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iaedp™ The International Association of Eating Disorders Professionals Foundation

 

The

CEDRD in

Eating Disorders Care

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THECEDRDINEATINGDISORDERCARE

Introduction:The iaedp™ Foundation provides a wide scope ofeducational opportunities for professionals to acquiretheknowledge, skills, and confidence to recognize andtreateatingdisorders.Eatingdisordersarecomplexbiopsychosocialdisordersthat require specialized treatment by amultidisciplinary team. The team is ethically bound totreat within a scope of competence and each treatingclinicianmustunderstandhisorherroletosupporttheteamandprovideeffectiveexpertise.Disclaimer: This document, created by theInternational Association of Eating DisorderProfessionals’ Nutrition Health ManagementCommittee, is intended as a resource to promoterecognition of the medical healthcare professionalcontributions to theeatingdisorder treatment team. Itis not a comprehensive clinical guide for treatment.Every attemptwasmade to include current evidencedbased references and clinical practice standards.Accordingly, the Committee has relied on peer‐reviewed sources and clinical expertise that reflectsevidence based approaches from a variety of eatingdisorder professionals and research conducted withintheUnitedStatesandinternationally.Thus,thecontentof this document reflects current knowledge andstandards of eating disorders management. However,credentialsaswellasthespecificrolesofprofessionals

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outside of the United States may differ according tolocalstandards,practices,andhealthcaredelivery.TheiaedpNutritionHealthManagementCommittee:Chair:KarenBeerbower,MS,RDN,CEDRD,LD,F.iaedpMembers:TammyBeasley,RDN,CEDRD,CSSD,LDJessikaBrown,MS,RDN,CEDRD,CSSD,ACEBrianCook,PhDMaryDye,MPH,RDN,CEDRD,KathrynFinkMartinez,MS,RDN,CEDRD,LDValerieMurrayHoughton,RDN,LDJoelJahraus,MD,FAED,CEDS,F.iaedpAnnaLutz,MPH,RDN,CEDRD,LD

Publishedbyiaedp™2015Secondedition2017www.iaedp.com

www.eatingdisordersreview.com

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TableofContents

Introduction,Disclaimer&iaedpNutritionHealthManagementMembers.............................................1TeamApproach/TeamReimbursement.......................4UnderstandingtheCredentials..........................................5RoleoftheCEDRDatEachLevelofEDCare.............10NutritionTherapyToolsUsedbytheCEDRD..........21HighRiskEDGroupsandtheCEDRD...........................24OngoingNutritionalManagement.................................28Resources.....................................................................................29

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TeamApproach/TeamReimbursementEatingdisordersareoneofthemostdifficultillnessestotreat having both mental health aspects as well asmedical and nutritional aspects. Whilemultidisciplinary team treatment is considered bestpractice, considerable variation exists in teamcompositiondependingon treatment settingandstageof illness. This variation often occurs due to thereimbursementissuesoftheRDonthetreatmentteam.RDs serve on numerous health care teams includingmetabolic support teams, diabetic care teams, renaltreatmentteamsetc. RDsaretheexperts,inbothfoodscienceandnutritionscience,trainedthrougheducationandexperiencetounderstandthecomplexrelationshipof food intake to overall physiological health. If theservicesofaRDarecoveredbyinsurancecarriers,itisundermedical/surgicalbenefits.

AtthevariouslevelsofcareasdefinedbytheAmericanPsychiatric Association (APA) Eating DisorderTreatment Guidelines, the following expectations arelisted: individual nutrition assessments, individualnutrition appointments, recommendations forappropriate meal plans and nutrition therapy,recommendations forphysical activity, groupnutritioneducationandmealexposureandresponse. Insurancereviewers are requesting extensive data to justifytreatmentwhichcomesdirectlyfromtheworkwiththeRD.Nutritiontherapyoverlapsmentalhealththerapiesandinvolveshelpingfamiliesandothersunderstandtherealities of eating disorders, aiding clients inunderstanding their irrational thoughts and behaviorsaround food, understanding normalized eating and

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overcoming barriers to changing their behaviors. Inaddition, RDs often act as case managers in theoutpatient setting as medical practitioners andpsychologistsincreasinglyfindtheydonothavetimetodo this critical aspect of care. Case managementinvolvesmakingsurethatallmembersoftheoutpatientteam have frequent communication and agree totreatmentdetails.Oftenthefamilywithachildwithaneating disorder needs coaching and guidance andsupport,anothervitalfunctionisperformedbyRDs.

The RD that has pursued the advanced training andcompletion of the CEDRD requirements of iaedp notonlyservestoenhancethequalityofEDtreatmentandthe multidisciplinary team approach, but provides aplatform for future reimbursement and best practiceservice available to all patients with behavioralnutritionchallenges.UnderstandingtheCredentialsWhatisaRD,LD,Nutritionist,RDN,LDN,NutritionEducator,NutritionTherapist/Counselor,orCEDRD?It is necessary to understand the difference in thefollowing terms to assemble the most effective EDtreatment team taking into consideration the needs ofthe patient and the availabilitywithin the community:dietitian, registered dietitian, licensed dietitian/‐nutritionist, nutritioneducator, nutrition therapist andcertifiedeatingdisorderregistereddietitian.

