Possible Role of Nutritionists in Multi-Disciplinary Teams Managing Patients with Eating Disorders in The Russian Federation

The goal of this publication was to weigh the benefits of including a nutritionist in a team of specialists managing patients with eating disorders (EDs). The article describes the professional status of nutritionists as of the first half of 2023, as well as their field of competence and limitations. The nutritionist is intended to play an auxiliary role in the team, primarily assisting the patient in following the recommendations of the attending physician(s). A nutritionist can also take preventive action by educating the population on the importance of good nutrition.

No professional standards currently exist in the Russian Federation for nutritionists. At the same time, there are already specialists, and even professional organizations, who have chosen nutrition as their primary professional activity. The employees of the “Scientific Research Institute of Nutrition”, representatives of the Russian Union of Nutritionists, Dietitians and Food Industry Specialists (RoSNDSPI), and members of the public association “Nutritionists of Russia” are actively working on a draft professional standard.

Nutritional science studies food, nutrients, and other food ingredients, their actions and interactions, and their role in maintaining health or causing disease. This field of knowledge is actively developing; it includes the study of consumption, assimilation, transfer, utilization, and excretion of nutrients from the body. Nutritional science also studies people’s motives for choosing food and how this choice affects their health¹.

Nutritionists are specialists who help their clients adhere to the principles of rational nutrition. They can also engage in public education or scientific research and collaborate with other specialists: dietitians, gastroenterologists, endocrinologists, psychiatrists, psychologists, coaches, food technologists, etc.

Until the professional standard is adopted, nutritionists in their work rely on Federal Law No. 323-FZ of November 21, 2011 “On Public Health Protection in the Russian Federation” (Federal Law No. 323-FZ)². This federal law defines what is considered medical service or intervention and what is not. Understanding this distinction is important, because a nutritionist is not a medical specialist. Therefore, nutritionists have no right to perform medical activities.

Nutritionists can rely on the Code of Professional Ethics of a Nutritionist of the Russian Federation, adopted by the Public Association “Nutritionists of Russia” (Code) ³. This Code consists of nine articles and includes a preamble; knowledge of professional ethics; limitation of professional competence; limitation of the means used; professional development; respect for the client; maintaining confidentiality; scope of professional activity of a nutritionist; and issues not within the professional competence of a nutritionist, and Code violation.

According to the Code, nutritionists:

• introduce clients to the rules of healthy eating;
• inform their clients about the impact of a lack or excess of nutrients on their health;
• inform them about food groups that should be included in the daily diet;
• teach them how to analyze the information displayed by manufacturers on food products;
• analyze nutrition and perform anthropometric measurements;
• provide an example menu to their clients, while the clients choose specific products themselves;
• help them implement the recommendations of their attending physician, if any, in everyday life.³

Nutritionists must:

• work within their field of competence, based on their education and experience;
• increase their professional competence and awareness in the field of nutritional science and nutrition;
• respect their clients regardless of their social status, nationality, religion, affiliation, race, gender, age, sexual orientation, etc.;
• respect the principle of confidentiality.³

Nutritionists are not specialists in alternative medicine and cannot recommend dietary supplement regimens or “nutrition protocols” for the treatment of diseases, detoxification programs, fasting — including intermittent fasting — or exclusion of food groups. Nutritionists do not prescribe laboratory tests and do not interpret the results, nor do they prescribe or stop medications for their clients. Such actions would be not only a gross violation of the Code, but also a violation of the federal law.

In the Russian Federation there is a shortage of dietitians, with the number of doctors not covering the needs of the country’s population. There is one doctor per 247,000 people, while the standard is one specialist per 25,000 citizens⁴. At the 17^th All-Russian Congress of Dietitians and Nutritionists with international participation, Alla Pogozheva, deputy chief external dietitian of the Ministry of Health of Russia, voiced the need to increase their staff levels⁵.

The shortage of dietitians in the Russian Federation may lead to an increase in the prevalence of diet-induced diseases and to a lack of proper understanding of rational nutrition by the population. The latter, in turn, may raise interest in “popular” diets and increase the total number of patients with eating disorders (EDs). In 2018, the Federal Statistics Service conducted a random survey of Russians’ diet. According to published data, 48.8% of people aged 14 years and over reported one or more diseases (conditions) associated with nutrition⁶.

Order of the Ministry of Health of the Russian Federation No. 920n of November 15, 2012⁷, does not regulate the time for one patient appointment. According to the Regulation on the Organization of the Activities of a Dietitian (approved by Order of the Ministry of Health of the Russian Federation No. 330 of August 5, 2003, the duties of a dietitian, in addition to advising patients on therapeutic and rational nutrition, include:

• organizing therapeutic nutrition in healthcare institutions;
• monitoring catering departments, including preparing the necessary documents, ensuring the proper storage of food;
• advising doctors on therapeutic nutrition;
• analyzing of therapeutic nutrition effectiveness;
• determining the list and size of food portions for patients in healthcare institutions;
• organizing advanced training of catering personnel on therapeutic nutrition;
• conducting sanitary and educational work on therapeutic and rational nutrition for employees of healthcare institutions, etc.⁸

Due to the limited time of any appointment, it may be difficult to discuss any strategy for introducing certain dietary habits and lifestyle modifications with the patient. This is where nutritionists intervene, working with clients to implement the doctor’s prescriptions. The dietitian and nutritionist can work effectively in tandem, staying in touch and sharing information about the process and consultation summaries. For example, at the Fomin Clinic (KDF-Zapad LLC), a private health care center in Moscow, joint management of patients by the gastroenterologist-nutritionist tandem has already been established.

