it.

And it was on men’s health. And of course like, well, I didn’t know that much

about men’s health.

You know, it, wasn’t my area of expertise. But we actually called the academy

based here in Chicago. And I said, you know, I need some information and they

faxed it to me. So that was in 1995. So yes, a lot has changed since then. And

yeah, the good news is that the world has opened up in order for dieticians to be

able to connect with each other and find resources like you.

But that’s still, we’re going to get into this. That’s still a little bit of an issue.

With dieticians in our field, not necessarily, you know, specializing in eating

disorders or disordered eating and perhaps not feeling comfortable, you’re still

serving this wonderful role to help educate them and give them confidence and

insight.

So we’re going to talk about that today. So this topic, eating disorders, it can

really be taboo. Yes. It can feel very daunting. It can be anxiety provoking. Sowhere should we start? You know, keeping in mind that we have a mixed

audience, we have the general public, we have dietitians and other healthcare

practitioners.

You know, where should we start? What do we need to know to set the stage

for eating disorders and disordered eating.

[00:09:25] Jessica: Gotcha. Great question. And the place I would start is with a

term that you used in your introduction, which is dysfunctional eating

behaviors. I feel like when we say the words, eating disorders, everyone gets

sort of a persona or an avatar in their mind of what that means the same way

that I, who had had an eating disorder thought that I didn’t have an eating

disorder because I didn’t meet XYZ picture that I had in my mind of what an

eating disorder was or the diagnostic criteria.

I think all of that, we need to kind of set aside because what it has led to

unfortunately, is a lot of missed opportunities to help people. And the diagnostic

criteria, the research in our field so much is based on these biased ideas of who

gets eating disorders that really, I feel like we need to use different terminology

that sort of takes us away from that this is a very small group of people who

have these very specific behaviors and enlarge it to everyone who eats can have

dysfunctional eating behaviors. And there’s no reason that someone couldn’t or

shouldn’t get help just because they don’t meet some criteria.

So part “A” is a lot of people don’t get help because the having a problem is not

recognized by the words, eating disorders. And another part of the problem is

that sort of outdated treatment for eating disorders. We’re really kind of thinking

of eating disorders as one thing, based on the symptoms, the outward symptoms.

And we need to start looking at that idea of anyone who eats can have

dysfunctional eating behaviors. They don’t even have to rise to the level of an

eating disorder to be an issue. And so I prefer the term dysfunctional eating

behaviors because I feel like it sort of opens up this continuum of, yeah, we all

have some, and my definition of dysfunctional eating behaviors is really, you

know, does eating support your goals or not support your goals?

You can’t really define it by someone’s individual behavior. There’s things we

can all agree are detrimental to health, but for many people it’s much more

individual than that. So for example, someone might be eating a Turkeysandwich for lunch and enjoying it. It’s delicious. And someone else might be

eating a Turkey sandwich for lunch because they’re scared to eat anything else.

And so the same food can be functional or dysfunctional for two different

people, or even for the same person in different situations. And so I felt like

dysfunctional eating behaviors really opens up the window for us to look

through and our own behaviors and include things like our motive for eating and

the results of our eating and whether we feel regret after eating and things like

that can sort of point to whether our behaviors are supportive to our lives or

destructive to our lives versus the specific behaviors that we all know and

associate with eating disorders.

[00:12:00] Melissa: Okay. Very good. And yes, this term dysfunctional eating

behaviors is a phrase or a term that you came up with and shared with me. So,

so that’s why I used it. And I’m so glad that you explained that to me and to our

listeners, you know, there there’s a stereotype and a stigma and there’s

symptoms and behaviors.

And it makes perfect sense that if we have this narrow view of it, like you said,

there’s a lot of missed opportunities. People falling through the cracks, even,

even in your situation, you thought, well, I don’t look like that. And when I say,

look, I mean, in my mind, like I’m not, I don’t identify with that. So that’s not, I

don’t have any detour because that’s not what I’m seeing.

Even for ourselves, there can be missed opportunities there. Yeah. Very good.

So then let’s build on that. You know, we’ve adjusted our lens, we’ve opened up

our minds and I’ll tell you as a dietician working in the hospital setting, whether

it was inpatients or outpatients, I worked with eating disorders and I found it

very challenging.

I felt frustrated and anxious that I couldn’t, I felt that I couldn’t help my patients

better, but also kind of had this epiphany leading back to this term,

dysfunctional eating behaviors where gosh, you know, eating disorders aside,

most people that I was seeing had some disordered eating. And like you said, it

didn’t necessarily rise to the level of, you know, like a formal diagnosis or

anything.

And this is just what people were telling me. Lord knows what they weren’t

telling me. It can be a lot. So let’s build on this. Is this a good spot for us to talk

about there’s four origins.[00:13:45] Jessica: Yes, but first let me say that I am totally with you and the

statistics support what you say. I think statistics about eating disorders are very

unhelpful in many, many cases.

Because again, as I said, they’re kind of based on this very biased thinking that’s

baked into the field, but one of the things I think we can trust, or it may be even

worse than the statistic is that only about one in 10 individuals with an eating

disorder is ever going to get specialty care. So that means nine out of 10 people

with eating disorders – and we’re not even talking about dysfunctional eating –

We’re just talking about truly diagnosable eating disorders. Nine out of 10 are

going to be in your care. They’re going to be in the diabetes clinic. They’re

going to be in the oncology service. They’re going to be on the med/surg floor.