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Dietitian: This title would indicate completion of aminimum of a bachelors program in dietetics orequivalentundergraduateprogramand isusuallyusedinconjunctionwith“RDeligible”whilewaitingtotakethenationalregistrationexam.RegisteredDietitian (RD): The RD designation is anational legally protected title. The RD is a voluntaryprofessional credential granted to an individual whomeets the qualifications established by theAccreditation Council for Education in Nutrition andDietetics (ACEND) and the Commission on DieteticRegistration (CDR), which is the credentialing agencyfortheAcademyofNutritionandDietetics.Note: Registered dietitian/nutritionist (RDN) may beusedinterchangeablywithRD.EducationoftheRDincludesthefollowing:

1. Completion of theminimum of a Baccalaureatedegree with coursework in food and nutritionsciences, organic chemistry, nutritionbiochemistry, genetics, microbiology,psychology, sociology, anatomy and physiology,foodservice systems management, communitynutrition, lifespan nutrition, communications,business,andcomputerscience

2. Supervisedpractice throughaDidacticProgramin Dietetics and Dietetic Internship or aCoordinated Program inDietetics accredited byACEND

3. Completion of a passing score on the nationalRegistration Examination for DietitiansadministeredbyCDRandmaintainedwithyearlyCDR‐approvedcontinuingeducation.

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UniquetotheRDisthequalificationtoprovideMedicalNutrition Therapy (MNT). MNT is an essentialcomponentofcomprehensivenutritioncare.Diseaseorconditionsmaybeprevented,delayed,ormanaged,andquality of life improved in individuals receiving MNT.During MNT intervention, RD’s counsel individuals onbehavioral and lifestyle changes that impact long‐termeating habits and health. MNT is an evidenced‐basedapplicationoftheNutritionCareProcessincluding:

1. performingacomprehensivenutritionassessment

2. determiningthenutritiondiagnosis3. planningandimplementinganutrition

interventionusingevidence‐basednutritionpracticeguidelines

4. monitoringandevaluatinganindividual’sprogresstowardgoals

LicensedDietitian (LD): Themajority of states haveenacted laws that regulate the practice of dietetics.Licensingstatues includeanexplicitlydefinedscopeofpractice, and performance of the profession is illegalwithout first obtaining a license from the state.Dieteticspractitioners are licensedby states to ensurethat only qualified, trained professionals providenutrition servicesor advice to individuals requiringorseeking nutrition care or information. Only licenseddietetics professionalspracticing in states that requirelicensure can provide nutrition counseling. Not everystatehas licensing fordietitians. It is important forallcare providers to know if this is a requirement forpracticeinyourstate.

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Nutritionist, RDN and LDN: There is no uniformdefinition for thetitleof“nutritionist”andthosestatesthatdefinenutritionist in statuesor regulationsdefineit according to theirowncriteria. Somestate licensureboardshaveenactedlegislationthatregulatesuseofthetitle nutritionist and/or sets specific qualifications forholdingthetitle.AccordingtotheAcademyofNutritionandDietetics,everyregistereddietitianisanutritionist,butnoteverynutritionist isa registereddietitian. Tothisend,theAcademyofNutritionandDieteticsandtheCommissiononDieteticregistrationhaveapprovedtheoptional use ofRDN or LDN to signify that indeed aregistereddietitianorlicenseddietitianisanutritionist.This communicates a broader concept of wellness(including prevention of health conditions beyondmedical nutrition therapy) as well as treatment ofconditions.Nutrition Educator: provides evidence basedinformation and education to individuals and/orgroups. Due to the brief and factual nature of theirinteractions,averyminimalrelationshipdevelops.Nutrition Therapist/Counselor (RDwith advancedskillset):meetswiththepatientoveralongerperiodoftime and encounters the complex area of humanrelationship dynamics. Level of involvement isindividualized depending upon the division ofresponsibilities within the treatment team. It isrecognized that by necessity RDs have had to learnbasiccounselingandbehaviorchangeskills,astheydealwith changing eating behaviors for many diagnosedillnesses. For this role, the dietetics practitioner mustfollow the code of ethics for nutrition counselorsestablishedbytheAcademyofNutritionandDietetics/

