Journal Entry 3: Center for Discovery with Theresa Carmichael

Theresa Carmichael is an eating disorder (ED) registered dietitian (RD) at Center for

Discovery located in Del Mar, San Diego. According to the Academy of Nutrition and Dietetics,

eating disorder dietitians fall under the dietetic practice group of behavioral health nutrition.​1

Professionals in this area of practice cares for patients with eating disorders, intellectual and

developmental disabilities, addictions, and mental health. ED RDs most commonly work with

patients who suffer from Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder

(BED), and Other Specified Eating and Feeding Disorders (OSFED). Co-morbid mental health

and medical diagnoses are quite common in addition to the ED. Common mental health

diagnoses include anxiety, depression, bipolar, obsessive compulsive disorder, post traumatic

stress disorder, and borderline personality disorder. Typical medical problems include functional

gastrointestinal disorders, thyroid disturbances, osteopenia/osteoporosis, dental complications,

PCOS, food allergies/intolerances, and diabetes. Due to multiple medical and mental diagnoses,

each patient requires unique treatment. RDs working with ED patients need great understanding

of professional boundaries, the complexities and sensitivities of eating behaviors, nutrition

intervention, and the psychodynamics of EDs.​2 ​RDs have a responsibility to identify nutrition

problems that relate to the patient's medical or physical condition, including eating disorder

symptoms and behaviors. They must assess and interpret anthropometric measurements, weight

and height history, growth patterns, biochemical data, and attitudes and patterns of weight,

shape, and eating. With this information, RDs create a nutrition diagnosis and coordinate a plan

to resolve nutrition problems while ensuring diet quality, regular eating patterns, and normal
perceptions of hunger and satiety. Additionally, providing psychosocial support and positive

reinforcement is an important responsibility that is unique to an ED RD. It is extremely

beneficial to have an ED RD on staff in eating disorder clinics because their background in

nutrition, counseling, and areas of psychology allows them to effectively guide patients towards

mindful eating by repairing their relationship with food and their body as they work toward

optimal nutrition status.​3

According to the facility’s website, Center for Discovery has multiple locations

nationwide where they provide treatment for men and women with eating disorders, teens with

eating disorders, teens with mental health disorders, and teens with substance abuse issues.​4​ Each

of their locations is dedicated solely to one of their specialized treatment programs in order to

provide the most effective and efficient treatment. The Del Mar Center for Discovery location is

an outpatient eating disorder program that includes a specialized program for binge eating

disorder. They treat those with AN, BN, BED, Avoidant/Restrictive Food Intake Disorder,

Orthorexia Nervosa, OSFED, and Co-Occurring Disorders with Eating Disorders. The website

highlights that they practice a customized approach which includes family-centered treatment

and guidance, nutritional support and education, evidence-based intervention, and ongoing

aftercare and support. The programs they offer are adolescent, adult, gender-specific, and are

LGBTQIA inclusive. This particular location treats approximately 30 patients with two RDs on

staff. Here, they offer two levels of care: Partial Hospitalization Program (PHP) and Intensive

Outpatient Program (IOP). Patients in PHP attend the center 7 hours per day for 3-5 days a week

while those in IOP attend the center 3 hours per day 3-5 days a week. All patients, whether in
PHP or IOP, get one 30-minute session with a dietitian every week where they discuss their

nutrition and behavior failures, successes, and goals.

Like many other facilities, Center for Discovery follows a multidisciplinary approach in

order to provide well-rounded care for their patients. Center for Discovery’s “Core 4” consists of

a program director, a dietitian, a primary therapist, and a facility coordinator. In addition to

directing the entire program as her title implies, the program director, Emily Walkley, also

provides individual and group therapy to clients and their families in all stages of the recovery

process. The dietitian, Theresa Carmichael, is responsible for teaching staff and clients the

dietary program philosophies and protocols. The primary therapist, Christine Capuano, utilizes

narrative, felt a sense, and Dialectical Behavior Therapy to help clients work toward repairing

their brain-body connection that can become disrupted when struggling with an ED. Lastly, the

facility coordinator, Sara Burris, handles administrative duties, research, clinical documentation,

and customer service while ensuring the facility remains a safe place for all. Together, the core 4

monitors the patient's behaviors and attitudes through their own specialized lens, whether it be

nutrition focused or behavior-therapy focused, to ensure they are continually moving forward on

the road to recovery. Every week, the Core 4 holds a meeting in order to collaborate with each

other and consult on every single patient. They spend two hours every week to discuss red flags

or successes in each patients eating behaviors or attitudes towards themselves or food. Together,

they brainstorm things they can do to continually strengthen their patients and challenge their

