For this week’s blog post, Merrit Elizabeth sat down with Casey Bonano to answer commonly asked questions from clients in recovery from anorexia. Casey is a registered dietitian and Certified Eating Disorder Specialist who has experience in all levels of treatment, including residential, partial hospitalization, intensive outpatient eating disorder treatment, and private practice. Casey worked at The Renfrew Center for Eating Disorders’ treatment center before starting her own private practice, Dallas Nutritional Counseling, which provides weight-inclusive eating disorder nutrition therapy.

She just opened her second location, Austin Nutritional Counseling. Her team of dietitians specializes in all eating disorders, gastrointestinal disorders, medical nutrition therapy, sports nutrition and athletes, chronic dieting, mindful eating, and more through a non-diet, Health at Every Size, trauma-informed lens.

Casey actively speaks at respected businesses in the DFW community and guest lectures for the Nutrition Department at Texas Christian University. She is a member of the Academy of Nutrition & Dietetics, the International Federation of Eating Disorder Dietitians, and the DFW chapter of the International Federation of Eating Disorder Professionals. Casey held positions on the DFW IAEDP Board of Directors for eight years, including president.

Casey truly loves spending time getting to know her clients so she can customize her approach to the individual’s needs. Casey proves that with the right support, overcoming an eating disorder is possible. She guides clients in all areas of the recovery process, from body image and low self-esteem to dealing with negative emotions, forming a strong support system, and improving every area of daily life.

The Merrit Elizabeth Recovery blog is proud to feature this interview, as Casey is one of the most sought-after eating disorder treatment providers, known for helping clients achieve full recovery. ​This interview will answer frequently asked questions submitted by clients in recovery from anorexia, touching on topics like weight restoration, appropriate food intake, finding the right treatment, and emphasizing the need for a team of professionals who are specialized in eating disorder recovery. We also chatted about important changes that should be made in schools to help young people have the best chance at forming nourishing eating habits.

You have extensive experience in treating eating disorders at every level of care. Would you please discuss the progression of nutrition rehabilitation in individuals in recovery from anorexia from inpatient through outpatient and at-home recovery? Please include significant determinants of progress and also the serious challenges that patients have when moving through the anorexia recovery stages.

I think that some specific things are hard and fast rules or regulations or recommendations. And then a lot of it is a little dependent on the situation, the person, all of the things. So, I’ll start with general inpatient to outpatient, and then we’ll talk about how that doesn’t always work out the way that we had hoped.

So, obviously, inpatient is going to be the highest level of care. And the difference between inpatient and residential, which is the next level of care, is really a heightened medical instability. So that might look like lab values that are out of range.

That could be a lot of heart abnormalities or a lot of digestive concerns. There are so many different medical considerations because of malnutrition. And so at that level, this is where for nutrition rehabilitation we see a lot of tube feedings. 

 We see a lot of pretty high meal plans, probably eating much more than someone would consider to be a standard amount during the day. And when we think about why, we’re really having to there’s a big backlog of nutrition stuff that the body has to do, and so it needs more than usual to do all of the things that it hasn’t been able to do. And that’s how I explain it in a nonscience way.

The other big thing with nutrition rehabilitation at those higher levels of care is that because there is medical instability, there needs to be more monitoring. Even if you’re not on a tube feeding or even if you’re on a typical meal plan, because of different parameters, perhaps how severe the restriction is, how much weight has been lost, regardless of where that puts you are on the BMI scale, changes in weight, dehydration, things like that, there just needs to be so much more monitoring to make sure that the person is safe and able to increase the meal plan in a safe way.

And then as you get to residential and PHP, those factors would be less so. And then in IOP, hopefully you’re looking at being on more of a maintenance meal plan, which then you can continue in outpatient.

Prescribing meal plans or advising nourishment for someone in recovery from anorexia is a very serious process utilizing evidence-informed strategies. Why is a registered dietitian who specializes in eating disorders the best-qualified professional to prescribe anorexia recovery meal plans?

I think that it’s just a bit more complicated than “eat more food,” which, obviously, is part of it. As a dietitian, we don’t learn about this in school. And so it’s not just that every dietitian has this information.

So you really want an eating disorder dietitian because we have been specifically trained on how to do this. And so that might be how to increase the meal plan effectively without putting the patient at risk, without potentially causing more GI distress, or how to increase the meal plan but decrease the different GI things going on with the patient.

We can cater to and change the meal plan to help that individual with whatever they are specifically dealing with, whether that’s heart stuff, GI stuff, feeling so full, or feeling so bloated. And then the other thing too is that we don’t want to underfeed, but we also don’t want to overfeed, and we’re really concerned about refeeding syndrome. And that’s more of a concern at higher levels of care, but we see it at outpatient too.

So we’re specifically educated and trained on how to do things in a certain way, and we’re informed about refeeding syndrome so that if that is if the patient is at risk, then we can make the appropriate recommendations for them to either go to a higher level care or be monitored by a medical professional, whether it’s their PCP or their psychiatrist so that we can make sure that they are medically safe. 

