Disordered Eating & Nutrition Professionals Amy Hunter-Manuel, MS, RD, LDN November 3, 2009

1. Disordered Eating & Nutrition Professionals Amy Hunter-Manuel, MS, RD, LDN November 3, 2009

2. To identify disordered eating and relevant facts related to it. To review literature regarding DE and nutrition professionals. To discuss examples of when dietitians can model good leadership skills and help to prevent the spread of disordered eating. Objectives

3. DE Definitions • Subthreshold conditions prior to ED dx (ADA position) • Troublesome eating behaviors (restrictive dieting, bingeing, or purging, which occur less frequently or are less severe than those required to meet the full criteria for the ED dx) • Eating-related issues which include, but are not limited to, eating for reasons other than hunger (comfort, stress); and labeling foods as “good,” “bad,” “unhealthy,” or “fattening,” (esp. if leading to feelings of anxiety & guilt if these foods are consumed) • http://www.youtube.com/watch?v=QYeFLVDSUBQ&feature=related Cory Everson

4. Background Research • Not large amount of data on DE esp concerning RDs • 80s (dance/drama majors) • ‘85 (jrs/srs dietetic college students vomit after eating • ’89 (24% dietetic majors-EDs/obsessions w/food) • ‘89 (emphasis on body image/food may > risk for dietitians to experience bulimia) • ‘91 (did not find high degree of DE in dietetic majors) • ‘93 (dietetic majors not more susceptible to bulimia)

5. DE & Nutrition Professionals Incidence of Eating Disorders among Selected Female University Students, ADA, (PalmquiestFredenberg, Berglund, Dieken), Jan 1996 • 5 grps female jrs/srs (N=163) 4 midW colleges • Voluntary • EAT (40 objective statements in 6-pt, forced-choice self report format(score of >29 s/s ED) • SAS used (Statistical Analysis System), scores analyzed by analysis of variance, Tukeys used for post hoc comparisons of means for ea grp

6. Table 1 - Dietetic students responses to statements on EAT OftenVery OftenAlways CP ___ _ DPD CP DPDCP DPD N=64; 30 students in CPs, 34 students in DPD

7. Table 2 - Mean (+/- standard deviation) EAT scores & % of scores symptomatic of ED for female groups C *Means are not significantly different according to Tukeysstudentized range test (p>.05) * Percent of subjects who scored in the symptomatic range for an ED as defined by an EAT score of 30 or greater

8. DE & Nutrition Professionals Eating Disordered Behavior in Dietetics Students and Students in Other Majors, ADA, (Sept ‘99) Vol 99:9, pg 1100-1102 • If…[women’s]…eating behavior is restrictive, …interest in food may manifest …through food-related activities such as collecting recipes, preparing food for others, or even exploring a career in nutrition. (ED Diagnostic & Statistical Manual of Mental Disorders IV, APA, 1994) • Based on prev. study’s inconsistencies, this study revisited same subject at NE university with undergraduate students

9. DE & Nutrition Professionals • 165 women/46 men (BMI normal = 24, ages = early 20s,) 6 majors/5grps, voluntarily answered (anonymous) self-report questionaire developed by National Eating Disorder Screening Program ’96 (21 item instrument scored on 4 choice format (never-all of the time), eg of ?s: -Are you bothered by the thought of having fat on your body? -Have you taken any laxatives to control your weight: -Have you exercised to control your weight even when advised not too? -Do your concerns/behaviors about eating/weight interfere with life?

10. DE & Nutrition Professionals • Biology/Nursing higher wt/BMI • Males higher ht/wt/BMI • Mean differences found/data analyzed using SPSS (Tukeystudentized range statistic & Kruskal-Wallis analysis of variance) • 4 variables summarized ?s– differences by major were examined by one-way analysis of variance w/ Tukeys used for post hoc comparisons, criteria set for .05 level of significance

11. Means & medians on summary variables for college females by major Means in same row with different superscripts differ significantly, Tukey test p<0.5

12. DE & Nutrition Professionals Prevalence of Eating Disorders in Dietetic & other Health-Related Majors: A Study of College Students, (Mehr, Clemens, Roach, Beech) Univ of Memphis, ADA Poster Session • Dietetic/pre-med/pre-nursing students from 10 TN universities • Online survey, ANOVA to analyze EAT-26 • Pre-med were signif higher than pre-nursing & dietetic majors • No signif difference b/w dietetic & pre-nursing students • Out of 18 participants that had EAT-26 indicative of EDs, only 4 (3 pre-med, 1 dietetic) had sought help