And so obviously not, everyone’s going to see a dietician, but those that do are

not very likely to see an eating disorder dietician just there’s 30 million people

with an eating disorder and less than a thousand dieticians that identify as

specializing in the eating disorder world. So yes, if you’re a dietician that doesn’t

specialize in eating disorders, that’s not gonna shield you from having patients

in your care whenever your service is that also have eating disorders.

And so, yeah, I think it’s really important to have a working knowledge of what

to do to help. And that’s why I actually came up with eating disorders bootcamp.

It wasn’t meant to be for specialists. It was meant to be for generalists or

dieticians in other areas to really help them when they encounter individuals

with eating disorders in those other areas.

So I agree. And when you look at the four different paths to eating disorders,

you can see how they can affect everyone. It’s not just this small sort of

subgroup that we’ve been led to believe. So there’s four major groupings of

paths toward eating disorders. There’s probably 30 million different paths to

eating disorders since there’s 30 million people.

Well, that’s just in the U S actually you may have listeners in other countries. So

there are millions of people with eating disorders, but I’ve tried to sort of narrow

down the origins of them into four major paths. So yes, we can go over those.

And I have a handout on this that we can put in the show notes if you’d like to.

Great! Because I’m going to say a lot of words and you won’t be able to write it

all down.

So the first grouping is the biologically based, dysfunctional eating behaviors.

And I use the word biology to describe this rather than genetic, because I think

genetic is one of those words that has very specific meanings, right. Inherited.And that’s not what I mean. Yes, there are probably some eating disorders that

are inherited, but there are also a lot of biological factors that are not inherited

that can influence an eating disorder.

A great example is concussions, right? Nothing inherited about that, but

someone could get a concussion and that can lead to the development of

dysfunctional eating behaviors because of the effects on the brain, right? It’s

traumatic brain injury. And even though it’s a closed head injury, you still have

effects on appetite effects on perception, all different kinds of things.

And so that’s just one example, other biologic behaviors or biologic factors that

affect eating behaviors are things like hyper or hypothyroidism, anything pretty

much that has a hormonal component. So any kind of diabetes, polycystic ovary

syndrome, and then you have the psychiatric illnesses like depression and

anxiety, obsessive compulsive disorder, all of these are biological conditions

that can influence eating behavior.

So it’s much more than just the genetic piece, which there probably is a genetic

piece to a lot of eating disorders, but that’s definitely not the whole picture. So

that’s type one. Type two of the path to eating disorders would be addiction

related. So there’s sort of a chicken and egg cycle that can happen with

addictions and by addictions I mean everything from substance abuse or

chemical dependency to behavior, process, addictions things like compulsive

gambling, et cetera, you have a situation where, you know, someone who’s

trying to recover from an addiction has, you know, the addiction is not to the

substance as much as to the chemical changes that the substance or the behavior

produces.

Right. And so food is a mood altering chemical. People don’t often identify it

that way, but if you’ve ever been hangry and you ate and you felt better – not as

cranky, you know, right. Food affects your mood. And so when someone is

dependent on a different substance and they’re trying to not use that substance or

abuse that substance, it can be really easy to turn to food.

You can also have a situation where someone develops an addiction because of

their dysfunctional eating behavior. So where someone turns to a certain type of

substance in order to let’s say, keep their weight down and prevent them from

eating or prevent them from having an appetite. So there’s a lot of connections

between addiction and eating and that’s another path.The third path is stress and trauma related dysfunctional eating behaviors. And

this is such a huge category. I’ll give a few examples, but basically it breaks

down into two major groups. I guess, to me, the difference between stress and

trauma is simply a traumatic event might happen one or more times.

Stress is something that could be low lying and may not even be identified as

traumatic, but it is traumatic because it occurs over time. So something like food

insecurity to me is stress that becomes a trauma because it keeps occurring over

time. And so you’ve got two major groups here. You’ve got traumatic events that

have nothing to do with food, but that are just a shock to the system.

They exceed someone’s ability to cope, probably anyone’s ability to cope. This

is things like, you know, and here’s where I hate to trigger someone, but

something like a death, a divorce, your house burning down – things that are just

so shocking that they affect your body chemistry and that can then affect all the

things I mentioned when we were talking about concussions. That can affect

your appetite. It can affect your mood. It can affect your ability to procure food

for yourself, your desire to eat. So many different things can be affected by a

single traumatic incident. And if someone has multiple traumatic incidents even

more so. Then there’s a group of stressful, traumatic incidents and events that

are related to food.

So that is something like if you were in hurricane Katrina, sitting on your roof

for three days, not knowing if anyone was going to rescue you and you had no

food. Or someone who was in a refugee situation, someone who went through

the great depression. And we’re all descended from individuals who experienced

some kind of food-related insecurity at some point.

And so we have this kind of food related trauma that then becomes even more

difficult to untangle because we have to deal with the food related rules and

thoughts and feelings that we develop based on that. And also whatever the

traumatic stressful incident was as well. So, you know, almost everyone has

something in their life that they remember or recall that happened related to

food.

For me, it’s that I ate life cereal and I threw it up and I can’t even stand to look at

the, those colorful letters of the word life. When I walk in the store, all I can

think of is how I threw it up. For my husband at the time, he had to sit overnight

with the mashed potatoes on the table that he didn’t want to eat.And he fell asleep on the table. So, you know, those are in the grand scheme of

life. It’s so easy to say, like that’s no big deal that happened so long ago that

wasn’t really that bad. It didn’t affect me, but Melissa, I’m telling you that stuff

that happens when you’re young, it really does continue to affect you throughout

life.