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Commission on Dietetic Registration, and scope ofpractice within their state, which is often very broad.Thenutritioncounselor/RDmustbeable toeffectivelyrecognize,assess,andappropriatelyplantreatmentfora patient with an ED. It is recommended that RDsworking with this population have advanced‐leveltraining via self‐study, continued education, andsupervision under those specialized in this area ofmedicine.Certified Eating Disorder Registered Dietitian(CEDRD)andiaedp:As the rate of individuals affected by eating disorderscontinues to grow, a greater need for qualified,knowledgeable treatment providers in the field exists.The International Association of Eating DisordersProfessionals (iaedp) has recognized that need byofferinganadvancedCertificationProgramtopromotestandards of excellence within the field of eatingdisorders, established in 2002 and continuallystrengthened and updated to maintain its strongreputation in the mental health field. It is iaedp’smission to promote excellence in competencyassessment for professionals in the eating disordersfield through offering a rigorous set of criteria for theevaluation of education, training, knowledge andexperience. Registered dietitians with the CertifiedEating Disorders Registered Dietitian credential(CEDRD) are experienced nutrition therapists whohavemet rigorous educational and skill requirements,have accumulated a minimum number of hours ofqualifyingwork experience, havemade a commitmentto stay abreast of current developments in the fieldthrough Continuing Education, and have agreed tocomply with the Association's Ethical Principles.

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Certification isevidencethatboththeprofessionalandiaedp are diligent in seeking advancement in training,education, research and competency in addressing thecomplexities involved in the treatment of eatingdisorders. In addition, both are united in theircommitment to the advancement of mental healthparity and advocacy for individuals strugglingwith aneatingdisorder.For consistency of terminology RD (CEDRD) will beused throughout this text. It is recognized thatnotallED teams will have a CEDRD and that RDs that aretrained and working within the standards establishedby certificationwill have the optimal skills to addresstheneedsofthispopulation.RoleoftheCEDRDatEachLevelofEDCareTheRD(CEDRD)maybethefirstpointofcontactforapatientseekinghelp foranED; therefore, theRDoftenbecomes responsible for helping the patient establishthetreatmentteam.Itisimportanttoknowthetrainedprofessionals within your community who are able tojoin the multidisciplinary team and provide the mosteffectivetreatment.Experienced RDs in treating eating disorders possesstheexpertiseandskillstoaddressissuesrelatedtofoodand nutrition knowledge, physiology, and behaviorchangeastheyplayoutinpsycho‐socio‐culturalrealmsof eating. They are uniquely qualified as theprofessional to provide medical nutrition therapyacross the full continuum of disordered eating and atvariouslevelsofcare.IncludinganRDonthetreatmentteam allows for the client to have a safe, designatedplace to discuss their foodbased thoughts and actions

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reserving their sessions with other providers toconcentrate on the non‐food facets of the eatingdisorder.Nutritioncounselingisconsideredanintegralcomponent in the treatment of eating disorders, andcollaboration between the RD (CEDRD) and othertreatmentteammembersoccursasfollows:

1. TheRD(CEDRD)focusesonphysicalandnutritionalrestoration,restoringhealthybodyweight,normalizingfoodhabits,expandingfoodchoices,changingattitudesandbeliefs,andcorrectingmisguidednotionsabouteating,food,bodysizeandshape.

2. TheRD(CEDRD)andthemedicalproviders(physician/nurse)collaborateonlabvalues,medicationandweightissuesasrelatedtothephysicalcomplicationsfromeatingdisorderbehaviors.

3. TheRD(CEDRD)andthepsychotherapistcollaborateonchangingfoodattitudesandbeliefs,bodyimageissues,andfood‐relatedbehaviortriggers

4. TheRD(CEDRD)andthepsychiatristcollaborateonfood‐relatedbehaviorsandattitudechangesasaresultofaneworchangedmedication.

5. TheRD(CEDRD)andthepatient’sfamilycollaborateonmealplanningandestablishingasupportiveenvironmenttopromoteweightrestorationandadecreaseineatingdisorderbehaviorswithinthefamilydynamics.

Withinthefullcourseoftreatment,shiftsofprioritywilloftenoccurdictatingwhichteammemberneedstobeintheprimarydirectiveroleoftreatment.Forinstance,ifthe medical issues are the primary focus and require

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acutedecisionsandstabilizationbeforeanytherapycanbe started or continued, then the medical physicianwould be directing the care plan with the dietitian tobegin restorative work and safe re‐feeding. At othertimes during treatment, when the behavioral andemotional issues are at the forefront of intensity, thetherapist may be directing the team. This underlinestheneed forallpractitioners involved tobeconstantlyassessing under their trained expertise andcommunicating as a team for the most effectiveoutcome.EDEnvironmentsandSpecificLevelsofCare:In determining a patient’s level of care or shift to adifferent level of care, it is important to consider theoverall clinical and social picture. The treatmentenvironmentisdeterminedbymanyfactors:

Medical/nutritionalstatus Co‐occurringpsychiatricdiagnosesthatmerit

treatment Levelofsupervisionrequired Availabilityofspecializedprogramswithina

geographicarea Availablefinances

In shifting between levels of care, it is important toestablish continuity of care. At times, patients mayerroneously conclude thatmoving to a less restrictivetreatment setting means that they are fully improvedwhen in fact, the shift might have occurred due tofinancial limitations. Because of the various factorsdictating the environment, maintaining high qualitystandardsofpracticeamongtheprofessionalsontheEDcare team will ensure continuity and uninterrupted

