+

Lindsay Stenovec, MS, RD & Kelly Hinds, RDUCSD Eating Disorder Treatment & Research Center

The Role of the RD in Eating Disorder Treatment:

If it’s not about the food, then why do patients need

a dietitian?

+Objectives

Define Registered Dietitian and Nutrition Therapist

Identify role of the Registered Dietitian in eating disorder treatment

Describe ideal collaboration between Registered Dietitian & Psychotherapist

+What is a Registered Dietitian? Trained Nutrition Professional with the credentials to

provide Medical Nutrition Therapy Counseling on behavioral and lifestyle changes related to

diet and exercise for specific diseases and disorders Medical professional that acts as a liaison between

treatment team, doctors & nurses Trained in motivational interviewing and able to assess

readiness for change

Nutrition Science Degree from accredited university

Professional Practice Internship

National Registration Exam

Continuing Education Units

+Nutrition is Science

Medical Nutrition TherapyNutritional BiochemistryChemistry

Organic ChemistryBiochemistry

BiologyMicrobiology & Food MicrobiologyFood ScienceAnatomy & Physiology

+What is a Nutrition Therapist?

Works as part of a multidisciplinary team

Understands underlying psychological issues Professional supervision Continuing education Understands relationship between psychology &

eating Recognizes when underlying issues need to be

worked out in therapy before moving forward

+

What is a Nutrition Therapist?

Ability to establish rapport with challenging patients

Communicates nutrition messages appropriately

Develops highly individualized treatment plans

+Evidence to Support the RD in ED Treatment

APA Guidelines recommend Nutritional Rehabilitation as a First goal in treatment of AN & BN (APA)

Nutrition therapy or cognitive therapy alone is ineffective, together they are most effective (APA)

Some people assume behaviors return to normal with psychotherapy (Beumont, O'Connor, Touyz, & Williams, 1988)

+Evidence to Support the RD in ED Treatment

Insufficient evidence to support that psychotherapy is effective in changing weight in eating disorder patients (Hay et al, 2003)

Can’t treat AN without weight restoration and psychotherapy is ineffective until weight is restored (Mehler et al., 2010)

Side effects of starvation need to be addressed before psychotherapy can be effective (Salvy & McCargar, 2002)

+Evidence to Support the RD in ED Treatment

The sooner eating disorder behaviors are stopped and nutrition and physical health are restored the better someone responds to therapy (Van Son GE et al., 2010, AAP Identifying and treating eating disorders, 2003)

Patients and family identify nutrition therapy as an important component in treatment (Escobar-Koch, et al., 2010)

Dietitians have strongest nutrition knowledge base of clinicians treating eating disorders (Cordery & Waller, 2006)

+A team that includes a Dietitian will…

Free the therapist to concentrate on therapy

rather than food

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Nutrition Counseling

Nutrition Education

Medical Nutrition Therapy

The Role of the Registered Dietitian

+Nutrition Counseling

It is not only about what to eat, but how to eat

Resolving the client’s relationship with food, not simply restoring weight, is the goal of treatment

Return of normal weight does not dispel the abnormal eating behaviors or disturbed attitudes about food

+Nutrition Counseling

Discover & challenge distorted beliefs/fears about food, weight & exercise and how they may enable eating disorder behaviors

Process patient’s use of food: emotional eating, self-punishment, sense of communication or control

Process barriers to progress – lack of motivation, underlying issues, lack of structure/planning

Incremental changes to meal plan with consideration of patient’s nutritional needs, level of progress and readiness for change

+Nutrition Counseling

Desensitization & Exposure Therapy to Increase Flexibility

Fear Food Challenges Food Rituals Social Eating Dining Out Grocery Shopping Cooking

+Nutrition Counseling

Hunger & Satiety Work

Physical vs Emotional Hunger

Continually weave in concepts of Normal Eating for enjoyment & wellness

Health at Every Size

Mindful Eating

+Nutrition Education

Basic Education on Macronutrients & Micronutrients Function of Nutrients in the Body Effects of Nutrient Deficiencies Food Facts & Fallacies

Anatomy & Physiology Starvation symptoms

Refeeding Process

+Nutrition Education

Weight & Metabolism

Effects of Compensatory Behaviors (purging, laxatives, diuretics, diet pills, exercise etc)

Relationship Between Food & Mood

+Nutrition Education

Assist clients in planning menus to meet needs

How to Grocery Shop

How to Cook

+Medical Nutrition Therapy Establish Goal Weight Range

Laboratory Data Weight History Family Weight History Body Composition

Monitor weight changes & educate accordingly Fluid Shifts Refeeding Effects Natural Weight Cycles

