Today’s Dietitian
Vol. 28 No. 4 P. 22
Eating disorders among children and adolescents are on the rise, and the treatment of restrictive eating disorders—including anorexia nervosa, avoidant/restrictive food intake disorder (ARFID), and other specified feeding or eating disorders (OSFED)—in this population requires navigating one of the most clinically complex intersections in health care. It’s not about simply treating a state of acute malnutrition, it’s also about intervening during a critical window of physical, neurocognitive, and emotional development,1 which means there isn’t time to wait for a malnourished adolescent to find “motivation” to recover.
Eating disorder dietitians working with this age group are seeing a shift from individual-focused nutrition counseling to family-centered models. Family-based treatment (FBT), also known as the Maudsley approach, has emerged as the gold-standard outpatient intervention for children and adolescents diagnosed with anorexia nervosa and bulimia nervosa.2,3 “It’s the only evidence-based treatment for eating disorders,” says Los Angeles-based Katherine Grubiak, RDN, cofounder of the Eating Disorder Provider Education Network (EDPEN), which focuses on community based, family-centered care.
Grubiak says while other evidence-based therapies, such as cognitive behavioral therapy (CBT), may be part of an overall treatment plan, FBT is the only treatment framework that has evidence showing that it can produce full recovery. Research has found that FBT results in a 6- to 12-month remission rate of 48.6% compared with 34.3% for individual treatment.4 “We can have these adjunct therapies be a part of it, but through family inclusion, caregiver inclusion, we’re doing all the things that we hope for. We’re interrupting the behavior. We’re able to get nutrition rehabilitation to the point where it’s stabilizing the physiology and the psychology. We’re able to hand over autonomy. It’s a treatment process; it’s not a therapy.”
Historically, FBT did not strictly require the inclusion of an RD, leading to some confusion about the RD’s place within the multidisciplinary team. However, the treatment model has evolved, and more dietitians are becoming trained in this model. But for dietitians, successfully engaging in FBT requires a paradigm shift: stepping away from traditional, patient-directed motivational interviewing and MNT and leaning into a consultative role that empowers the parents as the primary agents of refeeding to reverse energy deficits, protect developmental milestones, and pave the way for recovery.
The Developmental Imperative
When the body faces a sustained energy deficit, it downregulates or halts nonessential functions in order to preserve vital organ function. For a growing child or adolescent, this biological compromise has profound—sometimes irreversible—developmental consequences.
“Adolescents are going through times of growth and development. Weight loss, or failing to gain appropriate weight, during the teen years can lead to height stunting and permanent bone weakness,” says clinical psychologist Lauren Muhlheim, PsyD, FAED, CEDS, owner of Eating Disorder Therapy LA in Los Angeles and author of When Your Teen Has an Eating Disorder, which uses an FBT approach. She says there’s a limited time window to get their growth back on track.
Skeletal Compromise
Perhaps the most silent and long-lasting physical risk of adolescent restriction is the impact on bone mineral density (BMD). About 40% to 60% of adult bone mass is accrued during adolescence, with about 90% by age 18 in females, age 20 in males.5 This brief window is dependent on adequate energy availability, sufficient macro- and micronutrients, and normal sex hormone production.6
In a starved state, increased cortisol levels combined with diminished sex hormones trigger a decline in bone formation, leading to deficits in bone mass and putting adolescents with restrictive eating disorders at high risk for osteopenia and osteoporosis.7-10 Research indicates that adolescents with anorexia nervosa may not fully recover their BMD even after long-term weight restoration and resumption of menses, leaving them at a permanently elevated risk for fractures later in life.11
Endocrine and Linear Growth Stunting
The adolescent growth spurt accounts for roughly 17% to 18% of final adult height, and restrictive eating disorders can severely reduce this trajectory.12,13 Chronic malnutrition disrupts the growth hormone/insulin-like growth factor-1 axis,13,14 interfering with puberty and linear bone growth. Even when weight is fully restored, linear growth may not fully catch up if the epiphyseal (growth) plates on the end of long bones fuse before the genetic height potential is reached.15
Neurocognitive Starvation
The adolescent brain undergoes profound structural remodeling, characterized by a decrease in cortical grey matter (pruning) and a significant increase in white matter (myelination), which facilitates faster neural processing and executive functioning.16,17 Severe caloric restriction literally starves the brain, interfering with this remodeling.