So we can’t just discount those things, even if they don’t rise to the level of what

the therapist call a big T trauma. They still were less than nurturing, let’s say.

And so they felt traumatic to us as children and, and can definitely be still

affecting us. So that’s a third path. And then the fourth path is, is learned

behavior.

And this is caused by the environment, by society, whatever names you want to

call it by, you know, everything from diet culture to the thin Ideal is what it used

to be called. You know, appearance culture, consumer culture. This is caused by,

you know, filters and the fact that we never see celebrities looking like humans,

we only see them all glammed up.

There’s so many factors this can come from just learned behavior in a family. I

remember seeing on TV, a woman talking about her eating disorder

development and that her whole family would eat dinner and then they would

go move into the room with the television and order pizzas. And everyone in the

family would get their own pizza to eat while they watch TV.

And this was after dinner. So, you know, to me, some of these behaviors that are

learned are not perceived as dysfunctional at the time, but if we’re still doing

them later in our lives, they may now have become dysfunctional behaviors.

Another example would be something like sort of food rules, like a lady doesn’t

eat blank or doesn’t weigh blank or, you know, different kinds of messages that

we get that, you know, the solution is not necessarily an easy solution just

because it’s not biological. It might be very difficult to untangle these messages,

but it’s important to sort of try to find the source of dysfunctional eating

behaviors because that’s going to lead to the appropriate treatment.

[00:22:38] Melissa: Right? So each of these four different types in and of

themselves there’s a variety, like you said, there’s millions of reasons. Cause

there’s millions of unique individuals. Yes. But to your point, the goal is to try to

find the right treatment for the right person. And if you’re trying to treat

somebody with addiction related behaviors.And you’re just talking about diet culture, you kind of missing the point and

vice versa. Right?

[00:23:07] Jessica: Exactly. Exactly. And I do feel like that’s the dilemma that a

lot of people who have tried to find treatment for their eating disorder have

encountered that people are grouped together based on their outward symptoms.

So here’s three people who don’t eat enough to sustain life. They’re going to get

the same treatment. Here’s three people who use compensatory behaviors after

they eat. They’re going to get the same treatment. But if you put someone who

had a concussion in a group with someone who has had food insecurity in their

life.

I’m not saying they don’t have lots of things in common, but they don’t

necessarily have the same condition. And so therein lies the story of three bears

that I often tell the three bears and Goldilocks, which is that the three bears were

all coughing and Goldilocks came along and gave them each a cough drop.

And Papa bear said, oh, thanks, Goldilocks. I feel much better. And mama bear

said in between coughs, Well, that didn’t do anything for me and baby bear,

didn’t say anything and just started turning blue and passed out and they had to

call 9 1 1. Well, they were all coughing. They all got the same treatment. Well,

Papa bear, he had a sore throat.

So a cough drop was great – solved his problem. Mama bear had tuberculosis,

so a cough drop isn’t going to do anything for her. It’s just going to cough it right

out. Probably. And baby bear was already sucking on a cough drop. And two

cough drops was just too much for his little trachea. And so he actually started

choking because it blocked his airway.

So if you don’t look at what is the root of someone’s outward behavior, then,

how do you know you’re giving them the right treatment? And unfortunately, in

a lot of cases, not all, but in a lot of cases, that’s what traditional eating disorder

treatment is. It’s, let’s look at your outward sign of behavior and then let’s give

you a treatment based on that.

And some treatment is even based on what someone weighs, which has nothing

to do with the origin of their dysfunctional eating behavior. So a lot of missed

opportunities, as we said before.[00:24:59] Melissa: And you had mentioned, just because something might

have happened to you long ago, or it might seem just a long ago, memory

doesn’t mean it’s not affecting you today.

And I can appreciate the challenge here to kind of connect all the dots. And help

people do that for themselves as well. How, you know, I remember thinking

when I was working as an outpatient dietician that, gosh, you know, I can’t, I

need a degree in psychology to help these people, or I need to work closely with

a therapist.

Where are things at with that today regarding dieticians and therapists working

together? I mean, I know like tele-health has probably helped a lot of that

because you know, just the logistics involved. Where are things at with that?

[00:25:43] Jessica: Well, there’s a big difference between our training, right?

Dieticians are trained to work in a team approach. Therapists are often trained to

work very independently. Everything is confidential. So you can’t really make a

generalization about dieticians and therapists. I think there is a group of or, you

know, many therapists who really respect and value the input of dieticians and

are really good at working together.

I know I found that when I was working, there were, you know, certain

therapists that, you know, a patient would say to us, wow, did you talk to Suzy?

Because she said the same thing, you know, where we’re really kind of sharing a

wavelength. And then there are other therapists who don’t want anything to do

with the dietician, or they are sort of one modality therapist.

They really are very strongly into whatever that modality is, whether it’s FBT or

CBTE and those modalities don’t involve dieticians. So that’s fine, but it’s not

going to be a good working relationship if a patient wants to see a dietician and

one of those therapists. So I think it just depends. As far as what is the

dietician’s role there?

You know, first of all, let me just mention that I did do a workbook called Food

Fairytales, which is about delving in on your own for someone who isn’t really

ready to talk about it with a professional to just start delving in, on your own, on

what are those childhood messages and experiences that you had.

