ED Recovery Isn’t One-Size-Fits-All: Food Salience vs. Food Addiction
Understanding food salience in eating disorders and how it compares to food addiction through a real-life case vignette can shift how we work with clients.
I want to express a heartfelt thank you for all of the feedback I received on my 5-Part Food Addiction Series. I received such thoughtful questions; it’s clear that many smart and deeply caring providers are grappling with this topic.
In my last post, Bridging the Gap Between Food Addiction and Eating Disorder Treatment, I asked if any of you would be interested in a case vignette where I illustrate an approach to working with individuals who experience high food salience with certain foods (typically processed like fast food, chips, cakes, cookies, ice cream).
My gosh, that was a resounding YES! So here I am.
Historically, I haven’t used a food addiction model with my clients. But I do want to make it clear that I have undoubtedly observed and worked with clients who experience high food salience, and I have utilized highly individualized approaches with each of them.
What is food salience in eating disorders?
To clarify – this is when the experience of food is amplified psychologically and physiologically.
For some clients, stocking their cupboards with “trigger” foods and granting themselves unconditional permission to eat them can result in binge episodes, which leave them feeling discouraged and disempowered.
In these instances, we co-create a much more gradual process, which I suspect might mirror what food addiction proponents call a “harm reduction approach.” As I discussed in my final post on food addiction, Bridging the Gap Between Food Addiction and Eating Disorder Treatment, modifying certain foods (e.g. dose, context, timing) while engaging in other healing aspects of treatment (e.g. emotion regulation, trauma, community support, pursuing meaningful hobbies/interests, etc.) makes tremendous sense for some people. As healing occurs across multiple domains, a person’s capacity to navigate tricky foods changes and grows.
Let’s bring this to life with a former client, I am calling Sammy.
Many of Sammy’s personal details have been changed to protect her identity.
At 21 years old, Sammy (she/her) presented to my outpatient nutrition counseling practice after 2 months of treatment for bulimia nervosa (BN) at a higher level of care. Sammy grew up in a stable, loving home, but experienced severe sexual trauma at the age of 15. Shortly thereafter, Sammy began her disordered eating through dietary restriction, but her symptoms evolved, and she was diagnosed with BN at 17 years old alongside intensely distressing negative body image. In addition to her ED, Sammy also had diagnoses of ADHD, PTSD, and trichotillomania (pulling at her hair and eyelashes). She was taking medication to address her mental health challenges, as prescribed by her psychiatrist. She did not have any other addiction diagnoses.
As Sammy and I began our work, Sammy was still actively restricting, bingeing, and purging. She reported mostly bingeing on bread with a chocolate spread and baked goods like brownies, cupcakes, and cookies. Sammy loved these foods and wanted to see if I could help her eat them in a way that aligned with her recovery goals. She had tried cutting them out in the past, but found she really missed them and always began eating them again. She couldn’t really imagine a life where she never ate those foods again.
In addition to her nutrition therapy, Sammy was seeing a Dialectical Behavior Therapy (DBT) therapist and attending a weekly DBT group. She worked with a psychiatrist to refine the most effective pharmacological approach to manage her symptoms. She began pilates once a week and started using an app to help her practice meditation for 5 minutes a day. This work occurred over 2 years, and she made a tremendous improvement with emotion, self-regulation and impulsivity. These changes paved the way for Sammy to cultivate meaningful connections and purpose in life.
Alongside the significant therapeutic work Sammy was engaged with, she and I met weekly. Much of their focus was on typical aspects of ED treatment, including adequate caloric intake, developing a reliable pattern of eating every 3-4 hours, and incorporating a balanced distribution of macro and micronutrients, fiber, and fluids. Of course, I kept a careful eye on electrolyte imbalances and addressed Sammy’s malnutrition.
Most of our work focused on developing self-regulation skills with the foods she restricted, binged, and purged on. It became evident early on that including these “trigger foods” daily (as is often prescribed in traditional ED treatment) inevitably left Sammy bingeing and purging every time she ate them. This left Sammy discouraged. So together we tried a different approach.
Together, Sammy and I identified all of the foods that Sammy felt she could not control. Then, we created an additional inventory of factors which heightened her vulnerability to these foods. These provided us with insight on the contextual factors that contributed to her struggles and successes. Her list included: whether she was alone or with others, her emotional state (boredom, insecurity, and shame were significant), how well she slept the night before, whether she was well-nourished, time of day, access to fresh air and physical activity (she found both to be very regulating), ability to utilize her emotion regulation tools she was learning in DBT group and therapy, as well as whether she had taken her medication.
We began to slowly build opportunities for Sammy to practice eating her self-described “trigger” foods. We identified strategic “practices” where there were as many supports and as few vulnerabilities as informed by the inventory they co-created. During this time, Sammy did not want to have any of these foods in her home. In the beginning, Sammy only practiced eating these foods as part of a balanced meal in session with me (e.g., 2 slices of whole wheat bread with chocolate spread, banana, and milk). Together, we included mindful eating practices to help Sammy begin to more clearly discern her experience of the foods. Did they match her expectations? Did the food taste like she had hoped? What did she find satisfying or disappointing? What thoughts and food narratives went through her mind during and after these meals? These exposures were preceded and followed by a plan for adequate, balanced nutrition.
For months, Sammy only consumed her trigger foods with me. During that time, Sammy gained skills, experienced biological and psychological healing and growth through treatment, and developed a more grounded and less judgmental way of relating to and thinking about food. In time, her food choices were less morally and emotionally fraught, emerging from a place of self-awareness and self-care.
Sammy began to carefully create opportunities to “experiment” with these foods with trusted friends, but continued to leave them out of her home. She found that she learned to truly enjoy these foods when shared socially and as part of a diet mostly consisting of hearty meals (e.g., oatmeal with peanut butter, egg and avocado sandwiches, vegetarian burritos). This pattern of eating left her feeling highly satisfied and grounded.
By the time we ended our work, Sammy had moved in with her partner, who preferred to have many of Sammy’s trigger foods at home. At that point, Sammy felt able to have all foods in her home environment, but believed she needed a slow, step-by-step process to get her to that point.
Challenges providers face in using these frameworks.
Outpatient ED providers have the ability to provide highly individualized care. There is no need to be dogmatic (i.e. all foods are morally neutral, thus you must eat all foods!) nor do I think the vast majority of ED nutrition professionals approach our clients this way.
But there are many more challenges facing providers working at higher levels of care, where there tend to be policies, protocols, and standards applied across the board. It is far more complex working with numerous people within a system, so big kudos to my colleagues doing this important work!
And now, I have some questions for you…
How do you approach working with clients who experience high food salience?
What aspects of this approach align with a Food Addiction model of treatment?
What components diverge from a Food Addiction model of treatment?
Do you find “food salience” a useful or unhelpful alternative framework to the food addiction model? Feel free to DM me on Instagram with your thoughts. I’d love to know.
Thank you for being here!
This work is challenging and also rewarding.
If you are looking for extra resources to help, I have several free guides on my website to get you started. You can check them out here on the resources for clinicians page.
When you’re ready to uplevel and move into more formal professional development, be sure to check out my Food and Body Image HealersⓇ Training Institute. There are several sources to help you with clients, add to your counseling skills to improve how you work with clients.