June/July 2021 Issue

Trauma-Informed Nutrition Care
By Carrie Dennett, MPH, RDN, CD
Today’s Dietitian
Vol. 23, No. 6, P. 36

Learn why and how negative past experiences can impact counseling dynamics and determine patient outcomes.

Maggie grew up with a narcissistic mother, an emotionally unavailable father, and a violent brother. Food was her only source of love and comfort. Decades later, she has a loving partner and a fulfilling life, but feels “out of control” when she’s around sugary snacks.

Due to a sequence of traumatic childhood events, Nancy’s mind links vegetable prep to a sexual assault by a male relative, and she’s experienced symptoms associated with posttraumatic stress disorder (PTSD) when receiving advice from dietitians to eat more vegetables.

Jane was put on her first diet at the tender age of 8, and her parents were constantly critical of her body. As an adult, she feels resistance to any suggested behavior change—even changes that are weight-neutral.

These are just a few examples of trauma that may be buried in the psyche of clients seeking nutrition counseling—and why dietitians who work with individuals or groups need to understand trauma.

But what is trauma? Trauma isn’t something that happens to you, per se, such as an assault, says Australia-based trauma-informed dietitian Fiona Sutherland, APD, RYT. Trauma is what happens in the body as a result of an experience or series of experiences that felt like too much, too fast—or conversely, not enough. Trauma is both biological and psychological—it’s our autonomic nervous system (ANS) being hijacked because what we experience is beyond our ability to cope at the time. These painful life experiences—especially when they happen at a young age—can cause people to feel negative about themselves, about other people, and about the world.

The Nervous System
The ANS helps facilitate communication between the central nervous system and the rest of the body, and automatically regulates several body functions, including heart rate, digestion, and respiratory rate. The two branches of the ANS, the sympathetic and the parasympathetic, behave in a sort of complementary opposition to each other. For example, the sympathetic branch increases heart rate and decreases digestive activity, while the parasympathetic branch decreases heart rate and increases gastric motility and secretion of digestive enzymes.

The sympathetic branch, with nerves originating in the spinal column, also controls the “fight or flight” response. The primary nerve in the parasympathetic branch is the vagus nerve, which originates in the brain stem. According to what’s known as polyvagal theory, the vagus nerve has two pathways: the older dorsal pathway, which we inherited from our vertebrate ancestors, and the ventral pathway, which developed more recently in mammalian evolution. When our dorsal vagal pathway is activated, we may “freeze,” shut down, or dissociate. When our ventral vagal pathway is activated, we feel safe and socially engaged.1

The ANS subconsciously monitors our environment and visceral sensations, with the objective of minimizing risk and seeking safety. This ability to subconsciously distinguish safe from dangerous contexts is called neuroception.2 Before our brain can determine the meaning of an incident or situation, our ANS has finished its assessment and begun an adaptive survival response, which is influenced by past experiences—especially early-life experiences—that train it to expect either safety or danger.

For example, if you were raised in a safe, loving environment, when someone smiles at you, your ventral vagal pathway activates and you can socially engage with that person. However, if you were raised in an environment where adults were smiling one instant and abusive the next, a smiling stranger—perhaps you, the dietitian—might trigger a fight, flight, or freeze response rather than social engagement behaviors, even if the situation is objectively safe.

Adverse Childhood Experiences
Adverse childhood experiences (ACEs) are potentially traumatic events that happen between birth and age 17—or even before birth. The child doesn’t have to remember the incident to absorb the trauma. These events include experiencing violence, abuse, or neglect, or witnessing violence in the home or community.3,4 According to the Centers for Disease Control and Prevention, about 61% of adults surveyed from 25 states reported that they had experienced at least one type of ACE, and 16% reported they had experienced four or more types.3