And so we can put a link to that in the show notes and even put a discount code

for people if they’re interested. Great. As far as what is the dietician’s role versusthe therapist role? I think it’s really easy to me to say what the difference is. And

I will say, this is the number one question that dieticians always ask during

eating disorders Boot camp is how do I know that I’m not being a therapist?

And the easy answer is if you didn’t sleep, walk to school and go become a

counselor, you’re not accidentally being a therapist.

Dieticians and therapists both use counseling skills. But to me, the biggest

difference is what the topic is. So we might all use motivational interviewing or

mirroring or active listening or unpacking or all these different things

redirecting, reframing, but what makes the difference is that a therapist is using

those tools on things that are separate from what the dietician does. So the

dietician’s scope of practice is anything related to food and eating. And then

there’s, you know, some aspects of body and body size and things like that.

And then the therapist is using those exact same tools sometimes but to delve

into things like adverse childhood experiences and future dreams and

aspirations and career goals and time management and family relationships.

And it becomes really easy when you think about it that way to realize that as a

dietician, I’m only talking about family relationships as far as they relate to

someone’s food and eating. Once I realize this isn’t about food and eating, then

it’s real easy to say, you know what? I’m a good listener, but I don’t think I’m the

right person to advise you on this. Do you have a counselor? Or a best friend or

who helps support you when you have this kind of dilemma.

So it becomes really easy as a dietician to sort of you know, draw that line

gently, but for us and for the client and say, oh, you know what, this isn’t my

area of expertise. Now it might be different if you’re talking to a friend, but

when you’re talking as a dietician, your area’s really the food and nutrition

aspects.

And so it becomes really I think obvious once you get there, but sometimes you

don’t get there until you’ve gone down a bit of a rabbit hole. So I’ll give the

example of someone who let’s say is talking to a dietician about their specific

way that they like to eat. And they mentioned that they went to someone’s

wedding and that person did not accommodate their eating style and they just

felt very left out.

And so the dietician is kind of going along this conversation, thinking, okay,

we’re talking about how they manage their eating and what did they do in this

situation? But over a few minutes, you realize, wait, this is not about food andeating. This is about feeling insulted. This is about their relationship with that

person.

And when you realize that that’s when you can say, oh, you know what? I

thought we were talking about your eating, but I realized this is really more

about your relationship with that person. So I think this might be better

addressed with your counselor, and then you bring the topic back to eating. And

the easiest way to do that is to say, how did that affect your eating?

Right. We can always bring it a – almost always there’s exceptions to everything.

We can almost always bring a conversation back to food and nutrition and be

right there in our scope. And just to comfort those dietitians that worry,

sometimes I’ll say this, what a client or patient brings to you and says to you

does not make you in or out of your scope.

It’s what you say back. So if someone tells you something, that’s not really a

dietician’s area, you just simply say. Oh, you know what? That’s not really my

area. Is there someone else in your life that you could talk to about that? And

that’s all you have to say, just because someone told you about some experience

or something that isn’t related to food doesn’t mean you’ve done anything

wrong.

And I know as a new dietician, I thought that sometimes I thought, why is this

person telling me about X, Y Z. This isn’t about nutrition. And I realized that it’s

not the patient’s role to determine what is, and isn’t about nutrition. It’s my job

as a dietician to sift through it and find out where the nuggets that I need to take

and help with nutrition related advice versus which are the nuggets that are not

in my area.

And sometimes that does take practice, but like I said, it’s not ever wrong to talk

through something with someone, as you think you’re going towards food and

eating, and then they realize, oh, you know what? That wasn’t about food and

eating after all. And as a hospital dietician, this is another question you

mentioned that we haven’t really talked about yet, but that idea that I don’t know

what to do with this person to help this person in a short term situation, there

isn’t a lot you can do. You don’t have to figure out the origin of someone’s eating

behavior. Really the key in a short-term situation is to figure out, is there

anything that can nourish that person that you can provide?

So is there anything that they can keep down? Is there anything they can

tolerate? Is there anything they’re willing to eat? And even if that’s not the mostnutritious combo then, can you provide that in a safe environment for someone

to eat? And that’s really the key to the whole operation. And I do remember

many times recommending things that I thought, oh, my internship director

would not be impressed with this meal plan that I just gave someone because it

wasn’t balanced at all, but it wasn’t about balance, right?

It was about, is there something that this person can use as sort of a starting

point for practicing nourishing themselves?

[00:31:46] Melissa: Thank you so much for illuminating the therapist aspect,

the scope of practice, because I can imagine that that’s a huge barrier for

dieticians and that reassurance and that those guidelines are very helpful.

[00:32:01] Jessica: People often say to me, well, how do I know I won’t make

their eating disorder worse? And I always just think, you know, what? If they’re

in the hospital with an eating disorder, it’s already pretty bad. So you having

some compassion and listening and trying to find a way to help is already a step

in the right direction.

There’s not, I mean, again, there’s exceptions to everything, but there’s not a lot

you can do to make someone’s eating disorder worse when it’s already in that

place. I would say that the number one thing you can do, and unfortunately this

does happen, hopefully not by dieticians, but that can make someone’s eating

disorder worse is to say, well, your eating disorder really isn’t that bad.

Or, you know, based on your weight, you don’t really have an eating disorder.

Those are things that can make someone’s eating disorder worse in a sense that

they can discourage someone from getting the care that they need. But other

than that, Trying to help is a great service. And then the other piece is trying to

get them to the appropriate care that can help them more.

And that often falls to the social worker. But sometimes as a dietician, you may

have, you know, a network where you can ask, you know, where would be a

good place to recommend for this person or who would be a good dietician to

see them for the longterm.