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attention to important aspects of treatment and theindividuals’recoveryprocess.AtalllevelsofcaretheRD(CEDRD)isexpectedtocarryout responsibilities according to the Standards ofPractice and Standards of Performance for theRegistered Dietitian. A RD’s (CEDRD’s) role in thenutrition care of individuals with eating disorders issupported by the American Psychological Association,The Academy of Eating Disorders and the AmericanAcademyofPediatrics.RDs(CEDRDs)workingwithEDpatients require a thorough understanding of thepsychodynamics of eating disorders. RDs (CEDRDs)apply the Nutrition Care Process to identify nutritiondiagnoses, and develop a plan for resolution. Keynutrition therapies require expertise in nutritionalrequirementsforthelifestageoftheaffectedindividual,nutritional rehabilitation treatments, andmodalities torestorenormaleatingpatterns.Strong counseling skills are imperative in facilitatingchange among patients with eating disorders.Psychotherapeutic behavioral approaches allow apractitioner to develop a trusting relationship thatfacilitates guiding a patient through changes made infood selection, patterns of physical activity, andacceptanceofbodyweight,shape,orsize.ThefollowingenvironmentsdictatespecificconsiderationsforRD(CEDRD)intervention:Acute: The patient is usually hospitalized based onpsychiatricandbehavioral factors, includingarapidorpersistentdeclineinoralintake,adeclineinweight,andmedical instability. This level of care is designed to

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providesafetyandphysicalstabilization.Thereisahighdegreeofapatient’sdenialandresistancetoparticipateinhisorherowncare. SpecificconsiderationsfortheRD’s(CEDRD’s)roleatthislevelofcare:

Communicatewithallteammembersandmedicalphysicianregardingthemedical/nutritionalstatusofthepatientandinitialhydrationandfeedingdemands.

Activelyengageinthedecisionofthesourceofnutritionandmethodofdeliverywhichmaybeoral,tube,orinrarecases,hyper‐alimentation.

Providetheresearchtotheclinicalteamandpatientregardingliquiddietarysupplementsthatareappropriatefortheclinicalprofileandpresentnutritionaldemands.

Communicatewithallstaffonallshiftsregardingfeedingacceptance,tolerance,andprogressiontomeetthedefinedcareplan.

Reviewlaboratoryworkanddiscussfeedingadjustmentrecommendationswithmedicalphysicianandpatient.

Providetherapeuticpatientcounselingonadailybasis

Writedailyaccuratewrittenreports Provideinitialnutritioneducation Participateindischargeplanningand

communicatedirectlywithstep‐downcareteamResidential: Thepatientat this level is in fair tohighlevel of malnutrition. There is usually less patientresistancewhen involvedinhis/herownself‐care,andtheRD(CEDRD)isworkingcloselywiththepatientonadaily basis or often several times per day.However,thereisawidescopeofservicewithinthe"residential"level of treatment. If the facility provides a family

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physicianorinternistwithregularmedicalmonitoring,the RD (CEDRD) will have greater opportunity toinitiate aggressive nutritional support and follow. Ifmedical intervention is done off site, the RD (CEDRD)will be the team member who will establish therelationship with the medical care provider in thecommunity for nutrition, weight, fitness progressand/or complications. Specific considerations for theRD's(CEDRD’s)roleatthislevelofcareinclude:

Ongoingassessmentofnutritionrestorationandweightgoals

Nutritioncounselingfocusedonacceptanceofrapidandoftenaggressivemealplansandstructureregardingexercise

Progressivere‐feedingeducationcorrelatingwithstatusofre‐feedingandpatientslevelofunderstandingandacceptanceofphysicalandfoodchanges

Progressivenutritioneducation Closecommunicationwiththerapistabout

behavioralchallengesaswellastherapyprogress

Ongoingstaffinteractiontoensureenvironmentalcomplianceandpreventionofeatingdisorderbehaviors

Attentiontofoodritualsandeatingdisorderbehaviorsthatneedtobetreatedatpresentlevelofcareaswellaswhendischargedtothenextlevelofcare.

Closecommunicationandworkwiththefamilyregardingpatientprogressandfamilyeducationoftheillnessandassistancewithestablishingahomeenvironmentsupportiveforrecovery.

