The RD Road Map: Journey to Eating Disorder Expertise

Today we welcome your tour-guide Jill Sechi, RDN, CEDS-C to discuss her experience with starting up one of the first PHP/IOP programs in Houston, TX called Houston Eating Disorders Center (HEDC).  Houston was a desert when Jill started in the field and now its a thriving rainforest of many RTC and PHP/IOP programs.  PHP programming generally is 5-7 days a week and usually upwards of 12 hours a day. Most PHP programs have IOP programs as "step downs" in which the patient often gets to work with the same treatment team for consistency and support. Learn from Jill when to refer to this level, when not and the functions of PHP and IOP programming.  Most states have PHP and IOP programming. Some even have apartments connected to them so that they do not have to travel to and from home which can be difficult. We hope you find this informative and helpful as you navigate when and HOW  to refer patients! Join us on Apple Podcasts to listen to the full extended episode in our Subscriber Backend episodes!

oday we welcome guest Amanda Mellowspring, MS, RDN, CEDS-C who is currently the COO (Chief Operating Officer) for a large outpatient business called Healthier Tomorrows. Learn more here: https://healthiertomorrows.com/dietitian/amanda-mellowspring-ms-rd-ceds-c/ Amanda previously was the VP of Monte Nido and has worked in a residential treatment for many years. She has hired and trained dietitians in residential as well.  Residential treatment or RTC is a level of care that can provide some medical monitoring but generally provides 24/7 containment for patients that need much more support to restore weight or interfere with behaviors so that they can nourish themselves and their brain to do the hard work of recovery. There are MULTIPLE residential facilities throughout the United States. Amanda will provide a back end view of understanding the function and purpose of this level of care. Enjoy!

Today we welcome guest Meghan Foley, MS, RDN, CEDS-C who is the clinical nutrition manager at Denver Health ACUTE. ACUTE is the "highest 14er" you can climb. It was founded by Dr. Philip Mehler and the main focus is helping medically stabilize individuals with severe malnutrition before they hopefully step down to residential care.  Generally, those that admit here meet certain criteria such as a very low BMI (less than 15), very low or high electrolytes, at very high risk for refeeding syndrome which requires the patient to have 24/7 medical monitoring.  Not only is ACUTE a medical stabilization hospital, it is also a renowned research facility. Their research has provided the field with amazing understanding of medical complications of eating disorders and how to treat the medical symptoms. 

If you are a hiker, you know what "The 14ers" are; they are mountains that many like to climb located around the world. Not all of the hikes are difficult. What makes them difficult are the elevation changes. They are over 14,000 feet to the top and usually require a hiker to start at 6 am and "get back down" before noon as thunderstorms can develop quickly. We titled this new series The 14ers because we feel that understanding a Higher Level of Care (HLOC) can be difficult without exposure and a basic understanding of how to navigate:   When to decide to refer a patient to a HLOC   What are the different levels?   What facility do you refer your client to?   What level do you recommend? We will be having guest speakers that have worked in the various levels of care to give you perspective and an "inside look" into each level. If you are new to the field, knowing the basics and lingo is vital so that you can more accurately coordinate care and provide a good recommendation. Here are some resources on your journey from your tour guides! Know the lingo:   IP: Inpatient   RTC: Residential Treatment   PHP: Partial Hospitalization Program   IOP: Intensive Outpatient   OP: Outpatient Most states now have most levels of care (RTC through IOP). However, that doesn't mean those programs take your client's insurance or that they are a solid program. Ask around to other colleagues who are more seasoned in the field about which programs they might recommend. Keep in mind, not all clients do well in residential care on their "first round." They may not be ready or motivated, they may not have "stepped down" appropriately, or they may be too young and need family-based treatment, for example. We hope you find some good nuggets or perhaps just some validation of how difficult a 14er is. Experience, supervision, and knowledge are a good starting point even if you have never worked in that level of care.