13. DE & Nutrition Professionals Attitudes & Behaviors of Dietetic Educators & Their Students Towards Eating Disorders,(Beary, Flint) ADA, March 2003, Wash State University • Cross-sect. surveys, EAT-26 • 30 diff dietetic programs, 365 undergrads

14. DE & Nutrition Professionals • 41% binge, 12% vomit • signif amt students agreed they need skills on prevent/tx ED

15. DE & Nutrition Professionals • 93 educators (backward stepwise multiple regression used to show that educators who taught food prep & MNT agreed [sign.more than other educators] that if a student has a reason why they don’t want to sample foods, they should not have too), students indicated sampling food is problematic for them • Conclusions: students enrolled in dietetic programs may be more susceptible to eating disorders & educators should be aware of the implications allowing ED students enrollment in food-related courses

16. DE & Nutrition Professionals Eating Disorders among Dietetics Students: An Educator’s Dilemma, (Houston, Bassler, Anderson), ADA, April 2008 article • Dietetic practitioners & DE/obesity – inconsistent evidence “Although study findings are not consistent, evidence suggests that RDs throughout the world may be at greater risk for a wide range of DE issues when compared to other professionals.” • 1/3 of dietetics students studied are motivated to enter the field by personal experiences (self or friends) with obesity or eating disorders • Ethical considerations that arise when dietetic students willingly disclose such conditions to their program directors, preceptors, and/or clients makes it important to openly dialogue about these types of situations

17. DE & Nutrition Professionals • A common concern among educators is whether or not participation in the rigors of dietetics education will impede successful recovery or remission for those with ED • Specific resources may be needed to assist students to prevent a relapse or to provide care if a relapse occurs during academic career • Proactive course work, self assessment, & journaling • Outcomes assessment data indicate that changes through cognitive restructuring can take place in dietetic students’ relationships with food and their bodies when given the opportunity for this type of reflective journey.

18. DE & Nutrition Professionals • The ADA/CDR Code of Ethics for the Profession of Dietetics offers a framework to address the concerns identified by these scenarios…the dietetics practitioner: ● Principle 4: . . . assumes responsibility and accountability for personal competence in practice, continually striving to increase professional knowledge and skills and to apply them in practice. ● Principle 5: . . . recognizes and exercises professional judgment within the limits of his/her qualifications and collaborates with others, seeks counsel, and makes referrals as appropriate. ● Principle 17c: . . . withdraws from professional practice . . . [if he/she has] an emotional or mental disability that affects his/her practice in a manner that could harm the client or others.

19. DE & Nutrition Professionals • Some RDs liken experiences w/ ED to that of DM, CAD, or any other chronic condition, stating that real-world learning gives them insight he/she would never have ordinarily. • But how appropriate is it for RDs to disclose their own issues w/ food & DE/ED? • Before disclosing, they should ask him- or herself if it will serve a useful purpose? • Is now the best time to disclose the information? • Does the RD have adequate skills to handle the interaction once the disclosure has been made?

20. How Should Healthy Weight Be Defined? • 63% of healthcare professionals agree that a “healthy weight” falls into “normal” category for BMI • 91% agree that it is the weight that results from habit of wholesome eating & regular activity to maintain fitness regardless of BMI • 57% agree both are true • Everyone is an advertisement/role models imp

21. Resources:The Eating Disorders Clinical Pocket Guide, Quick Reference for Healthcare Providers by Jessica Setnick, MS, RD/LD understandingnutrition.com

22. Help Stop the Spread of Eating Disorders -Stop commenting negatively -Stop praising weight loss -Encourage following natural cues -Listen for the underlying messages -Seek professional help -Do not recommend weight loss as a method to “feel better about yourself.”

23. Top 10 Reasons Not to Diet Don’t work Dangerous Expensive Cause fatigue Disrupt normal eating Increase food preoccupation Diminishes women Decreases self-esteem Stunts mental & physical growth Increases size prejudice

24. Etiology of ED Family environment -Relatives w/ ED, you have 7-12x greater risk -Study of identical twins in diff family environment with diff diets/Their size & bone structures differed significantly --Consider a sunflower seed… Environment can activate the seed to grow

25. Etiology of ED Genes -----twin studies show disease is 80% genetic Genetics/Heritability AN 31-56% BN 50-80% BED 41% (1-5% pop)

26. Etiology of ED Culture DNA does not determine destiny Diet & Exercise count -Freshmen fifteen ED alone are up 10%/9 yrs on college campus’ (20% college students admit to ED)(75% have not sought help) -Hispanics migrating to US -42% of 1st-3rd graders want to be thinner -Highest risk pop.s: food/culinary industry, fashion models,collegestudents,athletes,& dancers