ACEs are linked to several chronic health problems, including cancer, diabetes, and CVD. They also contribute to depression, anxiety, PTSD, drug or alcohol misuse, and suicide; it’s estimated that as many as 1.9 million cases of heart disease and 21 million cases of depression could have been potentially avoided by preventing ACEs.3 Women who experienced ACEs are at increased risk of having an unintended pregnancy or pregnancy complications. And, parents who experienced maltreatment in their own childhoods may experience trauma response triggers during the perinatal period—pregnancy to two years postpartum—including while caring for their distressed infant. This may make it more difficult for parents to nurture their children and can lead to intergenerational cycles of trauma.5,6

Patients with eating disorders are more likely than the general population to report a history of childhood trauma. A 2016 study examined associations between self-reported childhood trauma and severity of eating disorder symptoms in 192 female patients. Emotional abuse predicted higher eating, shape, and weight concerns and lower daily functioning, while physical and sexual abuse predicted higher eating concerns. These associations were independent of any cooccurring psychiatric conditions, such as depression or anxiety. The researchers also found that while not all subtypes of childhood trauma have the same impact, they do have an additive effect.7

Childhood food neglect—restricted access to food due to caregivers disregarding their responsibilities to provide adequate food to their children, even if they have the financial resources to do so—may increase risk of developing eating disorders. One survey found that the lifetime odds of developing anorexia or binge eating disorder among adults reporting childhood food neglect were three times higher than that of the general population, even after adjusting for sociodemographic variables, history of other ACEs, and a history of receiving government financial assistance before adulthood.8

Window of Tolerance
Another way to understand the lingering impacts of trauma is the “window of tolerance,” a term coined by psychiatrist Daniel J. Siegel, MD, a clinical professor of psychiatry at UCLA’s David Geffen School of Medicine and founding codirector of the Mindful Awareness Research Center at UCLA. According to Siegel, a patient’s window of tolerance is the zone in which he or she can readily receive, process, and integrate information and respond to the demands of daily life without much difficulty. During times of extreme stress, which can include exposure to stimuli that the ANS deems dangerous, a patient may experience either hyperarousal (fight or flight response) or hypoarousal (freeze response).9

Someone with a history of trauma is likely to have a narrow window of tolerance and be more likely to become hyper- or hypoaroused in response to seemingly minor stressors, compared with someone who hasn’t experienced trauma. These responses are adaptive and geared toward survival, but they can interfere with the ability to regulate emotions, connect with others, and feel safe in relationships. They also make the person more vulnerable to depression or anxiety.

So how might trauma, especially childhood trauma, affect food-related behaviors?

“Feeling too much, particularly emotionally, might manifest in people restricting foods in a very well-intentioned effort to moderate internal sensations,” Sutherland says. “Feeling not enough—that our needs have not been met—might result in people reaching for what they feel will meet their needs, perhaps food, when it may be love, security, belonging, care, or something else that is needed.”

She says both of these experiences make complete sense in the context of people’s lived experiences, and they can happen together or separately. They also may develop into long-term patterns of reacting to thoughts, feelings, and sensations by using or avoiding food rather than attending to deeper needs. “Through a trusting partnership, dietitians can work slowly with people at a pace that feels right for them to gradually shift towards being able to meet their true needs rather than using or avoiding food in an attempt to feel safe and secure.”

How Trauma Shows Up in the Nutrition Setting
Let’s say you’re a hospital dietitian caring for a patient who was in a car accident. If that patient previously experienced physical or sexual assault, the accident is likely to produce more trauma than “normal.” Why? Because both the assault and the car accident were sudden intrusions on the body, so the experiences are compounded. Similarly, recommending restrictive diets—even if medically necessary—to patients who were bullied about their weight and served smaller portions of food than their siblings may trigger a trauma response, whereas it might not in patients who grew up in a “normal” food environment with a societally “acceptable” body.