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PartialHospitalizationProgram(PHP): Thislevelofcarecurrentlyrepresentsthewidestrangeofoptionsoflengthoftreatment,from20hoursperweektofulldaysof care, and serves patients that are just beginningtreatmentormaybesteppingdownfromahigherlevelofcare. SpecificconsiderationsfortheRD’s(CEDRD’s)roleatthislevelofcareinclude:

Communicationwithpreviouscareteam Well‐coordinatedtransitionofmealplan,

supplementationandnutritionalgoals Adjustmentofnutritionalgoalstomeetlevelof

supervisionandmedicalmanagementinpresentenvironment

Assistanceoftreatmentteaminrecognizingpotentialvulnerabilitiespresentedwithinthisenvironmentfortheindividualpatientandplansforrelapseprevention

Continuousassessmentforappropriatenessofenvironmentforpatientsneeds

Flexibilitywithnutritioninterventionwhichmayincludemultipleindividualsessionsweeklyandclosemonitoring,groupeducation,participationinprocessgroups,

Closecollaborationwithattendingphysicianandtherapist,alteringnutritioninterventionaccordingly

Communicationwiththefamily/participationinfamilysessions

Attentiontotheuniqueindividualneedsofpatients,focusingonrecoverygoalsandexpectationsastheyareexposedtopatientsinawiderangeofstagesoftheillnessinPHP

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Thoroughdischargeplanwhetherpatientisbeingshiftedtoahigherlevelofcareorsteppeddown

Intensive Outpatient (IOP): This level of care hasvariable levels of involvement for the RD. Someprograms have a RD (CEDRD) on staff, and someprogramsrequirethepatienttohaveanoutpatientRD(CEDRD).Thislevelofcareservespatientsthatarejustbeginning treatment ormay be stepping down from ahigherlevelofcare.SpecificconsiderationsfortheRD’s(CEDRD’s)roleattheIOPlevel:

Communicationwithpreviouscareteamtoensureconsistentgoals

Well‐coordinatedtransitionofmealplan,supplementationandnutritionalgoals

Adjustmentofnutritionalgoalstomeetlevelofsupervisionandmedicalmanagementinpresentenvironment

Assistanceinrecognizingpotentialvulnerabilitiespresentedwithinthisenvironmentfortheindividualpatientandplansforrelapseprevention

Continuousassessmentforappropriatenessofenvironmentforpatientsneeds

Flexibilitywithnutritioninterventionwhichmayincludemultipleindividualsessionsweeklyandclosemonitoring,groupeducation,participationinprocessgroups,

Collaborationwithattendingphysicianandtherapist,alteringnutritionalinterventionaccordingly

Communicationwiththefamily/participationinfamilysessions

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AttentiontotheindividualpatientstohelpeachfocusontheirrecoverygoalsandexpectationsastheyareexposedtopatientsinawiderangeofstagesoftheillnessinIOP

Thoroughdischargeplantoincludewhetherpatientisbeingshiftedtoahigherlevelofcareorsteppeddown

Outpatient:ThislevelofcarevariesforhowtheRD(CEDRD)isinvolved,dependingonpatientprogress,exhibitedbehaviors,motivationandfinances.Outpatientcareservespatientsthatarejustbeginningtreatmentorthosesteppingdownfromhigherlevelofcare.TheoutpatientRD(CEDRD)maybethefirstpointofcontactwiththepatient;therefore,theRD(CEDRD)oftenbecomesresponsibleforhelpingthepatientestablishthetreatmentteam.Itisimportanttoknowthetrainedprofessionalswithinthelocalcommunitywhoareabletojointhemultidisciplinaryteamandprovidethemosteffectivetreatment.Whenapatientstepsdownfrommoreintenselevelsoftreatment,itisrecommendedthatthepatientseetheoutpatientRD(CEDRD)atleastonceaweek.Asthepatientimproves,thefrequencyofthesessionswillvary.SpecificconsiderationsfortheRD’s(CEDRD’s)roleatthislevelofcare:

Communicationwithpreviouscareteam.Ifthisisthefirstpointofcontact,coordinatenewtreatmentteamwithlocalprofessionalstrainedinEDtreatment

Well‐coordinatedtransitionofmealplan,supplementationandnutritionalgoalsifpatientissteppingdownfromhigherlevelofcare.

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Adjustmentofnutritionalgoalstomeetlevelofsupervisionandmedicalmanagementinpresentenvironment

Assistanceinrecognizingpotentialvulnerabilitiespresentedwithinthisenvironmentfortheindividualpatientandplansforrelapseprevention

Continuousassessmentforappropriatenessofenvironmentforpatientsneeds

Flexibilitywithnutritioninterventionwhichmayincludemultipleindividualsessionsweeklyandclosemonitoring,buttypically1to2sessionsperweekinitially

Closecollaborationwithattendingphysicianandtherapist,alteringnutritionalinterventionasneeded

Communicationwiththefamily/participationinfamilysessionsasappropriate

Attentiontotheindividualpatientsinhelpingthemfocusontheirrecoverygoalsandexpectations,withtheeventualgoalofnormalizedeating

Weightandbehaviormonitoringofpatient Routine,consistentcommunicationwith

treatmentteamregardingpatientprogress Managementofthepatient’scase,sinceoften

theRD(CEDRD)actsasa“healthnavigator”intheoutpatientsetting,bymakingsurecommunicationsoccurbetweenteammembers,educatingpatientsandfamiliesaboutnextstepsandtreatmentoptions,andensuringpatientshavecontinuousaccesstonecessarytreatment.ThiscasemanagementtaskisanappropriateroleforRDs(CEDRDs)consideringtheirtraininginbothphysical/medicalandbehavioralrealms.