This is our last installment of medical complications to look for in eating disorder care.  Today's episode covers refeeding and underfeeding syndrome in eating disorder care. Now we are looking beyond the basics of what to pack in your backpack and more so of navigating what trail to take, what additional things to pack and how much time you have in a given day with the trail you've chosen. Refeeding syndrome can evoke fear and underfeeding syndrome (the less common one most think about) can evoke confusion! As your "tour guides" here are some things to consider before your journey. What additional things to pack beyond the basics and knowing where you are going and what is waiting for you on your journey.  Know the continued labs to follow and other considerations when working with someone with malnutrition. How little have they been eating, how rapid has their weight dropped or what is their BMI are all items that can place a person at higher risk for refeeding syndrome (pack a medical kit). Know what physical symptoms can be present with refeeding such as night sweats, sore muscles upon waking or heart palpitations and weight restoration. Make sure you are requesting they visit with a doctor to monitor this things (pack a rain jacket and light coat. The weather can change fast!) Understand underfeeding syndrome (which is way more common than refeeding). How much energy is added and when is vital to keep internal organs functioning (including the brain) and keeping up with metabolic demands as the body is repairing itself. How much weight do they need to gain and where to start calories all need to be considered.  (Avoid overpacking and starting too late on your journey. Eating disorders are like an 8 miler over several days. Make sure you have adequate fuel along the way).

 With hiking, climbing mountains or traveling, choosing the best pathway can be daunting. Often you might be hearing "word of mouth" for a particular trail or you've found a great "hiking trail" app on your phone. Individuals provide a few pictures, "what to look out for", and perhaps a few pros and cons. This is so similar to treating those with eating disorders. Especially when it comes to navigating GI issues, food intolerances or perceived allergies. You'll find they have eliminated every possible "route" (food) due to fear and misunderstanding. As the provider you are tasked with pushing them towards a trail head they are terrified of and YOU are equally scared because you have never hiked the trail either. Do you know what you are talking about? What will this look like in the room? The client is convinced they have gluten intolerance but they binge on pies, cookies and cakes with normal flour/gluten content. What now? In this episode we dig deep into allergies and food avoidance. First though, you need to have a decent understanding of food allergies, tests that are often ordered yet are not evidence based, and a general understanding of what causes food intolerances. Clients get to the point of severe malnutrition due to all the food elimination at the same time having visited multiple doctors (with their own bias and opinions) and a myriad of tests that are expensive, time consuming and often unnecessary. Understand an intolerance (often due to malnutrition) vs a food allergy (immune system). We'll also talk about a few clinical presentations and how we support these cases in session... Happy Listening! 

Have you ever climbed a mountain? Or hiked steep terrain? Well this is exactly what treating those with eating disorders and the myriad of associated medical complications can feel like as a clinician! Have no fear, your guides are here! Corny but it does rhyme! Yes there are some amazing resources out there that discuss medical complications and several resources will follow below. We also wanted to navigate in session things that can come up and what you might experience or hear your client say to clue you in.    Medical complications in eating disorders are well, just complicated! But if you see them through the lens of malnutrition they begin to become quite clear and interventions become a little more understandable: very similar to navigating your pathway up some steep terrain. What often makes medical complications complicated is that clients often start first with various medical doctors in their specific specialty; often most do not have any training or understanding of eating disorders (eating disorders are generally going to be associated with some level of malnutrition so its best to "rule in" the eating disorder first.) By the time they enter your office, they've gone to 5 different doctors and have been suggested various unhelpful or harmful interventions or oftentimes have been "dismissed" with an unknown cause and IBS. They feel overwhelmed and dismissed. In this podcast you'll learn important interventions to use to help a client navigate INTO a pretty scary situation- eating. Because eating just is uncomfortable, painful and terrifying. Yet the most important behavior to treat. You'll experience loads of resistance so its best to understand and speak their language as you help them navigate up this pathway. We are diving deep into gastroparesis, a pretty common side effect of malnutrition. And then we'll touch on SMA syndrome, a much less common side effect. We'll be discussing common scenarios you'll often hear clients report "in the room," medication interventions and nutrition interventions that are evidence-based and standard of care. Listen to the full EXTENDED episode with Mateus and Jill when you subscribe on Apple Podcast!

