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Hello, and welcome to our presentation on the Nutritional Program at Eating Recovery Center. This Nutritional Program presentation will focus on restrictive type eating disorders. Restricted food practices are at the base of all eating disorders, including binge eating disorder. Much of what is shared here applies to our treatment of binge eating disorder, however, the meal plans and the processes are different. This presentation does not cover nutritional treatments for individuals with binge eating disorder.

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Studies show that those who care for family members with eating disorders suffer much like caregivers who struggled to help patients with Alzheimer's disease or dementia, only much more so. Support, education, relief from stigma and blame are at the core of helping caregivers who are supporting loved ones with eating disorders. Supported and educated caregivers become recovery allies. Education on what is known about the origins course and treatment of eating disorders helps caregivers to take the blame off their shoulders, fear less, and hope more.

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Advance your education on eating disorders by watching all the recorded presentations provided on this site and check back here often for new educational offerings. This presentation on the Nutritional Program focuses on how the treatment is provided. Watch the following presentations to learn why nutritional rehabilitation is necessary for recovery. Caregivers who are supporting loved ones with avoidant restrictive food intake disorder, often called RFED, should begin their educational journey here. Dr. Bermudez, chief educational officer and senior medical director of child and adolescent services at Eating Recovery Center, presents on the causes course and treatment for individuals suffering with RFED.

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Recovery from RFED includes nutritional rehabilitation and weight normalization and the majority of what's available in this presentation applies to RFED. Caregivers providing support for patients with restrictive type eating disorders would benefit from starting with this presentation. Dr. Anne O'Melia, chief medical officer and chief clinical officer at Eating Recovery Center, who is a pediatrician and child psychiatrist presents on complex causes and the treatment of restrictive type eating disorders. Viewing of this presentation is necessary education for all caregivers and applies to all eating disorder diagnoses. Dr. Mehler, founder, and executive medical director of Denver Health's Acute Center for Eating Disorders and renowned national and international expert, provides in depth information on the medical complications and treatments for eating disorders.

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There are several common questions that arise for caregivers. Does my loved one have to restore weight, is a leading question. Not every patient needs to restore weight as part of their eating disorder treatment, although they all need to address malnutrition disordered eating and their restriction practices. When the outcome of restriction results in low body weight, leading eating disorder researchers and experts agree that weight restoration is key to recovery. Our own Dr. Mahler states, "Refeeding the patient with anorexia nervosa is essential to successful treatment. Weight restoration is not the whole treatment. However, without a concerted refeeding effort, no meaningful psychotherapy can take place because patients have starvation-induced cognitive deficits. Weight restoration however, it's one of the most challenging and frustrating parts of the recovery process for many patients and their families."

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Dieticians oversee restoration of weight, as well as the normalization of eating disorder behaviors. Refeeding patients with restrictive type eating disorders and supporting all patients to normalize their relationship with food is essential treatment. Eating Recovery Center's nutritional philosophy is to support patients suffering with eating disorders to have a healthy relationship with food. Eating a variety of foods in a balanced way and using moderation are the basics of having a healthy relationship with food. Our goal is to restore someone's relationship with food through oral intake of food.

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Although progressive oral refeeding is the basic mode of refeeding for patients, there are alternatives to this. The oral refeeding plan, along with behavioral interventions aimed at the eating disorder behaviors is nearly always the first choice because it provides a less invasive and more therapeutic method of treatment. However, there are defined indications for the use of tube feeding. These alternative modes of refeeding are not an easy way to achieve weight restoration and are not routine. Your loved one's doctor or dietician may recommend this alternative mode of feeding if there is a persistent failure to restore weight with the standard dietary therapies, or if there's life threatening loss or worsening psychological state, despite standard treatments, or is called for because of medical comorbidities. Tube feeding requirements can only be delivered at the highest levels of care.

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How do we accomplish the tasks of nutritional rehabilitation and interruption of eating disorder behaviors when working with fearful, medically and mentally compromised patients? This is a common question from caregivers, as many of them have tried to accomplish this task outside of treatment. The answer is it takes a team who support your loved one with a structured, planned, and consistent treatment.