Due to the above-mentioned shortage of dietitians and their primary field of competence, nutritionists ought to focus on helping patients with EDs, in which a healthy diet plays a special role in therapy. According to the Code, if clients have a disease, they can only be managed with the permission of the attending physician (Article 2.4)³. Nutritionists help clients follow the principles of a rational, balanced diet and the recommendations of the attending physician in everyday life (Article 7.11)³. It is forbidden for persons without psychological training to offer advice on issues related to EDs (Article 8.6)³.

Thus, nutritionists are not authorized to work with clients with EDs if these clients are not receiving medical care. Nutritionists must be aware of the limits of their competence and stay within these limits. It can be assumed that their role when working in tandem with a doctor or as part of a multi-disciplinary team will be auxiliary.

The functions of a nutritionist may include:

• diversifying the client’s diet;
• introducing new cooking methods, proposing various recipes;
• helping clients implement the recommendations of the attending physician;
• training in organizing nutrition and grocery shopping;
• meal planning;
• debunking food myths, including chemophobic beliefs;
• helping monitor physical activity and sleep;
• helping clients recognize the return of symptoms as soon as possible to prevent a relapse.

If a relapse is suspected, the nutritionist is supposed to refer the client to a doctor.

In anorexia nervosa, a dietitian or gastroenterologist determines the patient’s individual energy and nutrient needs and creates a meal plan meeting those needs. A nutritionist may play an auxiliary role after a client with anorexia nervosa has regained weight.

If a client has been diagnosed with bulimia nervosa, a nutritionist can assist in maintaining positive eating habits after eliminating compensatory behaviors:

• eating with utensils, not with hands;
• warming food before eating it;
• planning meals in advance;
• allowing a normal amount of fat in food;
• including all food groups in the diet;
• having 1–3 snacks per day in addition to main meals.

In binge eating, a nutritionist can play an auxiliary role after a significant reduction in binge episodes and help maintain changes:

• help the client recognize hunger and satiety;
• provide support with meal planning;
• remind the client of the importance of healthy eating and the dangers of fasting.

One of the important tasks of a nutritionist can be preventing EDs through education of the population. To achieve this, the specialist does the following:

• explains the effects of fasting and purging;
• speaks of the need for macro- and micronutrients, sufficient energy value of nutrition;
• teaches the client the basics of a balanced diet;
• encourages a varied and enjoyable diet, including products from all groups;
• debunks myths about nutrition;
• gives advice to clients with inadequate weight loss expectations;
• refers clients with suspected EDs to a psychiatrist.

Thus, in the future, a nutritionist may become part of a multi-specialist team that manages patients with EDs. Implementation of this initiative certainly requires a professional standard. Nutritionists must operate strictly within their field of competence and be aware of the limitations of the means they use. Their work would primarily consist of preventive measures, and they may interact with patients with EDs only as part of a multi-dsicplinary team.

¹ Martinchik AN Maev IV, Yanushevich OO. General Nutritionology: A textbook. Moscow: MEDpress-inform; 2005. 392 p. Russian.

² Federal Law No. 323-FZ of November 21, 2011 “On Public Health Protection in the Russian Federation”. Article 2. The basic concepts used in this Federal Law. Russian.

³ The Code of Professional Ethics of the NGO “Nutritionists of Russia” of December 28, 2021. [Internet]. Forum of nutritionists of Russia. [cited 2023 May 15]. Available from: https://nutritiologists.ru/code-of-ethics. Russian.

⁴ Russia’s facing a dearth of dietologists [Internet]. Practical dietetics; 2011. [cited 2023 May 15]. Available from: https://www.praktik-dietolog.ru/news/15.html. Russian.

⁵ Belova I. [Lack of dietologists is still an issue in Russia]. Rossiiskaya gazeta [Internet]. 2018 Oct 29 [cited 2023 May 15]. Available from: https://rg.ru/2018/10/29/reg-cfo/v-rossii-poka-ne-udalos-ustranit-nehvatku-dietologov.html. Russian.

⁶ Sample observation of the diet of the population [Internet]. Federal State Statistics Service; c2018 [cited 2023 May 15]. Available from: https://www.gks.ru/free_doc/new_site/food18/index.html. Russian.

⁷ Order of the Ministry of Health of the Russian Federation No. 330 of August 5, 2003 “On measures to improve therapeutic nutrition in medical institutions of the Russian Federation”. Russian.

⁸ Order of the Ministry of Health of the Russian Federation No. 330 of August 5, 2003 “On measures to improve therapeutic nutrition in medical institutions of the Russian Federation”. Russian.