ED.
 The Center for Discovery Del Mar facility is different from every other facility I’ve

visited so far. The past facilities we’ve visited looked a lot like typical hospitals or clinics, or

basic facilities we all go to when we are sick. Center for discovery did not look like a clinic at

all, it looked more like a home, a place of comfort. Right when you walk in, there are couches

just as you’d see in any ordinary home. There is a dining area, patio, along with multiple private

rooms which reminded me of a dorm. I believe that having resemblance to a home benefits ED

patients in many ways. The home-feel of the facility brings comfort, easing any anxiety that

patients may feel during this time of hardship. This will result in patients feeling safe and more

open to discussing their struggles which allows them to heal their bodies and minds in the

recovery process.

I learned that this particular field of practice deals with sensitive patients, and thus must

enforce rules to protect their mental and physical health. For example, it is very crucial for every

patient, staff, and family member to be aware of potentially triggering words or phrases that may

cause harm to patients progress. There was a paper on the wall of the dining area that condemned

conversations pertaining to exercise, weight, food, purging behaviors, and things of that nature.

Any conversation of this topic, especially during a sensitive time such as meal time, is

potentially triggering to patients with EDs and must not be brought up. Another rule that is

unique to this facility is that patients may not go to the restroom within the hour after meal time.

If they truly must go, they must ask a staff member for permission and utilize the buddy system

to ensure they do not purge in the restroom.

 During my visit, I learned just how life-threatening eating disorders can be. Some signs

of the ED such as weight loss or weight gain are apparent by looking at the patient, but there are

many other symptoms that are harder to catch such as bradycardia. Bradycardia, a heart rate

(HR) of less than 60 beats per minute, is associated with Anorexia Nervosa.​4​ Due to this, sudden

unexpected cardiac arrhythmic death can occur, which gives AN the highest mortality rate of all

psychiatric disorders. The study “The Significance of Bradycardia in Anorexia Nervosa”

collected heart rate data of 23 patients with AN between the years 2006 and 2009. They found

that 16 of the 23 patients showed HR less than 50 bpm, which demonstrates high prevalence of

bradycardia among AN patients. The mechanism of bradycardia in AN is thought to be a

physiological adaptation to increased vagal tone and decreased metabolism of energy utilization

due to malnutrition. Bradycardia could also be the result of decreased mass of the left ventricle

of the heart. Due to the potentially lethal arrhythmia, it is important for physicians to

acknowledge the role of bradycardia in AN and vice versa. It is important for practitioners to be

aware that bradycardia may imply the presence of an eating disorder that is not always obvious.

Careful monitoring of heart rate may result in treating disorders early and preventing premature

sudden death that comes with many patients with AN. Theresa Carmichael mentioned that her

level of care does not take patients with bradycardia. Patients with heart rates lower than 45 beats

per minute are automatically admitted to Rady’s Children's Hospital.

I also learned briefly about the nutritional treatment that ED patients receive at Center for

Discovery. All clients are on one of the four following meal plans: exchange-based, guideline

approach, intuitive eating, or the plate-method. The Exchange-based meal plan is the most

structured meal plan where clients are to count the amount of macronutrients they’re consuming
each day in order to ensure sufficient nutrient consumption. The guideline meal approach is

where patients choose their own food to make sure they are each a certain number of servings of

each food group per meal. The plate method is a plan to ensure your plate has a healthful amount

of diverse food groups which is primarily for those with binge eating disorder since many are

aversive to restrictive diets. Intuitive eating is not necessarily a diet but a way to go about eating

by honoring your body’s hunger and satiety cues and trusting your body and mind to choose the

foods that we need.​5​ A study evaluated the outcomes of 31 people with Binge Eating Disorder

completing an intuitive eating treatment. Prior to the study, binge frequency ranged from 0 to 11

binges with a mean of 4.10 binges.​6​ After the 8 week intuitive eating treatment, binge

frequencies ranged from 0 to 1, with a mean of 0.68. At outcome, 80.6% of the participants no

longer met the diagnostic criteria for Binge Eating Disorder. The study reports that Intuitive

Eating promotes acceptance of one’s emotions, hunger, satiety, food choice, and body which

releases the guilt and shame that is common in binge eaters. Intuitive eating seems to yield

significant results in the present study and is praised by many ED RDs such as Theresa. During

our tour and presentation, Theresa stated that if a person seeks a job at the Center for Discovery

but does not mention “Intuitive Eating” during their interview, they will not be hired.