[00:33:06] Melissa: Wow. That’s a powerful concern. How do I know I’m not,

not just not helping, but making it worse.

What are some other common pain points or concerns that you hear that I

assume we could talk about your eating disorder bootcamp in a little bit aboutlike, you know, what you cover and what, what you really feel like most

dieticians who just want to be better practitioners, like you said, I think it’s a

really important point that you don’t have to want to specialize in this.

We need more practitioners to just be a comfortable with this. Like I’m a

certified diabetes educator, but a lot of dieticians will talk with patients about

diabetes, you know, it’s going to happen and what can you do to improve and

increase their comfort level?

[00:33:48] Jessica: There’s a couple of things that I would say to dieticians that,

you know, I sort of learned the hard way and maybe I can save you some time.

One is that people who find it easy to change, aren’t seeing a dietician, right?

They just did it. They just changed. Or they saw a dietician one time got some

advice changed or they read a book and changed. The only people who end up

seeing a dietician usually are people who find it difficult to change and need

support and help.

And so there’s that aspect of what you had mentioned. I think at the beginning

of like, am I really helping? Or this is so frustrating. Well, yeah, if you’re

frustrated, believe me, that person who’s trying to change is frustrated too. And

so a lot of times my soundbite in that situation is something like, you know

what, you’re bringing a lot of work to the table.

I know I’m a good dietician, but it seems like the skills that we each bring to the

table are not adequate to manage this situation. So who can we bring in that

might be able to help us? Or who can we bring in that might have more

information and through that sort of involving family members, or maybe even

someone like a roommate.

Anyone that might be able to help support someone or provide more

information. I’m a big believer in getting more people on board. That could be

someone who’s a specialist in time management or in learning disorders. There

are so many different aspects that food intersects with that it’s really okay to say

as a dietician, I’m bringing my best to this situation.

And yet there doesn’t seem to be a lot of progress in the way that the client is

hoping for or that I’m hoping for. And so to bring more people on board, we

don’t need to fill ashamed – the same way someone, an individual shouldn’t feelashamed about their eating. We, as dietitians don’t need to feel ashamed that

we’re having difficulty helping someone.

We don’t even know what cures eating disorders. We don’t have a set protocol.

So a lot of it is creativity on the part of the dietician, trial, and error, seeing what

will help. And it’s really important not to judge yourself as a dietician. On the

other hand, if you feel like you’re outmatched, you can always get consultation

from another dietician who is a specialist in eating disorders.

And ultimately to me, I would rather coach someone who already has a good

relationship. So if you’re someone’s diabetes, dietician, and they need help with

an eating disorder I would rather coach you on how to help them because you

already have the relationship with them rather than sending them to me or to

another eating disorder dietician that they have to start over with.

Because to me, the relationship is so much of the de-shaming and the freedom

to talk about the things that are going on that I don’t want to disrupt that, but at

the end of the day, if someone listening feels like this is just not my bag. I get

too frustrated or I really feel like, I don’t know how to help no judgment on that

either.

It’s good to know yourself. And you can always simply say, you know what,

based on this new information or based on these symptoms that you’re sharing

with me, I’m really glad and honored that you shared, but I may not be the right

dietician for you. I’d like to help you find someone who specializes in that area.

And that’s okay, too. So there’s really no right or wrong, staying with a patient

and getting consultation to help you or saying I’d like to refer you on to

someone else. It’s really a decision that, that you have to make for yourself. And

I would say in consultation with a colleague, you know, our ethical guidelines I

have to say are very vague, but for the most part, what I take away from our

dietician ethical guidelines is the ethical dietician will consult with

knowledgeable colleagues when they have a dilemma.

And so it might make sense to talk it through with someone on your team and

say, you know, I’m not sure if I’m the right person, should I get consultation or

should I send them onward to someone else? I think that those are some of the,

you know, you kind of were asking about sort of pain points, but I think that’s a

lot of what I hear from dieticians is just that worry of, you know, am I

abandoning someone if I recommend someone else? And I don’t think that’s thecase at all. You’re actually bringing someone else on board the team in order to

help in a way that’s different from the skills that you have.

[00:37:35] Melissa: Oh, this is very interesting. And I can see, as you’re talking

for me, there’s some parallels with diabetes. I continue to learn with new

patients and new medications and new situations. And I find that invigorating. I

find that very interesting. I don’t find it daunting. I don’t feel insecure about that,

but with eating disorders, I can see that like some dieticians might find that

continual learning and growth in that particular cope very exhilarating as well

and very fulfilling. So I’m really glad that you’re bringing people into the fold..

[00:38:33] Jessica: Well, and that’s why there’s different specialties, right?

Yeah. But I do think a lot of people in school got the message that there is no

role for dieticians and eating disorders, or it’s a very rare job and that’s just

completely wrong.

We need more dieticians in the eating disorder field. If it’s an area, you have a

passion for. Absolutely. Let’s get you specialized in it. If it’s an area you don’t

want to specialize in. That’s great too, because we need dieticians in the other

areas too. It’s just helpful to have some knowledge of eating disorders, because

as we said before, just because you don’t specialize in this area, doesn’t mean, I

mean, maybe if you do research studies with, you know, rats, but that’s the only

situation I can think of anyone who’s doing any kind of counseling with humans

is encountering people with dysfunctional eating behaviors, but there’s a

difference between being an expert and having a working knowledge.

