Treatment often requires a long-term interdisciplinary team approach

Nutrition therapy provided by a dietitian trained in the area of eating disorders plays a significant role in treatment and management of eating disorders

The role of the nutrition therapist is to assist with the normalization of the client’s weight and eating behavior

Refer to Figure 16.1 Assisting a client with an eating

disorder takes years rather than months Current research suggests that

approximately 46% of patients with anorexia nervosa recover and 33% improve while 50% of patients presenting with bulimia nervosa recover and 30% improve

No counseling strategy is effective without first establishing rapport with your client

It is important for your client to see you as knowledgeable

The more you understand and empathize with your clients, the greater likelihood of establishing trust and bonding with them

One of your goals will be to assist clients in their motivation to make changes

The very first session often is crucial in setting the stage for long-term outcome

It is important to utilize good interviewing skills from the start and to avoid the common traps that hinder progress

Assessment is a dynamic, comprehensive, and organized system of gathering information relevant to nutritional care of your client

It should identify contributing factors to the eating disorder, starting points for therapy, and whether goals are met along the way

Assessment should be part of each session, not just an activity for the first session

Assessment questions should be presented in a motivational fashion

The initial medical evaluation of a client with an eating disorder should include a full physical examination performed by a medical provider familiar with eating disorders

This evaluation will assess vital signs, physical growth and development, and the physical signs of an eating disorder

Low Blood Pressure Seizures Abnormal Heart Rhythm Decreased Heart Rate Anemia Lowered Body

Temperature Kidney Complications Constipation Scars on back of hand Muscular weakness and

decreased muscle mass

Painful Muscle Spasm Swollen Feet Decreased Sexual Drive

and Performance Loss of Menstrual Cycle Electrolyte Imbalance Gastrointestinal Symptoms Abnormal Liver Function Regression of Breast

Development Decreased Thyroid

Hormone Increased Growth Hormone

Cardiovascular Changes

Hematologic Changes Endocrine Changes Renal Function

Changes Lanugo Hair Muscle Atrophy Brain Changes

Metabolic Abnormalities

Gastric Problems Osteoporosis Dental Problems Laxative Dependence Emetic Toxicity Swollen Glands Peripheral Edema

When gathering a diet history, make sure the client realizes your goal is not to judge but to have a better understanding of his or her food choices

In order to obtain the most accurate assessment of dietary intake the use of the 24 hour recall, a typical day recall, a food frequency questionnaire, or a 3 to 7 day food record are helpful tools

Food records can provide meaningful information, not only on types and quantities of food eaten, but also patterns of intake

Refeeding is a term often used when discussing the weight-gaining phase of treatment

The refeeding process can be divided into four phases

During refeeding it is critical to work with the medical professional and stay abreast of vital signs, electrolytes, physical symptoms, and weight changes to prevent refeeding syndrome

Refeeding syndrome is the series of metabolic readaptation complications brought about by the reintroduction of fluids and nutrients after a period of nutritional deprivation

The symptoms include swollen ankles, shortness of breath, tiredness, and anxiety

It is important for your client to understand that rebound edema is a normal physiological side effect

May last for up to 10 days at which time the body readjusts and the edema subsides

Goal weight refers to the weight that will restore normal physiological functioning

Goal weight should approximate the individual’s “set point”

Set point refers to a weight range that the client can maintain without needing to restrict his or her intake or overexercise; a weight where he or she is no longer preoccupied with food

It is unlikely that your client will comply with this meal plan initially, but it will serve as the goal to be accomplished as you work with your client on cognitive behavioral exercises

The objective of the meal plan is to provide nutrient categories at structured intervals not to exceed 6 hours

Emphasize that you do not want clients using diet foods

Initially in treatment, avoid high-risk foods

Ask the client to monitor thoughts, moods, behaviors, and food intake

Self-monitoring will enable the client to take a closer look at his or her thoughts and moods that precipitate eating disorder behavior and will serve as the basis for problem solving

It is important to review the food record at each session, always point out the positive changes first

Changing food attitudes and behaviors in clients with eating disorders requires knowledge and cognitive behavioral strategies

Along with providing information about food’s value to the body, you will also help your client make the connection between lack of food and current symptoms.

Nutrition-focused Cognitive-Behavioral Therapy (CBT) involves teaching a nutrition principle followed by techniques to empower the client to change eating behavior

CBT challenges the client’s irrational belief system, and helps him or her make positive changes in his or her life

Filtering Dichotomous

Thinking (Also referred to as Black and White Thinking)

Overgeneralization Mind Reading Catastrophizing

Personalization Discounting Self-fulfilling

Prophecy “Shoulds” Underlying

Assumptions Decatastrophizing Reattributon Decentering

Once the client has learned to identify his or her distorted thinking, the client then can begin to see how this way of thinking affects emotions and behavior

The client then can move to re-evaluate his or her current thought and underlying assumption when asked 4 questions:

1. What is the evidence to support or refute your current thought?

2. What is the function of your thought? What do you gain by holding on to that thought?

3. What are the implications of that thought?4. What are the alternative explanations for your thought?

Do not assume the meaning of your client’s words mirror your own

Conversely, your words may not be interpreted literally

People with eating disorders may distort the meaning of language as much as he or she distorts body image

Providing health care to individuals with chronic illness in the current environment of cost containment and outcome management has led to a focused effort to move toward disease case management

Chronic disease is defined as one that persists over a long period

Almost 7 out of every 10 Americans who die each year die of a chronic disease

A major contributing factor to the rising incidence of chronic disease is the aging American population

The costs of chronic diseases are staggering The increase in chronic disease means more complex

patients

The health care team should be proactive and integrated across time, place, and condition when developing a chronic illness care plan

Interventions to improve outcomes for these patients include: The use of protocols and practice guidelines so

care is not erratic or outdated Improved patient education with emphasis on

self-monitoring Improved access to expertise Greater availability of clinical information

In 1997, the Nutrition Screening Initiative (NSI) developed a nutrition care manual specific to chronic disease care

The NSI is a multidisciplinary coalition led by the American Dietetic Association, the American Academy of Family Physicians, the the National Council on Aging in collaboration with more than 25 national health and aging-related organizations

Patient-centered care emphasizes long-term, continuous, healing relationships

Patients want to be partners in their own care and receive more responsive care from health care providers

Care is individualized based on the patient’s needs and values, and emphasizes patient control in the health care process

Empowering patients through the provision of information is at the heart of patient-centered care

The Chronic Care Model is based on the premise that functional and clinical outcomes can be improved through collaborative efforts among various providers of healthcare Community Health Systems Self-Management Support Delivery System Design Decision Support Clinical Information Systems

Evidence-based practice is the reliance on scientific data and the results of scientific studies as the basis for practice decisions

The goal of evidence-based practice is to improve care using sound research

It is important for dietetic practitioners to have a systematic method for applying new knowledge and research data, regardless of practice setting, in order to achieve quality outcomes