1. Understand the full implications of ED… know what they are, and what they are not. ED represent the misuse of food to resolve emotional problems. Extreme or immoderate eating, including ritualized eating or eating the same food items every day with no variation is an indicator of pathology. The emotions underlying and driving dysfunctional behaviors must be addressed. Nutritionists must be capable of speaking the language of psychotherapy, just as psychotherapists must capable of speaking the language of food and nutrition.

2. Start where the client is. Understand the legitimate intention and purpose the ED plays for the client. Anticipate and field goal variation; goals and agenda of an anorexic child will be protective of disease, assuredly at odds with professional and parental goals… Prerequisite to treatment, the client must develop infinite trust in the practitioner in managing the coveted, feared, "abused substance," …in this case, food.

3. Start with what is possible; if the client requites 2400-3500 calories a day but is currently consuming 500, 800 to 1000 calories daily may be a more appropriate beginning goal. Re-feed slowly, increasing demands gradually, keeping expectations realistic and considering the needs and capacities of the client. In re-feeding a malnourished eating disordered individual, the weight goal sought is approximately one half pound to one pound and half pounds per week. With the severely malnourished body, anticipate that caloric intake may not produce an expected weight gain immediately as the body "cashes in" on the caloric debt, restoring function before weight. Some clients may experience a condition called "hyper-burn" a speeding up of the metabolism as they begin the re-feeding process that may result in weight gain delay.

4. Understand the uniqueness of the ED recovery process which is generally long-term and difficult, riddled with backslides and regressions. Remember that there is more to ED recovery than weight gain. Recovery goals/indicators include the client's self-awareness, judgment, self-reliance and courage which mark the repair of a dysfunctional relationship with food. Self awareness, self acceptance and self actualization make weight restoration possible. Learn to recognize recovery progress when you see it; it often resides hidden in the smallest and most elusive details of change. How much evidence do you need to recognize change and to help your client learn to differentiate them? When you see something good, say it. When you see something that isn't, have the client try to say it.

5. The quality of the client/clinician relationship will impact significantly on the nature and timeliness of recovery. A good relationship will inspire trust in practitioner, the healing process, and the patient's own capacity to change and recover.

6. ED clients are typically obsessed with weight and weighing; measurements of disease and recovery progress with clinical ED are typically determined by the scale. Do not perpetrate that myth. By banning home scales, clinicians can diminish compulsive preoccupations. A client's weight is significant in alerting health professionals to the possible need for immediate medical intervention; weight shifts are significant for the motivations behind them, the manner in which the weight was lost or gained, and the feelings evoked through that process. Achieving and maintaining an appropriate weight can be an outward manifestation of inward change. Do not misconstrue re-feeding fluid shifts and imbalances to indicate true weights. Bloating, reflux and numerous other gastroenterological problems generally heal completely within three months post recovery.

7. Welcome your client's resistance to change that comes in many forms, including denial, non-disclosure, hostility, oppositional behavior and manipulation. Dealing with resistance takes courage and foresight. Separate the eating disorder from the client, whose brain and body it inhabits. Through tough love/ limit-setting or caring warmth, nutritionists must communicate an understanding and non-judgmental acceptance of the enormity and implications of these problems. Dealing with resistance takes courage and foresight and offers an invaluable opportunity to begin a dialogue with the eating disorder within. Consider the declarative "No" or the passive refusal to cooperate to be the start of a conversation…not the end.

8. The message your client hears is not always the one you intend to send. Listen "between the lines" to the client's thinking and responses. When you say "You're doing great! (based on weight gain), I won't need to see you now for a month," your client may be hearing, "You are comfortably fat now and sufficiently over your disease to stop your efforts to recover. You've gained enough weight so you are free to start restricting again."

9. Team collaboration takes time and effort….particularly at the start of treatment, or when a client is in physiological danger and may need to be referred to an inpatient milieu. Nutritionist, therapist and medical doctor need to stay in touch, communicating in person, by phone, fax or via email. With their clients, nutritionists must become comfortable wearing the various "hats" of collaborating team members, speaking their parts, identifying and addressing medical and psychological issues across the board, referring clients back to specialists.

10. Don't lose sight of the importance of assessing the frequency and duration of physical exercise. The amount and quality of exertion will determine how many calories a person needs to nourish and sustain a healthy and active body. It is for the nutritionist, in conjunction with the therapist and medical doctor, to decide how much exercise is appropriate to allow ED recovery to occur. Be aware that exercise in ED individuals is often used as a purge technique; you need continual access to pertinent information about exercise activities.

11. Keep in mind that the body's set point weight is determined by the body's metabolism, not by the preference of the client or practitioners. Full recovery does not happen short of regaining body's set-point weight; full recovery is not assured however, simply through achieving that weight. Night sweats are a common indicator of the resumption of healthy metabolic function following a protracted stall.

12. Consider working with resistant ED clients in stages. Begin by offering the client a determined amount of time to heal herself without therapeutic assistance. If this effort fails, contract with (child) client (and parents as food monitors and mentors) to start psychotherapy. Consider using food supplements such as Ensure to boost caloric intake, stimulating client commitment to outpatient care. The need for more restrictive recovery opportunities may include a short-term day program milieu, hospitalization or residential care, to be determined by the client's needs and the outpatient professional team.