+Medical Nutrition Therapy

Monitor Nutrition-Related Labs & Medical Complications

Ongoing communication & coordination of care with physician

Prescribe Healthy Exercise

Prescribe Meal Plan

Optimize Resting Metabolic Rate

+Collaboration Between RD & Psychotherapist

It is not the role of the dietitian to do psychotherapy

Patients attempting to discuss therapy in nutrition sessions are distracting from the real issues

It is not the role of the psychotherapist to do nutrition therapy

Patients attempting to discuss food in therapy sessions are distracting from the real issues

Eating Disorders: Nutrition Therapy in the Recovery Process; Reiff & Reiff

+Collaboration Between RD & Psychotherapist

Defer all food issues to RD

Keep an open mind regarding nutrition science/media

Work on food issues in therapy

Discuss your own food beliefs with clients

Do’s Don’ts

Psychological aspects of treatment

Determines appropriate therapy

Informs team of progress in therapy

Explain pt issues that may influence how they work with team

Teaches ways to change food, exercise & wt –related behaviors

Educates on normal & abnormal eating, hunger, metabolic rate

Increase awareness of body

Model communication w/team & reinforce purpose of team

Reveal how food, wt & body image behaviors mirror life

Help pt develop sense of trust and connectedness in people & self

Collaboration Between RD & Pyschotherapist

Therapist Dietitian

Helps pt connect underlying issues to ED behaviors

Educates, discusses & prepares pt for working with team

Helps pt & family understand purpose of ED and explores pt willingness to get better

Assists pt in understanding connection between emotion & food behavior

Teaches pt how to develop healthy relationship with food

Update team regarding food, exercise & weight

Help pt identify needs

Help pt develop alternative ways to deal and cope

Support & encourage change in Ed behaviors & highlight development & growth

Collaboration Between RD & Pyschotherapist

Therapist Dietitian

+References

American Academy of Pediatrics, Committee on Adolescence. (2003). Identifying and treating eating disorders. Journal of Pediatrics , 111, 204-211.

American Psychiatric Association. (2006, July). Treatment of patients with eating disorders. Retrieved May 5, 2012, from Psychiatryonline: http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1671334

Ashley, M., & Crino, N. (2010). A novel approach to treating eating disorders in a day-hospital treatment program. Nutrition and Dietetics , 67, 155-159.

Beumont, P. J., O'Connor, M., Touyz, S. W., & Williams, H. (1988). Handbook of Eating Disorders, Part 1. Amsterdam: Elsevier Science.

Cockfield, A., & Philpot, U. (2009). Symposium 8: feeding size 0: the challenges of anorexia, managing anorexia from a dietitian's perspective. Proceedings of the Nutrition Society , 68, 281-288.

+References

Cordery, H., & Waller, G. (2006). Nutritional knowledge of health care professionals working in the eating disorders. European Eating Disorders Review , 14, 462-467.

Costin, C. (2007). The Eating Disorder Sourcebook (3rd ed.). New York, New York: McGraw Hill.

Escobar-Koch, T., Banker, J., Crow, S., Cullis, J., Ringwood, S., Smith, G., et al. (2010). Service user's views of eating disorder services: an international perspective. International Journal of Eating Disorders , 43, 549-559.

Hart, S., Russell, J., & Abraham, S. (2011). Nutrition management and dietetic practice in eating disorder management. Journal of Human Nutrition and Dietetics , 24, 144-153.

Hay, P., Bacaltchuk, J., Byrnes, R. T., Claudino, A., Ben-Tovim, D., & Yong, P. Y. (2003). Individual pyschotherapy in the outpatient treatment of adults with anorexia nervosa. Cochrane Database System Review .

Laessle, R. G., Beumont, P. J., Butow, P., Lennerts, W., O'Conner, M., Pirke, K. M., et al. (1991). A comparison of nutritional management with stress management in the treatment of bulimia nervosa. British Journal of Psychiatry , 159, 250-261.

+References

Mehler, P. S., Winkelman, A. B., Anderson, D. M., & Gaudiani, J. L. (2010). Nutritional rehabilitation: Practical guidelines for refeeding the anorectic patient . Journal of Nutrition and Metabolism , 10, 1-7.

Ozier, A. D., & Henry, B. W. (2011). Position of the academy of nutrition and dietetics: Nutrition intervention in the treatment of eating disorders. Journal of the American Dietetic Association , 111, 1236-1241.

Rock, C. L., & Curran-Celentano, J. (1996). Nutritional management of eating disorders. Psychiatric Clinics of North America , 19 (4), 702-713.

Van Son, G. E., Van Hoeken, D., Van Furth, E. F., Donker, G. A., & Hoek, H. W. (2010). Course and outcome of eating disorders in a primary care-based cohort. International Journal of Eating Disorders , 43, 130-138I.

Waterhous, T., & Jacob, M. A. (2011). Nutrition interventions in eating disorders. Academy of Nutrition and Dietetics.