Theresa Carmichael​ along with the principles of Center for Discovery, ​left a lasting

impression on me. I am in awe with what they teach and preach, which is Health At Every Size

(HAES) and Intuitive Eating. Throughout almost every nutrition class, it is drilled into our brains

that we must remain at a healthy weight/BMI and how important it is to consume a nutritious

diet. It is almost as if Center for Discovery needs to debunk what we’ve learned in school in

order to heal relationships with our bodies and food. I loved the different activities pateints did in
order to swear their loyalty to this movement for the betterment of their health. They held a scale

smashing ceremony, where they vowed to not obsess over their weight and never step on the

scale again. They also created an instagram page poster which was basically a collage of

instagram posts that are pro-recovery. Their advocacy for Intuitive Eating and HAES resonated

with me immensely and their movement is something that I see myself standing behind as a

future RD.

I believe that as social media becomes increasingly prevalent in today’s society, body

image issues, diet culture, and disordered eating will continue to persist, especially in young

women. I was once apart of the young girls affected by the “perfect” bodies presented on media

consequently resulting in a “drive for thinness” and a preoccupation of diet, exercise, body

weight and image. Fortunately for me, with nutrition education and self-love I was able to restore

my body’s hunger and satiety cues and replace my “drive for thinness” for a drive for strength

and wellness. Unfortunately for others, the journey towards recovery is not as easy. Thus, they

must seek treatment in facilities such as the Center for Discovery. My small experience with

disordered eating allows me to carry strong compassion and understanding for those who

struggle with EDs. This field trip to Center for Discovery, opened my eyes to a possible route

that I can take in the future. I would love to help others regain self-love and heal their

relationships with themselves and food. However at this extreme level field, dietitians deal with

very fragile and sensitive patients, calling for extreme care, patience, and caution which takes

time and effort to possess. I know that if I were to choose this field in the future, I would have a
lot of personal growing to do. I would also need more education in not just nutrition but

counseling and psychology as well.

The take home message of this trip with Theresa is that treatment of ED’s requires many

different skills, knowledge, and support from multiple people, not just the RD. In her

presentation, she stated the role of the RD is to identify nutrition problems or deficiencies and

provide nutrition therapy. Most importantly, they must work with the client, family, primary care

provider, primary therapist, family therapist, and psychiatrist to treat the ED as a team. Another

take home message is that if we want to work in this field as RDs, we must take a different

approach to nutrition as compared to what we’ve been typically taught in school. For example,

we should not label foods as “good” and “bad,” and we should not focus on diets or “health

foods.” In this field, it is extremely important to be aware of the consequences of what we say

and teach because we are working with patients with not just a nutrition problem but a

psychological illness as well.

 References

1. The Role of Registered Dietitian Nutritionists in Behavioral Health. Behavioral Health

Nutrition.
https://www.bhndpg.org/about/the-role-of-registered-dietitian-nutritionists-in-behavioral-
health/. Accessed November 18, 2019.

2. Ozier AD, Henry BW. Position of the American Dietetic Association: Nutrition
Intervention in the Treatment of Eating Disorders. ​J Am Diet Assoc.​
2011;111(8):1236-1241. doi:10.1016/j.jada.2011.06.016.

3. Nutrition Therapy at The Center for Eating Disorders. The Center for Eating Disorders.
https://www.eatingdisorder.org/treatment-and-support/therapeutic-modalities/nutritional-t
herapy/. Accessed November 18, 2019.

4. Yahalom M, Spitz M, Sandler L, Heno N, Roguin N, Turgeman Y. The significance of

bradycardia in anorexia nervosa. ​The International Journal of Angiology
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3709923/. Published June 2013.
Accessed November 18, 2019.

5. Flores A. What Does Intuitive Eating Mean? National Eating Disorders Association.
https://www.nationaleatingdisorders.org/blog/what-does-intuitive-eating-mean. Published
March 9, 2018. Accessed November 18, 2019.

6. Smitham DA. Evaluating an Intuitive Eating program for binge eating disorder: A
benchmarking study. ​ProQuest Dissertations Publishing​. 2010.