There are many certified holistic nutritionists/influencers who are very knowledgeable about foods and recipes. Why shouldn’t clients in recovery from anorexia simply follow their recommendations?

I think the simple answer is that they’re not trained in eating disorders. And even if they are, anyone can call themselves a nutritionist. Anyone can call themselves a holistic nutrition influencer, or whatever words you want to use to describe it. 

Let’s say, for example, you were like, “I’ve decided I want to be a vegetarian.”

They could say, “Okay. Well, like, here are here are foods that are vegetarian.” 

But when you’re talking specifically about medical nutrition therapy, only a registered dietitian is legally allowed to offer that because we are specifically trained for it. Previously, a dietitian had to have a bachelor’s degree. Now it’s a master’s degree.

You have to have gone through an internship with a certain number of hours and you have to sit for national boards. And then you have to maintain that license. Then on top of that, some of the dietitians have advanced certifications.

A nutritionist can have a certification from a nutrition program. But it’s not necessarily an accredited college or a bachelor’s or master’s degree or anything like that. It’s usually an online course.

There are just a lot less qualifications, a lot less experience, and a lot less oversight by anyone.

For a medically stable client in recovery from anorexia, what foods and liquids do you recommend in order to maintain healthy micronutrient and electrolyte levels?

I think this is dependent on the person. My hope for most people is that we get to a place where they can eat adequately and eat a wide range of food so that any kind of supplement is pretty minimal. We see a lot of calcium and vitamin D supplements, probiotics, prebiotics, and a lot of iron.

We recommend iron a lot. So it just depends on the client individually. And sometimes if they’re having trouble with more GI stuff, there are additional things that we can recommend. 

But multivitamins, nothing too wild, nothing too unique. But I’ve definitely had clients where it is very unique because of their specific circumstances. Ultimately, I’m hoping that most people can maintain their nourishment and health through just eating adequately, but that’s not always the case.

Do you recommend customized supplements for your clients in recovery from anorexia facing side effects like bloating?

I think it really, again, it depends on the client, but there are a handful of things that I’ve recommended specifically for GI distress, like magnesium and fish oil. There are ginger chews, one can also talk to the doctor about Zofran. So anything from over-the-counter stuff to prescription strength stuff, it just depends on the severity.

And, hopefully, as recovery goes on and there is a longer stretch of time in that recovery space, we can ease off of having to use all that. The cool thing about most medical consequences of an eating disorder is that they are reversed through just proper nutrition, not everything, but most stuff.  So that is really hopeful that people won’t be experiencing these side effects long term.

Obviously, there are always situations where some people have certain things that persist, but generally speaking, most of my clients can get rid of most of the medical side effects of their eating disorder.

Orthorexia is a form of dietary perfectionism that can quickly and easily transition into anorexia. Although it is not yet formally recognized under DSM-5, those of us treating eating disorders see this on a daily basis. Will you please explain how orthorexia can transition to anorexia and why those obsessed with healthy, clean eating behaviors should seek eating disorder treatment as soon as possible?

I think orthorexia is kind of a stepping stone to anorexia. I think a lot of times, the orthorexia starts with good intentions, of, “I’m trying to be healthy or I’m trying to eat well for my body.”

 And it’s not necessarily associated with trying to make themselves smaller or to lose weight. And I think that’s a bit of the difference, but because there are certain foods that are off limits, or there are certain rules or things can only be prepared in certain way, what ends up happening is that the person ends up restricting total quantity, not just types of food. And so it ends up starting that spiral more into anorexia even though that’s not necessarily wasn’t maybe their intention to start.

I think anytime we have specific rules about food, good and bad, healthy, unhealthy, it gets us into a more rigid cognitive place with food, which then if you have these other precursors to develop an eating disorder, it’s just the perfect storm of everything mixed together and it creates true anorexia. I’m sure there are people out there who can have some orthorexic tendencies and never fully develop an eating disorder. But I think if you already have those precursors, certain personality traits, or family history, it just makes you more susceptible to really fully step into the eating disorder space.

In the last decade, we have seen rising numbers in adolescents with anorexia. In the ideal school setting where you could implement nutrition education and eating disorder prevention, what would you do?

It’s a loaded question. Obviously, we could go into schools and do specific eating disorder prevention presentations, and I’ve definitely done that before. I think that it’s usually in response to something that’s already happened versus more of a preventative approach. But I think what probably would be more helpful is to educate whoever is doing the health classes on eating disorders because the kinds of assignments that are being assigned to students are just so disordered. 

I don’t know how many letters I’ve had to write for clients seeing me that they can’t track their calories, they can’t track their macros, and these are all assignments given to third graders, fourth graders, just very young impressionable kids, putting this idea in their minds of certain things are good, certain things are bad. There’s a certain amount that you should or should not eat. And for some, it might not phase them at all. 