Magnetic resonance imaging (MRI) studies of adolescents with anorexia nervosa show significant reductions in both grey and white matter volume, alongside enlarged ventricles (fluid-filled spaces in the brain).16 This atrophy clinically manifests as increased cognitive rigidity, difficulty with abstract problem-solving, and heightened anxiety—symptoms that fuel the eating disorder’s pathology. While grey matter volume typically returns to baseline following sustained nutritional rehabilitation, emerging evidence suggests that white matter deficits may persist, potentially impacting long-term cognitive flexibility.18-20
Medical Instability
Severe nutritional risk isn’t visually obvious or exclusively tied to a low BMI. Rapid weight loss is important indicator of medical instability in adolescents presenting with both “typical” anorexia and “atypical” anorexia (meeting all criteria for anorexia nervosa but remaining within or above a “normal” BMI range).21 Bodies of any size can experience starvation, endocrine failure, and bone density loss if artificially suppressed below the biological set point.
Adolescents with atypical anorexia may experience faster rates of weight loss, and research shows that they may also present with higher rates of medical complications compared to their lower-weight peers.22,23 When providers focus solely on standard growth chart percentiles or “ideal” weights rather than individual growth trajectory and the presence of a sustained energy deficit, they may overlook very real developmental consequences.
Demystifying Family-Based Treatment
Nutritional recovery in children and adolescents with eating disorders can’t be delayed, and FBT addresses the urgent biological needs of a malnourished adolescent. Traditional therapies used in eating disorder treatment often aim to build insight and motivation within the adolescent before expecting behavioral change. FBT flips this paradigm. Because a starved brain is biologically incapable of making rational, recovery-oriented decisions,24 FBT relies on the family to serve as the external executive functioning for the child.
“The focus on quick renourishment is like a brain rescue for a malnourished teen,” Muhlheim says. “We know that the malnourishment explains a lot of the symptoms. In most cases, you can’t reason a person out of their anorexia. It takes food. I think FBT is expert at that. And it’s less disruptive than residential treatment.” Muhlheim and Grubiak both point out that FBT can be equivalent to partial hospitalization programs (PHP) or residential treatment. “My own opinion is that treatment centers largely exist for the meal support,” Muhlheim says.
“We aren’t doing therapy,” Grubiak says. “That doesn’t mean building insight and therapeutic practices can’t be adjunct. But we’re going through a three-phase treatment process that doesn’t need the agreement from the one going through this. And that’s a strong statement. We would expect them to reject wanting to do this. When they’re less than 18, parents can create this.”
Some clinicians have expressed concerns about taking independence and autonomy away from the young patient. “Developmentally, we want independence, but independence often means being able to choose what they want to eat,” Grubiak says. “If the eating disorder goes on too long, is too strong, and has that independence, we’re in danger mode. How do you make change when the eating disorder is so strong? It’s compassionate to have somebody step in. It’s compassionate to have family members step in, partners, friends. And even at treatment centers, the caregiver stepping in and being a part of this, because ultimately everyone has to come home.”
The Three Phases of FBT: A Roadmap to Autonomy
FBT is distinctively divided into three phases,26 and the dietitian’s role morphs significantly as the family progresses through each stage.
PHASE 1: Full Parental Control and Weight Restoration (The Refeeding Phase)
In Phase 1, the adolescent is absolved of all food-related decision-making. Caregivers are entirely responsible for meal planning, grocery shopping, cooking, plating, and supervising meals. The sole focus is symptom interruption (halting restriction, purging, overexercise) and rapid weight restoration.
“The most unrecognized or unused potential treatment team members are the caregivers,” Grubiak says. “It takes a huge village to do this work. So, bringing in what is already resourced in a household means not having to extract a patient from their living environment, but still doing something just as intensive. I really do stand by FBT being the equivalent of residential treatment or PHP.”
Historically, parents were intentionally not involved in adolescents’ treatment for anorexia because they were viewed as a causal factor.27 But Muhlheim says, “In FBT, families come along for the ride and they get to learn all the good psychoeducation and challenge their own biases about weight and health and have the opportunity to modify the home environment, which the teen is going to continue to live in.”