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The first step is very important and it is a skill caregivers can learn also. It's called emotion coaching. The skill of emotion coaching is about co-regulation. It is not uncommon for patients suffering with eating disorders to experience meals and snacks as overwhelming and threatening, especially during the beginning phases of treatment. Patients often have poor regulation of emotions when faced with the task of eating. Staff who are trained in providing co-regulation support are fully involved in helping patients at each meal and snack.

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The professionals serving you and your loved ones have great compassion. We understand this illness and we understand the depth of the struggles and fear. We provide empathy with expectations. This means we understand, validate, and support while still expecting them to complete their meal plan.

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Individualized meal plans. Individualized meal plans are the cornerstone of weight restoration and normalization of food behaviors. Dieticians will conduct a nutritional assessment and create a meal plan that is specifically designed to address your loved one's nutritional needs. Meal plans are in place day one and throughout treatment and into aftercare.

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In the moment support. Staff members oversee all aspect of your loved one's nutritional intake. Trained staff are present in the meals to provide in the moment encouragement and redirection of eating disorder behaviors. Information about eating disorder behaviors will be covered later in this presentation. The trained staff that support your loved one in the meals, understand that behaviors are used as a way to cope with the tremendous challenge of eating and therefore, redirection of behaviors is done with compassion and an eye towards preserving individual dignity.

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Daily reviews. Daily reviews of the patient's meal successes and or struggles is done by the dietician. This ability to monitor and adjust meal plans and goals daily facilitates progress on nutritional rehabilitation goals in a safe and supported way. Labs can be drawn, and the team members consulted to determine the effectiveness of the meal plan. Meal plans evolve as your loved one moves through treatment.

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Education. Dieticians provide education on nutrition to patients and the parents or caregivers of our child and adolescents. Adult patients receive different education than our children. Let's take a moment to explain how the nutritional rehabilitation education and support differs between the two.

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Child and adolescent nutritional rehabilitation programming differs from adult programming in terms of approach. Child and adolescent nutritional rehabilitation treatment is based around family programming, which aims to help parents take control of their child's eating. Adult treatment tends to be based around individual therapy. The patient is taught how to take personal responsibility for making behavioral changes to support nutritional rehabilitation. There may be some crossover in programming between the two, depending on the individual's developmental stage and needs.

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Mealtimes are a struggle for people with eating disorders. The tool we use to support nutrition for patients is the food exchange system. Food exchange systems are based on the American Diabetic Association standards. The exchange system divides food into six different food groups. Patients, or their parents, depending on programming, are supported by their dietician to make food choices from these different categories at each meal. The food exchange-based plans helps patients reducing anxiety around food, decreases the focus on calories and supports them to build flexibility in their eating habits.

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Your loved one is provided with food choices and we strive to assure that our food tastes good and is visually appealing. Dieticians create the patient's meal plan. The daily menus provide variety and can support a vegetarian diet. In regard to a vegetarian diet or a vegan approach to eating people, practice vegetarian and vegan eating for many different reasons, including family, culture, religious beliefs, and ethical concerns, or a number of other reasons. However, both these approaches to eating have high correlation with eating disorders. Patients often choose vegetarian or vegan approaches to support restricted eating by using this approach to eliminate calories for weight loss. When patients state they're vegetarians, we spend time learning about why your loved one is a vegetarian. When restriction has driven the patient's decision to become a vegetarian, the goal would be to return to what they enjoyed eating prior to their eating disorder. Otherwise, vegetarianism can be supported for the goals of weight restoration.

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We cannot support vegan diets. Vegan diets are inherently of a restrictive nature, which for individuals with eating disorders strongly correlates with their eating disorder thought processes and behaviors. Additionally, the volume of food required for nutritional rehabilitation and weight restoration is not supportable on a vegan diet.

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What you see here is a typical meal plan and a typical dinner menu. Patients in adult programming are educated on the exchanges and supported to choose items from the daily menu to meet the exchanges. Patients who are children have their meals selected for them by the dietician or their parents, depending on their stage of care or their program. Here's how the exchange system is used with a daily menu. The patient with this meal plan needs to have two grains, three proteins, two fats, one to two vegetables, one milk and a dessert. You will see that there are three entrees to choose from. The white bean and portabella mushroom entree provides two grains, three proteins, two fats, and one vegetable. If the patient chooses this entree, they will need to choose one milk product and one of the desserts to meet their meal plan.