And then for one person, it just really is the starting point to something greater. So I would love to see our teachers being more educated on signs and symptoms and how to talk about food because, ultimately, they are in the position where they are talking about food. And then I would also love to educate teachers about things to say about food and things not to say about food.

I can’t tell you the amount of times that I’ve heard stories about teachers saying that certain kids’ snacks that they bring aren’t healthy and things like that. And obviously, I don’t think it’s from a malicious place. I think it’s from a place where they don’t realize the potential harm that they may cause.  

So I think it would be great to educate the students and the parents, but I think even more so educating the teachers because they’re the ones that are delivering some of this information. 

Takeaways: Navigating Recovery from Anorexia – Insights from Nutrition Expert Casey Bonano

In this extensive interview, Casey Bonano, a registered dietitian and Certified Eating Disorder Specialist, shares profound insights into recovery from anorexia. Drawing on her extensive experience, Casey delves into various levels of care, the pivotal role of dietitians, nuances in meal planning, potential pitfalls, and the intersection of orthorexia and anorexia. Furthermore, she offers recommendations for schools to create environments conducive to healthier relationships with food. Here are the key takeaways, elaborated for a deeper understanding:

1. Progression of Nutrition Rehabilitation in Recovery from Anorexia:

• Inpatient Care: At the pinnacle of care, inpatient treatment becomes imperative due to severe medical instability. Tube feedings and elevated meal plans are common strategies to address malnutrition-related medical concerns.
• Residential and Beyond: Transitioning to residential and partial hospitalization (PHP) signifies a reduction in medical instability and monitoring requirements. The goal is for intensive outpatient (IOP) and outpatient care to focus on sustaining a maintenance meal plan.

Insight: The progression through care levels is nuanced, highlighting the need for tailored approaches as patients move towards autonomy in managing their nutrition and maintaining a healthy weight. 

2. Role of Registered Dietitians in Recovery from Anorexia:

• Specialization Matters: Casey emphasizes the critical importance of consulting dietitians specialized in eating disorders. These professionals possess the expertise to navigate the complexities of anorexia recovery, ensuring meal plans are effective without compromising patient safety.
• Refined Expertise: Dietitians understand intricacies such as refeeding syndrome and tailor meal plans to address individual needs, including physical health concerns and psychological challenges. They are an absolutely essential part of the treatment team.

Insight: The role of a specialized dietitian extends beyond recommending increased food intake, encompassing a comprehensive understanding of an individual’s unique challenges during recovery and taking that into consideration when forming a treatment plan.

3. Customized Supplements and Micronutrient Levels for People in Recovery from Anorexia:

• Individualized Approach: Supplement recommendations depend on the client’s unique circumstances. While the overarching goal is to achieve optimal nutrition through a balanced diet, certain clients may necessitate additional supplements for micronutrient and electrolyte support.
• Hope in Recovery: Casey instills hope by highlighting that most medical consequences of an eating disorder can be reversed through proper nutrition, underscoring the resilience of the human body.

Insight: Individualized care extends to supplement recommendations, acknowledging the variability in nutritional needs during anorexia recovery.

4. Orthorexia and Transition to Anorexia:

• Stepping Stone: Orthorexia, characterized by rigid dietary rules for perceived health benefits, can serve as a precursor to anorexia. Restricting certain food types can lead to unhealthy eating behaviors and may inadvertently lead to a spiral into anorexic behaviors.
• Cognitive Rigidity: Developing rigid beliefs about good and bad foods contributes to cognitive inflexibility, making individuals more susceptible to transitioning into anorexia.

Insight: Understanding the link between orthorexia and anorexia emphasizes the need for early intervention and a nuanced understanding of disordered eating patterns.

5. Addressing Eating Disorders in Schools:

• Preventative Measures: Traditional prevention presentations are beneficial, but Casey advocates for a more comprehensive approach by educating teachers who wield significant influence in shaping students’ perceptions of food.
• Teacher Education: Teachers should be educated on recognizing signs and symptoms, fostering positive conversations about food, and avoiding potentially harmful comments. Assignments promoting specific eating habits need scrutiny.

Insight: Prevention in schools involves not only educating students but also empowering teachers to create environments that promote healthy attitudes toward food.

In conclusion, the interview with Casey offers a rich tapestry of insights into recovery from anorexia. The complexities of the journey are unravelled, emphasizing the importance of specialized care, individualized approaches, and the critical role of education in preventing eating disorders in schools. Casey’s expertise provides a roadmap for professionals and individuals navigating the intricate path toward overcoming anorexia nervosa, shedding light on the multifaceted nature of the recovery process.

Please check out Casey’s website here for information on support group offerings and individual nutritional counseling. Whether you are in recovery from anorexia, another eating disorder, or want to work on mindful eating, Casey’s team is here to help!

Posted by Merrit Elizabeth on February 29, 2024

Merrit Elizabeth

Merrit Elizabeth is an Eating Disorder Recovery Coach certified by The Carolyn Costin Institute. She holds a master’s degree in Health Promotion Management and has years of experience working with women with eating disorders.