[00:39:20] Melissa: And I think that’s the most powerful thing that I’ve learned

from you, besides of all, all the interesting intricacies about like the different

types of eating disorders, but just the point that we can have more dieticians

have that comfort level and confidence. And that, that way we can help that

many more people. You just published an article I’d like you to tell us about –

you surveyed some dieticians.

[00:39:43] Jessica: Yes. So Paula Quatromoni and I surveyed 182 dieticians

responded. We asked questions about job satisfaction. And what’s your

workload like and where did you get your education on eating disorders? And

one of the biggest findings that we had when looking at the results was that

most dieticians who, and this is dieticians working in the eating disorder field,

most of those dieticians did not get any training in school related to eating

disorder care.We, and I include myself in this group, we got our education from continuing

education that we did separately. I mean, there’s some on the job training in

some cases, but for the most part, it seemed like dieticians were paying for their

own supervision and consultation with more experienced dieticians paying for

their own conferences and other kinds of continuing education.

There wasn’t a lot of support on the job either. And so what we found was that

the most acute patients are being seen by the least experienced dieticians. And

we thought that that might have an impact on patient care, which isn’t something

that we studied, but it was one of our sort of possible items for future research.

And to me, every dietician should have, like we said, some education on eating

disorders and not just that one paragraph in a nutrition textbook that sort of

gives the diagnostic criteria, but it could roll into all counseling skills. And one

of the comments on our survey, which I thought was so crucial that we included

in the article was that they said that some level of eating disorder knowledge is

important for people working everywhere from corporate wellness to any other,

you know, area of dietetics. And I think that’s true. That really supports what I

think also. Simply because eating disorders – I’ve had conversations with

people who are sort of high up in different dietitian organizations.

And they say, well, you know what? Eating disorders is just never going to be in

our top 10 of priorities. And when I look at the top 10 of priorities, every single

one of them overlaps with dysfunctional eating behavior, food insecurity,

overlaps, dysfunctional eating behavior. Hunger and environmental nutrition

overlaps with dysfunctional eating behaviors, diabetes care, renal disease, every

single thing that’s in the top 10 is going to intersect with dysfunctional eating

behaviors in some way, whether it’s caused by them, whether it promotes them.

And so to say, it’s never going to make it into our top 10. I sort of laugh at that

and say, you’re right, it’s an umbrella over all of your top 10, but I haven’t quite

been able to get that message to the large organizations. That’s why I actually

ended up starting my own organization for eating disorder, dieticians or eating

disorder, interested students.

And we have a thousand members. So obviously there was a need for an

organization just for eating disorder dieticians.

[00:42:35] Melissa: Wonderful. Is that the eating disorder bootcamps or is that’s

something else?[00:42:38] Jessica: No, no. That’s the international Federation of eating disorder

dieticians, and we can put a link to that in the show notes.

[00:42:45] Melissa: Perfect. Wonderful. Well, I will say the diabetes world

hears you loud and clear. We’ve long known that diabetes and disordered eating

can very much go hand in hand more typically with type one because they tend

to be younger going through adolescence and puberty and everything, but

certainly with type two as well, you know, anytime that you have to, I shouldn’t

say, have to, but you’re called to change your eating habits and you’re

monitoring all of this stuff and your blood sugars and everything. It’s just, it can

be a lot and it can trigger a lot of things.

[00:43:18] Jessica: Well, sure. Because it triggers anxiety and anxiety can

influence food and eating behaviors. So, yeah, absolutely. I agree. And I’m not

talking about dieticians in the field.

I do think dieticians in the field, absolutely in many areas recognize the need.

It’s more of the organizations that are in charge of what students learn that I feel

like have not gotten the message.

[00:43:40] Melissa: Connecting those dots for sure. Well, you know, and I

could say the same thing about communications, but I do think that’s improving.

Gosh, you know, communications should be an integral part of everything that

dieticians do on every level. But I think that that’s improving.

So we talked about the four different origins and I would like to take an

opportunity to have you talk a little bit more about that fourth origin, the

external environment, diet culture because it’s, it’s just such a hot topic right

now, and I have not addressed it much on the podcast.

So I would love to kind of hear your little brain dump on what’s going on with

that origin and any insights you can share with us, whether, you know, we’re a

person struggling with this. And I think, I mean, I think everybody is impacted

by what we see in diet culture, from our own personal perspective, all the way

to a healthcare professional.

[00:44:29] Jessica: Oh yeah, absolutely. We are. Yeah. Well, we’re recording

this during eating disorders awareness week. I just gave a talk last night to a

college kid. And, you know, a big piece of what we’re sort of seeing with the

rise in eating disorders during COVID has been building for a long time. Sothere have always been aspects of the culture that have promoted you know,

your body isn’t good enough. And therefore you need a product. Whether that

product is a diet, whether that product is shampoo for your frizzy hair or razors

to shave your legs, right? There’s, there’s so many economies, industries that are

based on the idea that your body isn’t good enough as is. There’s products to

make your body bigger, products to make your body smaller, products to make

different parts of your body bigger or smaller.

Right. And so it’s really important to keep in mind that this is not new. And

something that was new for me was to learn that racism is a big factor in that.

