Lately I have seen an uptick in clients who “look” fine on the outside need urgent medical care. This got me thinking about the lies that the eating disorder voice (“Ed” for short) tells us.
Ed wants to be in control (which is funny because most people with eating disorders think they are in control. Silly humans.) and will tell you lies to keep up the disease process.
Have you ever hear the voice in your head say:
“You’re not thin enough yet.”
“You are not sick enough/you're not as sick as [other person].”
“Your heart rate is so low because you work out so much”
“You’re doing fine, you can [insert ED behavior] more [often/more strictly]”
“You’re the exception to the complications, it won't happen to you.”
Or something similar?
These are often precursors to the downfall of health.
Recently, I saw someone who had been dealing with bulimia on top of being an athlete have such low iron that she needed an immediate blood transfusion in the emergency room (Thank you to the doctor I work closely with for catching that!). I had another client peeing reddish urine with a “puffy” body that she said was hot to the touch that we believe is doing damage to her kidneys (or maybe experiencing rhabdomyolysis) from restricting (she ended up in higher-level care). Another is having severe gastrointestinal issues that are most likely due to years of laxative abuse and restricting that was misdiagnosed as “gastroparesis” until she finally saw a specialist.
The thing that all of these clients had in common? They said they were “fine” and didn’t need to go to the doctor. They weren’t “that bad” in their ED behaviors.
This is what scares me. How many people are walking around with medical issues that they have become so used-to that it feels normal?
PSA: Tell all of your providers from primary care physician, to specialists to therapists and dietitians about your eating disorder. Yes, even if you haven’t told anyone else. We can’t help you if we don’t know what is going on, and some providers won’t ask.
If you are struggling with disordered eating please take this as your sign to make sure you are getting regular check-ups from medical professionals that understand eating disorders and the hidden dangers. It can save your life.
Don’t wait to seek help. You have to be your own health advocate.
As a RD, I have gotten so many questions about the fad diet du jour: the "Keto" or "Ketogenic" diet. I finally decided to just write down the research in a reader-friendly version. Additional video on the history and use of the ketogenic diet at the bottom of this post. Here you go-
The ketogenic (or “keto”) diet is just another fad diet.
The Keto diet is an amped-up Atkin’s diet (that we all know now was/is terrible for your cardiovascular system, and not a sustainable way to keep weight off) where the majority of what you eat comes from fat, and carbohydrates are extremely limited (In contrast, a healthy diet should be a much more balanced macronutrient distribution of 20-35% protein, 45-65% carbohydrate, and only 10-35% fat). This skewed macronutrient distribution is actually very dangerous for the human body for several reasons -
#1, We use carbohydrate as fuel for our brain. Glucose is needed for cognitive function, and many people on the Ketogenic diet experience brain fog and difficulty focusing. Ketone bodies (specifically: beta-hydroxybutyrate (built up in blood serum), acetoacetate (found in urine), and acetone (responsible for that bad breath)), which are created when carbohydrates are not present, are not as effective (or healthy) for our brain. This may also cause metabolic acidosis which is characterized by a reduced pCO2 and/or lower pH (we need to stay in balance!).
#2, On a ketogenic diet, your intake of fruits and vegetables is extremely limited (if eaten at all) and we all know how important the fiber, vitamins, minerals, and other compounds in fruits/veggies are. On that note…
#3, The keto diet is extremely low in fiber! Fiber is not only protective against many gastrointestinal cancers, it is also a big factor in fullness and weight loss. Furthermore, constipation is very common on low-fiber diets like the Keto diet.
#4, Ketosis/ketoacidosis is what is happening in the body/brain on a chemical level – this is the body making fat into something the brain can use when carbohydrates are not available. It's a lot of work for the the body to produce, not as efficient as carbohydrate, and can be incredibly dangerous for diabetics. Additionally, we have some cells with few-to-no mitochondria. These cells are carbohydrate-dependant and must be fueled by glucose. These cells include certain cells with no mitochondria in our blood (erythrocytes), eyes (cornea, lens, and retina); cells with few mitochondria include renal medulla, testis, and leukocytes. (https://link.springer.com/article/10.1007/s11883-003-0038-6)
#5, “Keto breath.” Halitosis (bad breath) from (acetone) ketone bodies makes for an acetone-like smell on your breath that no amount of brushing/mouthwash can fix. Medical professionals look for (smell for?) this in malnourished patients.