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You will see on the other side of this meal plan, there is a column called meal replacement. Meal replacement is one of the ways that we support your loved one. When they are unable to complete their meal, the amount not completed is evaluated and then replaced with a nutritional supplement. We usually use Boost or Boost Plus. For example, if your loved one left 25% of their food uneaten, they would be given three ounces of Boost to drink. In this way we're able to help them take in the nutrition they need to progress in weight restoration. Our goal is to support restoration of two to four pounds a week. This process is overseen by the dietician and medical staff and has been shown to be a safe amount of restoration.

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Lindsey, could you please pick up your sandwich and take bites out of it instead of tearing it into pieces? These gentle, but consistent redirections are happening at all meals. Patients are supported to interrupt restriction and other eating disorder behaviors at every meal and snack. It is not uncommon for patients to be surprised to learn that they have eating disorder food behaviors, and some of the behaviors listed here as eating disordered might be surprising to you also. Some of these behaviors may have been present prior to the eating disorder, or they may just be normal for your family. However, in general, these behaviors have developed in response to the patient's daily challenge of eating when they are sick with an eating disorder.

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Your loved one may have an eating disorder behavior which is not listed here and if so, the behavior will be addressed specific to your loved one's care. Patients are educated on these eating disorder behaviors, and they all know that staff will address the behavior and asked for the replacement behavior in the moment at the meal. Patients may struggle at first, but almost all patients are grateful for the support and redirection. The dietary goal must be to move from the restricted eating approach to a truly balanced nutritional program with adequate calories to balance energy expenditure and the patient's developmental stage.

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Patients progress through a nutritional rehabilitation treatment programming. We will refer to these stages or phases of treatment as supervised, supported and practice phases of treatment. Although your loved one's treatment program may use different names, or they may just correlate these phases with the patient's level of care. Treatment is individualized. The path of progression shown here is not always traveled in a straight line forward. Patients may need to move around within these levels and are supported to do so based on their challenges and needs.

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Here's a general explanation of each of these phases of progression. Patients usually require full supervision at meals and snacks as they begin their treatment programming and the food choices are plated for them. Plated foods make it easier for patients as they do not need to struggle to figure out a serving size or what to place on their tray. Staff supervision is at its highest at the supervised phase of meals support. Staff sits next to, or is very near to the patient. They provide encouragement to the patients, sometimes bite by bite. Interventions at this level of care focus on supporting the patient to eat. Patients may be provided with opportunities for nutritional groups or challenges. However, at this phase, the main focus is to complete meals.

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Patients move to the next phase when the team sees they are able to eat without this level of direct intervention. In the supported phase, food is still plated. Staff are present, but not seated directly next to the patient. The patient still needs support, but requires less prompting and redirection. Patients at this phase are provided with opportunities to challenge themselves by choosing from a variety of snacks and depending on programming, joining into nutritional education or cooking groups, if this was not already in place. Patients in the child and adolescent program begin some form of family meal practices.

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Then as your loved one demonstrates progress, it's time to begin practice eating phase. They begin to practice eating in ways that provide real life challenges and experiences. Patients at the practice phase join in restaurant outings which are carefully plan and are staff supported. Patients continued to be challenged to expand their food choices in more and more normal settings. At the practice phase, patients and families have meals together on unit, with staff support as needed, and then progressed to having passes to leave with family, and to have snacks or meals outside of the unit without staff support. Any successes or struggles at this phase is simply data; data for where the patient continues to have struggles. Each meal practice is evaluated and when necessary, new skills or practices are put into place to support ongoing success.

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The interruption of restrictive food behaviors and the task of weight restoration is difficult for most patients, and for most caregivers. We are often asked how can I support weight restoration for my loved one when they're telling me, "I'm gaining weight too fast," or, "it's too much food," or that they are uncomfortable, or they feel like the treatment goal is to make them fat? This is a very challenging area for caregivers to provide support. You should expect to hear these things.

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Interruption of restricted eating and weight restoration is the evidence-based treatment intervention for eating disorders. The nutritional treatment plan for your loved one is individualized and highly monitored, and the treatment is often experienced as both physically and psychologically overwhelming. It is not uncommon for patients to feel that weight restoration is going too fast. The fact is, it is not. It's being watched closely. Weight restoration is key to recovery and supports their ability to benefit from all other aspects of the treatment program. However, it is not unusual for patients to share high levels of distress with their families. This is particularly true at the beginning of treatment, and for most patients, this phase of anxiety over the amount of food decreases as they move through the treatment and as they weight restore.

