1. + Lindsay Stenovec MS, RD & Kelly Hinds RD The Role of the RD in Eating Disorder Treatment: If it’s not about the food, then why do patients need a dietitian?

2. + Objectives Define Registered Dietitian and Nutrition Therapist Identify role of the Registered Dietitian in eating disorder treatment Describe ideal collaboration between Registered Dietitian & Psychotherapist

3. + 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

4. + Nutrition is Science Medical Nutrition Therapy Nutritional Biochemistry Chemistry Organic Chemistry Biochemistry Biology Microbiology & Food Microbiology Food Science Anatomy & Physiology

5. + 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

6. + What is a Nutrition Therapist? Ability to establish rapport with challenging patients Communicates nutrition messages appropriately Develops highly individualized treatment plans

7. + 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)

8. + 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)

9. + 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)

10. + A team that includes a Dietitian will… Free the therapist to concentrate on therapy rather than food

11. + Nutrition Counseling Nutrition Education Medical Nutrition Therapy The Role of the Registered Dietitian

12. + 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

13. + 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

14. + Nutrition Counseling Desensitization & Exposure Therapy to Increase Flexibility Fear Food Challenges Food Rituals Social Eating Dining Out Grocery Shopping Cooking

15. + 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

16. + 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

17. + Nutrition Education Weight & Metabolism Effects of Compensatory Behaviors (purging, laxatives, diuretics, diet pills, exercise etc) Relationship Between Food & Mood

18. + Nutrition Education Assist clients in planning menus to meet needs How to Grocery Shop How to Cook

19. + 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

20. + 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

21. + 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

22. + Collaboration Between RD & Psychotherapist Defer all food issues to RD Keep an open mind regarding nutrition science/media Communicate frequently with the RD Answer nutrition questions or work on food issues in therapy Discuss your own food beliefs with clients “I don’t eat desserts.” “I follow a low carb diet.” Make judgment statements about food “I was so bad this weekend! I ate chocolate chip cookies.” Do’sDon’ts

23. 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

24. 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

25. + 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.

26. + 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.

27. + 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.