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FamilyBasedTreatmentforChildrenandAdolescents(FBT):RDs(CEDRDs)canapplytheirknowledgeandskillset,at the expert level, in treatment of children andadolescentsdiagnosedwitheatingdisorders.Using thetreatment modality of home‐based re‐feeding for themedically stablechild, thechild remainsathome,withparents utilized as resources and as part of thetreatment team. The parents are trained by experthealth practitioners in the delivery of the re‐feedingtechniques. Keeping the child in the home communityallows the ability to go to school and interact withfamily and friends in themost normal fashion. Home‐basedre‐feedingmodalities forthetreatmentofeatingdisorders have been recently tested in clinical trials,demonstrating that parents can be trained andempowered to re‐feed their children at home. Mentalhealth professionals have been the clinicians used inclinical trials in the field testing of these modalities,known as Maudsley or family based treatment (FBT).RDs (CEDRDs) possess the skill set necessary in orderto help parents feed children at home, and have usedthis same skill set effectively in other settings forfamiliesthathavereceivedadifficultmedicaldiagnosisfor a child. For example, inborn errors of metabolismfrequentlyusediet therapyasamainstayof treatmentin order to prevent ongoing symptoms of the illness.RDs(CEDRDs)workingwith familieswhohaveachilddiagnosed with inborn errors of metabolism, type Idiabetes, or other illnesses and conditions whichrequirenutritiontherapyanddietarymanipulationaretrained toworkwith familieswho go through variousstagesof crises,havestrainedresources,havebarriersto effective treatment, and frequently need reassuring

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advice from the treatment team including the RD(CEDRD). Behavioralcounseling isanecessarypartoftheinterventionsandisemployedbyavarietyofhealthcareprofessionals. Standardsofpracticeandscopesofpractice for RDs (CEDRDs) do include behavioralcounseling as part of the scope of practice; therefore,RDs (CEDRDs) can also function as a parent coach orparenttrainerintreatmentofchildrenandadolescentswitheatingdisorders.Theyareabletoeducateparentsabout eating disorders, and provide ongoing support,helpingthemasnecessarytocreateappropriatedietarystrategies to help their child gain weight or maintainweight,includingdecisionsonhowtoadvancenutritionwhen their child resumes exercise or has some otherchange in state. In this slightly different model ofoutpatientcare,theRD(CEDRD)workswiththementalhealth professional in a collaborative partnership;therefore, the child diagnosedwith an eating disordercan still retain an individual therapist who providescounseling tohelpovercomecomorbiddiagnoses suchas anxiety or obsessive‐compulsive disorderwhile theparents are being educated and coached by the RD(CEDRD)on re‐feeding issues.ByworkingwithbothaRD (CEDRD) and behavioral counselor, time incounseling sessions for both disciplines can be usedmost effectively and efficiently, promoting positiveoutcomes.NutritionTherapyToolsusedbytheCEDRD:Here is a list of specialized nutrition therapy tools anutrition therapist is able to bring to the table whenworkingwitheatingdisorderedclients:

Expertiseregardingtheunderlyingissueswithwhichourclientsstruggle,resultinginaclient’s

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increasedabilitytomovethroughtheprocessofdevelopingahealthierrelationshipwithfood.

Knowledgeofmetabolicpathways Understandingofnormaleatingandthe

pathwaysthathelpaclientmovetowardsahealedrelationshipwithfood.

Anunderstandingofmanytherapeuticinterventiontechniquesincluding:

o CognitiveBehavioralTherapy(CBT)o DialecticalBehaviorTherapy(DBT)o Acceptance&CommitmentTherapy

(ACT)o FamilyBasedTherapy(FBT)o MotivationalInterviewing(MI)

Anunderstandingofmanyunderlyingcomponentsofrecoveryincluding:

o Thestagesofgriefo Thestagesofchangeandreadinessfor

changeo Theindicatorsofrecovery

ScreeningtoolsforEatingDisorders:

DiagnosticSurveyforEatingDisorders(DSED) EatingAttitudesTest(EAT) EatingDisordersExamination(EDE) EatingDisordersInventory(EDI) EatingDisordersQuestionnaire QuestionnaireofEatingandWeightPatterns Yale‐Brown‐CornellEatingDisordersScale YaleFoodAddictiveScale

AssessmenttoolsutilizedbytheNutritionTherapist:

Healthhistories

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Lifestyleassessmentincludingsocialimpactofeatingdisorder

Assessmentforpossibledrug‐nutrientinteractionsanddrug‐nutrientdepletion

Assessmenttoidentifysafeandappropriatesupplementalherbs,vitamins,andnutrients

Reviewoflaboratoryteststoassessnutrientstatus

Foodintakeassessmentandanalysiswithresultingmealplanning

Metabolicassessmentandestimatedneedsanalysis

Interventionsforfeeding:

Methodsoffeeding:o Oralo Tubefeedingo Totalparenteralnutrition

Nutritionsupplementationmethods Mealplanning Therapeuticdietsbasedonindividualneeds. Traditional,culturallybased,healingdiets Counseling(e.g.behavioralcounseling,

motivationalinterviewing,andgoalsettingasitrelatestonutrition,foodchoices,andphysicalactivity)topromoterecoveryandeventualmovetoconsciousornormaleating.