27. For every real image of a celebrity that we see, we see 100 untrue imagesMost models are 98% thinner then typical American women 80% of women are dissatisfied with their appearance(being overwt can symbolize: prosperity, the ability to survive, and fertility for women)30% of women getting infertility tx have ED

28. Etiology of EDs Psychodynamic Personality traits

29. Etiology of EDs Biology Ind diet & response

30. DE & Nutrition Professionals Mamavision.com • http://www.youtube.com/watch?v=I2BRuHwu9RU weight watcher bloggers • http://www.youtube.com/user/bringhomethebacon00 father verbally abusing daughter • http://americathebeautifuldoc.com/ • http://www.youtube.com/watch?v=C7143sc_HbU&NR=1 Jean KilbourneKilling Us Softly • http://www.youtube.com/watch?v=C7143sc_HbU&NR=1 endfattalk.org

31. DE & Nutrition Professionals Considerations re: tx of DE in RDs & others • Dx Criteria (DSM-IV Criteria for EDNOS (307.50) Disorders of eating that do not meet criteria for any specific ED (ins could eventually pay for prevention) • Assessing (free screening eatingdisorder.org) • Physical Signs • Medical Components (Labs) • Symptoms (ICD-9 Codes etc.) • Meds

32. DE Treatment • Individual Therapy • Interpersonal Therapy (IPT) • Cognitive Behavior Therapy (CBT) • Dialectical Behavior Therapy (DBT) Family Therapy Art Therapy Positive Music Therapy Occupational Therapy Nutrition Support [MD who will write prescriptions] Decreasing Exposure to Triggers (70% of people feel worse about their body after 3 min of viewing fashions mag[Eng Parliament may req warnings])

33. ED Treatment • Continuum of Care • Impatient (treatment early in the development of dx is crucial – a changed environment can change prevalence of s/s) the longer the ill eating habits go untreated, the more damaging • Partial Hospitalization • Intensive Outpatient • Outpatient with long-term support groups • Find a normal eater & model them • Factors to Consider when Matching Someone to a Treatment Center • Facility’s capabilities, philosophy, strong f/u care, cost, length of stay, other issues treated, visitors, religious affiliation

34. DE & Nutrition Professionals Position of ADA: Nutrition Intervention in the Tx of Anorexia, Bulimia & other ED(2006) - “EDNOS… …often overshadowed…it is at least as common as…” “Prevalence rates elude researchers because there is no simple definition of EDNOS.” “…a large proportion…are neglected.” • Binge eating is often coping to deal with emotional distress…” “often precedes dieting” • In attempts to identify causes of the obesity epidemic, researchers are addressing associations between binge eating disorder and obesity & overweight

35. DE & Nutrition Professionals • Factors that may contribute to the development of binge eating disorder behaviors include repeated exposure to negative comments about shape, weight, and eating; negative self-evaluation; perfectionism; and childhood obesity. Also, low self-esteem, high levels of body concern, high use of escape avoidance coping, and low levels of perceived social support are commonly seen in binge eating disorder • Supportive social structure in place to prevent relapse during stress (long-term management) • Nutritional components (meal planning, social eating, strategies, egs of restrictive eating styles)

36. ‘Americans who are 30 or more lb. over wt cost the country an est. $147 billion in wt-related medical bills in 2008 (double from a decade ago)…Former pres. Bill Clinton stated changes must be made in “what goes on at home, in the neighborhood, in the schools and in the community”… “We are trying to turn the Titanic around before it hits the iceberg.”’ -USA Today

37. “All that is necessary for the triumph of evil is for good men to do nothing” Edmund Burke

38. Insanity – doing the same thing over and over again and expecting different results “I had to shift my perspective and my lifestyle before I could let go of the excess weight and work on becoming strong and healthy.” - Victoria Johnson, fitness expert

39. After Boston Massacre:“If need be I will raise one thousand men, subsist them at my own expense, and march myself at their head for the relief of Boston.” George Washington

40. DE & Nutrition Professionals • What are you saying individually? • What are we saying corporately (together) to the public with DE? • Are we in harmony & louder than nutrition quackery or fast food commercials (to get a clear message across) • Is our lifestyle matching what we are saying? Does it matter? • Are we being proactive/operating on the offense?

41. NEDA: “Prevention efforts will fail, or worse, inadvertently encourage disordered eating, if they concentrate solely on warning the public about the signs, symptoms, and dangers of eating disorders. Effective prevention programs must also address: -Our cultural obsession with slenderness as a physical, psychological, & moral issue. -The roles of men & women in our society. -The development of people’s self-esteem & self-respect in a variety of areas (school, work, community service, hobbies, etc.) that transcend physical appearance.”