And that the ideal of whiteness is a big factor in some of the things that we sort

of imagine to be you know, that appearance ideal. So like I said, you know,

frizzy hair, less body hair, you know, having pale smooth skin, like there’s so

many things in sort of our cultural beauty ideal that are based on racism and

based on separating people into categories. And so it’s so not new. The only

thing that’s new is the difference in sort of technology in distributing those

messages. So where in order to look back at the messages, let’s say from the

1920s, you’re going to have to look at newspaper and magazine ads for

products. That’s where you’re going to see the beauty ideals of that era. Now

you look at Instagram or, you know, by the time this recording comes out, there

probably will be 10 new platforms. Right? You look at Tik TOK, you look at

social media and that’s where we’re getting our information about the body

ideals or the beauty ideals that supposedly we’re supposed to conform to.

And the bottom line is they’re all about things that we don’t even realize. We’ve

internalized them as being our own desires or we’ve even been, you know, sort

of lied to and told that these are sort of biological genetic constructs, like it’s

normal for, you know, let’s say men to be attracted to women with big boobs

and things like that.

We think we’ve been taught that’s in our genes and really its just a preference!

And it’s a preference we’ve been taught, you know, so that kind of thing, it’s

just, I wish we could look at bodies and just say, you know, basically there’s a

diversity of bodies, just like there’s a diversity of everything else. And I heard a

really good example.

I didn’t make it up. I wish I did, but it was something. You know, you don’t burn

a Picasso just because it’s not the Mona Lisa. Right. You can admire both of

them and think they’re both beautiful. And so it’s really about expanding our

minds to accept that even if we all ate the same foods and exercise the sameamounts and got the same haircut, we would still all look different and that’s

normal and that’s okay.

And so that is such a hard concept though, when you’re looking at yourself in

the mirror and whatever parts you don’t like seeing emphasized. It’s so

important that we recognize that we are being influenced by so much more than

our own beliefs. That’s what food fairytales is really about is looking back and

trying to figure out what messages you got.

And unfortunately, some of the messages conflict, and that’s because they’re not

real, right. If they were real, there’s only one truth. Right. But if, sometimes you

feel too big and sometimes you feel too little, neither one of those could

possibly be true. Right. If sometimes your hair’s too curly and sometimes it’s too

straight, you know, neither one of those is true because it can’t be the same

thing.

If you’re in a bad mood and suddenly you look down and your body seems to

have changed, that can’t be right. But we tend to think, we believe in our own

thoughts, let’s say. And so another sort of touchstone that I go to sometimes is

don’t believe everything you think. And maybe that will help someone who is

listening to this, you know, just very simple, write it down.

Don’t believe everything you think. Thoughts are just chemicals in a way, you

know, sort of like leaves floating down a river and you get to pick which one to

believe. So if your, your thoughts are equally not factual, why not pick the one

that says instead of the one that says I’m never good enough? And you know, it’s

not that easy to change, you know, I’m not saying it’s simple, but I think that you

know, accepting that diet culture or appearance culture or racism or genderism

or sizeism or ableism are all factors that are affecting us, whether we realize it

or not. I think that’s a first step, at least in untangling ourselves from, we cannot

untangle ourselves from culture unless you go live in a cave, but untangling

yourself from being so impressionable by the culture.

[00:49:10] Melissa: Very good. Very good. Yeah. I touched on the racism aspect

a little bit back on an episode, I believe it was called the science and culture of

obesity and it’s a two-part series. And I believe it was part two with Noel

Theodosiou. I will link to that in my show notes as well. If anybody’s interested

a little bit more, she’s a behavioral scientist you know, kind of just looking at the

origins of you know, some of the, what you mentioned, like thin ideal or youknow, the pale skin and, and all of that. And what culture says is attractive. So

just wanted to mention that.

As we’re wrapping up here, I want to hear any just general takeaways you have

or specific takeaways that you have for people who might be struggling with

disordered eating body image issues, and then also some takeaways for

healthcare professionals.

[00:50:03] Jessica: Sure. So for individuals who are struggling, which by the

way might also be healthcare professionals, right? It’s not two distinct groups.

Exactly. But anyone who is thinking, you know, well, my problems are so

minor, no one wants to hear about them or they don’t rise to the level of, you

know, you can’t see my finger quotes, but an eating disorder.

It’s not that big of a problem. I would just encourage you to think about the way

that what I learned from the college speakers when I was on a college speakers

bureau, they talked about alcohol abuse and they speak about it in a different

way that I remember when I was you know, that age and I, it’s not about how

much you drink.

It’s not about what you drink is not about which kind of alcohol you drink. It’s

not about how early in the morning. It’s about do problems happen when you

drink? That is the key issue with food as well. Do problems happen when you

eat or don’t eat? Because like I said, the same person could eat the same six corn

dogs and they’ll really fueled for their marathon.

Whereas there’s another person can eat six corn dogs and feel like they don’t

deserve to live. And not sure why I thought of corn dogs. I must be craving corn

dogs, but my point is, don’t worry about how you compare to others or how you

compare to even to yourself at a different time when maybe you did feel like

you had an eating disorder, think of it as do problems happen when you eat and

whether those problems are mental or physical or anything else, social.

Do you feel like you have to eat by yourself, you have to eat alone because

you’re embarrassed of your eating? I mean, these are things that are problems,

even if, you know, we don’t recognize them as a society as problems. And so I

would encourage you to meet with an eating disorder dietician, even if you don’t

feel like you identify with the word eating disorder.

Because that eating disorder dietician is going to be the person who can help

you sift through and see what is nutrition related and what isn’t. Because ifyou’re trying to solve problems with food or with not eating, that aren’t really

food related, it’s going to be very discouraging. And so I really encourage you to

talk with someone, if not a dietician, then a counselor, if not a counselor then a

best friend or someone supportive, that can be a good listener.