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Caregivers can support their loved ones through this phase when they understand that the treatment is necessary, even if it is difficult. It's important for you to know you are doing the right thing. A way to view your role for your loved one is to look at how you would be providing support if your loved one were in need of the ongoing distressing and painful treatments for another disease. For example, the very difficult disease of cancer. The treatments for cancer are often both physically and emotionally difficult for the patient to tolerate, but they are necessary.

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Perhaps you have had to support a loved one through another type of difficult treatment. It is not easy, but you would do it because you know the treatment is essential. Nutritional rehabilitation treatment is essential to recovery of an eating disorder. It is not easy to be in the role of the caregiver. Being on the other end of a phone call with a child or a loved one who is in distress and is pleading or bargaining with you to remove them from treatment is difficult. Expect yourself to have many feelings too. Caregivers experience fear, grief, anger, worry, guilt, and more. It's important to recognize that you're having strong feelings and that these feelings are normal.

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It's exhausting to be in the role of the caregiver. Get support. It may be helpful to know that other caregivers are feeling or have felt the same way. Explore the many different support groups available on our website at eatingrecoverycenter.com. We recommend that you watch the caregiver support skills training series by Dr. Easton, available on this site. Gain the knowledge and the advanced caregiver skills to optimize the power of your love. You are part of the treatment team.

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Please let us know what your loved one is telling you in case they haven't told us. There are many ways the team can support someone who is struggling. Talk to your loved ones, primary therapist. They are your liaison to the treatment team, and they can answer questions that arise for you during the treatment process and stay steady. This higher level of psychological and medical distress subsides as treatment progresses and their nutritional status improves. The more you know, the more confident you will be in providing support.

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Another frequently asked question from caregivers is what can I do to support them when we are eating together? Here are some suggestions for how to support during family meals on unit or when they return home. Have meals and snacks at consistent times. We all do best when we know what to expect and consistent times help reduce anxiety over meals. Another reason to have meals at consistent times is that meals are prescribed treatments. Sometimes we say food is medicine, and it is to be taken at consistent times. Each day meals are to be eaten by the clock and not by hunger cues. Practice enjoyable conversations and talk about issues other than food during the meals. You might want to have some conversation starter cards on the table. There are many to choose from online. Table topics is one of the decks that we have liked. It's okay to ask how you can provide support. It's not helpful to have the entire meal focused on food or talk about food, but it is natural and okay to ask how you can provide support. You might want to ask them before the meal or set up a time with your loved one to discuss how you might provide support in the next meal.

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Eat meals and snacks with your loved one as much as possible. There is solid research showing that we all eat in a more regulated manner when eating with others. One of the costs of our everyday busy lives is that it can be very difficult to eat together as a family. We recommend doing all. You can to have a support person eating with your loved one when possible. Remain with your loved one for a time following the meals. This is particularly important for people who have habitually used behaviors, such as overexercise or purging to get rid of calories or food, but it is good support for anyone in recovery. Stay together and do something relaxing and enjoyable after the meal, especially after the last meal of the day.

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And here are the main points we hope you take away. Interruption of restrictive food behaviors and when needed, weight restoration is essential to recovery from an eating disorder. Patients cannot recover without this step. Your loved one's nutritional treatment program is specifically designed by their dietician with the support of the medical team to meet their individual needs. Nutritional rehabilitation is often experienced as overwhelming, scary and anxiety-producing by patients.

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The ways in which we are able to achieve the goals related to nutritional support are based in hands-on, deeply involved and consistent support of trained and experienced and compassionate staff. You might find that it's not easy to be in the role of a supported caregiver. Family members and caregivers will experience a variety of emotions, as their loved one expresses their fears and symptoms related to eating. This is normal and it's helpful to get support for yourself. Keep your loved one in the treatment process. There are no shortcuts. And lastly, it does get better. It gets easier and less stressful as your loved one progresses through treatment.

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This concludes the presentation on the Nutritional Support Program at Eating Recovery Center. Thank you for watching.

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