Functional gastrointestinal (GI) disorders—GI symptoms with no identifiable structural pathology—including irritable bowel syndrome often co-occur with psychiatric disorders such as anxiety, depression, and PTSD. It’s proposed that these comorbid conditions have a common neurobiological origin of trauma, especially early-life trauma. Experiences that cause fight, flight, or freeze responses also may cause GI tract dysregulation, and functional GI symptoms may fluctuate with emotional states and life stresses. Rates of physical and sexual trauma among GI patients are high, yet most trauma histories go unreported to GI specialists.2

In the clinical or outpatient setting, when a patient is talking but not making eye contact, appears to not be listening, or isn’t following recommendations, they may be in fight, flight, or freeze mode. “From a polyvagal perspective, if a person doesn’t feel heard or seen, things are going too fast, or they’ve had negative experiences in the past, they might take our well-meaning attempts at nutrition counseling as a threat,” says Tracy Brown, RD, a somatic coach based in Naples, Florida.

Sutherland says that what we call—often unhelpfully—“noncompliant” can be understood as people feeling like something we’re asking of them is ‘too much.’” She adds, “This can offer us helpful information about how we can shift our own position and expectations rather than judging or blaming our client, which only harms our relationship with them and impacts their capacity to make change.”

Patients might be feeling overwhelmed, scared, or lacking in resources or support, Sutherland says, but if dietitians are worried that patients aren’t following through on recommendations, especially if they’re putting their health at risk, they might put pressure on patients in ways that aren’t helpful, even though it’s coming from a place of concern and care.

Dietitians may worry that trauma isn’t within their scope of practice, but Sutherland says trauma-informed care is much different from trauma-focused care, which specifically treats trauma and usually is done with an experienced therapist. “Trauma-informed care is relevant for everyone and anyone who is a human working with other humans, whether or not we, or they, identify as having experienced trauma,” she says. “Given the statistics of chronic stress and trauma in our community, dietitians will almost certainly be working with people whose food, eating, and body relationships are being impacted by other events and experiences, in which case having a working understanding about the nervous system is really useful and can support dietetics work in important ways.”

Brown says that, as dietitians, recognizing the physiology of how trauma impacts health—and our own reactions—is our business, and it’s important to understand that if our clients are in a threat-response state in our presence, they will be less likely to connect, take in, absorb, and act on suggestions that could help them. “They may even misinterpret our suggestions as a threat and of course not feel safe to integrate the nutrition counseling experience,” she says. “As dietitians, understanding what our bodies are saying about what is happening in the room can allow us not to be reactive to clients’ strong emotions and therefore provide a ‘relatively safe enough’ experience that fosters growth and learning.”

Creating ‘Safe-As-Possible’ Spaces
Sutherland emphasizes that many things can be perceived as threats, including criticism, particular foods, a change in our body shape and weight, or actual physical harm. “Having an understanding of the way our bodies respond when we perceive threat or danger, and the ways we seek safety, is critically important to understanding why we and our clients might respond in particular ways,” she says.

Many dietitians try to create a “safe space” for their clients, but safety is relative. “Safety is not simply a statement of intent; it’s a received, felt sense,” Sutherland says. “What feels safe and comfortable for one person may not feel the same by another, so one idea is that we name our intention as ‘as safe as possible’ to make room for people’s varied experiences.”

Brown says humans are by nature fallible, and even with good intentions we let people down or say the wrong thing. “While we can’t offer perfect safety in relationships, we can offer ‘relative safety’ with our efforts to stay present, listen, challenge in a nonconfrontational way, and offer repair when we sense, and ask, if something isn’t right,” she says.

In fact, our presence in the room can matter as much, or even more, than our words. Siegel talks about therapeutic presence as openness, observation, and objectivity, and attuning to what patients are saying through words, tone of voice, body language, and other behaviors without preconceived notions. When dietitians adopt an open and receptive body posture with soft eye contact and calm breathing, and when patients experience this repeatedly from us, it can help regulate their nervous system and help them feel safe.10,11 Mindfulness practices can help dietitians develop this presence, because they help cultivate present moment awareness, acceptance, openness, nonjudgment, and the ability to respond calmly rather than react.10

These strategies can help dietitians avoid amplifying the patient’s fight response. For example, Brown says that if a client says, “I just can’t be happy at this weight … it’s gross,” and the dietitian says, “All bodies are good bodies, and you can make peace, too,” this is meeting the patient’s fight response with more fight. On the other hand, using motivational interviewing to draw out information, such as asking, “Weight is gross? Tell me more,” or “When might weight not be gross, and how would you know inside?” can help calm the fight and avoid the “righting reflex.”