[00:52:04] Melissa: I want to just jump in. And you mentioned a couple of

times about kind of realizing, and these are my own words, but it’s kind of

paraphrasing what you’re saying. I think. when you realize your behaviors are

not really connected to the problem, or like, it’s not about food, I think that that’s

really powerful.

I remember learning that and that was like a really light bulb moment for me.

And I talk a little bit about my eating journey. I’m not going to say eating

disorder – my disordered eating issues a little bit. In an, in an episode that I did

with ballerina dietician. And I’ll link to that in my show notes as well.

But when I made that connection, it just like, it was a light switch. It just really

flipped everything for me. So I think it’s really powerful to reinforce that idea

when it just sort of helps kinda take a step back and reassess everything. I don’t

know if that’s, if that makes sense.

[00:53:00] Jessica: Yeah, I agree. And I had that kind of epiphany too –

realizing what I was doing with my eating wasn’t really about food.

It was about my feelings, about a particular person I had a crush on. So, you

know, absolutely. I think. There are lots of ways that dysfunctional eating

behaviors are not about food, but I think there are ways that they are too. And I

think that it’s easy for a dietician sometimes to say, well, I have no role here

because if this isn’t really about food, but I think it’s so important that there’s

both roles because no, it’s not about food, but when someone has been doing

behaviors with food or believing things about food, they don’t just change just

because they may solve the underlying issues.

Let’s say someone’s depressed and it’s affecting their eating. Maybe in a very

few cases, solving the depression, solves the eating – houray! But in a lot of

cases, someone’s going to need help with their depression and help with their

eating. And so that would be the message that I would leave with the health

professionals listening is that, you know, there is a place for a lot of different

pieces of the puzzle, someone who is struggling with their eating, maybe

compensating for some kind of medical issue, that’s been undiagnosed.We need to get a doctor involved, right? Sometimes an endocrinologist.

Sometimes a cardiologist. Don’t feel like you have to be the person who is doing

this alone. It’s, it’s actually, in my opinion, not appropriate to be doing it alone.

And so, you know, the same way I would say to an individual who’s struggling.

Try if you can to remember my words that, you know, whatever you’re doing, it

may be causing problems, but it’s nothing to be ashamed of. It doesn’t mean

there’s anything wrong or broken about you. Same thing with a health

professional that feels outmatched by someone’s eating disorder. It doesn’t mean

you’re wrong or broken, or you missed that day in school, you’re dealing with a

very difficult issue.

And I’ve said many times, you know, sometimes we only realize later that your

eating disorder is more severe than what we wanted it to be, or it’s more tricky

than what we wanted it to be, because if it wasn’t, you would have solved it a

long time ago. And so that’s why we need to bring someone else on board onto

the team.

So I guess my biggest message that goes to both individuals who are struggling

with their eating and professionals is simply, you know, don’t try to do it all

yourself. It’s not a DIY project. I know nutrition is sort of promoted out there as

something you can wrangle yourself, but to me, you can’t solve a problem with

the same mind that created it.

You’ve got to get at least one additional pair of eyes, maybe sometimes more

than one with different skillsets. And it’s okay if those people don’t agree, but

it’s really important to get other people helping you. It, it just, I think eating

disorders thrive in isolation and we need to sort of open the doors to individuals

to get care.

And there’s a lot of barriers and I hope you will not let shame be your barrier.

[00:55:34] Melissa: Thank you so much. You’re saying so many powerful

things. I’m sitting here going. Oh wow. So thank you, Jessica. Where can people

find out more information? I know you have a website and your social media

handles, and also if you want to just share like what people can find in the

eating disorders bootcamp too.

[00:55:52] Jessica: So my umbrella homepage website is Jessicasetnick.com.That’s where you can go to, you know, bring me to your campus to speak or

anything like that, schedule a consultation and then eating

disordersbootcamp.com is where the information on eating disorders bootcamp

1. And it’s really comprehensive. There’s three audio workshops. There’s books

that come with it. I mean, it’s really more than I can say right now, but you

know, you’re welcome to check it out on the website.

I just rerecorded a new introduction to eating disorders bootcamp, and that is

available as a free download with the slides for anyone who wants it, whether

you’ve taken eating disorders bootcamp before or not. You can listen to that new

introduction if you’d like to. Okay. But, yeah, I mean, I feel like there’s also

other people’s courses and I have a list of other resources on my site.

There’s a lot more out there than there used to be. And we can put a link to that

list of resources, even in your show notes, for someone who’s more advanced

that might be looking for something more advanced. I’m happy to help in any

way I can, you know, I wish that I could say I foresee the end of eating disorders

in my lifetime, and I could just retire and talk about it as like this thing that we

used to deal with, like polio, but I don’t see that happening. So we’re just going

to need lots more people who want to help.

[00:57:05] Melissa: And hopefully talking about it more helps remove some of

the mystery and stigma and barriers to access. So thank you so much for the

amazing work that you’re doing and for coming on my show and sharing all of

this important information. I’ll have people check out your website, but like you

said, we’ll have links in my show notes as well at soundbitesrd.com.

And I hope to see you in person sometime soon.

[00:57:29] Jessica: Yes. Same. Thank you for the platform. I really appreciate

the opportunity to spread the word and yes, I hope we get to see each other in

person as in-person meeting starts coming back.

[00:57:38] Melissa: Absolutely. Thank you again. And for everybody listening

as always enjoy your food with health in mind. Till next time.