Individualandgroupeducation/training(e.g.outliningtherelationshipbetweenfood,bodyfunction,andhealth)

 

High Risk Populations & Treatment Interventions    At ‐risk populations may have a greater propensity 

to develop an eating disorder as either a comorbid 

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diagnosis that exists alongside an existing illness or may exhibit specific characteristics or rituals unique to  the  specific  population  itself.  The  role  of  the certified medical provider is to treat the ED and any co‐occurring  risks  using  (or  recommending)  other specialists as deemed appropriate. Below is a table outlining  the  high  risk  populations,  treatment interventions  to consider when working with each population,  and  population  specific  co‐occurring medical  risks.  Please  note  the  medical  risks indicated  are  identified  as  more  common  in  the corresponding  high  risk  population;  however, medical risks are not limited to only those listed.  

 

HighRiskPopulation

TreatmentInterventionConsiderations

Co‐occuringMedicalRisks

Adolescents  ‐ The majority of eating disorders emerge between the ages of 12 and 25  

‐  Changes in growth trajectory  ‐ In females, amenorrhea or primary amenorrhea  

Athletes ‐ Any sport or position that emphasizes body type ideals or classes/divisions based on body weight (e.g. lean ideals for runners, bulking up for football, weight control for wrestling and subjectively judged sports or competitions (e.g. 

‐ Cardiovascular health ‐ Hydration status ‐Weightchanges

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equestrian, figure skating, diving, etc.) may increase risk of eating disorders ‐Supplementusefor“performanceenhancement”shouldbeevaluated

Autism Spectrum Disorders 

‐Feedingissuesincludingmechanical,sensory,andpreferencesimpactnutritionalintake

‐Nutritiondeficiencies‐Insufficientgrowthpatternsorfailuretothrive

Celiac Disease 

‐Dietaryrestrictionsimpactrelationshipwithfood

‐ Nutrition deficiencies  ‐ Gastrointestinal health monitoring 

Complicated Dieting History  

‐Culminationofdietinghistoryinfluencesbeliefsaboutfood

‐ Weight fluctuations with co‐occurring morbidities ‐ Nutrition deficiencies  

Diabetes Mellitus (DM) ‐Type 1 and 2 

‐Insulinusemaybemodifiedtocompensateforeatingbehaviors

‐Bloodglucosemonitoring‐Medicationadjustment

Food Allergies 

‐ Education on the difference between a true allergy, sensitivity, intolerance or dislike ‐ Substantiating food allergies with medical verification and appropriate testing  

‐Nutritiondeficiencies

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‐ Mayrequireareferral to registered dietitian with expertise in eating disorders 

Models/Actresses 

‐ Increased screening and education for high risk supplements ‐Industryspecificpressuresinfluencingbodycompositiongoals

‐ Hydration monitoring ‐ Cardiovascular monitoring 

Orthodox Jewish Population 

‐Culturalinfluencesonbodyshapeandsize‐Eatingissuesmaybestigmatizedandthereforeunderreported

‐ Weight monitoring  

Polycystic Ovary Syndrome (PCOS) 

‐SymptomsofPCOSmayinfluencebodyimageandimpacteatingbehaviors

‐ Hydration monitoring ‐ Cardiovascular monitoring ‐ Medication adjustment 

Bariatric Surgery Patient  

‐ Assessment to rule out eating disorder behaviors for patients prior to surgery ‐ Address eating behaviors in the context of post‐surgical weight loss ‐ Distinguish between the complex physical and psychological manifestations 

‐ Dumping syndrome ‐ Prevention of stomach stenosis and other GI complications 

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resulting from surgery alone or in combination with eating behaviors  

Pregnancy and Eating Disorders  

‐ Therapeutic intervention and education specific to the eating disorder and risk to mother and fetus  ‐ Knowledge of sensitive nature of weight gain  

‐Weightmonitoring

LGBTQ and Eating Disorders  

‐ Determination of weight goals based on hormone/muscle mass changes for transgender clients, adjusting calculations for sex change depending on type and duration of hormone therapy ‐ Therapeutic intervention and education specific to Intersection between gender and body image concerns ‐ Focus on socialization of groups and social pressures 