Episode 6: Climbing the Competency Mountain   Feeling confident in the eating disorder field ALWAYS starts by knowing what you DONT know. Focusing on mainly treating those with EDs (through a private practice position or hospital program position for example) and getting basics down can feel daunting. Yet so important in building competency. We're here to say its doable! In this episode Mateus and Jill talk about their "growth" in the field. Some similarities but many differences! Mateus received thorough education and mentorship through Wellness Coaching & Nutrition Therapy's Residency Program. This is discussed in Episode 5. In the backend learn about the 8 Core Competencies needed to effectively treat eating disorders. In the next several episodes we'll dive deep into each one with resources, case studies and even guest speakers in the field. One resource we think is helpful to have a good overview of topics as well as some of the research behind it is:  Treatment of Eating Disorders: Bridging the Research Practice Gap: https://www.amazon.com/Treatment-Eating-Disorders-Bridging-Research-practice/dp/0128102071.   We hope to see you in the "back end" exclusively when you subscribe on Apple podcast!

This episode is an introduction to the WWJD which is an extensive learning and training program offered exclusively at Wellness Coaching & Nutrition Therapy. Are you frustrated with the lack of hands-on learning you need to grasp and support those with eating disorders? Needing an organized educational program to grasp the fundamentals and helpful counseling skills to be more effective in your work? How about hands-on observing and clinician-observed sessions with real-time feedback? Introducing the WWJD which will officially in 2025! From basics to more intensive learning concepts such a cognitive behavioral therapy for Registered Dietitians, learn the fundamentals of eating disorders treatment and counseling skills.  Want even more hands-on support? The Residency is just for you. Interested? Go to https://jsechinutritiontherapy.com/membership-teaser and send in your email with interest. You'll be the first to know when the program launches!

Are YOU ready? This episode is our last installment of getting a "sneak peak" behind our paid membership paywall. Again, we hope that you'll find this content helpful and will want to continue listening with our paid membership with Episode 5 and onward! In this episode we are sharing and discussing a very important article that nicely describes the pathway to becoming a expert in the field of eating disorders: Academy of Nutrition and Dietetics: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Eating Disorders. You can access the full article here: https://www.jandonline.org/article/S2212-2672(20)30904-7/fulltext Or email us at [email protected] and we will send you the pdf!  When starting on the pathway to ED expertise, all start by becoming competent in the field. This ALWAYS starts by knowing what you DONT know. Focusing on mainly treating those with EDs and getting basics down. The next pathway is proficiency. One is competent but then builds to confidence with tons of education, supervision, TIME in the field, and EXPERIENCE with working with individuals with EDs Finally, you start the journey of expertise. Generally this is where individuals are able to provide consultation and or supervision to others. You know what you don't know and definitely know your journey doesn't stop! We want to also provide some resources on obtaining your CEDS (Certified Eating Disorders Specialist) credential. You can not get this credential in less than 2 years entering the field of eating disorders and must have at least 2500 supervised hours. And NO you don't have to be Bill Gate's child to afford other important aspects this credential which is working with a consultant regularily and FOCUSING most of your CEUs in the field of EDs. To learn more about this important credential click here: https://iaedpfoundation.com/certification/ or visit our website here: https://jsechinutritiontherapy.com/consultation. Let's GO!