42. ED & DE Resources • Intuitive Eating: A Revolutionary Program that Works By Evelyn Tribole, MS, RD and Elyse Resch, MS, RD, FADA. New York, NY: St. Martin’s Paperbacks; 1995. • The Rules of Normal Eating By Karen R. Koenig, MEd. Carlsbad, CA: Gurze Books; 2005. • Underage and Overweight: America’s Childhood Obesity Epidemic: What Every Family • Needs to Know By Frances M. Berg, MS. New York, NY: Hatherleigh Press; 2003. • Big Fat Lies: The Truth about Your Weight and Your Health By Glenn A. Gaesser, PhD. Carlsbad, CA: Gurze Books; 2002. • Am I Fat? Helping Young Children Accept Differences in Body Size By Joanne P. Ikeda, MA, RD and Priscilla Naworski, MS. Scotts Valley, CA: Education, Training, and Research Assoc; 1993.

43. ED & DE Resources • How to Get Your Kids to Eat . . . but Not Too Much By Ellyn Satter, RD. Palo Alto, CA: Bull Publishing; 1987. ellynsatter.com (competent eater, normal eating, internal regulation, eating attitudes) • Eating Disorders: A Clinical Guide to Counseling and Treatment. By Monika M. Woolsey, MS, RD. Chicago, IL: American Dietetic Association; 2002. • Eating Disorders Review http://www.gurze.com/client/client_pages/newsletteredt.cfm • Perspectives http://www.renfrewcenter.com/for-professionals/index.asp • The Remuda Review http://www.remudaranch.com/professional/index.asp • Kate Clemmer LGSW…AC Library Eating D/O Awareness on Campus

44. My Personal Story -Raised around DE & premature death like they are normal -Temp. experienced ED & low self-esteem -Recognized a problem to fix in society -Traditional healthcare industry/life…lost my vision -Appreciate AHEC/caucus

45. Good news: More RDs: • (Old saying: If you hang around with 4 people who are struggling (DE), you are probably going to the 5th.) • are getting tx for balancing life • asking themselves what motivates them • exploring if their goals are for the common good • discovering unique purposes/strengths • taking time off until they find their niche in nutrition in order to be replenished mentally, physically, & emotionally • learning to express their creativity • marketing (fashionable) nutrition to the populations only they can reach

46. DE & Nutrition Professionals In Summary: • DE is troublesome eating behavior that usually includes labeling foods and wt issues (national problem) • Words (esp negative comments) and actions can contribute to negative body image and DE…professionals should be aware of them • 1/3 of RDs enter the field w/ DE/obesity experience, some studies say there in higher risk for RDs to develop ED/DE & some indicate there is not (support systems should be avail)

47. DE & Nutrition Professionals • Some researchers propose DPDs need examined • Others believe all dietetic programs help reduce anxiety by exposure to accurate nut’n info • Results do not reflect epidemic of ED in dietetic majors • There is not enough research completed re: DE and nutrition professionals

48. Which RD would you trust or which would prevent DE disease and what messages are being given? • I don’t have a lot of time. This is my routine but no one seems to mind. Nutrition is frustrating anyway. • Casually dressed girl in a donut shop with donuts • She is being influenced more than she in influencing & has become complacent • When people look at her, what do they think • “She needs help.”

49. Which RD would you trust or which would prevent DE disease and what messages are being given? • This is so delicious. Do you want to taste it? I absolutely love my field. • Kitchen, Business attire, Fruited Bagel • After CE – time management life coaches to balance personal/professional goals, RD friends, change circle of influence who saw her as insignificant to those who believer in her learning about emotional, mental, physical and spiritual needs, getting her needs met so she can confidently go out into a nutritionally confused world and speak and model truth and balance

50. DE & Nutrition Professionals • Identify triggers & resolve or discuss what to do when they arise (eg. Popcorn, friends with bad attitudes) find positive triggers (creative hobbies/+music) & explain that these need to outweigh neg triggers or imbalance & unwanted behaviors will occur • Individual tx goals-include environmental goals (By next visit I will no longer allow myself to be entertained by TV programming that endorses overeating or I will have changed my lingo about food being something that control me) • Medical/physical stability & physical health restoration – eg. Reaching desired wt, corrected BP/BS, improved mental health (decreased depression meds) • “Normalized” (non-restrictive) eating, including variety, balance, nutritional adequacy & comfort with food