#6, High blood lipids/cholesterol/blood pressure. It’s a high fat diet- you didn’t see this coming? The body can only break nutrients down at a certain rate, and high levels of fat in the diet may lead to high levels of blood lipids are responsible for blockages (atherosclerosis), and other cardiovascular complications up to death. While you can reverse the numbers, the plaque buildup in arteries is almost impossible to reverse. Not worth it! (note: some people do see lowered blood lipid profiles on this diet).
#7, Following this diet is often a form of disordered eating or may lead to an eating disorder (just as with any restrictive diet). Cutting out whole food groups is not healthy. We need all 3 macronutrients in appropriate proportions (majority coming from carbohydrates) to have a healthy body. Our body needs a variety of foods for best health. The reason this diet “works” for weight loss is that it restricts the types of foods that people tend to over-do-it-on like chips, candy, pastries, etc. Any diet that cuts out your favorite foods will cause weight loss, but at what cost (physically and mentally?)
#8, Not all fats are created equal. Most people starting a Keto diet are not differentiating between saturated (solid at room temp, and not something we want in large quantities) and unsaturated fats (liquid at room temp, and “healthier”). Getting this wrong also increases complications from the diet. Additionally, many people who followed a diet high in medium-chain-triglycerides (MCT) experienced undesirable digestive issues.
#9, It may mess with your thyroid and other hormones – lowering your metabolism (isn’t the point of this diet weight loss? That’s counter-intuitive…), energy, and fertility. Every time we lower our metabolism through dieting it lowers the “set-point” of our metabolism, making it harder and harder to lose weight. This is an adaptive response for mammals in famine, but not what the average person wants nowadays.
Who it the Keto diet appropriate for?
The only population that the ketogenic diet is scientifically proven to be beneficial (and safe) for is a select group of people with epilepsy (seizure disorders). This is the position of the Academy of Nutrition and Dietetics.
The Keto diet especially sucks for athletes (and people working out to lose weight)
Since our preferred fuel source is glucose (carbohydrate) from either blood glucose or glycogen (fancy term for carbohydrate stores in the liver and muscle cells), running exclusively on fat slows athletic performance as the body works much harder to break down fat (dietary and adipose storage).
Additionally, the lower protein intake and change in hormones in the body with a keto diet lower the ability to build and maintain muscle mass. If “mirror muscles” like biceps are not motivating enough to keep you off it- remember that our organs like the heart are also muscle tissue that would be broken down by this diet, causing organ damage or failure.
It’ll get you, mentally and emotionally
Ketogenic diets cause headaches, brain fog, and often irritability and obsession with food. This type of diet will very likely make you think about food an unnecessarily large amount of time, and make it difficult to be social (not being able to eat at the same places as your friends; oh, and that bad breath!).
You may feel more depressed (especially if you are already prone to depression and/or taking antidepressants) as serotonin (the “happy” neurochemical) is produced from carbohydrates. If you take an SSRI know that this class of medications work directly on serotonin that is present, and the diet requires a minimum about of carbohydrate (as we learned from the works of Ancel Keys in his starvation study) to allow the SSRI medication to work.
So, what’s the verdict?
In case you didn’t get it from the above – the Keto diet sucks. Not only is it a fad-diet (aka – not suitable for long-term weight loss/lifestyle), it can be very dangerous.
If you need help figuring out what to eat, contact a Registered Dietitian. In the meantime, if you do need some structure, balanced eating like the Mediterranean diet or DASH diet is a better way to go.
For a YouTube video with more information on this diet: click the image below
Don’t give up the foods you love. There is room for all foods in a healthy diet. We just need to keep proportions and variety in mind to fuel our body optimally.
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nsurance companies are sooooo frustrating to deal with - you are not alone!
Due to individual insurance regulations and federal rules there is no "set" coverage that all insurance companies have to go by. Your best bet when seeking coverage is to call your insurance company and get a Case Manager to walk you through the to-dos.
The earlier you contact your insurance company in the process, the better. Additionally, the more "evidence" for need of treatment (doctor's referral notes, lots of documentation) that you have the better.
I made a round-up of the previous 3 blog posts (updated the links so they are current)
that I wrote about on insurance and packaged it up in a PDF for you.
Get it here:
How to get your insurance company to pay for treatment
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Unfortunately, unless it is part of a treatment program, Dietitians are very rarely covered by insurance. (Wha?!)
You can petition your insurance for some reimbursement by asking your RD ("nutritionists" without the RD credential are never covered because they are not qualified) to send you a "superbill" for services that have been provided (typically annually or quarterly) to submit to insurance (after paying out of pocket) to try for reimbursement. With enough supporting documentation (again, referrals from medical doctors help a lot!!) you can often get reimbursement (no promises, each company has it's own ways of dealing with each individual).