‐ Weight monitoring  

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OngoingNutritionalManagementImmediate treatmentgoals forpatientswithEDs includenutritional rehabilitation, weight restoration andstabilization, complete physiological restoration,managementofre‐feedingcomplications,andinterruptionof binge and purging/ compensatory behaviors. Longterm treatment includes achievement and acceptance ofhealthyweightandmeetingthephysicalandfoodrelatedgoalsestablishedbythecareteam.The RD (CEDRD) is needed at all levels of carethroughouttherecoveryprocess.Evidence‐based treatment delivered by healthprofessionals with specialized training in the care ofpatientswithEDswillleadtomoresuccessfuloutcomes.The RD (CEDRD) recognizes the need for more datacollection and well‐controlled studies to establish themost effective nutritional management protocols andcontributions to the multidisciplinary team. TheAcademyofNutritionandDietetics(AND)hasinitiatedaplatform to support patient care, data collection, andoutcomesresearch,calledtheAcademyofNutritionandDietetics Health Informatics Infrastructure (ANDHII).ThisANDHIIguidewillassistinthecollectionofimpactdatathatcanbeused inpublicpolicyaswellasqualityimprovement research. Guides such as these allow theRD(CEDRD)toconductmoreresearchinitiatives intheEDfield.TheRD(CEDRD)alsorecognizesthecontinuedefforts needed to obtain insurance reimbursement tocover nutritional management for ED patients andassure uninterrupted comprehensive care. Thiseducationbookletisastepforwardintheseefforts.

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ResourcesAllison DB, Baskin MK. Handbook of AssessmentMethods for Eating Behaviors and Weight‐RelatedProblems Measures, Theory, and Research. SAGEPublications:ThousandOaks,CA,2009.Alphin FB, Pilewsk K, Diekman C,Waterhous TS, et.al.TransitioningCareEffectively.SCANAdvancedPracticeGuide.American Psychiatric Association: Desk Reference tothe Diagnostic Criteria from DSM‐5, Arlington, VA,AmericanPsychiatricAssociation,2013.CostinC,SchubertGrabbG.8KeystoRecoveryfromanEatingDisorder. W.W.Norton andCompany Inc.NewYork,NY,2011.Grilo CM,Mitchell JE. (Eds.) The Treatment of EatingDisorders: A Clinical Handbook. The Guilford Press:NewYork,NY,2010.Keys A, Brozek J, Henschal A, Mickelsen O, Taylor HL.The Biology of Human Starvation (2 volumes),UniversityofMinnesotaPress,1950.MehlerPS, AndersonAE, EatingDisordersAGuidetoMedical Care and Complications. The John HopkinsUniversityPress:Baltimore,MD.2010.Mittnacht AM, Bulik CM. Best Nutrition CounselingPractices for the Treatment of Anorexia Nervosa: ADelphiStudy.IntJ.Eat.Disord.doi:10.1002/eat.22319.

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Reiff DW, Lampson Reiff KK. Eating Disorder:Nutrition Therapy in the Recovery Process. AspenPublishing,Inc.1992.Satter E. What is Normal Eating? 2014. Available atwww.ellynsatterinstitute.org.Setnick, J. ADA Pocket Guide to Eating Disorders.AmericanDieteticAssociation:USA,2011.Tholking MM, Mellowspring AC, Eberle SG, Lamb RP,et.al. American Dietetic Association: Standards ofPracticeandStandardsofProfessionalPerformanceforRegistered Dietitians (Competent, Proficient, andExpert) in Disordered eating and Eating Disorders.Journal of the American Association. August, 2011.111(8).1242‐149.e37.doi:10.1016/j.jada.2011.05.021.WaterhousTS, JacobMA.Nutrition Intervention in theTreatment of Eating Disorders. Practice Paper of theAmericanDieteticAssociation,2014.Yager J, Devlin MJ, Halmi KA,,Herog DB, et.al. PracticeGuideline for the Treatment of Patients with EatingDisorders.AmericanPsychiatricAssociation,2010.YagerJ,PowersPS.ClinicalManualofEatingDisorders.American Psychiatric Publishing, Inc. Washington, DC.2007.

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iaedp™

The International Association of Eating Disorders Professionals Foundation (iaedp™) established the certification process to promote standards of excellence within the field of eating disorders. Professionals who demonstrate clinical expertise through education, experience and a rigorous examination are eligible for the Traditional Certification as a Certified Eating Disorders Specialist (CEDS) for therapists and physicians, Certified Eating Disorders Registered Dietitian (CEDRD) for registered dietitians, Certified Eating Disorders Creative Arts Therapist (CEDCAT) for art, music, recreation and dance/movement therapists, or Certified Eating Disorders Registered Nurse (CEDRN) for registered nurses.

Individuals with iaedp™ Certification designations (CEDS, CEDRD, CEDCAT, or CEDRN) are health care professionals who have met rigorous educational and skill requirements, have accumulated a minimum number of hours of qualifying work experience, have made a commitment to stay abreast of current developments in the field through continuing education, and have agreed to comply with the Association's ethical principles.

iaedp™ Mission To promote a high level of professionalism among practitioners who treat those suffering from eating disorders by promoting ethical and professional standards, offering education and training in the field, certifying those who have met prescribed requirements, promoting public and professional awareness of eating disorders and assisting in prevention efforts.

www.iaedp.com