Trauma-Informed Dietetics
The most important skill a dietitian can have is the one we have been trained in the least: how to create a sense of safety and an environment conducive for growth and change. After all, topics brought up in nutrition counseling are sensitive (food, the body, health, etc.). All of the nutrition knowledge in the world means nothing if someone is not ready to apply it to their life.
I recently invested in a training: Trauma-Informed Dietetic Care, A Nervous System-Informed
Course for Nutrition & Health Professionals by dietitians Fiona Sutherland and Tracy Brown.
This course has already improved the ways I conduct sessions and work with clients.
What is Trauma-Informed Care?
Trauma-informed care is a term growing in popularity that refers to preventing re-
traumatization and enhancing feelings of safety in a clinical setting. It emphasizes listening to the client and recognizes that trauma, of any kind, has a significant impact on someone’s health and capacity for change. Trauma is often perceived as something that “happened” (assault, natural disaster, loss), but it is more about what “happens” in the body as a result of what “happened.” Our autonomic nervous system is designed to keep us safe by mobilizing a cascade of hormones, neurotransmitters, and bodily processes when it perceives a threat. Trauma and chronic stress can hijack the nervous system leading to negative health outcomes and perceptions that food or behavior change are “threats.”Two people can experience the same traumatic “event,” and have vastly different “experiences”' and lingering “effects” due to what has happened in their past and how their nervous system has developed. For instance, research suggests that someone who has had six or more adverse childhood experiences (violence, abuse, neglect, etc.) has a lifespan that is 20 years shorter than someone who had no adverse childhood experiences (1). The CDC suggests that up to 1.9 million cases of heart disease could potentially have been avoided by preventing adverse childhood experiences (2).
The Window Tolerance
The autonomic nervous system can be broken down into three categories: the
sympathetic (fight or flight), the dorsal vagal parasympathetic (freeze or please), and the ventral vagal parasympathetic (rest and digest.). While they all have their role, it is theoretically
improbable to effectively receive information and achieve behavior change when primarily in a “fight or flight” or “freeze or please” state. In contrast, when someone is alert but also calm (the ventral vagal nervous system is predominantly active), they are feeling safe, focused, curious, and more inclined to make a lifestyle change. Dr. Dan Siegel developed the concept of the window of tolerance, which explains that “when a person is operating within this zone or window, they can effectively manage and cope with their emotions. For clients who have experienced trauma, it is often difficult to regulate emotions and the zone of arousal where they can function effectively becomes quite narrow”(3). It is also theorized that a “faux window of tolerance” might develop. For example, someone may use food to achieve a sense of safety or comfort in a harmful way (restricting or binging).
Unfortunately, registered dietitians learn little if anything regarding trauma-informed care in our collegiate education. This is dangerous, since uninformed dietitians can unintentionally re-traumatize someone and perpetuate stigma and bias. Traditional nutrition counseling categorizes someone by a diagnosis and focuses on a lifestyle intervention that is numbers-
based.
Trauma-Informed Nutrition Counseling
Trauma-informed care starts with recognizing how our own nervous system functions. A
practitioner that stays within their own window of tolerance can listen better and facilitate a more regulated environment for clients. Deb Dana, an expert on polyvagal theory, states that “We need to know our own nervous system before we work with others.”Health professionals who do not work directly on trauma, should still incorporate trauma-
informed skills which serve as a powerful opportunity to provide co-regulation, safety, and validation. Nutrition counseling should be less about trying to make something happen and
more about making the “space” for something to happen.
Building Safety
Creating a truly “safe” space is likely impossible when discussing topics such as food,
the body, and behavior change, so the goal is to establish a “relatively safe” space. You cannot simply be “told” that you are safe since safety is an “embodied” sense. We have to “feel” safe, which is why the nervous system must be acknowledged. An important tool for increasing safety is asking permission. Clients may be surprised when a clinician asks if it is ok to provide education, but this simple step enhances safety by establishing consent. Offering clients multiple choices is a fabulous way to encourage safety. While the traditional approach might sound like: “you need to exercise 150 minutes a week,” a better approach might be to ask: “based on what we discussed today, which of these options are you most interested in trying: walking your dog in the evenings, practicing stress management, or cooking at home more often?” Creating awareness that there is a different path to health beyond the conventionalm healthcare approach can be monumental. If a client has only ever experienced diet culture, weight stigma, and guilt, their perceived options surrounding food and health may be extremely limited. Building safety and nurturing someone’s window of tolerance allows room for change while excessive education and talking “at” someone does not. The internet is full of free resources regarding meal planning, grocery lists, and recipes.
The issue is rarely a lack of nutrition information, but rather not knowing the path to success and not having the tools and support to get there. Dietitian and yoga teacher, Fiona Sutherland states that “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” (4).
As safety is being established, it can be helpful to begin bringing awareness to the
importance of the nervous system. It’s tempting to want to apply everything we learn
immediately, but trauma-informed care is a gentle and patient process. The pace should only be as fast as the slowest parts of ourselves allow (5).
Once someone is more attuned with their nervous system, a trauma-informed healthcare
professional might incorporate some simple techniques such as grounding, orienting, and deep breathing into their practice. By being mindful of the nervous system and tending to it when it is dysregulated, we can spend more time in our window of tolerance.
Conclusion
Although traditional dietetic approaches have not always considered the safety, learning
needs, and life experiences of the patient, trauma-informed care prioritizes these necessities.
By establishing a “safe-as-possible” space and recognizing the role of the nervous system, the likelihood of achieving change through nutrition counseling can increase tremendously. If you or someone you know is in need of nutrition counseling, consider working with a trauma-informed registered dietitian!
Nathan Slinkard, MS, RD, LD
References
1. Brown DW, Anda RF, Tiemeier H, Felitti VJ, Edwards VJ, Croft JB, Giles WH. Adverse
childhood experiences and the risk of premature mortality. Am J Prev Med. 2009
Nov;37(5):389-96. doi: 10.1016/j.amepre.2009.06.021. PMID: 19840693.
2. Centers for Disease Control and Prevention. (2022, April 6). Fast facts: Preventing
adverse childhood experiences |violence prevention|injury Center|CDC. Centers for
Disease Control and Prevention. Retrieved March 16, 2023, from
https://www.cdc.gov/violenceprevention/aces/fastfact.html
3. Ruth Buczynski, P. D. (2022, November 21). How to help your clients understand their
window of tolerance. NICABM. Retrieved March 16, 2023, from
https://www.nicabm.com/trauma-how-to-help-your-clients-understand-their-window-of-
tolerance/
4. Dennett, C. (2021, July). Trauma-informed nutrition care - today's Dietitian Magazine.
Today's Dietitian. Retrieved March 20, 2023, from
https://www.todaysdietitian.com/newarchives/JJ21p36.shtml
5. Posin, R. L. (2012). Go only as fast as your slowest part feels safe to go: Tales to Kindle
gentleness and compassion for our exhausted selves. Compassionate Ink.