+
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
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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
+
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
+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§ionid=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.