The first phase of FBT in particular demands a departure from traditional, patient-led counseling. During this phase, the dietitian primarily, if not exclusively, meets with the caregivers. Meeting alone with a malnourished adolescent can inadvertently lead to the RD engaging or “colluding” with the eating disorder as the adolescent tries to negotiate for lower calorie targets or more restrictive food choices.28
It’s also essential that the treatment team be aligned, because mixed messaging can create loopholes that the eating disorder will readily exploit.29 Muhlheim says for this reason, while an FBT-trained dietitian can work with a therapist and medical provider who are not—provided they’re on board with the dietitian doing FBT—the reverse is not true. “If the dietitian hands the teen a meal plan, that totally undermines the whole spirit of FBT, which is parents being in charge and also taking the rigid malnourished brain out of the process,” she says.
The dietitian’s clinical responsibilities in Phase 1 include:
- Calculating weight trajectories: Using historical growth charts, bone age, and pubertal stage to establish an individualized, biologically appropriate target weight range.
- Mitigating medical risk: Monitoring for risk of refeeding syndrome and assessing the need for specialized supplementation.30 Extreme hypermetabolism is common in early recovery, and dietitians must prepare parents for the reality that their child may require an exceptionally high caloric intake—often 3,000 to 6,000 kcal per day—to override the energy deficit and gain weight.
- Guiding nutritional interventions: Helping parents translate clinical goals into meals and support them in maintaining consistency and adherence and initiating exposure to “fear foods.” A 2024 randomized comparative effectiveness study31 evaluated dietary interventions in FBT and found that providing caregivers with a daily calorie target resulted in slightly faster weight gain and was highly preferred by caregivers who needed concrete guidance, countering historical fears that calorie targets might undermine parental intuition. Alternatively, many RDs successfully use visual frameworks like the Plate-by-Plate Approach, which teaches parents to build balanced, calorically dense meals without fixating on numbers.32
In Phase 1, caloric density and energy availability trump micronutrient perfection. Dietitians may need to reassure parents that food is medicine, even if that medicine is a fast-food milkshake required to hit an energy target.
PHASE 2: Gradual Return of Control (The Transition Phase)
Once an adolescent’s weight is nearly restored and their eating disorder behaviors have largely ceased, the family transitions to Phase 2. More eating choice is handed back to the client, and the focus shifts to gradually assuming age-appropriate food responsibilities.
At this point, the dietitian can begin meeting individually with the adolescent, if the adolescent chooses. Grubiak says that, in her experience, not all young clients take this option. Either way, dietitians can act as a bridge between parental control and adolescent independence. This involves:
- Exposure therapy: Guiding the adolescent and family through exposures to lingering “fear foods” and increasing dietary variety.
- Portion estimation: Helping the adolescent learn what appropriate portion sizes look like without the use of measuring cups or scales.
- Supervised independence: Assigning the adolescent the task of packing their own school snack or plating a single meal, with the parents reporting back on the success of the exercise. If the eating disorder voice returns, control is temporarily handed back to the parents.
PHASE 3: Establishing Healthy Independence (The Maintenance Phase)
In Phase 3, the adolescent’s weight is restored, and they’ve successfully resumed responsibility for their eating. The therapeutic focus broadens to address normal adolescent development and relapse prevention. Dietitians can help adolescents solidify their autonomy before discharging them from active nutritional care.
If working individually with the adolescent, the dietitian transitions into a more traditional counseling role, using psychoeducation to dismantle diet culture, and foster a peaceful relationship with food and body image. Whereas intuitive eating is contraindicated during the active malnutrition of Phase 1, because “listen to your body” doesn’t work when someone has gastroparesis and suppressed hunger cues, the dietitian can start teaching intuitive eating in Phase 3.
Final Thoughts
Grubiak acknowledges that the concept of not doing traditional MNT can feel strange to many dietitians. She says, “What I encourage dietitians to think of is, in how many clients have you noticed the change is just not enough, and you’re getting worried from the medical stability point of view? You’re trying to work on fear foods and are not even going down the list. Exposures aren’t really happening. Are you noticing that there needs to be something else, even if you don’t know what that something else is?”
“And the question really is, how long do we allow someone to be in therapy or work with a dietitian individually before we see there isn’t enough change on the behavioral side to make an impact on their physical and ultimately psychological health?” Grubiak says. “With FBT, we get to a more restored point where we see the psychology shift and we see more flexibility, less rigidity in mindset. And we have neuroscience to back that up. The brain heals.”
— Carrie Dennett, MPH, RDN, is the new editor of Today’s Dietitian as well as nutrition columnist for The Seattle Times and an eating disorder dietitian in private practice.
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