Good luck!! I hope this helps!
If you have more tips on how to get insurance to pay please leave them in the comments below, or email me to have it included.
I am so glad you asked!
Most people don't know; and honestly that is why I am now going by "Not Your Average Nutritionist" as my new business name, despite being an actual Registered Dietitian.
*2018 update - YouTube video on this topic (see bottom of this post)
As of 2018: Anyone, even with no training, can call themselves a "nutritionist." Literally.
You can buy a certification online with no education, you can just call yourself a nutritionist without buying anything, or you can have a degree in nutrition and dietetics.
A Registered Dietitian (or RD, or RDN) is also a "nutritionist," but there is a key difference - specific educational requirements! The same way a medical doctor or nurse goes through specific training, degree programs, and supervised residency/internships, dietitians have requirements.
A RD has at minimum completed:
-A Bachelor's of Science in Nutrition and Dietetics (or a Master's Degree in the same, if their B.S. was in a different field). This is heavy in biology and chemistry courses that get more specific to the molecules that make up foods/vitamins/minerals, and how the body processes them. Classes in counseling and teaching are also important aspects of the nutrition curriculum.
-A dietetic internship (D.I.) of at least 1200 hours in a variety of settings that RDs work in, under supervision. This is similar to a medical residency, and has strict requirements for what must be experienced, and competencies met and signed-off by supervising RDs. Dietetic Internships are also highly competitive, with less than 50% acceptance rate (at least that was the case in 2011). The process of being accepted requires not only good grades, but multiple essays, recommendation letters, work experience, interviews, and fees to apply to most sites.
-Upon completion of the D.I., the person, will study for, and take a national registration exam of 140+ questions covering areas of clinical nutrition, calculations, food service, counseling theory, and metabolism. A passing score makes the test-taker a RD!
-But wait - there's more! Every 5 years, there is a minimum of 75 hours of continuing education that must be documented and submitted to the Commission on Dietetic Registration (CDR), including at least 1 hour of Ethics training, to maintain the credential. Most RDs, like myself tend to go well over our required 75 hours, because there is constantly more to learn!
What else is special about RDs?
-Registered Dietitians are the only profession that can legally call themselves "nutrition experts," and give "Medical Nutrition Therapy" (MNT). MNT is diets/diet advice for specific medical concerns that is beyond generic nutrition advice like "eat more vegetables." Some disease states are very nutrition dependant for life and health. Medical Doctors are legally allowed to give nutrition advice, and sign off on dietary components in clinical settings, but most MDs have had only class of nutrition education in their whole college experience! (Some, of course, understand the importance and go on to do more).
(pssst... get a free macronutrient handout HERE for general healthy eating)
RDs can have many different kinds of jobs.
-Many work in hospitals or clinical settings where they are dealing with acute illness, and providing MNT.
-Some (like myself) go on to have additional training in counseling skills and psychology, to deal with clients on a behavioral and mental health basis.
-Other's get additional certifications in specialty areas like diabetes (certified diabetes educator), or renal (kidney) nutrition.
-Some work in food service, creating menus, ordering food in bulk, running a kitchen staff (doing staffing), working with food allergies and calorie counts.
-Research /or/ Research and Development have many RDs working to find best practices or develop new food products.
-Education. Whether teaching nutrition in colleges, or teaching classes or individuals in public health, RDs have a lot of info to cover that can help increase quality of life and prevent disease.
-Work in food technology and agriculture to create more nutritious food or solve hunger problems.
.....and many more potential areas! The field is growing, and so are options for dietitians!
I believe the median salary is low, because most people still do not understand what RDs can do for individuals, and the world. My hope is that more people will understand the importance of RDs, and the difference between "Registered Dietitian" and "Nutritionist" so that the jobs will go to the educated.
"All RDs are nutritionists, but not all nutritionists are RDs." - Academy of Nutrition and Dietetics.
Get weekly education from this RD by signing up here:
(originally posted 12/25/2015. libbysfitnutrition.com)
Have you been looking at my (or other RD's) websites and brochures and not sure what to expect? Nutrition counseling is a very individualized service just like with traditional psychotherapy. Some dietitians create specific meal plans, analyze intake with nutrient analysis software, help you manage diabetes medications, learn what food do in your body, and so much more.