Deciding the road and pathway in your understanding and essentially career in the eating disorders field can be daunting. We want you know have a sense of the direction you are going with loads of support, education, and guidance from a couple of well-traveled (at least one!) tour guides. We've been where you want to go and want to help you avoid the pot holes, and dangerous places, tolerate the heat and rain and enjoy the sunshine and beautiful views along the way. You get to see a sneak peak into the back end that only those that subscribe to the podcast get to experience. We hope you'll find this content eventually a great investment in your career. You'll also get to receive a lot of great resources that we've found helpful in our journey right at your fingertips. Remember: you start with what you DON'T know; then LEARN and THAT will help you become a well travelled and confident clinician. Let's climb: Malnutrition We wanted to start with malnutrition as a key pathway to understanding eating disorders. Malnutrition comes in all sizes and shapes and want you to be aware of what to begin looking for. Remember, this does not take the place of needed formal supervision or consultation but does help you know what to dig deeper in for knowledge and understanding of a complex population. Malnutrition is often MISSED by well meaning clinicians. It can show up through behavioral issues, emotion dysregulation, eating patterns, height changes, poor performance in sport, frustrated parents and clients (having gone through multiple treatment providers and tests) searching for THE answer, often found in what food to avoid. It has to be that simple right? Let's dig into how malnutrition is missed. Understand how BMI is a very poor indicator of health but IS important in the ED field. Things you can look for in anthropometrics and physical exam and how these things may not show you the full picture and resources to boot. Important take away resources: Nutrition Focused Physical Exam: https://www.eatrightstore.org/product-type/ebooks/nutrition-focused-physical-exam-pocket-guide-3rd-edition-ebook  Everything you need to know about the Minnesota Starvation Study: https://www.apa.org/monitor/2013/10/hunger  Journal article: https://jn.nutrition.org/article/S0022-3166(22)10249-X/fulltext Video from a participant: http://www.epi.umn.edu/cvdepi/video/the-minnesota-semistarvation-experiment/  Great podcasts: https://seven-health.com/2021/02/226-minnesota-starvation-experiment/  Another great podcast (follow up of participants) and important to know and see longer term effects of malnutrition: https://seven-health.com/2020/02/rebroadcast-the-minnesota-starvation-experiment-follow-up/#2  An important PURPLE Book (4th addition) to reference. You can provide this to physicians too who many not be versed in EDs. This resource is also published in many languages too!: https://higherlogicdownload.s3.amazonaws.com/AEDWEB/27a3b69a-8aae-45b2-a04c-2a078d02145d/UploadedImages/Publications_Slider/2120_AED_Medical_Care_4th_Ed_FINAL.pdf  

New to ED? This one is for you. Know what you DON'T know and if you have an active ED, think twice before supporting others in their recovery journey. Jill and Mateus discuss the lack of education for undergraduate RDs in eating disorders and why learning about them, developing skills, supervision/consultation while practicing and more is vital to be safe, effective and ethical. Know what you DON'T know is where you start. Understand the Dunning Kruger Effect. Here are some articles to learn more: What causes the Dunning-Kruger Effect? https://www.psychologytoday.com/us/basics/dunning-kruger-effect: Confidence is so highly prized that many people would rather pretend to be smart or skilled than risk looking inadequate and losing face.  Even smart people can be affected by the Dunning-Kruger effect because having intelligence isn't the same thing as learning and developing a specific skill. Many individuals mistakenly believe that their experience and skills in one particular area are transferable to another. Why do people fail to recognize their own incompetence? Many people would describe themselves as above average in intelligence, humor, and a variety of skills. They can't accurately judge their own competence, because they lack metacognition, or the ability to step back and examine oneself objectively. In fact, those who are the least skilled are also the most likely to overestimate their abilities." https://pubmed.ncbi.nlm.nih.gov/10626367/ If you are currently struggling with an eating disorder, we encourage you to get support and treatment, deserved healing and reach a full recovery for a good length of time before practicing in the field. Some say a solid 5 years. Carolyn Costin encourages a minimum of 2 before you can perform as an ED Coach in her coaching certificate program. Learn more here: https://www.carolyn-costin.com/institute  Read more about Carolyn's definition of recovery in her book "The 8 Keys to Recovery from an Eating Disorder" What is recovery? Here are some things to ponder: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2829357/  https://www.montenido.com/fully-recovered-vs-in-recovery/  https://www.feast-ed.org/defining-recovery/  We believe in the ability to fully recover is attainable.

Welcome to The RD Roadmap: Journey To ED Expertise hosted by Jill Sechi, MS, RDN, CEDS-C, LD and Mateus Milhomens, MS, RDN, IBCLC, ACE-CHC. This podcast series has been developed to provide a roadmap and a couple of tour guides on your journey to understand and build confidence as a provider in the field of eating disorders. Check back in with us next Monday to begin our weekly series!