According to Sutherland, “It makes complete sense that our ‘righting reflex’ or ‘fix it’ mindset stays pretty close to the surface. For many of us, our upbringing and training is very cognitively focused, and living in diet culture tells us in no uncertain terms that we must be expending our energy ‘working on ourselves’ in a state of constant self-improvement, and that this reflects our worth and value. There’s a lot of value in simply being with people when they—and we—are going through hard things.”

Final Thoughts and Resources
Trauma, and trauma-informed care, is a huge topic, and one worth exploring. Sutherland and Brown offer a beginner Trauma-Informed Dietetic Care course (themindfuldietitian.com.au), and Brown offers a more expansive course, Somatic Nutrition Counseling Skills (embodieddietitian.com). Recommended books include The Body Keeps the Score by Bessel van der Kolk, MD; Waking the Tiger by Peter A. Levine, PhD; The Polyvagal Theory in Therapy by Deb Dana, LCSW; and Radical Belonging by Lindo Bacon, PhD.

“It can feel so tempting for RDs to learn about something like trauma-informed care and want to ‘apply’ it right away in practice,” Sutherland says. “One suggestion I have is that when we’re learning something new, particularly if it involves some self-reflective work, that we really take our time to let things land and have patience as we’re integrating new learnings.”

— Carrie Dennett, MPH, RDN, CD, is the nutrition columnist for The Seattle Times, owner of Nutrition by Carrie, and author of Healthy for Your Life: A Holistic Guide to Optimal Wellness.

References
1. Porges SW. The polyvagal theory: new insights into adaptive reactions of the autonomic nervous system. Cleve Clin J Med. 2009;76 Suppl 2(Suppl 2):S86-S90.

2. Kolacz J, Kovacic KK, Porges SW. Traumatic stress and the autonomic brain-gut connection in development: polyvagal theory as an integrative framework for psychosocial and gastrointestinal pathology. Dev Psychobiol. 2019;61(5):796-809.

3. Preventing adverse childhood experiences. Centers for Disease Control and Prevention website. https://www.cdc.gov/violenceprevention/aces/fastfact.html. Updated April 6, 2021.

4. Adverse Childhood Experiences International Questionnaire (ACE-IQ). World Health Organization website. https://www.who.int/violence_injury_prevention/violence/activities/adverse_childhood_experiences/en/

5. Chamberlain C, Gee G, Harfield S, et al. Parenting after a history of childhood maltreatment: a scoping review and map of evidence in the perinatal period. PLoS One. 2019;14(3):e0213460.

6. Narayan AJ, Lieberman AF, Masten AS. Intergenerational transmission and prevention of adverse childhood experiences (ACEs). Clin Psychol Rev. 2021;85:101997.

7. Guillaume S, Jaussent I, Maimoun L, et al. Associations between adverse childhood experiences and clinical characteristics of eating disorders. Sci Rep. 2016;6:35761.

8. Coffino JA, Grilo CM, Udo T. Childhood food neglect and adverse experiences associated with DSM-5 eating disorders in U.S. national sample. J Psychiatr Res. 2020;127:75-79.

9. How to help your clients understand their window of tolerance. National Institute for the Clinical Application of Behavioral Medicine website. https://www.nicabm.com/trauma-how-to-help-your-clients-understand-their-window-of-tolerance/

10. Geller SM, Porges SW. Therapeutic presence: neurophysiological mechanisms mediating feeling safe in therapeutic relationships. J Psychother Integr. 2014;24(3):178-192.

11. Geller SM, Greenberg LS. Therapeutic presence: therapists' experience of presence in the psychotherapy encounter. Pers Cent Experiential Psychother. 2002;1(1-2):71-86.