Make sure whoever you choose to go to for nutrition services has a "R.D." or "R.D.N." credential. This is a indicator of education level and national standards of practice. As with any profession, we hope everyone is ethical in their business practice, but trust your gut, and never be afraid of getting 2nd opinions.
What do I do, specifically?
"The primary goal of nutrition counseling is behavior change."
Herrin & Larkin, Nutrition Counseling in the Treatment of Eating Disorders, 2013.
Here is a list of services that one may experience when working with me.
-Diet "check-ups": I go over your food journals to see what you are eating on a regular basis and what is working for you or areas that need improvement.
-Medical Nutrition Therapy (or "MNT): This is what separates dietitians from "nutritionists" "health coaches" and "health educators." Medical nutrition therapy is something only RDs are legally allowed to do (and medical doctors, but they don't have our training) going over complex medical diagnoses that have nutrition related care and intervention. This goes beyond "eat vegetables" that nutritionists can cover. This is also why RDs are only licensed in specific states like MDs are.
-Nutrition education: What does food do in the human body? This is the R.D.'s expertise. We study anatomy, physiology, biochemistry, metabolism, nutrition for specif diseases, and many other sciences involving the human body and food. This is what I studied in college for 7 years, plus a year of internship, and continue to learn about. I love helping people understand how proteins, carbohydrates, fats, and micro-nutrients interact in the body and keep it healthy.
-Individual needs: How many calories do you need? How does your exercise affect how much you need to eat? What proportion of carbohydrates/ protein/ fat do you need? What about supplements?
-Have an eating disorder?: This is my specialty area, figuring out what someone needs to be eating to recover. By working on slowly changing unhealthy habits, I strive to create a safe space using positive body-image talk, intuitive eating principles, and a mindset of health at every size, while educating on what is occurring in the body and mind while in the disordered behavioral mind-set.
-Contact with your other medical professionals: If allowed, I will work with your other health professionals to create a united team approach for your best health.
-Go over lab values: Bring lab results from your doctor and we can look at what might be going on and if there is nutritional deficiencies or medical dietary interventions (note: only RD/RDNs are qualified to make medical diet plans - "MNT").
-Meal outings/ snack challenges: Optional, but helpful for normalizing eating socially for those with restrictive eating.
-Referrals: To appropriate therapists, doctors, websites, apps, books, etc.
-Exercise planning: Though I don't actively train anymore, I use my experience as a personal trainer, fitness instructor, distance runner, and dancer to help you come up with an exercise plan, check form on moves, discern how much exercise you should be doing, and optimal nutrition for your sport.
-Weighing: Need to keep up with weights for your doctor or therapist? Need someone to keep track of weights (blind weighing) or keep you accountable?
-Safe plan for weight loss or gain as needed: Fad diets don't work! Safe rate of weight loss is up to 2#/week, and safe rate of gain is up to 4#/week. (Note: this is NOT a "weight loss" business, I take a weight neutral approach to letting your body figure out healthy weight based on appropriate eating and exercise.)
-Confidentiality: I use secure electronic medical records to keep your information confidential, and as with therapy, nothing you say will be shared unless you are going to harm others or yourself, or you give a release of information.
-Contact with family members: If under 18, or given release; I give parents piece-of-mind when students are away at college by giving updates on progress and health.
-I have a good relationship with local therapists, Cal Poly's Health Center, and other practitioners.
-Eating disorder training: I am working with a credentialed supervisor to get my "certified eating disorder registered dietitian" credential (iaedp.com), and continue to take opportunities for continuing education.
-Constant contact: I am available between sessions by e-mail/text to keep you on the path to success.
-Counseling skills: Motivational Interviewing, cognitive behavioral therapy, intuitive eating, and behavioral interventions.
Still have questions? Contact me!
(originally posted 12/21/2014. libbysfitnutrition.com)
As a Registered Dietitian, I don't often get to work with insurance, due to the fact that nutrition services are rarely covered by any form of insurance. How frustrating!
(Personally, I will write up a "super-bill" for you to submit to your insurance in hopes of getting reimbursement for nutrition services. I also take CenCal Health Insurance.)
Certain insurances, or certain levels of "illness" may get you full or partial coverage for nutrition counseling/Medical Nutrition Therapy by a RD (not just any "nutritionist").
Anyway, I have found a few articles by other websites/authors that may help you in your quest to get covered for services related to an eating disorder... good luck!!
P.S.- if anyone has more tips on getting reimbursement, please post in comments or e-mail me!
Libby is a Registered Dietitian focusing on student eating disorder treatment and prevention. She is working on the central coast to create wellness in individuals and the community.
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